Every finding on record at Medilodge of Midland

Based on observation, interview and record review, the facility failed to ensure medications and controlled substances were secured and/or destroyed as required for four residents (R3, R4, and R5, and R6).Findings Include:During an observation on [DATE] at 8:12 AM, a plastic up containing a syringe with clear liquid and a glucometer and alcohol swab was observed on top of a medication cart. No staff were in the vicinity of the medication cart. An independently ambulatory resident was approximately 15 feet away from the unattended cart and medication. During an observation and interview on [DATE] at 8:15 AM, Licensed Practical Nurse (LPN) A approached the medication cart and said the syringe contained insulin for Resident #3 (R3). LPN A said he left the medication unattended because he had to go to the medication room to obtain medication that was not in the cart. LPN A unlocked and opened the top drawer of the medication cart where 3 clear plastic medication cups containing pills were stacked together. LPN A reported the medication cups contained controlled substances for R3, R4, and R5. A clear plastic cup containing a reddish-pink fluid was also preset. LPN A reported the liquid medication was for R6. During an observation and interview on [DATE] at 8:18 AM, the Director of Nursing (DON) was informed of the findings and observed the preset medications with LPN A. A narcotic count was completed, and it was identified that LPN A documented the controlled substances ordered for R3, R4, and R5 were allegedly withdrawn from the double locked compartment at 7:00 AM. LPN A said they had already been documented as given on the Medication Administration Record (MAR) for each resident. Each order for controlled substances was reviewed during the narcotic count, and it was identified that each of the doses was scheduled (to be given at specific intervals) and were not as needed. The DON instructed LPN A to dispose of the insulin injection and said they would waste the controlled substances. During an observation and interview on [DATE] at 8:35 AM, the DON walked away to obtain a jug of drug buster (a drug disposal system). LPN A was observed emptying each plastic med cup containing controlled substances into the sharps container affixed to the medication cart. The DON reapproached the medication cart and confirmed they had not witnessed the waste of medication and proceeded to instruct LPN A how to document a wasted drug on the controlled substance log. The DON said the Electronic Medical Record (EMR) would need to be corrected to reflect the medications had NOT been given as ordered and the provider would need to be contacted to address the late administration of each of the doses of medication. Review of a facility policy Medication Storage revised [DATE] reflected It is the policy of this facility to ensure all medications housed on our premises will be stored according to the manufacturer's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security. The policy specified: c. During a medication pass, medications must be under the direct observation of the person administering medications or locked in the medication storage area/cart. a. Schedule II drugs and back of stock of Schedule III, IV, and V medications are stored under double lock and key. b. Schedule II controlled medications are to be stored within a separately locked, permanently affixed compartment when other medications are stored in the same area, such as in refrigerator. Review of a facility policy Medication-Destruction of Unused Drugs revised [DATE] reflected All unused, contaminated, or expired prescriptions shall be disposed of in accordance with state laws and regulations (refer to any state-specific requirements). The policy specified 1. Drugs will be destroyed in a manner that renders the drug unfit for human consumption and disposed of in compliance with all current and applicable state and federal requirements. 5. Non-controlled and schedule V controlled drugs must be destroyed in the presence of two (2) licensed nurses. Schedule II, III, and IV controlled drugs must be destroyed by the Director of Nursing Services (DON) and another licensed nurse. (Unless state regulations require Pharmacist) . 14. Staff shall contact the provider pharmacy if they are unsure of proper disposal of methods for a medication.

Based on interview and record review, the facility failed to transcribe and initiate a medication order timely for 1 resident (Resident #1) out of 9 residents reviewed. Findings include:Review of a facility Face Sheet reflected R1 admitted to the facility on [DATE] with diagnoses that included cerebral infarction (ischemic (reduced blood flow) stroke), aphasia (a communication disorder resulting from damage to brain areas controlling language, usually caused by stroke or head injury) following cerebral infraction, and rheumatic mitral valve disease. Review of a hospital After Visit Summary (AVS) dated 12/24/25, reflected R1 was to be given enoxaparin 40 mg (milligram)/0.4 mL (milliliter) syringe commonly known as: LOVENOX Inject 0.4 mL (40 mg total) under the skin every 12 (twelve) hours. Lovenox is an anticoagulant. Review of a Nurses' Notes dated 2/12/26 at 3:50 PM reflects Resident (R1) returns from cardiology appt (appointment) with consultation form: TEE (Transesophageal Echocardiogram), (name of physician) to complete, start Eliquis (oral anticoagulant) 5mg po (orally) every 12 BID (twice a day) DC (discontinue) Lovenox, consult (name of physician) at (name of health system) follow up 5.21.26 at 10:50 AM with (name of physician). Review of the February 2026 Medication Administration Record (MAR) reflected the order for Lovenox was discontinued on 2/12/2026. The February 2026 MAR reflected the order for Eliquis 5mg PO BID was not initiated until 2/18/26, six days later. Review of a Progress Notes dated 2/25/2026 at 8:00 AM reflected General: [AGE] year-old female patient seen today to follow-up on her lab work. Patient (R1) was recently started on Eliquis by vascular surgeon secondary to a DVT (deep vein thrombosis, a blood clot). Labs have been ordered weekly for monitoring and these labs exhibit a hemoglobin of 6.6 (normal hemoglobin for an adult female is 12.0-15.5 grams per deciliter). There have been no reports of black or bloody stools (an indication of a gastrointestinal bleed). I will place her Eliquis on hold for 3 days and set her up for a transfusion of 2 units of packed red blood cells. I have also started her on Carafate (a prescription medication used to treat and prevent duodenal ulcers by forming a protective, healing barrier over them) 1 g (gram) 3 times daily along with PPI (proton pump inhibitor). We will continue monitoring her lab work weekly and trend her hemoglobin. She is in no acute distress. During an interview on 5/12/2026 at 9:26 AM, the Director of Nursing (DON) reported when a resident goes out for an appointment they are sent with a consultation sheet which is returned to either the charge nurse or the unit manager upon return from the appointment. If orders are to be changed or initiated, either the charge nurse or the unit manager input the orders into the Electronic Medical Record. If there are any questions about the orders, the charge nurse or unit manager will contact the physician for clarification. After any orders are addressed, the consultation sheet is placed in the physician notification book for review. The DON was not able to explain why six days had elapsed before R1's Eliquis order was entered. Review of a Nurses' Notes dated 3/2/2026 at 10:03 AM reflected noted pt (R1) to have hematoma above left eye, NP (nurse practitioner) visit new order to send to ER (Emergency Room) for CT (computed tomography). Spoke with (name of POA for R1) he stated he wants to see of family can transport. d/t pt not having money for EMS (emergency medical services) bill. called (proper name), stated will be here to transport. Review of a hospital Plan dated 3/2/26 reflected Subsegmental pulmonary emboli: Troponin (measures the level of cardiac-specific proteins in the blood, which are released when the heart muscle is damaged) 0.083. BNP (brain natriuretic peptide) 2720 (normal BNP is generally less than 100 pg (picograms)/mL.) CT (computed tomography) chest with contrast demonstrates filling defects in the right lower lobe subsegmental pulmonary artery branch and right middle lobe subsegmental pulmonary artery branch consistent with pulmonary emboli (a life-threatening blockage of a main artery in the lung, usually caused by a blood clot (deep vein thrombosis or DVT) that travels from the legs or pelvis) without right heart strain. Trend troponin. Limited echocardiogram ordered. Initiate patient on heparin drip with pharmacy to dose. Discussed this with patient's daughter at bedside. Unable to count as Eliquis failure due to multiple breaks in therapy. Please see below. History of DVT in the left peroneal vein: DVT in the left peroneal vein noted during hospitalization 12/12/2025. Patient (R1) was discharged on twice daily Lovenox injections. (R1) was switched to Eliquis 5 mg twice daily when she saw cardiology 2/12/2026. Per the notes, it appears that patient's Lovenox was stopped that same day however (R1) was not initiated on Eliquis until the evening of 2/18. Holding Eliquis, heparin drip as above.

Based on observation, interview, and record review, the facility failed to follow professional standards of nursing practice for 5 residents (Resident #45, #47, #95, #53, and #29) out of 20, reviewed for medication administration.Findings: Resident #45 (R45) Review of an admission Record revealed R45 was an [AGE] year-old male, admitted to the facility on [DATE], with pertinent diagnoses which included: diabetes. Review of R45's Order Summary dated [DATE]-[DATE] revealed, metFORMIN HCl Oral Tablet 500 MG (Metformin HCl) Give 1 tablet by mouth one time a day.Hold if BSL (blood sugar level) is less than 120 mg/dl To be administered at 8:00 AM. Review of R45's Blood Sugar Summary and July Medication Administration Record revealed: *On [DATE] R45's blood sugar was 108 and the metformin was administered. *On [DATE] R45's blood sugar was 103 and the metformin was administered. *On [DATE] R45's blood sugar was 88 and the metformin was administered. *On [DATE] R45's blood sugar was 116 and the metformin was administered. Review of R45's Order Summary dated [DATE]-present revealed, metFORMIN HCl Oral Tablet 500 MG (Metformin HCl) Give 1 tablet by mouth two times a day.Hold if BSL is less than 120 mg/dl. To be administered at 8:00 Am and 8:00 PM. Review of R45's Blood Sugar Summary and July and August Medication Administration Record revealed: *On [DATE] R45's morning blood sugar was 88 and the metformin was administered. *On [DATE] R45's evening blood sugar was not assessed, and the metformin was administered. *On [DATE] R45's evening blood sugar was not assessed, and the metformin was administered. *On [DATE] R45's morning blood sugar was 95, and the metformin was administered. *On [DATE] R45's evening blood sugar was not assessed, and the metformin was administered. *On [DATE] R45's evening blood sugar was not assessed, and the metformin was administered. *On [DATE] R45's morning blood sugar was 103, and the metformin was administered. *On [DATE] R45's evening blood sugar was not assessed, and the metformin was administered. *On [DATE] R45's morning blood sugar was 93, and the metformin was administered. Review of R45's Electronic Medical Record revealed no documentation pertaining to the administration of the metformin outside of the ordered parameters. Resident #47 (R47) Review of an admission Record revealed R47 was an [AGE] year-old female, admitted to the facility on [DATE], with pertinent diagnoses which included: diabetes. Review of R47's Order Summary dated [DATE] revealed, HumaLOG Solution 100 UNIT/ML (Insulin Lispro (Human)) Inject 3 unit subcutaneously before meals for diabetes Hold if BSL is less than 120 mg/dl. To be completed at 7:00 AM (morning), 12:00 PM (afternoon), and 6:30 PM (evening). Review of R47's Blood Sugar Summary and July and August Medication Administration Record revealed: *On [DATE] at 12:56 PM R47's blood sugar was 116. R47's blood sugar was not assessed for the evening dose of Humalog and the result from 12:56 PM was utilized. R47's evening dose of Humalog was administered. *On [DATE] R47's blood sugar was 118 and the morning dose of Humalog was administered. *On [DATE] R47's blood sugar was 118 and the afternoon dose of Humalog was administered. *On [DATE] R47's blood sugar was 93 and the afternoon dose of Humalog was administered. *On [DATE] R47's blood sugar was 110 and the morning dose of Humalog was administered. *On [DATE] R47's blood sugar was 120 and the morning dose of Humalog was documented as 4-Vitals Outside of Parameters for Administration and the Humalog was not administered. Review of R47's Electronic Medical Record revealed no documentation pertaining to the administration of the Humalog outside of the ordered parameters or the withholding of the Humalog on [DATE]. Resident #95 (R95) Review of an admission Record revealed R95 was a [AGE] year-old male, admitted to the facility on [DATE], with pertinent diagnoses which included: heart disease and hypertension. Review of R95's Order Summary dated [DATE] revealed, Cozaar Tablet 25 MG (Losartan Potassium) Give 0.5 tablet by mouth one time a day.Hold if SBP (systolic blood pressure [top number]) is less than 120 mmHg. To be administered at 8:00 AM. Review of R95's Blood Pressure Summary and July and August Medication Administration Record revealed: *On [DATE] R95's morning blood pressure was 115/61 and the Cozaar was administered. *On [DATE] R95's morning blood pressure was 108/51 and the Cozaar was administered. *On [DATE] R95's morning blood pressure was 108/80 and the Cozaar was administered. *On [DATE] R95's morning blood pressure was 115/59 and the Cozaar was administered. *On [DATE] R95's morning blood pressure was 100/57 and the Cozaar was administered. *On [DATE] R95's morning blood pressure was 100/62 and the Cozaar was administered. *On [DATE] R95's morning blood pressure was 115/60 and the Cozaar was administered. *On [DATE] R95's morning blood pressure was not assessed and the Cozaar was administered. *On [DATE] R95's morning blood pressure was not assessed and the Cozaar was administered. *On [DATE] R95's morning blood pressure was 117/62 and the Cozaar was administered. *On [DATE] R95's morning blood pressure was 108/60 and the Cozaar was administered. *On [DATE] R95's morning blood pressure was 98/56 and the Cozaar was administered. *On [DATE] R95's morning blood pressure was 108/54 and the Cozaar was administered. *On [DATE] R95's morning blood pressure was 114/56 and the Cozaar was administered. *On [DATE] R95's morning blood pressure was 106/58 and the Cozaar was administered. *On [DATE] R95's morning blood pressure was 109/47 and the Cozaar was administered. *On [DATE] R95's morning blood pressure was 115/56 and the Cozaar was administered. Review of R95's Electronic Medical Record revealed no documentation pertaining to the administration of the Cozaar outside of the ordered parameters or without an assessment. Resident #53 (R53) Review of an admission Record revealed R53 was an [AGE] year-old male, admitted to the facility on [DATE], with pertinent diagnoses which included: hypotension. Review of R53's Order Summary dated [DATE] revealed, Midodrine HCl Oral Tablet 10 MG (Midodrine HCl) Give 1 tablet by mouth three times a day for hypotension Hold if SBP greater than 140. To be administered at 8:00 AM, 2:00 PM, and 8:00 PM. Review of R53's Blood Pressure Summary and July Medication Administration Record revealed: *On [DATE] R53's blood pressure was 136/61 at 8:24 AM and the Midodrine was administered. R53's blood pressure was not assessed for the 2:00 PM dose of Midodrine and the result from 8:24 AM was utilized. R47's 2:00 PM dose of Midodrine was administered. *On [DATE] R53's blood pressure was 125/52 and the 8:00 PM dose of Midodrine was administered. *On [DATE] R53's blood pressure was not assessed prior to the administration of the 2:00 PM dose of Midodrine. R53's morning blood pressure result was utilized and the Midodrine was administered. *On [DATE] R53's blood pressure was not assessed prior to the administration of the 2:00 PM dose of Midodrine. R53's morning blood pressure result was utilized and the Midodrine was administered. *On [DATE] R53's blood pressure was not assessed prior to the administration of the 2:00 PM dose of Midodrine. R53's morning blood pressure result was utilized and the Midodrine was administered. Review of R53's Electronic Medical Record revealed no documentation pertaining to the administration of the Midodrine outside of the ordered parameters or the lack of assessment prior to the administration. During an interview on [DATE] at 8:20 AM, Licensed Practical Nurse (LPN) S reported that vital signs should be obtained prior to the administration of a medication with ordered parameters. LPN S reported that the EMAR (electronic medication administration record) shows the entire ordered with parameters and prompts the licensed nurses and medication aides to document the vital sign results which also serves as a reminder to obtain the vital signs prior to the administration of the medication. During an interview on [DATE] at 12:45 PM, Director of Nursing (DON) and Regional Nurse (RN) T confirmed medication had been administered outside of parameters. DON and RN T reported that they had been working with the providers to discontinue parameters for residents that had been on medications long term with stable vital signs to promote a more homelike environment. DON and RN T reported that the expectation for licensed nurses and medication aides was to follow the provider ordered parameters and ensure vital signs and blood sugar were obtained prior to the administration of the medications. The DON and RN T were provided the above findings. No documentation disputing the findings were received prior to survey exit. Review of the facility policy Medication Administration dated [DATE] revealed, .8. Obtain and record vital signs, when applicable or per physician orders. When applicable, hold medication for those vital signs outside the physician's prescribed parameters. R29 Review of the medical record reflected R29 initially admitted to the facility [DATE] with a pertinent diagnosis of Type 2 Diabetes Mellitus. On [DATE] at 7:20 AM a review was conducted of the A Hall medication cart for rooms 9 through 15 with Registered Nurse (RN) R. The review revealed one [NAME] SoloStar Pen Injector (insulin pen) labeled for R29 and dated as placed in service on [DATE]. Review of the Doctor's Orders for R29 reflected an order for Lantus SoloStar Subcutaneous Pen Injector with the instructions to inject 17 units subcutaneously at bedtime with a start date of [DATE]. Review of the Lantus SoloStar Subcutaneous Pen Injector manufacturer's product information sheet, use and storage recommendations, reflected Only use your pen for up to 28 days after its first use. Throw away the Insulin (name of product) pen you are using after 28 days, even if it still has insulin left in it. Review of a calendar revealed that 28 days after [DATE] was [DATE] which indicated the one Lantus SoloStar injector pen for R29 in the medication cart remained available for continued use. Review of the Medication Administration Record (MAR) for [DATE] for R29 reflected the Resident had received two doses ([DATE] and [DATE]) from two different nurses after the manufacturer's recommended expiration date. The policy provided by the facility titled Medication Storage last reviewed/revised [DATE] was reviewed. The policy reflected, Policy: It is the policy of this facility to ensure all medications housed on our premises will be stored according to the manufacturer's recommendations. The policy provided by the facility titled Medication Administration last reviewed/revised [DATE] was reviewed. The document reflected Policy: Medications are administered by licensed nurses or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice in a manner to prevent contamination or infection. And 12, Identify expiration date. If expired, notify nurse manager.

Based on observation and interview, the facility failed to have an active plan for reducing the risk of legionella and other opportunistic pathogens of premise plumbing (OPPP). This deficient practice has the increased potential to result in waterborne pathogens to exist and to spread in the facility's plumbing system and an increased risk of respiratory infection among any or all the residents in the facility.Findings include:On 08/05/2025 at 1:20 PM, observation noted during walkthrough of the facility with Maintenance Director (MD) D; three dead end lines under the dirty dish side of the ware washing area. In that area, two of the dead-end lines are coming off the hot water line to the dish machine, another dead-end line with a faucet handle is closest to the current garbage disposal. When MD D was asked what the lines were for, he indicated they were not in use and was unsure what the lines had been used for or when they were removed from service. During a discussion regarding the dead-end lines in the kitchen and the facility's flushing schedule, MD D stated they are currently not flushing the dead-end lines in the kitchen area. On 08/05/2025 at 1:30 PM, observation of shower room located between A and B hall, a shower faucet handle and an uncapped pipe, coming out of the wall. MD D indicated that the faucet was not in use, and the line was not being flushed. When the shower faucet handle was turned on water came out of the pipe.Review of Operation Maintenance and Control Limits document, undated, on 08/05/2025 indicates that facility will flush low-flow pipe runs, dead legs and infrequently used fixtures weekly. On 08/05/2025 3:35 PM, observation during walkthrough of kitchen with Regional Maintenance Director (RMD) Q, a dead-end line with faucet handle under the clean dish side of the dish machine area. RMD Q stated he was unaware of that line being there and the dead-end line was not part of the flushing schedule.

Based on observation, interview, and record review, the facility failed to ensure timely replacement of respiratory equipment for 2 residents (R11 and R53) of 2 residents reviewed for respiratory concerns.Findings include:R11Review of an admission Record revealed R11 admitted to the facility on [DATE] with pertinent diagnoses which included congestive heart failure and chronic obstructive pulmonary disorder.In an observation on 8/5/2025 at 11:28 AM in R11's room, R11 was receiving oxygen therapy via a nasal cannula dated 7/16. In the corner of her room was a nebulizer machine with a nebulizer mask and tubing plugged into it dated 4/13. The nebulizer mask and tubing had begun to change to a yellowish color.In an observation on 8/7/2025 at 8:10 AM in R11's room, R11 was receiving oxygen therapy via a nasal cannula dated 7/16. In the corner of her room was a nebulizer machine with a nebulizer mask and tubing plugged into it dated 4/13, remaining unchanged from the previous observation.In an interview on 8/7/2025 at 8:15 AM, Registered Nurse (RN) N reported respiratory masks and tubing should be replaced weekly. RN N reported R11 received nebulizer treatments as needed and last received a treatment on 6/19/2025.R53Review of an admission Record revealed R53 admitted to the facility on [DATE] with pertinent diagnoses which included congestive heart failure and chronic obstructive pulmonary disorder.In an observation and interview on 8/5/2025 at 11:08 AM in R53's room, R53's wheelchair had a bag hanging on the back with a nasal cannula dated 6/18. R53 reported he used this oxygen cannula daily when out of his room.Review of facility policy/procedure Oxygen Administration, revised 10/26/2023, revealed .change oxygen tubing and mask/cannula weekly and as needed if it becomes soiled or contaminated. change nebulizer tubing and delivery devices every 72 hours.

Based on observations, interviews, and record reviews, the facility failed to provide tube feeding according to standards of care for resident (R19) of two residents reviewed for tube feedings.Findings include:Review of R19's admission record dated 8/7/24 revealed she was admitted to the facility on [DATE] with diagnoses that included malignant neoplasm of brain, epilepsy, gastrostomy status, dysphagia oropharyngeal, (difficulty swallowing) and weakness.R19 was observed in bed on 8/5/25 at 11:22 AM. R19's eyes were closed, and she did not respond to calling her name. R19 had a feeding tube pump next to her bed and a bottle of tube feed was connected to the pump. The tube feeding bottle was connected to the feeding tube and food was visible in the tube. The tube feeding bottle contained approximately 850 ml of the 1000 ml (full bottle). A water bag was also connected to the pump. The tube feeding bottle and water bag were not labeled with resident name or date or time started.During an interview with Licensed Practical Nurse (LPN) I on 8/5/25 at 11:25 AM, LPN I was asked about R19's tube feeding. LPN I said night shift hung the tube feeding and the water bag. LPN I said she turned it off at 8:00 AM. LPN I was asked if the tube feeding and water should be labeled. LPN I said they should be labeled with the resident name, date, and time started. LPN I said she would dispose the current supplies and report the concern.R19 was observed in the main dining room on 8/6/25 at 1:50 PM with the tube feeding pump on a stand next to her. The pump was covered with a pillowcase. LPN G was asked about R19's tube feeding. LPN G removed the pillowcase, and the pump was observed to be running. It was set to infuse 303 ml over 1 hour and 127 ml had been received. The TF was labeled with R19's name and was dated 8/6/25. However, the water bag was dated 8/5/25 at 12:00 PM (more than 24 hours).Review of R19's Medication Administration Record (MAR) dated 8/5/25 revealed LPN I provided R19 tube feeding at 8:00 AM. LPN I had reported she turned the tube feeding off at 8:00 AM.During an interview with the Director of Nursing (DON) on 8/6/25 at 3:20 PM the DON was provided with the information of the tube feeding and water not being labeled on 8/5/25 and the water bottle in use after 24 hours of being open on 8/6/25. The Surveyor asked what the facility practice was as the facility policy did not cover the date, label or expiration date of supplies. The DON said she would investigate it.During an interview on 8/7/25 at 8:15 AM the DON said the tube feeding and water are to be labeled with the resident's name and open date. The tube feeding is to be disposed of after 48 hours and the water after 24 hours. The DON confirmed LPN I did do the 8:00 AM feeding on 8/5/25 when the tube feed and water bag were not dated or labeled and were in use. The DON confirmed that LPN G did not dispose of the water bag on 8/6/25 after 24 hours and continued to use an outdated water bag.

Based on observation, interview, and record review the facility failed to provide safe wheelchair transport for 1 resident (R40) of 1 resident reviewed for accident hazards. Findings include:Review of an admission Record revealed R40 admitted to the facility on [DATE] with pertinent diagnoses which included dementia and anxiety.Review of a current activities of daily living Care Plan intervention for R40, with a revision date of 7/21/2025, revealed she used a low scoot wheelchair for locomotion.In an observation on 8/5/2025 at 10:20 AM in the hallway outside R40's room, a Certified Nursing Assistant (CNA) pushed R40 down the hallway and into her room to provide resident care. R40's legs were hanging freely and not on foot pedals, and one foot was dragging on the ground. A few minutes later, CNA P exited R40's room and pushed R40 quickly back down the hallway in her wheelchair, with both feet dragging on the ground.In an interview on 85/2025 at 2:11 PM, CNA O reported residents should not be pushed in wheelchairs with their feet hanging down. CNA O reported footrests should be used to prevent accidents from feet getting tangled up in the chair.In an observation on 8/5/2025 at 2:37 PM in the hallway outside R40's room, CNA P pushed R40 down the hallway and into the dining are for an activity. R40's legs were hanging down and dragging on the floor.In an interview on 8/5/2025 at 2:47 PM, the Director of Nursing (DON) reported staff are expected to use foot pedals when pushing residents in wheelchairs if the resident is unable to use their feet to move the wheelchair to prevent accidents and injuries from feet getting tangled under the wheelchair.

Based on observation, interview, and record review, the facility failed to accurately assess and measure a pressure ulcer for 1 resident (R13) of 2 residents reviewed for pressure ulcers.Findings include:Review of an admission Record revealed R13 admitted to the facility on [DATE] with pertinent diagnoses which included spina bifida and a pressure ulcer on left buttock.Review of R13's preadmission wound Visit Note Report, dated 7/3/2025, revealed she had a stage IV pressure ulcer on her left buttock measuring 4.4 cm long, 3 cm wide, and 2.2 cm deep.In an observation on 8/6/2025 at 2:59 PM in R13's room, left buttock wound care was observed. R13's left buttock pressure ulcer was measured to be 2.63 cm long, 3.17 cm wide, and 2.5 cm deep.In an interview on 8/6/2025 at 1:48 PM, Wound RN M reviewed wound documentation and reported R13's left buttock pressure ulcer was identified by the admission nurse on 7/7/2025 but it was not assessed or measured until 7/10/2025. Wound picture and documentation from 7/10/2025 were reviewed and R13's pressure ulcer measurement was documented as 4.3 cm long, 2.8 cm wide, and depth was documented as not applicable. Wound picture and documentation from 7/16/2025 were reviewed and R13's pressure ulcer measurement was documented as 2.9 cm long, 2.7 cm wide, and 0.1 cm deep. The pictures reviewed for this pressure ulcer taken on both 7/10/2025 and 7/16/2025 clearly showed depth to the wound that was not documented in the wound measurements. Wound RN M was not able to explain why R13's wound was not assessed and measured upon her admission to the facility on 7/7/2025 or why wound documentation from 7/10/2025 and 7/16/2025 did not accurately reflect the depth of her pressure ulcer.In an interview on 8/7/2025 at 10:02 AM, RN Unit Manager J reported R13 refused to allow her left buttock pressure ulcer to be assessed on 7/7/2025 when she was completing the admission assessment. RN Unit Manager J reported she did not document this refusal, and she did not discuss this refusal with staff or otherwise arrange for timely completion of this wound assessment. RN Unit Manager J reported she expected the wound measurement to be completed the next day during wound rounds.In an interview on 8/7/2025 at 9:15 AM, the Director of Nursing (DON) reported R13 refused to allow her pressure ulcer to be measured upon admission to the facility on 7/7/2025 but could not find any documentation of this refusal. The DON reported the refusal should have been documented in the medical record and the wound assessment and measurements should have been completed as soon as possible after the initial refusal. The DON reported the wound measurements from 7/10/2025 and 7/16/2025 that showed no depth to the wound were believed to be inaccurate, but she could not find any documentation as to the true depth of the wound on these dates. The DON reported the facility was piloting a new way of taking wound pictures in the electronic medical record and she believed technical issues caused the wound depth to inaccurately populate on those dates.Review of R13's Nutrition Data Collection/Evaluation documented by Registered Dietician (RD) K on 7/10/2025 revealed R13 was documented to have no skin issues.In an interview on 8/7/2025 at 10:04 AM, RD K reported she was not aware of R13's pressure ulcer when she completed her evaluation on 7/10/2025 because the ulcer had not yet been documented under skin and wound in the electronic medical record. RD K reported she would have ordered Pro-Stat (a nutrition drink with extra protein) to promote healing at that time had she been aware of R13's skin issues. Review of facility policy/procedure Pressure Ulcer/Skin Breakdown- Clinical Protocol, revised 3/20/2024, revealed .Based on the comprehensive assessment of a resident, a resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers. and a resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice to promote healing. an admission evaluation helps identify. residents with existing (pressure ulcers). Initial Screen. Complete the. admission skin assessment upon admission to the facility. All (pressure ulcers) . are measured and documented. The (inter-disciplinary team) will review each pressure ulcer weekly for progress and changes.

Based on interview and record review, the facility failed to ensure a Pharmacy Recommendation was acted upon for one resident (R3) of five residents reviewed for pharmacy recommendations. Findings include:Review of the Electronic Medical Record (EMR) reflected R3 admitted to the facility 7/10/24 with diagnoses that included Cerebral Infarction (stroke), Disorders of Electrolyte and Fluid Balance, and Gastrostomy (feeding tube).Review of the Pharmacy Recommendation dated 6/10/25 reflected, Note to Attending Physician/ Prescriber, Atorvastatin (a lipid lowering agent) Please add a lipid panel to the standing lab orders: (of) CBC (complete blood count), CMP (comprehensive metabolic panel), A1c every six months. The document reflected the physician had checked the agree box and signed on 6/12/25.Review of the EMR reflected since 6/10/25 R3 had three lab entry dates with results but a lipid panel had not been drawn. The EMR further reflected that a lipid panel had not been documented since admission and review of the Doctor's Orders did not reveal a pending order for a lipid panel. No other EMR documentation was identified that indicated a lipid panel was forthcoming.On 8/6/25 at approximately 2:00 PM an interview was conducted with the Director of Nursing (DON) regarding the Pharmacy Review of 6/10/25 for R3. The DON indicated a review would be conducted.On 8/7/25 a review of the Doctor's Orders for R3 revealed an order for lab work that included a lipid panel entered into the computer on 8/7/25.On 8/7/25 at 12:17 PM an interview and record review were conducted with the DON. The DON reported she had talked with the medical provider who indicated to the DON that she knew the lipid panel was out there. The DON provided EMR documentation dated 6/12/25 by a medical provider to Please add lipid panel to next standing order lab draw. However, prior to the lab order of 8/7/25 no documentation was identified in the EMR that indicated a lipid panel had been added.As of survey exit no additional information had been provided.

Based on interview and record review, the facility failed to notify responsible parties and family of changes in medication and condition and failed to notify the medical provider of blood pressures outside of established parameters for two Residents (R24 and R23) of three residents reviewed for notification of change. Findings: Resident #24 Review of the Electronic Medical Record (EMR) reflected Resident #24 (R24) admitted to the facility 4/7/24 with pertinent diagnoses that included dementia and hypertension. Review of the Minimum Data Set (MDS) dated [DATE] reflected R24 was severely cognitively impaired with a Brief Interview for Mental Status (BIMS) score of 0 out of 15. The medical record reflected a Durable Power of Attorney (DPOA) was in place that designated Responsible Party (RP) Q as the contact person with the authority to oversee the care and to make informed medical decisions for R24. During a telephone interview conducted 9/9/24 at 1:54 PM, RP Q reported the facility does not always ensure he is notified of medication changes. Review of the Medical Provider Progress Note dated 9/5/24 at 0000 revealed, I will start amlodipine 10 milligrams (mg) once a day for hypertension. The EMR reflected a corresponding Physicians Order for the medication. Neither this entry, or any on or near this date, reflected RP Q was contacted and informed of the the reason for, or the addition of, the medication. Review of EMR Progress Notes for R24 reflected an entry with a corresponding Physician's Order dated 8/20/24 at 10:39 AM for an increase in the frequency of the diuretic (water pill) Lasix 40 mg and a potassium supplement to twice a day for five days then return the frequency to once a day for edema and (hypertension). No documentation was found in the EMR that RP Q was notified of the medication frequency change or why it was being implemented. Additional Progress Notes with medication changes were identified on: 4/30/24 at 6:27 PM for Roxanol (opioid) for pain and Zofran for nausea and vomiting. 4/29/24 at 5:18 PM for Lasix daily (times) 5 doses. Neither of the above entries reflected RP Q was contacted and informed. The Physician Assistant (PA) Progress Note dated 4/17/24 at 0000 revealed nurse stated (RP Q ) states (R24) has a severe allergy to morphine, nurse would like to switch to dilaudid, gave ok. nurse also stated (R24) has allergies, order given to nurse for Flonase . Neither this entry or prior and post entries in the Progress Notes (reflected) that RP Q was aware of the medication change to dilaudid or the addition of Flonase. On 9/11/24 at 11:58 AM an interview was conducted with the Director of Nursing (DON) in the DON office. The DON was informed of the dates that medication changes were documented in the EMR without documentation that RP Q had been informed of the changes and the reason for the changes. The DON indicated a review would be conducted. As of survey exit no further documentation or information regarding notification to RP Q of medication and treatment changes was provided. R24 Continued Review of the documentation binder provided by the facility reflected Education/ In-service Record dated 7/9/24. Topic/Title: Provider notification and vitals outside parameters/ complete documentation on (Medication Administration Records) and (Treatment Administration Records) in (EMR). Objectives/ Content: - Monitor and follow all orders that have parameters .Following standing provider parameters if not listed in (Doctor's)order. - Rechecking vital signs (related to) premedication time, activity .and any .chronic condition prior to notifying provider. - Report vitals outside thresholds parameters to provider and document all notifications in (EMR). -Ensure you are checking the alerts (red bell in ((EMR)) for any outside of threshold parameters for follow-up throughout the shift. -Ensure all tasks are completed and documented in (EMR) prior to end of shifts. Reminder: treatments not documented are not done. Included in the Education binder was the document titled Threshold Vitals for ALL (sic) residents. The document reflected Notify provider if vital trends are outside these parameters. These listed notification parameters included a systolic (top number) blood pressure of either a finding lower than 90 millimeters of mercury (mm hg) or a finding of higher than 170mm hg. Also listed is the diastolic (bottom number) blood pressure parameter of a finding of less than 50 mm hg and a finding greater than 100 mm hg. The Threshold Vitals for ALL residents document further reflected Red Dot Alerts noted under red bell in (EMR) Should be checked by nursing throughout the shift to (sic) for vitals outside of threshold. And Nurses need to note in (EMR) that re-check is completed and any new provider orders (related to) vitals outside threshold. (ie physician aware, no new orders, or medications given, vitals rechecked and (within normal limits). Lastly, the document reflected *Reminder to notify and document in (EMR) any and all vitals outside parameters, medications held, and/or given (related to) parameters. The Education binder included a sign-in sheet that revealed the signatures of twenty Registered Nurses (RN) and Licensed Practical Nurses LPN) as attending the meeting on 7/9/24. Review of the EMR blood pressure history for R24 after 7/9/24 revealed: 7/18/24 at 12:54 AM - BP 177/70 mm hg - the next BP documented was taken on 7/20/24 at 9:49 AM, approximately 32 hours later, indicating no recheck was taken of a systolic finding above the 170 mm hg notification parameter. Furthermore, the finding on 7/20/24 was 176/86. The next BP documented approximately 24 hours later on 7/21/24 at 8:28 AM was 190/80 mm hg with no rechecks or EMR entries found that the provider had been notified. The BP history continued to reveal blood pressure results outside the notifying parameters on 7/26/24 (190/78), 7/28/24 (170/91), 7/30/24 (184/86), 7/31/24 (171/76), and another five elevated BPs until 8/15/24 at 8:30 AM when a BP finding of 178/111 is documented without a recheck until 8/16/24 at 9:00 AM which also was elevated at 180/83. On 8/19/24 at 8:28 AM a BP of 204/91 is documented without a recheck until 9:57 PM, more than 13 hours later. Review of the EMR did not reflect any nursing documentation of red bell alerts or that BPs were rechecked or that the provider had been contacted and tasks completed consistent with the Objectives/ Content of the education that was provided on 7/9/24. On 9/11/24 at 11:58 AM an interview was conducted with the DON in the DON office. The DON was informed a review of the blood pressure history of R24 had been completed. The DON was asked about the elevated blood pressures and the lack of physician notification and the absence of documented recheck blood pressures. The DON reported the facility uses a texting system and that the medical providers were likely notified through this. The DON indicated she expects a blood pressure be rechecked after a finding outside of the normal parameters. The DON reported she will review for physician notifications and provide an update. On 9/11/24 at 1:43 PM the DON reported that the texting communications to the medical providers could not be obtained. The DON did not indicate that the texting communications were consistent with the protocols and documentation that were reviewed at the education meeting of 7/9/24. However, the DON reported recheck blood pressures should be documented in the EMR. On 9/11/24 at 12:44 PM Registered Nurse (RN) I reported if a blood pressure is obtained outside of the notifying parameters, she would assess the resident, recheck the blood pressure, and notify the physician if the blood pressure remained elevated. On 9/11/24 at 12:45 AM Licensed Practical Nurse (LPN) H reported she would recheck an elevated blood pressure and contact the medical provider if needed. On 9/11/24 at 12:49 PM RN D reported she would recheck the blood pressure and check to see if the resident had any (as needed) medication for blood pressure control, then notify the (medical) provider for further direction. As of survey exit no further pertinent information or documentation was provided by the facility. 45410 Resident #23 Review of an Admission Record revealed Resident #23 (R23) admitted to the facility on [DATE] with pertinent diagnoses which included chronic obstructive pulmonary disorder and dementia. Further review revealed Family Member P to be R23's designated emergency contact. Review of a Minimum Data Set (MDS) assessment for R23, with a reference date of 6/22/2024 revealed a Brief Interview for Mental Status (BIMS) score of 13, out of a total possible score of 15, which indicated R23 was cognitively intact. Review of R23's Nurses Notes, dated 9/9/2024 at 11:38 AM, revealed the medical provider ordered an x-ray to rule out pneumonia. Review of R23's Physician's Orders revealed an order for doxycycline hyclate oral capsule 100 mg's, written 9/10/2024 at 6:35 AM, with instructions to take 1 capsule two times a day for pneumonia. In an interview on 9/11/2024 at 10:35 AM, Staff Development RN E reported the medical provider ordered doxycycline for R23 on 9/10/2024 after his chest x-ray resulted positive for pneumonia. Staff Development RN E reported she was not aware whether R23's emergency contact had been notified of this change in condition. In a telephone interview on 9/11/2024 at 11:02 AM, Family Member P reported she was not aware of R23's pneumonia diagnosis and treatment and she would like to have been contacted by the facility about this. In an interview on 9/11/2024 at 11:28 AM, R23 reported he had not notified Family Member P of his pneumonia diagnosis and treatment, and he preferred the facility to keep Family Member P informed of things like this. In an interview on 9/11/2024 at 10:47 AM, the Director of Nursing (DON) reported she was not aware whether R23's emergency contact had been notified of his pneumonia diagnosis and treatment. The DON reported the nurse who placed the antibiotic order on 9/10/2024 should have notified Family Member P and documented this in a progress note. The DON was unable to find documentation that Family Member P had been notified of this change of condition. Review of facility policy/procedure Notification of Changes, revised 8/29/2024, revealed .The facility must inform the resident, consult with the resident's physician and/or notify the resident's family member or legal representative when there is a change requiring such notification . Circumstances requiring notification include . Accidents . Significant change in the resident's physical, mental or psychosocial condition such as deterioration in health, mental or psychosocial status . Circumstances that require a need to alter treatment . Additional considerations . Competent individuals . The facility must still contact the resident's physician and notify resident's representative .

This Citation pertains to Intake Number MI00140074. Based on interview and record review, the facility failed to 1.) Ensure that pressure injury/wound assessments were complete and accurate, 2.) Ensure that wound treatments were ordered and completed, and 3.) Ensure that wound treatments and care planned interventions were reviewed/revised following the worsening of a wound for 6 of 8 residents (Resident #5, Resident #12, Resident #13, Resident #14, Resident #19, and Resident #20) reviewed for alterations in skin integrity/pressure ulcers, resulting in incomplete and inaccurate wound assessment and a delay in wound treatment. Findings include: Resident #5 (R5): Review of an Admission Record revealed R5 was an [AGE] year-old male, admitted to the facility on [DATE]. Review of R5's preadmission Wound, Ostomy, & Continence Nurse note dated 10/3/24 revealed, Right Ischium (buttock), stage II pressure injury, which was a blister, area measures 2.2 x 2.4 x 0.1 cm, without tunneling or undermining. Wound bed with pink base .Left Ischium (Buttock), stage II pressure injury, which appears to have a shear component given the irregular margins and peeling skin, area measures 1.2 x 1.1 x 0.1 cm, without tunneling or undermining. Wound bed with pink base .Sacrococcygeal with deep tissue injury present. Area is a deep purple/maroon, intact and without exudate. Measures 0.8 x 0.8 cm. Peri area is red and blanchable with notable superficial shearing distally . Treatment: Bilateral Ischium's & Sacrococcygeal: Cleanse with saline; apply silicone bordered foam dressing (Mepilex Foam sacrum) over wound 2 fingerbreadths above anus. Change dressing every 3 days and prn (as needed) . Indicating R5 had 3 pressure injuries prior to his admission to the facility. Review of R5's Order Summary dated 10/6/23 revealed, Cleanse buttocks with NS, par dry. Apply Mepilex to open area Q 3 days and prn for wound care one time a day every 3 day(s) for wound care for 3 Days -Start Date-10/07/2023. Review of R5's Treatment Administration Record revealed the wound treatment was not completed on 10/10/23 (was documented as completed on 10/7/23). Review of R5's Nursing Admission Evaluation-Part 1 (Section V-Skin) dated 10/6/23 revealed Moisture Associated Skin Damage (MASD) to R5's sacrum, right buttock, and left buttock. Review of the section C. Skin Related Care Plans revealed care planned interventions related to Risk of Skin Impairment were initiated but interventions for Impaired Skin were left blank. Review of the section D. Skin Related Tasks revealed the tasks floating heels, heels up cushion, pressure redistribution device to chair, pressure redistribution foot device, pressure redistribution mattress to bed, and turn and reposition per care plan and as needed were left blank. (MASD is irregular in shape and affects moist, friction-prone areas. Pressure injuries will have defined edges and will be over a bony prominence.) Review of R5's Skin & Wound Evaluations (x 3) dated 10/6/23 revealed MASD to coccyx, MASD to left gluteus, and MASD to sacrum. The Nursing Admission Evaluation-Part 1 and Skin & Wound Evaluations reflected the licensed nurse inaccurately identified/staged R5's skin injuries and/or did not complete a thorough admission assessment utilizing the Wound, Ostomy, & Continence Nurse consultative assessment and recommendations. Review of R5's Skin assessment dated [DATE] revealed, Coccyx-quarter size pressure wound of superficial skin. Redness noted. No Drainage. There were no wound measurements included in the assessment. Review of R5's Nurses' Note dated 10/7/23 revealed, .Coccyx has quarter size pressure wound with redness surrounding area . Review of R5's Electronic Health Record revealed no documentation that R5's emergency contact/wife was notified of the worsening/deterioration of the skin injury. There was no treatment change made. R5's initial assessment of the breakdown was documented as MASD. This assessment indicated there was a deterioration of R5's skin injury from MASD to a stage II pressure injury. (Stage II pressure injury is a partial thickness loss of dermis (skin) presenting as a shallow open ulcer with red and/or pink wound bed.) Review of R5's Hospital Records dated 10/11/23 revealed, .Coccyx , unstageable, pressure injury, measuring 0.6 x 1.2 x 0.1 cm, without tunneling or undermining. Wound bed is obscured of yellow slough tissue. Left Ischium stage III pressure injury, area measures 1.2 x 1.1 x 0.1 cm, without tunneling or undermining. Wound bed with a mix of yellow and pink tissue . Confirming the presence stageable pressure injuries at the time of R5's hospital transfer. Resident #12 (R12): Review of an Admission Record revealed R12 was an [AGE] year-old female, admitted to the facility on [DATE]. Review of R12's Wound Evaluations from 5/1/24-6/1/24 revealed: *5/1/24 no measurements were documented *5/8/24 no depth was documented *5/13/24 no depth was documented *5/15/24 no depth was documented R12's wound assessments on 5/22/24 and 5/29/24 included a depth measurement confirming the wound had a measurable depth. Review of R12's Order Details revealed, Wash sacrum with wound wash and pat dry. Sprinkle collagen particles into wound bed, Apply skin prep to surrounding tissue and cover with silicone pad dressing daily and prn until healed. everyday shift for wound -Start Date- 4/11/2024. Review of R12's June Treatment Administration Record revealed R12's wound treatment was not completed on 6/6/24. Review of R12's Electronic Health Record revealed no documentation regarding a rationale for the incomplete wound assessment and/or wound treatments. Resident #13 (R13): Review of an Admission Record revealed R13 was a [AGE] year-old male, admitted to the facility on [DATE]. Review of R13's Order Details dated 6/6/24 revealed, Cleanse Stage II to coccyx with NS (normal saline), pat dry. Apply hydrogel and cover with island drsg (dressing) daily and prn (as needed) one time a day for Stage II present on admit with a start date of 6/7/24 and end date 6/10/24. Indicating the wound treatment was not ordered on the date of his admission (6/5/24). Review of R13's June Treatment Administration Record revealed R13's did not have a dressing change on 6/6/24. Review of R13's Order Details dated 6/10/24 revealed, Cleanse Stage II to coccyx with NS, pat dry. Apply xeroform. one time a day for Stage II present on admit with a start date of 6/11/24. Review of R13's June Treatment Administration Record revealed R13's did not have a dressing change on 6/9/24. Resident #14 (R14): Review of an Admission Record revealed R14 was a [AGE] year-old male, admitted to the facility on [DATE]. Review of R14's Order Details dated 3/27/24 revealed, Cleanse sacrum with wound wash and pat dry. Apply collagen, cover with telfa and secure with small amount of tape. every day shift for wounds AND as needed for wound with a start date of 3/28/24 and end date of 5/9/24. Review of R14's May Treatment Administration Record revealed the ordered treatment was not completed on 5/4/24. Review of R14's Order Details dated 5/9/24 revealed, Cleanse sacrum with wound wash and pat dry. Apply xeroform to wound bed, cover with bordered foam. Change daily and as needed every day shift for wounds AND as needed for wound with a start date of 5/10/24 and end date 5/30/24. Review of R14's May Treatment Administration Record revealed the ordered treatment was not completed on 5/18/24 or 5/20/24. Review of R14's Wound Evaluations from 5/1/24-6/1/24 revealed: *5/1/24 no depth measurement was documented *5/7/24 no length, width, or depth measurement was documented *5/21/24 no depth measurement was documented *6/4/24 no depth measurement was documented Review of R14's Electronic Health Record revealed no documentation for a rationale for the missed wound treatments and/or incomplete measurements. Resident #19 (R19): Review of an Admission Record revealed R19 was a [AGE] year-old female, admitted to the facility on [DATE], with pertinent diagnoses which included: pressure ulcer of sacral region-unstageable. Review of R19's Skin & Wound Evaluation dated 5/30/24 revealed R19 had an unstageable pressure injury on her intergluteal cleft present on admission. No wound measurements were documented (length, width, depth, or area). Review of R19's Order Details revealed, For sacrum wound, cleanse with dermal wound cleanser, apply nystatin powder to periwound skin and dab only with no sting skin prep to all periwound skin and allow to dry. DO NOT WIPE. Apply medihoney to wound base. Gently pack wound with 1/4 sheet of alginate, cover with allevyn life. NO saline moistened gauze, wound is too wet. in the afternoon for sacral wound -Start Date- 05/22/2024 Review of R19's June Treatment Administration Record revealed R19's wound treatments were not completed on 6/7/24 and 6/9/24. Review of R19's Electronic Health Record revealed no documentation regarding a rationale for the incomplete wound assessment and/or wound treatments. Resident #20 (R20): Review of an Admission Record revealed R20 was a [AGE] year-old female, admitted to the facility on [DATE], with pertinent diagnoses which included: pressure ulcer of sacral region stage 4. Review of R20's Order Details revealed, Per Wound Clinic Recommendations: Coccyx Wound: cleanse with wound cleanser, apply skin prep peri wound, place prisma to wound base, then fill void with aquacell, cover with bordered foam dressing daily. one time a day Ok to use equivalent dressing treatments -Start Date- 03/09/2024. Review of R20's May Treatment Administration Record revealed the wound treatment was not completed on 5/4/24, 5/19/24, or 5/26/24. Review of R20's June Treatment Administration Record revealed the wound treatment was not completed on 6/2/24 or 6/9/24. Review of R19's Electronic Health Record revealed no documentation regarding a rationale for the missed wound treatments. During an interview on 6/11/23 at 10:08 AM, Nursing Home Administrator (NHA) reported the facility had 3 Unit Managers that were wound certified and completed weekly wound evaluations. NHA reported the wound evaluations included a picture of the wound, description of the wound, and measurements following standards of care. During an interview on 06/11/2024 at 12:11 PM, Unit Manager (UM) F reported that she and the other Unit Managers worked together managing the wound program at the facility. UM F did not recall R5 specifically but reported the wound management program included initial wound assessments, initiation of treatments, and implementation of care planned interventions. UM F reported that when a resident is admitted to the facility the licensed floor nurses are responsible for completing the nursing assessment and transcribing the ordered medications and treatments into the electronic health record. UM F reported that the managers were responsible for ensuring all medications and treatments were ordered and/or reconciled for new admissions and readmissions. UM F reported that if a resident was admitted late on a Friday or over the weekend then the Unit Managers would ensure all medication and treatment orders were reconciled/ordered when they returned to the building on the following Monday and concluded that that was why there may have been a delay in R13's treatment order. UM F reported that the licensed floor nurses were responsible for the weekly skin assessments which would include notification to the provider, family/guardian, and management if a new skin injury was identified. UM F reported the unit managers were responsible for the weekly wound assessments, measurements, and wound pictures. UM F confirmed that the facility utilized a camera that would upload the picture the health record and would also measure the length and width of the wound. UM F reported the depth of a wound could not be captured by the camera and had to be measured by the unit managers and documented in the Skin & Wound Evaluations. UM F reported that the licensed floor nurses were responsible for completing wound treatments if they were scheduled during their shifts. UM F reported that if a treatment was not completed it should be documented in the Treatment Administration Record with a rationale. UM F reported R14 was not one to refuse treatment but did have a preference for the time of day it was completed. UM F reported that she was not aware that treatments were not being completed as ordered and reported that the unit managers were not currently completing audits on ordered treatments. During an interview on 6/11/24 at 2:55 PM, Director of Nursing (DON) confirmed R12, R13, R14's missed treatments in the Treatment Administration Records and reported she would review the resident's charts and provide a basis if able. During an interview on 6/11/24 at 5:00 PM, NHA and DON reported that the expectation for the licensed nurses was to complete all treatments as ordered and document in the electronic health record any refusals and/or missed treatments as well as ensuring complete and accurate assessments. Requested documentation/follow-up related to the incomplete wound treatments and/or wound assessments for R12, R13, and R14 via email on 6/11/24 at 1:00 PM. No additional documentation was received regarding the above listed treatments and/or wound evaluations prior to survey exit. Review of the facility policy Pressure Injury Prevention and Management last reviewed/revised 1/1/22 revealed, .2. The facility shall establish and utilize a systematic approach for pressure injury prevention and management, including prompt assessment and treatment; intervening to stabilize, reduce or remove underlying risk factors; monitoring the impact of the interventions; and modifying the interventions as appropriate. 3. Assessment of Pressure Injury Risk a. Licensed nurses will conduct a pressure injury risk assessment, using the [NAME] or Braden tool on all residents upon admission/re-admission, weekly x four weeks, then quarterly or whenever the resident's condition changes significantly. b. Licensed nurses will conduct a full body skin assessment on all residents upon admission/re-admission, weekly, and after any newly identified pressure injury. Findings will be documented in the medical record. c. Assessments of pressure injuries will be performed by a licensed nurse and documented in the medical record .4. Interventions for Prevention and to Promote Healing a. After completing a thorough assessment/evaluation, the interdisciplinary team shall develop a relevant care plan that includes measurable goals for prevention and management of pressure injuries with appropriate interventions .e. The goals and preferences of the resident and/or authorized representative will be included in the plan of care. f. Interventions will be documented in the care plan and communicated to all relevant staff. 5. Monitoring a. The attending physician will be notified of i. The presence of a new pressure injury upon identification. ii. The progression towards healing, or lack of healing, of any pressure injuries weekly. iii. Any complications (such as infection, development of a sinus tract, etc.) as needed. b. The effectiveness of current preventative and treatment modalities and processes will be discussed in accordance with the QAA Committee Schedule, and as needed when actual or potential problems are identified. 6. Modifications of Interventions .b. Interventions on a resident's plan of care will be modified as needed. Considerations for needed modifications include: i. Changes in resident's degree of risk for developing a pressure injury. ii. New onset or recurrent pressure injury development. iii. Lack of progression towards healing . Review of Fundamentals of Nursing ([NAME] and [NAME]) 10th edition revealed, The health care record is a valuable source of data for all members of the health care team. Data entered into the health care record serve many purposes, including facilitating interprofessional communication among health care providers, providing a legal record of care provided, justification for financial billing and reimbursement of care. Data are also used to audit, monitor, and evaluate care provided to support the process needed for quality and performance improvement. [NAME], [NAME] A.; [NAME], [NAME] Griffin; Stockert, [NAME] A.; Hall, [NAME]. Fundamentals of Nursing - E-Book (p. 366). Elsevier Health Sciences. Kindle Edition. Review of Fundamentals of Nursing ([NAME] and [NAME]) 10th edition revealed, Review of Fundamentals of Nursing ([NAME] and [NAME]) 10th edition revealed, Record the results of the nursing health history and physical examination in a clear, concise manner using appropriate terminology. This information becomes the baseline to identify a patient's nursing diagnoses and health problems, to plan and implement care, and to evaluate a patient's response to interventions . The Nurse Practice Acts in all states and the American Nurses Association Nursing's Social Policy Statement (ANA, 2010) require accurate data collection and recording as independent functions essential to the role of the professional nurse. [NAME], [NAME] A.; [NAME], [NAME] Griffin; Stockert, [NAME] A.; Hall, [NAME]. Fundamentals of Nursing - E-Book (p. 222). Elsevier Health Sciences. Kindle Edition.

This Citation pertains to Intake Number MI00140074 Based on interview and record review, the facility failed to follow professional standards of nursing practice for medication administration for 4 of 8 residents (Resident #10, Resident #8, Resident #15, and Resident #17), reviewed for the provision of nursing services, resulting in medication errors and medications being administered outside of the physician-ordered parameters. Findings include: Resident #10 (R10): Review of an Admission Record revealed R10 was an [AGE] year-old male, admitted to the facility on [DATE], with pertinent diagnoses which included: Diabetes type II. Review of R10's Order Details dated 4/2/24 revealed, Insulin Glargine Solution 100 UNIT/ML Inject 12 unit subcutaneously two times a day for diabetes Hold if bs (blood sugar) less than 110. Review of R10's Medication Administration Record and Blood Sugar Summary revealed: * On 5/1/24 at 8:16 AM R10 had a blood sugar of 89 and the insulin was administered. * On 5/3/24 at 7:47 AM R10 had a blood sugar of 68 and the insulin was administered. * On 5/7/24 at 8:14 AM R10 had a blood sugar of 93 and the insulin was administered. * On 5/14/24 at 7:47 AM R10 had a blood sugar of 96 and the insulin was administered. * On 5/18/24 at 6:47 AM R10 had a blood sugar of 92 and the insulin was administered. * On 5/22/24 at 7:50 AM R10 had a blood sugar of 62 and the insulin was administered. * On 5/31/24 at 8:10 AM R10 had a blood sugar of 90 and the insulin was administered. * On 6/2/24 at 7:24 AM R10 had a blood sugar of 78 and the insulin was administered. * On 6/6/24 at 7:16 AM R10 had a blood sugar of 76 and the insulin was administered. Resident #8 (R8): Review of an Admission Record revealed R8 was an [AGE] year-old female, admitted to the facility on [DATE], with pertinent diagnoses which included: hypertension (high blood pressure). Review of R8's Order Details dated 4/4/24 revealed, Metoprolol Succinate ER Oral Tablet Extended Release 24 Hour 25 MG (Metoprolol Succinate) Give 0.5 tablet by mouth one time a day for hold if sbp (systolic blood pressure) less than 100 or pulse less than 60. Review if R8's Medication Administration Record, Blood Pressure Summary, and Pulse Summary revealed: *On 6/3/24 at 7:44 AM R8 had a heart rate of 50 and the Metoprolol was administered. *On 6/10/24 at 8:06 AM R8 had a blood pressure of 80/48 and the Metoprolol was administered. Resident #15 (R15): Review of an Admission Record revealed R15 was an [AGE] year-old female, admitted to the facility on [DATE], with pertinent diagnoses which included: neuropathy (nerve pain). Review of R15's Order Details dated 3/25/24 revealed, Gabapentin Capsule 300 MG (Gabapentin) *Controlled Drug* Give 1 capsule by mouth three times a day for Neuropathy. (Note that Gabapentin is no longer classified as a controlled substance in the state of Michigan. However, the facility licensed nurses were continuing to sign out the Gabapentin following the previous guidelines). Review of R15's Control Substance Record revealed on 6/9/24 at 1:55 PM a dose of Gabapentin was documented as removed/administered and at 8:30 PM a dose of Gabapentin was documented as removed/administered. This was confirmed due to the correct amount remaining of Gabapentin reflected on the Control Substance Record. (Nurses are required to account for each capsule removed from the residents dispensed medication by counting the remaining number of capsules at shift change.) Review of R15's June Medication Administration Record revealed all 3 doses of Gabapentin were documented as administered on 6/9/24. Review of R15's Electronic Health Record revealed no documentation that a dose of Gabapentin was held and/or a provider order to hold Gabapentin on 6/9/24. Resident #17 (R17): Review of an Admission Record revealed R17 was a [AGE] year-old female, admitted to the facility on [DATE], with pertinent diagnoses which included: chronic pain syndrome. Review of R17's Order Details dated 2/29/24 revealed, Neurontin Capsule 300 MG (Gabapentin) *Controlled Drug* Give 300 mg by mouth three times a day. Review of R17's Control Substance Record revealed: *On 6/2/24 at 8:00 AM a dose of Gabapentin was documented as removed/administered and at 8:40 PM a dose of Gabapentin was documented as removed/administered. *On 6/7/24 at 8:00 AM a dose of Gabapentin was documented as removed/administered and at 9:19 PM a dose of Gabapentin was documented as removed/administered. *On 6/8/24 at 8:00 AM a dose of Gabapentin was documented as removed/administered and at 8:37 PM a dose of Gabapentin was documented as removed/administered. Confirmed due to the correct amount remaining of Gabapentin reflected on the Control Substance Record. Review of R17's June Medication Administration Record revealed all 3 doses of Gabapentin were documented as administered on 6/2/24, 6/7/24, and 6/8/24. Review of R17's Electronic Health Record revealed no documentation that Gabapentin was held and/or a provider order to hold Gabapentin on 6/2/24, 6/7/24, and 6/8/24. During an interview on 06/10/2024 at 10:53 AM, Registered Nurse (RN) E reported that controlled medications were signed out of the Control Substance Record at the time they were removed from the residents medication and signed out of the Electronic Health Record after they were administered. During an interview on 6/11/24 at 5:00 PM, Director of Nursing (DON) confirmed the medication errors for R15 and R17 Gabapentin. DON confirmed that R10 and R8 received medications outside of the physician ordered parameters and reported the expectation for the licensed nurses was to ensure medications were administered and/or held following the provider orders. Review of the facility policy Medication Administration last reviewed/revised 1/17/23 revealed, .8. Obtain and record vital signs, when applicable or per physician orders. When applicable, hold medications for those vital signs outside the physician's prescribed parameters .17. Sign MAR after administered. For those medications requiring vital signs, record the vital signs onto the MAR. 18. IF medication is a controlled substance, sign narcotic book . Review of Fundamentals of Nursing ([NAME] and [NAME]) 10th edition revealed, (Nurses) are responsible for documenting any preassessment data required of certain medications such as a blood pressure measurement for antihypertensive medications or laboratory values, as in the case of Warfarin, before giving the medication. [NAME], [NAME] A.; [NAME], [NAME] Griffin; Stockert, [NAME] A.; Hall, [NAME]. Fundamentals of Nursing - E-Book (p. 609). Elsevier Health Sciences. Kindle Edition. Review of Fundamentals of Nursing ([NAME] and [NAME]) 10th edition revealed, Legal Guidelines for Documentation . Errors in recording can lead to errors in treatment or may imply an attempt to mislead or hide evidence . Record must be accurate, factual, and objective. Be certain that each entry is thorough. A person reading your documentation needs to be able to determine that a patient received adequate care. [NAME], [NAME] A.; [NAME], [NAME] Griffin; Stockert, [NAME] A.; Hall, [NAME]. Fundamentals of Nursing - E-Book (p. 366). Elsevier Health Sciences. Kindle Edition.

This citation pertain to Intakes MI 241 and MI 781. Based on observations, interview, and record review the facility failed to provide adequate supervision to prevent injury for 5 residents (R1, R2, R4, R5 and R6) resulting in ongoing fear and emotional distress, bruises, and the potential for serious harm. Findings included: R2 Review of R2's face sheet dated 10/5/22 revealed she was an [AGE] year-old female admitted to the facility on [DATE] and had diagnoses that included: nontraumatic intracerebral hemorrhage (brain damage), dementia, [CONDITION(S)] with hallucinations due to known physiological condition, restlessness, and agitation. She was not her own responsible party. R2 was observed on 10/4/22 at 11:51 AM on the A hall going in and out of resident's rooms. R2's room was on the E hall and was not in eyesight of A hall. Staff were not in observance of R2. On 10/4/22 Certified Nurse Aide (CNA) C said she was working on the E hall and came to get R2 to take her to lunch (R2's room was currently on E hall). CNA C said she tries to keep an eye on R2, but she has 12 residents to care for and when she goes into resident rooms, she is not able to keep track of R2. On 10/5/22 at 7:04 AM R2 was observed in the main entry of the building. No staff were observed at the main entry or in eyesight of R2. During an interview with CNA C on 10/5/22 at 7:10 AM, CNA C said R2 was sent to the hospital last night and returned to the facility. CNA C said R2 had been up in her wheelchair since 6:30 AM. CNA C was questioned about how R2 was supervised when she was up in her wheelchair and CNA C said she does her best to watch her when she is on E hall but when R2 goes past the lobby area it is up to facility staff to supervise her. CNA C said she was the only caregiver on E hall at this time. CNA C did not indicate there was a incidence with R2 or any reason for her being sent to the hospital the evening of 10/4/22. During an interview with Registered Nurse (RN) G on 10/5/22 at 7:20 AM, RN G said she had cared for R2 frequently. RN G reported that R2 was no longer easily redirectable. RN G revealed R2's husband used to be able to calm her down and now that does not routinely work. RN G said the facility does not a have any program or low stimulation room available for the care of dementia patients. RN G said the facility does their best to intervene when they know a resident is escalating in behavior, but R2 is unpredictable. RN G said staff are not always successful at redirecting R2 when she does become agitated so R2 is very difficult to keep R2 and other residents safe. R6 Review of R6's face sheet dated 10/5/22 revealed she was a [AGE] year-old female admitted to the facility on [DATE] and had diagnoses that included: multiple fractures of ribs, displaced fracture of lateral end of right clavicle, laceration without foreign body of right forearm, muscle weakness, cognitive communication deficit and presence of cardiac pacemaker. She was her own responsibility party. During an interview on 10/05/22 at 9:17 AM, R6 said that R2 had a history of coming into her room and getting candy out of the bowl on her nightstand. R6 said the candy was for everyone so it was not a problem. R6 said R2 came in her room the night before, on 10/4/22, and staff told her R2 could not come in her room and said they should keep the door closed to keep R2 out of her room. R6 said a short time after that around 7:00 PM to 7:30 PM, she did not hear R2 enter the room but R2 was in her room again. R2 wanted R6 to go somewhere with her. R6 said she lied to R2 and tried to get R2 to leave by saying 'I have company coming so I cannot go'. When R6 would not go with R2, R2 grabbed her by both wrists. R6 said she could not get away and when staff came in they physically had to remove R2's hands from her wrists before taking R2 out of R6's room. R6 felt bad for R2 because she had been allowing her to come in her room to get candy. R6 was aware after the incident that R2 was sent to the hospital. R6 said she was not afraid of R2 because she understood she was confused. R6 said she did not sleep well because she was worried about R2. R6 said now she understood why staff wanted to keep R2 out of her room as she said she was not strong enough to get R2 to let go of her. R6 held out her right arm and pointed to a red bruise on the back of her arm about 6 inched above her wrist that was about the size of a quarter. R6 had at approximately 5 other dime size bruises on her right arm. R6 said this bruise was new one today and was not there prior to R2 grabbing her. R6 said she bruises very easy and did want R2 to get into any trouble. Review of a Statement of Witness dated 10/4/22 (no time) revealed Registered Nurse (RN) H interviewed Certified Nurse Aide (CNA) I about R2. The note revealed, I saw R2 in the room of R6. Holding two wrist and talking. I came directly take (sp) R2 out of the room of R6. Take (sp) slowly and gently take her two hands. On 10/5/22 at 9:45 AM, the Surveyor asked the Nursing Home Administrator (NHA) A how they tracked resident to resident altercations and where in the medical record this information was located along with interventions that had been implemented to prevent any further incident. NHA A said she had only been working at the facility a few months and was not aware of any way to track resident to resident altercations in the medical record. The NHA offered to have her staff do a timeline for resident-to-resident altercations for R2 for the last year with interventions placed to prevent further incidents. NHA A said R2 had another resident-to-resident altercation on 10/4/22 and she had reported this altercation to the State in the FRI (facility reported incident) system around 8:30 AM. The NHA said it was still under investigation and the facility had not implemented any new interventions to prevent resident to resident altercations as of this time. The surveyor requested copies of all information the facility had regarding the investigation of the resident-to-resident altercation on 10/4/22 between R2 and R6. Upon exit, the facility provided a document that they had submitted a FRI on 10/5/22 at 8:34 AM, however the report did not give any resident names or information as to why they reported a FRI. The timeline provided by the facility indicated R2 had resident-to-resident altercations that occurred on 4/30/22, 8/28/22 and 10/5/22. The timeline documented multiple interventions placed on R2's care plan related to her behaviors. After each resident-to-resident altercation R2 was temporarily placed on 1:1 supervision. No reason was provided as to why the 1:1 supervision was stopped. During an interview with NHA A on 10/5/22 at 1:00 PM the facility timeline for R2 was reviewed. The NHA was asked how the facility assesses the effectiveness of behavior care plans after resident-to-resident altercations. The NHA said they meet daily to review behaviors. R2's behavior notes were reviewed and revealed 1:1 supervision was last discontinued on 9/16/22. Multiple entries of aggressive and wandering behaviors were noted after 9/16/22 and there was no indication R2 was under any type of supervision that would ensure she would be supervised around other residents. The NHA was unable to locate any intervention that kept R2 supervised around other residents and prevented her from wondering into other resident's rooms. R2 had a known altercation with R6 on 10/4/22 around 7:00 PM and appropriate supervision was not put in place after R2 returned from the hospital following a resident to resident incident. Review of the State Mi-FRI reporting system revealed the facility submitted a FRI for a resident to resident altercation between R2 and R6 on 10/5/22 at 7:15 AM, for an incident that occurred on 10/4/22 at 7:30 PM. Under Incident Summary revealed, Contact was made between two residents, Residents denying abuse. Staff immediately intervened. Investigation initiated. Review of a care plan provided with the timeline for R2 revealed, R2 has little or no activity involvement r/t (related to) Dementia, Disinterest. R2 has hx (history) of becoming physical to which Activity Director will redirect with activities of R2's choosing. Date initiated 4/10/22. Two interventions were started. may contact husband to help de-escalate mood and behaviors. Date initiated 8/29/22 and Resident to be offered 1:1 evening activity by staff or family member as resident allows. Date initiated 8/29/22. Review of the State Mi-FRI system revealed R2 had 4 reported Resident to Resident altercations in the last year. One 12/6/21 at 7:45 PM with R4, one on 4/30/22 at 2:05 PM with R5, one on 8/28/22 at 6:30 PM with R1 and one on 10/4/22 at 7:30 PM with R6. Review of R2's medical record did not reveal a history of R2 having multiple physical altercation and altercations in other residents rooms over the last year. Review of R2's care plan did not reveal any history of resident-to-resident altercations. Review of an incident report (internal facility document) for R2 dated 7/24/22 at 12:50 PM revealed R2 was witnessed reaching for another resident's food in the dining room and pushing the other residents hand away. The other resident involved was only identified as Resident B. Review of the Mi-FRI system revealed there was no FRI for the incident on 7/24/22 at 12:50 PM for the altercation at meal time between R2 and an unknown resident B. R1 Review of R1's face sheet revealed she was a [AGE] year-old female admitted to the facility on [DATE] and had diagnoses that included: multiple [CONDITION(S)], neuromuscular dysfunction of the bladder, major depressive disorder, and [CONDITION(S)]. R1 was her own responsible party. Review of an incident report (internal facility document) for R1 dated 8/28/22 at 6:10 PM, revealed, This resident reported to staff that another resident entered her room and hit her upper left arm multiple times. Patient used call light for staff assistance. The other resident was removed from this resident's room and was assessed. Upon assessment resident stated 'you don't need to check me out; I am fine, she didn't hurt me, she just scared me'. Patient assessed and No injuries noted upon assessment. Under Immediate Action Taken, staff wrote, The other resident was removed from this resident's room. Police were called to speak to this resident about altercation. This resident notified her emergency contact and son came to bedside. DON (director of nursing), Administrator, and Physician notified. Immediate intervention was to place stop sign on resident's door. This document revealed R1 was oriented to person, place, time, and situation. There was no way to identify who the resident was at hit R1 multiple times. During an interview with R1 on 10/4/22 at 2:38 PM, R1 recalled the incident that was documented as occurring on 8/28/22 at 6:10 PM. R2 was only able to identify the resident that hit her by first name. The name R1 provided was the same first name as R2. R1 said R2 has been in her room several times since the incident on 8/28/22. R2 said she is not able to sleep well since the incident. R1 said her son installed an alarm over her door so she can tell when someone enters her room. R1 said she is blind so she cannot see when people come in her room. R1 said when staff enter her room, they call out first. R1 said if the person does not answer, or she hears R2's voice she puts on her call light and starts yelling. R1 said staff are faster to come now and R2 has not hit her since 8/28/22. R1 said she called the police on 8/28/22 but they said they cannot do anything because R2 is confused, and a judge would throw the case out. Review of a facility reported incident (FRI) located in the State reporting system dated incident discovered 8/28/22 at 6:45 PM revealed. There was a resident-to-resident altercation with R1 and R2. The incident was not observed (R2 was not supervised when she was in R1's room). The report conclusion revealed, Upon thorough investigation the facility was unable to substantiate there was intent to cause harm. Facility staff reacted promptly after observing R2 exiting R1's room. R2 was able to be redirected away from R1 and was monitored at the nurse's station until her husband arrived for additional support. R1 was placed on 15-minute checks for 24 hours with no increase or change in behavior symptoms noted. Both residents were assessed with no pain or injuries noted. Resident responsible parties, physicians, and Police were notified. R4 Review of R4's face sheet dated 10/5/22 revealed he was a [AGE] year-old male, admitted to the facility on [DATE] and had diagnoses that included: [CONDITION(S)], dementia, difficulty in walking, and changes in retinal vascular appearance (vision problems). R4 was not his own responsible party. Review of the State reported incident dated, incident discovered 12/6/21 at 7:50 AM, revealed, in the incident summary, R4 was upset when R2 went into his room early in the morning and left, then returned and started going through his belonging (sp). He said he was protecting his property. R2 has a P.O.A. (power of attorney) related to having a Non-traumatic intracranial hemorrhage, Dementia, other diseases classed elsewhere with behavioral disturbance, and restlessness and agitation. She self-propels and is easily redirected. R2 went into R4's room early in the morning, started going through his belongings, left, then returned and was going to take a piece of candy. R4 does not like having anyone in his room, even staff to help care for him. He felt he needed to protect his room and personal belongings. To ensure another immediate occurrence does not happen, R4's door was closed, and a magnetic stop sign banner. R5 Review of R5's face sheet dated 10/5/22 revealed she was a [AGE] year-old female admitted to the facility on [DATE] and had diagnoses that included: [CONDITION(S)], diabetes mellitus with retinopathy (affecting vision), dysphagia (difficulty swallowing) and vascular dementia. She was not her own responsible party. Review of an incident report (internal facility document) for R2 dated 4/30/22 at 2:00 PM revealed R2 was in a resident-to-resident altercation in the hallway by the fish tank with R5. This resident-to-resident altercation was not witnessed. R2 was not being supervised at the time of this incident. The facility implemented 1:1 supervision after the incident. Review of a State reported incident (FRI) for R2 dated incident discovered 4/30/22 at 2:10 PM revealed there was a resident-to-resident altercation at that time with R2. The summary revealed, R2 was in the hallway headed towards the front hall. R2 grabbed R5's right arm and was pulling on it, accusing her of having her husband's phone number. I heard R5 yell stop it, ran to the area, CNA (certified nurse aide) was already there attempting to get R2's hands off R5's arm. Residents were immediately separated and R5's arm assessed, no injuries noted, no complaints of pain. The conclusion revealed, R2 continued to display verbal and physical behaviors toward staff after the occurrence and was placed on 1:1 supervision at the nurse's station. Physician was contacted and order received for R2 to be sent to ER (emergency room ) for psych (psychiatric) evaluation and medical work up due to her change in cognition and increased behaviors. R2 remained with a nurse until EMS (emergency medical services) arrived. All testing completed at the hospital was negative. Upon return R2 was reassessed and had returned to her cognitive and behavioral baseline.

Based on interview and record review, the facility failed to recognize an acute need for increased supervision and implementation of safety measures for one resident (Resident (R) 27) with escalating confusion and displays of at-risk behaviors, resulting in a fall with injury and the potential for all facility residents who are at risk for falls for delayed response to safety needs. Findings include: Review of the Electronic Medical Record (EMR) revealed R27 was originally admitted to the facility 7/21/21 with diagnoses that included Dementia, Alzheimer's Disease, and was Legally Blind. Review of the Minimum Data Set (MDS) dated [DATE] reflected a Brief Interview for Mental Status (BIMS) score of 4 out of 15 which indicated the Resident was severely cognitively impaired. Review of the facility document titled Fall RCA Investigation Tool reflected that on 4/11/22 at 3:31 PM a Therapy staff member saw R27 walking in the hall. The facility document reflected the Therapy staff member started walking toward R27 when the Resident began to gain speed shuffle stepping, tripped, and hit the left side of his head on the floor. The facility document reflected the Resident's wheelchair was 2 doors away at the time of the fall. The facility document reflected that R27's usual mental status and usual psychological status was normally not verbally aggressive, and a baseline of pleasantly confused/happy. The facility document reflected a statement by the primary staff member who observed and/or assisted the resident during the three hours prior to the fall that R27 was confused, seemed lost/wandering, irritable, and argumentative. The facility document reflected the root cause of the fall to be, walking in hallway without assistive device or staff assistance. The EMR Progress Notes for R27 were reviewed. The Progress Notes of 4/10/22 reflect R27 was under treatment for a Urinary Tract Infection ([CONDITION(S)]). The Progress Notes reflected serial documentation of escalating behaviors that began at 9:00 PM on 4/10/22 when R27 had displayed increased confusion and wondering (sic) around his room touching surfaces . The EMR Progress Notes reflected at 2:00 AM on 4/11/22, R27 was observed walking outside of the facility but was immediately brought back in by staff. The entry reflected R27 had reported he was going to the bank. At 7:30 AM on 4/11/22 the documentation of the EMR Progress Notes reflected (R27) on and off since (6:00 AM) has had periods of increased confusion with stumbling around and getting agitated and swearing. He has been coming out of his room and grabbing onto [brand name of mechanical lift device] and trying to walk it. Wandering into other resident rooms. At 9:33 AM on 4/11/22 the documentation of the EMR Progress Notes reflected R27 was wandering the halls, argumentative, agitated at times, overly tired. At 10:21 AM on 4/11/22 the documentation of the EMR Progress Notes reflected R27 was out and wandering without his walker, was agitated and swearing which is unusual for him. At 2:35 PM on 4/11/22 the documentation of the EMR Progress notes reflected, (R27) in hallway again outside his room without his walking (sic) using the rail on the wall to try and walk without falling. 2 staff ran to get his wheelchair and sit him back down. Patient still angry and arguing but ended up calming down without further incident. On 4/11/22 at 3:31 PM the documentation of the EMR Progress Notes Nurse entry reflected Was called to D hall for an emergency. Therapy assistant [name of this person] witnessed (R27) stumbling so she ran as quickly as she could to reach him, but she was unable to get to him fast enough. (R27) fell on the floor face first with his glasses on .R27) was in and out of responsiveness at that time . staff held C-spine (holding the head in a neutral position to prevent spinal cord damage or further spinal cord damage) until EMS (Emergency Medical Services) arrived to take over. During an interview conducted 6/29/22 at 2:52 PM the Director of Nursing (DON) reported R27 fell in front of staff who could not get to him in time to prevent the fall. The DON reported that the fall on 4/11/22 was the first fall R27 had at the facility. The DON indicated that there was no reason to implement increased safety measures for R27 until this fall. The documentation of the EMR Progress Notes reflected a severe change of mentation and behavior for R27 beginning on 4/10/22 at 9:00 PM. This EMR Progress Note entry reflected R27 had increased confusion and wandering in his room, and touching surfaces. The documented change in R27's behavior continued 4/11/22 when, at 2:00 AM, the EMR Progress Notes reflect R27 walked outside of the facility having to be retrieved by staff. Then, the EMR Progress Notes reflected at 7:30 AM and 9:33 AM that R27 was stumbling around, agitated, and overly tired. Then, at 10:21 AM on 4/11/22 the EMR Progress Notes reflect that R27 was wandering without his walker and displaying other behaviors that were unusual for him. At 2:35 PM the EMR Progress Notes reflect R27 was observed using the rail on the wall to try and walk without falling. Review of the medical record did not reveal, despite these documented persistent displays of confused and risky behaviors, that any measures were implemented to ensure the safety of R27. In the interview of 6/29/22 at 2:52 PM the DON reported that staff were present at the time of the fall but could not reach R27 quickly enough. This suggests that care staff were keeping R27 under observation. However, the documentation of the medical record and the Fall RSA Investigation Tool reflect that it was Therapy staff, someone not assigned to resident care, who had coincidently come upon the Resident as he was falling. The hospital Physician documentation, dated 4/11/22 at 5:52 PM, revealed R27 had sustained Subarachnoid hemorrhage (bleeding in the space between the brain and the tissue covering the brain), Intracranial contusion( bruising of the brain), Nasal bone fracture (broken nose), Left orbit fracture(broken bones around the eye), Left maxillary sinus fractures(most commonly caused by [MEDICATION(S)] force trauma), and Left eye contusion ([MEDICATION(S)] injury to the eye) as a result of the fall on 4/11/27.

Based on interview and record review, the facility failed to ensure professional standards were maintained by following and clarifying physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings: Resident #32 (R32) Review of an Admission Record reflected R32 admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Care Plan initiated on 10/30/21 reflected R32 had Altered Cardiovascular Status r/t (related to) [CONDITION(S)] (high blood pressure), peripheral [CONDITION(S)] with Hx (history of) ulcerations, CHF ([CONDITION(S)], CAD ([CONDITION(S)]), DM2 (type 2 diabetes). The goal of the care plan was that R32 would be free of cardiac complications and included the intervention Monitor VITAL SIGNS per protocol. Notify MD (physician) of significant abnormalities. Review of an incident report dated 1/30/22 at 12:15 AM, reflected R32 sustained a witnessed fall while attempting to self-transfer at the nurse station. According to the report, R32 appeared to become weak and slid down the wall. Orthostatic blood pressure was obtained and reflected R32's blood pressures were 103/57 when lying down, 83/56 when sitting and 88/55 while standing. According to the RCA (root cause analysis) Investigation Tool, orthostatic blood pressures changes contributed to the fall. The conclusion of the analysis was that Res (R32) experienced orthostatic [CONDITION(S)] (a form of low blood pressure that happens when standing up from sitting or lying down). Physician to review meds due to being on multiple cardiac meds/antidepressants, [NAME] BP's (orthostatic blood pressures) to be obtained x 3 days. Review of an incident report dated 1/30/22 at 10:00 AM, R32 sustained another witnessed fall when he self-transferred out of his wheelchair and proceeded to ambulate 15 feet down a hallway, falling down onto his buttocks before a staff person could assist him back into his wheelchair. R32's blood pressure was checked and measured 72/38. The Fall RCA Investigation Tool reflected R32 had low blood pressure and it was thought this was related to dehydration and intravenous fluids were ordered. The conclusion of the RCA was that R32 has decreased oral intake at times which may have caused fluid deficit and decreased blood pressure. Review of R32's January 2022 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the MAR, the medication was given as ordered twice on 1/29/2022 and in the morning on 1/30/22 despite the fall related to low blood pressure at 12:15 AM on 1/30/22. Further review of the MAR/TAR did not reflect entries reflecting blood pressure or pulse had been assessed as ordered by the physician prior to administration of the medication. Review of the Blood Pressure Summary for R32 reflected that prior to R32's fall on 1/30/22 at 12:15 AM, R32's blood pressure had no been assessed since 1/26/22 and was not recorded again until 1/31/22 after R32's second fall related to low blood pressure on 1/30/22 at 10:00 AM. Review of R32's MAR/TAR records from January 2022-June 29, 2022 reflected that the prescribed [MEDICATION(S)] Tablet 25 mg (milligram) Give 0.5 tablet by mouth two times a day related to UNSPECIFIED [CONDITION(S)] hold if SBP (systolic blood pressure) less than 100 and pulse less than 60 - start date 1/5/22 at 2000 (8:00 PM) had been given twice every day as ordered except on 3/16/22 at 8:00 PM due to a chart code indicating R32 was in the hospital; 4/18/22 due to a chart code indicating R32 was sleeping; 5/1/22 due to a chart code indicating R32 refused the medication. Further review of a Blood Pressure Summary for the date range 1/5/22-6/28/22 reflected R32's blood pressure was not being consistently assessed prior to the administration of the [MEDICATION(S)] Tablet 25 mg (milligram) Give 0.5 tablet by mouth two times a day related to UNSPECIFIED [CONDITION(S)] hold if SBP less than 100 and pulse less than 60 - start date 1/5/22 at 2000 (8:00 PM) as directed by the physician. During an interview on 6/29/22 4:18 PM, the Director of Nursing (DON), Regional Clinical Specialist, Registered Nurse (RN) B and Regional RN Consultant A confirmed the blood pressures were not being recorded and could not validate they had been taken consistently prior to the medication administration. The DON and RN A maintained that the blood pressure readings were a part of the medication administration function in the electronic health record and were given the opportunity to produce the information by the close of business on 6/30/22. As of 6/30/22, the facility had not produced evidence licensed nursing staff were evaluating vital sign parameters for R32 as prescribed by the physician prior to the administration of the [MEDICATION(S)]. Review of the Fundamentals of Nursing revealed, The health care provider is responsible to provide accurate, complete, and understandable medication orders .also responsible for documenting any preassessment data required of certain medications such as a blood pressure measurement for antihypertensive medications or laboratory values, as in the case of [MEDICATION(S)], before giving the medication. After administering a medication, immediately document which medication was given on a patient's MAR per agency policy to verify that it was given as ordered. Inaccurate documentation, such as failing to document giving a medication or documenting an incorrect dose, leads to errors in subsequent decisions about patient care. For example, errors in documentation about insulin often result in negative patient outcomes. Potter, Patricia A.; Perry, Anne Griffin; Stockert, Patricia A.; Hall, Amy. Fundamentals of Nursing - E-Book (p. 609). Elsevier Health Sciences. Kindle Edition. R27 Review of the Minimum Data Set (MDS) dated [DATE] reflected R27 was admitted to the facility 7/21/21 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Doctor's Orders (DO) for R27 reflected a current order entered 4/22/22 that gave instructions if the blood sugar of R27 was less than 60 and If blood sugar is greater than 400 notify (Doctor). Review of the EMR Blood Sugar Summary for R27 reflected on 6/29/22 at 9:45 AM, R27 had a documented blood sugar result of 450 milligrams per deciliter (mg/dL). Review of the EMR Progress Notes did not reveal the Doctor had been notified of the blood sugar greater than 400 as indicated by the DO initiated 4/22/22. Further review of the DO's for R27 revealed a conflicting order entered 4/21/22, the day before the DO directing the physician be notified for blood sugar results greater than 400. This older and conflicting DO revealed a sliding scale for [MEDICATION(S)] insulin which directs increasing doses based on blood sugar results. For example, according to the DO for R27 the Resident is to receive 6 units of Lispo insulin if a blood sugar result is 251 to 300 mg/dL. However, this DO revealed that if a blood sugar result greater than 451 mg/dL is obtained then the Doctor is to be notified. It was noted that no time of administration or time of the blood sugar checks were assigned to this DO in the Orders section of the EMR. The Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The entry for 6/29/22 at 7:00 AM revealed a blood sugar at that time of 450mg/dL with the administration of 12 units of [MEDICATION(S)] insulin. Review of the EMR did not reveal documentation of why a blood sugar was obtained at 9:45 AM on 6/29/22 recorded in the Blood Sugar Summary and a similar result of 450 mg/dL recorded at 7:00 AM on the MAR. The EMR did not reveal if any treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . On 6/29/22 at 4:32 PM an interview was conducted in the office of the DON with Regional Nurse Consultant (RN) A and the DON. The DON reported that DO's are reviewed by the management team and the DON. The DON reported that DO's were audited after the last survey. The DON reported that staff were to follow the latest order but that one of the orders should have been discontinued.

Based on interview and record review, the facility failed to monitor and address abnormal laboratory results for 1 (Resident #44), resulting in the potential for adverse effects of too much [CONDITION(S)] medication that can lead to undiagnosed thyrotoxicosis. Findings include: Resident #44 (R44) Review of a Face Sheet revealed R44 is a [AGE] year-old male originally admitted to the facility on [DATE] and has pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of laboratory results ordered by Nurse Practitioner (NP) D dated 4/18/22 for R44 revealed a Sensitive TSH ([CONDITION(S)] stimulating hormone) level result of 0.038 UIU/ML (normal is 0.465 - 4.680), indicating a hyperthyroid state. The document was acknowledged and signed on 4/22/22. No documentation indicating the laboratory levels were addressed and the resident is monitored for symptoms. Review of a laboratory result ordered 5/2/22 by the physician for R44 revealed a Sensitive TSH level result of 0.145 UIU/ML, indicating a hyperthyroid state. No documentation indicating the laboratory levels were addressed and the resident is monitored for symptoms. Review of a handwritten Nurse Practitioner progress note dated 6/15/22 for R44 revealed he had a weight change and labs were ordered, including a TSH. Review of a laboratory result ordered 6/17/22 by the NP for R44 revealed a Sensitive TSH result of <0.015 UIU/ML, indicating a hyperthyroid state. No documentation indicating the laboratory levels were addressed and the resident is monitored for symptoms. Review of a Transcribed Nurse Practitioner progress note dated 5/27/22 for R44 revealed he was seen to review his plan of care and nursing staff reported the resident has remained in his usual state of health. He is on 112 mcg (micrograms) of [MEDICATION(S)] ([CONDITION(S)] medication) daily, and every Monday, Wednesday, and Friday he is on [MEDICATION(S)] 500 mg (milligrams) (a medication used for his high platelet counts). Review of his systems show his endocrine system was negative for hot flashes, [CONDITION(S)] problems, and cold intolerance. Review of his cardiovascular system revealed he is positive for a systolic murmur. He is on [MEDICATION(S)] for thrombocythemia. [CONDITION(S)]: TSH within normal limits and is on [MEDICATION(S)] (brand name for [MEDICATION(S)]) 125 mcg daily. Review of a Nursing Progress note dated 6/14/22 for R44 revealed the nurse collaborating with the [CONDITION(S)] center regarding the resident declining. The [CONDITION(S)] center indicated they only monitored labs related to [CONDITION(S)]. The continued to express concern to address with the resident's physician to review/assess the resident due to a general decline in food intake and withdrawn from social interactions in the past few months and just a general different in the past month or two. Review of the April -June Medication Administration Records for R44 revealed on 1/27/22 an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . No changes in these medications are noted. During this survey on day one, R44 was observed in the dining room alone at a table for lunch. On day two, the resident went to [CONDITION(S)] in the morning and did not want to talk to this surveyor. R44 was tired after his treatment and not in a pleasant mood. In an interview on 6/28/22 at 4:40 PM, the Director of Nursing (DON) reported it was not clear if any actions were taken to address R44's TSH levels and to provide more information. In an interview on 6/29/22 at 8:14 AM, the DON reported there was a medication change a while back but did not have any information on the timeline of events regarding R44's laboratory [CONDITION(S)] levels and was to provide more information. In an interview and record review on 6/29/22 at 3:08 PM, the electronic medical records did not have the pharmacy reviews in the chart for R44. Requested pharmacy records from the facility the day before. The Regional Nurse Consultant (RN) A reported the R44 went to a hematologist and did not make any changes to his [CONDITION(S)] medication. When queried, RN A confirmed the hematologist may not be the one to address [CONDITION(S)] medication then reported the physician made a revision to the [CONDITION(S)] medication on 6/22/22, but reviewing the orders revealed the resident has been on the same dose of [MEDICATION(S)] 125 mcg for several months. RN A reported they follow what the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . In an interview on 6/29/22 at 4:28 PM, NP D reported R44 started on [MEDICATION(S)] which will cause the TSH to rise. When informed the lab values show the resident is extremely on the hyperthyroid end of the spectrum, NP D reported the resident was complaining of significant fatigue and does not treat based on labs but treats the patients and did not want to make any changes. NP D reported the resident sees a hematologist and a nephrologist and they did not make any changes to his [CONDITION(S)] medication. No more information provided as to why they would address an abnormal [CONDITION(S)] level when a nephrologist addresses renal failure and a hematologist addresses blood disorders. NP A reported the progress note on 5/27/22 that shows R44 was on 112 mcg of [MEDICATION(S)] was a mistake due to the translation of the progress note. Review of the Davis's Drug Guide, 18th edition online version (https://www.drugguide.com/ddo/view/Davis-Drug-Guide/ 3/all/[MEDICATION(S)]?q=[MEDICATION(S)]#0) revealed [MEDICATION(S)] is a [CONDITION(S)] hormone medication to treat [CONDITION(S)] and/or [CONDITION(S)] cancer. It is to be used cautiously in cardiovascular disease and severe renal insufficiency and advises that geriatrics are extremely sensitive to [CONDITION(S)] hormones. Adverse reactions usually only seen when excessive doses cause iatrogenic [CONDITION(S)] include but not limited to [CONDITION(S)] (fast heart rate), arrhythmias (irregular heartbeat), [CONDITION(S)], abdominal cramps, gastrointestinal upset, weight loss, headache, [CONDITION(S)], and irritability. Toxicity and Overdose: Overdose is manifested as [CONDITION(S)] ([CONDITION(S)], chest pain, nervousness, [CONDITION(S)], diaphoresis, tremors, weight loss). Usual treatment is to withhold dose for 2-6 days then resume at a lower dose. Acute overdose is treated by induction of emesis or gastric lavage, followed by activated charcoal. Sympathetic overstimulation may be controlled by antiadrenergic drugs (beta blockers), such as [MEDICATION(S)]. Oxygen and supportive measures to control symptoms are also used. Review of the National Institutes of Health National Library of Medicine website (https://www.ncbi.nlm.nih.gov/books/NBK 6/) last updated September 28, 2021 revealed: Thyrotoxicosis is the clinical state associated with excess [CONDITION(S)] hormone activity, usually due to inappropriately high-circulating [CONDITION(S)] hormones. The clinical presentation varies, ranging from asymptomatic to life-threatening [CONDITION(S)] storm. Symptoms are due to the hypermetabolic state induced by excess [CONDITION(S)] hormones and include weight loss, heat intolerance, and palpitations. There are many different causes of thyrotoxicosis. It is important to determine the cause since treatment is based on the underlying etiology. Thyrotoxicosis can lead to serious complications when not diagnosed and treated appropriately, including [CONDITION(S)], altered mental status, [CONDITION(S)], muscle weakness, [CONDITION(S)], congestive heart failure, thromboembolic disease, cardiovascular collapse, and death.

Based on interview and record review the facility failed to ensure a valid Advance Directive was in place for one resident (Resident (R) 58) resulting in the potential for the wishes of the resident to not be honored and the potential for all facility residents to not have Advance Directives consistent with their wishes or be properly completed. Findings: Review of the medical record reflected R58 was admitted to the facility 3/1/21 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Admission Minimum Data Set (MDS) dated [DATE] and the most recent quarterly MDS dated [DATE] reflect R58 was severely cognitively impaired and rarely/never made decisions. Review of the Face Sheet for R58 reflected R58 was listed as the Responsible Party for Financial and Clinical matters. Review of the medical record did not reveal documentation that R58 had been deemed incompetent by two clinicians. Review of the medical record for R58 revealed an Advance Directive dated 3/1/22 that indicated a code status was selected of Do not Resuscitate (DNR). The signature line for Legal Representative held the signature of a family member listed on the Face Sheet as a contact. The Advance Directive document reflected that if a Legal Representative had signed and their printed name, then add the relationship to the Resident, and add Type of Legal Appointment. These areas were blank on the Advance Directive for R58. The document was also signed by a Registered Nurse (RN) as the Facility Representative. On 6/29/22 at 8:54 AM, the Director of Nursing (DON) was informed that no documentation was found in the medical record of R58 that the family member that signed the Advance Directive of 3/1/22 and that no documentation was found that this person had the authority to do so. On 6/29/22 at 12:49 PM, Social Work (SW) C reported that R58 had a competency evaluation by one physician at the time of admission but had not been evaluated by a second clinician. SW C indicated the code status of R58 should not be DNR without the proper evaluations and documentation.

Based on interview and record review, the facility failed to submit a Preadmission Screening (PAS)/Annual Resident Review (ARR) for 1 (Resident #10), resulting in the potential for unmet needs and services. Findings include: Review of a Face Sheet revealed Resident #10 is an [AGE] year old who admitted to the facility on [DATE] with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Preadmission Screening (PAS)/Annual Resident Review (ARR) document for R10 revealed the resident did not have an updated PASSR in her medical records. In an interview on 6/28/22 at 5:32 PM, Social Worker (SW) C reported R10 did not have a PASRR completed for 2021 and just filled one out this day and prepared to submit it. SW C confirmed they are to be done once a year.

Based on interview and record review, the facility failed to ensure that the attending physician or the Medical Director had responded to an identified irregularity noted by a consultant pharmacist during a monthly medication review for one resident (Resident (R) 2) resulting in the potential for an unnecessary medication and the potential for all facility residents receiving medication to have an identified irregularity of their medication regimen not responded to by a qualified medical professional. Findings: Review of the Minimum Data Set (MDS) dated [DATE] reflected R2 was admitted to the facility 3/11/22 with diagnoses that included [CONDITION(S)] and Depression (other than [CONDITION(S)]). The MDS reflected a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R2 was cognitively intact. Review of the Doctor's Orders (DO) for R2 revealed a current order written for [MEDICATION(S)] ([MEDICATION(S)], an atypical antipsychotic medication) 25 milligram (mg) give 1 tablet at bedtime for [CONDITION(S)]. The DO reflected this order was initiated on 3/11/22. Review of the manufacturer's package insert for [MEDICATION(S)] reflected indications for use for treatment of [CONDITION(S)] [CONDITION(S)] and [CONDITION(S)]. The Consultant Pharmacist's Medication Regimen Review for R2 dated 5/27/22 was reviewed. The Consultant Pharmacist's recommendation reflected, This resident was recently admitted on [MEDICATION(S)] ([MEDICATION(S)]) 25 mg (orally) (at hour of sleep). Due to increased risk of falls, sedation, confusion, (continued list of adverse symptoms) use is strongly discouraged by (Center for Medicare and Medicaid Services) in the absence of [CONDITION(S)], [CONDITION(S)], or [CONDITION(S)]. Consider clarifying the diagnosis and documenting a risk versus benefit statement for continued use or discontinuing the [MEDICATION(S)] order. The Consultant Pharmacist's Medication Regimen Review revealed an undated handwritten note on the document that reflected, continue order (no punctuation) nurses note added for statement (related to) continued use. Review of the Electronic Medical Record (EMR) Progress Notes for R2 revealed a Nurses' Note dated 6/6/22 at 4:36 AM entered by Unit Manager (UM) Registered Nurse (RN) H. The entry reflected, (Patient) has paranoia observed and is receiving [MEDICATION(S)] for mental health. (Gradual Dose Reduction) of this drug is contraindicated at this time (due to) adverse behaviors observed and charted. Review of the EMR did not reveal any physicians' entries between the Consultant Pharmacist's Medication Regimen Review dated 5/27/22 and the Annual Survey entrance date of 6/27/22. No documentation was found in the EMR that revealed a physician responded to or addressed the Consultant Pharmacist's recommendation. No documentation was found that the physician had considered clarifying the diagnosis or had documented a risk versus benefit statement for continued use. The only entry located in the EMR regarding the Consultant Pharmacist's recommendation was entered by UM RN H who is not qualified as a medical professional to validate a Pharmacist's recommendation or document a rationale for continued use. On 6/29/22 at 1:15 PM an interview was conducted with the Director of Nursing (DON). The DON reported that UM RN H was no longer at the facility. The DON reported that the Medical Director (MD) refers all use of [CONDITION(S)] medication to (name of outside psyche service). The DON did not indicate why the Consultant Pharmacist's Medication Regimen Review dated 5/27/22 had not been reviewed or commented on by an attending physician or MD. Review of the EMR did not reveal any comment by the MD that the Consultant Pharmacist's Medication Regimen Review dated 5/27/22 was referred to an outside service for review. No further information was provided by the facility by survey exit.

Based on interview and record review, the facility failed to ensure the medication regimen was free of unnecessary medications for one resident (Resident (R) 2) resulting in the continued administration of a medication deemed unnecessary at the previous frequency and the potential for all facility residents to receive unnecessary medications. Findings: The Electronic Medical Record (EMR) documentation by Nurse Practitioner (NP) D of the encounter with R2 on 5/13/22 was reviewed. The documentation reflected an Assessment and Plan, change [MEDICATION(S)] to 25 mg every other day [MEDICATION(S)] 10mg daily [MEDICATION(S)] 15 mg daily. This indicated that maintaining [MEDICATION(S)] daily was not necessary. Review of the Doctor's Orders (DO) reflected that the [MEDICATION(S)] order had not been changed and had continued from when originally ordered on 3/11/22. Review of the EMR did not reflect documentation from a medical provider after the NP evaluation on 5/13/22 why it was necessary to continue [MEDICATION(S)] daily. On 6/29/22 at 1:15 PM an interview was conducted with the Director of Nursing (DON). The DON reported when R2 arrived at the facility the Resident triggered for a referral to (name of outside psyche services group). The DON reported that R2 is on the list to be evaluated by this group. The DON did not indicate why, if R2 triggered for an evaluation when admitted on [DATE] more than three months later, R2 still has not had the evaluation. The DON was asked about the documented evaluation conducted by NP H on 5/13/22 and the Plan to change the administration order of [MEDICATION(S)]. The DON reported that all the physicians notes and orders are reviewed the Interdisciplinary Team (IDT) The DON reported that the IDT reached out to the Medical Director (MD) regarding the NP note of R2 dated 5/13/22 and that we went with his instruction because he is the Medical Director (MD). The DON reported that the MD will not change [CONDITION(S)] medication orders, that he leaves that to (name of outside psyche services group). The DON reported that she did not know why anything was documented about this at that time. The DON stated, I wish I had a better answer.

This citation pertains to intake #MI 255 and #MI 513 Based on observation, interview, and record review, the facility failed to provide quality care for 3 residents (Resident #101, Resident #100, and Resident #108) out of 3 residents reviewed, resulting in (1) for Resident #101 (a) delayed wound care, (b) additional facility acquired skin concerns, (c) unmonitored and untreated decreased oxygen saturation, (d) significant drops in blood pressure not reported to the provider, (e) inability to accurately assess for weight gain/loss for a resident with [CONDITION(S)], and (f) unmonitored low blood sugars, (2) for Resident #100 (a) unassessed vomiting, (b) untreated constipation, (c) a decline in the ability to move independently with no access to the call system, and (d) the potential for aspiration, choking, or [CONDITION(S)] activity and not being able to call for help, and (3) for Resident #108 (a) delayed treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings: Resident #101 (R101) Review of an Admission Record revealed R101 was an [AGE] year old male, admitted to the facility on [DATE] after a 17 day hospital stay in which R101 received care for the following: (a) pneumonia with [CONDITION(S)], (b) CHF ([CONDITION(S)]), (c) Insulin dependent diabetes, and (d) an acute (occurred while in the hospital) upper GI (gastrointestinal) bleed causing blood loss [CONDITION(S)] (received 11 units of blood in the hospital) and melena (dark sticky feces containing partially digested blood), and requiring open abdominal surgery to locate and stop the bleed and several days spent in the ICU (intensive care unit). Review of a hospital Inpatient Discharge Summary for R101, dated 10/29/21, reflected weight at time of discharge from the hospital on 10/29/21 was 180 pounds (81.7 kilograms). Review of a Nursing Admission Evaluation (NAE) Part 1, dated 10/29/21, reflected R101 admitted to the facility with the following identified skin conditions (a) a coccyx pressure wound, stage 2, measuring 1 cm (centimeter) x 1 cm x 0 (length x width x depth) and (b) an abdominal surgical incision (no condition of surgical wound given). The same NAE Part 1 reflected the following additional information about R101 at the time of admission: (c) 3 separate dark colored areas were identified on the anterior aspect of the right iliac crest, (d) most recent weight and date weight was obtained-was not answered, (e) R101 could not lift both arms or legs off the mattress (one limb at a time), (f) the question can the resident maintain sitting with little or no help was not answered, (g) the date of the most recent fall R101 had was listed as 10/29/21 and according to the nursing documentation, the fall occurred at the facility at 5 P.M., after R101 arrived on 10-29-21, (h) although identified as diabetic, the diabetic foot screen (lists a multitude of foot concerns that could occur with diabetes) was not completed, (i) The nursing evaluation summary also indicated that R101 was admitted to the facility from the resident's home (not hospital), occasional confusion noted, was alert and oriented x 2, and had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of an Electronic Medication/Treatment Administration Record (Emar/Etar) for R101, dated 10/29/21 to 10/31/21, reflected: (a) there were no orders in place to assess, monitor, and treat the stage 2 coccyx pressure wound identified at admission, (b) no orders to monitor and assess the abdominal surgical site, and (c) no orders to monitor daily weights for R101 who was prescribed a diuretic and was diagnosed with [CONDITION(S)]. Fluid retention is an important clinical sign of CHF. Immediate detection and proper handling of weight increase to keep the body weight stable can effectively prevent CHF aggravation, thereby reducing hospitalization frequency. Patients with CHF should be weighed daily.https://www.ncbi.nlm.nih.gov/pmc/articles/PMC 24/ Review of a NAE Part 2, dated 10/30/21, reflected the following information about R101's condition: Cardiovascular Assessment: (a) identifying history of cardiovascular concerns-use of anticoagulants (blood thinner) and the presence of a prosthetic heart valve were not included, and (b) Nutrition Risk-identified risks for dehydration, a risk factor that R101 had, but was not identified included- dependent on staff for provision of fluid intake. Review of a NAE Part 3, dated 10/30/21, reflected the following information about R101's condition: The Oral/Dental Status Evaluation had only 2 questions that were answered, both related to whether or not R101 had artificial teeth, partials, or dentures; R101 had none of those. The questions that assessed if R101 had any mouth sores, difficulty chewing, how much assistance was needed to perform daily oral/dental care, and whether any of those concerns, if present, would affect intake, were not answered. No orders or instructions for staff to monitor for melena were found in the medical record. R101's Care Plan only instructs staff to monitor for signs & symptoms of bleeding, but did not identify the signs and symptoms of bleeding (dark tarry stools, abdominal pain, vomiting, fatigue, weakness, decrease in blood pressure, increased heart rate, trouble breathing, and dizziness). No documentation that staff assessed color and consistency of bowel movements, was located in the medical record. During an interview on 11/02/21 at 10:20 A.M., Assistant Director of Nursing (ADON) K stated that the three part nursing admission evaluation was very important and needed to be accurate because the information collected in the evaluation drove the resident's plan of care moving forward. ADON K also stated that the use of Skilled Daily-Medically Complex nursing notes, in addition to traditional progress notes, allowed nurses to assess for and document more in depth medical concerns. Review of a Skilled Daily-Medically Complex (SDMC) nursing note dated 10/30/21 at 4:45 P.M., reflected the following information about R101: was alert and oriented x 4 and (a) required supervision or touching assistance to bring food or liquids to the mouth and swallow food and/or liquid once placed before the resident, (b) the most recent documented blood pressure, respirations, oxygen saturation, temperature, and pulse were from the previous evening (10/29/21 at 11:30 P.M.), (c) skin items present for this review-surgical wound identified however no description of the wound or dressing was given, abnormal skin conditions (such as the stage 2 coccyx pressure ulcer)-not identified, (d) are treatments or daily monitoring needed related to wounds-yes (no treatments or monitoring ordered as noted above from Emar/Etar dated October 2021), and (e) was any teaching conducted- no (despite residents fall in the facility on 10/29/21, that R101 required some level of supervision to eat and drink, was prescribed a diuretic, had a stage 2 pressure wound, and had a healing surgical incision). Review of a SDMC nursing note dated 10/31/21 at 4:45 P.M., reflected the following information about R101: was alert and oriented x 2 and (a) required only set up or clean up assistance to eat or drink, (b) the most recent documented blood pressure, respirations, oxygen saturation, temperature, and pulse were from the evening of admission to the facility (10/29/21 at 11:30 P.M.), (c) skin concerns present for this review-none identified despite R101 had a surgical wound and a previously identified stage 2 coccyx pressure ulcer, (d) cardiac assessment indicated R101 was not receiving any medications to assist with blood pressure or heart rate, (review of physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The professional standard of quality for performing complete respiratory assessments is to assess respiration rate, rhythm, and depth, increased, decreased, or irregular respirations, lung sounds, oxygen saturation level, hypoxemia (low oxygen saturation level), labored or painful breathing, using accessory/chest muscles to breathe, the color of skin, nail beds, lips or mouth, restlessness, irritability, confusion, reduced level of consciousness, color and consistency of sputum, and the assessment of labs. (Mosby Seventh Edition Medical-Surgical Nursing Concepts and Clinical Practice, [NAME], [NAME], [NAME]) Review of a SDMC nursing note dated 11/01/21 at 12:45 P.M., reflected the following information about R101: was alert and oriented x 2 and (a) required only set up or clean up to eat or drink, (b) the most recent documented blood pressure, respirations, oxygen saturation, temperature, and pulse were from the evening of admission (10/29/21 at 11:30 P.M.), (c) no documentation of the condition of the stage 2 pressure ulcer or abdominal incision, and (d) no documented lung sounds. Review of an Occupational Therapy Treatment Encounter Note for R101, dated 11/01/21, revealed: closing eyes during session, COTA (certified occupational therapy assistant) checked oxygen saturation and was between 87% and 90%, nursing notified of resident's low oxygen saturation on this date, resident unable to tolerate full therapy session. No nursing notes were found in R101's medical record that documented the low oxygen saturations reported by occupational therapy on 11/01/21. Review of an Emar/Etar, dated 11/01/21 to 11/30/21, for R101, reflected an order (start date 11/01/21 at 8:00 P.M.) to provide wound care for the stage 2 coccyx pressure wound. Review of 4 Skin & Wound Evaluations for R101, all dated 11/02/21, reflected (a) an assessment of the coccyx pressure wound identified at admission, (b) a facility acquired stage 2 pressure wound measuring 1.5 centimeters (cm x 1.2 cm located on the right posterior thigh, (c) a facility acquired wound located on the left buttock measuring 2 cm x 1.5 cm, and (d) a sacral wound measuring 1.3 cm x 1.2 cm and documented as present on admission. Review of a Skilled Daily-Medically Complex (SDMC) nursing note dated 11/02/21 at 9:45 A.M., reflected the following information about R101: was alert and oriented x 1 and (a) was completely independent to eat or drink, (upgraded despite a noted decrease in cognitive status) (b) the most recent set of vitals were from 11/02/21, except the most recent oxygen saturation noted was from 10/29/21 at time of admission, (c) R101 required only partial to moderate assistance to move in bed from sitting to lying and to move from lying to sitting on side of bed (previous assessments since admission reflected R101 required substantial/maximal assist with this task), (d) R101 was not receiving oxygen therapy, (e) no documented lung sounds, and (f) no teaching was conducted. Review of a Skilled Daily-Medically Complex (SDMC) nursing note dated 11/03/21 at 9:45 A.M., reflected the following information about R101: was alert and oriented x 1 and (a) required set up or clean up to eat or drink, (b) R101 was not receiving medications for blood pressure and heart rate, (c) oxygen therapy was not documented however the most recently charted oxygen saturation was 93% oxygen via nasal cannula, (d) no new labs ordered during this period was documented, however labs had been drawn earlier the morning of 11/03/21, (e) no documented lung sounds, and (f) no teaching was conducted. A progress note could not be located that discussed when and why oxygen therapy was initiated and if lung sounds had been assessed. A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] .M., for check oxygen saturation every shift and as needed for oxygen dependence. Documentation of oxygen saturation and how many liters of oxygen being delivered each shift required. Documentation was not available for 11/05/21 during day shift. No specific parameters for oxygen delivery rate and saturation levels that needed to be maintained, were documented. Review of a physician order, start date 11/3/21, reflected: Daily weights-notify provider of weight gain of 3+ pounds in 24 hours or 5+ pounds in 1 week. every day shift for 3 days. The only weight documented for R101 with this order was on 11/04/21 and recorded a weight of 260 pounds. NAE Part 1 above, did not have a most recent weight listed at the time of admission on 10/29/21. A previously obtained weight at the time of discharge from the hospital on 10/29/21 was 180 lbs. Review of a Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] .M. (5 days after admission) Review of a Skin Assessment for R101 and dated 11/04/21 reflected no there were no existing abnormal areas of skin concern. Review of the first physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . Noted physician concerns included: (a) lung sounds- Rhonchi, (b) sacrococcygeal stage 2 ulcer, and (c) R101 currently on oxygen. Review of the admission Nutrition Evaluation, dated 11/04/21,(completed 7 days after admission to the facility) revealed the following assessments for R101: (a) Med Plus 2.0 4 ounces twice daily recommended for additional calories and protein related to poor intake and wounds (started 11/04/21), (b) most recent weight-260 lbs and ideal body weight was 160 lbs +/- 10%, usual body weight-unknown, (c) food acceptance record reviewed with approximately 40% acceptance over last 5 days, and (d) able to independently feed self. No documentation reflected that R101's poor intake and if the resident's ability to feed self was re-assessed or investigated. Review of a Skilled Daily-Medically Complex (SDMC) nursing note dated 11/04/21 at 9:45 P.M., reflected the following information about R101: was alert and oriented x 1 and (a) required supervision or touching assistance to eat or drink, (downgraded from past 3 days), (b) lung sounds not assessed or documented, (c) any signs/symptoms of low blood sugar present-no (blood sugars on 11/04/21 were recorded as 65 at 7:28 A.M., 61 at 12:31 P.M., and 51 at 4:42 P.M.), (d) no new labs completed during this period was documented, however labs had been drawn on 11/03/21 and reviewed by the provider on 11/04/21 with new orders in place), and (e) no teaching was conducted. No documentation was located that described what, if any, nursing interventions were in place and utilized (including rechecking the low blood sugars 15 minutes later) to treat the low blood sugars and if a provider was notified to discuss the residents poor oral intake and the safe administration of prescribed antihyperglycemic medications and long acting insulin. In an article in Diabetes Forecast, March 2020, By [NAME], [CONDITION(S)] (low blood glucose) is defined as a blood glucose of less than 70 mg/dl. The recommended treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . If the level is still below 70, treat again with carbohydrates, and so on until glucose is 70 or above. Review of a Skilled Daily-Medically Complex (SDMC) nursing note dated 11/05/21 at 9:45 P.M., reflected the following information about R101: was alert and oriented x 1 and (a) setup or clean up assistance needed to eat or drink, (b) lung sounds not assessed or documented, (c) oxygen saturation documented was from 11/04/21 at 7:37 P.M., (d) skin items present for review- no abnormal skin conditions noted (R101 had 4 documented skin concerns), and (e) no teaching was conducted. Review of a Physical Therapy Treatment Encounter Note for R101, dated 11/05/21, revealed: after sitting in wheelchair BP (blood pressure) was taken and reads 94/51 and pulse 75, 82/48 and 71 after 5 minutes of sitting resting, 97/51 and 72 with ankle pumps .continue with reps and then 86/49 and 71 beats per minute and resident assisted back to bed. No documentation reflected that the provider was notified of the low blood pressures. Review of a Skilled Daily-Medically Complex (SDMC) nursing note dated 11/06/21 at 10:45 A.M., reflected the following information about R101: was alert and oriented x 1 and (a) was independent to eat or drink, (b) lung sounds not assessed or documented, (c) any signs/symptoms of low blood sugar present-no (blood sugars documented on 11/06/21 were 66 at 7:45 A.M. and 65 at 12:19 P.M.), (d) skin items present for review- no abnormal skin conditions noted (R101 had 4 documented skin concerns), and (e) no teaching was conducted. Review of a Blood Pressure Summary reflected a blood pressure for R101 on 11/06/21 at 1:59 P.M.- 94/49. Review of a nursing progress note for R101, dated 11/06/21 at 7:30 P.M., revealed: resident and family request (R101) goes to the hospital for evaluation and treatment. Review of emergency room physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] .(b) Blood pressure was 105/53 .(c) (R101 appears dehydrated and mental status is- confused .(d) it would appear (R101) was not regularly taking in fluids or solids, (R101) has been deteriorating .stool is hemoccult positive .(e) 48 hours ago (R101's) BUN was 11 creatinine was 1 with a GFR greater than 60. Today the BUN is 25 and creatinine 2.1, both of them more than double what they had been previously and his GFR has fallen to 58 indicating acute kidney injury . and (f) positive for urinary tract infection, started on antibiotics. Resident #100 (R100) Review of an Admission Record revealed R100 was a [AGE] year old female, originally admitted to the facility on [DATE] for short term rehabilitative services following a fractured left fibula and 2 lumbar compression fractures. Pertinent medical history included [CONDITION(S)] following a stroke, [CONDITION(S)] disorder, pacemaker with the use of blood thinners, and a urinary tract infection with continued antibiotic use at the time of admission to the facility. During an observation on 12/01/21 at 9:20 A.M., R100 sat in a wheelchair ( in the resident's assigned room), head down, eyes closed, and the right side of the face resting on an emesis basin that was held in place by the right arm. Vomit was observed in R100's mouth, a moderate amount of green emesis sat in the emesis basin, and the call light light was 6 feet behind the resident, clipped to the pillow on the bed, out of sight and out of reach of the resident. R100 did not open eyes or arouse to name x 3 attempts. During an interview on 12/01/21 at 9:25 A.M., Certified Nurse Aide (CNA) O indicated that R100 had not been feeling well the past 24 hours, did not sleep well last night, and did not eat breakfast this morning because R100 was vomiting. During an interview on 12/01/21 at 9:30 A.M., the Director of Nursing (DON) indicated that R100 was very behavioral, get's worked up and wants to go home, and gets so worked up (R100) will make herself kind of throw up. The DON attempted to arouse R100 by name and touch and was unable to awake the resident. During an interview on 12/01/21 at 9:35 A.M., Registered Nurse (RN) G entered R100's room, indicated that R100 was not really vomiting, it was just behavioral. When asked if RN G thought that the contents in the emesis basis were not really vomit, RN G walked over to the resident, looked into the emesis basis, and stated yes that's vomit. RN G indicated that R100 received Zophran this morning and an abdominal x-ray had been done to cover our bases. RN G then left the room without any additional assessment of R100's condition. The DON and CNA O stayed in the room and attempted to exchange the emesis basin for a clean one and clean the vomit out of R100's mouth. During an observation on 12/01/21 at 10:34 A.M., R100's door to the room was closed. Inside the room, R100 sat slumped in the wheelchair, head down, eyes closed, no emesis basin on or near the resident, and the call light remained clipped to the pillow at the head of the bed, out of reach and out of sight of R100. Review of a Bedside Kardex Report for R100, listed a safety intervention of be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The Professional Standards of Quality for Staff Roles and Responsibilities in Monitoring Patients with Acute Changes of Condition for the nurse includes recognizing condition change early and assessing the patient's symptoms and physical function and document detailed description of observations and symptoms. (Process Guidelines for Acute Change of Condition, AMDA Clinical Process Guidelines, 2019). Review of a Task Monitor-Bowel Elimination record for R100, revealed R100 had a small bowel movement on 11/19/21 at 1:59 P.M., and did not have another bowel movement until 11/26/21 at 11:44 A.M. (7 days later). R100's normal bowel pattern was documented as every other day in the Nursing Admission Evaluation-Part 2 dated 10/27/21. Review of an Emar/Etar, dated 11/01/21 to 11/30/21, reflected R100 did not receive any of the 3 PRN (as needed) medications ordered to treat constipation between 11/19/21 and 11/26/21. Resident #108 (R108) Review of an Admission Record revealed R108 was a [AGE] year old female, admitted to the facility on [DATE], following an inpatient hospital stay for pneumonia and open abdominal surgery for [MEDICAL RECORD OR PHYSICIAN ORDER] Review of a Nursing Admission Evaluation (NAE) Part 1, dated 10/18/21, reflected R108 admitted to the facility and the following weights and vitals were documented: (a) most recent height-60 inches- date obtained 12/06/19, (b) most recent weight-147.6-date obtained 01/09/20, (c) most recent temperature-97.1- date obtained 01/05/20, (d) most recent pulse-74-date obtained 01/09/20, (e) most recent respirations-16- date obtained- 01/05/20, (f) most recent blood pressure-121/74- date obtained 01/09/20, and most recent oxygen saturation-95% on room air- dated obtained 12/06/19. None of the documented vitals and weight for R108 at admission were current. Review of a Order Summary Report for R108 reflected an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The order did not instruct nursing staff to notify the provider of any weight loss. Review of an Admission Nutrition Data Collection Evaluation, for R108 and dated 10/25/21, revealed the following information: (a) R108 had dentures but they were not currently at the facility, (b) food acceptance record for past 5 days showed R108 accepted approximately 60% of meals offered, (c) R108 reported a decreased appetite due to pain (had recent abdominal surgery), (d) R108 reported feeling like there had been some weight loss, and (e) recommendations were for R108 to start health shakes with all meals to provide 200 calories and 6 grams of protein. Review of an Emar/Etar dated 11/01/21 to 11/30/21, reflected the following order for R108: Health Shake with meals for supplement. Start date 11/04/21 at noon. (10 days after the recommendation was made) Review of an SOC-Nutrition/Hydration progress note, dated 11/04/21, reflected the the following regarding R108's nutritional status: initiated for weights loss, poor oral intake since admission (10/18/21), and resident has had a 9.8 pound weight loss since admission. Review of an SBAR Communication Form and progress note, dated 10/28/21, the following changes in R108's condition were documented: (a) increased confusion, decreased appetite and urinary frequency- started on 10/28/21, (b) Medication Alerts-changes in the last week (describe below) no description of any recent med changes listed, (c) needs more assistance with ADL's (activities of daily living such as eating and drinking), and (d) resident confused and not able to feed self well. No new documented interventions to assist and ensure that R108 could eat and drink fluids were located in the medical record. Review of a physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Weight Summary showed R108's weight on 11/02/21 was actually 137 lbs. The physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of an Emar/Etar for R108, dated 11/01/21 to 11/31/21, reflected the following: an order to start IV (intravenous) fluids [MEDICATION(S)] 0.9% solution 100 milliliters/hour, 24 hours a day x 3 days for [CONDITION(S)]. Start date 11/08/21. No orders or instruction for staff to monitor for fluid overload were given (monitoring lung sounds and for [CONDITION(S)]). No documentation was located in the medical record that nursing had monitored R108's lung sounds and checked for [CONDITION(S)] while the resident received IV fluids for 3 days. Review of an article Excess Fluid Volume, nurselab.com, September 8, 2020, [NAME] BSN, R.N. reflected the signs and symptoms of fluid overload that can be quickly assessed by nurses include: abnormal breath sounds: crackles, blood pressure changes, [CONDITION(S)], intake exceeds output, jugular vein distention, shortness of breath, [CONDITION(S)] and third heart sound: S3. Review of Pertinent Charting-Change in Condition for R108, (related to the SBAR dated 10/28/21 which identified confusion and decreased ability to feed self), dated 11/11/21 at 6:15 P.M., documentation reflects that R108 was alert and oriented to person and place. Review of Pertinent Charting-Change in Condition for R108, (related to the SBAR dated 10/28/21 which identified confusion and decreased ability to feed self), dated 11/12/21 at 2:19 A.M., revealed documentation that did not address whether R108 experienced any confusion during the shift. During an interview on 11/30/21 at 4:10 P.M., R108 indicated having the following concerns with care received at the facility the night of 11/11/21: (a) R108 woke up and didn't feel right, (b) R108 activated the call light and no staff responded, (c) R108 began to have trouble breathing and still no staff responded, (d) R108 started yelling for staff and no one responded, it was very scary, (e) R108 began yelling please call an ambulance but was having difficulty yelling out because of the difficulty breathing, (f) finally someone came and checked me and said to the other worker the breathing is low, (g) R108 heard the other worker say we are in big trouble, and (h) I've never been so scared in my whole life. Review of a Skilled Daily-Medically Complex nursing note, dated 11/12/21, reflected the following information about R108 the morning of 11/12/21: (a) oriented only to person, (b) current blood pressure was 176/107, (c) pulse was 110, (d) respirations were 22 breaths per minute, and (e) oxygen saturation with supplemental oxygen was 78%. At 6:20 A.M., R108 was sent to the hospital via ambulance for emergency treatment. Review of an Emergency Department Provider progress note, dated 11/12/21, reflected the following: (R108) was sent to the emergency room after being found hypoxic and short of breath . (R108) is normally on oxygen via nasal cannula and this had been turned up to 6 L (liters per minute) and the oxygen saturation was 78% upon arrival here . (R108) was placed on a nonrebreather and the oxygen saturation initially improved but then dropped down into the upper 80's. Breathing treatments were ordered and R108 was placed on [CONDITION(S)] (a bi-level breathing machine that are used in hospitals to treat breathing emergencies) . R108 also had bilateral lower extremity pitting [CONDITION(S)], there was concern for fluid overload, head and neck were positive for JVD (jugular vein distention), and lung sounds were positive for Rhonchi and rales in the right middle and lower lobes and and left middle and lower lobes. [MEDICATION(S)] (a diuretic) IV (intravenous) ordered to be administered daily.

This citation pertains to intake # MI00- 1, MI00- 4, MI00- 8, MI00- 7, MI00- 9 This citation has multiple (5) deficiency practice statements (DPS). DPS-A Based on observation, interview, and record review, the facility failed to (1) provide coordinated care with specialists for a new diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] #8), reviewed for quality of care, resulting in an Immediate Jeopardy (IJ) when, beginning on 03/18/2020, facility staff did not provide coordinated quality care for R8 causing a delay of administration of treatments and services, and exacerbating the potential irreversible progression of MS This deficient practice resulted in the high likelihood for residents with chronic treatable conditions to be at risk for serious harm, serious injury, and/or death. Findings: Resident #8 (R8) Review of an Admission Record revealed R8 was a 47- year-old female, admitted to the facility on [DATE], with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R8 required extensive 2 person assist from staff for bed mobility, transfers, getting dressed, using the bathroom, and moving about in a wheelchair. A Brief Interview for Mental Status (BIMS), completed 07/22/21, revealed a score of 15 out of 15, which indicated R8 was cognitively intact. Review of an article produced by the Mayo Clinic described MS as .a potentially disabling disease of the brain and spinal cord (central nervous system). In MS, the immune system attacks the protective sheath (myelin) that covers nerve fibers and causes communication problems between your brain and the rest of your body. Eventually, the disease can cause permanent damage or deterioration of the nerves. Signs and symptoms of MS vary widely and depend on the amount of nerve damage and which nerves are affected .Some people with MS experience a gradual onset and steady progression of signs and symptoms without any relapses, known as primary progressive MS. Some people with severe MS may lose the ability to walk independently or at all, while others may experience long periods of remission without any new symptoms. There's no cure for multiple [CONDITION(S)]. However, treatments can help speed recovery from attacks, modify the course of the disease and manage symptoms .[MEDICATION(S)] ([MEDICATION(S)]) is a humanized monoclonal antibody medication that is the only disease modifying therapy approved by the FDA to treat both the relapse-remitting and primary progressive forms of MS. Clinical trials showed that it reduced relapse rate in the relapsing disease and slowed worsening of disability in both forms of the disease .Physical therapy is used to build muscle strength and ease some of the symptoms of MS. (mayoclinic.org/diseases-conditions/multiple-[CONDITION(S)]/diagnosis-treatment/drc- 2274 accessed on 8/27/2021 at 10:00 a.m.) Review of an Inpatient Discharge Summary dated 3/4/20, received by the facility, listed instructions to schedule an appointment for R8 as soon as possible for a visit in 2 weeks with a neurology specialist. The address and phone number to the neurology office were listed. Review of a facility physician Medical History and Physical evaluation, completed 03/05/20, listed the following in the Summary/Plan, (a) pressure ulcer of left upper back stage 2-continue with santyl ointment, (b) mild protein calorie malnutrition- continue high protein diet, (c) [CONDITION(S)]- continue to follow up with psychiatry consult, (d) Hypertensive Heart Disease (high blood pressure) continue with [MEDICATION(S)], and (e) [CONDITION(S)] recurrent- continue with [MEDICATION(S)] (an antidepressant in the SSRI class of drugs). The evaluation did not mention the new diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of lab results, drawn 03/06/20, revealed the following results for a lipid profile: cholesterol-186 (normal range 100-200), tryglyceride-101 (normal range- less than 150), HDL cholesterol-23 (normal range-greater than 40), LDL-143 (normal range-less than 130). The lab report was initialed by a facility medical provider on 03/11/20, indicating that it had been reviewed. Another lipid profile, for continued monitoring, was not located in R8's medical record. Review of a Nutrition Data Collection Evaluation, completed 03/09/20, reflected the (1) Nutrition Summary that identified (a) R8's diagnoses' (it did not mention the new diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . As of 8/12/21, no orders for lab work or results for lab work were located in R8's medical chart, following the lab work completed on 03/06/20. Review of a facility physician Nursing Home 30/60 Day Visit evaluation, completed on 03/11/20, did not list the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Nursing Progress Note, dated 03/18/21 at 3:10 P.M., reflected several appointments made for resident per discharge orders. Brother (who is attempting to obtain guardianship) notified of appointments and indicated I can't be at these appointments; I have my own stuff going on. Brother educated that he is required to attend the initial consult for signing of paperwork and that follow ups after that would not require him to be present. Brother stated, Let me check my calendar and get back to you. Transport and nursing attempted to contact brother with no response meaning all appointments had to be rescheduled for a later date. It was unclear from the nursing progress note, who had made the decision to cancel the appointments. Review of a Neurology Progress Note, dated 04/02/20, written by neurology physician assistant (NPA) R, revealed the following: (a) chief complaint- emergency department follow up and multiple [CONDITION(S)] (MS), (b) R8 had an extended stay in the hospital from 02/12/20 to 03/04/20, following deteriorating condition at home, of unknown etiology (what caused it) that included altered mental status, [CONDITION(S)], dehydration, malnutrition, decubitus ulcer and bilateral foot drop, (c) diagnostic tests done in the hospital suggested a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Assessment/Plan: diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] *C-reactive protein (lab): future, *SED Rate (lab): future, *Epic Miscellaneous Lab (Send Out): future, (2) After reviewing the imaging and diagnostic studies completed during the hospital course, I agree that this clinical picture is consistent with a progressive form of multiple [CONDITION(S)]. Treatment should be initiated at this point and continue through disease course. We will begin [MEDICATION(S)] infusion at this time .(3) R8 is still altered during mental exam, at this point it is unclear the etiology of the altered mental status or if this is baseline mentation. Given poor history prior to admission, we cannot determine this at this point. Mental status may continue to improve as R8 slowly recovers from the various medical issues for which R8 was hospitalized , but this remains unclear, (4) R8 was encouraged to work with physical therapy to the best of ability, as this is the best way to rehabilitate R8's legs, and (5) return in about two months (around 6/2/2020) for recheck MS-after initial infusions. Review of a facility physician Nursing Home 30/60 Day Visit evaluation, dated 04/18/20, reflected Diagnosis/Plan: (1) MS: extensive assist with care, follow up with neurologist for infusion, and (2) Major Depressive Disorder (MDD): Mental health services consult. Review of a facility physician Nursing Home 30/60 Day Visit evaluation, dated 05/15/20, indicated the following: R8 had a weight increase to 141 lbs, up from 138.7 lbs at admission. Diagnosis/Plan: MS . dependent of care, to follow up with neurology appointment, and MDD-did not mention whether a mental health services consult had been obtained as requested in the Nursing Home 30/60 Day Visit evaluation dated 04/18/20, and in the Medical History and Physical evaluation dated 03/05/20. Review of a Nutrition Data Collection Evaluation, dated 06/09/20, reflected: (a) R8 would continue with regular diet, vitamins, and prostat due to delicate condition of skin, (b) oral intake was variable but did not present a concern at that time, (c) no new lab results were available to review (despite labs requested and not obtained as noted in the evaluation dated 3/9/20), and (d) dietary would continue to monitor weights and labs (but no indication of which labs to be monitored was listed). Review of a facility physician Nursing Home 30/60 Day Visit evaluation, dated 06/26/20, did not record a current weight or mention the weight increase from last month (noted in Nursing Home 30/60 Day Visit evaluation, dated 05/15/20). Status of Chronic Problems: Stable-extensive assist with ADL care, feeds self. Diagnosis/Plan: MS-stable, extensive assist with care- requires care supervision, no mention if follow up with neurology had occurred as requested in the Nursing Home 30/60 Day Visit evaluation's dated 04/18/20 and 05/15/20. (2) MDD- did not mention if a mental health services consult had been obtained as requested in the Nursing Home 30/60 Day Visit evaluation, dated 04/18/20. Review of a daily Nursing Progress Note, dated 06/28/20, reflected that R8 complained of painful urination. Observed dark concentrated urine with odor. UA (urine analysis) was ordered. Review of a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of an Emar/Etar, (electronic medication administration record/electronic treatment administration record) dated June 2020, reflected that the UA was completed on 06/30/20. Review of R8's medical record produced no (a) lab result for the UA collected 06/30/20, (b) indication whether or not the bladder flush had been completed and if so, had R8 tolerated it and what were the results of the flush (c) additional daily nursing progress notes related to R8's complaints of painful urination and if it had resolved, nor whether the dark odorous urine had resolved, and (d) whether a physician reviewed the result of the UA. Review of a facility physician Nursing Home 30/60 Day Visit evaluation, dated 07/30/20, indicated that R8 had a weight gain and current weight was 150.8 lbs, up from 138.7 lbs at admission. Diagnosis/Plan: (1) MS-resident wishes for neurology consult, please set up consult (this request had been made in previous Nursing Home 30/60 Day Visit evaluations dated 04/18/20 and 05/15/20). (2) MDD (major depressive disorder)- follow up with psych (psychiatric) services (this request was made in the Nursing Home 30/60 Day Visit evaluation dated 04/18/20). Review of a facility physician Nursing Home 30/60 Day Visit evaluation, dated 08/28/20, did not indicate whether a neurology consult had been obtained for R8 as requested previous times by the medical prescribers, nor did it indicate whether a psychiatric consult had been obtained, also as previously requested. Following multiple requests for a psychiatric consult, R8 was first evaluated by psych services on 09/17/20 and then again on 11/25/20. The consultation notes reflected the following: Review of a Psychiatric Initial Evaluation, dated 09/17/20, reflected R8 (1) was seen for depression and anxiety, (2) had significant social stressors and uncertain living arrangements upon discharge, (3) had a suicide attempt by over dose at the age of 15 or 16, (4) had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Psychiatric Note, dated 11/25/20 and received by the facility on 11/27/20 at 2:31 P.M., indicated .did discuss pharmacy recommendation to decrease [MEDICATION(S)] and (R8) stated that was not a good idea and felt an increase in the medication would be helpful as (R8) felt (R8) had uncontrolled depression .Disposition: R8 seen in follow up today with regard to the above noted diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . At this time given R8's uncontrolled depressive symptoms would recommend increasing [MEDICATION(S)] to 20 mg daily. R8 is agreeable with this plan. Review of an Emar/Etar for R8, dated December 2020, showed that an order to increase [MEDICATION(S)] from 15mg (milligram) to 20 mg daily was initiated on 12/05/20 (8 days after the recommended dose increase was received by the facility) and that R8 did not receive a dose of [MEDICATION(S)] on 12/04/20. Review of a Care Plan for R8 revealed the following: FOCUS-R8 has a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Date initiated 03/06/20, revision on 01/12/21. GOAL - R8 will have improved mood state (happier, calmer appearance, no s/sx (signs or symptoms) of depression, anxiety, or sadness) through review date .INTERVENTIONS -Administer medications as ordered. Monitor/document for side effects and effectiveness .Behavioral health consults as needed .Monitor/record mood to determine if problem seems to be related to external causes (i.e. medications, treatments, concern over diagnosis). Review of R8's Emar/Etar's and nursing progress notes, no records were located that demonstrated the facility was monitoring some or any of the following, on a daily basis for R8: (a) level of depression, (b) thoughts of self-harm, (c) anxiety level, (d) sleep disruptions, and (e) feelings of self-worth. Review of a facility physician Nursing Home 30/60 Day Visit evaluation for R8, dated 10/02/20, reflected: MS-patient had neuro consult nursing reports possible infusions for MS. Please obtain consult notes. (The neuro consult referenced in this note was the consult that had occurred on 04/02/20) Review of a facility physician Nursing Home 30/60 Day Visit evaluation, dated 11/05/20, indicated that R8 was [NAME] chair bound (a kind of movable chair used primarily for positioning), continue with physical and restorative therapy, and consult neurology. Review of a Neurology inter-office communication note, dated 11/23/20, reflected that a telephone call was made by neuro medical assistant (NMA) II to (the facility) at 8:49 A.M. on 11/23/20. NMA II spoke with facility receptionist (FR) BB and the receptionist was going to have a nurse call back regarding R8 and set up a virtual appointment. Per NPA R, R8 had not been seen since April 2020 and needed to follow up. During an interview on 08/17/21 at 2:40 P.M., FR BB recalled receiving a telephone call from neurology regarding R8 and stated that the message was given to a nurse (could not recall which nurse specifically). Review of a facility physician Nursing Home 30/60 Day Visit evaluation for R8, dated 12/10/20, did not mention any information about the requested neurology consult nor any information regarding the treatment plan for MS. Review of a facility physician Nursing Home 30/60 Day Visit evaluation for R8, dated 01/22/21, reflected MS-patient dependent of care. No mention of a neurology consult and whether it had been scheduled, as previously requested, was listed. Review of a facility physician Nursing Home 30/60 Day Visit evaluation, dated 02/12/21, indicated that R8 had an overall ADL decline, please try to get neurology consult for the patient. Review of a Neurology Progress Note, dated 03/02/21, written by NPA R reflected the following: Pt was last seen by myself on 04/02/20 for MS. (R8) had been prescribed [MEDICATION(S)] for the presumptive diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] .we would like to repeat a lumbar puncture with basic panel and MS panel as well as obtain MRI of [MEDICATION(S)] and lumbar spine, which have not been imaged before .we will place another referral for physical therapy. Review of a Neurology Progress Note dated 04/01/21, NPA 'R noted the following: Lumbar MRI completed, and findings noted, Lumbar Puncture completed and findings noted, no lab results were available to review, R8 noted interest in repeating physical therapy for lower extremity weakness, [MEDICATION(S)] infusions are ordered, and an order placed for physical therapy. Review of a Neurology Office Note, conversation with patient, dated 05/07/21, reflected: (R8) called the neurology office stating that (R8) has not gotten the labs done needed to receive the infusion. The lab orders were faxed again to (the facility). Review of a Neurology Office Note, conversation with the infusion center, dated 05/14/21, reflected: the infusion center reached out for the pre-treatment labs needed. The orders were faxed again today (to the facility). Neurology staff OO also called (the facility) at 9 A.M. and attempted to speak with R8's nurse, they would not come to the phone, I asked for a call back and gave (the facility) my direct line. As of 4:30 P.M. on 05/14/21, Neurology staff OO had not received a call back from the facility. I am asking my manager to step in to see if I can get some help. During an interview on 08/11/21 at 5:25 P.M. Neurology Physician Assistant (NPA) R indicated (a) frustration with the lack of treatment R8 had received over the past year while in the nursing home, (b) concerned that R8 had lost a year of initial treatment following the MS diagnosis, (c) after seeing R8 on 03/02/21, the decision was made to hold starting [MEDICATION(S)] at that point because additional labs and tests needed to be completed, and because it had been a year since the initial testing was completed, (d) R8 was seen again on 04/01/21, test results were discussed and an order was placed to start [MEDICATION(S)] infusions and physical therapy, (e) additional labs were to be completed prior to starting [MEDICATION(S)], and (f) NPA R could not say if the [MEDICATION(S)] infusions could reverse any disease progression that may have taken place over the past year while R8 was untreated, but was hopeful that the infusions would slow the disease progression. Review of an Occupational Therapy- OT Evaluation & Plan of Treatment, for R8, Certification Period: 2-11-21 to 2-11-21-Eval Only- reflected the following: (a) R8 was cooperative with the evaluation, (b) R8 was evaluated and found to be at PLOF (prior level of functioning) for OT services, (c) R8 was worried about falling, (d) will OT treat to address contracture impairment - No, PT will address. Review of a Physical Therapy- PT Evaluation & Plan of Treatment, for R8, Certification Period: 02/11/21 to 04/07/21, reflected the following: (R8) participated in evaluation on 02/11/21 and the order requesting physician authorization for therapy services was not signed until 02/26/21. Review of a Physical Therapy- PT Discharge Summary, dated 02/25/21 (the day before the above referenced order for therapy services), reflected that the reason for discharge from therapy services was Patient and/or RSP (responsible person) declines further tx (treatment). During an interview on 08/12/21 at 9:45 A.M., R8 reported never not wanting to participate in therapy. I would never say that, I want to walk and be able to go home. During an interview on 08/18/21 at 9:15 A.M., R8's guardian unequivocally denied ever refusing any kind of therapy for R8. Review of a Speech Therapy-SLP Evaluation and Plan of Treatment, certification period: 03/14/21-04/24/21 that would allow for SLP (speech-language-pathology) three times a week for six weeks, reflected R8 . demonstrates good rehab potential as evidenced by ability to follow 1-step directions, ability to imitate targets, ability to learn new information, active participation in skilled treatment, attentive to tasks, compliance with techniques, good self-monitoring skills, supportive caregivers/staff and recognition of familiar people . A physician signature, on 03/16/21, certified that the need for SLP therapy services were medically necessary .Reason for Referral-change in patient's cognitive status .Clinical Impressions: (R8) was alert and cooperative for duration of evaluation. Areas of challenge were noted to be word finding and immediate memory. Areas of strength were found to be temporal and spatial orientation. (R8) would benefit from skilled interventions to targeting cognition and word finding abilities to enhance (R8's) ability to effectively communicate wants/needs and recall daily information/events .Reason for Skilled Services- (R8) requires skilled SLP services for cognition/communication to develop and instruct in compensatory strategies, enhance cognitive skills, facilitate immediate memory, improve ability to communicate self-care and/or medical needs, improve cognitive-linguistic skills and increase verbal problem solving .Risk Factors: Due to the documented physical impairments and associated functional deficits, without skilled therapeutic intervention, the patient is at risk for; increased dependency upon caregivers, decreased participation with functional tasks, decreased leisure task participation and further decline in function. Review of a Speech Therapy-SLP Discharge Summary, dated 03/14/21, reflected Reason for Discharge: 'other'. No other explanation was found in the record for why an SLP evaluation was completed, treatment was authorized, and then services were discontinued. Review of an Occupational Therapy- OT Evaluation & Plan of Treatment, for R8, Certification Period: 06/22/21-07/21/21, reflected the following: (a) Patient Goals: to stand and walk again, (b) Reason for Referral: (R8) referred to OT secondary to infusions secondary to MS diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . (R8) is motivated to get better and participate in therapy, (c) Prior Medical History: (R8) is a LTC (long term care) resident of this facility with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . As of 08/12/21, R8 had not received ongoing Occupational Therapy Services since 11/02/2020. Review of a Physical Therapy-PT Evaluation & Plan of Treatment, for R8, Certification Period: 07/07/21-08/05/21, reflected the following: (a) Patient Goals: Patient to increase functional independence with transfer to get rid of the total lift for bed to wheelchair and walk again, (b) Reason for Referral: (R8) is a LTC resident of this facility with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . As of 08/12/21 R8 had not received ongoing Physical Therapy Services since 12/22/20. During an interview on 08/12/21 at 9:45 A.M., R8 indicated not receiving therapy services at this time. I'm waiting, they said I was gonna start a while ago. During the same interview, CNA U and CNA V stated that R8's mobility has improved a ton since getting the 2 infusions (of [MEDICATION(S)]). (R8) can move toes better, pick up legs, it's amazing. During an interview on 08/12/21 at 10:00 A.M. the Director of Rehabilitative Services (DOR) Q indicated that therapy services for R8 had been denied, couldn't remember exactly why, and would look into the matter. DOR Q requested authorization forms from their corporate office (rehabilitative services are contracted out by the facility) to ascertain the reason for the denial of services. During an interview on 08/12/21 at 11:50 A.M., DOR Q reported that the request for R8's therapy services (OT and PT), made in June and July of 2021, had not been submitted and that was the reason R8 was not currently receiving any rehabilitative services. The previously mentioned denial of services had not occurred. On 08/17/21 at 3:40 p.m., the Director of Nursing (DON) and the Regional Director of Nursing (RDON) were verbally notified and received written notification of the Immediate Jeopardy (IJ) that was identified on 08/17/21, due to the facility's failure to provide coordinated quality care. A written plan for removal of the Immediate Jeopardy was received on 08/18/21 and the following was verified on 08/18/21: 1. On 8/17/21 all residents medical records reviewed to identify any ordered consults in past 30 days. 2. On 8/17/21 assured all consults were addressed and had been acted upon. 3. On 8/17/21 all current residents with therapy orders audited to ensure they have received therapy services. 4. On 8/17/21 reviewed policy/procedure Physician/Practitioner Orders-Consulting to ensure its accuracy and relevance 5. On 8/17/21, re-education initiated for all licensed staff regarding the policy/procedure to ensure appointments/consults are initiated. No Staff will work past 8/18/21 without first receiving education. 6. On 8/18/21 Social Service followed up to assure R8's son continues to be with his guardian/family and remains in a safe environment. Although the Immediate Jeopardy was removed on 08/18/21, the facility remained out of compliance at a scope of pattern and severity of actual harm due the fact that (1) additional residents identified in this citation were also harmed by deficiencies pertaining to the quality of care (2) not all facility staff have received education, and (3) sustained compliance has not been verified by the State Agency. DPS-B Based on observation, interview, and record review, the facility failed to provide quality care for 1 Resident (Resident #320), resulting in the need for emergency medical treatment and two hospitalization s for [CONDITION(S)], after staff failed to (a) provide wound care as ordered by the physician, (b) strictly adhere to infection control practices, (c) provide [CONDITION(S)] care, and (d) treat and monitor wounds resulting in [CONDITION(S)]. Findings: Resident # 320 Review of an Admission Record revealed Resident #320 (R320) was a [AGE] year-old female, originally admitted to the facility on [DATE] with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R320 was non-verbal. During an observation on 8/10/21 at 1:30 P.M. the following was observed for R320: (a) a used suction catheter tip, with dried secretions visible, laid in a bucket of clean supplies, (b) the oxygen concentrator filter was completely covered with a thick layer of dust, and (c) the nebulizer apparatus was not disassembled, moisture noted on the inside, and had been placed in a plastic bag. Review of an Emar/Etar August 2021 reflected the following order for R320: Cleanse coccyx with normal saline wound wash, pat dry, apply ABD (a type of dressing called an abdominal dressing) and tape in place 1 time a day - Start Date 8/6/2021. No documentation noted that the above order was carried out on 8/9, 8/11, 8/12 and 8/13/2021. The E-mar/E-tar entry for 8/14/21 showed a 9, indicating the wound care had not been completed and directed the reviewer to a progress note for clarification and no progress note explaining why the treatment was not done, was in the medical record. Review of Emar/Etar July 2021 for R320 reflected three separate coccyx wound care orders coinciding with R320s various admissions and subsequent discharges to the hospital. Of the three orders reviewed for the month of July 2021, nursing staff failed to implement physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of an Emar/Etar June 2021 for R320 reflected an order: Cleanse sacrum with saline and pack lightly with saline moistened 4x4, cover with ABD and secure with tape bid (twice daily) every evening and night shift for wound. Start date-06/10/21, End date-06/15/21. No documentation was located to show that the wound care was completed on 06/14/21. A new order (a) was started 06/14/21 for wound care for a stage 4 coccyx wound, (b) that included the use of a wound vac, and (c) instructed staff to clean wound and replace wound vac sponge every Monday, Wednesday, and Friday. Start date 06/14/21, D/C date 07/06/21. Per documentation, the new order for wound care (stage 4 coccyx wound) that was to start on 06/14/21 was not initiated until 06/18/21. According to the documentation, R320 did not receive wound care for the stage 4 wound between 06/13/21 and 06/18/21. Additionally, no documentation was present for the ordered wound care and vac sponge change every three days, on 06/28/21 and 06/30/21. Review of Emar's/Etar's for R320 for the months of August 2021, July 2021, and June 2021 revealed an order: Elevate HOB (head of bed) every shift while enteral feed is being administered. No documentation in the records to indicate this order was followed on 6/26/21, 6/28/21, 07/04/21, 07/05/21, 07/16/21, 07/24/21, 07/26/21, and 8/9/21. Review of an Order Recap Summary for R320, date range 05/01/21-08/31/21, reflected an order to: Change disposable inner cannula of [CONDITION(S)] as needed AND every day shift. Start date-06/30/21 and End date-08/03/21. An order to change the disposable inner cannula of R320's [CONDITION(S)], prior to 06/30/21 and after 08/03/21, was not located in the medical record. Review of an Emar/Etar dated July 2021, reflected the above order, to change disposable inner cannula of the [CONDITION(S)] daily, was not documented as completed for R320 on 07/05, 07/16, 07/24, and 07/26. Review of Hospital Records for R320, course of treatment from 07/28/21 to 08/05/21 revealed the following: 07/28/21-R320 presented to the ER from the nursing home, nursing home reported R320 had fevers the past couple of days with the most recent fever being 104.2, R320 received 1 liter of [MEDICATION(S)] IV bolus via EMS prior to arrival at ER. Physical Exam: Pulse 124, temperature 102.1, mouth-oral mucosa appears dry, film noted on tongue .Plan: (1) [CONDITION(S)]- concern for [C

This citation pertains to intake #MI00- 8 and MI00- 9 Based on observation, interview and record review the facility failed to develop and implement comprehensive resident focused care plans based on a comprehensive assessment for 3 residents (Resident #4, Resident #320 and Resident #9), resulting in unidentified care needs and hospitalization as the result of complications from inadequate provision of care according to standards of practice. Findings: Resident #320 (R320) Review of an Admission Record revealed Resident #320 (R320) was a [AGE] year-old female, originally admitted to the facility on [DATE] with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R320 was non-verbal. During an observation on 8/10/21 at 1:30 P.M. the following was observed for R320: (a) a used suction catheter tip, with dried secretions visible, laid in a bucket of clean supplies, (b) the oxygen concentrator filter was completely covered with a thick layer of dust, and (c) the nebulizer apparatus was not disassembled, moisture noted on the inside, and had been placed in a plastic bag. Review of a Care Plan Report reflected the following focus area for R320 was initiated on 6/10/21 (over a month after R320 admitted to the facility), The resident has a [CONDITION(S)] r/t (related to) acute and chronic [CONDITION(S)] with [CONDITION(S)], [CONDITION(S)], cerebral infarction, [CONDITION(S)]. Shiley #6 DCIF (a kind of disposable inner cannula). Goals pertaining to the focus area included: (1) The resident will have no abnormal drainage around [CONDITION(S)] site through the review date, (2) The resident will have no signs or symptoms of infection through the review date, and (3) The resident's [CONDITION(S)]/cannula cleaning needs will be met by staff as evidenced by patency of [CONDITION(S)]. Interventions to achieve the goals of the focus area included: (a) Ensure that [CONDITION(S)] ties are secure at all times (b) monitor/document respiratory rate, depth and quality. Check and document every shift, (c) Observe stoma for redness, [CONDITION(S)], or skin breakdown, (d) Provide good oral care daily and as needed, (e) Reassure resident to decrease anxiety, (f) Replace [CONDITION(S)] collar as ordered, (g) Suction as necessary, (h) [CONDITION(S)] care every shift and as needed, (i) TUBE OUT PROCEDURES: Keep extra [CONDITION(S)] tube and obturator at bedside. If tube is coughed out, open stoma with hemostat. If tube cannot be reinserted, monitor/document for signs of respiratory distress. If able to breath spontaneously, elevate HOB (head of bed) 45 degrees and stay with resident. Obtain medical help IMMEDIATELY, and (j) Use UNIVERSAL PRECAUTIONS as possible. Review of an Order Recap Summary for R320, date range 05/01/21-08/31/21, reflected an order to: Change disposable inner cannula of [CONDITION(S)] as needed AND every day shift. Start date-06/30/21 (nearly two months after R320 admitted to the facility) and End date-08/03/21. An order to change the disposable inner cannula of R320's [CONDITION(S)], prior to 06/30/21 and after 08/03/21, was not located in the medical record. Review of an Emar/Etar dated July 2021, reflected the above order, to change disposable inner cannula of the [CONDITION(S)] daily, was not documented as completed for R320 on 07/05, 07/16, 07/24, and 07/26. Review of Hospital Records for R320, course of treatment from 07/28/21 to 08/05/21 revealed the following: 07/28/21-R320 presented to the ER from the nursing home, nursing home reported R320 had fevers the past couple of days with the most recent fever being 104.2, R320 received 1 liter of [MEDICATION(S)] IV bolus via EMS prior to arrival at ER. Physical Exam: Pulse 124, temperature 102.1, mouth-oral mucosa appears dry, film noted on tongue .Plan: (1) [CONDITION(S)]- concern for [CONDITION(S)] but also findings of [CONDITION(S)] of the sacrum and coccyx seen on CT. Consult placed to infectious disease as well as orthopedic surgery. Order for wound culture placed. (2) Chronic [CONDITION(S)]- Hemoglobin actually improved from baseline but suspect this is related to a dehydrated state. (3) [CONDITION(S)]-concern for dehydration. (4) Concern for aspiration pneumonia on CXR (chest x-ray). (5) No excretion within the kidneys on the delayed kidney images raising the concern for potential developing acute renal failure. 07/29/21-Inpatient Physician Consultation: R320 was admitted to the hospital for [CONDITION(S)] related to wound infection, [CONDITION(S)], and possible aspiration on 07/28/21. Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] . This is R320's fifth hospitalization in 5 months for respiratory concerns and [CONDITION(S)]. Review of Hospital Records for R320, course of treatment from 08/15/21 to 08/23/21 revealed the following: (a) on 08/15/21 R320 presented to the ER from the nursing home for shortness of breath and a fever, (b) R320 was warm and had dry mucous membranes, (c) very dry brown foreign residue on the roof of the mouth, (d) green discharge from the trachea tube, (e) temperature 103.5, pulse 155, respirations 22, and WBC (white blood count) was 18.7, (f) on arrival patient looked dry, feverish, and sweaty, (g) R320's [CONDITION(S)] was suctioned multiple times-small amounts of thick green mucous removed, (h) concern for dehydration-started on aggressive hydration, (i) an x-ray of the patient's right forearm was completed due to a possible injury, contusion of posterior elbow, and (j) an APS (adult protective services) report was done due to the physical state the patient was in when (R320) arrived to the hospital. During an interview on 8/27/21 at 5:20 P.M., Hospital Registered Nurse (HRN) PP indicated R320 was admitted to the hospital floor from the ER, into the care of HRN PP and the following were observed: (a) R320 had dried tube feed material caked in (R320's) hair, (b) the tube feed was plugged and non-functional, (c) R320's sacral wound had dried stool packed in the wound, (d) new skin concerns were observed since R320's last hospitalization , per previous hospital documentation reviewed by HRN PP, and (e) R320's [CONDITION(S)] presented with thick dried sputum that had dried to the inner and outer portions of the [CONDITION(S)]. Resident #9 (R9) Review of an Admission Record revealed Resident #9 (R9) was a [AGE] year-old male, originally admitted to the facility on [DATE], with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R9 had severe cognitive impairment, was in a neurovegatative state, and was dependent on staff for all activities of life. During an observation on 08/24/21 at 8:10 A.M., (which lasted 30 minutes) two CNA's completed peri care for R9 and then the following were noted: (a) R9 coughed multiple times; wet, productive, thick secretions were heard (b) the suction cannister was almost full of secretions, (c) the tonsil suction tip at bedside was used and dried secretions were visible on and in the suction tip, (d) the breathing treatment apparatus, sat on the bedside table, was put together and had moisture in the mask and chamber-indicating it had been used and not taken apart and cleaned, (e) a CNA alerted nursing to R9's coughing and RN HH responded, (f) the suction cannister was changed and RN HH could not locate a new clean suction tip and began suctioning R9 with the previously used tonsil suction tip, (g) RN HH requested a pulse oximeter and it took staff 5 minutes to locate a functioning pulse oximeter, (h) initial pulse oximetry reading was 83%, (i) multiple suctions were required to clear the secretions, (j) lung sounds were not assessed once suctioning was completed, and (k) RN HH did not know when the last time R9 was suctioned-reported not receiving any information about suctioning at shift exchange, (l) RN HH administered [MEDICATION(S)] drops (used to help reduce secretions), did not massage them in to the cheek as directed, and then suctioned R9's mouth again, and (m) RN HH' noted that the [MEDICATION(S)] patch (used to prevent secretions) on R9 was dated 8-16 and should have been changed by now. Review of an Electronic Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the entire Care Plan Report for R9, who admitted to the facility on [DATE] did not reflect care plan focus areas, goals or interventions to address R9's need for suctioning or the management of excess secretions, management of suction equipment and related monitoring. Review of R9's July and August 2021 Emar/Etar's reflected two orders for medications to be administered to R9 twice daily every day, for constipation (Docu Liquid and Sennoside). No additional orders were located for any PRN (as needed) medications to be administered to R9 if constipation developed. Review of a POC (Point of Care) Response History document-Task: Bowel & Bladder Monitor: Bowel Elimination revealed R9 (a) did not have a bowel movement for 5 days, between the morning of 07/30/21 and the afternoon of 08/04/21 and (b) did not have a bowel movement for 5 days, between the evening of 08/20/21 and the morning of 08/25/21. Review of Care Plans for R9 revealed no specific goals or interventions listed to assess for, monitor, and treat constipation. Resident #4 (R4) Review of an Admission Record revealed R4 was a [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R4 was admitted to the facility after being treated at the hospital 05/27/21 through 06/03/21 for [CONDITION(S)] and a [CONDITION(S)]. A left lung nodule, newly found during this hospitalization , was deemed suspicious of cancer. Review of a Care Plan for R4: FOCUS-The resident has and/or is at risk for pressure ulcer development to the following areas-feet related to deformities and loss of sensation, GOAL-The resident's pressure ulcer will progress through the healing process and remain free from infection, INTERVENTIONS- (a) Administer treatments as ordered and evaluate for effectiveness, (b) Daily skin evaluations by licensed nurse if current pressure ulcer (see TAR), Evaluate dressing every shift to ensure it is intact and adhering. Report loose dressing to treatment nurse, and (c) Monitor/document/report any changes in skin status: appearance, color, wound healing, s/sx (signs and symptoms) of infection, wound size (length x width x depth), stage. All initiated on 06/04/21. Review of a Care Plan for R4: FOCUS-The resident has potential for fluid volume deficit, GOAL- The resident will be free of symptoms of dehydration and maintain moist mucous membranes, good skin turgor, INTERVENTIONS- (a) Monitor and document intake and output as per facility policy, (b) Monitor for changes in mental status, (c) Monitor vital signs as ordered/per protocol and record. Notify MD of significant abnormalities, (d) Administer medications as ordered. Monitor/document for side effects and effectiveness, and (e) Refer to dietary/RD as appropriate. All initiated 06/04/21. Review of a Care Plan for R4: FOCUS-The resident has hypertension, GOAL-The resident will remain free from s/sx of hypertension through the review date, INTERVENTIONS-(a) Avoid taking the blood pressure reading after physical activity or emotion distress, (b) Educate the resident/family/caregiver about: the importance of maintaining a normal weight for height, the value of regular exercise, limiting salt intake, the adverse effects of tobacco and alcohol, the importance of medication and diet compliance, (c) give anti-hypertensive medications as ordered. Monitor for side effects such as [CONDITION(S)] and increased heart rate ([CONDITION(S)]) and effectiveness, (d) Monitor for and document any [CONDITION(S)]. Notify MD and (e) Monitor/document/report to MD PRN any s/sx of malignant hypertension: Headache, visual problems, confusion, disorientation, lethargy, nausea and vomiting, irritability, [CONDITION(S)] activity, difficulty breathing (Dyspnea). All initiated on 06/04/21. Review of an Inpatient Discharge Summary for R4, dated 06/03/21, revealed the following brief overview of R4's inpatient hospital stay from 05/27/21 to 06/03/21: (a) Primary Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . (c) Blood cultures were obtained and these were positive for group C Streptococcus, imaging was negative for any other source of infection, (d) Infectious Disease specialty and podiatry both evaluated the patient, (e) started IV [MEDICATION(S)] for total of 14 day course stop date will be 6/9/21, and (f) patient to follow up with the (Wound Treatment Center) for the left toe ulcer and infection, address and phone number listed, with instructions to call in 1 week. Review of an admission Hydration Risk Evaluation completed on 06/04/21, reflected the following omissions and subsequent incorrect score determination and plan of care for R4's hydration risk: SECTION f. Health conditions: (identify if the resident has any of the following)- Diabetes was not selected, diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The only health condition selected in this section was Unstable acute or chronic condition. SECTION h. Measure systolic blood pressure while sitting and 1 and 3 minutes after standing- the answer selected was no drop in pressure noted. No record of the blood pressures recorded to make that determination were found in the medical record. Review of a Nursing Admission Evaluation Part 1, dated 06/03/21, reflected the following assessments: (1) FALL RISK EVALUATION A. 8. measure systolic blood pressure (BP) while lying, sitting, and 1 and 3 minutes after standing-unable to obtain, reason could not measure: resident too weak to sit and stand. (2) SKIN A. 1. Identified skin conditions/wounds- listed all skin concerns for R4 at time of admission including 4th toe on left foot, pressure, 0.9 x 0.9 cm, unstageable. Review of a Nursing Admission Evaluation Part 2, dated 06/04/21, reflected the following assessment under NUTRITIONAL & HYDRATION RISK A. 2. Dehydration risk as evidenced by .(c) dependent on staff for provision of fluid intake .(g) IV medication . and, (l) use of diuretics or cardiovascular agents. Review of an SOC-INFECTION progress note dated 06/07/21, revealed R4 was currently receiving an antibiotic and listed the intervention as: increase fluids. Review of an SOC-SKIN progress note dated 06/11/21, revealed R4 had 3 open areas of skin at admission: (1) left foot fourth digit, (2) left knee, and (3) left elbow. Measurements were listed for each area of concern. It was unclear if the facility had followed up with the Wound Treatment Center as instructed on the Inpatient Discharge Summary. Review of an Electronic Treatment Administration Record (Etar) for R4, dated June 2021, reflected one order related to the monitoring of and treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Start date-06/09/21 and D/C date-06/08/21. No monitoring of the 4th toe left foot was documented. Review of a Nursing Home 30/60 Day Visit physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of blood pressures recorded for R4, in addition to the two low blood pressures listed above, reflected the following low blood pressure readings: 06/13/21 BP-78/61, 06/18/21 BP-85/39, 06/18/21 BP-93/52, 06/19/21 BP-95/52, 06/22/21 BP-99/65, 06/22/21 BP-99/50, 06/23/21 BP-96/49, 06/26/21 BP-99/52, 06/30/21 BP-92/51, 07/02/21 BP-93/57, 07/07/21 BP-100/54, 07/10/21 BP-94/56, 07/14/21 BP-90/50, 07/17/21 BP-87/48, 07/19/21 BP-75/38, (R4 was hospitalized from 07/22/21 to 08/05/21), 08/23/21 BP-90/53, 08/25/21 BP-92/47, 08/25/21 BP-97/46. Review of an Emar/Etar for R4, dated June 2021, revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Hold if SBP (systolic blood pressure) is less than 100. Start date-06/30/21, D/C date-07/27/21. Further review of the Emar/Etar reflected the following: (a) on 06/22/21 at 2 P.M. R4's BP was 99/65 and the medication was given, (b) on 06/23/21 at 2 P.M. R4's BP was 96/49 and the medication was given. Review of an Emar/Etar for R4, dated July 2021, revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Hold if SBP (systolic blood pressure) is less than 100. Start date-06/30/21, D/C date-07/27/21. Further review of the Emar/Etar reflected the following: (a) on 07/02/21 at 10 P.M. R4's BP was 93/57 and the medication was given, (b) on 07/10/21 at 10 P.M. R4's BP was 94/56 and the medication was given. Review of a Nursing Home 30/60 Day Visit physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Fall Incident Accident Report for R4, dated 07/18/21, revealed that R4 was being transferred via sit to stand lift, R4 became weak and fell out of the sling and came to rest on the floor. Factors identified that may have contributed to the fall: weakness, [CONDITION(S)], using a sit to stand. Did orthostatic BP's suggest the BP change contributed to the fall? N/A (non-applicable) was written in. Recommendations made (a) for therapy to evaluate transfer status and (b) facility physician to evaluate BP medications. No indication was made that prior low BP's were reviewed after the fall. BP was recorded as 87/48 on 07/17/21, one day before the fall occurred. Review of a Nursing Progress Note, dated 07/21/21 at 12:34 P.M. reflected that the facility physician was made aware of R4's periodic low blood pressure, medications adjusted, see orders. Per MEDICATION ORDERS FOR [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of an Alert Progress Note, dated 07/23/21 at 07:15 A.M., reflected that R4 was sleeping all the time. fell asleep on bed pan. Sent to ER for eval and treatment. Review of an Alert Progress Note, dated 07/23/21 at 07:16 A.M., reflected the following for R4: no bowel movement documented for 64 hours- hospitalized . Review of a Transfer Form dated 07/22/21 at 10:39 A.M., reflected the following information regarding R4's transfer to the ER: (a) report was called to the ER by facility nursing staff on 07/22/21 at 11:00 A.M., (b) vitals signs including blood pressure, pulse, respirations, and temperature, that were listed on the Transfer Form were last collected at 1:19 A.M. on 07/22/21. No set of current vitals were taken and reported to the ER or facility physician, (c) current mental status- alert, disoriented, but cannot follow simple instructions (this was a documented change from R4's usual mental status), (e) Additional Relevant Information: resident had fall to floor on 7-18-21 without injury or hitting head. Increased confusion with transfer and has exhibited several episodes of projectile emesis and this morning. Refusing to eat meals with blood sugars low in 70-80, resident is a diabetic. Fluids offered and often refused. Requires extensive assistance with bed mobility and all aspects of care. Review of Dietary Progress Notes and physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] .M. Additionally, documentation related to R4's refusal of fluids and meals was not located in the nursing progress notes as well. POC Response History documentation-Fluid Intake: reflected that R4 had refused fluids the morning of 07/16/21, at each meal on 07/17/21, and the morning of 07/18/21. Review of a SBAR Communication Form for R4, dated 07/22/21 at 10:56 A.M. reflected the following information regarding R4's condition prior to transfer to the ER: (a) instructions for staff to check vital signs before calling the facility prescriber was checked as completed, (b) vital signs including blood pressure, pulse, respirations, and temperature, that were listed on the SBAR Communication Form were last completed at 1:19 A.M. on 07/22/21. No set of current vitals were taken and reported to the facility physician or ER, (c) Mental Status Changes: increased confusion and decreased consciousness were noted, (d) GI (gastrointestinal)/Abdomen concerns noted: vomiting and decreased appetite. Review of Hospital Records for R4, relevant to hospital stay 07/22/21 to 08/05/21, revealed the following information: (a) Per ED triage note: Pt (patient) here via EMS with c/o (complaints of) weakness for the past 3 days and projectile vomiting. Pt denies any pain or nausea on arrival. Pt is alert and answering questions, (b) Per ED Physician note: Pt presented to ED from (facility) with complaints of emesis and generalized weakness .Pt explained that symptoms started last night and reports the last time Pt urinated was also last night .Per triage notes, the Pt stated the symptoms have been going on for the past 3 days, (c) Blood work revealed the following lab levels: White Blood Count-13.4, Potassium-6.2 (normal range is 3.5 to 5.0) [CONDITION(S)], BUN-131 (normal range varies but is close to 6-18), (d) Pt has no prior history of kidney disease, (d) nephrology consult obtained- they will arrange for emergent hemodialysis (ultimately the Pt responded well to fluid replacement and treatment, therefore R4 did not require emergent hemodialysis), (e) Electrocardiogram demonstrates normal [MEDICATION(S)] rhythm with Right Bundle Branch Block and peaked T waves (associated with the very high Potassium level). Prior tracing reveals incomplete Right Bundle Branch Block, (f) Clinical Impression: Acute Renal Failure, [CONDITION(S)], Acute electrocardiogram changes, and Metabolic Acidosis (likely due to severe dehydration), treatment plan in place, (g) SLP (speech, language, pathology) evaluation, completed 07/26/21, revealed R4 complained of a sore throat and had a painful grimace on face with each swallow, (h) physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . R4 had [CONDITION(S)] (redness) affecting the uvula and palatal glossal arch bilaterally-treatment plan initiated, ENT to evaluate, (i) discharge planning-Pt may return to (facility) when appropriate oral food intake is achieved, family may select a different extended care facility given dissatisfaction with the care at R4's prior facility, (j) lung biopsy completed on 08/02/21, during inpatient hospital stay, and was found to be [CONDITION(S)], and (k) R4 was discharged from the hospital in stable condition back to (facility) on 08/05/21.

This citation pertains to intake #MI00- 8 and #MI00- 9 Based on observation, interview and record review, the facility failed to prevent the development and worsening of pressure ulcers and implement treatments and monitoring for pressure ulcer prevention and healing for 3 residents (Resident #320, Resident #9, and Resident #4) resulting in infection, hospitalization and avoidable development and worsening of pressure ulcers. Findings: Resident #320 (R320) Review of an Admission Record revealed Resident #320 (R320) was a [AGE] year-old female, originally admitted to the facility on [DATE] with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R320 was non-verbal. Review of a Care Plan Report reflected R320 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . A goal for the care plan initiated on 5/20/21, revised 6/23/21 was that (R320's) risk of significant skin injury will be reduced/minimized. A second goal initiated on 6/10/21, revised on 6/23/21 was (R320) will have no complications related to skin impairment. Interventions to reach the goals of the focus area included: (a) Float heels while resident in bed, (b) Reposition frequently for comfort and pressure relief, (c) Follow facility protocols for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] ., (f) Monitor/document location, size and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . to physician/provider, (g) Obtain blood work such as complete blood count with differential (CBC with diff), blood cultures and culture and sensitivity (C&S) of any open wounds as ordered by physician, (h) The resident uses the following devices to relieve pressure (pressure reducing mattress), (i) Use a draw sheet or lifting device to move resident (maxi slide), (j) Use caution during transfers and bed mobility to prevent striking arms, legs and hands against any [NAME] or hard surface, (k) Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate and any other notable changes or observations. Review of an Emar/Etar August 2021 reflected the following order for R320: Cleanse coccyx with normal saline wound wash, pat dry, apply ABD (a type of dressing called an abdominal dressing) and tape in place 1 time a day - Start Date 8/6/2021. No documentation noted that the above order was carried out on 8/9, 8/11, 8/12 and 8/13/2021. The E-mar/E-tar entry for 8/14/21 showed a 9, indicating the wound care had not been completed and directed the reviewer to a progress note for clarification and no progress note explaining why the treatment was not done, was in the medical record. Review of Emar/Etar July 2021 for R320 reflected three separate coccyx wound care orders coinciding with R320s various admissions and subsequent discharges to the hospital. Of the three orders reviewed for the month of July 2021, nursing staff failed to implement physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of an Emar/Etar June 2021 for R320 reflected an order: Cleanse sacrum with saline and pack lightly with saline moistened 4x4, cover with ABD and secure with tape bid (twice daily) every evening and night shift for wound. Start date-06/10/21, End date-06/15/21. No documentation was located to show that the wound care was completed on 06/14/21. A new order (a) was started 06/14/21 for wound care for a stage 4 coccyx wound, (b) that included the use of a wound vac, and (c) instructed staff to clean wound and replace wound vac sponge every Monday, Wednesday, and Friday. Start date 06/14/21, D/C date 07/06/21. Per documentation, the new order for wound care (stage 4 coccyx wound) that was to start on 06/14/21 was not initiated until 06/18/21. According to the documentation, R320 did not receive wound care for the stage 4 wound between 06/13/21 and 06/18/21. Additionally, no documentation was present for the ordered wound care and vac sponge change every three days, on 06/28/21 and 06/30/21. Review of Hospital Records for R320, course of treatment from 07/28/21 to 08/05/21 revealed the following: 07/28/21-R320 presented to the ER from the nursing home, nursing home reported R320 had fevers the past couple of days with the most recent fever being 104.2, R320 received 1 liter of [MEDICATION(S)] IV bolus via EMS prior to arrival at ER. Physical Exam: Pulse 124, temperature 102.1, mouth-oral mucosa appears dry, film noted on tongue .Plan: (1) [CONDITION(S)]- concern for [CONDITION(S)] but also findings of [CONDITION(S)] (inflammation/infection of bone and bone marrow usually caused by bacteria) of the sacrum and coccyx seen on CT. Consult placed to infectious disease as well as orthopedic surgery. Order for wound culture placed .07/29/21-Inpatient Physician Consultation: R320 was admitted to the hospital for [CONDITION(S)] related to wound infection, [CONDITION(S)], and possible aspiration on 07/28/21. Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] . This is R320's fifth hospitalization in 5 months for respiratory concerns and [CONDITION(S)]. 07/29/21- Wound, Ostomy & Continence Nurse evaluation revealed the following information about R320's two pressure injuries: #1-Sacrum, Stage 4 Pressure Injury; present on admission (full thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer; slough and/or eschar may be visible .measures 7.2 x 10 x 3.3 cm with undermining 9-1:00 o'clock at 2.4cm. Wound bed is pink and non-granular with some exposed bone and yellow slough. Peri-wound is intact with some new areas of breakdown with signs of pressure. Physician completed bedside sharp debridement of sacral wound. #2-Right 5th metatarsal head, Unstageable Pressure Injury, present on admission; (full thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar, if slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed .0.7 x 1 0.1 cm with dry stable eschar. 07/30/21-PICC (peripherally inserted central catheter-used to administer antibiotics) inserted, right arm, single lumen in basilic vein. 08/05/21- Registered Nurse attempted to give report to facility regarding discharge from hospital today, was left on hold. Review of a Nursing Readmission Evaluation dated 08/05/21, reflected the following skin concerns for R320, noted by nursing, upon readmission to the facility on [DATE]: SITE-Coccyx, TYPE-Pressure, LENGTH, WIDTH, DEPTH-no measurements were documented, and STAGE-2. The unstageable pressure ulcer on R320's right fifth metatarsal head, was not noted in the evaluation. Review of a Skilled Daily-Medically Complex progress note, dated 08/10/21 at 4:11 P.M., reflected that R320 had the following skin concerns at the time of the assessment-none. Review of a Skilled Daily-Medically Complex progress note, dated 08/11/21 at 4:11 P.M., reflected that R320 had the following skin concerns at the time of the assessment-none. Review of a Skilled Daily-Medically Complex progress note, dated 08/12/21 at 4:11 P.M., reflected that R320 had the following skin concerns at the time of the assessment-none. Review of a Skin Assessment for R320 dated 8/12/2021 reflected: Any new abnormal skin areas-no, existing abnormal skin areas-yes: (1) Coccyx stage 4, no measurements or wound description were given and (2) left knee scab. Review of a Skilled Daily-Medically Complex progress note, dated 08/13/21 at 4:11 P.M., reflected that R320 had the following skin concerns at the time of the assessment-Abnormal skin conditions. Review of a Skilled Daily-Medically Complex progress note, dated 08/13/21 at 10:00 P.M., reflected that R320 had the following skin concerns at the time of the assessment-none. Review of a Skilled Daily-Medically Complex progress note, dated 08/14/21 at 9:00 A.M., reflected that R320 had the following skin concerns at the time of the assessment-Abnormal skin conditions. Review of Hospital Records for R320, course of treatment from 08/15/21 to 08/23/21 revealed the following: (a) on 08/15/21 R320 presented to the ER from the nursing home for shortness of breath and a fever, (b) R320 was warm and had dry mucous membranes, (c) very dry brown foreign residue on the roof of the mouth, (d) green discharge from the trachea tube, (e) temperature 103.5, pulse 155, respirations 22, and WBC (white blood count) was 18.7, (f) on arrival patient looked dry, feverish, and sweaty, (g) R320's [CONDITION(S)] was suctioned multiple times-small amounts of thick green mucous removed, (h) concern for dehydration-started on aggressive hydration, (i) an x-ray of the patient's right forearm was completed due to a possible injury, contusion of posterior elbow, and (j) an APS (adult protective services) report was done due to the physical state the patient was in when (R320) arrived to the hospital. Review of an Inpatient Consult to Wound, Ostomy, & Continence Nurse, dated 08/16/21, revealed the following skin concerns for R320 at admission to the hospital 1. Right calf, Deep Tissue Pressure Injury 2. Right foot 5th metatarsal head, 1 x 0.5 x 0.1cm, dry stable eschar 3. Bilateral heels blanchable [CONDITION(S)] 4. Left knee, trauma wound 1.5 x 1.5 x 0.1cm, dry stable eschar 5. Left elbow, blanchable [CONDITION(S)] 6. Right elbow, Deep Tissue Pressure Injury, 7. Right posterior [MEDICATION(S)] area, Deep Tissue Pressure Injury 8. Right axilla, intact fluid filled blister with pink base, unknown etiology 9. Sacrum Stage 4 Pressure Injury, measures 6.5 x 11 x 2cm, with undermining from 7-10 o'clock at 2cm. Peri wound with tape trauma partial thickness on Right buttock, other peri-wound area with some redness. Per nurse, sacral dressing on admission was full of stool. During an interview on 8/27/21 at 5:20 P.M., Hospital Registered Nurse (HRN) PP indicated R320 was admitted to the hospital floor from the ER, into the care of HRN PP and the following were observed: (a) R320's sacral wound had dried stool packed in the wound, (b) new skin concerns were observed since R320's last hospitalization , per previous hospital documentation reviewed by HRN PP. Resident #9 (R9) Review of an Admission Record revealed Resident #9 (R9) was a [AGE] year-old male, originally admitted to the facility on [DATE], with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R9 had severe cognitive impairment, was in a neurovegatative state, and was dependent on staff for all activities of life. During an observation on 08/20/21 at 9:19 A.M., R9 was observed with two small sores that were visible on R9's right ear (one on the outer ear and one where the top part of the ear connects to the head). R9 wore oxygen tubing that sat on the second area. Review of R9's Emar/Etar for August 2021, July 2021, and June 2021, revealed no medications or treatments were ordered to care for the 2 small sores on the right ear, as described in the above observation made on 08/20/21 at 9:19 A.M. During an observation on 08/24/21 at 8:10 A.M., two small sores were visible on R9's right ear (one on the outer ear and one where the top part of the ear connects to the head). R9 wore oxygen tubing that rested on the second area. No dressings were visible. During an interview on 08/24/21 at 12:05 P.M., Family Member (FM) FF reported visiting R9 three times a week and had just placed a dressing on R9's right ear between the skin and oxygen tubing. FM FF also reported making and placing the dressing because the sores on R9's right ear were not getting any better. During an interview on 08/24/21 at 12:10 P.M. and while observing R9, Wound Care Nurse (WCN) M identified the 2 areas of skin concern on R9's right ear, indicated not knowing one area was open, and proceeded to obtain pictures and measurements of the two areas of skin damage on the right ear. Following the observation, WCN M completed a Skin/Wound Evaluation that described the two skin concerns on R9's right ear as stage 2 pressure ulcers. During an observation on 08/24/21 at 8:08 A.M., Certified Nurse Aide (CNA) N and CNA F provided peri care to R9 and when R9 was positioned on the right side, a dressing with the date 08/15 was on R9's thigh/ buttock. When asked about the dressing, neither CNA knew about the wound. Review of records relevant to R9's right ear and thigh/buttock skin concerns reflect inconsistencies and are as follows: 1. The last Skin & Wound Evaluation (used to document known existing skin concerns that require monitoring) located in R9's medical record was dated 04/13/21. 2. Skin assessment dated [DATE], reflected: no new existing skin concerns were observed, and yes existing area of abnormal skin included right ear-0.4cm (centimeters) x 2 cm- area blanchable. No documentation of any treatment implemented for the skin concern. 3. Skin assessment dated [DATE], reflected: no new existing skin concerns were observed, and no existing abnormal skin areas were observed. 4. Skin assessment dated [DATE], reflected: no new existing skin concerns were observed, and no existing abnormal skin areas were observed (related to R9's right ear or buttock). 5. Skin assessment dated [DATE], reflected: no new existing skin concerns were observed, and yes existing area of abnormal skin included right ear-red area. No description or measurements of the skin concern was documented nor treatment, if any, implemented to treat the abnormal skin area. 6. Skin assessment dated [DATE], reflected: no new existing skin concerns were observed, and yes existing area of abnormal skin included left ear-small sore developed. No description or measurements of the skin concern was documented. Put on Band-Aid was listed for the treatment administered. 7.Skin assessment dated [DATE], reflected: no new existing skin concerns were observed, and yes existing area of abnormal skin included right ear-slight abrasion. No description or measurements of the skin concern was documented nor treatment, if any, implemented to treat the abnormal skin area. 8. Skin assessment dated [DATE], reflected: no new existing skin concerns were observed, and no existing abnormal skin areas were observed. 9. Skin assessment dated [DATE], reflected: no new existing skin concerns were observed, and yes existing area of abnormal skin included right ear. No description or measurements of the skin concern was documented nor treatment, if any, implemented to treat the abnormal skin area. The dressing and skin concerns on R9's thigh/buttock were not mentioned in the note. Review of a POC (Point of Care) Response History document-Task: Monitor Skin: revealed (a) on 08/10/21 at 12:21 P.M. and on 08/15/21 at 1:59 P.M., nurse aides documented open area found on R9, and (b) on 08/14/21 at 1:57 P.M., documented red area found on R9. As referenced above, the Skin assessment dated [DATE], reflected that R9 had no new areas of skin concern and no existing areas of skin concern. Review of R9's nursing progress notes revealed there were no daily nursing notes between 08/08/21 to 08/20/21. Therefore, unable to ascertain if the above mentioned 3 POC-Task: Monitor Skin concerns from 08/10/21, 08/15/21, or 08/14/21 were reported to nursing staff. During an interview on 08/24/21 at 11:00 A.M. RN HH and Facility Physician J, while rounding on residents, stated that they were not aware of a dressing on R9's thigh/buttock, dated 08/15, nor that there had been any reported concerns with skin breakdown on R9's thigh/buttock. Review of a Care Plan Report reflected the following focus area initiated for R9 on 2/07/20, revised on 7/16/21: At risk for impaired skin integrity and moisture associated skin [CONDITION(S)] (MASD) related to a history of MASD to right and left buttocks, incontinence of bowel & bladder, impaired mobility, hx/of (history of) pressure wound to right ear, has nasal canula for O2 (oxygen) & PEG tube. The only goal for the care plan focus area was MASD will heal without becoming infected. Interventions to meet the goal of the focus area did not specifically address R9's risk for developing a pressure sore on his ear as identified in the focus area. Interventions included the following: (a) Keep off excoriated area as much as possible and as much as the resident can/will comply, (b) Medications/Treatments as ordered-electronic health record for specific instructions, (c) observe are for increased redness/drainage/[CONDITION(S)]. Notify the physician as needed, (d) Observe for sxs (signs and symptoms) of pain-administer analgesics as ordered. Observe for effectiveness and complications, (e) Standard precautions, (f) Use care when moving resident to prevent friction and shear as much as possible and as much as the resident can/will allow. Resident #4 (R4) Review of an Admission Record revealed R4 was a [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R4 was admitted to the facility after being treated at the hospital 05/27/21 through 06/03/21 for [CONDITION(S)] and a [CONDITION(S)]. A left lung nodule, newly found during this hospitalization , was deemed suspicious of cancer. Review of an Inpatient Discharge Summary for R4, dated 06/03/21, revealed the following brief overview of R4's inpatient hospital stay from 05/27/21 to 06/03/21: (a) Primary Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . (c) Blood cultures were obtained and these were positive for group C Streptococcus, imaging was negative for any other source of infection, (d) Infectious Disease specialty and podiatry both evaluated the patient, (e) started IV [MEDICATION(S)] for total of 14 day course stop date will be 6/9/21, and (f) patient to follow up with the (Wound Treatment Center) for the left toe ulcer and infection, address and phone number listed, with instructions to call in 1 week. Review of a Nursing Admission Evaluation Part 1, dated 06/03/21, reflected the following assessment: (2) SKIN A. 1. Identified skin conditions/wounds- listed all skin concerns for R4 at time of admission including 4th toe on left foot, pressure, 0.9 x 0.9 cm, unstageable. Review of an SOC-SKIN progress note dated 06/11/21, revealed R4 had 3 open areas of skin at admission: (1) left foot fourth digit, (2) left knee, and (3) left elbow. Measurements were listed for each area of concern. It was unclear if the facility had followed up with the Wound Treatment Center as instructed on the Inpatient Discharge Summary. Review of a Care Plan for R4: FOCUS-The resident has and/or is at risk for pressure ulcer development to the following areas-feet related to deformities and loss of sensation, GOAL-The resident's pressure ulcer will progress through the healing process and remain free from infection, INTERVENTIONS- (a) Administer treatments as ordered and evaluate for effectiveness, (b) Daily skin evaluations by licensed nurse if current pressure ulcer (see TAR), Evaluate dressing every shift to ensure it is intact and adhering. Report loose dressing to treatment nurse, and (c) Monitor/document/report any changes in skin status: appearance, color, wound healing, s/sx (signs and symptoms) of infection, wound size (length x width x depth), stage. All initiated on 06/04/21. Review of an Electronic Treatment Administration Record (Etar) for R4, dated June 2021, reflected one order related to the monitoring of and treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Start date-06/09/21 and D/C date-06/08/21. No monitoring of the 4th toe left foot was documented.

This citation pertains to intake #MI00- 8 Based on observation, interview and record review, the facility failed to provide [CONDITION(S)] care and respiratory suctioning according to professional standards for 2 residents (Resident #320 and Resident #9), resulting in complications including hospitalization with pneumonia, missed treatments, cross contamination and failure to assess residents requiring respiratory/[CONDITION(S)] care and suctioning. Findings: Resident # 320 (R320) Review of an Admission Record revealed Resident #320 (R320) was a [AGE] year-old female, originally admitted to the facility on [DATE] with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R320 was non-verbal. During an observation on 8/10/21 at 1:30 P.M. the following was observed for R320: (a) a used suction catheter tip, with dried secretions visible, laid in a bucket of clean supplies, (b) the oxygen concentrator filter was completely covered with a thick layer of dust, and (c) the nebulizer apparatus was not disassembled, moisture noted on the inside, and had been placed in a plastic bag. Review of a Care Plan Report reflected the following focus area for R320 was initiated on 6/10/21 (over a month after R320 admitted to the facility), The resident has a [CONDITION(S)] r/t (related to) acute and chronic respiratory failure with [CONDITION(S)], [CONDITION(S)], cerebral infarction, [CONDITION(S)]. Shiley #6 DCIF (a kind of disposable inner cannula). Goals pertaining to the focus area included: (1) The resident will have no abnormal drainage around [CONDITION(S)] site through the review date, (2) The resident will have no signs or symptoms of infection through the review date, and (3) The resident's [CONDITION(S)]/cannula cleaning needs will be met by staff as evidenced by patency of [CONDITION(S)]. Interventions to achieve the goals of the focus area included: (a) Ensure that [CONDITION(S)] ties are secure at all times (b) monitor/document respiratory rate, depth and quality. Check and document every shift, (c) Observe stoma for redness, [CONDITION(S)], or skin breakdown, (d) Provide good oral care daily and as needed, (e) Reassure resident to decrease anxiety, (f) Replace [CONDITION(S)] collar as ordered, (g) Suction as necessary, (h) [CONDITION(S)] care every shift and as needed, (i) TUBE OUT PROCEDURES: Keep extra [CONDITION(S)] tube and obturator at bedside. If tube is coughed out, open stoma with hemostat. If tube cannot be reinserted, monitor/document for signs of respiratory distress. If able to breath spontaneously, elevate HOB (head of bed) 45 degrees and stay with resident. Obtain medical help IMMEDIATELY, and (j) Use UNIVERSAL PRECAUTIONS as possible. Review of an Order Recap Summary for R320, date range 05/01/21-08/31/21, reflected an order to: Change disposable inner cannula of [CONDITION(S)] as needed AND every day shift. Start date-06/30/21 (nearly two months after R320 admitted to the facility) and End date-08/03/21. An order to change the disposable inner cannula of R320's [CONDITION(S)], prior to 06/30/21 and after 08/03/21, was not located in the medical record. Review of an Emar/Etar dated July 2021, reflected the above order, to change disposable inner cannula of the [CONDITION(S)] daily, was not documented as completed for R320 on 07/05, 07/16, 07/24, and 07/26. Review of Hospital Records for R320, course of treatment from 07/28/21 to 08/05/21 revealed the following: 07/28/21-R320 presented to the ER from the nursing home, nursing home reported R320 had fevers the past couple of days with the most recent fever being 104.2, R320 received 1 liter of [MEDICATION(S)] IV bolus via EMS prior to arrival at ER. Physical Exam: Pulse 124, temperature 102.1, mouth-oral mucosa appears dry, film noted on tongue .Plan: (1) [CONDITION(S)]- concern for [CONDITION(S)] but also findings of [CONDITION(S)] of the sacrum and coccyx seen on CT. Consult placed to infectious disease as well as orthopedic surgery. Order for wound culture placed. (2) Chronic [CONDITION(S)]- Hemoglobin actually improved from baseline but suspect this is related to a dehydrated state. (3) [CONDITION(S)]-concern for dehydration. (4) Concern for aspiration pneumonia on CXR (chest x-ray). (5) No excretion within the kidneys on the delayed kidney images raising the concern for potential developing acute renal failure. 07/29/21-Inpatient Physician Consultation: R320 was admitted to the hospital for [CONDITION(S)] related to wound infection, [CONDITION(S)], and possible aspiration on 07/28/21. Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] . This is R320's fifth hospitalization in 5 months for respiratory concerns and [CONDITION(S)]. Review of Hospital Records for R320, course of treatment from 08/15/21 to 08/23/21 revealed the following: (a) on 08/15/21 R320 presented to the ER from the nursing home for shortness of breath and a fever, (b) R320 was warm and had dry mucous membranes, (c) very dry brown foreign residue on the roof of the mouth, (d) green discharge from the trachea tube, (e) temperature 103.5, pulse 155, respirations 22, and WBC (white blood count) was 18.7, (f) on arrival patient looked dry, feverish, and sweaty, (g) R320's [CONDITION(S)] was suctioned multiple times-small amounts of thick green mucous removed, (h) concern for dehydration-started on aggressive hydration, (i) an x-ray of the patient's right forearm was completed due to a possible injury, contusion of posterior elbow, and (j) an APS (adult protective services) report was done due to the physical state the patient was in when (R320) arrived to the hospital. During an interview on 8/27/21 at 5:20 P.M., Hospital Registered Nurse (HRN) PP indicated R320 was admitted to the hospital floor from the ER, into the care of HRN PP and the following were observed: (a) R320 had dried tube feed material caked in (R320's) hair, (b) the tube feed was plugged and non-functional, (c) R320's sacral wound had dried stool packed in the wound, (d) new skin concerns were observed since R320's last hospitalization , per previous hospital documentation reviewed by HRN PP, and (e) R320's [CONDITION(S)] presented with thick dried sputum that had dried to the inner and outer portions of the [CONDITION(S)]. Resident #9 (R9) Review of an Admission Record revealed Resident #9 (R9) was a [AGE] year-old male, originally admitted to the facility on [DATE], with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R9 had severe cognitive impairment, was in a neurovegatative state, and was dependent on staff for all activities of life. During an observation on 08/24/21 at 8:10 A.M., (which lasted 30 minutes) two CNA's completed peri care for R9 and then the following were noted: (a) R9 coughed multiple times; wet, productive, thick secretions were heard (b) the suction canister was almost full of secretions, (c) the tonsil suction tip at bedside was used and dried secretions were visible on and in the suction tip, (d) the breathing treatment apparatus, sat on the bedside table, was put together and had moisture in the mask and chamber-indicating it had been used and not taken apart and cleaned, (e) a CNA alerted nursing to R9's coughing and RN HH responded, (f) the suction canister was changed and RN HH could not locate a new clean suction tip and began suctioning R9 with the previously used tonsil suction tip, (g) RN HH requested a pulse oximeter and it took staff 5 minutes to locate a functioning pulse oximeter, (h) initial pulse oximetry reading was 83%, (i) multiple suctions were required to clear the secretions, (j) lung sounds were not assessed once suctioning was completed, and (k) RN HH did not know when the last time R9 was suctioned-reported not receiving any information about suctioning at shift exchange, (l) RN HH administered [MEDICATION(S)] drops (used to help reduce secretions), did not massage them in to the cheek as directed, and then suctioned R9's mouth again, and (m) RN HH' noted that the [MEDICATION(S)] patch (used to prevent secretions) on R9 was dated 8-16 and should have been changed by now. Review of an Electronic Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the entire Care Plan Report for R9, who admitted to the facility on [DATE] did not reflect care plan focus areas, goals or interventions to address R9's need for suctioning or the management of excess secretions, management of suction equipment and related monitoring.

This citation pertains to intake #MI00- 9 Based on observation, interview and record review the facility failed to ensure 2 residents (Resident #4 and Resident #9) were free from significant medication errors when (a) medications were administered outside physician prescribed parameters on several occasions resulting in and (b) medications were not administered as ordered, (c) medications were given incorrectly and resulting in serious complications related to incorrect administration and omission of prescription medication. Findings: Resident #4 (R4) Review of an Admission Record revealed R4 was a [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R4 was admitted to the facility after being treated at the hospital 05/27/21 through 06/03/21 for [CONDITION(S)] and a [CONDITION(S)]. A left lung nodule, newly found during this hospitalization , was deemed suspicious of cancer. Review of a Nursing Admission Evaluation Part 1, dated 06/03/21, reflected the following assessment: (1) FALL RISK EVALUATION A. 8. measure systolic blood pressure (BP) while lying, sitting, and 1 and 3 minutes after standing-unable to obtain, reason could not measure: resident too weak to sit and stand. Review of a Nursing Home 30/60 Day Visit physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of blood pressures recorded for R4, in addition to the two low blood pressures listed above, reflected the following low blood pressure readings: 06/13/21 BP-78/61, 06/18/21 BP-85/39, 06/18/21 BP-93/52, 06/19/21 BP-95/52, 06/22/21 BP-99/65, 06/22/21 BP-99/50, 06/23/21 BP-96/49, 06/26/21 BP-99/52, 06/30/21 BP-92/51, 07/02/21 BP-93/57, 07/07/21 BP-100/54, 07/10/21 BP-94/56, 07/14/21 BP-90/50, 07/17/21 BP-87/48, 07/19/21 BP-75/38, (R4 was hospitalized from 07/22/21 to 08/05/21), 08/23/21 BP-90/53, 08/25/21 BP-92/47, 08/25/21 BP-97/46. Review of an Emar/Etar for R4, dated June 2021, revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Hold if SBP (systolic blood pressure) is less than 100. Start date-06/30/21, D/C date-07/27/21. Further review of the Emar/Etar reflected the following: (a) on 06/22/21 at 2 P.M. R4's BP was 99/65 and the medication was given, (b) on 06/23/21 at 2 P.M. R4's BP was 96/49 and the medication was given. Review of an Emar/Etar for R4, dated July 2021, revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Hold if SBP (systolic blood pressure) is less than 100. Start date-06/30/21, D/C date-07/27/21. Further review of the Emar/Etar reflected the following: (a) on 07/02/21 at 10 P.M. R4's BP was 93/57 and the medication was given, (b) on 07/10/21 at 10 P.M. R4's BP was 94/56 and the medication was given. Review of a Nursing Home 30/60 Day Visit physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Fall Incident Accident Report for R4, dated 07/18/21, revealed that R4 was being transferred via sit to stand lift, R4 became weak and fell out of the sling and came to rest on the floor. Factors identified that may have contributed to the fall: weakness, [CONDITION(S)], using a sit to stand. Did orthostatic BP's suggest the BP change contributed to the fall? N/A (non-applicable) was written in. Recommendations made (a) for therapy to evaluate transfer status and (b) facility physician to evaluate BP medications. No indication was made that prior low BP's were reviewed after the fall. BP was recorded as 87/48 on 07/17/21, one day before the fall occurred. Review of a Nursing Progress Note dated 07/21/21 at 12:34 P.M. reflected that the facility physician was made aware of R4's periodic low blood pressure, medications adjusted, see orders. Per MEDICATION ORDERS FOR [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #9 (R9) Review of an Admission Record revealed Resident #9 (R9) was a [AGE] year-old male, originally admitted to the facility on [DATE], with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R9 had severe cognitive impairment, was in a neurovegatative state, and was dependent on staff for all activities of life. During an observation on 08/20/21 at 9:19 A.M., R9 had a small round medication patch on the left side of the neck and the patch was dated 08/16. Review of an Electronic Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Start date: 06/23/21. Review of the Emar revealed the [MEDICATION(S)] patch was applied on 08/16/21 and was due to be changed on 08/19/21 but had not been changed. During an interview on 08/20/21 at 12:02 P.M., Registered Nurse (RN) C reviewed R9's Emar/Etar (electronic treatment administration record) and looked through the medication cart. Documentation showed the [MEDICATION(S)] patch had been re-ordered on 08/19/21 and no patches were available in the medication cart. RN C stated that the patch would most likely be in that evening (08/20/21). Per the Administrator, via email communication on 08/25/21, the [MEDICATION(S)] patches for R9 were delivered to the facility the evening of 08/20/21. During an observation on 08/24/21 at 8:05 A.M., R9 had a [MEDICATION(S)] patch on the left side of the neck and the patch was dated 08/16. Nursing staff changed the [MEDICATION(S)] patch later in the morning of 08/24/21, 6 days after the date it was ordered to be changed and 5 days after the patch had been delivered to the facility and was available to be changed. During the above mentioned observation on 08/24/21 at 8:10 A.M., (which lasted 30 minutes) two CNA's completed peri care for R9 and then the following were noted: (a) R9 coughed multiple times; wet, productive, thick secretions were heard (b) the suction cannister was almost full of secretions, (c) a CNA alerted nursing to R9's coughing and RN HH responded, (d) multiple suctions were required to clear the secretions, (e) RN HH did not know when the last time R9 was suctioned-reported not receiving any information about suctioning at shift exchange, (f) RN HH administered [MEDICATION(S)] drops (used to help reduce secretions), did not massage them in to the cheek as directed (decreasing the efficacy of the drug), and then suctioned R9's mouth again, potentially removing any remaining medication and (g) RN HH' noted that the [MEDICATION(S)] patch (used to prevent secretions) on R9 was dated 8-16 and should have been changed by now. Review of an Electronic Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] .

This citation pertains to intakes MI 919 and MI 903 Based on observation, interview, and record review, the facility failed to revise care plans following falls for two residents (R 321 and R 330) out of three residents reviewed for care planning following falls. This deficient practice resulted in care plans not updated following falls and continued falls with injuries. Findings include: R 321 According to the Minimum Data Set (MDS) Admission assessment, dated 5/31/21, R 321 had multiple diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R 321 had one fall without injury since admission to the facility. Staff assessed R 321 with a Brief Interview of Mental Status (BIMS) score of 02 out of 15 indicating severe cognitive impairment. R 321 no longer resided in the facility. Review of Incident report dated 5/29/21, revealed staff found R 321 on the floor in their room at 4:09 PM. R 321 reported that they were going to bed. The wheelchair was unlocked, and R 321 was seated on the floor in front of the wheelchair. Staff documented, Resident has never attempted self-transfer prior to this occurrence. Resident BIMS 2. IDT (Inter Disciplinary Team) determined this was an isolated occurrence and will con't (continue) to monitor and implement Standard Safety precautions. Review of R 321's care plan revealed no updates made after the fall occurring 5/29/21 to prevent additional falls. Review of an Incident report dated 6/18/21, revealed staff found R 321 on the floor in the doorway of another resident's room at 5:00 AM. Staff documented that R 321 was assisted per care plan with every two hours rounding (checks by staff) (this is standard of practice and indicated the facility failed to increase supervision after first fall on 5/29/21) and that R 321 was pleasantly confused. Under Fall Huddle, staff documented, Alert Staff of residents change in fall risk. Care plan and Kardex updated. Staff determined that the Root Cause of the fall was R 321's confusion and loss of strength-balance. Initial interventions staff implemented were to remind resident and re-educated on call light system and waiting for assistance with each interaction while in bed, despite R 321's impaired cognitive status and confusion. Resident 321's care plan updates included, Kardex updated to alert staff of residents risk for falls. There was no documentation related to R 321's response to education i.e. whether she was able to recall education or follow instructions to use call light and there was no documentation indicating the frequency at which staff were to increase their supervision. Review of R 321's Fall care plan indicated staff updated the interventions on 6/18/21 with fall prevention. There was no indication as to what fall prevention measures were put in place, the frequency of such measures, whether they were effective, nor outcomes. A third Incident Report dated 6/21/21 revealed staff found R 321 on the floor in their room at 6:40 PM. R 321 was sent to the local emergency department where they were found to have a 3-centimeter laceration to the left eyebrow, left [CONDITION(S)], left temporal lobe subdural hematoma, multiple maxillary [MEDICATION(S)] fractures, several orbital (eye) socket fractures, and a hematoma in the left eye socket. As a result of the injuries, R 321 was transferred that same day at 10:00 PM to a trauma hospital under guarded condition. During an interview on 7/1/21 at 4:00 PM with Interim Director of Nursing (IDON) EE, and joined by the Nursing Home Administrator (NHA). The IDON was asked for documentation regarding interventions to prevent R 321 from falling after the fall on 5/29/21 and 6/18/21. Additional documentation was requested at this time that would indicate what the facility had implemented fall prevention interventions following R 321's first and second falls to prevent future falls. Additional documentation provided by the facility on 7/2/21, indicated on 6/29/21 R 321's investigation form dated 6/29/21 was updated to reflect, Follow up to confirm it was done on 6/29/21. No other documentation indicating staff implemented additional interventions for R 321 to prevent future falls was provided prior to the end of this survey. During an interview on 6/29/21 at 9:40 AM, Family Member (FM) II reported R 321 was not a surgical candidate and that the injuries from the fall occurring 6/21/21 has led to end-of-life care as R 321 is not expected to recover from the fractures. FM II stated that the facility did not utilize a fall risk care plan, toileting plan, or other fall interventions to prevent R 321 from falling after the first and second fall. R 330 According to the MDS assessment, dated 3/31/21, R 330 had multiple diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R 330 required extensive assistance of one staff member for moving in bed, transferring, dressing, and hygiene needs. R 330 was independent with propelling a wheelchair. Staff assessed R 330 with a Brief Interview of Mental Status (BIMS) score of 02 out of 15 indicating severe cognitive impairment. During an observation and interview on 6/29/21 at 12:40 PM, R 330 was in the foyer watching the birds and fish. R 330 had a purple discoloration around the left eye. When greeted, R 330 repeated a nonsensical word. R 330's right leg was on a foot pedal, the left foot rested on the floor. Certified Nursing Assistant (CNA) BB identified R 330 and reported that R 330 had fallen causing the bruise. Review of Incident report dated 4/24/21, staff found R 330 on the floor. The report does not identify what time of the day the fall occurred. The report revealed R 330 was confused and fell in their room while self-transferring. R 330 told staff that they were trying to get into bed. Review of R 330's care plan revealed no new interventions documented to prevent additional falls. Review of R 330's progress notes revealed on 4/27/21, 4/30/21, and 5/3/21, R 330 attempted to self- transfer and R 330 fell again on 5/23/21. According to Policy Fall Prevention Program, reviewed/revised 10/30/20, read, Each resident's risk factors and environmental hazards will be evaluated when developing the resident's comprehensive plan of care. a. Interventions will be monitored for effectiveness. b. The plan of care will be revised as needed, and When any resident experiences a fall, the facility will: a. Assess the resident. b. Complete a post-fall assessment. c. Complete an incident report. d. Notify physician and family. e. Review the resident's care plan and update as indicated. f. Document all assessments and actions. g. Obtain witness statements in case of injury.

This citation pertains to intakes MI 919 and MI 903 Based on observation, interview, and record review, the facility failed to prevent falls with injury for two residents (R 321 and R 330) out of three residents reviewed for falls. This deficient practice resulted in repeated falls causing fractures or injuries, decline in functional status, and potential for continued falls with injury. Findings include: R 321 According to the Minimum Data Set (MDS) Admission assessment, dated 5/31/21, R 321 had multiple diagnosis including heart rhythm irregularities and dementia. R 321 required extensive assistance of one staff member for moving in bed, transferring, and hygiene needs including using the bathroom. R 321 had one fall without injury since admission to the facility. Staff assessed R 321 with a Brief Interview of Mental Status (BIMS) score of 02 out of 15 indicating severe cognitive impairment. R 321 no longer resided in the facility. Review of Incident report dated 5/29/21, revealed staff found R 321 on the floor in their room at 4:09 PM. R 321 reported that they were going to bed. The wheelchair was unlocked, and R 321 was seated on the floor in front of the wheelchair. Staff documented, Resident has never attempted self-transfer prior to this occurrence. Resident BIMS 2. IDT (Inter Disciplinary Team) determined this was an isolated occurrence and will con't (continue) to monitor and implement Standard Safety precautions. The last page of the report, under heading Falls Team Meeting Notes, the form was blank for sections summary, conclusion, additional care plan / nurse aide assignment updates, signatures with date and time. Review of R 321's care plan revealed no updates made after the fall occurring 5/29/21 to prevent additional falls. Review of an Incident report dated 6/18/21, revealed staff found R 321 on the floor in the doorway of another resident's room at 5:00 AM. Staff documented that R 321 was assisted per care plan with every two hours rounding (checks by staff) (this is standard of practice and indicated the facility failed to increase supervision after first fall on 5/29/21) and that R 321 was pleasantly confused. Under Fall Huddle, staff documented, Alert Staff of residents change in fall risk. Care plan and Kardex updated. Staff determined that the Root Cause of the fall was confusion and loss of strength-balance by R 321. Initial interventions staff implemented were to remind resident and re-educated on call light system and waiting for assistance with each interaction while in bed despite R 321's impaired cognitive status and confusion. Resident 321's care plan updates included, Kardex updated to alert staff of residents risk for falls. There was no documentation related to R 321's response to education i.e. whether she was able to recall education or follow instructions to use call light and there was no documentation indicating the frequency at which staff were to increase their supervision. Review of R 321's Fall care plan indicated staff updated the interventions on 6/18/21 with fall prevention. There was no indication as to what fall prevention measures were put in place, the frequency of such measures, whether they were effective, nor outcomes. A third Incident Report dated 6/21/21 revealed staff found R 321 on the floor in their room at 6:40 PM. Staff found R 321 face down in a large puddle of blood around their head. Staff determined R 321 was self-transferring at the time of the fall. Due to uncontrolled bleeding from a laceration to the forehead, left hip pain, distorted leg alignment, and inability of R 321 to perform active range of motion to the left leg, R 321 was transferred to the local emergency room that same day at 6:53 PM. According to hospital records dated 6/21/21, R 321 had a 3-centimeter laceration to the left eyebrow, left hip fracture, left temporal lobe subdural hematoma, multiple maxillary [MEDICATION(S)] fractures, several orbital (eye) socket fractures, and a hematoma in the left eye socket. As a result of the injuries, R 321 was transferred that same day at 10:00 PM to a trauma hospital under guarded condition. Additionally, hospital documentation indicated R 321 was uncomfortable with any movement. During an interview on 7/1/21 at 4:00 PM with Interim Director of Nursing (IDON) EE, and joined by the Nursing Home Administrator (NHA). The IDON was asked for documentation regarding interventions to prevent R 321 from falling after the fall on 5/29/21 and 6/18/21. The IDON reported that the nurse working with R 321 on 5/29/21 was passing medications at the time of the fall and did not hear or see R 321 enter another resident room. The NHA reported that R 321 was impulsive and would just get up but also stated that therapy had evaluated R 321 and they did not expect R 321 to fall as she would not do anything in therapy. Additional documentation was requested at this time that would indicate what the facility had implemented fall prevention interventions following R 321's first and second falls to prevent future falls. Additional documentation provided by the facility on 7/2/21, indicated on 6/29/21 R 321's investigation form dated 6/29/21 was updated to reflect, Follow up to confirm it was done on 6/29/21. No other documentation indicating staff implemented additional interventions for R 321 to prevent future falls was provided prior to the end of this survey. During an interview on 6/29/21 at 9:40 AM, Family Member (FM) II reported R 321 was not a surgical candidate and that the injuries from the fall occurring 6/21/21 has led to end-of-life care and R 321 is not expected to recover from the fractures. FM II stated that the facility did not utilize a fall risk care plan, toileting plan, or other fall interventions to prevent R 321 from falling after the first and second fall. R 330 According to the MDS assessment, dated 3/31/21, R 330 had multiple diagnosis including non-traumatic [CONDITION(S)] and stroke with right side weakness. R 330 required extensive assistance of one staff member for moving in bed, transferring, dressing, and hygiene needs. R 330 was independent with propelling a wheelchair. Staff assessed R 330 with a Brief Interview of Mental Status (BIMS) score of 02 out of 15 indicating severe cognitive impairment. During an observation and interview on 6/29/21 at 12:40 PM, R 330 was in the foyer watching the birds and fish. R 330 had a purple discoloration around the left eye. When greeted, R 330 repeated a nonsensical word. R 330's right leg was on a foot pedal, the left foot rested on the floor. Certified Nursing Assistant (CNA) BB identified R 330 and reported that R 330 had fallen causing the bruise. CNA BB was not aware if R 330 had fallen prior to this event. Review of Incident report dated 4/24/21, staff found R 330 on the floor. The report does not identify what time of the day the fall occurred. The report revealed R 330 was confused and fell in their room while self-transferring. R 330 told staff that they were trying to get into bed. This report was one page and did not include the facility investigation. On 6/29/21 at 2:00 PM, the NHA reported that she was looking for the rest of the report. Later that same day, Corporate Staff HH was unpacking boxes in the DON's office and reported she was looking for the rest of R 330's incident reports and investigations. Review of R 330's care plan revealed no new interventions documented to prevent additional falls. Review of R 330's progress notes revealed on 4/27/21, 4/30/21, and 5/3/21, R 330 attempted to self- transfer. Review of Incident report dated 5/23/21 at 7:30 PM, staff found R 330 on the floor. R 330 was attempting to self-transfer into bed. This report was one page and did not include the facility investigation. On 6/29/21 at 2:00 PM, the NHA reported that she was looking for the rest of the report. Later that same day, Corporate Staff HH was unpacking boxes in the DON's office and reported she was looking for the rest of R 330's incident reports and investigations. Review of R 330's care plan indicated on 5/24/21 staff initiated a new intervention, Offer to go to bed after dinner. Review of R 330's progress notes indicated on 5/23/21 new interventions were implemented, and staff were educated regarding new interventions. According to an Incident report dated 6/23/21 at 2:00 PM, staff found R 330 on the floor in their room in front of their wheelchair. The report indicated R 330 had slid out of wheelchair, the wheelchair was not locked. The Root Cause or contributing factors to this fall was blank. R 330 was sent to the local emergency department for a 1.4-centimeter laceration near the right eye requiring glue to adhere the edges and bruising. R 330 returned the same day and was treated with Tylenol for pain control and an antibiotic for a urinary tract infection. Review of R 330's Fall care plan, initiated 2/7/20, new interventions to prevent future falls included therapy to evaluate a new pedal for the wheelchair (6/23/21), Dycem (anti slip material) to be applied to foot pedal (6/29/21), and offer to lay resident down in bed after lunch daily. Document refusals and inform nurse (6/29/21). During an interview on 7/1/21 at 4:00 PM, the NHA stated that the investigations for falls occurring on 4/24/21 and 5/23/21 could not be found. The NHA indicated that even though R 330 was somewhat confused R 330 understands directions well. No additional information was provided by the facility prior to the end of the survey. According to Policy Fall Prevention Program, reviewed/revised 10/30/20, read, When a resident who does not have a history of falling experiences a fall, the resident will be placed on the facility Fall Prevention Program, Each resident's risk factors and environmental hazards will be evaluated when developing the resident's comprehensive plan of care. a. Interventions will be monitored for effectiveness. b. The plan of care will be revised as needed, and When any resident experiences a fall, the facility will: a. Assess the resident. b. Complete a post-fall assessment. c. Complete an incident report. d. Notify physician and family. e. Review the resident's care plan and update as indicated. f. Document all assessments and actions. g. Obtain witness statements in case of injury.

This citation pertains to intake MI 157 Based on observation, interview, and record review, the facility failed to assess, monitor and promote the healing of a pressure ulcer and prevent the development of facility acquired pressure ulcers for 1 of 3 residents (Resident #1) reviewed for pressure ulcers. This deficient practice resulted in Resident #1's non healing of an unstageable pressure ulcer to the coccyx and the development of 3 new facility acquired pressure ulcers. Findings include: The facility provided a copy of the Wound and Skincare Guidelines with a last revised date of 1/2017 for review. The guidelines defined the different stages of pressure ulcers and suggested treatment for [REDACTED]. Listed under Treatment Goal reflected, Protect and remove the cause. The guidelines did not reflect the specific steps staff should take at the facility when a new wound is noted. During a telephone interview on 12/17/20 at 2:10 PM, Licensed Practical Nurse (LPN) G stated upon the discovery of a new wound the staff are responsible to assess, measure, notify the physician, start a treatment, initiate a care plan, consult the dietitian, refer to the wound clinic if advised, obtain weekly assessments and measurements, notify the physician if the wound does not show signs of healing after 2 weeks, notify the physician if the wound shows signs of decline and obtain a wound referral if the wound shows signs of infection. Resident #1 Review of the Face Sheet and Minimum Data Set ((MDS) dated [DATE] revealed Resident #1 admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the Brief Interview for Mental Status (BIMS) reflected a score of 9 out of 15 which represents Resident #1 had moderate cognitive impairment. Resident #1 had a Resident Representative who made medical decisions and required staff assistance for all activities of daily living. During an observation of incontinence care on 12/16/20 at approximately 10:00 AM performed by Certified Nurse Assistant (CNA) A and B a dressings to the coccyx was noted with a loose corner that a wound with dark eschar was noted under the dressing. The dressing reflected a date of 12/15/20. The resident also had a dressing to the left lower leg that reflected the date of 12/16/20. According to the Medication Administration Record [REDACTED]. The weekly pressure ulcer assessments and measurements could not be located in the electronic health record. The facility provided all weekly wound assessments for review. On 12/16/20 at approximately 2:45 PM, the DON provided two assessment dated [DATE] (day of admission) and 12/10/20. When asked why there was a gap of 4 weeks between assessments and measurements the DON stated that was due to the recent leaving of a Unit Manager and it was not done. The DON stated that the resident has an upcoming appointment to have the wound debrided. According to the 11/12/20 assessment the pressure ulcer measured 7.5 cm x 5.0 cm x undetermined, with 100% necrotic/eschar covering the wound bed. According to the 12/10/20 assessment the pressure ulcer measured 6.5 cm x 8.5 cm x undetermined, with 75% necrotic/eschar covering the wound bed. According to the facility guidance the pressure ulcer will be measured weekly and the facility should report the lack of progression in healing and any worsening of the wound to the physician. There was no evidence of this documented. The following weekly skin assessments identified the areas of skin integrity breakdown: 11/19/20 the coccyx (no other areas listed) 11/26/20 the coccyx (no other areas listed) 12/3/20 a new open area on the back of the head (the ongoing coccyx wound was not listed) 12/10/20 the coccyx, open area to the back of the head, none of the areas were measured 12/17/20 the coccyx, open area to the back of the head, reddened area to the scapula, and a new open area to the left lower outer leg which reflected, pressure area treatment in place According to the nursing progress notes dated 12/5/20 the open area to the back of the head measured 1 cm x 1 cm and the reddened area to the scapula measured 6.0 cm x 3.0 cm. According to the Treatment Administration Record (TAR) for December 2020 a treatment was started on 12/5/20 for a dark red blanchable skin area to the left scapula, on 12/6/20 topical antibiotic ointment was ordered for the wound to the back of the head, and on 12/16/20 a daily dressing was started to a new open area on the left lower outside leg. The skin assessment dated [DATE] reflected the following: Coccyx - measured 9.0 cm x 7.0 cm with 3 cm undermining at 3, 6, and 9 o'clock of wound. Depth of wound measures 3 cm deep at deepest point. Yellow, stringy slough of tissue remains to superior part of wound and a very small part of eschar remains. Left lower leg (rear) - open area to lateral side of left lower leg. Order of wound measuring 3.5 cm x 1.2 cm with border tissue red but blanchable. Center of wound presents with yellow wound bed measuring 0.5 cm x 1.5 cm scant amount of yellow drainage noted on dressing when removed. Back of head - wound to back of head measuring 1.5 cm circular light pink area with yellow slough to center of wound measuring 0.7 cm x 0.6 cm. Other (specify) - bilateral ischium's present with dryness and discoloration (purple/red) but remain blanchable. There was no assessment of the scapula or measurement that according to the December 2020 TAR was still being treated. Record review of the care plan for the unstageable pressure ulcer to the sacrum, dated 11/12/20 and last revised on 11/24/20, did not reflect the other pressure ulcers that developed on 12/5/20 to the back of the head and scapula, and 12/16/20 to the left lower leg. Listed under Interventions reflected two interventions to Administer treatments as ordered and evaluate for effectiveness dated 11/12/20 and Evaluate dressing to ensure it is intact and adhering. Report loose dressing to the treatment nurse dated 11/12/20 last revised on 11/17/20. There were no interventions listed to assist the residents with offloading or frequent repositioning as the facility Wound and Skincare Guidelines reflected. During a telephone interview on 12/21/20 at 3:00 PM, the DON stated that the wound to the back of the head is an abrasion and the resident was admitted with it. (According to the nursing note 12/5/20 the wound was new.) The DON stated that the reddened area to the scapula was a Stage 1 pressure ulcer. When asked what the left lower leg wound (first noted on 12/16/20) was the DON stated that it has not been determined yet. According to the 12/17/20 weekly assessment it was noted as a pressure area. When asked if the area were identified on a care plan and interventions put into place for the new pressure areas the DON stated, I didn't see it on there. According to the physician noted dated 12/6/20 listed under Care Plan reflected, 4. Pressure ulcer over the sacrum and occiput (back of head) - will continue to monitor. The physician refers to the wound as a pressure ulcer and therefore according to the facility Wound and Skincare Guidelines should be assessed, monitored and promote the healing. According to the Radiology Report dated 12/8/20 an X-ray of the sacrum/coccyx was taken. The report reflected, Results Question subtle bone loss of the dorsal aspect of the sacrum/coccyx. Soft tissues appear swollen with ulceration dorsally. Conclusion: Cannot exclude osteo[DIAGNOSES REDACTED] (bone infection), recommend MRI.

Based on interview and record review, the facility failed to implement Care Plan interventions and timely revise the plan of care for one resident (Resident #13) of two residents reviewed for Care Plans, resulting in hospitalization of one resident and the potential for all facility residents to not have Care Plan interventions implemented preventing reaching their goals and highest practicable level of function. Findings: The facility face sheet reflected Resident #13 was initially admitted to the facility 1/11/19 with [DIAGNOSES REDACTED]. Review of the current and resolved Care Plan for Resident #13 reflected, pages 26 and 27 of 52, Focus(Resident #13) has (potential fluid deficit) related to (r/t) mobility status, dependent on staff for meals, acute blood loss. This area of care reflected a Cancelled goal of, The resident will be free of symptoms of dehydration and maintain moist mucous membranes, good skin turgor. The Care Plan reflected the goal was initiated on 1/14/19 and cancelled on 1/16/19. Although this area was titled Cancelled it included a revision date of 10/15/19. A current goal of, The resident will not experience fluid volume deficits as evidenced by skin turgor within normal limits, moist mucous membranes, and lab values within normal limits for resident's baseline, initiated 1/14/19 and revised 10/15/19. Interventions included: Monitor and document intake and output per facility policy, Monitor/document/report nurse /MD as needed (prn) any signs or symptoms (s/s) of dehydration: decreased or no urine output, .recent/sudden weight loss. Initiated 1/14/19, Obtain and monitor lab/diagnostic work as ordered. Report results to MD and follow up as indicated initiated 1/14/19. Page 29 of 52 reflected a Focus of (Resident #13 has Diabetes Mellitus II, initiated 1/15/19, with a Goal of The resident will have no complications related to diabetes through the review date initiated 1/15/19, revised 10/15/19, with a review date of 6/3/20. The interventions included, Monitor/document/report to MD prn any s/s of [MEDICAL CONDITION]: increased thirst .weight loss, fatigue stupor ., initiated 1/15/19. Review of the medical record reflected discharge documentation from the hospital dated 12/11/19. The hospital documentation for Resident #13 reflected on 12/6/20 Resident #13 was transported to the hospital with the chief complaint of abnormal lab results. Resident #13 was admitted to the hospital and treated for [REDACTED]. Review of the Electronic Medical Record (EMR) for Resident #13 reflected a document titled, Hydration Risk completed 10/21/19. The document reflected, Based on answers above resident who scores 8 or higher may be at risk for dehydration. The document reflected a score of 10 for Resident #13. Section 2, titled, summary of evaluation, reflected Resident #13 was not at risk for dehydration. The comments portion of section 2 did not provide clarification of why Resident #13, whose score was greater than the at risk threshold, was determined to not be at risk for dehydration. During an interview conducted 3/12/20 at 8:48 AM, Unit Manager (UM) K reported Resident #13 was identified as having decreased fluid intake and received an infusion 3380 milliliters (ml) of fluid on 12/5/20. UM K reported after the fluid infusion Resident #13 had labs drawn on 12/6/20. Review of the Basic Metabolic Panel blood test results of 12/6/19, for Resident #13 reflected a Blood Urea Nitrogen (BUN) result of 135 milligram per deciliter (mg/ml). The BUN normal range is 9 to 20mg/ml. A blood glucose level of 324 mg/di with a normal range of 65 to 99mg/dl The sodium level of Resident #13 was 168 milliosmoles per liter (mOsm/l) which is outside the normal range of 137 to 145 mOsm/l. A review of the British Medical Journal (2015), revealed normal serum osmolality is 275 to <295 mOsm/kg (milliosmoles per kilogram), impending dehydration is 295 to 300 mOsm/kg, and current dehydration is >300 mOsm/kg (Diagnostic accuracy of calculated serum osmolarity to predict dehydration in older people: adding value to pathology laboratory reports;(NAME) et al.; BMJ 2015 5(10); retrieved on 3/19/20 at (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC 68/). Therefore, using Resident #13's lab test results, dated 12/6/19, Resident #13 had a calculated ( 2(na+) + (BUN/2.8) + (Glu/18) ) serum osmolarity of 402.2 mOsm/kg which indicated severe dehydration. Review of the Doctor's Orders and Medication Administration Record [REDACTED]. The medical record also reflected that the physician was to be contacted with any blood sugar test result greater than 400 mg/dl. Review of the medical record for Resident #13 reflected an average daily blood glucose level of 344 mg/dl from 11/24/20 to 12/6/20. The record reflected 2 successive days of blood glucose levels greater than 400mg/dl (11/30/19 -494mg/dl and 12/1/19 -458 mg/dl. ) the medical record did not reveal that the physician had been contacted and informed of the trend of blood sugars consistently greater than 300 mg/dl or that the physician was notified of the blood sugar test result of 494 mg/dl on 11/30/20. The medical record of Resident #13 reflected on 12/1/19, the physician was contacted, and the blood sugar result of 458 mg/dl was conveyed. However, the focus of the communication was regarding, Resident has bright red hot to the touch left arm from hand to shoulder. The physician was also informed of, low grade fever, decrease appetite, resident is in pain, and mental status changes. The medical record reflected the resident was placed on an oral antibiotic. During an interview conducted 3/12/20 at 11:29 AM, Medical Director (MD) U reported Resident #13 requires total care and his medical condition is, very serious. MD U reported that it is our responsibility (the facility) to provide care for Resident #13. During the interview the history of blood glucose results of November and December 2019 was viewed on the EMR by UM U. MD U reported that he should have been contacted with the trend of blood sugar test results greater than 300mg/dl. MD U reported these consistent results of high sugars were indicative of dehydration, and that the sustained high glucose levels act as an osmotic diuretic. (high glucose levels inhibit the retention of intracellular fluid (ICF) resulting in [MEDICAL CONDITION] (high sodium level) and increased water loss from the body. (https://www.merckmanuals.com/ ./electrolyte-disorders/[MEDICAL CONDITION])). MD U reported, blood sugars are an indicator of sickness and infection, and that dehydration can be corrected if we can pick it up in time. MD U stated it is, our job to keep an eye on this. reported that Resident #13 was nutrition at risk and had dysphagia, difficulty in swallowing. MD U stated, I insisted we document his intake. During an interview conducted in the Dining Room on 3/12/20 at 11:21 AM, Certified Dietary Manager (CDM) N and Registered Dietician (RD) EE both reported they were familiar with Resident #13. It was reported that the Certified Nurse Aide staff record resident intake and output (amount of food and fluid consumed and waste from the body). The intake and output documentation for Resident #13 from 11/20/2019 to 12/6/19 was requested. A follow up interview with RD EE was conducted in the Conference Room on 3/12/20 at 11:56 AM. RD EE reported, in general, a resident's fluid intake should be 25 to 30 milliliters (ml ) per kilogram per day. No documentation of the intake and output for Resident #13 was provided at this time or by the time of survey exit. Resident #13 was the only specific Resident discussed during this interview. The EMR reflected on 11/20/19 Resident #13 weighed 180.2 pounds (lbs.) or 81.9kg. The calculation provided by RD EE indicated Resident #13 required a daily fluid intake of approximately 2047 ml (81.9 kg x 25 ml) Review of the EMR for Resident #13 reflected a Progress Note entry on 11/29/19 at 10:54 AM. The entry reflected Resident #13 had, 871 ml fluid intake on average x 7 days. This reflected an average shortfall of fluids of 1176 ml per day for the previous 7 days. This entry concluded with, No new recommendations at this time. Continue to monitor. The medical record also reflected a weight loss of 13.2 lbs. from 181.4 lbs. on 11/27/19 to 168.2 lbs. on 12/4/19. This Care Plan reflected the addition of a Focus area on 12/5/19, one day prior to hospitalization that reflected the administration of subcutaneous fluid and indicated 3380 ml received and completed. On 12/13/19 - started oral hydration encouragement (every)2 (hours), post-hospitalization . The Care Plan and medical record for Resident #13 did not reflect the status of Resident #13 had been monitored for changes as outlined in the Care Plan. The medical record did not reflect the documentation of: intake, blood glucose test results, weight loss, and signs and symptoms of [MEDICAL CONDITION] and fluid volume deficit had been noted and evaluated by skilled staff to keep the physician apprised of the Resident's status. The medical record did not reflect the Care Plan interventions had been timely reviewed, implemented, or revised.

Based on observation, interview, and record review, the facility failed to identify, timely assess and monitor for dehydration for one vulnerable and physically compromised resident (Resident #13) out of 2 Residents reviewed for hydration, resulting in hospitalization and the potential for all facility residents to have dehydration unrecognized by skilled staff . Findings: The facility face sheet reflected Resident #13 was initially admitted to the facility 1/11/19 with [DIAGNOSES REDACTED]. Review of the medical record reflected discharge documentation from the hospital dated 12/11/19. The hospital documentation for Resident #13 reflected on 12/6/20 Resident #13 was transported to the hospital with the chief complaint of abnormal lab results. Resident #13 was admitted to the hospital and treated for [REDACTED]. Review of the Electronic Medical Record (EMR) for Resident #13 reflected a document titled, Hydration Risk completed 10/21/19. The document reflected, Based on answers above resident who scores 8 or higher may be at risk for dehydration. The document reflected a score of 10 for Resident #13. Section 2, titled, summary of evaluation, reflected Resident #13 was not at risk for dehydration. The comments portion of section 2 did not provide clarification of why Resident #13, whose score was greater than the at risk threshold, was determined to not be at risk for dehydration. During an interview conducted 3/12/20 at 8:48 AM Unit Manager (UM) K reported Resident #13 was identified as having decreased fluid intake and received an infusion 3380 milliliters (ml) of fluid on 12/5/20. UM K reported after the fluid infusion Resident #13 had labs drawn on 12/6/20. Review of the Basic Metabolic Panel blood test results of 12/6/19, for Resident #13 reflected a Blood Urea Nitrogen (BUN) result of 135 milligram per deciliter (mg/ml). The BUN normal range is 9 to 20mg/ml. A blood glucose level of 324 mg/dl with a normal range of 65 to 99mg/dl The sodium level of Resident #13 was 168 milliosmoles per liter (mOsm/l) which is outside the normal range of 137 to 145 mOsm/l. A review of the British Medical Journal (2015), revealed normal serum osmolality is 275 to <295 mOsm/kg (milliosmoles per kilogram), impending dehydration is 295 to 300 mOsm/kg, and current dehydration is >300 mOsm/kg (Diagnostic accuracy of calculated serum osmolarity to predict dehydration in older people: adding value to pathology laboratory reports;(NAME) et al.; BMJ 2015 5(10); retrieved on 3/19/20 at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC 68/). Therefore, using Resident #13's lab test results, dated 12/6/19, Resident #13 had a calculated ( 2(na+) + (BUN/2.8) + Glu/18) ) serum osmolarity of 402.2 mOsm/kg which indicated severe dehydration. Review of the Doctor's Orders and Medication Administration Record [REDACTED]. The medical record also reflected that the physician was to be contacted with any blood sugar test result greater than 400 mg/dl. Review of the medical record for Resident #13 reflected an average daily blood glucose level of 344 mg/dl from 11/24/20 to 12/6/20. The record reflected 2 successive days of blood glucose levels greater than 400mg/dl (11/30/19 -494mg/dl and 12/1/19 -458 mg/dl. ) the medical record did not reveal that the physician had been contacted and informed of the trend of blood sugars consistently greater than 300 mg/dl or that the physician was notified of the blood sugar test result of 494 mg/dl on 11/30/20. The medical record of Resident #13 reflected on 12/1/19, the physician was contacted, and the blood sugar result of 458 mg/dl was conveyed. However, the focus of the communication was regarding, Resident has bright red hot to the touch left arm from hand to shoulder. The physician was also informed of, low grade fever, decrease appetite, resident is in pain, and mental status changes. The medical record reflected the resident was placed on an oral antibiotic. During an interview conducted 3/12/20 at 11:29 AM, Medical Director (MD) U reported Resident #13 requires total care and his medical condition is, very serious. MD U reported that it is our responsibility (the facility) to provide care for Resident #13. During the interview the history of blood glucose results of November and December 2019 was viewed on the EMR by UM U. MD U reported that he should have been contacted with the trend of blood sugar test results greater than 300mg/dl. MD U reported these consistent results of high sugars were indicative of dehydration, and that the sustained high glucose levels act as an osmotic diuretic. (high glucose levels inhibit the retention of intracellular fluid (ICF) resulting in [MEDICAL CONDITION] (high sodium level) and increased water loss from the body. ( https://www.merckmanuals.com/ ./electrolyte-disorders/[MEDICAL CONDITION])). MD U reported, blood sugars are an indicator of sickness and infection, and that dehydration can be corrected if we can pick it up in time. MD U stated it is, our job to keep an eye on this. reported that Resident #13 was nutrition at risk and had dysphagia, difficulty in swallowing. MD U stated, I insisted we document his intake. During an interview conducted in the Dining Room on 3/12/20 at 11:21 AM, Certified Dietary Manager (CDM) N and Registered Dietician (RD) EE both reported they were familiar with Resident #13. It was reported that the Certified Nurse Aide staff record resident intake and output (amount of food and fluid consumed and waste from the body). The intake and output documentation for Resident #13 from 11/20/2019 to 12/6/19 was requested. A follow up interview with RD EE was conducted in the Conference Room on 3/12/20 at 11:56 AM. RD EE reported, in general, a resident's fluid intake should be 25 to 30 milliliters (ml) per kilogram per day. No documentation of the intake and output for Resident #13 was provided at this time or by the time of survey exit. Resident #13 was the only specific Resident discussed during this interview. The EMR reflected on 11/20/19 Resident #13 weighed 180.2 pounds (lbs.) or 81.9kg. The calculation provided by RD EE indicated Resident #13 required a daily fluid intake of approximately 2047 ml (81.9 kg x 25 ml). Review of the EMR for Resident #13 reflected a Progress Note entry on 11/29/19 at 10:54 AM. The entry reflected Resident #13 had, 871 ml fluid intake on average x 7 days. This reflected an average shortfall of fluids of 1176 ml per day for the previous 7 days (2047ml - 871ml = 1176ml). This entry concluded with, No new recommendations at this time. Continue to monitor. The medical record also reflected a weight loss of 13.2 lbs. from 181.4 lbs. on 11/27/19 to 168.2 lbs. on 12/4/19. During a telephone interview conducted 3/10/20 at 11:08 AM, Responsible Party (RP) SS reported Resident #13 was hospitalized for [REDACTED]. RP SS stated, if (Resident #13) was being seen weekly by a Doctor, how could this have happened?. RP SS reported a belief that so much attention was being given to a chronic wound that hydration was ignored. RP SS stated that the hospitalization , Should not have happened.

This citation refers to intake number MI 388 Based on interview and record review, the facility failed to identify and assess a change in condition for one resident (Resident #1), out of three residents reviewed for change in condition, from a total sample of six residents. This deficient practice resulted in an urinary tract infection to go unnoticed and untreated with subsequent hospitalization and death. Findings include: According to the Minimum Data Set (MDS), dated [DATE], Resident #1 was severely cognitively impaired and had a history of [REDACTED]. This same MDS assessment indicated Resident #1 required extensive assist of two people for transfers and toileting and was incontinent of bowel and bladder. Review of the Electronic Medical Record revealed Resident #1 had a history of [REDACTED]. The organism for each UTI was cultured as escherichia coli (E-coli). Review of Resident #1's Food Acceptance Record, dated [DATE] through [DATE], reveals the following meal acceptance: [DATE] Breakfast refused, lunch ate 25%, dinner ate 0% [DATE] Breakfast refused, lunch refused, dinner ate 8% [DATE] Breakfast refused, lunch refused Resident was transferred to the hospital by emergency medical services (EMS) on [DATE] at 6:28 PM. This meal acceptance indicated the first signs of Resident #1's change in condition. During an interview on [DATE] at 11:57 AM, the Director of Nursing (DON) B stated, .(Resident #1's) family had asked about transferring her to the hospital, that is when the doctor was called and lab orders received and encouraged to push fluids . Resident #1's chart was reviewed for vital signs taken at that time, none were found. The DON agreed no vital signs had been documented for Resident #1 in the medical record since [DATE]. During an interview on [DATE] at 11:20 AM, RN Q, the nurse working with Resident #1 on [DATE], stated she did not recall Resident #1's status that day and could not remember if Resident #1 had abnormal behavior, RN Q stated that if vital signs were taken they would be recorded in the electronic medical record. RN Q could not recall if vital signs had been taken. During an interview on [DATE] at 2:15 PM, CNA J and CNA K stated they recalled working with Resident #1 that weekend ([DATE] and [DATE]). It was reported Resident #1 typically went to the dining room for meals, and even though they had tried to get Resident #1 to eat, she wouldn't. CNA J stated, .she (Resident #1) was declining before going to the hospital, her (Resident #1) urine got real smelly, we told the nurse (could not recall which nurse) but did not do a stop and watch (written notification to nurse regarding status change). Neither CNA J or K could recall being asked to obtain a set of vital signs when telling the nurse of Resident #1's changes. Review of Resident #1's SBAR (Situation, Background, Assessment, Recommendation) Communication Form and progress note dated [DATE] at 18:08 with a lock date of [DATE] at 08:20 reads, .Resident has increased lethargy, decreased cognition, ADL's (activities of daily living), resp (respirations) shallow, resident is pale .Things that make the condition or symptom worse are attempting to get resident to eat or drink .treatment for [REDACTED].Resident has a hx (history) of urosepsis and frequent UTI's .Mental Status Changes: Increased confusion, Decreased consciousness .Functional Status Changes: Needs more assistance with ADL's, Decreased mobility, Slurred speech, Trouble swallowing .GI (gastrointestinal)/Urine Changes: Urinating more frequently, New or worsening incontinence, urine dark, cloudy, strong odor .Family wishes to have resident sent to ER .I suggest or request: Monitor vital signs every ,[DATE] hours, Lab work, Transfer to the hospital . There were no vital signs documented in the Vital Signs section of this document. The facility was asked for a urinary tract infection policy and this Surveyor was provided a Care Path Symptoms of Urinary Tract Infection, dated 2011, this document was a flow sheet and the first box was titled Symptoms or Signs of UTI: Painful urination, lower abdominal pain or tenderness, blood in urine, new or worsening urinary urgency, frequency, incontinence. This first box had an arrow pointing to the second box titled Take Vital Signs: Temperature, BP (blood pressure), pulse, apical HR (heart rate), respirations, oxygen saturation, finger stick glucose. Review of the EMS Patient Care Report dated [DATE] revealed Resident #1's vital signs were taken by EMS staff. Resident #1's blood pressure was ,[DATE], heart rate 108, respirations 22 (normal ,[DATE]), and oxygen saturation 87% (normal over 95 - 100%). Review of the last vital signs taken by the facility on [DATE] revealed Resident #1 had a blood pressure of ,[DATE] and a heart rate of 70. Review of urinalysis collected by the facility on [DATE] revealed Resident #1 had a urinary tract infection. According to the emergency room record dated [DATE] Resident #1 was admitted to the hospital on [DATE] with a [DIAGNOSES REDACTED]. Hospital records indicated Resident #1 died on [DATE]. According to the Centers for Disease Control, updated [DATE], retrieved from https://www.cdc.gov/sepsis/basic/index.html, identifies UTI's as one of four types of infections that [MEDICAL CONDITION]. One of the three most common organisms is E-coli. Adults over 65 are at a higher risk of [MEDICAL CONDITION]. Symptoms [MEDICAL CONDITION] include confusion, shortness of breath, high heart rate, fever, pain, and sweaty skin. Early recognition and treatment are necessary for recovery.

Based on observation, interview and record review, the facility failed to provide appropriate and adequate [MEDICAL CONDITION] care for 1 resident (Resident #60) reviewed for [MEDICAL CONDITION] care, from a total sample of 21 residents, resulting in an immediate jeopardy when (1) on 02/09/18 Resident #60 was admitted to the facility with a [MEDICAL CONDITION] and no physician orders were in place for suctioning, (2) staff lacked knowledge regarding aseptic technique for suctioning increasing Resident #60's chance for an infection, (3) no system was in place to ensure uninterrupted humidified oxygen delivery, (4) Resident #60 developed skin excoriation due to respiratory secretions expelled from the [MEDICAL CONDITION] pooling on her chest, and (5) Resident #60 was not properly assessed for ability to use a call light to get help if needed. This deficient practice placed 1 resident receiving [MEDICAL CONDITION] care at risk for serious harm, injury and/or death. Findings include: Review of a Face Sheet revealed Resident #60 was a [AGE] year old female, originally admitted to the facility on [DATE], with pertinent [DIAGNOSES REDACTED]. Review of a Minimum Data Set (MDS) for Resident #60, with a reference date of 02/16/18, indicated that Resident #60 had severe cognitive impairment. Review of the facility policy and procedure [MEDICAL CONDITION] Care, last revised 06/26/16, indicated that Aseptic technique must be used: . (3) During endotracheal suctioning . (9) A replacement [MEDICAL CONDITION] must be available at the bedside at all times. (10) A suction machine, supply of suction catheters, exam and sterile gloves and flush solution, must be available at the bedside at all times. During an observation on 02/26/18 at 03:57 PM, Resident #60's oxygen humidifier was out of water and delivering unhumidified (no moisture added) oxygen. The suction machine was located on bedside table with a visibly dirty (used) suction tip attached to the suction tubing. Resident #60's head of bed was elevated to 20 degrees. There were no sterile suction tips, sterile water or sterile gloves on bedside table. During an interview on 02/26/18 at 04:10 PM, RN Unit Manager RNUM (D) was unable to locate an emergency tracheal replacement within 90 seconds. It should be here. RNUM D also indicated that the head of the bed appeared to be at 20 degrees, not 30 to 45 degrees as dictated by best practice. Review of current physician orders for Resident #60 revealed no physician orders for scheduled or PRN (as needed) suctioning. Review of Electronic Medication Administration Record [REDACTED]. During an observation on 02/28/18 at 12:00 PM, Resident #60 had a large amount of thick yellowish/green respiratory secretions (phlegm) that had been expelled from the [MEDICAL CONDITION] and had collected on her chest area skin located just below the [MEDICAL CONDITION]. The [MEDICAL CONDITION] did not have a dressing around it. During an interview on 02/28/18 at 12:10 PM, Licensed Practical Nurse (LPN) H stated that Resident #60 had developed a skin rash because the respiratory secretions were very thick and can leak out of [MEDICAL CONDITION] onto her skin. During an observation on 02/28/18 at 12:15 PM, Licensed Practical Nurse (LPN) H was performing endotracheal suctioning for Resident #60 and gathered supplies which included unsterile water (a cup of tap water) to be used for suctioning the catheter to clear it of secretions. LPN H did not at any time during tracheal suctioning check oxygen saturations for Resident #60. LPN H completed two passes of endotracheal suctioning, clearing the suction tip with tap water in between, and then placed the contaminated suction tip back in the package and set package with the suction machine. The suction container that collects secretions was tipped up out of the holder and the fluids that had gathered inside the suction container were near the top of the suction container and had partially blocked the intake valve, possibly limiting the amount of suction provided by the machine. During the same observation on 02/28/18 at 12:30 PM, the humidifier for the oxygen delivery system was observed to be out of water and was no longer delivering humidified oxygen. Resident #60 began to cough again and audible secretions were heard in her throat. LPN H proceeded to suction Resident #60 again with unsterile gloves and with the used/contaminated suction catheter that she had used during the first suctioning. Following the second suctioning, LPN H again returned the suction catheter to the packaging and placed it near the suction machine. Review of Records indicate that Resident #60 had a physician order for [REDACTED]. The results of the culture indicated that Resident #60 had a Staphylococci infection. During an interview on 02/28/16 at 4:30 PM, Licensed Practical Nurse (LPN) I, currently assigned to Resident #60, reported that she would handle an emergency extubation of Resident #60's [MEDICAL CONDITION] by reinserting [MEDICAL CONDITION] 10 to 15 minutes before things start to contract. LPN I then indicated that she would not want to put it back in dirty so I would clean it up really good before putting it back in. LPN I stated she would insert it in sideways and then drop it in the rest of the way. During an interview on 02/28/18 at 5:20 PM, RNUM D indicated that sterile gloves and aseptic technique are always used for endotracheal suctioning and that sterile water are used to clear the suction tip between each endotracheal pass of the suction tip. RNUM D also stated that dirty/contaminated suction tips should be wrapped up inside a glove and discarded immediately. They should never be reused. RNUM D stated that the unit coordinators usually in-service nursing staff before or shortly after a [MEDICAL CONDITION] resident is admitted but does not believe that it was done before or shortly after the admission of resident #60. RNUM D explained that if there is no water in the humidifier for oxygen administration, then the resident is only receiving unhumidified oxygen and this can allow the secretions to dry up cause blockage in the airway. During an observation on 02/28/18 at 5:35 PM, Resident #60's water was empty in her oxygen delivery system and was delivering unhumidified oxygen. During an observation on 02/28/18 at 5:42 PM, LPN I entered Resident #60's room to check on the resident. LPN I did not assess nor acknowledge that the humidifier for the oxygen delivery system was empty. During an observation on 02/28/18 at 6:05 PM, Resident #60's call light was located on her right side above her shoulder and out of reach. Assistant Director of Nursing (ADON) M came to the room to assess Resident #60's ability to reach and use the call light. ADON M indicated that Resident #60 could not reach nor correctly use the call light to alert staff if she needed assistance and stated well this is useless for her. ADON M indicated that Resident #60 had no way to alert staff. During the same observation, ADON M did not assess nor acknowledge that Resident #60's humidifier for her oxygen delivery system was empty. During an observation on 02/28/18 at 6:25 PM, Resident #60's oxygen delivery system was out of water and not delivering humidified oxygen. On 03/01/18 Administrator A was notified of Immediate Jeopardy that began on 02/09/18. On 03/05/18 this surveyor verified that the facility completed the following to remove the Immediate Jeopardy: 1. On 03/01/18 Resident #60 was assessed by DON B. 2. On 03/01/18 DON B ensured that the humidified oxygenation was in place. 3. On 03/01/18 physician orders were obtained for endotracheal suctioning. 4. On 03/01/18 Resident #60 was placed on a 1:1 to assess for risk of decannulation. 5. on 03/01/18 LPN H was removed from providing direct care to residents in the facility until re- education and validation of understanding of the education was provided. 6. All other residents were assessed for above concerns and no other current residents have a [MEDICAL CONDITION]. 7. Medical Director was notified of the above IJ on 03/01/18 8. A supply cart containing neck ties, gloves, tracheal dressings, suction catheters, [MEDICAL CONDITION] care kits and extra inner cannulas was placed in Resident #60's room on 03/01/18. 9. QAPI plan initiated with date in place. 10. Education of all 16 nurses began on 03/01/18. Education included [MEDICAL CONDITION] care and skin care, assessment and humidified oxygen, infection control during care, emergency procedures for decannulation, and supplies needed and their location. 11. Resident #60's husband was notified and updated regarding the removal plan. Although the immediate jeopardy was removed on 03/01/18, the facility remained out of compliance at a scope of isolated and severity of actual harm that is not immediate jeopardy due to the fact that sustained compliance had not yet been verified by the State Agency and all education had not yet been completed.

This citation contains 2 deficient practice statements (#1 and #2). Deficiency statement #1 Based on observation, interviews, and record review, the facility failed to appropriately manage severe hypoglycemic episodes (a condition of low blood sugar that can lead to accidents, injuries, coma and death), and the physician of changes in condition for 3 of 19 residents (Resident #59, #58 and #39)reviewed for blood sugar management in a total sample of 21 residents, resulting in an immediate jeopardy when Resident #59 demonstrated a pattern of low blood sugars, was found unresponsive, required emergency medical interventions and had to be hospitalized due to lack of necessary emergency medications and inability to provide emergency diabetic care at the facility. This deficient practice caused harm to one resident (#59) and puts all 21 diabetic residents at risk for serious harm and/or death. Findings include: Resident #59 Review of the Face Sheet and Minimum Data Set (MDS), dated [DATE] reflected Resident #59 was an [AGE] year-old male, who was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of Brief Interview for Mental Status (BIMS), reflected a score of 9 out of 15 which represents Resident #59 had moderate cognitive impairment. Resident #59 required staff assistance with all activities of daily living and transfers. The following is a summary of the blood sugars from the medical record and there was no notes found that indicated that the physician was notified of the changes in condition on the following dates: 2/19 blood sugar of 55 2/22 blood sugar of 53 2/24 blood sugar of 45 and 35 2/25 blood sugar of 44 and 58 2/25 9:15 PM, per progress note the CNA reported to the nurse that Resident #59 was found sweaty, pale, and clammy. The nurse checked the blood sugar which was 58. 2/26 blood sugar 48 2/26 blood sugar 474 (extremely high) at 7:11 AM and there was no immediate physician notification. 2/26/18 the physician evaluated Resident #59 (note not timed) and discontinued one of the oral hypoglycemic agents. 2/26 11:00 PM CNA found Resident #59 unresponsive and diaphoretic. Resident #59's blood sugar was 33 and continued to drop to 29, was transferred to the emergency room by EMS and subsequently hospitalized . During an interview on 2/27/18 at 4:09 PM, the NHA A stated that she received a call from LPN C on 2/26/18 at 11:10 PM. LPN C informed the NHA A that Resident #59 had an extreme low blood sugar and the facility had no [MEDICATION NAME] (an injection to low blood sugar) and glucose gel (oral agent to treat low blood sugar). The NHA A stated that she advised the LPN C to complete an SBAR (a change in condition notification) and call the physician. During a telephone interview on 2/27/18 at 10:09 AM and 4:50 PM, LPN C stated at 11:00 PM the CNA went to check on Resident #59 found that he was unresponsive with his eyes were fixed. LPN C stated that she checked his blood sugar and it was 33. LPN C stated the staff thickened water and added sugar packets and attempted to provide them to Resident #59. LPN C stated that she first placed call to the DON B and did not get an answer so she left a voicemail. Second, LPN C called the NHA A and reported that the facility did not have the emergency medications [MEDICATION NAME] or glucose gel. LPN C stated that the NHA A advised her to complete the SBAR and call the physician. LPN C stated that she called the physician on call service and advised them of the urgent need to talk with the physician. LPN C stated that the physician called right back and ordered [MEDICATION NAME] to be given and when she notified him that the facility did not have [MEDICATION NAME] available the physician directed the LPN C to call 911. LPN C state that she called 911 and Resident #59's blood sugar dropped to 29 by the time the EMS arrived at 11:30 PM. LPN C informed the EMS that Resident #59 had a pattern of hypoglycemic episodes over the weekend and was subsequently taken to the emergency room for further treatment/evaluation and was hospitalized . During an interview on 2/27/18 at 2:27 PM and 3:41 PM, the DON B was interviewed regarding management of [DIAGNOSES REDACTED]. The DON B reviewed Resident #59 record and could not locate any orders or parameters for Resident #59's blood sugars, nor did the facility have standing orders to manage [DIAGNOSES REDACTED] for other residents at the facility. The DON B stated that the emergency box for the facility is stocked with 2 [MEDICATION NAME] injections and the emergency box is restocked once weekly. When asked the dates, time and residents the [MEDICATION NAME] was used, the DON B stated she was unable to locate that information because the facility staff did not sign it out. The DON B stated that she expected the nurse to call the physician on all blood sugars under 60, and document it in the medical record using the SBAR. According to CMS 802 Roster/Matrix provided upon entrance there were 21 residents identified as receiving insulin. On 2/28/18 NHA A was notified of Immediate Jeopardy that began on 02/19/18. On 3/2/18 the survey team verified that the facility completed the following to remove the Immediate Jeopardy: Removal plan for IJ Facility identified that [DIAGNOSES REDACTED] management was not being correctly followed/ documented. February 28-2018 14 of 70 current residents with [DIAGNOSES REDACTED]. List the residents: #67, #65 ,#58 , #7, #272, #20, #50, #40, #123, #13, #64, #5, #269 and #218. The above residents were found to have no negative outcomes. #59 was sent to hospital on [DATE] with admitting DX UTI [MEDICAL CONDITION] and [DIAGNOSES REDACTED] per H&P dated 2/27/18 from the hospital, same document also reads, acute metabolic [MEDICAL CONDITION] secondary to severe [DIAGNOSES REDACTED] . February 28th -2018 16 out of 16 Current licensed nursing staff have been re-educated on diabetes protocol including physician notification and glucose monitoring and perimeters of if accuchecks below 60 or above 400 Notify physician. If BS is under 60 and resident is unresponsive or unable to take orally, administer [MEDICATION NAME] IM per manufacturer recommendation. Re-check BS in 15 minutes. If blood sugar less than (60) administer OJ, Food or glucose gel per manufacturer recommendation. Recheck in 15 minutes if no improvement notify MD. If BS is over 400, notify MD for further orders. Education was provided to the licensed nurses regarding calling 911 and or physician in case of an emergency. February 28th (YEAR)-The Physician has been notified and orders have been obtained for each resident with a diabetes [DIAGNOSES REDACTED]. If BS is under 60 and resident is unresponsive or unable to take orally, administer [MEDICATION NAME] IM per manufacturer recommendation. Re-check BS in 15 minutes. If blood sugar less than (60) administer OJ, Food or glucose gel per manufacturer recommendation. Recheck in 15 minutes if no improvement notify MD. If BS is over 400, notify MD for further orders for notification and instructions for medication management has been obtained including insulin dosages and emergency treatment. A routine every shift order that states (if accucheck is below 60 or above 400 notify physician See PRN orders for below 60 interventions). 2 PRN orders added stating (If blood sugar is below 60 administer OJ, food or glucose gel. Re check in 15 minutes. If no improvement notify MD) and (If resident is unable to swallow or is unresponsive administer [MEDICATION NAME] IM, recheck in 15 minutes). Parameters placed in these resident's baseline accuchecks to flag on the dashboard if they have a below 60 or above 400. The dashboard is reviewed in the AM by the IDT team. This will allow the team to assess and address any further concerns and to assure the episode was documented and managed correctly. Education provided to nurses on process including new orders, parameters, how to notify physician using the SBAR, re-ordering of medication and documentation. New admits will be screened during morning clinical meeting to assure they have orders in place if applicable and that baseline parameters are set. [MEDICATION NAME] was sent from pharmacy on 2/27/2018 at 1:43am. The center is now stocking each med cart with 2 extra [MEDICATION NAME] and 2 extra glucose gel. Licensed nurses have been re-educated on the protocol for re-ordering of PRN does and all emergency medications. February 28th (YEAR)- Physicians have been educated on [DIAGNOSES REDACTED] management and with setting of parameters. February 28th (YEAR)-QAPI plan initiated and Audit in place. Will continue with weekly audits for 4 weeks and then monthly with results submitted to QAPI. Although the immediate jeopardy was removed on 2/28/18, the facility remained out of compliance at a scope of isolated and severity of actual harm that is not immediate jeopardy due to the fact that sustained compliance had not yet been verified by the State Agency and all education had not yet been completed. Resident #58 Review of the Face Sheet and Minimum Data Set ((MDS) dated [DATE] revealed Resident #58 is an [AGE] year old male originally admitted into the facility on [DATE] and most recently admitted on [DATE] with [DIAGNOSES REDACTED]. He required moderate assistance for activities of daily life (ADLs) and the Brief Interview for Mental Status (BIMS) score of 09/15 indicated Resident #58 was cognitively impaired. Review of Resident #58's Blood Sugar Summary, medication administrative records (MAR), treatment administration records (TAR), assessments (specifically Situation, Background, Assessment and Recommendation, SBAR), and electronic medical record progress notes revealed: On the MAR for December, (MONTH) and (MONTH) there is a standing schedule to chart for [MEDICATION NAME] Emergency Kit 1 MG ([MEDICATION NAME] (rDNA)) Inject 1 mg intramuscularly as needed for diabeties (sic) administer 1 mg IM (intramuscularly) if NPO (nothing by mouth) or unable to swallow, recheck BS (blood sugar) in 15 min (minutes). If BS remain below 60 and unable to swallow contact Dr. -Start Date- 02/20/2017 0600. There is also a standing schedule to chart for If blood sugar less than (60) administer OJ, Food or glucose gel per manufacturer recommendation. Recheck 15 minutes if no improvement notify MD as needed for DM (diabetes management) related to TYPE 2 DIABETES MELLITUS WITHOUT COMPLICATIONS (E11.9) Follow protocol for FBS (fasting blood sugar) under 60 -Start Date- 02/20/2017 0600. For December: On 12/20 at 07:45 a reading of 58.0 mg/dL was documented, there was no nurses note, no mar/tar record of administering [MEDICATION NAME], OJ, food or glucose, no SBAR, and a blood sugar recheck was documented on 12/20 at 08:20 with a reading of 96.0 mg/dL 12/22 at 07:53 a reading of 54.0 mg/dL was documented, there was no nurses note, no mar/tar record of administering [MEDICATION NAME], OJ, food or glucose, no SBAR, and a blood sugar recheck was documented several hours later on 12/22 at 16:36 with a reading of 260.0 mg/dL All doses of [MEDICATION NAME] (diabetes medication) were administered in December. For January: On 1/7 at 08:24 a reading of 49mg/dL was documented, there was no nurses note, no mar/tar record of administering [MEDICATION NAME], OJ, food or glucose, no SBAR, and a blood sugar recheck was documented on 1/7 at 08:51 with a reading of 74 mg/dL. On 1/20 at 07:02 a reading of 59 mg/dL was documented, there was no nurses note, no mar/tar record of administering [MEDICATION NAME], OJ, food or glucose, no SBAR, and a blood sugar recheck was documented on 1/20 at 07:37 with a reading of 112 mg/dL. On 1/25 at 07:08 a reading of 54 mg/dL was documented, there was no nurses note, no mar/tar record of administering [MEDICATION NAME], OJ, food or glucose, no SBAR, a blood sugar recheck was documented at 1/25 at 07:42 with a reading of 92 mg/dL. All [MEDICATION NAME] doses were administered in January. For February: On 2/2 at 07:07 a reading of 53 mg/dL was documented, there was no nurses note, no mar/tar record of administering [MEDICATION NAME], OJ, food or glucose, no SBAR, a blood sugar recheck was documented at on 2/2 at 07:36 with a reading of 83 mg/dL. On 2/5 at 07:59 a reading of 51 mg/dL was documented, there was no nurses note, no mar/tar record of administering [MEDICATION NAME], OJ, food or glucose, no SBAR, a blood sugar recheck was completed on 2/5 over 9 hours later at 17:08 with a reading of 260 md/dL. All [MEDICATION NAME] dose were administered in (MONTH) until 2/6/18, the medication [MEDICATION NAME] was discontinued on 2/6/18, and [MEDICATION NAME] was began as the medication to treat diabetes. An interview with DON B on 2/27/2018 at 4:30 PM was completed regarding Resident #58. DON B stated that she could not find any documentation on what was done in response to Resident #58's low blood sugars. DON B stated that staff would be expected to note in the MAR/TAR if they responded to a low blood sugar. DON B stated that staff would also be expected to document in electronic medical record progress notes or in an SBAR assessment what was administered to the resident and what the outcome was. Resident #39 Review of the Face Sheet and Minimum Data Set ((MDS) dated [DATE] revealed Resident #39 was an [AGE] year old male initially admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. He required extensive assistance for activities of daily life (ADLs) and the Brief Interview for Mental Status (BIMS) score of 08/15 indicated Resident #39 was cognitively impaired. Review of Resident #39's Blood Sugar Summary, medication administrative records (MAR), treatment administration records (TAR), assessments (specifically Situation, Background, Assessment and Recommendation, SBAR), and electronic medical record progress notes revealed: an order for [REDACTED]. There was a standing order starting on 12/04/2017 to obtain Accuchecks or blood sugar levels two times daily. There were no instructions or orders noted related to the actions to follow regarding a blood sugar outside of normal levels. For December: On 12/05 at 06:54 a reading of 43.0 mg/dL was documented, there was no nurses note, no mar/tar record of administering [MEDICATION NAME], OJ, food or glucose, no SBAR, and a blood sugar recheck was documented on 12/05 at 07:12 with a reading of 61.0 mg/dL. On 12/6 at 07:54 a reading of 42.0 mg/dL was documented, there was no nurses note, no mar/tar record of administering [MEDICATION NAME], OJ, food or glucose, no SBAR, and a blood sugar recheck was documented on 12/6 at 08:30 with a reading of 47.0 mg/dL. An additional blood sugar recheck was not documented until over an hour later at 09:47 with a reading of 108 mg/dL. On 12/09 at 08:21 a reading of 56.0 mg/dL was documented, there was no nurses note, no mar/tar record of administering [MEDICATION NAME], OJ, food or glucose, no SBAR, and a blood sugar recheck was documented on 12/09 at 08:57 with a reading of 84.0 mg/dL. On 12/10 at 08:11 a reading of 46.0 mg/dL was documented, there was no nurses note, no mar/tar record of administering [MEDICATION NAME], OJ, food or glucose, no SBAR, and a blood sugar recheck was documented on 12/10 at 08:45 with a reading of 96.0 mg/dL. For January: On 1/1 at 08:22 a reading of 54.0 mg/dL was documented, there was no nurses note, no mar/tar record of administering [MEDICATION NAME], OJ, food or glucose, no SBAR, and a blood sugar recheck was not documented for more than 9 hours on 1/1 at 18:17 with a reading of 110.0 mg/dL. On 1/8 at 07:48 a reading of 57.0 mg/dL was documented, there was no nurses note, no mar/tar record of administering [MEDICATION NAME], OJ, food or glucose, no SBAR, and a blood sugar recheck was not documented for more than 11 hours on 1/8 at 19:24 with a reading of 224.0 mg/dL. An interview with DON B on 2/28/2018 at 1:36 PM was completed regarding Resident #39. DON B stated that she could not find any documentation on what was done in response to Resident #39's low blood sugars. DON B stated she did note that the doctor changed Resident #39's doses of insulin several times in response to the low blood sugar. Review of facility policy Acute Condition Changes- Clinical Protocol with a revision date of 3/2017 revealed: 1. The facility identifies changes in condition through several processes such as but not limited to: a. Daily clinical review of 24 hour reports, weights vital fluctuations, behavior monitoring, first response programs such as stop and watch, caring partner rounds, and other facility programs for first response to minor changes of status. 2. For changes of condition the facility may utilize the SBAR (situation, background, assessment, and recommendation) process for assessment, documentation and report to the practitioner. Review of facility policy Diabetes -Clinical Protocol with a revision date of 6/2017 revealed under Assessment and Recognition: 2. Management includes monitoring may include but not limited to: .e. Resident's blood sugar; f. Usual patterns (fluctuations, trends) of blood sugars over recent months; g. Onset, duration of any changes; h. medications . Under Monitoring and Follow-Up 1. The physician will follow up on any acute episodes associated with a significant change in blood sugars or deterioration of previous glucose control and document resident status at subsequent visit until the acute situation is resolved .4. The physician will order desired parameters for monitoring and reporting information related to diabetes or blood sugar management. a. The staff will incorporate such parameters into the Medication Administration Record [REDACTED] On 2/27/18 at 2:27 PM an interview with DON B confirmed that low blood sugars should be documented in the progress notes in the electronic medical record or in an SBAR assessment, and a reading under 60 would be considered low blood sugar. Deficiency statement #2 Based on observation, interview, and record review the facility failed to follow standards of practice for a Peripherally Inserted Central Catheter (PICC) for one resident (#36), out of 19 residents reviewed for standards of practice, from a total sample of 21 residents. This deficient practice resulted in a PICC line dressing to go unchanged and an unknown flush schedule of the same PICC line. Findings include: Resident #36 According to the Minimum Data Set (MDS) admission assessment, dated 10/25/17, Resident #36 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. This same assessment revealed Resident #36 had a Brief Interview for Mental Status (BIMS) score of 12 indicating Resident #36 was moderately cognitively impaired. Review of hospital records, dated 2/12/18, provided by the facility, indicated on 2/12/18, Resident #36 had a Peripherally Inserted Central Catheter (PICC) (a tube placed into the vein in the upper arm and extending into the heart) placed. The policy titled Central Vascular Access Device Dressing Change, revised 5/1/15, and provided by the facility read, in part, .1. Sterile dressing change using transparent dressings is performed: 1.1 24 hours post-insertion or upon admission 1.2 At least weekly 1.3 If the integrity of the dressing has been compromised (wet, loose or soiled) . The Centers for Disease Control, (YEAR), recommends changing a PICC line dressing every 7 days to reduce risk of infections. Retrieved 3/8/18 from https://www.cdc.gov/infectioncontrol/guidelines/BSI/index.html#rec12 According to the PICC line manufacturer, Resident #36's PICC line should be flushed, .every 7 days or after each use. Retrieved 3/8/18 from http://bardaccess.com/assets/literature/MC-0084-01_PICC_and_Maintenance_Guide_web.pdf An observation on 2/26/18 at 11:00 AM of Resident #36's PICC line revealed the dressing was undated, loose, and the insertion site was uncovered. During an interview with Resident #36 at that time the resident stated they had told staff about the loose dressing two days prior. Another observation that same day at 2:00 PM revealed the PICC line dressing remained loose and the PICC line insertion site remained uncovered. On 2/27/18 Resident was out of the facility for an appointment. An observation on 2/28/18 at 08:14 AM revealed Resident #36's PICC line dressing remained loose and the insertion site was exposed. The dressing looked the same as it had been on 2/26/18. LPN JJ was in Resident #36's room at that time to administer medication through the PICC line, when LPN JJ was asked about the dressing, LPN JJ stated, I guess we should change that first and left the room. Registered Nurse (RN) and Unit Manager D entered Resident #36's room and changed the PICC line dressing. During an interview on 2/28/18 at 11:50 AM, the Director of Nursing (DON) stated she was unsure when the PICC line was placed, unsure about having physician orders [REDACTED]. During an interview on 3/05/18 at 11:52 AM RN and Unit Manager D stated, Somehow it (PICC dressing) slipped past (the staff) .When the consultation comes back (documents from the hospital), the nurse should call doctor .it is expected that staff to get orders for flushes and PICC (line) dressing changes .it (PICC line) was flushed after a lab draw on 2/15/18 . The facility was unable to provide evidence the PICC line dressing had been changed since the time it was inserted. According to Resident #36's (MONTH) (YEAR) Medication Administration Record, [REDACTED]. There were no orders for PICC line flushes found in Resident #36's medical record. Resident #36's care plan was reviewed on 2/27/18 and there were no interventions for PICC line dressing changes or flushes. Resident #36's care plan was reviewed again on 3/1/18 and a care plan was initiated for PICC line care by the facility on 2/28/18, 16 days after the PICC line was inserted.

Based on observation, interview, and record review, the facility failed to practice effective infection control techniques for 4 residents (Resident's #67, #60, #36, #168 ) from a total sample of 21 residents resulting in the potential spread of infection when contact precautions and proper glove use were not performed for 1 resident (#67), when aspetic (sterile) suctioning practices were not followed for 1 resident (#60), when a PICC line dressing was not maintained for 1 Resident (#36), and when best practice guidelines were not followed for wound care for 1 resident (#168). Findings include: Resident #67 During and observation on 02/26/18 at 7:15 PM, Registered Nurse (RN) CC checked Resident #67's blood sugar with gloves on, completed the task, did not remove the gloves used to check the blood sugar and collected unused supplies into a plastic cup. During an interview on 02/26/18 at 7:19 PM, RN CC stated that she did not have enough supplies on her medication cart so she will need to keep the extra alcohol wipes that she had placed in the plastic cup. RN CC left Resident #67's room with the cup of supplies that were gathered with used gloves, and returned them to the medication cart on E Hall. Resident #60 During an observation on 02/28/18 at 12:15 PM, Licensed Practical Nurse (LPN) H was performing endotracheal suctioning for Resident #60 and gathered supplies which included unsterile water (a cup of tap water) to be used for suctioning the catheter to clear it of secretions. LPN H completed two passes of endotracheal suctioning, clearing the suction tip with tap water in between, and then placed the contaminated suction tip back in the package and set package with the suction machine. LPN H donned unsterile gloves and began assessing Resident #60s [MEDICAL CONDITION] site. Resident #60 began to cough again and audible secretions were heard in her throat. LPN H proceeded to suction Resident #60 again with unsterile gloves and with the used/contaminated suction catheter that she had used during the first suctioning. Following the second suctioning, LPN H again returned the suction catheter to the packaging and placed it near the suction machine. Resident #36 According to the Minimum Data Set (MDS) admission assessment, dated 10/25/17, Resident #36 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. This same assessment revealed Resident #36 had a Brief Interview for Mental Status (BIMS) score of 12 indicating Resident #36 was moderately cognitively impaired. Review of hospital records, dated 2/12/18, provided by the facility, indicated on 2/12/18, Resident #36 had a Peripherally Inserted Central Catheter (PICC) (a tube placed into the vein in the upper arm and extending into the heart) inserted on 2/12/18. The policy titled Central Vascular Access Device Dressing Change, revised 5/1/15, and provided by the facility read, in part, .1. Sterile dressing change using transparent dressings is performed: 1.1 24 hours post-insertion or upon admission 1.2 At least weekly 1.3 If the integrity of the dressing has been compromised (wet, loose or soiled) . The Centers for Disease Control, (YEAR), recommends changing a PICC line dressing every 7 days to reduce risk of infections. Retrieved 3/8/18 from https://www.cdc.gov/infectioncontrol/guidelines/BSI/index.html#rec12 An observation on 2/26/18 at 11:00 AM, of Resident #36's PICC line, revealed the dressing was undated, loose, and the insertion site was uncovered. During an interview with Resident #36 at that time the resident stated she had told staff (unidentified) about the loose dressing two days prior. Another observation that same day at 2:00 PM revealed the PICC line dressing remained loose and the PICC line insertion site remained uncovered. On 2/27/18 Resident was out of the facility for an appointment. An observation on 2/28/18 at 08:14 AM, revealed Resident #36's PICC line dressing remained loose and the insertion site was exposed. The dressing looked the same as it had been on 2/26/18. LPN JJ was in Resident #36's room at that time to administer medication through the PICC line, when LPN JJ was asked about the dressing, LPN JJ stated, I guess we should change that first and left the room. Registered Nurse (RN) and Unit Manager D entered Resident #36's room and changed the PICC line dressing. During a wound care observation of Resident #36's right lower buttock wound on 03/05/18 at 02:33 PM with Licensed Practical Nurse (LPN) JJ and RN D, scissors were removed from RN D's pocket, not cleaned, and placed on the table with the dressing supplies. The same unclean scissors were used to cut a sponge that was placed directly into Resident #36's right lower buttock wound bed. Immediately following the wound care, RN D stated, regarding the unclean scissors, They were clean when I put them in my pocket .they should have been cleaned before using. According to physician orders, dated 2/16/18, Resident #36 is currently receiving Vancomyacin (an antibiotic administered via PICC-directly into the upper chamber of the heart) to treat an infection in this wound. Resident #168 Review of the Face Sheet and Minimum Data Set (MDS), dated [DATE] reflected Resident #168 was a [AGE] year-old female, who was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of Brief Interview for Mental Status (BIMS), reflected a score of 5 out of 15 which represents Resident #168 had severe cognitive impairment. Resident #168 required staff assistance with all activities of daily living and transfers. During an observation and interview on 03/01/18 at 09:52 AM, Resident #168 was seated in her room in the wheelchair. Resident #168 had a grimaced expression on her face and when asked if she was in pain she stated, Yes, my bottom hurts. I have a sore on it and I want to get in my bed. At approximately 10:05 AM, CNA GG and CNA LL were walking down the hall, looked into Resident #168's room, stopped and entered the room. Both CNA's (without performing hand hygiene) donned gloves, assisted Resident #168 back to bed and positioned her in the bed, removed their gloves, and washed their hands. The CNA's were asked when hand hygiene should be performed and both stated before you put on your gloves. When this surveyor confirmed that there was not an observation of them performing hand hygiene before they donned their gloves, both CNA's stated that they should have and that they had forgot to do it. During an observation on 03/06/18 at 09:41 AM, CNA Y and CNA KK assisted Resident #168 off the bed pan and provided peri care. Resident #168 had a bowel movement and it had smeared on the skin that extended up under the dressing of the coccyx pressure ulcer. CNA Y stated that she would notify the nurse because Resident #168 needed a PRN dressing change. This surveyor observed CNA Y wash BM from under the bottom portion of the dressing. The integrity of the dressing was no longer intact to prevent the spread of microorganisms into the wound bed. On 03/06/18 at 09:55 AM, LPN U stated, when asked about changing Resident #168's dressing, .There is a small amount of stool on the edge of the [MEDICATION NAME] and I would not normally change it (the dressing) but I would trim the soiled edge off. A wound care observation was made on 03/06/18 at 10:00 AM with LPN U and Certified Nursing Assistant Y. The dressing was changed after this surveyor expressed the need to see the wound. LPN U removed a dressing dated 3/5/18 from Resident #168's coccyx that was loose and had a brown substance under the clear [MEDICATION NAME]. LPN U removed the old dressing from Resident #168, cleaned the wound, changed gloves, and applied the new dressing. Hand hygiene was not performed by LPN U between removal of old dressing and application of new dressing. LPN U used scissors that were brought into the room with the dressing supplies to cut the collagen that was placed in Resident #168's coccyx wound bed. The scissors were later taken from the room and given to another, unidentified staff member. There were no observations of the scissors being cleaned before or after leaving Resident #168's room. There were no observations of hand hygiene after the procedure and leaving the room. There was another, undated, occlusive dressing on Resident #168's left hip. During an interview immediately following this wound care observation, LPN U stated, I cleaned the scissors before I went into the room and (unidentified staff member) will clean them .I didn't wash my hands (while doing the dressing change) but I changed my gloves multiple times and washed my hands before I started.

This citation contains 2 deficient practice statements (#1 and #2). Deficiency statement #1 Based on observation, interview, and record review, the facility failed to safely transfer residents by utilizing wheelchair footrests (footplate's), for 4 residents (Resident #52, Resident #61, Resident #22, Resident #269) and properly use a gait belt for 1 resident (Resident #168) of 12 residents reviewed for accidents and hazards, from a total sample of 21 residents, resulting in the potential for injury. Findings include: Review of Mosby's Textbook for Long-Term Care Nursing Assistants by(NAME)Kostelnick, 6th Edition 2014 revealed on page 135, wheelchair safety staff were to Position the person's feet on the footplate's (foot pedals), Make sure the person's feet are on the foot plates before moving the chair (wheelchair). Never push a person in a wheelchair without feet resting on footplate's. During an interview on 02/28/18 at 12:12 PM, Director of Nursing (DON) B stated that the facility does not have a specific policy and procedure for the use of foot rests when pushing residents in a wheelchair, rather they follow the accepted standard of practice. Resident #52 Review of a Face Sheet revealed Resident #52 was an [AGE] year old female, originally admitted to the facility on [DATE], with pertinent [DIAGNOSES REDACTED]. During an observation on 02/28/18 at 7:40 AM, Certified Nursing Aid (CNA) T was pushing Resident #52 from C Hall to the dining room and Resident #52 did not have foot rests on her wheel chair. During an interview on 02/28/18 at 7:44 AM, CNA T stated that pushing a resident without footpedals can lead to accidents. During an interview on 02/28/18 at 7:45 AM, Registered Nurse, Clinical Coordinator (RNCC) L stated that there is never a reason to push a resident in a wheelchair without footpedals. Serious accidents can happen. During an interview on 02/28/18 at 12:13 PM, DON B indicated that staff are instructed to never push a residents without footpedals because they could put their feet down at any time and fall. Resident #61 During an observation on 2/26/18 at 12:24 PM in the main dining room, a family member was pushing Resident #61 in wheelchair, there were no foot pedals used. Staff present did not redirect the visitor to push wheelchair with foot pedals or have resident self-propel. Resident #22 On 2/26/18 at 12:45 PM, CNA GG was observed propelling Resident #22 down the hall without foot pedals. Resident #269 On 03/06/18 at 01:05 PM, CNA EE was viewed pushing Resident #269 in his wheelchair in the hall near the administrative offices without foot pedals. During an interview on 02/28/18 at 08:12 AM, DON B reported it is the expectation that staff only gently assist a resident to self propel by holding the residents hand and walking next to the resident while the resident does all the leg work. When asked what the expectation was for the family/visitors that are observed propelling a resident in a wheelchair without foot pedals the DON B reported the expectation was to re-educate the family about the risk for injury to the resident if the resident is propelled without foot pedals. Resident #168 Review of the Face Sheet and Minimum Data Set (MDS), dated [DATE] reflected Resident #168 was a [AGE] year-old female, who was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of Brief Interview for Mental Status (BIMS), reflected a score of 5 out of 15 which represents Resident #168 had severe cognitive impairment. Resident #168 required staff assistance with all activities of daily living and transfers. During an observation and interview on 03/01/18 09:52 AM, Resident #168 was seated in her room in the wheelchair. The bedside table was behind her and out of reach. The call light was clipped to the privacy curtain which was pushed up against the wall (out of reach). Resident #168 had a grimaced expression on her face and when asked if she was in pain she stated, Yes, my bottom hurts. I have a sore on it and I want to get in my bed. At approximately 10:05 AM, CNA GG and CNA LL were walking down the hall, looked into Resident #168's room, stopped and entered the room. Both CNA's assisted Resident #168 back to bed. CNA LL moved the wheelchair next to the bed and set the wheelchair brakes, then placed a gait belt around Resident #168's waist. Each CNA put one hand on the gait belt and the other under Resident #168's arms and lifted up on the the belt and under her arms as they pivot transferred her from the chair to the bed. During the transfer the gait belt was noted to have at least a 2 inch gap and was not noted to be snug to the resident. When asked how a gait belt should be applied for transfers, both CNA's stated that it should be snug and not loose. When asked where the staff's hands should be placed to assist residents with transfers both CNA's stated that one hand should be on the gait belt and the other under the arm of the resident. This observation and interview was not consistent with the facility policy for transferring a resident with a gait belt. A request was made for the facility procedure for gait belt use. The facility provided an untitled and undated document that reflected, The gait belt should be snug because it will tend to become looser on the resident once he/she stands .Standing Pivot Transfers .Ask resident to push down on the sitting surface as the knees straighten and trunk extends .Hold the gait belt underhanded with one hand at each side of the resident's body . Deficiency statement #2 Based on interview and record review, the facility failed to prevent falls for 1 of 19 residents (Resident #59) reviewed for falls, in a total sample of 21 residents. This deficient practice resulted in Resident #59 sustaining multiple preventable falls and the potential for serious injury. Finding include: Review of the Face Sheet and Minimum Data Set (MDS), dated [DATE] reflected Resident #59 was an [AGE] year-old male, who was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of Brief Interview for Mental Status (BIMS), reflected a score of 9 out of 15 which represents Resident #59 had moderate cognitive impairment. Resident #59 required staff assistance with all activities of daily living and transfers. According to the care plan dated 1/23/18 for Resident #59 requires assistance of 2 staff members to reposition in bed and for all transfers. The impaired thought process care plan dated 1/23/18 reflected, Resident needs will be anticipated by staff . The MDS dated [DATE] reflected frequent incontinence of bowel and bladder. The Care Area Assessment reflected, He (Resident #59) has had both B&B incontinence and is at risk for skin breakdown and infection. He requires assist with toileting cares. There was no care plan developed for bowel and bladder incontinence, and to provide Resident #59 with staff assistance for toileting to prevent falls. The fall report dated 2/8/18 reflected that Resident #59 sustained a fall and staff observed him on the floor near his bed. The report reflected that his O2 Sat was 82%. The blood sugar level was left blank. The SBAR reflected, Resident had a very low O2 sat leading to confusion, combative behavior, and subsequent fall. Listed under other new requested/suggested orders reflected, Supplemental O2 to keep resident's O2 sat at 90% or above, fall mat to prevent injury in case incident happens again. Record review of the physician orders [REDACTED].#59 who was admitted on [DATE] with pneumonia and pleural effusion. Record review of the O2 Sat from 2/7/18 -2/26/18 reflected no monitoring of oxygen saturation until after the fall on 2/9/18. The fall report dated 2/10/18 at 2:40 AM reflected that Resident #59 was observed by staff on the floor near his bed. There was no blood sugar obtained. He was brief was wet as well as the bed. He was last assisted to the bathroom at 11:00 PM (over 3 1/2 hours before). The intervention to prevent further falls reflected that staff will offer to assist to the bathroom every 2 hours. The care plan did not reflect this new intervention. The fall report dated 2/23/18 reflected that Resident #59 was observed on the floor next to his bed. The blood sugar was left blank. The SBAR reflected that he was not wearing his oxygen and his O2 was 86% on room air. The resident stated that he was attempting to reach for his gown. The root cause reflected, Resident was confused and was reaching for his gown which was half off. The new intervention reflected to keep the door open and check him every hour. The SBAR reflected that not having oxygen on made resident more confused and it become better when applied. On 3/5/18 at 11:24 AM, an interview and record review of the falls was conducted with RN UC L. RN UC L stated the fall on 2/8/18 was preventable and the staff should have obtained orders for oxygen upon admission to the facility on [DATE]. RN UC L reviewed the physician orders [REDACTED]. RN UC L stated that the fall on 2/10/18 was preventable because the staff was aware that the resident had incontinence, poor memory and should have already been offered assistance to use the bathroom every 2 hours prior to the fall. RN UC L stated that it was assigned to the CNA's through the task system but agreed it was not on the CNA Kardex or the nursing care plans. RN UC L stated that the fall on 2/23/18 was preventable because the staff did not tie the gown that they put on Resident #59, they knew he was confused and did not use his call light. RN UC L stated the staff should not have had his door completely closed.

Based on observation, interview, and record review, the facility failed to prevent, monitor, and treat pressure ulcers for three residents (#36, #59, and #168) of three residents reviewed for pressure ulcers out of a total sample of 21 residents. This deficient practice resulted in the development of an unstageable facility acquired pressure ulcer for Resident #36, a stage 2 facility acquired pressure ulcer for Resident #59 and failed to promote the healing of a stage 2 pressure ulcer for Resident #168. Findings include: The facility provided the policy for Pressure Ulcers/Skin Breakdown undated with a revision date of 11/28/17 for review. The policy reflected, Initial Screen: c. Complete the Nursing Data Evaluation and/or admission skin assessment upon admission to the facility (skin assessment portion completed preferably within first 8 hours of admission); d. All PU/PI (pressure ulcer/pressure injury) or other skin related issues are measured and documented .e. Staging will be documented .11. The physician will help clarify relevant medical issues .1. The physician will authorize pertinent orders related to wound treatments, including pressure reduction surfaces, wound cleansing and debridement approaches, dressings .1. During the resident visits, the physician will evaluate and document the progress of the wound healing-especially for those with complicated, extensive, or non-healing . Resident #36 According to the Minimum Data Set (MDS) admission assessment, dated 10/25/17, Resident #36 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. This same assessment revealed Resident #36 had a Brief Interview for Mental Status (BIMS) score of 12 indicating Resident #36 was moderately cognitively impaired. An observation of Resident #36's left upper buttock wound care was made on 03/05/18 at 03:37 PM with Registered Nurse (RN) D revealed an unstageable pressure injury that was 40% eschar (black, dead tissue) and 60% yellow slough (non viable) tissue. A Skin Assessment, dated 2/21/8, indicated Resident #36 had a new abnormal skin area on the left buttock described as Pressure Ulcer SDT (suspected deep tissue injury). A wound note dated 2/21/18 provided by the facility describes Resident #36's upper left buttock pressure injury as Unstageable and Necrotic/Eschar. This same document reveals the pressure injury was acquired while Resident #36 was in the facility. During an interview on 2/28/18 at 11:48 AM, Director of Nursing (DON) B confirmed the pressure injury was acquired in the facility and stated, .it (pressure injury) was caused from her wheelchair .Physical Therapy is looking at her chair to find a way to prevent the back from causing pressure on her skin . DON B agreed that if Resident #36's wheel chair had been assessed prior to the pressure injury occurring, the pressure injury may have been avoidable. An observation on 2/28/18 at 2:12 PM of Resident #36's wheelchair revealed a lower back support with a hard edge in the same area of Resident #36's pressure injury of her left upper buttock. A wound care observation of Resident #36's right lower buttock wound on 03/05/18 at 02:33 PM with Licensed Practical Nurse (LPN) JJ and RN D revealed: 1. Scissors were removed from RN D's pocket, not cleaned, and placed on the table with the dressing supplies. The same unclean scissors were used to cut a sponge that was placed directly into Resident #36's right lower buttock wound bed. Immediately following the wound care, RN D stated, regarding the unclean scissors, They were clean when I put them in my pocket .they should have been cleaned before using. According to physician orders, dated 2/16/18, Resident #36 is currently receiving Vancomyacin (an antibiotic administered via a Peripherally Inserted Central Catheter-directly into the upper chamber of the heart) to treat an infection in this wound. 2. The dressing removed from Resident #36's right lower buttock did not have a date indicating when the dressing was applied. RN D stated it had been on since Resident #36 visited the wound clinic on 2/27/18, 5 days prior to this observation and interview, and stated the dressing that was removed was not the same dressing the facility uses as the facility has to make their own bridging system. Review of (MONTH) (YEAR) Treatment Administration Record (TAR) revealed orders to change the dressing and wound vac canister on Resident #36's right lower buttock every Monday, Wednesday, and Friday. On Friday, 3/2/18, the TAR was initialed indicating the wound care and wound vac canister was changed. During an interview immediately following the wound care observation, LPN JJ confirmed the initials on the TAR dated 3/2/18 were his and that he did not change Resident #36's dressing that day, he only changed the wound vac canister on 3/2/18. Review of Physician orders [REDACTED].#36 read, Change wound vac dressing and canister to right ischium (bone area of lower buttock) every Monday, Wednesday, Friday, and PRN (as needed), as needed for wound care AND every day shift every Monday, Wednesday, Friday Remove old dressing, cleanse area thoroughly, re-apply wound vac dressing, replace canister. Resident #59 Review of the Face Sheet and Minimum Data Set (MDS), dated [DATE] reflected Resident #59 was an [AGE] year-old male, who was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of Brief Interview for Mental Status (BIMS), reflected a score of 9 out of 15 which represents Resident #59 had moderate cognitive impairment. Resident #59 required staff assistance with all activities of daily living and transfers. According to the care plan dated 1/23/18 for Resident #59 requires assistance of 2 staff members to reposition in bed and for all transfers. The impaired thought process care plan dated 1/23/18 reflected, Resident needs will be anticipated by staff . The MDS dated [DATE] reflected no pressure ulcer on admission, frequent incontinence of bowel and bladder. The Care Area Assessment reflected, He (Resident #59) has had both B&B incontinence and is at risk for skin breakdown and infection. He requires assist with toileting cares. There was no care plan developed for bowel and bladder incontinence to prevent the skin breakdown. Record review of the nursing notes dated 2/23/18 reflected that Resident #59 had a new stage 2, facility acquired pressure ulcer to the coccyx. The stage 2 pressure ulcer measured 3.0 x 0.5 x 0.0 cm. The treatment indicated that a dressing (duoderm) was placed to the coccyx every 3 days and as needed but did not indicate how the wound should be cleansed. Record review of the physician orders [REDACTED]. Record review of the pressure ulcer care plan reflected that it was initiated on 2/26/18 (3 days after the development of the stage 2 pressure ulcer to the coccyx). Record review of the physician noted dated 2/26/18 did not include any evaluation of the new stage 2 facility acquired pressure ulcer that developed to the coccyx on 2/23/18. Record review of Resident #59's bowel history reflected the following from 2/16/18 - 2/26/18: 2/16 no bowel movement 2/17 one incontinent bowel movement 2/18 no bowel movement 2/19 one continent bowel movement 2/20 one incontinent bowel movement 2/21 one continent bowel movement 2/22 one continent bowel movement 2/23 no bowel movement 2/24 one continent bowel movement 2/25 one continent bowel movement 2/26 one incontinent bowel movement According to the nursing notes Resident #59 had a very low blood sugar, was unresponsive and was sent to the hospital 2/26/18 at approximately 11:30 PM. An interview and record review was conducted on 3/1/18 at 3:51 PM with Registered Nurse, Unit Coordinator (RN, UC) L. The RN, UC L stated that the Resident #59 had many [DIAGNOSES REDACTED]. RN UC L stated that she called and notified the physician of the newly acquired pressure ulcer but forgot to write the treatment order and change the care plan until 2/26/18. RN UC L stated the Resident #59 had previously lived with his family prior to admission and family had told the staff that he needed assistance to use the bathroom once every hour but RN UC L could not provide record review on the Kardex or the care plans that this was being provided to the resident. The facility staff failed to follow their own policy to prevent a facility acquired pressure ulcer, ensure timely treatment orders from the physician, care plan and to ensure the physician evaluated the wound and of the surrounding circumstances that led to the development of the facility acquired pressure ulcer. Resident #168 Review of the Face Sheet and Minimum Data Set (MDS), dated [DATE] reflected Resident #168 was a [AGE] year-old female, who was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of Brief Interview for Mental Status (BIMS), reflected a score of 5 out of 15 which represents Resident #168 had severe cognitive impairment. Resident #168 required staff assistance with all activities of daily living and transfers. During an interview and record review on 3/1/18 at 2:38 PM, RN UC L stated that Resident #168 admitted on [DATE] with a pressure ulcer to the coccyx. RN UC L stated that it was a stage 2 and it was measured on 2/22/18, 3.5 x 3.0 x 0.2 cm. When asked if a care plan was developed on admission and implemented for the pressure ulcer to the coccyx, RN UC L stated it should have been started within 48 hours but was not initiated until 2/26/18 (4 days after the admission assessment). The RN UC L stated that she could not answer why the care plan was not initiated sooner. During an observation on 03/06/18 09:41 AM, CNA Y and CNA KK assisted Resident #168 off the bed pan and provided peri care. Resident #168 had a bowel movement and it had smeared on the skin that extended up under the dressing of the coccyx pressure ulcer. CNA Y stated that she would notify the nurse because Resident #168 needed a PRN dressing change. This surveyor observed CNA Y wash BM from under the bottom portion of the dressing. The integrity of the dressing was no longer intact to prevent the spread of microorganisms into the wound bed. On 03/06/18 at 09:55 AM, LPN U stated, when asked about changing Resident #168's dressing, .There is a small amount of stool on the edge of the [MEDICATION NAME] and I would not normally change it (the dressing) but I would trim the soiled edge off. A wound care observation was made on 03/06/18 at 10:00 AM with LPN U and Certified Nursing Assistant Y. The dressing was changed after this surveyor expressed the need to see the wound. LPN U removed a dressing dated 3/5/18 from Resident #168's coccyx that was loose and had a brown substance under the clear [MEDICATION NAME]. LPN U removed the old dressing from Resident #168, cleaned the wound, changed gloves, and applied the new dressing. Hand hygiene was not performed by LPN U between removal of old dressing and application of new dressing. LPN U used scissors that were brought into the room with the dressing supplies to cut the collagen that was placed in Resident #168's coccyx wound bed. The scissors were later taken from the room and given to another, unidentified staff member. There were no observations of the scissors being cleaned before or after leaving Resident #168's room. There were no observations of hand hygiene after the procedure and leaving the room. There was another, undated, occlusive dressing on Resident #168's left hip. During an interview immediately following this wound care observation, LPN U stated, I cleaned the scissors before I went into the room and (unidentified staff member) will clean them .I didn't wash my hands (during the wound care) but I changed my gloves multiple times and washed my hands before I started. The facility failed to promote the healing of Resident #168 pressure ulcer by initiating a care plan, ensuring the integrity of the dressing placed on the pressure ulcer, and did not ensure that clean technique was maintained for a wound dressing change.

Based on observation, interview and record review the facility failed to assess, monitor and prevent a facility acquired pressure ulcer for 1 of 2 residents (Resident #6) reviewed for pressure ulcers in a total sample of 16 residents resulting in Resident #6 developing a facility acquired stage III pressure ulcer to the left heel. Findings include: The facility provided the document Pressure Ulcer/Skin Breakdown - Clinical Protocol dated 3/21/11 for review. The protocol reflected, The nursing and Attending Physician will assess and document an individual's significant risk factors for developing pressure sores .In addition, the nurse shall assess and document/report the following: vital signs, full assessment of pressure sore including location, stage, length, width and depth, presence of exudates or necrotic tissue .During resident visits, the physician will evaluate and document the progress of wound healing-especially for those with complicated, extensive or non-healing wounds . The facility form titled Skin Grid - Pressure/[MEDICAL CONDITION] Ulcer/Other reflected, Stage III - full thickness loss, subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling .Unstageable - Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green, or brown) and/or eschar (tan, brown or black) in the wound bed . Review of the Face Sheet and Minimum Data Set (MDS), dated [DATE], reflected that Resident #6 was a [AGE] year-old male, who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #6's MDS, dated [DATE], for Brief Interview for Mental Status (BIMS), reflected a score of 7 out of 15 which represents moderate cognitive impairment. Resident #6 required 1-2 staff assistance for all activities of daily living. During an observation of Resident #6's dressing change done by Licensed Practical Nurse (LPN) F on 1/26/16 at approximately 1:45 PM, Resident #6 was observed to have an open area to the left heel. The wound bed was red and had minimal amount of red drainage. During an interview on 1/26/16 at approximately 2:00 PM, Resident #6's family member stated that she was the first person to notice an open area to Resident #6's left heel and reported it to the nurse. Resident #6's family members stated, It was later in August that it (left heel wound) was noticed. It started out the size of a nickel but then it increased to the size of a clementine. It didn't seem to get better so I spoke to the doctor about it and he seemed unaware of the condition. According to the nurses notes dated 8/21/15, Resident #6 was noted with an open area to the left heel and a treatment order was obtained to cleanse and dress the wound daily. During an interview and record review on 1/27/16 at approximately 9:45 AM, Registered Nurse (RN) I stated the facility's expectation of pressure ulcer prevention and pressure ulcer management included weekly skin checks done by the nurses and initialed on the Treatment Administration Record (TAR), assess, measure and document new findings/developments on the back of the TAR and in the nursing progress notes, notify the doctor, obtain a treatment order, notify the family and continue to measure and monitor the wound weekly until healed. RN I stated that the facility also completes a form to evaluate all of the mitigating factors (root cause analysis) and it is kept in the chart. RN I was not able to locate the initial wound assessment and documentation (for 8/21/15), weekly wound measurements from 8/21/15- 10/1/15, nor the form the facility used for the root cause analysis of the stage III facility acquired pressure ulcer. The facility did not provide documentation to review for the assessing and monitoring of a newly developed pressure ulcer for approximately 6 weeks. Record review of the TAR from 8/21/15 - 1/26/16 reflected there was a treatment and dressing order in place for an open wound to the left heel. There were no initials that represented that the treatment and dressing was changed on the following dates: 8/28/, 8/29, 8/30, 10/6, 10/7, 10/18, 10/24, 10/30, 11/4, 11/7, 11/8, 12/4, 12/19, 12/25 and 1/23/16. According to the physician progress notes [REDACTED]. The following weekly measurements for the left heel stage III pressure ulcer were provided for review by the facility: no initial measurements of the wound for 41 days (8/21/15 - 10/1/15) 10/1/15 4.3 x 4.5 x 0.2 with red drainage and black eschar (unstageable pressure ulcer) 10/15/15 1.6 x 2.4 x 0.1 10/21/15 2.8 x 3.0 x 0.1 (no measurement for 14 days) 11/4/15 6.5 x 6.5 x 0.1 Stage III 11/10/15 7.0 x 6.0 x 0.1 11/18/15 4.5 x 4.2 x 0.1 11/24/15 3.8 x 4.0 x 0.1 (no measurement for 10 days) 12/4/15 2.4 x 3.4 x 0.1 (no measurement for 26 days) 12/30/15 2.1 x 3.2 x 0.1 (no measurement for 19 days) 1/18/16 2.8 x 2.0 x 0.1 During an interview and record review on 1/27/16 at approximately 2:45 PM, the Regional Clinical Coordinator K and the Director of Nursing (DON) B stated that the facility had provided staff education and transitioned from paper charting of pressure ulcers to the electronic (computer) charting during the fall of 2015 and were unable to provide wound measurements and physician documentation from 8/21/15 - 10/1/15. A copy of Central Region Root Cause Analysis in House Acquired Wound dated 3/26/15 was provided for review. The form indicated that Resident #6 had previously developed a pressure ulcer to the left heel. The form gave a clinical picture of how Resident #6 looked over the 30 days that preceded the pressure development and did not reflect how Resident #6's clinically appeared 30 days prior to the development of the facility acquired pressure ulcer on 8/21/15. (# )

Based on interview and record review, the facility failed to provide adequate supervision, update care plans and implement interventions to prevent falls for 2 residents (Resident #6 and #8) out of 6 residents reviewed for falls from a total of 16 residents sampled resulting in avoidable fall for Resident #8 with a hematoma and two avoidable falls for Resident #6 who sustained a laceration and a hematoma. Findings include: According to a facility face sheet dated 4/28/14, Resident #6 was an [AGE] year old female admitted to the facility on [DATE] at 10:00 a.m. with the cumulative [DIAGNOSES REDACTED]. Resident #6 was assessed as a fall risk according to a facility document titled, Fall/Injury assessment: Prevention and Management Plan of Care dated as rewritten 3/25/14. Resident #6 was noted to have a history of falls, pain, shuffled gait, stiffness, unsteady, osteoporosis, osteoarthritis, bladder incontinence, sensory deficits and dementia that placed Resident #6 at risk for falls. A facility document titled, Resident Incident dated 3/23/14 at 7:30 p.m. reflected that Resident #6, Res(ident) was observed on the floor mat next to her bed after her room mate yelled out (name of Resident #6) needed help. This writer ran to the room and found her (Resident #6) next to the bed between it (the bed) and the wheelchair. She (Resident #6) stated she was trying to get into bed. An interview on 10/16/14 at 1:20 p.m. with Unit Manager (UM) E confirmed that Resident #6 attempted to self transfer from the wheelchair to the bed on 3/23/14 at 7:30 p.m. and that Resident #6 was not injured. UM E stated that anti roll back brakes was the intervention added to prevent another fall. A facility document titled, Resident Incident dated 8/12/14 at 10:45 a.m. reflected, Resident #6 was found lying on the floor with legs extended over the wheelchair foot pedals and her head rested up against her dresser. The document reflected that Resident #6 was injured during this fall and had a laceration (cut) to left frontal lobe (forehead) measuring 1 1/2 cm (centimeters). The facility document also reflected, Root cause found to be Dycem (a rubber mat applied to chair to prevent slippage of the residents buttocks) missing in wheelchair cushion (causing) slippage. The Dycem mat, an intervention to prevent a fall from Resident #6's wheelchair was not in place; therefore, the fall with a head laceration was avoidable. According to a facility document titled, Accidents and Incidents Report, Investigation, Follow up and Final Disposition dated revised on 4/2012 reflected, An avoidable accident was an incident that occurred when the center failed to: .implement interventions including adequate supervision consistent with resident goals, needs, plan of care and current standard of practice, monitor and modify intervention. Review of progress notes dated 8/12/14 at p.m. reflected that Resident #6 was experiencing, laceration with bruising slightly to left temple about 4 cm by 4 cm (the size of a silver dollar) from fall yesterday outline of glasses slight bruising. No other wounds. Resident appears slightly more anxiety (sic) since fall with jumping at fast movements/sounds. Resident #6 experienced not only physical injury from this fall but also increased anxiety from the fall. A facility document titled, Resident Incident dated 8/23/14 at 10:40 a.m. reflected, Resident #6 was found on the floor (name of CNA), (name of CNA) stated 'walking past residents room, noted resident lying on her back with her head towards the door, feet towards (the) bed '. This document reflected that Resident #6 was injured during this fall and had a hematoma (a collection of blood outside the blood vessel ). The injury to Resident #6 was described as a Bump on right side/back of head 4 cm (centimeters, the size of a Silver Dollar) in diameter, tender to touch. An interview on 10/16/14 at 1:20 p.m. with Unit Manager (UM) E, confirmed that Resident #6 attempted to self transfer from her wheelchair. Review of a timeline prepared by UM E during the week of the standard survey reflected, On 8/14/14 the UA (urinalysis for Resident #6) returned with greater than 100,000 (bacteria count) of E. Coli (a bacteria found in the bowels). Resident #6 was diagnosed with [REDACTED].#6) had increased confusion with weakness related to urinary tract infections from differing bacteria that contributed to the August falls. During an interview with UM E on 10/16/14 at 1:20 p.m., UM E was asked if a resident would need to be monitored/supervised more closely when diagnosed with [REDACTED]. UM E agreed that increased supervision was needed. ( See also F 279) ( ) According to the October 2014 physician's orders [REDACTED]. A review of the Fall Care Plan for Resident #8 also showed a note, Continued further declines in condition may be expected R/T (related to) dementia with psychosis. The Care Plan also had a note dated 5/29/14 which stated, Attempts self transfers. Nurses' notes dated 6/12/14 indicated that the resident experienced a fall on that date. The Incident/Accident report, dated 6/12/14 noted, Resident was on the toilet when CNA (Certified Nurse Aide) went to get towels and wipes from the linen closet in the hall. Resident attempted to stand up on her own. She lost her balance and fell to the floor striking her head. She has a 4 cm (centimeter) diameter hematoma to the Left side of forehead. Routine neurological checks were documented and other than brief discomfort, there was no other lingering outcome from the head injury from the avoidable fall. According to an interview with the Director of Nursing, staff B on 10/15/14 at 10:15 a.m., the aide was disciplined with a 1-1 inservice regarding not leaving a person with dementia alone on the toilet which is the facility's policy and expectation. ( )

This citation pertains to MI# 992 Based on observation, interview and record review, the facility failed to ensure the residents environment remains as free of accident hazards as is possible and each resident receives adequate supervision to prevent accidents in 1 (#102) of 4 sampled residents, from a total sample of 4 residents, resulting in resident #102 receiving second degree burns from smoking with oxygen on with no staff present. Findings include: Record review of the facility reported 24/hr. report dated 6/6/13 revealed that Resident #102 was an alert and oriented resident went outside the facility with son. Son reports having to remove nasal cannula as resident attempted to light a cigarette with oxygen on. Initial assessment notes no significant injury. Family and physician were aware. CXR indicates no acute pulmonary issues. Resident denies pain and is stable. Injury was noted as nasal irritation. Observation on 6/11/13 at 8:30 AM with registered nurse #4 of the park area located outdoors between the A hall and B hall wings revealed there to be a child swing set, a gazebo and a wheelchair glider swing. Observation of the area revealed that there were no fire extinguishers or cigarette but deposit containers in sight. The RN #4 stated that this was not a designated smoking area for residents, but acknowledged that this was the location of the resident when he lit a cigarette while wearing oxygen flowing at 3 liters via nasal cannula with no staff present. RN #4 acknowledged that the residents' assigned smoking area was at the back of the building outside the dining room. In an interview on 6/11/13 at 11:35 AM with Registered Nurse (RN) #4 revealed that Resident #102's son came to the facility to visit and stopped at the nursing station to get the residents smoking supplies of cigarettes and lighter, which RN #4 gave to the son and watch them proceed to the front of the building. RN #4 stated that the resident was in his wheelchair with his oxygen at 3 liters per nasal cannula flowing with the portable oxygen tank attached to the back of the wheelchair heading out of the building near the front. In an interview on 6/11/13 at 11:12 AM with the son revealed that he had taken his father (Resident #102) out the front door to smoke to the park area on the side of the facility, shut off the oxygen flow, but left the nasal cannula in place on Resident #102's face, and that his father had two cigarettes which the son stated was his usual. The son stated that he turned the oxygen back on to 3 liters of oxygen set the cigarettes and lighter on the bench beside the resident and walked over to the child swing set area when he heard a poof and saw sparks/flames from the nasal cannula on Resident #102's face. The son of Resident #102 stated that he knocked/swatted the nasal cannula off the residents face and stomped on it to put out the flame, then took the resident back into the facility. Record review of facility MI (Michigan) Smoking Policy dated 10/2012 revealed that resident's that live at the facility are permitted to smoke in designated areas outside the Center, subject to certain requirements and restrictions set forth. 1.) all residents who smoke will be assessed upon admission.........3.) All residents who smoke may only smoke in designated areas. 4.) Residents may only smoke under staff supervision, designated smoking area and at times established by the center. 6) Residents requiring oxygen smoking is prohibited within 25 feet of an oxygen container or supply. Staff will turn off oxygen supply and remove nasal cannula from resident's face, if they wish to smoke. Store nasal cannula, oxygen supply, etc. away from residents during the smoking session...... In an interview and record review on 6/12/13 at 11:30 AM with the corporate consultant # 2 revealed that Resident #102 was admitted on [DATE] and assessed by the Director of Nursing (DON) #3 whom noted Resident #102 to be a 3 pack a day smoker for [AGE] years and that the admission assessment noted that staff should complete 'Smoking safety Data Collection and Assessment' form. Record review of Resident #102's 'Smoking safety Data Collection and Assessment' form dated 5/28/13 revealed that "all residents are supervised". Record review of facility 'Resident Supervision' policy dated 2009, which the corporate consultant acknowledged was the current facility policy, revealed that 'Volunteers and visitors may not be given the responsibility for resident supervision. State surveyor reviewed Resident #102's 'Fall/Injury' care plan dated 6/3/13 that identified Resident #102 as a smoker with interventions of smoking will be supervised by staff, ensure O2 (oxygen) is off during smoking, Monitor compliance to smoking policy. Corporate consultant #2 declined to respond. Observation on 6/12/13 at 11:10 AM with the nursing home administrator (NHA) #1 of the front of the building near the front entrance outdoors revealed that there was a cigarette butt depositor container located near the front entrance and numerous cigarette butts noted on the ground around the front entrance. The NHA #1 stated that the front entrance was not a designated smoking area. The state surveyor and the NHA #1walked through the building to the back dining room door that lead to an enclosed patio off the dining room at the back of the building, where the NHA #1 stated was the designated smoking area. Observation of the smoking area noted that there was no sign posted to indicate that it was the designated area so that visitors would know the designated smoking area. Record review of Resident #102's local emergency room record dated 6/6/13 at 12:43 PM revealed that the resident was diagnosed with [REDACTED]. In an interview on 6/12/13 at 10:00 AM with the social worker #10 revealed that that she did a brief interview of mental status (BIMs) post incident and that the resident was 14 out of 15 cognitively intact. In an interview on 6/12/13 at 9:00 AM with Resident #102 revealed that he didn't know what happened. Resident #102 stated that he did lite a cigarette, it went poof and he stated that he didn't know much else. Resident #102 stated that he was smokes outside the dining room patio and when his son comes he goes with him to smoke. There were no burn marks noted on the residents nose/mustache area and the resident denied pain to the area. Resident #102 looked out his room window and acknowledged that the incident happened outside the window in the park area. #

This citation pertains to MI# 568 Based on interview and record review, the facility failed to provide nursing services that meet professional standards of care in 1 (#102) of 5 residents, from a total sample of 5 residents, when Resident #102 sustained a fall on the afternoon shift, complained of hip pain, and was not assessed for left leg shortening or rotation by the afternoon or night shift nurse, resulting in a delay in treatment and Resident #102 being sent to the hospital on the following day shift. Findings include: According to the 'Basic Nursing' 7th edition, Potter-Perry, copyright 2011 Mosby, pg. 311, section: Skills of Physical Assessment-Inspection, included: Inspection (visualize) is a simple technique, and the quality of the inspection depends upon the willingness to be thorough and systematic. To inspect body parts accurately follow these principles: 1.) Adequate lighting.......3.) Inspect each area for size, shape, color, symmetry, position, and abnormalities. Record review of facility 'Falls and Injuries' policy dated 4/2012, defined a fall as unintentionally coming to rest on the ground, floor or other lower level....... Record review of Resident #102's 'Resident Incident' form dated 7/5/12 at 6:10 PM revealed that staff responded to the residents wheelchair alarm sounding and observed the resident on the floor in front of his wheelchair sitting upright with both of his legs out in front of him. Staff noted that the resident was very agitated with the alarm sounding and stated that the certified nurse assistant turn the alarm off. The resident denied pain at the time of the fall. Record review of Resident #102's SBAR communication and progress note written by licensed practical nurse (LPN) #7 dated 7/5/12 at 6:00 PM revealed that the resident was very agitated, trying to get out front door, WanderGuard was already placed on residents right wrist due to alert to person only and residents wife stated resident wanted to go home with her. Resident #102 was taken back to his room and dinner tray was given to resident. Resident #102 started to eat dinner, safety measures in place. Physician was notified of incident and new order for [MEDICATION NAME] was given. At 6:10 PM the nurse noted Resident #102 was observed on floor in resident room in front of his wheelchair. When the writer entered Resident #102's room, the resident was sitting upright with legs out in front of him. Resident was able to lift his arms over his head and bend both knees. Resident denied pain at the time. Record review of Resident #102's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Record review of Resident #102's '[MEDICATION NAME] record/Pain flow sheet' dated July 2012 used for pain assessment on the back of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] Further record review of Resident #102's SBAR progress note, dated 7/5/12 at 7:00 PM, revealed Resident #102 was noted to complain of left hip pain and the resident was asked to bend his left knee, and LPN #7 noted that Resident #102 stated that he could not. LPN #7 wrote an order for [REDACTED]. There was no assessment note of lower left extremities inspection of leg shortening or leg rotation noted. In an interview on 10/31/12 at 10:44 AM, LPN #7 revealed that she remembered the resident as confused and was going through alcohol withdrawal with behaviors. The nurse stated that the certified nurse assistant came to the nurses' station and told her that the resident was on the floor. LPN #7 stated that the resident denied pain and was put into bed. LPN #7 stated that about an hour later the resident complained of pain to his left hip and that she obtained an order for [REDACTED]. Record review of Resident #102's closed medical record revealed that there was no documentation noted by the nightshift nurse from 7/5/12 at 10:00 PM through 6:00 AM. There was no assessment of the resident noted or if pain was assessed throughout the night. Record review of Resident #102's radiology report dated 7/6/12 at 1:11 AM revealed an acute complete femoral neck fracture without displacement. Record review of 'Resident Transfer Form' dated 7/6/12 at 7:00 AM revealed the resident #102 was transferred at that time to the hospital due to fracture. Record review of Resident #102's progress note dated 7/6/12 at 7:00 AM revealed LPN #10 wrote that she sent resident to ER (emergency room ) for eval and treat for [MEDICAL CONDITION]. LPN #10 noted that the resident had a temperature of 101.9 and that he needed oxygen applied at 2 liters via nasal cannula, but did not note the oxygen saturation level. There was no assessment noted related to the [MEDICAL CONDITION] or leg shorting or leg rotation noted. In an interview on 10/30/12 at 10:25 AM, LPN #10 revealed that she worked the day shift (6 AM-2 PM) and that the resident had fallen prior to her shift. LPN #10 stated that she and a unit manager found the positive x-ray results on the fax machine and that she sent the resident out. Record review of Resident #102's post fall emergency room record dated 7/6/12 revealed the physician noted left leg shortened and rotated. #

This citation pertains to MI# 568 Based on observation, interview and record review, the facility failed to provide the necessary care and services to maintain the highest practical well-being (nursing staff did not perform appropriate assessments and follow up with x-ray results following a fall) in 1 of 5 residents (#102), from a total sample of 5 residents, resulting in prolonged pain and a delay of treatment for [REDACTED]. Findings include: Resident #102: Record review of facility 'Radiology and Other Diagnostic Services' policy dated 10/2009 revealed the facility strived to assure that the resident receives quality and timely radiological and diagnostic services so their needs for diagnosis, treatment, and prevention will be met. (The facility) will obtain radiology and other services to meet the needs of its residents. (The facility) will be responsible for the quality and timeliness of services provided by the outside agency. Procedure: 2.) Assure radiology and other services are completed and results provided to the center (facility) or physician within a normal time frame (no time frame was noted) for appropriate interventions. 4.) Assure nursing notifies the physician promptly of the findings. Record review of facility 'Falls and Injuries' policy dated 4/2012, defined a fall as unintentionally coming to rest on the ground, floor or other lower level....... Record review of Resident #102's 'Resident Incident' form dated 7/5/12 at 6:10 PM revealed that staff responded to the residents wheelchair alarm sounding and observed the resident on the floor in front of his wheelchair sitting upright with both of his legs out in front of him. Staff noted that the resident was very agitated with the alarm sounding and stated that the certified nurse assistant turned the alarm off. The resident denied pain at the time of the fall. Record review of Resident #102's SBAR communication and progress note dated 7/5/12 at 6:00 PM revealed that the resident was very agitated, trying to get out front door, WanderGuard was already placed on resident's right wrist due to alert to person only and residents wife stated resident wanted to go home with her. Resident was taken back to his room and dinner tray was given to resident. Resident (#102) started to eat dinner, safety measures in place. Physician was notified of incident and new order for [MEDICATION NAME] was given. At 6:10 PM the nurse noted Resident was observed on floor in resident room in front of resident's wheelchair. Further record review of Resident #102's SBAR progress note dated 7/5/12 at 7:00 PM revealed Resident #102 had complained of left hip pain and when asked by LPN #7 to bend his left knee, Resident #102 stated that he could not. The nurse wrote an order for [REDACTED]. There was no assessment note of lower left extremities inspection of leg shortening or leg rotation noted. In an interview on 10/31/12 at 10:44 AM with licensed practical nurse (LPN) #7 revealed that she remembered the resident as confused and was going through alcohol withdrawal with behaviors. The nurse stated that the certified nurse assistant (CNA) came to the nurses' station and told her that the resident was on the floor. LPN #7 stated that the resident denied pain and was put into bed. LPN #7 stated that about an hour later the resident complained of pain to his left hip and that she obtained an order for [REDACTED]. Record review of Resident #102's radiology report dated 7/6/12 at 1:11 AM revealed an acute complete femoral neck fracture without displacement. Record review of Resident #102's closed medical record revealed that there was no documentation noted by the nightshift nurse from 7/5/12 at 10:00 PM through 6:00 AM. There was no assessment of the resident noted or if pain was assessed throughout the night. The state surveyor requested the policy and who was responsible for checking the fax machine from the nursing home administrator (NHA) during an interview on 10/31/12 at 2:05 PM. The NHA stated that the nurses and medical records person were responsible to check the fax machine at least once or twice a shift. The NHA stated that there was no policy that she knew of. Observation during the investigation 10/30/12 thru 11/2/12 of the center circular nursing station revealed that the fax machine used by the nursing staff to receive x-ray and diagnostic results was located at the counter height and accessible to all nursing staff. In an interview on 10/31/12 at 2:08 pm, Registered Nurse (RN Unit Manager) #3 revealed that nurses are responsible to check the fax machine at least twice a shift and more diligently if expecting a fax. Unit manager #3 stated that LPN #10 found Resident #102's positive [MEDICAL CONDITION] on the fax machine between 6-7 AM on 7/6/12. Record review of 'Resident Transfer Form' dated 7/6/12 at 7:00 AM revealed the resident #102 was transferred at that time to the hospital due to a fracture. Record review of Resident #102's progress note dated 7/6/12 at 7:00 AM revealed LPN #10 wrote that she sent resident to ER (emergency room ) for eval and treat for [MEDICAL CONDITION]. LPN #10 noted that the resident had a temperature of 101.9 and that he needed oxygen applied at 2 liters via nasal cannula, but did not note the oxygen saturation level. There was no assessment noted related to the [MEDICAL CONDITION] or leg shortening or leg rotation noted. In an interview on 10/30/12 at 10:25 AM, LPN #10 revealed that she worked the day shift (6 AM-2 PM) and that the resident had fallen prior to her shift. LPN #10 stated that she and a unit manager found the positive x-ray results on the fax machine and that she sent the resident out to the hospital. Record review of Resident #102's post fall emergency room record dated 7/6/12 revealed the physician noted left leg shortened and rotated. #

This citation pertains to MI# 833 Based on observation, interview and record review, the facility failed to prevent a fall (care planned interventions not in place and not working) in 1 (#103) of 5 residents, from a total sample of 5 residents, resulting in Resident #103 falling and sustaining fractures of the lumbar (back) and ribs. Findings include: Record review of Resident #103's minimum data set ((MDS) dated [DATE] revealed an [AGE] year old female with Brief interview of mental status (BIMs) score of 5 having severe impairment. Active [DIAGNOSES REDACTED]. Record review of Resident #103's 'Fall/Injury Assessment: Prevention and Management Plan of Care' dated 4/2/12 revealed a history of falls with dates listed: 5/27/12, 6/10/12, 7/25/12 next to bed, 7/25/12 in restroom, 9/29/12. Interventions included: Bed and chair pad alarms, matt to floor, non-skid socks. Record review of Resident #103's incident report dated 9/29/12 revealed that a certified nurse assistant (CNA) observed the resident (#103) sitting on the floor in her room. It was noted that the resident was asked why the sensor alarm was not sounding and that the resident stated that she turned it off. Record review of Licensed Practical Nurse (LPN) #12's hand written statement dated 9/29/12 revealed that the resident had on regular socks (not the non-skid socks). In an interview on 10/31/12 at 10:20 AM, CNA #11 revealed that he worked the C-Hall on the night shift (10:00 PM -6:00 AM) and that he was the only CNA for 19 residents. CNA # 11 stated that Resident #103 turns her alarms off when she can reach it. The CNA stated that he did not hear the alarm. CNA #11 stated that he was in another room. CNA #11 stated that the nurse for C-Hall does three halls on 3rd shift (Halls C, D, and E). CNA #11 stated that he is always on the hall by himself. CNA #11 stated that there was supposed to be a float person (CNA) to assist, but that he does not get any help on his hall. CNA #11 stated that when Resident #103 fell , LPN #12 was on a different hall and he couldn't find LPN #12. CNA #11 stated that he found another nurse that watched the C-Hall while he went to find LPN #12. CNA #11 stated that Resident #103 had a history of [REDACTED]. CNA #11 stated that a floor mat alarm was put in place so when she steps on it, it alarms and that staff were to keep the sensor box out of Resident #103's reach. In an interview on 10/31/12 at 1:00 PM, LPN #12 revealed that CNA #11 found Resident #103 on the floor and that the alarm was not sounding. LPN #12 stated that the resident was between the bed and her recliner with legs straight out in front of her. LPN #12 stated that the resident told her that she shut the alarm off. LPN #12 stated that no one (staff) heard the alarm. LPN #12 stated that the resident did not have on gripper socks, just regular socks. Record review of the facility 5 day summary (undated) revealed that Resident #103 was sent to the hospital for x-rays and that L4 compression fracture, L1-L3 transverse process fracture and non displaced rib fractures at level 11 and 12 were noted. Record review of Resident #103's hospital discharge instructions dated 10/2/12 revealed discharge [DIAGNOSES REDACTED]. #

This citation pertains to MI# 145 Based on observation, interview and record review, the facility failed to provide adequate and appropriate care to prevent, treat and prevent infection of a pressure sore in 1 (#101) of 6 sampled residents, from a total of 6 sampled residents, resulting in resident #101 developing a pressure sore to the coccyx area that became infected and necrotic with foul smelling drainage. Findings include: Record review of facility 'Therapeutic Support Surface Algorithm' dated 01/2012, reflected that with a stage II or III pressure sore an alternating pressure mattress or air floatation mattress should be used. Progress in healing in 10 days yes or no (follow the algorithm) no-evaluation of treatment plan by team. Record review of resident #101's nutrition progress note dated 2/3/12 revealed that resident #101 had a significant weight loss over 30 days and 2 cal med pass (nutritional supplement) 3 ounce, TID (three times daily) was added related to the weight loss. Record review of resident #101's March 2012 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Record review of resident #101's quarterly nutrition progress note dated 3/23/12 revealed a significant weight loss over 180 days and to continue with the 2 cal med pass related to weight loss and poor oral intake. The note revealed that the resident had no open skin areas. Record review of resident #101's skin grid- pressure/[MEDICAL CONDITION] ulcer form dated 3/28/12 identified location of coccyx- 'maceration (softened) area of 2 centimeters (cm) in length X 0.8 cm in width, with no depth measurable, no drainage, color white, no odor, and no tunneling. Noted that wound presents as a macerated slit to inner coccyx, no noted drainage. Small circular area to center measuring 0.1 X 0.1 cm that is reddened, no drainage'. Record review of resident #101's physician orders [REDACTED]. Record review of resident #101's nurse note dated 3/28/12 reflected a 2 X 0.8 cm wound to inner buttocks with 0.1 X 0.1 cm reddened center. There was no documentation that the family was notified of the change to the coccyx area. Record review of resident #101's skin integrity assessment: Prevention and treatment plan of care dated 7/30/11 reflected that the resident was at risk related to general weakness, dementia, and incontinence. There were no documented interventions implemented at that time noted on the care plan. There was no air mattress applied to the bed, no increase in positioning to off load pressure area, and no wound culture ordered. Record review of resident #101's skin grid- pressure/[MEDICAL CONDITION] ulcer form dated 4/2/12 identified location as coccyx- area of 3 centimeters (cm) in length X 1.5 cm in width, with no depth measure, with serosanguineous drainage, color yellow, no odor, and no tunneling. The wound was surrounded by macerated tissue, hard yellow center measuring 1 cm X 0.5 cm, small amount of serosang (serosanguinous- composed of serum and blood) drainage. Record review of resident #101's skin grid- pressure/[MEDICAL CONDITION] ulcer form dated 4/10/12 identified the location as the coccyx- area of 2.1 centimeters (cm) in length X 1 cm in width, with no depth measure, no drainage, color white and yellow, no odor, and no tunneling. Noted wound bed white to yellow. Record review of resident #101's skin grid- pressure/[MEDICAL CONDITION] ulcer form dated 4/17/12 identified the location of the wound as the coccyx- area of 1.6 centimeters (cm) in length X 0.6 cm in width, with no depth measure, with no drainage, color yellow, no odor, and no tunneling. The form also indicated that the wound bed was yellow, edges rolled, slightly macerated. Record review of resident #101's skin grid- pressure/[MEDICAL CONDITION] ulcer form dated 4/24/12 identified the location of the wound as the coccyx- area of 1.6 centimeters (cm) in length X 0.6 cm in width, with no depth measure, with serosang drainage, color yellow, no odor, and no tunneling and edges of wound rolled. Record review of resident #101's skin grid- pressure/[MEDICAL CONDITION] ulcer form dated 5/2/12 identified the location of the wound as the coccyx- area of 1 centimeters (cm) in length X 0.5 cm in width, with no depth measure, with no drainage, color pink/yellow, no odor, and no tunneling. Documented pink tissue surrounding wound. Record review of resident #101's skin care plan revealed there was no nursing intervention implemented on 5/2/12. Record review of resident #101's skin grid- pressure/[MEDICAL CONDITION] ulcer form dated 5/8/12 identified the location of the wound as the coccyx- area of 2 centimeters (cm) in length X 0.5 cm in width, with no depth measure, with no drainage, color red, no odor, and no tunneling. Noted 100% granulation tissue to wound bed. Record review of resident #101's skin care plan revealed there was no nursing intervention implemented on 5/8/12. There was no air mattress applied to the bed, no increase in positioning to off load pressure area, or wound culture ordered. Record review of resident #101's skin grid- pressure/[MEDICAL CONDITION] ulcer form dated 5/16/12 identified the location of wound as the coccyx- a stage II (partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister) area of 2 centimeters (cm) in length X 0.6 cm in width, with no depth measurement, with bloody drainage, color red/yellow, no odor, and no tunneling. Noted top half of wound bloody, bottom wound bed yellow with bloody drainage. Record review of resident #101's skin grid- pressure/[MEDICAL CONDITION] ulcer form dated 5/22/12 identified the location of the wound as the coccyx- stage II area of 1.3 centimeters (cm) in length X 1 cm in width, with no depth measure, with serosanguineous drainage, color red, no odor, and no tunneling. Noted top half of wound bloody, bottom wound bed yellow with bloody drainage. Record review of resident #101's skin care plan revealed that area of impairment was dated 5/24/12 of a stage II coccyx wound was added to the care plan. There were no nursing interventions implemented on 5/24/12. There was no air mattress applied to the bed, no increase in positioning to off load pressure area, or wound culture ordered. Record review of resident #101's nurse note dated 5/27/12 at 2:00 PM written by the licensed practical nurse (LPN) nurse #6 revealed coccyx wound deteriorating, area of 2.5 X 3 X 0.5 (no measure tool identified) with necrotic tissue at center. Surrounding area red and blanchable. Area cleansed with dermal wound cleanser, pat dry. Santyl (enzymatic) sparingly, allevyn (dressing) applied. Message left for wound care nurse RN #21. No documentation of family being notified. Record review of the pharmacy supplied medication information for 'Santyl- an enzymatic [MEDICATION NAME] ointment used in [MEDICATION NAME] of chronic dermal ulcers should be applied once daily (or more frequently if dressing becomes soiled)'. Record review of physician orders [REDACTED]. Record review of resident #101's skin grid- pressure/[MEDICAL CONDITION] ulcer form dated 5/28/12 identified the location of the wound as the coccyx- unstageable (Full thickness tissue loss in which the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed) area of 3.5 centimeters (cm) in length X 2 cm in width, with no depth measure, with serosanguineous drainage, color necrotic/slough, with foul odor, and no tunneling. Record review of resident #101's skin care plan revealed area of impairment added as unstageable to coccyx and nursing interventions implemented on 5/28/12 were to increase protein intake and a supplemental multi vitamin. There were no new interventions implemented. Record review of a medical equipment work order dated 5/28/12 revealed that a Pro-tech mattress low loss air mattress was ordered and applied to resident #101's bed. Record review of physician orders [REDACTED]. There was no wound culture ordered at that time. Record review of SBAR note dated 5/30/12 at 9:00 PM for resident #101 reflected that licensed practical nurse (LPN) #7 had: 'spoken to the physician at 4:45 PM and explained in detail what led up to current status of the wound. Physician ordered resident sent to emergency room (ER) for evaluation and treatment. The daughter was notified. After talking it over for a few minutes daughter returned phone call and family has decided that they would like resident sent to ER. Family is upset stating that they "don't want mom to die from a wound on her butt". Resident was sent out at 7:19 PM to ER'. The nurse noted calling the ER, that lab work was being done, that the resident would be coming back to facility that evening and will have to go to surgery to have the wound debrided. The nurse noted that the ER stated that they don't do that there. In an interview on 7/11/12 at 9:45 AM, nurse LPN #7, who sent the resident out to hospital, revealed that she had spoken with the daughter of the resident (POA) about the resident's condition and that the daughter wanted to wait until 9:00 PM. LPN #7 stated that the resident's grand-daughter called the facility and quizzed her about blood sugar, vital signs, and resident appearance. LPN #7 stated that the grand-daughter OK'd to send the resident to the hospital. Record review of resident #101's IDT (inter-departmental team) note dated 5/30/12 reflected that the resident was to be evaluated by PT/OT (physical/occupational therapy) related to wound on coccyx (unstageable). Resident up in gel pommel cushion and standard wheelchair. Per OT resident needs pommel more so to prevent contracture. A ROHO cushion was investigated but OT felt staff education as to repositioning maybe more beneficial at that time. Record review of resident #101's nurse note dated 5/31/12 at 4:00 AM reflected that new orders from the emergency room included a Geri-chair, turn q 1 (hourly), and to follow up with surgeon. Record review of resident #101's skin care plan revealed area of impairment added as unstageable to coccyx and nursing interventions implemented on 5/31/12 were to position every hour and on 6/1/12 interventions of turning side to side every hour and a Geri chair with roho cushion were added. In an interview on 7/10/12 at 1:05 PM, with unit manager RN #3, resident #101's skin care plan was reviewed with the state surveyor and the unit manager could not give a reason as to why an air mattress or other nursing interventions were not implemented prior to 5/28/12 when the wound was identified on 3/28/12, more than 14 weeks prior. Nurse note on 5/31/12 at 5:10 PM reflected that the wound care nurse did speak with the surgeon's office in regard to a follow-up appointment to be scheduled. In an interview on 7/10/12 at 10:40 PM, the B-hall licensed practical nurse (LPN) #7, while reviewing the 5/27/12 santyl order, revealed that she did write the order for the dressing change. In a second interview on 7/11/12 at 12:30 PM, unit manager RN #3 revealed that on 5/28/12 the wound care nurse RN #21, the director of nursing RN #2 who is wound care certified and the regional wound care consultant, all worked that day in the facility. On 6/1/12 at 4:50 PM, resident #101's santyl dressing changes to coccyx were changed to daily. In an interview on 7/11/12 at 10:00 AM, the director of nursing registered nurse #2, who is wound care certified, was asked why the 5/27/12 Santly dressing was ordered sparingly and cover with allevyn every 3 days and PRN (as needed) was not ordered per manufactures/pharmacy supplied medication information for 'Santyl- an enzymatic [MEDICATION NAME] ointment used in [MEDICATION NAME] of chronic dermal ulcers should be applied once daily (or more frequently if dressing becomes soiled)'. The DON could not explain. #

THERE ARE TWO DEFICIENT PRACTICE STATEMENTS UNDER THIS DEFICIENCY, "A" AND "B". (A) BASED ON OBSERVATION, INTERVIEW, AND RECORD REVIEW, THE FACILITY FAILED TO PROVIDE ADEQUATE SUPERVISION FOR ONE (#1) COGNITIVELY IMPAIRED, WHEELCHAIR MOBILE RESIDENT OF NINE RESIDENTS REVIEWED FOR ELOPEMENT RISK OUT OF A SAMPLE OF 18 RESIDENTS FROM A TOTAL RESIDENT POPULATION OF 90. THE FACILITY'S DEFICIENT PRACTICE RESULTED IN RESIDENT #1 ELOPING FROM THE FACILITY, IN THE WINTER TIME, PLACING HIM IN IMMEDIATE JEOPARDY TO HIS HEALTH AND SAFETY. THE IMMEDIATE JEOPARDY WAS IDENTIFIED ON 2/22/12 AT 4:22 P.M. THE IMMEDIATE JEOPARDY BEGAN ON 2/12/12 AT APPROXIMATELY 4:55 P.M., WHEN RESIDENT #1 EFFECTIVELY LEFT THE FACILITY IN A WHEELCHAIR, UNDETECTED BY FACILITY STAFF. ACCORDING TO WWW.WUNDERGROUND.COM ,THE AREA TEMPERATURE ON 2/12/12 AT APPROXIMATELY 4:55 P.M., WAS RECORDED AS 32.2 DEGREES FAHRENHEIT(?F) WITH A WIND CHILL OF 21.1 ?F. WHEN RESIDENT #1 WAS FOUND, HE WAS IN A WHEELCHAIR, DRESSED IN TAN SLACKS, A DARK COLORED LONG SLEEVE COTTON SHIRT AND SHOES AND SOCKS, AT THE INCLINE OF A DRIVEWAY, ON A RESIDENTIAL STREET LOCATED ACROSS FROM THE FACILITY BY WITNESS "A". DURING AN INTERVIEW CONDUCTED ON 2/22/2012 AT 3:50 P.M., WITNESS "A" STATED HE SAW TWO CARS SWERVE, JUST BEFORE HE SAW RESIDENT #1 IN HIS WHEEL CHAIR IN THE STREET. WITNESS "A" STATES HE SAW THAT ANOTHER CAR HAD STOPPED AND WAS BLOCKING TRAFFIC TO PROTECT RESIDENT #1 FROM ONCOMING CARS. ACCORDING TO WITNESS "A", RESIDENT #1 HAD BECOME STUCK IN THE DRIVEWAY ACROSS THE STREET FROM THE FACILITY BECAUSE HE COULD NOT MANEUVER HIS WHEELCHAIR UP AN INCLINE. THE IMMEDIATE JEOPARDY BEGAN ON 2/12/2012, AT APPROXIMATELY 4:45 P.M. WHEN RESIDENT #1 WAS BELIEVED TO HAVE EXITED THE FACILITY UNSUPERVISED. DURING AN INTERVIEW CONDUCTED ON 2/22/2012 AT 3:50 PM, WITNESS "A" STATED THAT IT WAS APPROXIMATELY 4:55 P.M. ON 2/12/2012 WHEN HE SAW TWO CARS SWERVE, JUST BEFORE HE SAW RESIDENT #1 IN HIS WHEEL CHAIR IN THE STREET ACROSS FROM THE FACILITY. WITNESS "A" STATES HE SAW THAT ANOTHER CAR HAD STOPPED AND WAS BLOCKING TRAFFIC TO PROTECT RESIDENT #1 FROM ONCOMING CARS. ACCORDING TO WITNESS "A", RESIDENT #1 HAD BECOME STUCK IN THE DRIVEWAY ACROSS THE STREET FROM THE FACILITY BECAUSE HE COULD NOT MANEUVER HIS WHEELCHAIR UP AN INCLINE. THE FACILITY'S DIRECTOR OF NURSING WAS NOTIFIED OF THE IMMEDIATE JEOPARDY AT 4:22 PM ON 2/22/2012. THE IMMEDIATE JEOPARDY WAS REMOVED AT 11:40 A.M. ON 2/23/2012, AFTER THIS SURVEYOR CONFIRMED BY OBSERVATION, INTERVIEW AND RECORD REVIEW THAT THE FACILITY HAD IMPLEMENTED ALL OF THE FOLLOWING: 1. ON 2/12/2012, A WANDER GUARD (BRACELET STYLE ALARM DEVICE) WAS INITIATED FOR RESIDENT #1 AND A HEAD COUNT OF ALL RESIDENTS WAS OBTAINED. 2. ON 2/13/2012, ASSESSMENTS OF ELOPEMENT RISK WERE COMPLETED FOR 90 OF 90 RESIDENTS IN THE FACILITY ALONG WITH CARE PLAN AND CARE DELIVERY GUIDE UPDATES. 3. ON 2/13/2012, WANDER GUARD ALARMS WERE PLACED FOR 19 RESIDENTS WHO WERE ASSESSED TO BE AT RISK FOR ELOPEMENT. 4. ON 2/13/2012, DAILY MONITORING FOR PLACEMENT AND FUNCTION OF WANDER GUARD ALARMS WAS INITIATED. 5. ON 2/13/2012, ELOPEMENT BOOKS WERE UPDATED AT BOTH THE FRONT AND CENTER NURSES STATIONS TO INCLUDE THE UPDATED RESIDENT ACTION PLAN ELOPEMENT RISK ROSTER AND INDIVIDUAL RESIDENT PHOTOGRAPH/INFORMATION SHEETS. 6. ON 2/14/2012, ELOPEMENT DRILLS WERE COMPLETED FOR ALL SHIFTS. 7. ON 2/13/2012, A TEMPORARY ALARM WAS ADDED TO THE FACILITY'S FRONT DOOR AS AN INTERVENTION UNTIL A KEY PAD ALARM COULD BE INSTALLED. 8. BY 2/15/2012, ALL SCHEDULED STAFF WERE INSERVICED REGARDING THE FACILITY'S ELOPEMENT POLICY AND PROCEDURE. ANY STAFF MEMBER WHO HAD NOT RECEIVED THIS EDUCATION WAS REMOVED FROM THE SCHEDULE UNTIL EDUCATION COULD BE COMPLETED. ALTHOUGH THE IMMEDIATE JEOPARDY WAS REMOVED ON 2/23/12, THE FACILITY'S DEFICIENT PRACTICE WAS NOT CORRECTED AND CONTINUES AT A PATTERN LEVEL WITH POTENTIAL FOR MORE THAN MINIMUM HARM, PENDING THE FACILITY'S ABILITY TO: 1. COMPLETE ELOPEMENT RISK ASSESSMENTS ACCORDING TO FACILITY POLICY FOR NEWLY admitted AND readmitted RESIDENTS, AND RESIDENTS EXHIBITING A CHANGE IN CONDITION AND/OR NEW RISK BEHAVIORS. 2. CONTINUE WITH THE ELOPEMENT AUDIT, TO BE COMPLETED MONTHLY AND AS NECESSARY. 3. DEMONSTRATE THAT ANY RESIDENT AT RISK FOR ELOPEMENT WILL BE PROTECTED FROM EXITING THE BUILDING UNSUPERVISED. 4. SUSTAIN COMPLIANCE AS VERIFIED BY THE STATE AGENCY. FINDINGS INCLUDE: ACCORDING TO THE FACE SHEET, DATED 1/24/2012, RESIDENT #1 WAS A [AGE] year OLD MALE admitted to the facility on [DATE]. THE [DIAGNOSES REDACTED]. A PHYSICIAN ORDER [REDACTED]. A PROGRESS NOTE DATED 2/8/2012 AT 1630 (4:30 P.M.) REFLECTED THAT RESIDENT #1 WAS readmitted TO THE FACILITY, AND A [DIAGNOSES REDACTED].#1 WAS CONFUSED AT TIMES AND WAS BEING ADMINISTERED OXYGEN RELATED TO ABNORMALLY LOW BLOOD OXYGEN SATURATION LEVELS, WHEN NOT ADMINISTERED OXYGEN, OF 60 TO 70%. (THE NORMAL LEVEL FOR A HEALTHY ADULT IS AROUND 97%.) A PROGRESS NOTE DATED 2/11/2012, AFTER THE RESIDENT'S READMISSION TO THE FACILITY, REFLECTED THAT RESIDENT #1 WAS ABLE TO PROPEL HIMSELF INDEPENDENTLY IN HIS WHEELCHAIR. FURTHERMORE, A FACILITY FORM ENTITLED "ONE-CLICK (MDS 3.0) REPORT", PRINTED ON 2/22/2012, REFLECTED THAT RESIDENT #1 HAD BEEN INDEPENDENT IN LOCOMOTION, OFF THE UNIT, ON 2/10/2012 AND 2/11/2012. ALTHOUGH A FACILITY PROGRESS NOTE DATED 2/8/2012 AT 1800 (6:00 P.M.) REFLECTED THAT SAFETY ALARMS WERE IN PLACE ON RESIDENT #1'S BED AND WHEELCHAIR, THERE WAS NO DOCUMENTATION TO INDICATE THAT AN ELOPEMENT RISK ASSESSMENT HAD BEEN INITIATED. ACCORDING TO A FACILITY REPORTED "INTAKE INFORMATION" FORM (RECEIVED DATE 2/13/12) RESIDENT #1 EXITED THE FACILITY BUILDING IN HIS WHEEL CHAIR ON 2/12/12. ACCORDING TO THE ATTACHED "INVESTIGATIVE SUMMARY", THE APPROXIMATE TIME OF THE RESIDENT'S EXIT WAS 1645 (4:45 P.M.) DURING AN INTERVIEW ON 2/22/2012 AT 3:50 PM, WITNESS "A" STATED THAT HE HAD BEEN DRIVING NORTH ON THE STREET to the facility on [DATE] AT ABOUT 4:55 PM, WHEN HE OBSERVED THE TWO CARS IN FRONT OF HIM SWERVING. AS HE GOT CLOSER, HE STATED THAT HE OBSERVED RESIDENT #1 IN HIS WHEEL CHAIR IN THE STREET. WITNESS "A" STATED THAT HE PARKED HIS CAR IN THE FACILITY PARKING LOT, GOT OUT, AND AND THEN WENT TO THE STREET WHERE HE SAW THAT ANOTHER CAR HAD STOPPED AND WAS BLOCKING TRAFFIC TO PROTECT RESIDENT #1 FROM ON-COMING CARS. WITNESS "A" STATED THAT RESIDENT #1 HAD BECOME STUCK IN THE DRIVEWAY, ACROSS THE STREET FROM THE FACILITY, BECAUSE HE COULD NOT MANEUVER THE WHEELCHAIR UP AN INCLINE. WITNESS "A" STATED HE APPROACHED RESIDENT #1 AND ASKED IF HE WAS COLD, TO WHICH RESIDENT #1 REPLIED "H*** YES !!" WITNESS "A" REPORTED THAT HE THEN WHEELED RESIDENT #1 BACK INTO THE BUILDING AND FOUND THE NURSE FOR THE REHABILITATION UNIT WHERE RESIDENT #1 RESIDED, BUT THE NURSE WAS IN ANOTHER RESIDENT'S ROOM. WITNESS "A" REPORTED THAT THE NURSE WAS SURPRISED AND HAD BEEN UNAWARE THAT RESIDENT #1 HAD ELOPED. ACCORDING TO THE MINIMUM DATA SET RESIDENT assessment dated [DATE], RESIDENT #1 HAD SCORED 8 OUT OF 15 POSSIBLE POINTS ON THE "BRIEF INTERVIEW FOR MENTAL STATUS". HOWEVER, WHEN AN ATTEMPT WAS MADE TO INTERVIEW RESIDENT #1 ON 2/22/2012 AT 10:30 AM, HE WAS ORIENTED ONLY TO PERSON (SELF) AND COULD NOT RECALL EVENTS. DURING AN INTERVIEW WITH STAFF CERTIFIED NURSING ASSISTANT (CNA) "M" ON 2/22/2012 AT 3:30 PM, SHE STATED THAT SHE HAD ASSISTED RESIDENT #1 INTO HIS WHEEL CHAIR ON 2/12/2012 AT ABOUT 4:30 PM. SHE STATED THAT RESIDENT #1 TOLD HER HE WAS GOING TO A RESTAURANT. STAFF CNA "'M" STATED THAT SHE THOUGHT NOTHING ABOUT HIS STATEMENT BECAUSE SHE BELIEVED HE MEANT THE DINING ROOM. STAFF CNA "M" STATED THAT RESIDENT #1 WAS DRESSED IN TAN SLACKS, A DARK COLORED LONG SLEEVE COTTON SHIRT AND SHOES AND SOCKS. STAFF CNA "M" STATED THAT RESIDENT #1 WAS CAPABLE OF PROPELLING HIS OWN WHEEL CHAIR. STAFF CNA "M" STATED THAT SHE DID NOT RECALL HOW MUCH OXYGEN WAS IN THE PORTABLE TANK ON THE BACK OF RESIDENT #1'S WHEELCHAIR. DURING AN INTERVIEW WITH THE DIRECTOR OF NURSING ON 2/22/2012, AT 11:00 AM, SHE STATED THAT RESIDENT #1 WAS BELIEVED TO HAVE ELOPED THROUGH THE FACILITY'S FRONT DOOR. SHE EXPLAINED THAT THE FRONT DOOR HAD NOT BEEN EQUIPPED WITH A KEY PAD ALARM AT THE TIME WHEN RESIDENT #1 HAD LEFT THE FACILITY UNSUPERVISED ON 2/12/12. THE FRONT DOOR WAS EQUIPPED WITH A WANDER GUARD ALARM SYSTEM, BUT RESIDENT #1 HAD NOT BEEN WEARING A WANDER GUARD ALARM BRACELET AT THAT TIME, SO HE WOULD NOT HAVE TRIGGERED THE ALARM. THE DIRECTOR OF NURSING SAID THAT RESIDENT #1'S INDEPENDENT MOBILITY, AND HIS ABILITY TO SELF PROPEL HIS WHEELCHAIR, HAD IMPROVED FROM THE TIME OF HIS READMISSION ON 2/8/2012, BUT THE FACILITY HAD NOT REASSESSED HIM FOR INCREASED ELOPEMENT RISK. ON 2/22/2012 AT ABOUT 11:30 AM, RESIDENT #1'S ELOPEMENT PATH WAS RE-TRACED WITH THE DIRECTOR OF NURSING. THE FACILITY HAD A HALF CIRCLE DRIVEWAY THAT LED INTO THE STREET. ONE SIDE WAS IN FRONT OF THE "E" WING OF THE BUILDING, ON THE NORTH SIDE. ACROSS FROM THIS DRIVEWAY WAS A DRIVEWAY INTO A MEDICAL OFFICE BUILDING THAT HAD A STEEP INCLINE INTO THE PARKING LOT. THE AREA WHERE THE DIRECTOR OF NURSING INDICATED THAT RESIDENT #1 HAD BEEN FOUND WAS ABOUT 100 TO 120 YARDS FROM THE FACILITY'S FRONT DOOR. THE DIRECTOR OF NURSING STATED THAT THE ELOPEMENT HAD BEEN RECREATED BY FACILITY STAFF AND IT TOOK A STAFF MEMBER ABOUT 3 MINUTES IN A WHEEL CHAIR TO REACH THE SPOT WHERE RESIDENT #1 HAD BEEN FOUND BY A VISITOR. ( ) B) BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO ENSURE THAT SHARPS WASTE CONTAINERS ATTACHED TO THREE OF FIVE MEDICATION CARTS OBSERVED (THE "B", "D" AND "E" CARTS) WERE NOT FILLED BEYOND CAPACITY, RESULTING IN THE POTENTIAL FOR INJURY TO AFFECT RESIDENT #14 AND ANY OF THE APPROXIMATELY 49 RESIDENTS RESIDING ON THE 'B", "D" AND "E" UNITS WHERE THESE SHARPS WASTE CONTAINERS WERE LOCATED. FINDINGS INCLUDE: MEDICAL WASTE SHARP'S CONTAINERS ATTACHED TO MEDICATION CARTS WERE OBSERVED FILLED ABOVE THE FILL LINE IN THE FOLLOWING LOCATIONS ON THE FOLLOWING DATES AND TIMES: 1. THE "B" HALLWAY MEDICATION CART ON 2/22/12 AT 11:15 A.M. 2. THE "E" HALLWAY MEDICATION CART ON 2/22/12 AT 1:10 P.M. 3. THE "D" HALLWAY MEDICATION CART ON 2/22/12 AT 2:00 P.M. 4. THE "B", "D" AND "E" HALLWAY MEDICATION CARTS ON 2/23/12 AT 7:00 A.M. AND 2:30 P.M. THE MAXIMUM FILL LINE IS DELINEATED ON THE SHARPS CONTAINERS TO INDICATE THE LINE, ABOVE WHICH, NEEDLES OR OTHER SHARP INSTRUMENTS CONTAMINATED BY BLOOD OR OTHER BODY FLUIDS COULD POSSIBLY PROTRUDE FROM THE CONTAINER AND/OR BE ACCESSIBLE. ACCORDING TO THE ROSTER/SAMPLE MATRIX, (UNDATED; RECEIVED FROM THE FACILITY BY THE SURVEY TEAM ON 2/28/12), FORTY-NINE RESIDENTS RESIDED ON THE "B", "D" AND "E" UNITS. ACCORDING TO PHYSICIAN RECORDS DATED 2/1/12-2/29/12, RESIDENT #14 WAS AN [AGE] year OLD FEMALE admitted to the facility on [DATE] WITH [DIAGNOSES REDACTED].M. AND, AT THAT TIME, SIX OTHER RESIDENTS WERE OBSERVED SITTING IN THEIR WHEEL CHAIRS, IN A LINE, ALONG THE RIGHT SIDE OF THE HALLWAY. ON THE LEFT SIDE OF THE HALLWAY, RESIDENT #14 WAS OBSERVED SITTING NEXT TO THE "B" HALL MEDICATION CART. A SHARPS CONTAINER ATTACHED TO THE MEDICATION CART WAS OBSERVED FILLED ABOVE THE SAFE-FILL LINE. RESIDENT #14 WAS IN PROXIMITY TO THE CONTAINER, AND WAS OBSERVED TO HAVE SOME COGNITIVE IMPAIRMENT AS WELL AS ACTIVE REACH AND MOBILITY IN HER ARMS AND HANDS. RESIDENT #14 WAS OBSERVED TO HOLD A BABY DOLL WHILE ALSO TOUCHING HER WHEEL CHAIR WITH ACTIVE HANDS AND REACHING OUT FOR STAFF AS THEY WALKED BY. BECAUSE SHE WAS BOTH PHYSICALLY ACTIVE AND COGNITIVELY IMPAIRED, RESIDENT #14 WAS AT INCREASED RISK OF COMING INTO CONTACT WITH THE OVER-FILLED SHARPS CONTAINER ON THE "B" HALL MEDICATION CART. ( )

This citation pertains to MI# 157 Based on observation, interview and record review, the facility failed to prevent significant weight change in 1 (#101) of 7 sampled residents, resulting in resident #101 experiencing a 30 pound weight loss and was noted to have confusion at times. Findings include: Observation on 4/8/11 of the morning meal revealed there to be residents in the front of the main dining room that brought themselves to the dining room and had their orders taken of the meal food choices, from a staff member in a restaurant style fashion. The orders were then taken to the kitchen for the order to be filled and a tray brought to the resident. While the residents waited for their food choices, staff poured coffee and juices and residents were noted to socialize with their table mates over drinks. Observations of further back in the dining room revealed there to be residents with special diets such as textured/puree, thickened, soft, ect.... that needed assistance with tray set-up and cueing for meals. The residents that needed assistive dining were seated with four residents to a table and one staff member to assist with placement, feeding and cueing. Record review of the hospital Physician's Transfer and Admitting Orders for Extended Care, form dated 1/7/11 for resident #101 revealed that there was a note to extended care facility written by the discharging physician to maintain a stable weight. Record review of resident #101's Nutrition Risk Data Collection and Assessment notes dated 1/19/11 revealed that the resident was 69 inches tall and 198 pounds. The resident was assessed and scored a 13 and noted to be a high risk category. Record review of facility food preference record dated 1/10/11 revealed that the resident was on a regular diet with no added salt, with an 1800 cc fluid restriction. The form noted that the resident did have chewing or swallowing problems, noted the resident stated once in a while chewing. The form noted that the resident needed set-up (tray assist). The food preference record noted on the day of admission that the resident appeared confused with answering questions. On 1/19/11, 2-eggs in the AM, and cottage cheese with lunch were noted related to decreased [MEDICATION NAME] (plasma protein). On 1/24/11 homemade health shake at 3:00 PM and bedtime were noted. Record review of the resident #101's care delivery guide dated 1/11/11 revealed under the nutritional status that the resident a dysphasia III no added salt diet with a fluid restriction of 1800 cc. The resident was checked to have meals in the dining room for breakfast, lunch, dinner with set-up. Oral problem on the care guide was checked adaptive equipment, but there was no type of adaptive equipment noted. The care guide also noted that the resident was confused at times. Record review of the residents Nutritional Risk Plan of Care dated 1/19/11 revealed the assessment of diabetes, decreased [MEDICATION NAME], diuretic therapy, Goals: resident to consume 75% of meals, weight will remain stable plus or minus 5 pounds, labs will improve (increase [MEDICATION NAME]). Interventions: Provide diet as ordered, Dysphasia III, thin liquids, monitor weight weekly, monitor labs (no time/day written when to monitor), multivitamin, health shakes, monitor intake of meals, speech therapy consult, intake and output, fluid restriction of 1800 cc. Record review of nutrition note dated 1/24/11 revealed that the resident's weight loss was discussed with family and that the physician was notified. On 1/25/11 the spouse was notified of change in dining option from choice dining to the back of the dining room which was more monitored. Record review of the Care Conference Sign-in form dated 1/24/11 revealed that there was a care conference which involved the family members, noted that weight issues were discussed and possible foods to add, because resident #101 had a significant weight decrease. Record review of nutrition notes dated 1/25/11 revealed that the IDT (inter departmental team) services meet with family to discuss weight loss. Weight was 181 pounds, a decrease of 17 pounds. Health shakes were implemented and resident was noted to eat 77% of meals. Abnormal laboratory values were noted. Resident #101 had a 17 pound loss in 7 days. Record review of nutritional notes dated 1/28/11 revealed: Resident (Resident #101) decreased additional 13 pounds this week. Current weight is 168 pounds. Ordered homemade health shake at 3:00 PM and bedtime. Also offering extra protein-2 eggs with breakfast, cottage cheese with lunch. Moved resident from choice dining and pain medication was changed to as needed. Will discuss with family again this week and continue to monitor weekly as well as changing interventions as needed. Resident #101 had an additional 13 pound loss in 3 days for a total of a 30 pound weight loss. An interview on 4/8/11 at 10:15 AM with the nurse manager for resident #101 revealed: "Managers work in dining room; the resident (#101) was on choice dining, sitting in the front of the dining room. They make their own choice on meal foods/restaurant style. I would pass trays and notice he (#101) wouldn't eat, I would remind him to eat. I brought it up at the afternoon meeting at 3:00 PM. I didn't know if he was depressed or more confused. We moved him to a rehab table or assist feeding table......" An interview on 4/8/11 at 11:10 AM with the dietary manager and her dietary notes revealed: "He (resident #101) would not eat or drink. He had an admit weight of 198 pounds on 1/7/11. I assessed on 1/19/11 did the admit assessment for nutrition, he was on weekly weights, he had some weight loss". The dietary manager revealed that the resident was on [MEDICATION NAME] (diuretic medication) and on 1/17/11 had a decreased [MEDICATION NAME] lab. The dietary manager stated that on resident #101's weight on 1/24/11 was 181 pounds and she notified the physician and a family care conference with the resident present. They discussed the 17 pound weight loss of over 5% and resident #101 not eating or drinking. The dietary manager stated that on 1/25/11 she called the spouse to discuss moving the resident to the back of the dining room for more monitoring. On 1/28/11 resident #101 was weighed and there was a 13 pound decrease in weight, resident weight was 168. The dietary manager stated that on Saturday 1/29/11 resident #101 went to hospital in the night or she would have addressed a tube feeding for the resident. Record review of resident #101's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED].#208, 1/14/11 wt. #189.4, 1/19/11 wt. #187, 1/21/11 #181, 1/25/11 wt. #184 and 1/28/11 wt. #168. Record review of the nurse notes for the days resident #101 was weighed revealed there was only one note, on 1/19/11, about the resident refusal to be weighed. There was no documentation that the nursing staff were monitoring the resident weight while receiving diuretic therapy. Record review of physician progress notes [REDACTED]. Record review of the facility Significant Weight Change Report printed for the state surveyor on 4/11/11 revealed a baseline weight on 1/14/11 at 2:28 pm of #198, 1/21/11 at 11:25 am of #181, a 17 pound change from baseline or decrease of 8.6%, and on 1/28/11 at 1:12 pm of #168 a 13 pound change from baseline or a decrease of 15.2% body weight. Record review of resident #101's Meals and Fluids Detailed Entry Report printed off for the state surveyor on 4/11/11 revealed meal choices and estimated amounts of eaten foods and beverage from 1/1/11 through 1/29/11. Review of the days recorded revealed there to be a multiple meals were the resident ate less than half or refused all or most of meal. There was documentation of a 3:00 pm afternoon fluid intake on 1/27/11 (health shake) and most of the bedtime snacks (health shakes) were refused. From 1/7/11 to 1/28/11 resident #101 loss a total of 30 pounds in 21 days while at the facility. #

This citation pertains to intake number MI 157. Based on interview and record review, the facility failed to ensure and provide sufficient fluid intake to maintain the proper hydration and health in 1 (#107) of 7 sampled residents, resulting in resident #101 being hospitalized with a [DIAGNOSES REDACTED]. Findings include: Record review of resident #101's Minimum Data Set ((MDS) dated [DATE] revealed a [AGE] year old male with a history of a surgical wound with an infectious disease process. Record review of the cognitive loss assessment analysis noted that confusion was new to resident #101 per his spouse. The facility Communication V01 form revealed a decline in cognitive status. Record review of resident #101's admission orders [REDACTED]. A diet of no added salt with a fluid restriction of 1800 cc was noted. Record review of the facility admission orders [REDACTED]. Record review of resident #101's physician orders [REDACTED]. Record review of resident #101's physician orders [REDACTED]. Record review of resident #101's physician orders [REDACTED]. Record review of physician progress notes [REDACTED].#101's medication therapy. Record review of resident #101's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Record review resident #101's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED].#208, [DATE] wt. #189.4, [DATE] wt. #187, [DATE] #181, [DATE] wt. #184 and [DATE] wt. #168. Record review of the resident #101's care delivery guide dated [DATE] revealed under the nutritional status that the resident had dysphasia III no added salt diet with a fluid restriction of 1800 cc. The resident was checked to have meals in the dining room for breakfast, lunch, dinner with set-up. Oral problem on the care guide was checked adaptive equipment, but there was no adaptive equipment noted. The care guide also noted that the resident was confused at times. Record review of facility Intake & Output Record dated [DATE]-[DATE] revealed that the resident #101 had no documented intake for 7 shifts and those that were documented were not totaled. Record review of the Fluid Restriction policy/procedure dated ,[DATE] revealed nursing services responsibilities include that intake will be monitored until a pattern of intake has been determined. Record review of the Hydration Status policy/procedure dated ,[DATE] revealed monitoring for factors that put the resident at risk for dehydration included: Altered thirst perception, Arthritis or joint pain, Dependence on staff for provision of fluid intake, Diuretic medications, Dysphagia/Dysphasia, Infectious process, [MEDICAL CONDITION]. The policy identified clinical signs/symptoms on insufficient fluid intake including: Acute confusion, Change in mental status, Deterioration in cognitive status, Elevated blood urea nitrogen/Creatinine, Failure to eat. Record review of the residents Nutritional Risk Plan of Care dated [DATE] revealed the assessment of diabetes, decreased [MEDICATION NAME], diuretic therapy, Goals: resident to consume 75% of meals, weight will remain stable plus or minus 5 pounds, labs will improve (increase [MEDICATION NAME]). Interventions: Provide diet as ordered, Dysphasia III, thin liquids, monitor weight weekly, monitor labs (no time/day written when to monitor), multivitamin, health shakes, monitor intake of meals, speech therapy consult, intake and output, fluid restriction of 1800 cc. Record review of the Care Conference Sign-in form dated [DATE] revealed that there was a care conference which involved the family members, noted that weight issues were discussed and possible foods to add due to resident #101's significant weight loss. An interview on [DATE] at 10:15 AM with the nurse manager for resident #101 revealed: "Managers work in dining room; the resident (#101) was on choice dining, sitting in the front of the dining room. They make their own choice on meal foods/restaurant style. I would pass trays and notice he (#101) wouldn't eat, I would remind him to eat. I brought it up at the afternoon meeting at 3:00 PM. I didn't know if he was depressed or more confused. We moved him to a rehab table or assist feeding table......" An interview on [DATE] at 11:10 AM with the dietary manager and her dietary notes revealed: "He would not eat or drink. Admit weight of 198 pounds on [DATE]. I assessed on [DATE] did the admit assessment for nutrition, he was on weekly weights, he had some weight loss". The dietary manager revealed that resident #101 was on [MEDICATION NAME] and on [DATE] had a decreased [MEDICATION NAME] lab. The dietary manager stated that on resident #101's weight on [DATE] was 181 pounds and she notified the physician and had a family care conference with the resident present. They discussed the 17 pound weight loss and the resident not eating or drinking. The dietary manager stated that on [DATE] she called the spouse to discuss moving the resident to the back of the dining room for more monitoring. On [DATE] resident #101 was weighed and there was a 13 pound decrease in weight; resident #101's weight was #168. The dietary manager stated that on Saturday [DATE] resident #101 went to hospital in the night or she would have addressed having tube feeding for the resident. Record review of the Weight Monitoring policy/procedure dated ,[DATE], revealed that licensed nurse responsibilities include monitoring weight reported for significant changes and for gradual insidious changes that may indicate a risk factor for nutrition or hydration status and/or clinical condition. Record review of resident #101's Meals and Fluids Detailed Entry Report printed off for the state surveyor on [DATE] revealed meal choices and estimated amounts of eaten foods and beverage from [DATE] through [DATE]. Review of the days recorded revealed there to be a multiple meals were the resident ate less than half or refused all or most of meal. There was documentation of a 3:00 pm afternoon fluid intake on [DATE] (health shake) and most of the bedtime snacks (health shakes) were refused. Record review of the facility Hydration policy/procedure dated ,[DATE] revealed that identifying causes or risk factors which included diuretic medications, Dysphasia/Aphagia/Dysphagia. The policy noted to closely monitor weights of those individuals on a diuretic. Record review of resident #101's nurse notes revealed that the resident was confused at times and wandered throughout facility without purpose. There was note or assessment that mention/monitor of the resident weight loss or hydration status. On [DATE] resident #101 presented to the local hospital emergency room with a peripherally insert central catheter (PICC) that was dislodged, volume depletion and dehydration. Record review of hospital history & physical dated [DATE] revealed resident #101 was on oral diuretics and had pulled out his PICC line. Resident #101 was found to be significantly dehydrated and was admitted for further evaluation and treatment. The resident was not able to communicate at that point with the physician. The physician noted that most of the information was obtained from resident #101's spouse and that she felt very uncomfortable with the situation. Record review of the hospital admission clinical record dated [DATE] through [DATE]. On [DATE] records revealed the resident received a peg tube placed for tube feedings, and then the resident experienced a cardiac event and deceased . #

THIS CITATION PERTAINS TO INTAKE #MIOOO . BASED ON INTERVIEWS AND RECORD REVIEW, THE FACILITY FAILED TO PROVIDE CARE AND SERVICES THAT MET PROFESSIONAL STANDARDS OF QUALITY BY NOT PROVIDING COMPLETE AND ACCURATE HYDRATION ASSESSMENTS FOR 1 OF 5 SAMPLED RESIDENT'S (#100), RESULTING IN hospitalization FOR SEVERE DEHYDRATION AND [MEDICAL CONDITION] (HIGH SODIUM LEVEL). FINDINGS INCLUDE: DUE TO THE REQUIREMENTS OF THE HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT (HIPPA), THE FINDINGS IN THIS REPORT ARE LIMITED. REVIEW OF THE FACE SHEET, HOSPITAL HISTORY AND PHYSICAL DATED [DATE] AND [DATE], HOSPITAL DISCHARGE SUMMARY DATED [DATE], AND THE MINIMUM DATA SET (MDS, RESIDENT ASSESSMENT TOOL) DATED [DATE] REVEALED RESIDENT #100 WAS admitted to the facility on [DATE] WITH A HISTORY OF DEMENTIA, CHRONIC HEART AND LUNG DISEASE, ARTHRITIS, HIGH BLOOD PRESSURE AND A PACEMAKER. RESIDENT #100 WAS MODERATELY COGNITIVELY IMPAIRED WITH SHORT TERM MEMORY LOSS, HAD PRESSURE ULCERS, CHRONIC URINARY TRACT INFECTIONS, REQUIRED ASSISTANCE WITH ACTIVITIES OF DAILY LIVING (ADL'S) AND USED A WHEELCHAIR FOR LOCOMOTION. RESIDENT #100 WAS admitted TO THE HOSPITAL ON [DATE] WITH ALTERED MENTAL STATUS,[MEDICAL CONDITION] (INFECTION), DEHYDRATION AND [MEDICAL CONDITION] (ABOVE NORMAL SODIUM LEVEL). THE RESIDENT WAS readmitted TO THE HOSPITAL ON [DATE] UNRESPONSIVE WITH SEVERE DEHYDRATION, AND DID NOT RETURN TO THE FACILITY. DEHYDRATION: REVIEW OF THE CLOSED CLINICAL RECORD REVEALED RESIDENT #100 HAD PRESSURE ULCERS, CHRONIC URINARY TRACT INFECTIONS, INCREASED TEMPERATURE'S, DYSPHAGIA (SWALLOWING DIFFICULTIES), DECREASED ORAL INTAKE WITH FLUID RESTRICTIONS, CONFUSION, CHANGES IN MENTAL STATUS, DEPENDENCY ON STAFF FOR FLUID INTAKE AND RECEIVED [MEDICATION NAME] (A MEDICATION TO PULL EXCESS FLUID OUT). THESE CONDITIONS PUT THE RESIDENT AT HIGH RISK FOR DEHYDRATION. REVIEW OF THE RESIDENT'S CLINICAL RECORD REVEALED NO DOCUMENTATION OF EXPECTED DEHYDRATION OR PALLIATIVE CARE. REVIEW OF THE SKIN INTEGRITY CARE PLAN DATED [DATE], STATED "MAINTAIN GOOD HYDRATION". REVIEW OF THE NUTRITION CARE PLAN DATED [DATE], REVEALED STAFF WERE TO ASSESS AND "MONITOR FOR SIGNS OF DEHYDRATION". A CLINICAL ASSESSMENT FOR SIGNS AND SYMPTOMS OF DEHYDRATION INCLUDES, SKIN TURGOR, DRY MOUTH, THIRST, CRACKED LIPS, DARK URINE, DRY SKIN, INCREASED TEMPERATURE/LOW GRADE TEMP., URINARY TRACT INFECTION'S (UTI'S), DECREASED URINE OUTPUT, LETHARGY AND CHANGES IN MENTAL STATUS. (MOSBY FUNDAMENTALS OF NURSING CONCEPTS, PROCESS, AND PRACTICE, PATRICIA A. POTTER, ANNE G. PERRY) RESIDENT #100 WAS TRANSFERRED TO THE HOSPITAL ON [DATE], AND REVIEW OF THE emergency room REPORT DATED [DATE], STATED "DECREASED RESPONSIVENESS AND FEVER AND SENT PT (PATIENT) HERE". REVIEW OF THE HOSPITAL HISTORY AND PHYSICAL DATED [DATE], REVEALED ON [DATE] RESIDENT #100'S NA (SODIUM LEVEL) WAS ELEVATED AT 150 (NORMAL ADULT SODIUM=135 TO 145) AND HER BUN WAS 55 (BLOOD, UREA, NITROGEN, NORMAL=8 TO 20). (SODIUM AND BUN LEVELS ARE ELEVATED WITH DEHYDRATION). REVIEW OF THE HOSPITAL PROGRESS NOTE DATED [DATE], STATED "DECREASED HYDRATION STATE ON ADMISSION". THE RESIDENT WAS diagnosed with [REDACTED]. REVIEW OF THE FACILITY LAB DATED [DATE], REVEALED RESIDENT #100'S SODIUM WAS "150", AND HER BUN WAS "33" . REVIEW OF THE NURSE PRACTITIONER (NP) NOTES DATED [DATE], STATED " F/U (FOLLOW-UP) LAB RESULTS, CONFUSED, SPEECH LIMITED ", WITH NO DOCUMENTATION OF HYDRATION STATUS. THE SURVEYOR WAS UNABLE TO INTERVIEW THE NP AFTER SEVERAL ATTEMPTS TO CONTACT. REVIEW OF THE PRIMARY PHYSICIAN'S NOTES DATED [DATE], STATED "DEHYDRATION WITH TEMP. (PERSISTENT). PLAN: WILL CONTINUE WITH IV ANTIBIOTICS, WILL ADD IV FLUIDS". REVIEW OF THE PHYSICIAN ORDERS [REDACTED]. REVIEW OF THE PHYSICIAN ORDER [REDACTED]. RESIDENT #100 WAS TRANSFERRED THE SECOND TIME TO THE HOSPITAL ON [DATE]. REVIEW OF THE emergency room REPORT DATED [DATE], STATED "FEVER, UNRESPONSIVENESS, T (TEMP) 101.1". REVIEW OF THE HOSPITAL HISTORY AND PHYSICAL DATED [DATE], REVEALED IN THE emergency room (ON [DATE]), THE RESIDENT #100'S SODIUM WAS "165", BUN WAS "71", AND WAS diagnosed with [REDACTED]. REVIEW OF THE HOSPITAL PHYSICIAN CONSULTATION REPORT DATED [DATE], REVEALED ON [DATE] THE RESIDENTS NA WAS "165" AND BUN WAS "71". THE CONSULTATION REPORT ([DATE]), STATED "THE PATIENT HAS ACUTE KIDNEY INJURY (DAMAGE TO THE KIDNEYS), MOST LIKELY RELATED TO VOLUME DEPLETION (LOSS OF H2O, INADEQUATE FLUID INTAKE) AND [MEDICAL CONDITION]. CURRENTLY THE RENAL FUNCTIONS ARE WORSENING. CLINICALLY SHE SEEMS VOLUME DEPLETED WITH NO SIGNIFICANT IMPROVEMENT IN HER SERUM SODIUM". REVIEW OF RESIDENT #100'S NURSES NOTES AND ACUTE CHANGE OF CONDITION DOCUMENTATION DATED [DATE] THROUGH [DATE], REVEALED NO DOCUMENTATION OF CLINICAL ASSESSMENTS/MONITORING FOR DEHYDRATION. THE RESIDENT HAD AN INCREASE IN TEMP., IRREGULAR PULSE AND LABORED BREATHING (SIGNS OF DEHYDRATION). THE NURSE'S NOTES CONTAINED NO EVIDENCE THAT THE FACILITY ASSESSED RESIDENT #100'S HYDRATION STATUS PRIOR TO HER HOSPITAL ADMISSION ON [DATE]. REVIEW OF RESIDENT #100'S NURSES NOTES DATED [DATE] AT 12:45 P.M., STATED "RESIDENT CONTINUES TO RUN LOW GRADE TEMP. 99.1, COOL COMPRESS APPLIED, TYLENOL GIVEN THIS A.M.". NURSE'S NOTES DATED [DATE] AT 5:00 P.M., STATED "TEMP. 100.1, LABORED BREATHING, ATYPICAL PULSE VERY IRREGULAR. CALLED (THE PRIMARY PHYSICIAN), ORDER RECEIVED TO SEND TO emergency room (ER)". SIGNS OF DEHYDRATION WHEN FLUID LOSS REACHES 5% ARE INCREASED HEART RATE AND INCREASED TEMPERATURE. A SIGN OF DEHYDRATION WHEN FLUID LOSS REACHES 10% IS DIFFICULTY BREATHING. (LANGE MEDICAL BOOK, CURRENT MEDICAL [DIAGNOSES REDACTED].SYMPTOMSOFDEHYDRATION) A COMPONENT OF THE NURSING PROCESS INCLUDES ASSESSMENT, THE GATHERING, VERIFYING AND COMMUNICATION OF DATA. THE DATA SELECTED FOCUSES ON THE PATIENT'S HEALTH STATUS, ACTUAL OR POTENTIAL. (MOSBY FUNDAMENTALS OF NURSING CONCEPTS, PROCESS, AND PRACTICE, PATRICIA A. POTTER, ANNE G. PERRY) AN INTERVIEW WAS DONE ON [DATE] AT 1:00 P.M. WITH THE DIRECTOR OF NURSING (DON) AND THE ASSISTANT DIRECTOR OF NURSING (ADON). BOTH THE DON AND ADON WERE UNABLE TO FIND DOCUMENTATION IN THE NURSES NOTES ([DATE] THROUGH [DATE]), OF CLINICAL ASSESSMENTS FOR DEHYDRATION PER THE RESIDENTS NUTRITION CARE PLAN DATED [DATE]. THE DON AND ADON AGREED STAFF SHOULD HAVE ASSESSED RESIDENT #100 FOR CLINICAL SIGNS/SYMPTOMS OF DEHYDRATION. ON [DATE] AT 10:15 A.M., THE NURSE CONSULTANT INFORMED THE SURVEYOR THAT THE FACILITY RECOGNIZED THERE WAS A PROBLEM WITH STAFF IDENTIFYING AND ASSESSING RESIDENTS FOR DEHYDRATION. THE PROFESSIONAL STANDARD OF QUALITY FOR PERFORMING COMPLETE ASSESSMENTS FOR FLUID IMBALANCE IS TO ASSESS FOR "ACTUAL OR POTENTIAL FLUID IMBALANCE. A NUMBER OF SIGNS AND SYMPTOMS CAN REVEAL DEHYDRATION: POOR SKIN TURGOR, FLUSHED DRY SKIN, DECREASED TEARING OR SALIVATION, COATED TONGUE, DECREASED URINE OUTPUT, CONFUSION, AND IRRITABILITY. A DIMINISHED ABILITY OF THE KIDNEYS TO FORM AND EXCRETE URINE IS FREQUENTLY CAUSED BY DEHYDRATION. IN SEVERE DEHYDRATION THE CLIENT (RESIDENT) MAY EVEN BE COMATOSE ". (MOSBY FUNDAMENTALS OF NURSING CONCEPTS, PROCESS AND PRACTICE, PATRICIA A. POTTER, ANNE G. PERRY) INTERVIEWS WERE DONE ON [DATE] (AT 1:30 P.M.) AND PER PHONE ON [DATE] (AT 9:10 A.M.) WITH THE NURSE MANAGER OF THE UNIT RESIDENT #100 WAS ON. THE NURSE MANAGER SAID THE NURSES USE THE POST ACUTE CHANGE OF CONDITION MONITORING RECORD TO DOCUMENT THE RESIDENT'S CLINICAL HYDRATION STATUS BY PUTTING A CHECK MARK BY PROBLEMS OR CHANGES REGARDING HYDRATION, AND WHAT IS IDENTIFIED AS A PROBLEM IS THEN TO BE ADDRESSED IN THE NURSE'S NOTES. REVIEW OF THE CHANGE OF CONDITION RECORDS DATED [DATE] THROUGH [DATE], REVEALED CHECK MARKS NEXT " DIURETIC USE" AND "SWALLOWING DIFFICULTIES", WITH NO FOLLOW-UP DOCUMENTATION REGARDING THE RESIDENTS HYDRATION STATUS IN THE NURSES NOTES. REVIEW OF THE CHANGE OF CONDITION RECORD DATED [DATE] THROUGH [DATE], REVEALED NO CHECK MARKS FOR THE HYDRATION/NUTRITION SECTION. THE NURSE MANAGER SAID THE FACILITY REVIEWED RESIDENT #100'S CLINICAL RECORD AFTER SHE WAS discharged TO THE HOSPITAL ON [DATE]. THE NURSE MANAGER STATED "WE (THE FACILITY) RECOGNIZED WE HAD A PROBLEM WITH DEHYDRATION AFTER SHE (RESIDENT #100) LEFT (discharged ), I KNOW SHE WAS ONE (CLINICAL RECORD) WE LOOKED AT ". AN INTERVIEW WAS DONE ON [DATE] AT 8:30 A.M., WITH NURSE #1 (ASSIGNED TO THE UNIT RESIDENT #100 WAS ON). NURSE #1 WAS UNABLE TO FIND NURSING DOCUMENTATION OF RESIDENT #100 BEING ASSESSED FOR CLINICAL SIGNS/SYMPTOMS OF DEHYDRATION IN THE CLOSED CLINICAL RECORD. NURSE #1 STATED "YES WE (STAFF) SHOULD HAVE ASSESSED HER (RESIDENT #100) FOR DEHYDRATION ". REVIEW OF THE FACILITY HYDRATION POLICY DATED ,[DATE], STATED "THE FACILITY STRIVES TO REDUCE THE RISK OF FLUID IMBALANCE BY PREVENTING, MANAGING, STABILIZING AND REVERSING DEHYDRATION AND PROMOTING RESIDENT CARE PRACTICES TO IMPROVE HYDRATION. (THE FACILITY) IDENTIFIES AND ASSESSES RESIDENTS AT RISK FOR DEHYDRATION ". THE HYDRATION POLICY RISK FACTORS FOR DEHYDRATION WERE, "DEPENDENCE ON STAFF FOR PROVISION OF FLUID INTAKE, DIURETIC MEDICATION, DYSPHAGIA, ELEVATED TEMPERATURE, AND INFECTIOUS PROCESS ". REVIEW OF THE FACILITY HYDRATION STATUS IDENTIFICATION POLICY DATED ,[DATE], REVEALED RESIDENT ASSESSMENTS FOR SIGNS/SYMPTOMS OF INSUFFICIENT FLUID INTAKE INCLUDED "CHANGE IN MENTAL STATUS, CONSTIPATION, CRACKED LIPS, DARK URINE, DRY MUCOUS MEMBRANES, DRY SKIN, POOR SKIN TURGOR, THIRST ". REVIEW OF THE CLINICAL RECORDS AND HOSPITAL RECORDS REVEALED RESIDENT #100 WAS admitted TO THE FACILITY FOR RECONDITIONING AND REHAB SERVICES ON [DATE], AND WAS IDENTIFIED AT RISK OF DEHYDRATION PER THE NUTRITION AND SKIN INTEGRITY CARE PLANS. STAFF WAS TO MAINTAIN GOOD HYDRATION AND ASSESS FOR CLINICAL SIGNS/SYMPTOMS OF DEHYDRATION. REVIEW OF THE RECORD AND PER INTERVIEWS, NO DOCUMENTATION WAS FOUND IN THE NURSES NOTES FROM ADMISSION ([DATE]) TO DISCHARGE ([DATE]), OF NURSING CLINICAL ASSESSMENTS FOR SIGNS OF DEHYDRATION. THE RESIDENT WAS TRANSFERRED TO THE HOSPITAL FOR DECREASED RESPONSIVENESS AND FEVER ON [DATE] AND RETURNED to the facility on [DATE] diagnosed with [REDACTED]. AT THE HOSPITAL THE RESIDENTS NA WAS 165 AND BUN WAS 71, BOTH ABOVE NORMAL LEVELS AND SHE WAS [DIAGNOSES REDACTED]. REVIEW OF THE CERTIFICATE OF DEATH DATED [DATE], REVEALED RESIDENT #100 deceased AT THE HOSPITAL ON [DATE]. RESIDENT #100'S CAUSES OF DEATH WERE "DEHYDRATION, ACUTE ON [MEDICAL CONDITIONS], DECUBITUS ULCERS AND [MEDICAL CONDITION]". URINARY TRACT INFECTION [MEDICAL CONDITION]: REVIEW OF THE INFECTION PLAN OF CARE DATED [DATE], REVEALED STAFF MONITORED FOR SIGNS OF INFECTION (INCREASED TEMPERATURE, CHANGE IN BEHAVIOR, DECREASED ORAL INTAKE, WEIGHT LOSS, INCREASED CONFUSION) REVIEWED LABS, GAVE MEDICATIONS PER PHYSICIAN ORDERS [REDACTED]. REVIEW OF THE RAP DATED [DATE]; REVEALED RESIDENT #100 WAS OCCASIONALLY INCONTINENT WHICH INCREASED HER RISK FOR AN UTI. THE RESIDENT WAS ON A TOILETING PROGRAM WITH STAFF ASSISTANCE. REVIEW OF THE CLOSED CLINICAL RECORD REVEALED THE FACILITY MONITORED RESIDENT #100'S ORAL AND IV INTAKE, OUTPUT, VITAL SIGNS, WEIGHTS AND TEMPERATURE. REVIEW OF THE PHYSICIAN ORDERS [REDACTED]. THE FLUID RESTRICTION WAS DUE TO THE RESIDENT'S CHRONIC HEART AND LUNG DISEASE AND INCREASED THE RISK OF AN UTI. REVIEW OF THE PHYSICIAN ORDER [REDACTED]. REVIEW OF THE INTERDISCIPLINARY TEAM PROGRESS NOTE DATED [DATE], REVEALED THE RESIDENT WAS ASSESSED AND MONITORED FOR "S/S (SIGNS AND SYMPTOMS) OF UTI". REVIEW OF THE FACILITY LABS DATED [DATE], [DATE], [DATE], [DATE], [DATE] AND [DATE], REVEALED THE FACILITY MONITORED LABS THAT INDICATED INFECTION (WBC'S, WHITE BLOOD CELLS). REVIEW OF THE NURSES NOTES AND physician progress notes [REDACTED]. REVIEW OF THE MEDICATION OBSERVATION RECORD DATED ,[DATE] AND ,[DATE], REVEALED THE RESIDENT RECEIVED ANTIBIOTICS PER PHYSICIAN ORDERS. REVIEW OF THE HOSPITAL PHYSICIAN CONSULTATION DATED [DATE], STATED "SHE (RESIDENT #100) WAS admitted to the hospital with [REDACTED]. REVIEW OF THE RESIDENT COUNCIL MEETING MINUTES DATED [DATE] THROUGH [DATE], REVEALED NO DOCUMENTATION OF CONCERNS FROM RESIDENT'S OR FAMILY MEMBERS REGARDING UTI'S. ( )