Every finding on record at North Point Healthcare & Wellness Centre LP

Based on observation, interview, record review, and facility policy review, the facility failed to ensure gloves were changed between dirty and clean tasks for 2 (Resident #7 and Resident #76) of 2 sampled residents reviewed for pressure ulcer/injury. Findings included: A facility policy titled, Dressings- Application, revised 01/01/2012, indicated, Remove dressings and discard into plastic bag. The policy indicated, Remove and discard non-sterile disposable gloves in plastic bag at bedside. Wash hands before and after each procedure. A facility policy titled, Hand Hygiene, revised 09/01/2020, indicated, The following situations require hand hygiene: After contact with blood, other body fluids, secretions, excretions, mucous membranes, non-intact skin, wound drainage and soiled dressing. 1. An Admission Record indicated the facility admitted Resident #7 on 02/12/2025. According to the Admission Record, the resident had a medical history that included a diagnosis of stage 3 sacral pressure ulcer. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/19/2025, revealed Resident #7 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident had intact cognition. The MDS indicated the resident had one or more unhealed pressure ulcers/injuries. Resident #7's Order Summary Report, with active orders as of 03/22/2025, contained an order dated 03/22/2025, that directed staff to clean the coccyx stage 3 pressure injury with normal saline, pat dry, apply medical honey gel, and cover daily. Resident #7's Care Plan Report, included a focus area initiated 03/26/2025, that indicated the resident had a stage 3 pressure injury to the coccyx. Interventions directed staff to administer treatments as ordered and monitor for effectiveness. During an observation on 03/26/2025 at 9:15 AM, Licensed Vocational Nurse (LVN) #1 provided wound care for Resident #7. LVN #1 with gloved hands removed a dressing from the resident's coccyx. Without changing gloves or performing hand hygiene, LVN #1 obtained gauze and normal saline and cleaned the open pressure ulcer with the same gloved hands. LVN #1 then removed her gloves, washed her hands, reapplied gloves, and completed the wound care. During an interview on 03/26/2025 at 12:26 PM, LVN #1 stated when she cleaned a wound, she used gloves because the wound was soiled. LVN #1 stated she changed gloves after she cleaned the wound because then the wound was considered clean to apply the treatment. LVN #1 stated she set up a clean barrier for the supplies to have a clean area. LVN #1 stated the wound dressing was considered dirty that she removed. LVN #1 stated she set up gauze in separate piles, and after she removed the dressing she reached over to the clean area slowly, got the gauze and normal saline, cleaned the wound, and then removed gloves, washed her hands, and applied gloves to finish treatment. During an interview on 03/26/2025 at 2:13 PM, the Infection Preventionist (IP) stated the process for changing gloves during wound care was if anything dirty was touched then change gloves and perform hand hygiene before touching anything clean. The IP stated if the staff removed a soiled dressing they should perform hand hygiene before they touched clean supplies. The IP stated that the treatment nurse should have changed her gloves after she removed the dressing during wound care. According to the IP, not changing gloves after removing the dressing was dirty and that was an infection control issue. During an interview on 03/27/2025 at 9:42 AM, the Director of Nursing (DON) stated it was important to change gloves between dirty and clean because it was for infection control. The DON stated LVN #1should have changed her gloves after she removed the dressing. The DON stated her expectation was for gloves to be changed after removing a dressing during wound care because that was dirty to clean and they should always change gloves. During an interview on 03/27/2025 at 9:50 AM, the Administrator stated the importance of changing gloves between dirty and clean tasks so staff did not cross contaminate items. The Administrator stated LVN #1 should have changed her gloves at the time she removed the dressing from the resident's coccyx before she touched the gauze and normal saline on the clean area. The Administrator stated she expected gloves to be changed between dirty and clean tasks. 52452 2. An Admission Record indicated the facility admitted Resident #76 on 10/03/2023. According to the Admission Record, the resident had a medical history that included diagnoses of Alzheimer's disease and encounter for palliative care. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/03/2025, revealed Resident #76 had a Brief Interview for Mental Status (BIMS) score of 3, which indicated the resident had severe cognitive impairment. The MDS indicated the resident had one or more unhealed pressure ulcers/injuries. Resident #76's Care Plan Report, indicated a focus area initiated 03/26/2024, that indicated the resident had a stage 3 coccyx pressure ulcer. Interventions directed the staff to administer treatments as ordered and monitor the effectiveness. Resident #76's Order Summary Report with active orders as of 03/01/2025, revealed an order dated 02/10/2025, that directed the staff to clean the resident's coccyx stage 3 pressure injury and peri wound with betadine solution, pat dry, apply Dakin's solution, moisture gauze to the wound base and cover with foam boarder every day and evening shift. During an observation of wound care on 03/26/2025 at 10:14 AM, Licensed Vocational Nurse (LVN) #1 removed the soiled dressing from the resident's coccyx area and placed it in the bag. LVN #1 then proceeded to reach over with her soiled gloved hand and picked up several clean 4x4 gauze and proceeded to pat dry the resident's buttock and area around the pressure ulcer. LVN #1 then picked up several clean 4x4s and placed them into the betadine solution and proceeded to clean around and into the deep pressure ulcer. After cleaning the entire area, LVN #1 discarded the betadine soaked 4x4s into the plastic bag, removed her gloves, and washed her hands with soap and water. During an interview on 03/26/2025 at 10:31 AM, LVN #1 stated that the removal of the soiled dressing and the cleansing of the wound was all one step. LVN #1 stated the dressing was dirty, and the patting and cleaning of the wound with the betadine solution was also a dirty part of the procedure. LVN #1 stated she did not need to change her gloves after she removed a dirty dressing because she was not done cleaning the dirty wound. During an interview on 03/26/2025 at 3:47 PM, the Director of Nursing (DON) stated that her expectation would be that each nurse would follow the policy and procedure for hand hygiene and dressing application. The DON stated the nurse who completed Resident #76's wound care should have removed her soiled gloves and washed her hands after she removed the soiled dressing from the resident's coccyx wound before she began to clean it. During an interview on 03/26/2025 at 3:51 PM, the Regional Quality Assurance Nurse stated her expectations were that the nurse should remove their gloves and wash their hands after they removed a soiled dressing from a resident's wound and prior to cleaning the wound. During an interview on 03/27/2025 at 10:22 AM, the Administrator stated the nurse should change her gloves between dirty and clean tasks and follow the facility policy and procedures.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure the licensed nursing staff clarified a medication order with the physician. The pharmacy sent empagliflozin 10 milligrams (mg) to the facility 26 times from 10/2024 to 03/2025 and the licensed nursing staff never informed the physician that the medication was being delivered and the pharmacy never notified the physician that the medication had been ordered by the resident's cardiologist for 1 (Resident #28) of 4 residents observed for medication administration. Findings included: A facility policy titled, Medication Ordering and Receiving from Pharmacy updated 03/2024, revealed Medication are administered only upon the clear, complete and signed order of a person lawfully authorized to prescribe. The policy specified, (b) If the order is from a prescriber other than the attending physician, the order is verified with the current attending physician. An Admission Record indicated the facility admitted Resident #28 on 10/09/2023. According to the Admission Record, the resident had a medical history that included diagnosis of hypertensive heart disease and type 2 diabetes mellitus. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/18/2025, revealed Resident #28 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. Resident #28's Care Plan Report, indicated a focus area initiated 10/10/2023 and revised 10/16/2023, that indicated the resident had diabetes mellitus with neuropathy and hyperglycemia. Interventions directed staff to administer diabetes medication as ordered by the doctor. During a concurrent interview and medication administration observation on 03/25/2025 at 8:22 AM, Licensed Vocational Nurse (LVN) #1 removed four pills, to include empagliflozin 10 milligrams (mg), from a medication cup and did not administer the medication to Resident #28. LVN #2 stated she did not administer the medication because she could not determine if the medication was supposed to be administered. Resident #28's Order Summary Report that contained active orders as of 03/01/2025, revealed no evidence of a physician order that directed the staff to administer empagliflozin 10 mg to the resident. Resident #28's Medication Administration Record [MAR] for the timeframe 03/01/2025 - 03/31/2025, revealed no evidence of the transcription of a physician's order for empagliflozin 10 mg. During an interview on 03/25/2025 at 8:58 AM, LVN #1 stated she removed empagliflozin from Resident #28's medication cup as the medication was not listed on the resident's MAR and there was no physician's order. During an interview on 03/27/2025 at 1:04 PM, the Pharmacy Consultant stated the order for empagliflozin 10 mg for Resident #28 was never ordered through the facility's Primary Physician and the resident had never been on empagliflozin 10 mg since admission to the facility. During an interview on 03/27/2025 at 1:19 PM, the Pharmacist stated the pharmacy received the prescription for empagliflozin 10 mg directly from Resident #28's cardiologist's office on 10/02/2024. Per the Pharmacist, the medication had been sent every week in the medication roll to the facility. A New Prescription Summary from Resident #28's cardiologist, revealed an order dated 10/02/2024, for empagliflozin 10 mg, take one tablet by mouth every morning. The pharmacy Fill History, revealed the pharmacy dispensed empagliflozin 10 mg to the facility 26 times from 10/03/2025 to 03/26/2025. During an interview on 03/27/2025 at 2:06 PM, LVN #4 stated he worked twice a week and gave Resident #28 their day-shift medications. LVN #4 stated that when he gave the medication, he verified the medication to the MAR then placed the medication into the medication cup. LVN #4 stated he noticed Resident #28 had a empagliflozin 10 mg to be given at the 8:00 AM, but he never saw it on the resident's MAR or in their orders, so he took it out, took it to the medication room, placed the pill in the destruction box, and informed his supervisor. LVN #4 stated he never gave the medication to the resident. According to LVN #4, the process would be to contact the pharmacy and let them know about the medication was always in the resident's roll of medications, but there was no order for it. During an interview on 03/27/2025 at 2:16 PM, LVN #2 acknowledged that LVN #4 told him about the empagliflozin medication in Resident #28's medication rolls and that it was not ordered or on the resident's MAR. LVN #2 stated he faxed the pharmacy but could not remember when. During an interview on 03/27/2025 at 2:47 PM, LVN #3 stated Resident #28 had the medication empagliflozin in their pills, to be given at 8:00 AM. LVN #3 stated she always took the medication out, did not administer it to the resident, destroyed the medication, and notified her supervisor. LVN #3 acknowledged she never called the pharmacy to report the medication. During a follow-up interview on 03/27/2025 at 3:00 PM, the Pharmacist stated the pharmacy never received an order to discontinue the empagliflozin 10 mg medication and there had been no information or communication about the medication from the facility. According to the Pharmacist, if a facility nurse called and stated there was not a physician order for the medication, they would instruct the staff to send over an order to discontinue the medication. During an interview on 03/27/2025 at 3:41 PM, Resident #28's Primary Physician (PP) stated he took over care of the resident in late February 2025. The PP stated the empagliflozin medication was ordered by the resident's cardiologist back in October of 2024, and the pharmacy should have never sent it to the facility, if he did not order it. The PP stated he expected that if a medication was not listed on a resident's MAR and there was no order for the staff to call the pharmacy or physician for clarification. The PP stated the doctor who ordered the medication should have sent a note to the facility and he would have reviewed it to determine if the resident needed it. The PP stated neither the pharmacy nor the facility called him about the issue. During an interview on 03/27/2025 at 3:54 PM, the Director of Nursing (DON) stated her expectations were if the facility did not have an order for a resident's medication, the nurse should call the pharmacy and let them know that a medication did not have an order, and it needed to be stopped. The DON stated that no one told her that the medication. The DON stated the nurse should also call the physician and tell him that the medication came without an order, and he could manage it and/or discontinue it. During an interview on 03/27/2025 at 4:06 PM, the Administrator stated her expectation would be that the nurse and the DON follow the facility policy.

Based on observation, interview, record review, and facility policy review, the facility failed to maintain a medication error rate of 5 percent (%) or less. There were two errors out of 35 opportunities, which resulted in a 5.71% medication error rate for 1 (Resident #28) of 4 residents observed for medication administration. Findings included: A facility policy titled, Medication-Administration revised 01/01/2012, revealed Purpose To ensure the accurate administration of medications for resident in the Facility. Policy I. Medication will be administered directed by a Licensed Nurse and upon the order of a physician or licensed independent practitioner. II. No medication will be used for any patient other than the patient for whom it was prescribed. An Admission Record indicated the facility admitted Resident #28 on 10/09/2023. According to the Admission Record, the resident had a medical history that included a diagnosis of primary open-angle glaucoma, bilateral. Resident #28's Order Summary Report that contained active orders as of 03/01/2025, revealed an order dated 12/17/2024, for [brand name] ophthalmic solution 2-0.5 %, instill one drop in both eyes two times a day for glaucoma and an order dated 12/06/2023, for vitamin c oral tablet 500 milligrams, give one tablet by mouth two times a day for supplement. During medication administration observation on 03/25/2025 at 8:22 AM, Licensed Vocational Nurse (LVN) #1 failed to administer Resident #28's [brand name] ophthalmic solution eye drops and vitamin c tablet according to physician orders. During an interview on 03/25/2025 at 11:37 AM, LVN #1 acknowledged that she did not give Resident #28 vitamin c or the [brand name] eye drops. LVN #1 stated she did not give the medications but acknowledged she placed her initials on the resident's electronic medication administration record as if the medication had been administered. During an interview on 03/25/2025 at 12:50 PM, the Director of Nursing stated she expected a nurse to verify the medication order while the medication was being prepared for administration. During an interview on 03/27/2025 at 4:06 PM, the Administrator stated she expected a nurse to follow the policy.

Based on observation, interview, and record review, the facility failed to maintain essential equipment in a safe operating condition when one of three boiler system (a device that heats water) burner tray was full of dust, debris, and water deposits across burners used to heat water for resident's shower rooms and residents room sink faucets. This failure contributed for a non-functioning boiler system and scheduled residents' showers on 1/11/25 were not provided. Findings: During an interview on 1/13/25 at 1:10 PM with Resident 2, Resident 2 stated she did not get a shower on Saturday. The CNA run the water for 20 minutes, but it did not get warm enough for me to take my shower. Resident 2 stated the facility had not told her when she will get a shower. During an interview on 1/13/25 at 1:45 p.m. with Maintenance Director (MD), the MD stated on 1/11/25 Saturday he received a call from the Director of Staff Development (DSD) the facility had no hot water to use for residents' showers. The MD stated he called and directed the Maintenance Assistant (MA) to check the facility water temperature. The MD stated the MA informed him the shower room water temperature was not warm enough to provide residents showers. The MD stated on 11/12/25 Sunday he went to the facility and checked the two-shower room water temperature. The MD stated the water temperature was below 90 degrees Fahrenheit (a temperature scale) and was lukewarm to cold. The MD stated he sent out a group text to all facility departments and the facility Administrator did not reply. The MD stated he called several plumbing companies but would not be available to come to facility until Monday. During an interview on 1/13/25 at 2: 45 p.m., with the DSD, the DSD stated, she was in the facility on 1/11/25 Saturday and facility staff informed her there was no hot water for residents' showers. The DSD stated, she sent a group text to the Administrator (ADM), MD and Maintenance Assistant (MA). The DSD stated the MD responded and informed her the MA was in the facility. The DSD stated she informed all nursing staff to not provide showers because there was no hot water. During an interview on 1/13/25 at 3: 20 p.m., with the ADM, the ADM stated, facility does not have showers scheduled on Sundays. The ADM stated she was made aware of the lack of hot water on the two-shower room on 1/13/25 Monday at around 10 a.m. The ADM stated, she was informed the laundry and kitchen had hot water. During an interview on 1/14/25 at 9:40 a.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 stated he was scheduled to work on 1/11/25 Saturday A.M. shift. LVN 1 stated he was informed by staff at around 9 am the shower water was not hot enough to provide showers to residents. LVN 1 stated he immediately informed the DSD. LVN 1 stated residents have the right to have essentials for bathing and showering. LVN 1 stated residents have the right to be able to shower at comfortable water temperature. LVN 1 stated the facility did not meet the residents needs for bathing and showering due to inadequate water temperature. During an interview on 1/14/25 at 10:35 a.m., with the DSD, the DSD stated, she was informed by LVN 1 on Saturday morning regarding the lack of hot water in the shower rooms. The DSD stated she informed ADM, MD, and MS on 1/11/25 at 11:44 am the water was cold. The DSD stated residents have the right to have their showers on their scheduled days and as requested. During an interview on 1/14/25 at 11:00 a.m., with CNA 4, CNA 4 stated she was assigned to work on 1/11/25 Saturday A.M. shift. CNA 4 stated she was not able to shower her residents on Saturday because there was no hot water in the shower rooms. CNA 4 stated the residents have the right to be showered on their scheduled shower days. CNA 4 stated the facility bears the responsibility to meet residents needs to have a shower at the desired water temperature. During an interview on 1/14/25 at 12 p.m., with the ADM, the ADM stated she was notified by a group text on 1/11/25 Saturday the shower rooms did not have hot water. The ADM stated she did not receive a text message on 1/12/25 Sunday indicating the hot water issue had not been resolved. The ADM stated the hot water heater was essential part of the facilities residents to maintain a quality of life and to provide a homelike environment. The ADM stated residents have the right to shower at a comfortable water temperature. During an interview on 1/28/25 at 1:13 p.m. with the MD, the MD stated he does know when the last time the boiler was check by an outside vendor (a company or individual that sells goods or services) for maintenance. The MD stated he does not have an instruction for use for the old boiler. The MD stated he called the boiler company and was told he just needs to flush the boiler system monthly. The MD stated for preventative maintenance he checks the outside of the boiler for dust and flushed the system monthly. The MD stated the burner tray was located inside of the boiler and was full of dust and debris, the vendor told him it was from years of neglect. The MD stated the burner tray helps with the ignition of the boiler. The MD stated he does not have the expertise to check the inside of the boiler. The MD stated the vendor told him the boiler was old and needs to be replace and should be check annually by a professional for preventive maintenance. During a review of a document titled INVOICE from the {Name of Plumbing Company} dated [DATE], the document invoice indicated, .Found left hand water heater off and not lighting. Burner tray is full of dust and debris, showing water deposits across burners, .Replaced ignition module to restore heater to service . During a review of the facility's P&P titled, Water Temperatures, dated 01/12/2012, the P&P indicated, to ensure the health, safety, and comfort of residents, visitors and facility staff .The facility ensures water is maintained at temperatures suitable to meet the resident's needs .Water heaters that service resident rooms, bathrooms. Common area, and tub/shower areas are set to temperatures per state regulations. During a review of the facility's P&P titled, Unusual Occurrences Reporting, dated 05/30/2024, the P&P indicated, The facility reports the following events by phone and in writing to the appropriate State or Federal agencies .Interruptions of essential services (heating, air conditioning, food, water, linens sewage, or needed medical supplies) provided by the facility .Unusual occurrences are reported to the appropriate agency within 24 hours by telephone and then confirmed in writing .The facility conducts and documents timely and thorough investigations into all unusual occurrences and takes corrective action as appropriate .

Based on observation, interview, and record review the facility failed to maintain a safe, and homelike environment for 13 of 37 sampled residents when the ceiling light in the dining room was not working and did not provide adequate lighting to meet residents needs. This failure resulted for 13 residents in the facility who routinely used the dining room to have decreased visibility inside the dining room which had the potential to result in eye straining, falls and accidents. Findings: During an observation on 1/23/23 at 12:10 p.m. in dining room A, there were ten ceiling light box covers observed, there was one light box located on the back corner of the dining room that was not working. The back corner of the dining room did not have adequate lighting. During a concurrent observation and interview on 1/23/24 at 12:14 p.m. with Resident 87 in the dining room, the ceiling light above Resident 87's dining room table was observed off and area was observed with dim lighting. Resident 87 stated during dinner the dining room was dark and was difficult to see during meals. Resident 87 stated she had requested the facility to replace the light bulbs. During a review of Resident 87's Admission Record (a summary of information regarding a patient which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), indicated Resident 87 was admitted to the facility on [DATE] diagnosis included, . Hemiplegia (paralysis of one side of the body) affecting the right dominant side . During a review of Resident 87's Minimum Data Set (MDS- a resident assessment tool used to identify cognitive (mental processes) and physical functional level assessment dated [DATE], the MDS indicated Resident 87's Brief Interview for Mental Status (BIMS - screening tool used to assess resident cognitive level) score was 15 out of 15 (0-7 indicated severe cognitive impairment - [memory loss, poor decision making-skills] 8-12 moderate cognitive impairment, (13-15) cognitively intact) which indicated Resident 87 was cognitively intact. During a concurrent observation and interview on 1/23/24 at 12:15 p.m. with Resident 73 in the dining room, the ceiling light above Resident 73's dining room table was observed off and area was observed with dim lighting. Resident 73 stated the dining room was too dark to eat during dinner and was a safety concern when moving around in the dining room. During a review of Resident 73's Admission Record, the Admission Record indicated, Resident 73 was admitted to the facility on [DATE], diagnosis included, . encounter for orthopedic aftercare (recovery program after surgery) following surgical amputation (removal of a limb) . legal blindness . During a review of Resident 73's MDS, dated [DATE], the MDS indicated Resident 73's Brief Interview for Mental Status score was 15 out of 15, indicating Resident 73 was cognitively intact. During a concurrent observation and interview on 1/24/24 at 3:28 p.m. with the Assistant Maintenance Supervisor (AMS) inside the dining room. The AMS stated the ceiling light had not worked for at least a year and was in the process for replacement approval from administration. The AMS did not provide the work order for the light fixture upon request and stated the maintenance supervisor would provide it. During an interview on 1/25/24 at 9:08 a.m. with the Maintenance Supervisor (MS), the MS stated dining room ceiling light had not worked for a year. The MS stated the back corner of the dining room was dark but had not received grievances or complaints from residents. The MS stated he was waiting to find the best pricing to fix the ceiling light. The MS did not provide the work order for the light fixture upon request. During a review of facility's, Resident Council Minutes (RCM), dated 1/16/24, the RCM indicated, . List of topics discussed and recommendations, and old business requiring further action . Maintenance light in dining room needs covers and light bulbs need to be replaced . During an interview on 1/26/24 at 9:30 a.m. with the Activities Director (AD), the AD stated the residents was concern of the dining room ceiling light not working. The AD stated the residents wanted to know when the facility would fix ceiling lights. The AD stated maintenance was notified of the ceiling lights not working. During an interview on 1/26/24 at 9:35 a.m. with the Director of Nurses (DON), the DON stated 13 residents routinely used the dining room. The DON stated the facility's expectation was to provide adequate lighting for residents to ensure safety when residents performed dining task. The DON stated maintenance was responsible to fix the ceiling light in dining room. The DON stated the residents concern was valid, the dining room was dark and was hard for residents to see during dinner. During a review of the facility's policy and procedure (P&P) titled, Maintenance Services, dated 1/1/12, indicated, . the maintenance is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times . maintaining the building in good repair and free from hazards . maintaining lighting levels that are comfortable . establishing priorities in providing repair service .

Based on observation, interview and record review the facility failed to maintain complete and accurate medical records in accordance with accepted professional standards and practices for five of five sampled residents (Resident 24, Resident 36, Resident 80, Resident 42 and Resident 56) when Physician Orders for Life Sustaining Treatment (POLST- a portable form with instructions for emergency medical care that travels with a resident) was not completed in its entirety. These failures had the potential for Resident 24, Resident 36, Resident 80, Resident 42 and Resident 56's medical information to not be readily accessible and portable in case of an emergency. Findings: During a review of Resident 24's Physician Orders for Life Sustaining Treatment (POLST), dated 11/3/20, the back side of the POLST form that provides resident information, supervising physician, and additional contact information was not completed. During a review of Resident 24's Admission Record (a summary of information regarding a patient which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), indicated Resident 24 was admitted to the facility on [DATE]. During a review of Resident 24's Minimum Data Set (MDS- a resident assessment tool used to identify cognitive (mental processes) and physical functional level assessment dated [DATE], the MDS indicated Resident 24's Brief Interview for Mental Status (BIMS - screening tool used to assess resident cognitive level) score was 15 out of 15 (0-7 indicated severe cognitive impairment - [memory loss, poor decision making-skills] 8-12 moderate cognitive impairment, (13-15) cognitively intact) which indicated Resident 24 was cognitively intact. During a review of Resident 36's Physician Orders for Life Sustaining Treatment (POLST), dated 6/13/23, the back side of the POLST form was not completed. During a review of Resident 36's Admission Record, indicated Resident 36 was admitted to the facility on [DATE]. During a review of Resident 36's Minimum Data Set (MDS- a resident assessment tool used to identify cognitive (mental processes) and physical functional level assessment dated [DATE], the MDS indicated Resident 36's Brief Interview for Mental Status score was 3 out of 15 (0-7 indicated severe cognitive impairment - [memory loss, poor decision making-skills] which indicated Resident 36 had severe cognitive impairment. During a review of Resident 80's Physician Orders for Life Sustaining Treatment (POLST), dated 6/7/23, the back side of the POLST form was not completed. During a review of Resident 80's Admission Record, indicated Resident 80 was admitted to the facility on [DATE]. During a review of Resident 42's Minimum Data Set (MDS- a resident assessment tool used to identify cognitive (mental processes) and physical functional level assessment dated [DATE], the MDS indicated Resident 42's Brief Interview for Mental Status score was 15 out of 15 (13-15 cognitively intact) which indicated Resident 42 was cognitively intact. During a review of Resident 42's Physician Orders for Life Sustaining Treatment (POLST), dated 8/15/22, the back side of the POLST form was not completed. During a review of Resident 42's Admission Record, indicated Resident 42 was admitted to the facility on [DATE]. During a review of Resident 56's Physician Orders for Life Sustaining Treatment (POLST), dated 8/21/23, the back side of the POLST form was not completed. During a review of Resident 56's Admission Record, indicated Resident 56 was admitted to the facility on [DATE]. During a review of Resident 56's Minimum Data Set (MDS- a resident assessment tool used to identify cognitive (mental processes) and physical functional level assessment dated [DATE], the MDS indicated Resident 56's Brief Interview for Mental Status score was 6 out of 15 (0-7 indicated severe cognitive impairment). During a concurrent interview and record review on 1/24/24 at 9:27 a.m. with Licensed Vocational Nurse (LVN) 2, Resident 36's POLST form, dated 6/13/23 was reviewed. The POLST indicated, the back of the form was not completed to its entirety. LVN 2 stated it was expected that the POLST form be completed because the form gives information on Resident 36's code status and full treatment in an emergency. During a concurrent interview and record review on 1/24/24 at 9:30 a.m. with LVN 2, Resident 56's POLST form, dated 8/21/23 was reviewed. The POLST indicated, the back of the form was not completed. LVN 2 stated the back of the POLST form was not completed to its entirety and it was important to have the physician information filled out on the POLST to know the physician discussed the form with Resident 56 or resident representative (RP). During an interview on 1/24/24 at 10:14 a.m. with Registered Nurse Supervisor (RNS), the RNS stated it was important that the back of the POLST form to be completed with Nurse Practitioner (NP) or Physician information to know who the supervising health care provider was. RNS stated it was important to have additional contact information for the facility staff to know who to call in case of emergency. During an interview on 1/24/24 at 10:24 a.m. with LVN 1, LVN 1 stated it was important to have the backside of the POLST form completed to have signatures of completion and to make the form official. LVN 1 stated the facility process was for the nurse to initiate the POLST form completion and it was followed up by the social services department. During an interview on 1/24/24 at 10:49 a.m. with the Social Services Director (SSD), the SSD stated it was the responsibility of the social services department to ensure that the POLST form be completed to its entirety. The SSD stated the POLST should have been completed on the back to ensure staff was given the complete form during an emergency. During an interview on 1/26/24 at 20:49 a.m. with the Director of Nurses (DON), the DON stated it was the expectation for the POLST be completed to its entirety. The DON stated it was important to have the additional contact in the POLST if available during an emergency. During a review of the facility's policy and procedure titled, Physician Orders for Life-Sustaining Treatment (POLST), dated 6/3/2020, indicated, . A completed and signed POLST form is a legal physician order that is immediately actionable . The POLST form must be completed, signed, and dated, include the practitioner's medical license number and be signed by the resident, resident's representative or the resident's health care decision maker . During a review of a professional reference titled, American Nurses Association: Principles of Nursing Documentation, dated 2010, page 8 indicated, .Patient documentation frequently is used by professionals who are not directly involved with the patient's care. If patient documentation is not timely, accurate, accessible, complete, legible, readable, and standardized, it will interfere with the ability of those who were not involved in and are not familiar with the patient's care to use the documentation .

Based on observation, interview and record review, the facility failed to ensure a comprehensive, person-centered care plan (a plan that provides direction for individualized care of the resident) was developed and implemented to meet the identified needs for two of 37 sampled residents (Resident 11, Resident 12) when: 1. Resident 11 did not have a care plan for the change of texture of his dessert. This failure had the potential to result for Resident 11's dietary safety needs to go unmet which could lead to aspiration or choking, and poor oral intake. 2. Resident 12's care plan for the used of Quetiapine (a psychotropic [medications that affect the mind, emotions, behavior] medication used to treat several kinds of mental health conditions) did not identify a targeted behavioral goal (the actual undesirable/unwanted behaviors that occurs as a result of a medical behavior) This failure had the potential to result for Resident 12 to receive unnecessary psychotropic medication and decreased psychosocial wellbeing. Findings: 1. During a concurrent observation and interview on 12/23/24 at 12:14 p.m. in the dining room, Resident 11 was observed eating in the dining room. Resident 11's meal ticket indicated puree dessert. Resident stated he did not know what his dessert was and did not like it. During a review of Resident 11's Admission Record (AR), (a document containing pertinent resident profile information) dated 1/25/24, the AR indicated, Resident 11 was admitted to the facility on [DATE], with diagnoses which included convulsions, muscle weakness and paranoid schizophrenia (pattern of behavior where a person feels distrustful and suspicious of other people and acts accordingly). During a review of Resident 11's Minimum Data Set (MDS-a resident assessment tool used to identify resident cognitive, physical abilities and needs) assessment dated [DATE], the MDS assessment indicated Resident 11's Brief Interview for Mental Status (BIMS-screening tool used to assess resident cognition status) 0-15 scale (0-6 severe cognitive deficit, 7-12 moderate cognitive deficit, 13-15 no cognitive deficit) assessment score was 10 out of 15 which indicated Resident 11 had moderate cognitive deficit. During a concurrent interview and record review on 1/26/24 at 8:49 a.m. with the Dietary Supervisor (DS), she stated she was not aware when Resident 11's dessert texture was changed to puree and was not able to find documentations it was discussed to Resident 11. The DS stated there was no care plan for the change of diet texture and a care plan should have initiated. The DS stated it was her responsibility to initiate a care plan. During a concurrent interview and record review on 12/26/24 at 9:55 a.m. with Licensed Vocational Nurse (LVN) 1, Resident 11's Electronic Medical Record (EMR), undated was reviewed. LVN 1 stated she was not aware Resident 11's dessert texture was changed to puree. LVN 1 stated Resident 11's changed of dessert texture was not document on the EMR. LVN 1 stated the changed of dessert texture should have been care planned to monitor for aspiration and poor oral intake from the change of texture. During a concurrent interview and record review on 1/26/24 at 4:35 p.m. with the Director of Nursing (DON), Resident 11's EMR, undated was reviewed. The DON stated she was not aware Resident 11's dessert diet texture was changed. The DON stated there was no documentations in Resident 11's EMR to reflect the change. The DON stated the changed should have been care planned and the physician notified. During a review of the facility's policy and procedure (P&P) titled, Comprehensive Person-Centered Care Planning, dated 11/18, the P&P indicated, . Additional changes or updates to the resident comprehensive care plan will be made based on the needs of the resident . The comprehensive care plan will be periodically reviewed and revised . the comprehensive care plan will also be reviewed and revised at the following times: Onset of new problems . Other times as appropriate or necessary . 47205 2. During a review of Resident 12's Admission Record dated 1/25/24, indicated Resident 12 was admitted to the facility on [DATE] with diagnoses which included dementia (the loss of cognitive functioning - thinking, remembering, and reasoning - to such an extent that it interferes with a person's daily life and activities) with other behavioral disturbance (any persistent and repetitive pattern of behavior that violates societal norms or rules, seriously impairs a person's functioning), Depression (a constant feeling of sadness and loss of interest, which stops you doing your normal activities), schizoaffective disorder (a mental health disorder that is marked by a combination of hallucinations, mood disorder symptoms, such as depression or mania[elevated energy level or activity]) bipolar type (includes episodes of mania and sometimes major depression). During a review of Resident 12's Brief Interview for Mental Status assessment dated [DATE], the BIMS assessment score was 2 out of 15 which indicated Resident 12 had severe cognitive deficit. During an observation on 1/23/24, at 9:56 a.m., in Resident 12's room, Resident 12 laid in bed with eyes closed. Resident 12 did not respond when spoken to. During a review of Resident 12's Order Summary Report dated 1/25/24, the Order Summary Report indicated .Monitor target behaviors for use of Quetiapine (medication used to treat mental health conditions including bipolar disorder and schizophrenia) D/T [due to] bipolar disorder manifested by episodes of unusual change of mood from depress to mania or vice versa every shift indicate Y[yes] if behaviors exist, N[no] if no behaviors indicated . During a review of Resident 12's Medication Administration Record (MAR) dated 1/1/24, the MAR indicated no behaviors on day shift, 16 behaviors on evening shift and no behaviors on night shift between 1/1/24 and 1/24/24. During a review of Resident 12's Behavior Monitoring and Interventions Report dated 1/25/24, Behavior Monitoring and Interventions report indicated no behaviors observed for report .Date Range: 2024-01-01 to 2024-01-25 . During a concurrent interview and record review on 1/25/24, at 11:24 a.m., with Licensed Vocational Nurse (LVN) 3), Resident 12's Care Plan (CP), dated 10/1/22 was reviewed. The CP indicated, . Focus: The resident uses psychotropic medications (Quetiapine medications) r/t [related to] Behavior management DX [diagnosis] bipolar disorder . Interventions: Monitor/record occurrence of for target behavior symptoms q shift . LVN 3 stated Resident 12's CP did not identify specific behaviors nursing staff needs to monitor and did not specify the number of behavioral episodes when to notify the physician. LVN 3 stated the specific behavior, and the frequency of behavior should be documented, and care planned for the physician to review, provide appropriate medication therapy, and for nursing staff to implement behavioral interventions. During a telephone interview on 1/26/24 8:13 AM with Pharmacist (PharmD) 1, PharmD 1 stated Resident 12's Care Plan should have a targeted behavioral goal indicated for psychotropic medications to ensure resident safety and manage drug regimen to determine medication dosage effectiveness in controlling Resident 12's specific targeted behaviors. During a review of the facility's policy and procedure (P&P), titled, Comprehensive Person-Centered Care Planning, dated November 2018, the P&P indicated, . Policy It is the policy of this Facility to provide person-centered, comprehensive and interdisciplinary care that reflects best practice standards for meeting health, safety, psychosocial, behavioral, and environmental needs of residents in order to obtain or maintain the highest physical, mental and psychosocial well-being . Procedure .IV. Comprehensive Care Plan a. within 7 days from the completion of the comprehensive MDS [Minimum Data Set] assessment [a standardized assessment tool that measures health status in nursing home residents], the comprehensive care plan will be developed. All goals, objectives, interventions, etc. from the current baseline care plan will be included in the resident's comprehensive care plan

Based on observation, interview, and record review, the facility failed to ensure one of two sampled residents (Resident 299) received treatment and care in accordance with professional standards of practice when Resident 299's serum glucose (a type of sugar in the body) were not reported to the physician according to the physician's orders. This failure placed Resident 99 at risk for hypoglycemia (when the level of glucose in the blood drops below what is healthy), or hyperglycemia (high blood glucose), and hospitalization . Findings: During a review of Resident 299's Admission Record, dated 1/25/24, the admission record indicated, Resident 299 was admitted to the facility on [DATE] with diagnoses which included muscle weakness, urinary tract infection (UTI- infection in any part of the urinary system-kidneys, ureters or bladder), diabetes mellitus (when the body can not produce enough hormone called insulin (used to regulate sugar in the body), or the insulin it produces is not effective), spinal stenosis (when the space inside the backbone becomes too small), heart failure (the heart is unable to pump blood around the body properly), and transient ischemic attacks (mini stroke or when there is a temporary disruption of the blood supply to a part of the brain). During a review of Resident 299's Minimum Data Set (MDS-a resident assessment tool used to identify resident cognitive [pertaining to reasoning memory and judgement] and physical functional level) assessment, dated 1/14/24, the MDS indicated Resident 299's Brief Interview for Mental Status (BIMS- screening tool used in nursing home to assess cognition) assessment score was 15 out of 15 (0-15 scale [0-6 severe cognitive deficit, 7-12 moderate cognitive deficit, 13-15 no cognitive deficit]) which indicated Resident 299 had no cognitive deficit. During a review of the facility's job description titled RN Staff Nurse, undated, the job description indicated, . provides nursing care as prescribed by physician/health care professional in accordance with the legal scope of practice, any Board of Licensing restrictions, and within established standards of care, polices and procedures . Administers professional services and provide care consistent with allowing residents to attain or maintain his or her highest practicable physical, mental, and emotional well-being utilizing the nursing process of assessing, planning, implementing, and evaluating patient care . completes medical treatments as indicated and ordered by the physician . During a concurrent observation and interview on 1/24/24, at 9:28 a.m., Resident 299 was lying in bed, in clean gown and in no apparent distress. Resident 299 stated, when she was at home, she had episodes where her serum glucose would get very low. Resident 299 stated, at the facility, the staff had been checking her Finger Stick Blood Sugar (FSBS - one method of glucose monitoring) for about a week but have stopped now. Resident 299 stated, she had talked to the physician about adjusting her insulin when she first was admitted . During a concurrent interview, and record review, on 1/24/24, at 3:50 p.m., with Registered Nurse (RN) 1, Resident 299's physician orders titled Order Summary Report, dated 1/24, and Medication Administration Record, dated 1/24, were reviewed. RN 1 stated, the provider had adjusted the dosage of the insulin for Resident 299 when she was admitted . RN 1 stated, the treatment order was for Resident 299's to have FSBS before meals for 7 days, call the provider if the results are greater than 350 or less than 70 and then fax the results to the provider. RN 1 stated, in summary, during the 7 days, Resident 299 had one result of 84, two times greater than 300 and several in the 100 to 200 range. RN 1 stated, the ordered started on 1/9/24 and ended on 1/15/24. RN 1 stated, the results were not faxed to the provider. RN 1 stated, the provider's order was not followed. RN 1 stated, the provider did not have the information to evaluate the change in the medication. During a concurrent interview and record review on 1/25/24, at 10:30 a.m., with the Director of Nursing (DON), Resident 299's physician orders titled Order Summary Report, dated 1/24, and Medication Administration Record, dated 1/24, were reviewed. DON stated, she had not been able to find that the provider had been notified about the FSBS results for the 7 days. DON stated, the nurse did not follow the provider orders and the facility policies. During a review of the facility's Policy and Procedure (P&P) titled Physician Orders, August 21, 2020, the P&P indicated, . VIII. Whenever possible, the licensed nurse receiving the order will be responsible for documenting and carrying out the order . XII. Documentation pertaining to physician orders will be maintained [in] the Resident's medical record . XIII. The current month's administration records will be maintained in the MAR and TAR binders . During a professional reference review, retrieved from [NAME] Manual of Nursing Practice 10th Edition, dated 2014, page 16-17 indicated, Standards of practice General Principles .The practice of professional nursing has standards of practice setting minimum levels of acceptable performance for which its practitioners are accountable .These standards provide patients with a means of measuring the quality of care they receive .A deviation from the protocol should be documented in the patient's chart with clear, concise statements of the nurse's decisions, actions, and reasons for the care provided, including any apparent deviation . Legal claims most commonly made against professional nurses include the following departures from appropriate care: failure to assess the patient properly or in a timely fashion, follow physician orders, follow appropriate nursing measures, communicate information about the patient, adhere to facility policy or procedure, document appropriate information in the medical record . Failure to formulate or follow the nursing care plan . During a professional review titled, Does a Nurse Always Have to follow a Doctor's Orders? undated, retrieved from https://www.registerednursing.org/does-nurse-always-follow-doctors-orders/ indicated, .nurses cannot just randomly decide which order to follow and which not to follow. Unless there is a safety concern or an order that conflicts with personal or religious beliefs, failing to carry out orders can be grounds for discipline by the employer as well as the board of nursing, as it could be deemed 'neglect .

Based on interview and record review, the facility failed to ensure the Level l Preadmission Screening and Resident Review (PASRR-The State is required to ensure that every person entering a Medicaid certified Nursing Facility [NF] receives a Level I screening and if necessary a Level II evaluation to ensure that their NF residence is appropriate and to identify what specialized services they may need) was completed for one of five sampled residents (Resident 74) when Resident 74 was readmitted to the facility on [DATE]. This failure had the potential for Resident 74 to not receive the necessary and appropriate psychiatric level of treatment and evaluation in the facility. Findings: During a review of Resident 74's Admission Record (AR), dated 1/25/24, the AR indicated, Resident 74 was readmitted to the facility on [DATE] with diagnoses which included adjustment disorder with disturbance of conduct and depression (sadness). During a concurrent interview and record review on 1/25/24 at 10:24 a.m. with Minimum Data Set Nurse (MDSN), Resident 74's PASSR dated 8/5/23 was reviewed. The MDSN stated the PASSR was completed at the general acute care hospital (GACH) and a copy was sent to the facility when Resident 74 was admitted in the facility on 8/7/23. MDSN stated Resident 74 was sent out to GACH and was away for more than 24 hours and was readmitted in the facility on 10/30/23. MDSN stated she was not able to find a PASSR assessment for Resident 74 when readmitted in the facility and there should have been one. MDSN stated the facility staff are responsible for completing the PASSR assessment for resident readmitted to the facility. MDSN stated for new admission, GACH's are responsible for completing the assessment and send a copy to the nursing facility. MDSN stated the consequences of not having a PASSR completed was the facility will not get re-imburssed for services provided and missed opportunity to asses for mental health and not able to provide the care needed to address the mental health issue. During an interview on 1/26/24 at 2:05 p.m. with the admission director (AD), she stated Resident 74 was admitted to the GACH and readmitted back to the facility on [DATE]. AD stated there should have been a PASSR assessment completed when Resident 74 was readmitted and it was the responsibility of the facility staff to complete the assessment. AD stated it was the responsibility of the licensed nurse to complete the assessment. The AD stated, . No one has noticed that there was no PASSR assessment until now . During an interview on 1/26/24 at 5:05 p.m. with the administrator (ADM) 1, she stated the licensed nurses in the facility are responsible in completing a PASSR assessment for residents readmitted in the facility. ADM 1 stated her expectation was to make sure the PASSR was completed on the day of admission. ADM 1 stated PASSR assessment was important because it is a tool for mental health screening. During a review of facility's policy and procedure (P&P) titled, Pre-Admission Screening Resident Review (PASRR), dated 8/15/16, the P&P indicated, . PASRR must be completed by midnight of the date of admission or the facility will not be able to bill for any dates service . The facility MDS coordinator will be responsible to access and ensure updates to the PASRR is done .

Based on observation, interview and record review, the facility failed to provide services which met professional standards of care for one of three sample residents (Resident 46) when the nasal cannula (a flexible tube that goes around your head and into your nose and helps deliver supplemental oxygen) and humidifier (a plastic bottle designed to attached to oxygen machines and add moisture to the end users oxygen) for Resident 46 was undated. This failure placed Resident 46 at risk for respiratory infection which could lead to serious medical condition. Findings: During a concurrent observation and interview on 1/23/24 at 9:45 a.m. in room [ROOM NUMBER] A during the initial tour, Resident 46 was lying in bed, with the oxygen concentrator (medical device that can help patient/resident breath) turned on and set at 2(two).5(five) L (liters-unit of measurement). The nasal cannula and humidifier did not have label with date when it was changed last. Resident 46 stated his nasal cannula tubing had not been replaced recently and was not sure how much oxygen he was supposed to be receiving. Resident 46 stated he needs the oxygen for his breathing. During a concurrent observation and interview on 1/23/24 at 10:40 a.m., with Licensed Vocational Nurse (LVN) 4, LVN 4 checked the oxygen nasal cannula and humidifier of Resident 46 and stated the nasal cannula and humidifier did not have label to indicate the date when it should be changed. LVN 4 stated the practice was for the night shift nurse to change the nasal cannula and humidifier once a week. LVN 4 stated the nasal cannula, and the humidifier should have been dated to ensure it has been changed. During a review of Resident 46's clinical record titled, Record of Admission, dated 1/25/24 Resident 46 was admitted to the facility on [DATE], with diagnoses which included, atrial fibrillation (irregular, often rapid heart rate that commonly causes poor blood flow), obstructive sleep apnea (throat muscles relax and block the airway). During an interview on 1/26/24 at 4:30 p.m. with the director of nursing (DON), the DON stated her expectation was for licensed nurses to follow the facility policy and practice to change the nasal cannula and humidifier weekly and label with the date it was changed. The DON stated it was an infection control issue. During a review of the facility's policy and procedure (P&P) titled, Oxygen Therapy, dated 11/17, the P&P indicated, .The humidifier and tubing should be changed no more than every 7 days and labeled with the date of change . Oxygen tubing, mask and cannulas will be changed no more than every seven (&) days and as needed. The supplies will be dated each time they are changed. Humidifier equipment will be maintained and/or changed per manufacturer's guidelines or no more than every 7 days. They will be dated each time they are changed . During a professional reference review retrieved from https://www.emphysemafoundation.org/index.php/about-uss/privacy/97-therapeutic-toolbox-articles/519-managing-supplemental-oxygen-supplies#:~:text=Clean%20oxygen%20concentrator%20filters%20weekly,replace%20the%20nasal%20cannula%20immediately. titled, Managing Supplemental Oxygen Supplies, dated 2023, For people living with chronic obstructive pulmonary disease (COPD), supplemental oxygen is one of the most important therapies available when they experience reduced oxygen levels. But effectively managing oxygen can be challenging. To help, the National Heart, Lung, and Blood Institute (NHLBI), part of the National Institutes of Health (NIH), has published tips for doing so, including managing tubing, keeping supplies clean, and practicing oxygen safety . Keeping it clean . Ideally, nasal cannulas should be replaced every two weeks and the long oxygen tubing attached to stationary equipment every three months.

Based on observation, interview and record review, the facility failed to store, prepare and serve food in accordance with professional standards for food safety when Dietary Supervisor (DS) did not wear a hairnet while walking around in the dry storage area inside the kitchen. This failure had the potential to cause foodborne illness to residents, staff and visitors. Findings: During a concurrent observation and interview on 1/23/24 at 8:50 a.m. with the DS and Registered Dietitian (RD) in the kitchen, DS was observed not wearing a hair net while walking around inspecting foods inside the dry storage room. DS excused herself after a few minutes and left the dry storage room. The RD stated the DS left because she was not wearing a hair net. The RD stated the practice and the expectation was for everyone who enters the kitchen to wear a hair net. During an interview on 1/25/24 at 9 a.m. with the Dietary Aide (DA), he stated the expectation was for hair net to be worn upon entry into the kitchen and wash hands before starting any work. The DA stated it was important to wear hair net to avoid hair falling on to foods served to resident. During an interview on 1/26/24 at 9:20 a.m. with DS, the DS stated she was not wearing a hair net when doing a walk through in the kitchen with surveyor and RD. The DS stated she forgot to put on a hair net and the practice was to wear a hair net before entering the kitchen. The DS stated it was an infection control issue and did not want any hair in residents food. The DS stated she wanted everything in the kitchen kept clean and sanitary. During an interview on 1/26/24 at 5:20 p.m. with the administrator (ADM) 1, she stated the expectation and practice was to ensure anyone entering the kitchen are expected to wear a hair net as soon as they set foot in the kitchen. ADM 1 stated it was an infection control issue and to ensure there are no hair in the food served to residents. During a review of facility's policy and procedure (P&P) titled, Dietary Department-Infection Control for Dietary Employee, dated 11/9/16, the P&P indicated, . To ensure that the dietary department is maintained in a sanitary condition in order to prevent food contamination and growth of disease producing organism and toxins . Personal cleanliness is required in sanitary food preparation A. Clean working attire will be worn B. Clean hair-covered with an effective hair restraint while in all kitchen and food storage areas. (And beard/mustache covering when applicable) .

Based on observation, interview, and record review, the facility failed to maintain a safe environment with an effective infection prevention and control program to prevent the transmission of communicable diseases (illnesses that are spread from one person to another) or infections (occurs when harmful germs enters the body and cause illnesses) when licensed nurse (LN) and certified nursing assistant (CNA) provided care to Resident 2, Resident 7, Resident 8, Resident 9, and Resident 10 without performing hand hygiene (technique to clean the hands, including hand washing with soap and/or the use of alcohol based hand rubs) in between residents. This failure had the potential to place residents at increased risk for cross-contamination (the physical transfer of harmful bacteria from one person to another which could cause infections) and spread of communicable diseases. Findings: During an observation on 5/16/23, at 10:10 a.m., in the hallway outside of Resident 2's room, CNA 1 entered Resident 2's room and donned (put on) a pair of gloves without performing hand hygiene. CNA 1 proceeded to provide care for Resident 2. During a concurrent observation and interview on 5/16/23, at 10:31 a.m., with Licensed Vocational Nurse (LVN) 3, in front of the nurse's station, LVN 3 entered Resident 7, Resident 9, and Resident 10's room without performing hand hygiene and provided care to the residents in the room. LVN 3 stated, he did not perform hand hygiene prior to entering and exiting Resident 7, Resident 9, and Resident 10's room. LVN 3 stated, he should have performed hand hygiene prior to entering and after exiting a resident's room and when providing care in between residents to prevent cross-contamination. During an observation on 5/16/23, at 10:36 a.m., in front of the nurse's station, CNA 2 donned a pair of gloves without performing hand hygiene, entered Resident 7, Resident 9 and Resident 10's room and provided care to the residents in the room. During a concurrent observation and interview on 5/16/23, at 10:45 a.m., with CNA 2, in front of the nurse's station, CNA 2 performed hand hygiene, entered Resident 8's room, donned a pair of gloves and after providing care to Resident 8, CNA 2 removed her gloves and exited Resident 8's room without performing hand hygiene. CNA 2 stated, she should have performed hand hygiene prior to donning and doffing (removing) of gloves and entering and exiting Resident 7, Resident 9, Resident 10's room and Resident 8's room. CNA 2 stated, she should have performed hand hygiene when providing care in between residents to prevent cross contamination. CNA 2 stated, residents could get sick from an infection. During a concurrent interview and record review, on 5/16/23, at 5 p.m., with the Infection Preventionist (IP), the facility's policy and procedure (P&P) titled, Hand Hygiene, dated 9/1/20 was reviewed. The P&P indicated, .The following situations require appropriate hand hygiene: .immediately upon entering and exiting a resident room . The IP stated the expectations was for the licensed nurse and CNA to perform hand hygiene prior to and after providing resident care to residents. The IP stated the importance of hand hygiene was to prevent the spread of infections in the facility. The IP stated, by not following the P&P for Hand Hygiene, licensed nurse and CNA could transmit communicable diseases and cause residents to developed infections. The IP stated, licensed nurse and CNA did not follow the facility P&P on Hand Hygiene and should have. During an interview on 5/16/23, at 5:37 p.m., with the Administrator (ADM), the ADM stated, the expectations was for the direct care staff to perform hand hygiene prior to entering and exiting resident's room, and prior to and after providing care to residents. The ADM stated the importance of hand hygiene was to provide the best environment for residents and to prevent the spread of infections. During a review of the facility's P&P titled, Hand Hygiene, dated 9/1/20, the P&P indicated, .To establish the use of appropriate hand hygiene for all Facility staff, healthcare personnel (HCP), Residents, volunteers and visitors while at the Facility .The Facility considers hand hygiene as the primary means to prevent the spread of infections. Hand hygiene means cleaning your hands by handwashing (washing hands with soap and water), antiseptic hand wash or antiseptic hand run (i.e. alcohol-based hand rub (ABHR) including foam or gel) .Facility staff are trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare associated infections (HAI) [infections people get while they are receiving health care for another condition] .Facility staff follow the hand hygiene procedures to help prevent the spread of infections to other staff, Residents, volunteers and visitors . During a professional reference review from the National Institute of Health, the article titled, Hand Hygiene (Article), dated 8/1/22, the Article indicated, .Handwashing practices in the patient care setting began in the early 19th century. The practice evolved over the years with evidential [based on evidence] proof of its vast importance and coupled with other hand-hygienic practices, decreased pathogens [a tiny living thing] responsible for . hospital-acquired infections (HAI). Contaminated [dirty] hands of healthcare providers are a primary source of pathogenic [capable of causing disease] spread. Proper hand hygiene decreases the proliferation [to grow by rapid production] of microorganisms [a living thing that can be seen only through a microscope (an instrument that can be used to observe small objects)], thus reducing infection risk and overall healthcare costs, length of stays, and ultimately, reimbursement. According to the Centers for Disease Control and Prevention (CDC), hand hygiene is the single most important practice in the reduction of the transmission of infection in healthcare settings .

Based on observation, interview, and record review, the facility failed to ensure resident grooming needs were met for one of three sampled residents (Resident 1), when Certified Nursing Assistants (CNAs) did not bathe Resident 1 for 11 days (from the date of his admission on 6/06/22 through 6/16/22). This failure resulted in Resident 1 not receiving a shower for 11 days and placed him at risk for skin breakdown, infections, and discomfort. Findings: During an interview on 6/16/22, at 2:05 p.m., with CNA 1, CNA 1 stated she worked at station 3 and 4 which was the facilities yellow zone (PUI or Yellow zone is the designated unit to care for residents either exposed to individuals with COVID-19 (respiratory infection) or potentially exposed.) CNA 1 stated unit 3 and 4 were designated as the yellow zone, and she was unable to give showers to residents that were housed in the yellow zone. CNA 1 stated she could not take residents out of their rooms and into the hallway when they were in quarantine in the yellow zone. CNA 1 stated she would give residents bed baths instead of showers during the residents' quarantine time in the yellow zone. During a concurrent observation and interview on 6/16/22, at 2:51 p.m., in Resident 1's room (yellow zone), Resident 1 was lying in bed with unkempt and oily hair. Resident 1 stated, he wanted to take a shower because he had not had a shower since the day, he was admitted to the facility on [DATE]. Resident 1 stated, he did not like the way he was feeling without showering for so long (11 days). During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool used to identify cognitive (mental processes) and physical functional level assessment dated [DATE], the MDS indicated Resident 1's Brief Interview for Mental Status (BIMS - screening tool used to assess resident cognitive level) score was 14 out of 15 (0-7 indicated severe cognitive impairment - [memory loss, poor decision making-skills] 8-12 moderate cognitive impairment, (13-15) cognitively intact) which indicated he was cognitively intact. During a review of Resident 1's Admission Record dated 6/16/22, the admission record indicted Resident 1 was admitted to the facility on [DATE]. During a concurrent interview and record review on 6/16/22, at 2:26 p.m., with CNA 2, Resident 1's shower schedule was reviewed, CNA 2 stated Resident 1's shower days were schedule to be on Mondays and Thursdays (two times a week) every week. CNA 2 stated once CNAs completed a resident shower, CNAs would document completion of the shower on the shower sheet in the electronic health record. CNA 2 reviewed the electronic health record and stated there were no showers documented for Resident 1. CNA 2 reviewed the binder in the nurse's station titled Shower Schedule, CNA 2 reviewed Resident 1's shower days in the binder and stated there were no completed shower sheets for Resident 1 in the binder. During a concurrent interview and record review on 6/16/22, at 3:05 p.m., with Licensed Vocational Nurse (LVN) 1, a blank Shower Sheet undated was reviewed, the shower sheet included fillable lines which included, Resident name, room number, CNA and LVN names. LVN 1 stated the CNAs would document of the shower sheet the completion of resident's shower after giving the shower. LVN 1 stated once the CNA had documented resident was showered, the nurse would sign the shower sheet and place it into the binder, indicating resident received a shower. LVN 1 reviewed the entire binder and stated that there were no shower sheets completed for Resident 1. LVN 1 stated there was no record of Resident 1 receiving a shower since admission 6/6/22. LVN 1 stated the facility did not have shower restrictions for residents no matter what unit they were housed in. LVN 1 stated residents could take showers and should be given their showers to ensure they maintain healthy skin, free of skin breakdown or infection. During an interview on 6/16/22, at 3:11 p.m., with CNA 1, CNA 1 stated she offered Resident 1 a bed bath and he refused. CNA 1 stated he was not comfortable receiving a bed bath and wanted to take a shower. CNA 1 stated she did not give Resident 1 a shower. During an interview on 6/16/22, at 3:55 p.m., with Infection Preventionist (IP), IP stated although the facility was in yellow zone, there were no restrictions on providing residents showers. During a concurrent interview and record review on 6/16/22, at 3:59 p.m., with the Director of Staff Development (DSD), the facility job description titled Certified Nursing Assistant undated was reviewed. The job description indicated, .A nursing assistant responsible for providing routine nursing care .to assure the highest degree of quality resident care can be maintained at all times .Bathe residents as assigned and in accordance with established facility procedures . The DSD stated, it was the CNA's responsibility to shower residents on their assigned shower days. The DSD stated, after the completion of the shower the CNA should document in the electronic health record and the shower sheet indicating resident was given a shower. During a review of the facility policy titled Showering and Bathing dated 1/2012 was reviewed. The policy indicated, .A tub or shower bath is given to the residents to provide cleanliness, comfort and to prevent body odors .

Based on observation, interview, and record review, the facility failed to ensure the kitchen sanitation water bucket used to sanitize food preparation and distribution surface kitchen areas contained manufacturer's recommended concentration levels of quaternary ammonium (a group of chemicals used for killing bacteria, fungi, and viruses) for sanitization (to reduce the number of disease-causing pathogens). This failure had the potential to spread foodborne illness (disease or period of sickness caused by food contamination) to residents that were served meals from the kitchen. Findings: During a concurrent observation and interview, in the facility's kitchen on 2/1/22, at 10:35 a.m., Cook 2 was observed wiping the kitchen counter with a rag from a red water bucket. Cook 2 stated the red bucket contained sanitizer used to minimize cross contamination. Cook 2 stated he did not know the name of the liquid sanitizer she used but demonstrated the test strip used to test the level of the sanitizer in the red water bucket. Cook 2 dipped the test strip into the water in the red bucket and stated sanitizer level I the water measured 200 ppm (parts per million) when compared to the levels on the bottle manufacture recommended level. Cook 2 stated he left the test strip in for 10 seconds and counted by saying 1 pause, 2 pause etc. Cook 2 stated he left the test strip in for longer than 10 seconds. Cook 2 was asked to recheck the level again counting to 10 using 1 one thousand 2 one thousand etc. The test strip was compared to the levels on the sanitizer manufacture recommended level and Cook 2 stated the level was 150 ppm. Cook 2 stated the sanitizer level was not okay. The Dietary Supervisor (DS) confirmed the sanitizer level was at or below 150 ppm and that it was not high enough to ensure sanitation of surface areas and the water needed to be changed. During a concurrent observation, interview, and record review in the facility's kitchen on 2/1/22, at 3:03 p.m., the (brand name) sanitizer poster on the kitchen wall was reviewed with the (DS). The DS stated the (brand name) sanitizer needed to be above 200 ppm in order to be effective. During an interview with the Registered Dietician (RD) 1 on 2/2/22, at 2:40 p.m., RD 1 stated he expected the sanitizing water buckets to be at 200 ppm per manufacturer's sanitizer guidelines. RD 1 stated water buckets of sanitizer should not be used if it did not contain the standard level of sanitization. RD 1 stated the facility did not have a policy and procedure for red water bucket sanitizer guidelines but provided the policy and procedure for cleaning pots and pans with quaternary ammonium. During a review of the facility's policy and procedure (P&P) titled, Pot and Pan Cleaning, dated 10/1/14, the P&P indicated, .ii. Record the PPM on Form A - pot and pan sanitizer log. 200 ppm is the required minimum for quaternary sanitizer. During a review of the professional reference retrieved from https://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfcfr/cfrsearch.cfm?fr=178.1010, titled, FDA U.S. Food and Drug Administration . Subpart B - Substances Utilized To Control the Growth of Microorganisms, dated 1/6/22 indicated, Solutions identified in paragraph (b)(10) of this section shall provide not more than sufficient trichloro melamine [sanitizer chemical] to produce 200 parts per million of available chlorine and either sodium [MEDICATION(S)] sulfate [sanitizer chemical] at a level not in excess of the minimum required to produce its intended functional effect or not more than 400 parts per million of dodecyl benzenesulfonic acid [sanitizer chemical].

Based on observation, interview, and record review, the facility failed to maintain a safe environment with an effective infection prevention and control program to prevent the development and transmission of communicable (spreads from one person to another) disease and infections when: 1. One of two direct care staff Certified Nurse Assistant (CNA) 3 did not perform hand hygiene (techniques to clean the hands, including handwashing with plain and antimicrobial soaps and/or the use of alcohol-based hand rubs) after touching mask and before putting on Personal Protective Equipment (PPE). 2. One of two direct care staff Licensed Vocational Nurse (LVN) 1 in the yellow zone (residents exposed to virus were observed) did not ensure N95 (respiratory protective device designed to achieve a very close facial fit and very efficient filtration of airborne [transported by air] particles) mask appropriately fit her face. 3. Clean items were not stored in space free from cross contamination. 4. The call light for Resident 478 was picked up off the floor and given to Resident 478 before it was sanitized. 5. Two of four sampled oxygen concentrators (for Resident 475 and 480) outer covering and filter were found with lint and dust. This failure had the potential to expose Resident 475 and 480 and staff to contaminants and contribute to the increased risk of developing respiratory infections (infections that happen in the lungs, chest, sinuses, nose, and throat). Findings: 1. During a concurrent observation and interview on 1/31/22, at 11:14 a.m., with the Infection Preventionist (IP) in the hallway, CNA 3 was observed touching the front of her mask, CNA 3 did not perform hand hygiene and donned (to put on) PPE. CNA 3 entered resident's room and provided care to Resident 475. The IP stated CNA 3 should have performed hand hygiene after she touched the front of her mask and before donning PPE to prevent the spread of infection. During a concurrent interview and record review on 2/3/22, at 1:45 p.m., with the Director of Nursing (DON), the facility's policy and procedure (P&P) titled, Hand Hygiene was reviewed. The DON stated facility staff should have performed hand hygiene after touching the front of mask and before donning of PPE. The DON stated the facility's P&P titled Hand Hygiene should be followed to prevent infection and the spread of germs and diseases. During a review of the facility's policy and procedure (P&P) titled, Hand Hygiene, dated 9/1/20, the P&P indicated, . Purpose . To establish the use of appropriate hand hygiene for all Facility staff, healthcare personnel (HCP), Residents, volunteers, and visitors while at the Facility . Policy . The Facility considers hand hygiene as the primary means to prevent the spread of infections. Hand hygiene means cleaning your hands by handwashing (washing hands with soap and water), antiseptic hand wash or antiseptic hand rub (i.e. alcohol-based hand rub (ABHR) including foam or gel) . Procedure . Facility staff follow the hand hygiene procedures to help prevent the spread of infections to other staff, Residents, volunteers and visitors . Hand hygiene products and supplies (sinks, soap, towels, alcohol-based hand rub with 60-95% alcohol) . D. Facility staff, healthcare personnel (HCP), Residents, visitors, and volunteers must perform hand hygiene to prevent the transmission of Hospital Acquired Infections (HAI's) . E. The following situations require appropriate hand hygiene . Before donning . of Personal Protective Equipment (PPE) . 2. During a concurrent observation and interview on 1/31/22, at 10:39 a.m., with the IP, in the hallway of yellow zone, LVN 1 was observed talking to physician with her nose not covered with N95 mask. The IP stated, in the yellow zone everyone should wear N95 mask appropriately. The IP validated LVN 1 was not wearing her N95 mask appropriately to ensure employee was protected. The IP stated LVN 1 should wear her N95 mask appropriately to prevent infection. During a concurrent interview and record review on 2/3/22, at 2:05 p.m., with the DON, the facility's P&P titled, Personal Protective Equipment dated 1/1/12 and Respiratory Protection Program dated 9/9/21 was reviewed. The DON stated, Facility staff should wear N95 mask covering the nose and mouth and ensure an adequate fit of N95 mask to prevent spread of infection. The DON stated facility's P&P should be followed. During a review of the facility's policy and procedure (P&P) titled, Personal Protective Equipment dated 1/1/12, the P&P indicated, Purpose . To ensure the availability of personal protective equipment as required . Policy . Personal protective equipment appropriate to specific task requirements is available at all times . Procedure . Facility Staff required to perform tasks that may involve exposure to blood/body fluids are provided appropriate protective clothing and equipment . The type of protective clothing and equipment to be used is based on . The likelihood of exposure . The probable route of exposure; and the overall working conditions and task requirements . Masks . Face masks are only be handled by the strings when being removed . Face masks are changed when they become moist or soiled . Facility Staff who fail to use personal protective equipment when indicated will be disciplined . During a review of the facility's policy and procedure (P&P) titled, Respiratory Protection Program dated 9/9/21, the P&P indicated, Purpose . To reduce employee exposure to infectious agents in the workplace through the proper use of respirators during an during an influenza or other respiratory disease emergency or pandemic . Policy . The Facility will provide its employees with a safe work environment. Respiratory protection is provided at no cost to the employees. The implementation of this respiratory protection program is provided as a means of giving the highest levels of protection to employees during an influenza or other respiratory disease emergency or pandemic, as defined by Cal/OSHA (California Division of Occupational Safety and Health - provides free safety and health assistance to employers, with the goal of preventing occupational injuries and illnesses) . The [Respiratory protection Program Administrator] RPPA with the IP are responsible for administering the program. Duties of the RPPA and IP include the following: . Identify work areas, processes or tasks that require respiratory protection. This means identifying patient care practices and other circumstances likely to present a transmission risk during an infectious respiratory disease emergency or respiratory pandemic . Monitor respirator use to confirm that respirators are used in accordance with their certification . Training will cover the following . Proper and improper fit and usage, limitations and capabilities for maintenance, cleaning and storage . Inspecting, donning and doffing, user seal checks and troubleshooting . Respirator Fit Testing . Fit tests are conducted to determine that the respirator fits the user adequately and that a good seal can be obtained. Respirators that do not seal do not offer adequate protection . 3. During a concurrent observation and interview on 1/31/22, at 11:10 a.m., with the IP, in yellow zone at room [ROOM NUMBER], clean diapers were observed opened and exposed at the counter near the sink. The IP validated room [ROOM NUMBER] was shared by two residents. The IP stated, clean diapers should be kept in residents' cabinet to prevent cross contamination. During a concurrent interview and record review on 2/3/22, at 1:50 p.m., with the DON, the facility's P&P titled, Infection Control - Policies & Procedures dated 1/1/12 was reviewed. The DON stated, Facility staff should not place clean items such as opened diapers at the counter near the sink. The DON stated clean items should be stored in a sanitary and clean environment. The DON stated the counter near the sink was not considered a clean area. The DON stated the facility's P&P titled Infection Control - Policies & Procedures should be followed to prevent infection and the spread of germs (microorganism, especially one which causes disease) and infection. During a review of the facility's policy and procedure (P&P) titled, Infection Control - Policies & Procedures dated 1/1/12, the P&P indicated, Purpose . To provide infection control policies and procedures required for a safe and sanitary environment . Policy . The Facility's infection control policies and procedures are intended to facilitate maintaining a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections . Procedure . The Facility's infection control policies and procedures are intended to facilitate maintaining a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections Objectives . Maintain a safe, sanitary, and comfortable environment for personnel, residents, visitors . Provide guidelines for the safe cleaning and reprocessing of reusable resident care equipment . 4. During a concurrent observation and interview on 2/1/22, at 9:20 a.m., in Resident 478's room, Resident 478 was lying in bed and the call light was on the floor. CNA 4 picked up the call light and set it on top of Resident 478's lap. CNA 4 stated he should have wiped it off with a sanitizer wipe before he gave it to Resident 478. CNA 4 stated there was nothing in the room to disinfect (clean and to destroy bacteria) the call light. During an interview on 2/2/22, at 3:44 p.m. with the IP, the IP stated the staff should not pick up a call light on the floor and give it to Resident 478 without cleaning it. The IP stated, The problem is infection control. The IP stated they needed to clean it up with a sanitizer cloth right away. The IP stated, It could cause contamination and Residents [Resident 478] could get an infection. During an interview on 2/3/22, 3:18 p.m., with the DON, the DON stated, [The call light] should be cleaned first before handing it to a Resident. They should wipe it with the sanitizer before giving it to Residents [Resident 478]. During a review of the facility's Policy and Procedure (P&P) titled, Cleaning and Disinfection of Resident-Care Items and Equipment, dated 1/2022 the P&P indicated, The P&P indicated, . Resident-care equipment, including reusable items and durable medical equipment will be cleaned and disinfected according to current CDC [Centers for Disease Control and Prevention] recommendations for disinfection and the OSHA (Occupational Safety and Health Administration, a government agency in-charge of monitoring the working conditions of workers enforcing standards, providing training, outreach, education and assistance) .non-critical items are those that come in contact with intact skin but not mucous membranes .some items that can come in contact with non-intact skin for a brief period of time are usually considered non-critical surfaces as well and are disinfected with intermediate-level disinfectants .ethyl or isopropyl alcohol . During a review of professional reference retrieved from https://professionals.wrha.mb.ca/old/extranet/ipc/files/manuals/acutecare/Pull_Cords_and_Call_Bells.pdf titled, INFECTION PREVENTION & CONTROL COMMUNICATION FORM PULL CORDS AND CALL BELLS, , dated 7/2017, the professional reference indicated, .Call bells have been linked to transmission of microorganisms and outbreaks. Pull cords are not regularly changed between patients and can become easily contaminated .Microorganisms and contaminated material migrate under the button and contaminate the inside of push button call bells. Call bells have been directly implicated in hospital outbreaks. An investigation into one hospital outbreak found evidence of heavily contaminated fecal material inside of a disassembled call bell. String cords cannot be physically cleaned between patients and may harbor organisms. Improper cleaning of the physical environment has been related to transmission of many types of pathogenic organisms, e.g. C. difficile . [a germ that causes severe diarrhea and [CONDITION(S)] -an inflammation of the colon]. 5. During an observation on 1/31/22, at 10:30 a.m., in Resident 475's room, Resident 475 was resting in bed, and had a nasal cannula connected to an oxygen concentrator. The oxygen concentrator did not have an air filter on the back of the machine. The area approximately four inches wide by eight inches in length was observed as a grid for a filter and was covered with white fuzzy substance. During a concurrent observation and interview on 2/1/22, at 11:20 a.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 entered Resident 475's room to exchange the oxygen concentrator machine that had a light flashing on it. LVN 1 stated the machine needed to be serviced. LVN 1 stated it was normal to get dust from the air and wiped off the grid with a wet paper towel. During a concurrent observation and interview on 2/1/22, at 11:33 a.m., with the Maintenance Supervisor (MS) in the oxygen storage room, the MS stated the oxygen concentrator that had been in Resident 475's room was replaced due to a malfunction, and it was missing the exterior filter at the back of the machine. The MS stated, When it was cleaned, [the filter] wasn't put back .whoever set it [in the oxygen storage room] should have verified that it [filter] was there. The MS stated he could not find replacement filters in the storage room. The MS stated the exterior filter was another barrier for contaminants and would affect the life of the internal filter. The MS stated, I don't have a date on the cassette bacteria filter inside and it's missing the exterior filter. During a concurrent observation and interview on 2/1/22, at 12:00 p.m., with the MS, the MS lifted the filter off the oxygen machine that had been used by Resident 480. The filter showed scattered clumps of white substance. The MS stated the filter did not look like it had been cleaned recently. During an interview on 2/3/22, at 3:14 p.m., with the DON, the DON stated she had no knowledge of the maintenance for oxygen concentrators. The DON stated, I am not well versed on the schedule for cleaning the filters. My expectation is to follow their policy. I don't know what it is. The DON stated she did not know how this practice would affect the health of the Residents. During an interview on 2/3/22, at 3:34 p.m., with LVN 1, LVN 1 stated it was the responsibility of the nurse to check the concentrator and clean the filter weekly. During an interview on 2/3/22, at 4:24 p.m., with the Administrator (ADM), the ADM stated, They [Nurses and maintenance] should have followed the policy who would clean [the oxygen concentrator and filter] and follow up. That's how we make sure things are being completed and the Residents are safe. During an interview on 2/3/22, at 4:49 p.m., with the MS, the MS stated there was no tracking of the oxygen concentrators being used. The MS stated his audit system did not track what was checked on each concentrator and when they were checked. During a review of Resident 480's PO, dated 1/25/22, the PO indicated, a physician's order, OXYGEN AT 2LPM [liters per minute] VIA NASAL CANNULA TO KEEP OXYGEN AT OR ABOVE 92 AS NEEDED FOR SOB [shortness of breath]. During a review of Resident 475's Physician Orders [PO] dated 1/26/22, the PO indicated, a physician's order, OXYGEN AT 2 LPM [liters per minute, unit of measurement] VIA NASAL CANULA TO KEEP O2 [oxygen] SAT [saturation of oxygen in the blood] AT OR ABOVE 90% PRN [as needed] FOR SHORTNESS OF BREATH DX [diagnosis] CHF [congestive heart failure- the heart is unable to provide sufficient pump action to circulate blood]. During a review of the facility policy and procedure (P&P) titled, Oxygen Therapy dated 11/2017, the P&P indicated, .Oxygen is administered under safe and sanitary conditions to meet resident needs. Licensed Nursing staff will administer oxygen as prescribed .If oxygen concentrators are used, the filters will be cleaned per manufacturer's guidelines .There will be a log maintained to identify each time the filters are changed . During a review of the Manufacturer's Instructions for Use (IFU) titled, Caring for Your [Company Name] Oxygen Concentrator, (undated), the document indicated, The air filter and connector should be cleaned at least once a week. To clean, follow these steps: Remove the air filter, located on the back of the unit .Wash in a solution of warm water and dishwashing detergent .Rinse thoroughly with warm tap water and towel dry. The filter should be completely dry before reinstalling.

Based on interview and record review, the facility failed to ensure nursing staff possessed appropriate competencies and skills sets to provide nursing and related services to assure resident safety for one of one Director of Staff Development (DSD) when the DSD did not have a process in place to verify the mandatory staff dementia (the loss of cognitive function)competency trainings and in-services of Registry staff (contracted staff). This failure had the potential to place resident who suffer from dementia care at risk when placed under the care of a registry staff who did not complete the required dementia competency training and in-services mandated by State and Federal regulations. Findings: During an interview on 2/3/22, at 10:07 a.m., with the DSD, the DSD stated she had been employed at the facility as the DSD coordinator for three years and had DSD experience since 2006. The DSD stated annual mandatory Abuse and Dementia (the loss of cognitive function) competency trainings were required for all nursing staff upon hire and annually. The DSD stated the facility began to utilize Registry staff in 2021, during the staffing shortage. The DSD stated Registry staff were not required to complete the mandatory dementia competency training at the facility. The DSD stated the facility had a staffing contract with the registry to provide staff when the facility had staffing shortages. The DSD stated she did not know if Registry staff had completed mandatory dementia competency staff training with their perspective Registry's. When the DSD was asked to provide a sample of the Registry staff's training and in-services from the registry staff personnel file. The DSD stated she did not have registry staff files and would have to call the Agency's Director for information. During an interview on 2/3/22, at 4:57 p.m., with the Director of Staff Development Consultant (DSDC), the DSDC stated all staff including Registry staff was expected to follow the facility's policy and procedures on State and Federal mandatory competency training requirements. The DSDC stated the facility did not have a system to ensure registry staff had the required competency training. The DSDC stated the facility failed to follow up with the registry agency to ensure registry staff had all the mandatory dementia competency training that was required. The DSDC stated it was the DSD's responsibility to verify with the registry agency that Registry staff completed the required competency training and in-services prior to the employment start date and that did not occur. During a concurrent interview and record review on 2/3/22, at 5:36 p.m., with the DSD, the facility's job description titled, Director of Staff Development was reviewed. The DSD's job description indicated, The DSD is responsible for planning, implementation, direction, and evaluation of the facility's educational programs for all employees and quality assurance and improvement in the facility . General duties and responsibilities: Orientation . Provide all documents supporting orientation to the facility's policy and procedures for maintenance in the individual employees file folders . Administrative: Maintains all in-service records on all employees in current, neat, and orderly fashion . The DSD stated the expectation of the facility DSD was to follow the DSD facility's job description. The DSD stated she should have created an employee file that contained registry staff completed required competency trainings and in-services prior to employment start date and kept a record of the trainings and in-services in the Registry staff's personnel file.

Based on observation, interview, and record review, the facility failed to ensure one of one sampled resident (Resident 48) received food prepared in a form that meets individual swallowing needs during the lunch meal service on 2/2/22. This failure had the potential to place Resident 48 at increased choking risk and decreased nutritional intake. Findings: During a concurrent observation and record review on 1/31/22, at 12:05 p.m., in the kitchen, during the lunch meal service, the kitchen serving steam table had puree salad, puree chili, and puree cornbread. Resident 48's lunch meal ticket was reviewed. The lunch meal ticket indicated, Liquid Puree. Resident 48's plate had three scoops of puree food. Resident 48 was not served a liquid puree diet. During a concurrent interview and record review, on 1/31/22, at 12:25 p.m. with the Registered Dietitian (RD) 1 in presence of the Registered Dietician Director of Operations (RDDO), the RDDO stated he was not sure what was the liquified puree diet. RD 1 stated the liquified puree diet was a diet that consisted of food items puree to a drinkable consistency that was served in mugs. He stated the facility had a recipe for liquified puree diet to ensure the diet was the appropriate consistency and nutritional value equivalent. RD 1 confirmed that Resident 48 was supposed to receive a liquified puree diet that should have been served in drinkable mugs. During a review of Resident 48's Diet Order, dated 1/28/22, the Diet Order indicated, Resident 48 was on a fortified ([MEDICATION(S)] with butter or milk to add nutrients to food) puree (blended) liquid diet in mugs with thin liquids. Resident 48 had a history of muscle weakness and dysphagia (difficulty to swallow). During a record review of the facility's recipe titled, Liquefied Pureed Diet, dated 2020, the recipe description indicated, The liquefied pureed diet is designed for residents who have difficulty eating solid food from a spoon or fork, whether assisted by staff or self-initiated. The diet would be considered for those who have more success consuming foods in liquid form from a mug, cup, or glass. The texture of all foods served will be smooth, free of lumps and liquefied adequately to flow freely from a mug. The regular servings for a pureed diet are to be served and then thinned to a drinkable consistency using appropriate fluids. This is done to ensure proper nutrition . During a review of Resident 48's Diet Order, dated 1/28/22, the Diet Order indicated, Resident 48 was on a fortified (enrichment such as butter or milk used to add nutrients to food) puree (blended) liquid diet in mugs with thin liquids. Resident 48 had a history of muscle weakness and dysphagia (difficulty to swallow). During a record review of the facility's recipe titled, Liquefied Pureed Diet, dated 2020, the recipe description indicated, The liquefied pureed diet is designed for residents who have difficulty eating solid food from a spoon or fork, whether assisted by staff or self-initiated. The diet would be considered for those who have more success consuming foods in liquid form from a mug, cup, or glass. The texture of all foods served will be smooth, free of lumps and liquefied adequately to flow freely from a mug. The regular servings for a pureed diet are to be served and then thinned to a drinkable consistency using appropriate fluids. This is done to ensure proper nutrition .

Based on observations, interviews, and record review, the facility failed to develop and implement a person-centered care plan for one of one sampled resident (Resident 6) when Resident 6 acquired multiple bruises on his left and right arms from IV (Intravenous -a needle with tube, inserted into a vein to give medications or fluids) line infiltration (when the IV solution leaks into the tissue or skin around the insertion site) and a care plan was not implemented to monitor healing of the bruises. This failure had the potential for Resident 6's IV infiltration and bruising not being monitored for skin infection and bleeding complications. Findings: During a review of Resident 6's Admission Record (document containing demographic information and medical diagnoses) undated, the Admission Record indicated Resident 6 was admitted to the facility on [DATE]. During a concurrent observation and interview, on 1/31/22, at 10:40 a.m., with Resident 6, in Resident 6's room, Resident 6 was observed with red and purple skin discoloration areas on his right and left arms. Resident 6 stated approximately a week ago a doctor poked his arms to draw his blood. Resident 6 stated the doctor could not find a vein and kept poking him. During a review of Resident 6's Minimum Data Set (MDS- a comprehensive assessment of resident's functional capabilities and helps nursing home staff identify health problems and care needs) dated 1/24/22, the MDS assessment indicated, Resident 6's Brief Interview for Mental Status (BIMS assessment of attention, orientation, and memory) assessment score was 15 out of 15 possible points which indicated Resident 6 was cognitively intact (0-7 severe cognitive impairment, 8-12 moderate cognitive impairment, 13-15 no cognitive impairment). During a concurrent interview and record review, on 2/2/22, at 11:37 a.m., with Registered Nurse (RN) 1, Resident 6's nursing note dated 1/23/22, at 10:30 p.m. was reviewed. The nursing noted indicated, [on] 1/26/22 Resident IV line found infiltrated during rounds of changing shift . RN 1 stated Resident 6's arms appeared bruised from the IV infiltration. RN 1 reviewed the Situation Background Assessment Recommendations [SBAR]) Summary ., dated 1/23/22, at 10:40 p.m., the SBAR Summary note indicated, Resident found IV line clogged and infiltrated. RNs tried 4 times. But, still unable to locate good veins . RN 1 reviewed the Long Term Care Evaluation (LTCE) Weekly note dated 2/2/22, at 4:27 a.m., RN 1 stated the skin portion of the evaluation did not address Resident 6's IV infiltration and bruises to his right and left arms. RN 1 reviewed Resident 6's care plan and stated a care plan should have been initiated for IV infiltration and bruises. During a concurrent interview and record review, on 2/3/22, at 9:25 a.m., with Licensed Vocational Nurse (LVN) 4, Resident 6's LTCE assessment, dated 2/2/22 at 4:27 a.m. was reviewed. LVN 4 stated she completed the LTCE assessment dated [DATE] at 4:27 a.m. LVN 4 stated she was aware Resident 6 had bruising from the IV infiltration and stated, I did not mention it [infiltration and bruising] in the assessment. LVN 4 stated, My note is not accurate and the note should have mentioned the infiltration and bruising. During an interview on 2/3/22, at 2:20 p.m., with the Director of Nursing (DON), the DON stated Resident 6 was admitted to the skilled nursing facility in June 2019. The DON stated Resident 6 was alert and oriented. The DON stated Resident 6 was on IV fluids and his IV had infiltrated which resulted in the bruising. The DON stated on 2/2/22 she observed Residents 6's arms with the bruising. The DON stated a care plan should have been developed because staff were aware how Resident 6 obtained the bruising and the staff needed to monitor Resident 6's arms for complications and to provide the proper care. During a concurrent interview and record review, on 2/3/22, at 3:46 p.m., with the DON, the facility policy and procedure (P&P) titled, Skin and Wound Management, dated 1/1/12 was reviewed. The DON reviewed the P&P and stated, . Licensed Nurse will complete the Weekly Skin Evaluation for each resident . Treatments of skin problems, wounds and non-pressure ulcers will be assessed and completed by the License Nurse . A Licensed Nurse will report any changes in resident skin condition to the attending physician, Director of Nursing Services (DNS), the interdisciplinary team (IDT)-Skin Committee, and the responsible party . The Licensed Nurse will document the status of all skin conditions at least weekly or as otherwise indicated in the resident's Care Plan . The DON stated a LTCE assessment note dated 2/2/22 at 4:27 a.m. was completed but there was no skin evaluation for 1/26/22 and it should have been completed. The DON stated the LTCE assessment note for 2/2/22 at 4:27 a.m. indicated, .No Skin issues noted. Skin is WNL [Within Normal Limits]. The DON stated the assessment documented in the LTCE note was not an accurate assessment of Resident 6's bruises. The DON stated the licensed nurses should describe the skin condition, cause of the injury and a care plan for the concern should have been initiated. The DON stated this was not done and should have been done. During a review of the facility's P&P titled, Skin and Wound Management dated 1/1/12, the P&P indicated, .Documentation, A. The Licensed Nurse will document the status of all skin conditions at least weekly or as otherwise indicated in the resident's Care Plan .

Based on observation, interview and record review, the facility failed to provide services which meet professional standards of quality for two of five sampled residents (Residents 34, and 47) when: 1. Resident 47 was administered oxygen (medical gas) at 4 liters (L- unit of measurement) per minute by way of nasal cannula (tubing used to deliver oxygen) instead of oxygen at 2L in accordance with the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] This failure resulted in Resident 47 receiving a higher dose of oxygen than ordered from the physician and had the potential for compromised lung function due to high doses of oxygen. 2. Resident 34 was not administered his nutritional supplement (supplement containing vitamins, minerals, and extra calories) for the month of September 2021 and October 2021 according to the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] This failure resulted in Resident 34 not receiving his nutritional supplement and had the potential to contribute to Resident 34's ongoing weight loss. Findings: 1. During a concurrent observation and interview, on 1/3/22 at 11:52 a.m., with License vocational nurse (LVN) 3, in Resident 47's room, Resident 47 was in bed with her eyes closed, and connected to an oxygen concentrator (a medical device used for delivering oxygen to individuals with breathing-related disorders). Resident 47 oxygen concentrator was set to deliver oxygen at 4 L per minute (pm) by way of nasal cannula (oxygen tubing). LVN 3 stated Resident 47's oxygen levels should have been set to deliver oxygen at 2 Lpm. LVN 3 stated she did not check the settings of the oxygen concentrator at the start of her shift (work schedule) and had not checked Resident 47 was receiving double the dose of oxygen that he was prescribed. LVN 3 stated she should have checked the oxygen concentrator setting to make sure Resident 47 was received the correct oxygen dose. LVN 3 stated too much oxygen would cause oxygen poisoning. During a concurrent interview and record review, on 1/3/22, at 11:55 a.m., with LVN 3, Resident 47's Physician Orders, dated 1/11/22 were reviewed. The Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . LVN 3 stated she should have followed the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] During a concurrent interview and record review, on 2/2/22, at 11:35 a.m., with the Director of Nursing (DON), Resident 47's Physician Orders, dated 1/11/22 and the facility's policy and procedure (P&P) titled, Oxygen Therapy, dated 11/2017 was reviewed. The Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The P&P indicated, To ensure the safe storage and administration of oxygen in the facility. Oxygen is administered under safe and sanitary conditions to meet resident needs. License Nursing staff will administer oxygen as prescribed . Administer oxygen per physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] During a review of Resident 47's Admission Record dated 1/11/22, the Admission Record (document containing resident demographic information and medical diagnosis) indicated Resident 47 was admitted to the facility with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of the professional reference retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC 03/ titled, Bench to bedside review: Oxygen as a drug dated 2/24/2009, indicated, .Oxygen is one of the most widely used therapeutic agents. It is a drug in the true sense of the word, with specific biochemical and physiologic actions, a distinct range of effective doses, and a well-defined adverse effect at high doses . During a review of the professional reference retrieved from https://myhealth.ucsd.edu/RelatedItems/3, , titled, Understanding Oxygen Toxicity dated 1/2020, indicated, Oxygen toxicity is lung damage that happens from breathing in too much extra (supplemental) oxygen. It's also called oxygen poisoning. It can cause coughing and trouble breathing. In severe cases it can even cause death. When you breathe, oxygen from the air enters your lungs and goes into your blood. The oxygen then goes to all parts of the body through the blood. It keeps organs and tissues working normally. But too high a level of oxygen can harm lung tissues. The tiny air sacs (alveoli) in the lung may fill with fluid. Or they may no longer inflate (collapsed lung). The lungs then can't take in air normally. This can make it harder for the lungs to send oxygen into the blood . 2. During a review of Resident 34's Face Sheet (FS-document containing demographic information and medical diagnosis), dated 2/2/22, the FS indicated, Resident 34 was admitted on [DATE] with a history of [CONDITION(S)] ([CONDITION(S)] [stroke], cerebral palsy (a congenital disorder of movement, muscle tone, or posture), [CONDITION(S)] (paralysis of one side of the body), [CONDITION(S)] (loss of ability to understand or express speech), dysphagia (difficulty of swallowing), G-tube (gastrostomy tube [tube inserted into the stomach to provide nutrients]), and muscle weakness. During a review of Resident 34's Diet Order, (DO) dated 7/7/21, the DO indicated, (brand name) a nutritional supplement used to add calories and protein twice a day was ordered from 7/7/21 through 12/21/21. During an interview on 2/1/22, at 10:15 a.m., with Resident 34, Resident 34 stated, I weighed 171 pounds on admission. Now I weigh 134 pounds [37-pound weight loss]. Resident 34 stated he was losing weight because he did not like the food he was served in the facility. Resident 34 stated, The puree bread is too doughy. Resident 34 stated he received tube feeding supplements via his G-tube after meals. During a review of Resident 34's Weight and Vitals Summary (WVS), dated 2/3/22, the WVS indicated, Resident 34 had severe weight loss (greater than 10% weight loss in a six-month period) since admission. On 5/6/21, Resident 34 weighed 149.4 lbs (pounds). On 11/1/21, Resident 34 weighed 131.9 pounds which is a 11.71 % loss. On 2/2/21, Resident 34 weighed 162.8 lbs. On 8/2/21, Resident 34 weighed 134.6 pounds which is a 17.32 % weight loss. During a review of Resident 34's Nutrition/Dietary Note (NDN), dated 7/7/21, the NDN indicated, the Registered Dietitian 2 (RD 2) documented Resident 34 had significant weight change 6.60%, -8.6 pounds times five weeks related to inadequate oral intake as evidenced by oral intake 0-25% of most meals. RD 2 documented to add the nutritional intervention of nutritional supplement [brand name] twice a day starting 7/7/21. Nutritional supplement was to be served at breakfast and dinner and to monitor and evaluate weights, oral intake, and acceptance of nutritional supplement twice a day. During a concurrent interview and record review, on 2/3/22, at 1:19 p.m., with the Registered Dietician Director of Operations (RDDO), Resident 34's Nutrition/Dietary Notes (NDN), were reviewed. The RDDO indicated on the NDN, dated 6/11/21, Some weight loss was anticipated as we attempted to wean dependence from TF (tube feeding). Diet: Puree and nutritional supplement [brand name] BID [twice a day] with breakfast and dinner. The RDDO stated the nutritional supplement was added as an oral supplement on 8/18/21, 9/15/21, and 12/21/21 Nutritional/Dietary Notes. During a concurrent interview and record review, on 2/3/22, at 2:39 p.m., with the Director of Nursing (DON), Resident 34's Medication Administration Records (MAR), dated September 2021 and October 2021 was reviewed. The DON stated the nutritional supplement order was not documented on the MAR and was not administered for September 2021 and October 2021. During a review of the facility's policy and procedures (P&P) titled, Physician Orders, dated 8/21/20, the P&P indicated, .IX. Medication and treatment orders will be transcribed onto the appropriate resident administration record (e.g., medication administration record (MAR) or treatment administration (TAR) . XII. Documentation pertaining to the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on observation, interview, and record review, the facility failed to perform a comprehensive resident assessment and ensure treatment was initiated in accordance with professional standards of practice for one of one sampled resident (Resident 6) when Resident 6's skin was not accurately assessed to develop an individualized treatment and monitoring plan to monitor multiple bruising on Resident 6's left and right arms. This failure had the potential to result in Resident 6 not receiving treatment and monitoring to the multiple bruises on Resident 6's left and right arms which placed Resident 6 at risk for undetected bleeding and skin infection. Findings: During a review of Resident 6's Admission Record (document containing demographic information and medical diagnosis), undated, the Admission Record indicated, Resident 6 was admitted to the skilled nursing facility on 6/18/19. During a concurrent observation and interview, on 1/31/22, at 10:40 a.m., with Resident 6, in Resident 6's room, Resident 6 was observed with red and purple areas to his right and left arms. Resident 6 stated about a week ago a doctor poked his arms to draw his blood. Resident 6 stated the doctor could not find a vein. During a review of Resident 6's Minimum Data Set (MDS- assessment used to identify resident care needs) assessment, dated 1/24/22, the MDS assessment indicated, Resident 6 was cognitively intact with a Brief Interview for Mental Status (BIMS- an evaluation of attention, orientation and memory recall) score of 15 (0-7 severe cognitive impairment, 8-12 moderate cognitive impairment, 13-15 no cognitive impairment). During a concurrent interview and record review, on 2/2/22, at 11:37 a.m., with Registered Nurse (RN) 1, Resident 6's Alert note, dated 1/23/22 at 10:30 p.m. was reviewed. The Alert note indicated, .Resident IV [Intravenous (IV- giving medications or fluids through a needle and tube inserted into a vein] line found infiltrated (when the IV solution leaks into the tissue or skin around the insertion site) during rounds of changing shift . RN 1 stated Resident 6's arms appeared bruised from an old intravenous. RN 1 reviewed the .[Situation Background Assessment Recommendations (SBAR)] Summary ., dated 1/23/22, at 10:40 p.m., the noted indicated, Resident found IV line clogged and infiltrated. RNs tried 4 times. But, still unable to locate good veins . RN 1 reviewed the Long Term Care Evaluation (LTCE) (Weekly note) dated 2/2/22 at 4:27 a.m., RN 1 stated the skin portion of the evaluation did not address Resident 6's bruises to his right and left arms. RN 1 reviewed Resident 6's care plan and stated she initiated Resident 6's care plan on 2/2/22 and added the new focus, The resident has potential/actual impairment to skin integrity RN 1 stated a care plan should have been initiated for this concern. During concurrent interview and record review, on 2/3/22, at 9:25 a.m., with Licensed Vocational Nurse (LVN) 4, Resident 6's LTCE, dated 2/2/22 at 4:27 a.m. was reviewed. LVN 4 stated she completed the assessment for LTCE, dated 2/2/22 at 4:27 a.m. LVN 4 stated she was aware Resident 6 had bruising from the IV and stated, I did not mention it in the assessment. LVN 4 stated, My note is not accurate and the note should have mentioned the old bruising. During an interview on 2/3/22, at 2:20 p.m., with the Director of Nursing (DON), the DON stated Resident 6 was admitted in June 2019. The DON stated Resident 6 was alert and oriented. The DON stated Resident 6 was on IV fluids and his IV was infiltrated and the physician was called. The DON stated on 2/2/22 she observed Residents 6's arms and the bruising was fading. The DON stated a care plan should have been developed because staff were aware how Resident 6 obtained the bruising and the staff needed to monitor Resident 6's and provide the proper care. During a concurrent interview and record review, on 2/3/22, at 3:46 p.m., with the DON, the facility's policy and procedure (P&P) titled, Skin and Wound Management, dated 1/1/22, was reviewed. The DON reviewed the P&P and stated, . Licensed Nurse will complete the Weekly Skin Evaluation for each resident . Treatments of skin problems, wounds and non-pressure ulcers will be assessed and completed by the License Nurse . A Licensed Nurse will report any changes in resident skin condition to the attending physician, Director of Nursing Services (DNS), the interdisciplinary team (IDT)-Skin Committee, and the responsible party . The Licensed Nurse will document the status of all skin conditions at least weekly or as otherwise indicated in the resident's Care Plan . The DON stated a LTCE note for 2/2/22 at 4:27 a.m. was completed but there was no LTCE weekly skin evaluation for 1/26/22 and should have been completed. The DON stated the LTCE note for 2/2/22 at 4:27 a.m. indicated, .No Skin issues noted. Skin is WNL . The DON stated what was documented in the LTCE note was not an accurate assessment of Resident 6's bruises. The DON stated the licensed nurses should describe the skin condition and a care plan should have been initiated. The DON stated Resident 6's skin should have been monitored but was not. During a review of the facility's P&P titled, Skin and Wound Management dated 1/1/22, the P&P indicated, .Procedure, II. Skin and Wound Management . A. A Licensed Nurse will complete the Weekly Skin Evaluation for each resident .C. Treatments of skin problems, wounds and non-pressure ulcers will be assessed and completed by the License Nurse . D. A Licensed Nurse will report any changes in resident skin condition to the attending physician, Director of Nursing Services (DNS), the interdisciplinary team (IDT)-Skin Committee, and the responsible party .III. Documentation, A. The Licensed Nurse will document the status of all skin conditions at least weekly or as otherwise indicated in the resident's Care Plan . Skin and Wound Management dated 1/1/12, was reviewed. The DON reviewed the P&P and stated, . Licensed Nurse will complete the Weekly Skin Evaluation for each resident . Treatments of skin problems, wounds and non-pressure ulcers will be assessed and completed by the License Nurse . A Licensed Nurse will report any changes in resident skin condition to the attending physician, Director of Nursing Services (DNS), the interdisciplinary team (IDT)-Skin Committee, and the responsible party . The Licensed Nurse will document the status of all skin conditions at least weekly or as otherwise indicated in the resident's Care Plan .

Based on observation, interview, and record review, the facility failed to ensure resident environment was free of accidents and hazards for three of nine sampled residents (Resident 53, Resident 6 and Resident 30) when: 1. Certified Nursing Assistant (CNA) 28 turned Resident 53 in bed without the assistance of a second person and Resident 53 slid out of her bed. Resident 53 was assessed on 3/29/19, as requiring two persons to assist with bed mobility and nursing staff were aware of the need to provide care to Resident 53 with two staff. This failure resulted in Resident 53's fall after one nursing staff memeber turned her in bed instead of two nursing staff members; Resident 53 fell to the floor, and sustained a raised hematoma (swelling of clotted blood within the tissues) on her forehead, and laceration (cut) to her eyebrow and required an emergency room evaluation. 2. Resident 6 and Resident 30 used unauthorized portable space heaters in their room to keep warm. This failure had the potential to place residents, staff and visitors at risk [MEDICAL CONDITION] placed the facility at potential risk for fire. Findings: 1. During review of Resident 53's Interdisciplinary Team (IDT - a team made up of members from a variety of facility departments such as nursing, dietary, and physical therapy) Conference Review notes dated 6/13/19, indicated Resident 53 an elderly female had an incident of fall on 6/13/19 at 11:20 AM. Investigation revealed CNA (Certified Nursing Attendant) while giving ADL (Activity of Daily Living) care resident was turned by the CNA on the lt (left) side resident rolled over and slid out of the bed .resident sustained [REDACTED].Upon interview with assigned CNA and licensed nurse other contributing factors when the CNA turned resident towards left side resident slid out of the LAL (low-air-loss mattress - a specialty mattress covered in slick parachute-like material) due to weight shift .Action plan Resident use of LAL to be evaluated if appropriate. Educate Nursing staff on proper turning and repositioning during patient care. Implement buddy system if needed when doing care . During a concurrent interview and record review with the assessment coordinator (MDSC) 2, on 6/27/19, at 3:07 PM, MDSC 2 stated she completed the Functional Status- section G of the Minimum Data Set (MDS-assessment of functional abilities and needs) assessment for Resident 53 dated 3/29/19. MDSC 2 stated the ADL Care Plan dated 9/12/18, indicated Resident 53 had a history of [REDACTED]. MDSC 2 stated Resident 53 required the assistance of two staff members with bed mobility. MDSC 2 stated the care plan did not reflect her need for two staff for bed mobility when turning side-to-side. During review of Resident 53's MDS assessment dated [DATE], Section G indicated Resident 53 was totally dependent on staff for bed mobility and transfers with the support of two staff members. During review of Resident 53's care plan titled, Activities of Daily Living dated 9/12/18, indicated, At risk for complications (related to) dependent on staff for all ADL's (Resident) has a (history) of resistance with care (as evidenced by) body tightening up. Resident strikes out .Goal .Resident will demonstrate minimal complications related to decreased ADL performance .Approach .Monitor changes in self-performance of ADL's report significant changes to (medical doctor), provide adaptive equipment: wheelchair-tilt back, provide assistance with ADL care as needed, provide praise for effort, not just success, break tasks into manageable segments, allow sufficient time for ADL tasks, cue resident with ADL care needs, turn and reposition with care . Resident 53's ADL care plan did not reflect her need for two people physical assistance with bed mobility or transfers. During a concurrent observation of Resident 53 and interview with Licensed Vocational Nurse (LVN) 5, on 6/27/19 at 3:21 PM, Resident 53 was in her room and had a raised bump on the right side of her forehead, the size of a golf-ball that was raised approximately one-inch. The base of the raised area was circular and approximately two-inches around and a small steri-strip (surgical tape) below her right eyebrow. LVN 5 stated Resident 53 was dependent on staff and was unable to help with her own care. LVN 5 stated Resident 53 sustained a fall on 6/13/19, after sliding out of bed during care provided by one staff member (CNA 28). LVN 5 stated, If two people had been providing care it is unlikely she would have fallen. LVN 5 stated Resident 53's mattress was covered in a slick blue parachute-like material. LVN 5 stated, (The mattress surface) is slick. Once (Resident 53) got to the side of the bed she slid off. LVN 5 stated he saw Resident 53 when she returned the day after her fall. LVN 5 stated CNA 28 was no longer employed by the facility. During a review of Resident 53's general acute care hospital clinical record titled, (Computed [NAME]ography-combination of X rays and computer graphics to create pictures of internal organs and bones.) CT Maxilofacial dated 6/13/19, at 3:08 p.m., indicated, There is a scalp hematoma noted right forehead region. There is right periorbital (space around the eye) soft tissue swelling noted . During an interview with Certified Nursing Assistant (CNA) 1, on 6/27/19 at 3:53 PM, CNA 1 stated, I get help to turn her, always did, even before she fell . CNA 1 stated Resident 53 always required two-person assistance with bed mobility. During an interview with the Restorative Nurse Assistant (RNA) on 6/27/19, at 3:57 PM, the RNA stated Resident 53 was always provided with two-person assistance for all of her activities of daily living including bed mobility. During an interview with the Administrator (ADM) and MDSC 2, in the Administrator's office, on 6/27/19 at 4:20 PM, MDSC 2 stated when Resident 53 fell on [DATE], CNA 28 was providing care without help and she should have had a helper. MDSC 2 stated the specialty mattress (with the slick covering) also contributed to Resident 53 falling off the bed. ADM stated, (There was) nothing to keep (Resident 53) from falling. A second person might be the barrier between the resident and the floor. 2. During a concurrent observation and interview with Resident 6, on 2/27/19, at 4:13 p.m., in Resident 6's room, a space heater was turned off and placed on the nightstand next to the bed. Resident 6 stated another resident gave it to him nine months ago. Resident 6 stated he would turn on the space heater in the morning when his room was cold. During a concurrent observation and interview with Resident 30, on 2/27/19, at 4:26 p.m., in Resident 30's room, a space heater was turned off and placed on the floor near Resident 30's bed. Resident 30 stated she had obtained the space heater on 2/25/19. Resident did not state where she obtained the space heater from. Resident 30 stated her room was cold in the mornings and she would turn on the space heater while she changed her clothes. Resident 30 stated the space heater would not get hot and would only blow out hot air when she would check it. During a concurrent observation and interview with CNA 15, on 2/27/19, at 4:34 p.m., she stated she was unsure how long Resident 6 had the space heater in his room. CNA 15 stated she first observed Resident 30's space heater on 2/25/19. CNA 15 stated she was unsure if space heaters were allowed in the facility. CNA 15 stated when she observed the space heater in Resident 30's room she did not notify facility administrative staff. During an interview with Licensed Vocation Nurse (LVN 7), on 2/27/19, at 4:40 p.m., she stated she first observed Resident 6's space heater on 2/26/19 on his bedside table. LVN 7 stated the space heater was a fan with heating but was unsure what is was used for. LVN 7 stated she was unaware of when Resident 30's space heater was placed in her room. During an interview with the Administrator (ADM), on 8/5/19, at 12:52 p.m., stated she had not approved the space heaters and was unaware if the previous ADM had approved them for resident use. Review of the facility document tiled, Life Safety code K781, dated 10/16, indicated, Portable space heating devices shall be prohibited in all health care occupancies (facilities).

Based on observation, interview, clinical record and professional reference review, the facility failed to ensure 45 of 94 residents (Residents 1, 2, and 3; Resident 4, Residents 7 and 8; Residents 11 and 12; Resident 14, Resident 16, Residents 18 through 27; Residents 29 and 30; Residents 34 and 35; Resident 37, Resident 39, Residents 43 and 44; Residents 49 and 50; Resident 52, Residents 56 and 57; Resident 60, Resident 66, Residents 70 and 71; Resident 75, Resident 78 and Residents 80 through 85) were free from significant medication errors when: 1. Physician prescribed medications for Resident 1 were not administered as ordered. Resident 1 was given 2 of 6 doses of [MEDICATION NAME] 500 milligrams (mg) (antibiotic-medication prescribed to treat bacterial infections), for the [DIAGNOSES REDACTED]. This failure resulted in medications not given for a known bacterial infection and led to Resident 1's transfer to the General Acute Care Hospital (GACH) with the [DIAGNOSES REDACTED]. 2. Licensed Nurse (LN) 1, LN 2, and LN 9 failed to use the appropriate needle attachment made for use with Insulin Flex Pens (a dial-a-dose, pre-filled insulin pen for discreet mealtime management) when LN's withdrew insulin out of the pen using a non-intended syringe with needle. This practice was not in accordance with the directions for use of the Insulin Flex Pens and placed residents on Insulin at risk for unsafe administration of medications. 3. The Facility LNs (LN 1, LN 2, LN 3, LN 4, LN 5, LN 6, LN 7, LN 8, LN 9, LN 10, LN 13 and LN 14 ) assigned to administer medications using three of three medication carts failed to administer multiple medications as prescribed for scheduled and prn (as needed) medications affecting multiple residents (Resident 3, Resident 4, Resident 7, Resident 8, Resident 9, Resident 12, Resident 14, Resident 18, Resident 19, Resident 20, Resident 21, Resident 22, Resident 23, Resident 24, Resident 25, Resident 26, Resident 27, Resident 28, Resident 29, Resident 30,Resident 40, Resident 50, Resident 56, Resident 57, Resident 60, Resident 66, Resident 70, Resident 71, Resident 78, Resident 80, Resident 81, Resident 82) on numerous occasions. On multiple occasions there was no follow up by the nursing staff to ensure availability and accessibility of medications for timely and accurate administration. There were no open dates on Insulin Flex pens used for multiple residents. These failures placed residents at risk of serious harm from medications given or not given as prescribed; and from Insulin medication administered from Flex Pens not dated with the potential to affect resident's blood sugar stability. 4. Physician orders [REDACTED]. As a result of this failure, multiple significant medications were not administered as ordered for 3 of # of residents (Resident 5, Resident 6, and Resident 13). This placed Resident 5, Resident 6 and Resident 13 at risk for harm from significant medication errors. Because of these failures and the identified serious actual harm to Resident 1 and potential serious harm to all residents with prescribed medications, an Immediate Jeopardy Situation was called on 1/25/18 at 6:50 p.m. with the facility administrator and the Interim Director of Nursing (DON). The facility submitted an interim Action Plan (AP) to address the safe administration of medications for the 1/25/18 8 p.m., 1/26/18 midnight and 1/26/18 morning medication administration that included Interim DON proctoring the medication passes. The Flex pens were removed from accessibility and use as part of the interim AP. The facility submitted APs on 1/26/18, 1/30/18 and 1/31/18 that were reviewed and unacceptable. The District Office management staff teleconferenced multiple times with the Administrator and IDON to explain the need to develop an Action Plan that effectively addressed the multi-factorial, system failures. The facility was directed to determine a system of proctoring each licensed nurse for medication administration and determine competency and safety parameters. On 2/1/18 at 12: 04 p.m. the facility submitted an action plan that was acceptable. The survey team continued to find significant medication errors following the acceptance of the AP. The facility failed to implement the AP and an exit conference was done on 2/8/18 at 8:50 a.m. without removing the IJ situation. The Administrator and corporate Vice President of Operations were present at the time of the exit. Findings: 1. During an observation and concurrent interview with Resident 1, on 1/11/18 at 1:25 pm, Resident 1 was in his room lying on his bed with an air mattress (special mattress designed to conduct a flow of air and to promote skin circulation). Resident 1 was awake, alert and appropriately responded to questions. Resident 1 stated he was admitted to the facility on [DATE] for wound management of his right buttock pressure ulcer and was on oral antibiotics to treat the infection. Resident 1 was observed with amputations of both his legs and he confirmed he had undergone an above the knee amputation (AKA) on his right leg and [MEDICAL CONDITION] (BKA) on his left leg. The facility face sheet (document with resident profile information) indicated Resident 1 was admitted on [DATE] at 9:47 a.m. The (MONTH) (YEAR) Physician order [REDACTED]. The Physician order [REDACTED]. (End) completion of drug regimen) on 1/6/18 8 a.m. (for a total of five doses to be given). The Delivery Manifest (document provided with the pharmacy delivery of medications) for the facility for Resident 1's [MEDICATION NAME] 500 mg capsule, quantity 6 indicated delivery on 1/5/18 at 1:51 a.m. Resident 1's MAR indicated the [MEDICATION NAME] was not administered on 1/3/18 at 8 p.m., 1/4/18 at 8 a.m., 1/4/18 at 8 p.m. The MAR indicated the [MEDICATION NAME] was administered on 1/5/18 at 8 a.m. and 1/5/18 at 8 p.m. The MAR entry for 1/4/18 at 8 p.m. was marked with a circle (indicating not administered) and the reverse of the MAR page documented the following: [MEDICATION NAME] 500 mg, called pharmacy to get code, but not available in Cubex (a locked container of medications which may be needed on short or emergency notice and and can be opened with a code from the pharmacy). During an observation and concurrent interview with Director of Staff Development (DSD - licensed nurse in charge of training all staff), on 1/19/18 at 3:10 p.m. the [MEDICATION NAME] bubble pack prescribed for Resident 1 was identified and contained four capsules of the medication. The DSD stated Resident 1 should have been administered all six doses of the antibiotic [MEDICATION NAME] and the bubble pack should have been empty. During an interview and concurrent record review of Resident 1's MAR and Physician order [REDACTED].M. the Interim Director of Nursing (IDON) stated the antibiotic [MEDICATION NAME] was not administered as ordered. The IDON stated the MAR did not accurately reflect the prescription for [MEDICATION NAME]. The IDON stated one of the risks for not administering [MEDICATION NAME] as ordered could be complication of the infection. IDON did not comment on the expectation for nurses to clarify orders because the IDON stated her employment start date with the facility was on 1/12/18, after the incident with Resident 1. During an interview and concurrent record review of Resident 1's MAR and Physician order [REDACTED]. LN 1 stated Resident 1 should have received six doses of [MEDICATION NAME] and did not. LN 1 stated the MAR was pre-printed with completion date of 1/6/18 and was the reason he did not administer the [MEDICATION NAME] on 1/6/18. LN 1 stated that the 1/4/18 8 a.m. dose was not given because the medication was not available. LN 1 stated he should have called the physician for clarification and did not. LN 1 stated a new MAR should have been generated based on the physician clarification but was not. LN 1 agreed the original MAR was not accurately transcribed from the Physician order [REDACTED]. LN 1 stated the [MEDICATION NAME] was not in the Cubex and not delivered to the facility until 1/5/18 and a new MAR should have been generated and was not. The facility face sheet for Resident 1 indicated he was admitted on [DATE] with the following Diagnoses: [REDACTED]. The History and Physical Exam clinical record dated 1/4/18 indicated Resident 1 . was transferred to the SNF (Skilled Nursing Facility) for short term rehab and wound care Resident 1's clinical record titled, Minimum Data Set (MDS) (an assessment used to identify resident level of care which drives care planning decision) assessment dated [DATE], indicated Resident 1 had no cognitive (pertaining to short and long term memory) impairment. Resident 1's clinical record titled, ANTIBIOTIC OR CONTROLLED DRUG RECORD undated, indicated, [MEDICATION NAME] 500 mg CAPSULE (quantity) 6 CAP .TAKE ONE CAPSULE BY MOUTH 2 TIMES A DAY FOR 3 DAYS. The document indicated the antibiotic was signed for on 1/5/18 at 8 a.m., and 8 pm. Resident 1's clinical record titled, Progress Notes dated 1/10/18 at 3:56 p.m. created by Primary Care Physician (PCP) indicated, Chief Complaint: Follow up visit .patient had loose bowel movements last week that has improved now, he is taking antibiotics and compliant with medications .SKIN; skin ulcer on his back is slightly worsened in size and appearance with surrounding skin [DIAGNOSES REDACTED] (redness) It is 27.5 X 15 cm and has ++ exudative layer of necrotic tissue . Resident 1's Clinical Notes dated 1/13/18 at 1:19 a.m., indicated, (temperature) 102.0 (normal temps 97-99 degrees Fahrenheit) .RESIDENT DOES HAVE A FEVER TYLENOL 325 MG TWO TABS GIVEN THIS IS A MALE ADULT WITH BILATERAL AMPUTATIONS (RELATE TO)[MEDICAL CONDITION] RESIDENT IS CLEARED FROM ISOLATION ABLE TO MAKE NEEDS KNOWN . Resident 1's Clinical Notes dated 1/14/18 at 1:04 p.m., indicated, resident was noted to be uncomfortable and restless, (oxygen saturation) 90% (normal value 90-100) and has cough .resident sent to (acute care) for further eval . During an interview with, Resident 1's PCP 1 on 1/23/18 at 3:34 p.m., stated he visited Resident 1 within 3 days of his admission to the facility. PCP 1 stated Resident 1 was a challenge due to his various illnesses and was a high risk patient. PCP 1 stated Resident 1 did not want to be in the facility and wished to return home but required skilled nursing services due to his medical needs. PCP 1 stated Resident 1 had a previous history of a wound infection. PCP stated he visited Resident 1 for a second time and noticed the wound was larger. PCP 1 stated he ordered wound cultures and continued wound care. PCP 1 stated Resident 1 was on ordered antibiotic [MEDICATION NAME] 500 mg two times a day for 3 days for the treatment of [REDACTED]. PCP 1 stated Resident 1's infection could have worsened [MEDICAL CONDITION] and the infection itself could have increased the size of the wound because of the antibiotic not being administered. PCP 1 stated he ordered Resident 1 be transferred to the acute care hospital on [DATE] for [MEDICAL CONDITION]. PCP 1 stated he was disappointed when he saw Resident 1's wound was larger on his second visit on 1/10/18 at 3:56 p.m. On arrival to the Acute Care Hospital (ACH) the Emergency Department (ED) RN documented ED Nursing Note: Pt (patient) arrived from SNF with c/o (complaint of) SOB (shortness of breath) cough; has a wound on the SACRUM (tailbone) area getting treated by wound RN in the SNF . The Active Hospital Problems listed (principal)[MEDICAL CONDITION] WO (without) acute organ dysfunction; pressure ulcer of back unstageable; pneumonia;[MEDICAL CONDITION](hypertension); DM (diabetes mellitus) 2 W (with) [MEDICAL CONDITION]. The ACH records indicate Resident 1 was discharged from the hospital on [DATE] to continue care at SNF 2. 2. During an observation and concurrent interview on Station Two, with LN 9 on 1/24/18 at 11:20 a.m., LN 9 was drawing insulin from a [MEDICATION NAME] (fast acting insulin - starts to work 15 minutes after being injected) Flex pen (used to inject insulin) 100 unit (measurement) / (per) ml (milliliter) for Resident 10 using an insulin syringe with needle and was asked about the process for using a Flex pen. LN 9 stated, After taking the insulin pen out of the medication cart, I identify the resident and dosage on the MAR. I take the insulin pen to the resident's room with an alcohol swab. I swab the area where I will inject the ordered dose of insulin. LN 9 stated We (facility) do not have insulin needles for the insulin (Flex) pens. LN 9 stated, I was told by (LN 1) during medication training to use insulin syringes to withdraw insulin from the insulin (Flex) pens. LN 9 stated, I have been withdrawing insulin from the insulin pens since (MONTH) 6, (YEAR). On 1/25/18 at 7:05 a.m., during a clinical record review, Resident 2's MAR indicated Resident 2's blood sugar value was 457; according to the sliding scale (a scale of ranges identified by a blood sugar check for which the physician has ordered a dose of Insulin to be administered) 12 units of insulin was to be administered using the [MEDICATION NAME] Flex pen. During a medication (med) pass observation on 1/25/18 at 7:28 a.m. in Station 1, LN 2 prepared the medications for Resident 2. The MAR for Resident 2 indicated she was prescribed [MEDICATION NAME] Flex pen 100unit/ml. The MAR indicated Resident 2 was on a Sliding Scale for the administration of a fast acting Insulin (Insulin effect to lower blood sugar is within 15 minutes). The form indicated, Blood sugar is less than 60 or greater than 500 notify MD, Blood sugar is 70-200, 0 units (no Insulin to be given), Blood sugar is 201-249, 2 units, Blood sugar is 250-299, 4 units, Blood sugar is 300- 349, 6 units, Blood sugar is 350-399, 8 units, Blood sugar is 400-449, 10 units, Blood sugar is 450-499, 12 units of Insulin Subcutaneous (SQ) three times daily starting 1/11/2018. The MAR indicated to administer [MEDICATION NAME] for Resident 2 with the insulin Flex pen. LN 2 was unable to locate the correct needle for the [MEDICATION NAME] in Station 1 Medication Cart. LN 2 interrupted the med pass to walk to Station 2 and ask Station 2 LN for Flex pen needles. Station 2 LN indicated she did not have any Flex pen needles on her cart. LN 2 then walked to Station 3, and Station 3 LN indicated she did not have any Flex pen needles on her cart. LN 2 then walked to the Central Supply Office and spoke to the Director of Staff Development (DSD - licensed nurse in charge of facility staff training) who stated the facility was out of Flex pen needles. LN 2 then walked back to Station 1 and asked LN 6 to order Flex pen needles immediately from the pharmacy. LN 2 then walked back to Station 1 Med cart to resume the med pass. LN 2 located an insulin syringe and needle, uncapped the needle and inserted the needle into the Flex pen and withdrew [MEDICATION NAME]from the Flex pen. LN 2 then administered the insulin by injection to Resident 2 using the same syringe with needle used to withdraw the Insulin from the [MEDICATION NAME]. During a medication pass observation on 1/25/18 at 8:17 a.m., LN 2 prepared medications for Resident 11. The MAR for Resident 11 indicated she was prescribed [MEDICATION NAME] Flex pen 100 unit/ml insulin pen subcutaneous four times daily starting 11/29/17. The MAR indicated, Notes: Insulin [MEDICATION NAME] ([MEDICATION NAME]) 100 units/ml injection. Inject SQ 30 minutes before meals (bolus),(blood sugar values) less than 150- no coverage, 150-200=2 units, 201-250=4 units, 251-300= 6 units, 301-350=8 units, 351-400 10 units, above 400 call MD. Also notify MD if less than 60. The MAR indicated to administer [MEDICATION NAME] for Resident 11 (by way of) insulin Flex pen. On 1/25/18 at 8:10 a.m., the MAR indicated Resident 11's Blood sugar value was 391 and 10 units of insulin was to be administered using the [MEDICATION NAME] Flex pen. LN 2 located an insulin syringe and needle, uncapped the needle and inserted this into the [MEDICATION NAME] and withdrew [MEDICATION NAME]from the Flex pen. LN 2 then administered the insulin to Resident 11. During an interview with LN 2 on 1/25/18 at 3:25 p.m., LN 2 stated, Since I have been working here we have run out of pen needles for the residents' Flex pens on two or three occasions. I have been using the insulin syringes to withdraw insulin from the Flex pens when pen needles were unavailable. I felt that my residents needed their insulin and I used my nursing judgement to withdraw insulin from the [MEDICATION NAME] using an insulin syringe. I alerted the Central Supply staff on two occasions of the need to order Flex pen needles. LN 2 stated Central Supply staff was responsible for ordering needed medical supplies. LN 2 stated it was possible the residents may not be getting the correct dose of insulin when drawing insulin from the Flex pen using an insulin needle and syringe rather than the specific needle intended for use with the Flex pen. LN 2 stated the DSD and Central Supply staff were aware the pen needles were needed for the current morning medication pass on 1/25/18. During an interview with on 1/26/18 at 11:25 a.m., LN 4 explained the process of administering insulin by using a Flex pen. LN 4 stated the facility had run out of Flex pen needles in the past. LN 4 stated, when the facility did not have Flex pen needles, she uncapped the Flex pen, then using an insulin syringe, inserted the syringe into the Flex pen, pushed air into the pen to match the amount of insulin to be withdrawn. LN 4 stated after withdrawing the insulin from the Flex pen she administered the insulin to the residents using the syringe with needle (the same needle used to withdraw the insulin from the flex pen used to inject the Insulin into the resident). LN 4 stated, I have been using the insulin syringes (to withdraw from the flex pen) for a week. LN 4 stated she had used the syringes to draw both [MEDICATION NAME] and [MEDICATION NAME] (long acting) insulin for residents. LN 4 stated it was possible the insulin dose was not correct when drawing from the Flex pen in this manner and the residents may not have received the correct dose. LN 4 stated she should have notified the Director of Nursing (DON) about not having [MEDICATION NAME] needles and the needles should have been ordered. A document titled, [MEDICATION NAME] Flex Pen Quick Guide, https://www.[MEDICATION NAME].com/type-2diabetes/just-heard-about-[MEDICATION NAME]-2/[MEDICATION NAME]/using-flex ., indicated, Step 1 .Pull off the pen cap .Remove the protective tab from the needle and screw it onto your Flex Pen tightly. It is important that the needle is placed on straight .Never place a disposable needle on your Flex Pen until you are ready to take the injection .Step5 .Remove the needle from the Flex Pen after each injection to prevent infection, insulin leakage and to ensure proper dosing.If Flex Pen is not working .Screw on a new Novofine needle. Review of Professional Reference, Institute for safe medication practices, (YEAR), Guidelines for Optimizing Safe Subcutaneous Insulin Use in Adults indicated, Insulin as a High-Alert Medication, Medications that are associated with the highest risk of injury when used in error are known as high-alert medications .A variety of a type of errors have been associated with insulin therapy, including incorrect use of insulin delivery devices .Many errors result in serious [DIAGNOSES REDACTED] (low blood sugar values or [MEDICAL CONDITION] (high blood sugar values) .Misuse of insulin pen devices .Insulin cartridges within pens have been misused as multiple-dose vials when staff who preferred to administer insulin using a conventional syringe attempted to withdraw an insulin dose from the pen's cartridge. This practice could introduce air into the cartridge or reservoir, leading to subsequent insulin under-doses and subcutaneous injection of air . 3. On 1/24/18 at 10:30 a.m., a review of the Medication Administration Records (MAR)'s for residents residing on Station 3 was conducted. The MARs consisted of a computerized generated schedule of physician ordered medications. The listed medications included dosing, scheduled times for administration and directions about the physician's orders [REDACTED]. The box was for the LN to initial after a medication was administered or not administered. The back of the MAR indicated, NURSE'S MEDICATION NOTES. There were columns and rows available for LNs to enter the time a medication was not administered with the reason why a medication was not administered. During the review, numerous discrepancies were identified on 23 of 30 residents' (Resident 3, Resident 4, Resident 7, Resident 8, Resident 14, Resident 18, Resident 19 Resident 20, Resident 21, Resident 22, Resident 23, Resident 24, Resident 25, Resident 26, Resident 27, Resident 29, Resident 30, Resident 50, Resident 71, Resident 78, Resident 81, Resident 82) MARs. The discrepancies consisted of blank entries, circled LN initials when a medication was not administered and no corresponding reason documented as to why the medication was not administered, and documented entries indicating medications were not available from the pharmacy. On 1/24/18 at 10:30 a.m., a preliminary review of the Medication Administration Record (MAR) was conducted for station 1. The MAR review identified numerous discrepancies for 14 of 28 residents (Residents 11, 13, 15, 35, 36, 38, 40, 41, 42, 43, 44, 45, 46 and 73). The identified discrepancies consisted of blank entries, which were not initialed by the LN to indicate the medication was administered; and circled LN initials indicating a medication was not administered with no corresponding written explanation for the omitted medications. Medications that were not initialed as administered by the LNs included medications for treatment of [REDACTED]. During an interview with Licensed Nurse (LN 9) on 1/24/18 at 11:25 a.m., and concurrent record review, LN 9 looked at the MAR's for the residents in Station 3 and stated, We have to document the reason for not administering a medication. I see there are multiple blank entries on a lot of residents. LN 9 stated the documentation should have been written on the back of the MAR indicating the reason why a medication was circled as not given. LN 9 stated the MAR's should not be left blank for any medication with a scheduled time to be given. During an interview and concurrent record review with the Medical Records Designee (MRD), on 1/24/18 at 11:45 a.m., the MRD stated she was responsible to audit all of the resident MARs and Treatment Administration Records (TAR's) in the facility. The MRD stated, These are non-negotiable audits. The MRD explained the audits were to be completed on a daily basis and given to the nurses daily to complete. The MRD stated the nurse's documentation was audited each time the MAR's were left with blank entries, circled initials on medications not administered without a documented reason why. The MRD stated the audit also included medications prescribed for and given on an as needed basis which had no documented reason why the medications were not given. The MRD stated for all three nursing stations, the MARs contained many missing entries. The MRD stated the facility had been without a consistent DON since (MONTH) (YEAR), and stated the lack of entries had increased over this time period. The MRD stated she had given the results to the DON but the documented omissions continued. During an observation and concurrent interview with LN 9 on 1/24/18 at 10:55 a.m., LN 9 took a blood pressure cuff (BPC) (medical device used to measure blood pressure) and stethoscope (device used to hear heart and breath sounds)to Resident's 57's room. LN 9 placed the BPC to Resident 57's right upper arm to take his blood pressure and received a reading of 144/72, which was within the parameter to give the blood pressure medication. LN 9 initialed on the MAR for 8 a.m. administration dose as given. LN 9 did not circle and document on back of MAR that medication was given outside of the prescribed time of 8 a.m. (two hours 55 minutes past 8 a.m.). LN 9 stated, We can pass medication one hour before and one hour after medication is due. I am late passing medications because I had a lot of interruptions this morning. During an observation and concurrent interview with LN 9 on 1/24/18 at 11:30 a.m. on Station Two medication cart, LN 9 was unable to locate the 8 a.m. medication, [MEDICATION NAME] (oral antidiabetic medication) 50 mg (milligram) tablet for Resident 60. LN 9 stated, This medication ([MEDICATION NAME]) needs to be ordered. LN 9 stated medication is ordered at the end of the shift. When asked about the process for reordering medications, LN 9 stated, I don't know how many days before reordering medication because I am barely new here (employed at the facility). During an interview with the DSD, on 1/24/18 at 1 p.m., the DSD stated, Whoever discovers medication that need to be reordered must notify the pharmacy. We (facility) also have a Cubex (machine that have emergency medication stocked) that has some medication in it but can only be accessed after notifying pharmacy. During an observation and concurrent interview on 1/24/18 at 1:40 p.m. in Station Two, LN 9 found a plastic bag at the bottom of the medication cart on Station Two. The bag contained a pack of nine tablets for Resident 60. A label on the plastic bag had [MEDICATION NAME] 50 mg tablets, take one tablet daily written on it. LN 9 stated, The 8 a.m. dose was missed because it was misplaced in the medication cart. During a medication pass observation on medication cart 3 on 1/25/18 at 7:06 a.m., LN 3 stated Resident 4's [MEDICATION NAME] (medication used to treat [MEDICAL CONDITION] arthritis that has not responded to other treatments) was not in the medication cart. LN 3 proceeded to prepare Resident 4's [MEDICATION NAME] ER (extended release) (medication used to lower high blood pressure) and dispensed it into a medication cup. LN 3 entered Resident 4's room and handed Resident 4 the medication cup containing the blood pressure medication. LN 3 stated she had not taken Resident 4's blood pressure. LN 3 walked to Resident 4's bedside and was handing Resident 4 the medication cup which contained the blood pressure medication; when LN 3 was asked if she should take the blood pressure before giving Resident 4 the medication, she replied Oh .I haven't taken it. LN 3 took the medication cup back from the residents hand then proceeded to take the blood pressure on Resident 4. When asked what the result could have been if LN 3 had administered the blood pressure medication without first taking the residents blood pressure, LN 3 stated Resident 4's blood pressure could have dropped further if the blood pressure had been low. LN 3 stated she should have taken the residents blood pressure before deciding to give her the medication. The prescribed [MEDICATION NAME] was not administered. During a review of the clinical record for Resident 4's physician orders [REDACTED]. During a medication pass observation of LN 3 assigned to medication cart 3, on 1/25/18 at 7:24 a.m., there was one medication not administered as ordered by the physician for Resident 7. LN 3 stated she was not able to administer [MEDICATION NAME]. (Medication used to treat [MEDICAL CONDITION] --a condition of increased pressure within the eyeball which could cause gradual loss of sight) because the prescription label on the container was peeled off. LN 3 stopped the medication pass and went to the medication room in search of a spare eye drop medication for Resident 7. LN 3 returned to the medication cart and stated, We do not have it ([MEDICATION NAME] eye drops) available. Resident 7 did not receive the ordered eye drops for the 8 a.m. dose. During a review of the clinical record for Resident 7 titled, (MONTH) (YEAR) Physician order [REDACTED]. During a medication pass observation with LN 3, on 1/25/18 at 7:58 a.m., there was one medication not administered as ordered by the physician for Resident 3. LN 3 stated Resident 3's Jardiance F/C (a once-daily oral medication that is used to control blood glucose levels in Type II Diabetes Mellitus) was not available. LN 3 continued the medication pass without locating the medication and without administering the medication to Resident 3. During a review of the clinical record for Resident 3 the document titled, (MONTH) (YEAR) Physician order [REDACTED]. During a review of the clinical record for Resident 3 titled, Clinical Notes Report dated 1/25/18 at 9:37 p.m., indicated, Jardiance 25 mg was not given at 8 a.m., MD notified. During a medication pass observation with LN 3, on 1/25/18 at 8:20 a.m., there was one medication not administered as ordered by the physician for Resident 69. LN 3 stated she did not have Resident 69's [MEDICATION NAME] (medication to treat high blood pressure) 10 mg in the medication cart and would have to call the pharmacy and request an access code for the Cubex (medication dispenser). LN 3 stated there were only certain medications that were available in the Cubex. During an interview with the Interim Director of Nursing (IDON) on 1/25/18 at 8:50 a.m., the IDON stated, Our pharmacy is non-compliant with the medication delivery. They do not deliver within the time stipulated under Title 22 (California Code of Regulations). I have identified this problem when I started working here. (The IDON began working in the facility on 1/12/18) The IDON stated the pharmacy was to deliver a medication within 4 hours of being ordered by the physician. The IDON stated the pharmacy who supplied the facility medications was not a local pharmacy and was located several hours away from the facility. The IDON stated the pharmacy did not have contracts with local pharmacies to expedite the medication delivery. The IDON stated the nurse was to call the pharmacy and notify the physician when a medication was not available to be administered. The IDON stated the nurse was responsible to document on the residents MAR and nursing progress notes. The IDON stated the nurse was to reorder the medication at least 5 days prior to running out of the medication. The IDON stated she noticed the medication pass with three nurses was a heavy load. The IDON stated, We need four nurses on the a.m., and p.m., shift and three nurses for the N[NAME] (night) shift. It is a heavy

Based on observation, interview, and record review, the facility failed to ensure residents received care and treatment in accordance with professional standards of practice for 3 of 3 sampled residents with wound care and unresolved pain (Resident 83, 82 and 84) when: 1. Resident 83 had verbal and physical expressions of pain from a surgically debrided wound (surgical removal of dead, damaged, or infected tissue) from a Stage IV Pressure Ulcer (localized injury to the skin and and underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shearing.) Wound care had not been provided as ordered by the physician; pain management had not consistently been provided; and Resident 83 was transferred to the acute care hospital for appropriate care of the wound, infection, and pain. 2. Resident 82 and Resident 84 were not given requested pain medication before, during, or after wound care treatments were rendered. These failures resulted in Residents enduring prolonged and unrelieved pain. Findings: During an observation on 2/3/18, at 11: 47 AM, in Resident 83's room, Resident 83 was observed lying on his right side holding himself by the hospital bed side rail. At the foot of his hospital bed were three packages of black foam wound dressing, gauze and a treatment cart with multiple wound dressings on top. Resident 83 was observed grimacing (facial expression of severe pain) and anxious as the Licensed Nurse (LN 6) administered his 8 AM medication late at 11:47. Resident 83 stated to LN 6, I need something done to my wound. I can't stay like this. I don't want my wound to get worse or infected. Please, I need something done. LN 6 stated, I know. LN 6 stated Resident 83 complained of pain earlier that morning and was not given pain medication because of stomach issues. Resident 83 took his 8 AM medications (at 11:47 a.m.) then LN 6 walked out of the room without performing an assessment of Resident 83's pain. A Certified Nursing Assistant (CNA) entered the room with Resident 83's lunch tray and Resident 3 stated, I can't eat in this position and I can't go on my back because my wound is open and uncovered. I need something done about my wound. The CNA walked out of the room with the uneaten lunch meal. Resident closed his eyes and put his head against the side rail grimacing. During an interview with Resident 83, on 2/3/18, at 12 PM, he stated he was admitted to the facility on [DATE] for wound care. Resident 83 stated, The doctor (surgeon) did a great job on my wound. I don't want it to get worse and I don't want it to get infected. The nurse removed the wound dressing and the machine this morning and put some gauze in my wound and left it uncovered. I have to stay on my side because I don't want to cause any more problems on my wound. I'm in pain 8/10 (measures of pain intensity 8- Physical activity severely limited, can read and converse with effort, nausea and dizziness may occur) and afraid of my wound getting worse. It's horrible, why did they bring me here if the nurses don't know how to care for my wound? A review of the clinical record for Resident 83, the Medication Administration Record (MAR) dated 2/3/18, 8 AM, medication reconciliation (the process of reviewing the physician orders [REDACTED]. The medication order, MS ([MEDICATION NAME], a narcotic ordered for severe pain)[MEDICATION NAME] mg (milligrams) (1) tablet, extended release oral every day. The MAR indicated LN 6 had not administered the [MEDICATION NAME] pill as ordered. The MAR indicated, [MEDICATION NAME] 5-325 mg (1) tablet oral as needed for pain was signed as given. During an interview with LN 6, on 2/3/18, at 2 PM, she reviewed the MAR and confirmed the findings and stated, I don't know how I missed that. (giving the pain medication to Resident 83). The MAR dated 2/18, had no pain monitoring for Resident 83. LN 6 confirmed the lack of documented monitoring, and stated the standard was to monitor pain levels every shift and stated that was not done for Resident 83. During a review of the clinical record for Resident 83, the Minimum Data Set, (MDS) assessment (a comprehensive assessment tool used to identify physical and psychosocial abilities of the resident) dated 2/1/18, indicated under Brief Interview for Mental Status (BIMS) a score of 15 (a score of 13 to 15 cognitive intact). The MDS section J-Health conditions pain assessment was not complete. The MDS section M-Skin conditions unhealed pressure ulcers was not completed. During a review of the clinical record for Resident 83, a pain and/or wound care plan was not developed. A BRADEN scale document (assessment tool used to determine a resident's risk of developing or worsening pressure ulcer) was not completed, the document was left blank. The Weekly Pressure Injury/Ulcer Progress report (assessment tool) was not completed, the document was left blank. LN 6 confirmed the findings. During a concurrent record review and interview with Licensed Nurse (LN 8), on 2/6/18, at 11:21 a.m., she stated, It's too much for one nurse to do.pain assessments are left out. During an interview with LN 11, on 2/6/18, at 9:32 a.m., LN 11 reviewed the clinical record and was unable to find a pain assessment, a wound assessment, pain or wound care plan. LN 11 stated, The MDS is not complete. LN 11 stated Resident 83 did not receive assessments for his admission healthcare needs. Review of Resident 83's GACH clinical record titled, Progress Notes dated 2/5/18 indicated, Assessment and Plan .BIBA (brought in by ambulance) from SNF (skilled nursing facility) for a sacral wound that patient says is not being taken care of at the nursing home .Not currently taking any antibiotics .Patient (Resident 83) stated for last 2 to 3 days there is worsening drainage and foul smelling odor from wound .Decubitus ulcer (pressure ulcer) of coccygeal (tailbone) region, stage 4 with infection. Plan: IV [MEDICATION NAME] (an antibiotic) and [MEDICATION NAME] (an antibiotic) .wound consult placed, surgery (MD) consulted .will likely need wound vac once infection clearing and healing and also plastic surgery referral . 2. During an observation on 2/4/18, at 11:34 AM, Resident 82 was laying on her bed turned to her right side, LN 6 informed Resident 82 she was ready to perform the treatment for [REDACTED]. LN 6 asked the CNA 1 to hold Resident 82 onto her right side and then exposed Resident 82's bottom. A wound was observed to the left buttocks and another wound on the right buttocks. LN 6 began to clean a white ointment from both wounds using warm soapy water. LN 6 stated the treatment read zinc oxide to left stage II pressure sore. Resident 82 was observed grimacing and stated, Ouch it hurts, it hurts, it hurts. Resident 82 verbalized pain ten times during the wound treatment and LN 6 continued the treatment without offering pain relief medication. LN 6 applied zinc oxide ointment to both left and right stage II wounds. Resident 82 stated, Can you cover it (wound) with something? Every time they (staff) move me, change me it (wound) really hurts. LN 6 did not ask Resident 82 about pain intensity, duration, or any other assessment questions. LN 6 finished the treatment dressing and CNA 1 repositioned Resident 82 in her bed. Resident 82 stated to LN 6 Can I have something for pain? LN 6 stated I will tell your nurse. LN 6 did not perform a pain assessment or give the resident pain medication. LN 6 stated, We don't have a treatment (order for the stage II pressure ulcer for the right buttocks). LN 6 continued with her treatments and did not notify the medication nurse of Resident 82's pain medication request. During an interview with Resident 82, on 2/4/18, at 11:47 AM, she stated Resident 82 stated, I have pain 8/10 (measures of pain intensity 8- Physical activity severely limited. Able to read and converse with effort. Nausea and dizziness may occur.) I have had the two sores for over two months . Resident 82 stated she stays on her side the majority of the time in an attempt to heal the wounds and because of the pain. She stated, I started with one wound now I have two. I don't want more. The nurses come once or twice a week and put something on my sores. But most of the time no one does anything for them, that's why they don't heal. It's horrible you can't get anyone to help you. I have to stay in bed. I can't get up or do anything because of the pain (to pressure ulcers). During an interview with LN 6, on 2/6/18, at 8:06 AM, LN 6 was asked about the pain medication requested by Resident 82 on 2/4/18, at 11:34 AM. LN 6 reviewed the clinical record and was unable to find documentation of pain medication administration for resident 82. LN 6 stated, Oh, I got busy and forgot. During a concurrent record review and interview with Licensed Nurse (LN 8), on 2/6/18, at 11:21 a.m., she stated It's too much for one nurse to do.pain assessments are left out. During an observation on 2/6/18, at 2:54 PM, Resident 82 was on her bed lying on her right side. LN 15 informed Resident she was getting ready to perform the wound treatment to both stage II wounds. LN 15 stated, (Resident 82) are you in pain? LN 15 told Resident 82 she was getting ready to do the wound treatment. Resident 82 stated, Yes, I'm always in pain. LN 15 stated, Do you want something for pain before we start, or would you be okay without it? Resident stated, Oh yes that would be good (have pain medication). Resident 82 requested to be pre-medicated with something for pain. LN 15 stated, Do you think we can try to do the treatment and see how you do? Resident 82 quietly stated, Oh, okay we can try. LN 15 began the treatment procedure with Resident 82 making verbal expressions of pain It hurts, it hurts. Resident 82 was observed grimacing during the treatment procedure. LN 15 stated I know, this looks like it hurts. I'm sorry. Resident 82 stated, Please can you cover it. The sheets, every touch hurts it (wounds). I can't be on my back because it makes it hurt more. I'm in pain all the time 7/10 (pain scale of 7- difficulty in concentration, interferes with sleep, Resident can still function with effort). Resident asked, Did you cover it? LN 15 stated yes. Resident 82 stated, Oh, thank God. I have been suffering for over two months with this. LN 15 stated, I will tell your nurse that you need a pain pill. LN 15 left Resident 82's room, did not inform the medication nurse Resident 82 was requesting a pain medication and continued with her treatments. During an interview with Certified Nursing Assistant (CNA) 1, on 2/6/18, at 9:05 AM, CNA 2 stated she (Resident 82) has had those wounds on her bottom for a long time. But they are getting worse. They are bigger and she has pain when we clean her or move her. She will ask us to not touch or press on that area because she says she hurts. We offer to get her up and she refuses. She hurts. During an interview with LN 15, on 2/6/18, at 4:30 PM, LN 15 was asked about the pain medication requested by Resident 82 on 2/6/18, at 2:54 PM. LN 15 reviewed the clinical record and was unable to find documentation of pain medication administration for resident 82. LN 15 stated, I got busy and forgot to tell the nurse. This Tylenol is not going to take care of the pain expressed. It's like throwing skittles (candy) at the pain. During a review of the clinical record for Resident 82, the MAR dated 2/18, indicated, Tylenol 325 mg (2 tabs) totaling 650 (milligrams) mg oral every 4 hours for pain in left hip. The MAR indicated Resident 82 had not received the pain medication Tylenol for the month of February. During a concurrent interview and record review on 2/6/18, at 4:30 p.m., Resident 84's Physician order [REDACTED]. No other pain medication orders were documented. LN 15 confirmed these facts. The MAR dated 2/18, had no pain monitoring documented for Resident 84. LN 15 confirmed the findings and stated the standard is to monitor pain levels every shift and that was not done for Resident 82. During an interview with CNA 3, on 2/5/18, at 3:10 PM, CNA 3 stated Resident 82's stage II wounds (on right and left buttocks) were open. She stated Resident 82 required extensive assistance with all care needs and was unable to transfer and reposition self. During an observation of wound care on 2/6/18, at 10:52 AM, Resident 84 was assisted onto his bed to perform the wound care to his stage III pressure ulcer. LN 15 began the wound treatment and Resident 84 stated It hurts, it hurts all the time and I'm not a cry baby. Resident 84 made statements of complaints of pain eight times during the care. LN 15 stated Where. Resident 84 placed his hand on his bottom. LN 15 stated do you want me to tell your nurse that you want something for pain. Resident 84 stated Yes, it hurts, it hurts. Resident noted grimacing during treatment procedure. LN 15 stated I will tell your nurse. LN 15 completed the wound treatment and walked out of the room. LN 15 continued with her wound treatments and did not notify the medication nurse of Resident 84's pain medication request. During an interview with Resident 82, on 2/5/18, at 3:20 PM, Resident 84 stated, I have a sore and I don't know how I got it. During an interview with LN 15, on 2/5/18, at 3:50 PM, she stated Resident 82's wound was open and the treatment order was no longer appropriate. She stated The wound is a stage III (pressure ulcer). During an interview with the LN 11, on 2/6/18, at 9:32 a.m., she reviewed the clinical record and was unable to find a pain assessment and pain or wound care plan. She provided no additional information. During a concurrent record review and interview with Licensed Nurse (LN 8), on 2/6/18, at 11:21 a.m., she stated It's too much for one nurse to do.pain assessments are left out. During an interview with LN 15, on 2/6/18, at 4:30 PM, she was asked about the pain medication requested by Resident 84, at 10:52 AM. LN 6 reviewed the clinical record and was unable to find documentation of pain medication administration for Resident 84. LN 15 stated I got busy and forgot to tell the nurse. This Tylenol is not going to take care of the pain expressed. It's like throwing skittles (candy) at the pain. During a review of the clinical record for Resident 84, the Physician order [REDACTED]. An ointment for the skin used to treat diaper rash, minor burns, severely chapped skin, or other minor skin irritations) to peri (around) wound, apply (that removes dead tissue from wounds so they can start to heal ) to wound bed and cover with foam. The Physician order [REDACTED]. During a concurrent interview and record review, Resident 84's MAR dated 2/18, indicated Resident 84 had not received medication for pain, Tylenol 500 mg for the month of February. The MAR had no pain monitoring for Resident 84. LN 15 confirmed these findings and stated the standard was to monitor pain levels every shift and LN 15 verified that was not done for Resident 84. During a review of the clinical record for Resident 84's MDS assessment dated [DATE], indicated under the section, Brief Interview for Mental Status (BIMS) a score of 3 (a score of 0-7: severely cognitive impaired). During a concurrent interview with LN 6 and record review for Resident 84, on 2/4/18, at 10:50 a.m. LN 6 reviewed the clinical record and was unable to find documentation of a pain and/or wound care plan, she stated one was not developed. A BRADEN scale (assessment tool used to determine a resident's risk of developing or worsening pressure ulcer) dated 1/31/18, indicated a score of 17 (total score of 12 or less represents high risk). The MDS dated [DATE], section G, indicated Resident 84 required extensive bed mobility assistance with one person assist needed and extensive assistance with transfers required. LN 6 stated the Braden scale was completed incorrectly and did not reflect Resident 84's condition accurately. The MDS dated [DATE], section, M-Skin conditions indicated unhealed pressure ulcers coded as a 1. The Weekly Pressure Injury/Ulcer Progress report dated 1/31/18, indicated, Unstageable pressure ulcer. The treatment record indicated Resident 84 did not receive wound treatments to his pressure ulcer on 2/2/18, 2/3/18 and 2/4/18. LN 6 confirmed the findings and stated the facility had no treatment nurse to perform the wound treatments. The facility policy and procedure titled, Pain Management dated 11/16, indicated, Facility staff will help the resident attain or maintain their highest level of well-being while working to prevent or manage the resident's pain. A licensed Nurse will assess each resident for pain when there is pain, exacerbation of pain. The Licensed Nurse will complete a Pain assessment for resident identified as having pain . The Licensed Nurse will assess the resident's pain based on non-verbal cues. (Examples grimacing, restless, not eating). The nurse will advise the Attending Physician, so the Attending physician can consider ordering pain medication to alleviate symptoms. The Licensed Nurse will administer pain medication as ordered and document medication administered on the MAR. The Licensed Nurse will assess the resident for pain and document results on the MAR each shift using the 0-10 pain scale . The shift pain score will indicate the highest pain level that occurred on that shift. Nursing staff will implement timely interventions to reduce an increase in severity of pain.

Based on interview and record review, the facility failed to ensure 2 of 3 sampled Residents (Resident 83, Resident 82) who had wound care orders, received the necessary treatment and services to promote healing, prevent infection and prevent new ulcers from developing when: 1. Resident 83 did not have care and treatment of [REDACTED]. Resident 83's [DEVICE] was not working properly, and Licensed Staff were not trained on the equipment. Resident 83 was transferred to the acute care hospital for proper application of a [DEVICE] to treat the Stage IV pressure ulcer, and infection of the wound; including new antibiotic therapy. 2. Resident 82 developed a second pressure ulcer of the right buttocks which was not identified and treated timely. This failure resulted in a potential worsening of the second pressure ulcer and pain with potential infection for Resident 82. Findings: 1. During an observation in Resident 83's room on 2/3/18, at 11: 47 a.m., Resident 83 was observed lying on his right side holding himself by the bed rail. At the foot of his bed were three packages of black foam wound dressing, gauze and a treatment cart with multiple wound dressings sitting on top of the cart. Resident 83 was observed grimacing (facial expression of severe pain) and anxious and jittery as the licensed nurse administered his medication scheduled for 8 a.m., at 11:47 a.m. for treatment of [REDACTED]. Resident 83 stated to Licensed Nurse (LN) 6, I need something done to my wound. I can't stay like this. I don't want my wound to get worse or infected. Please, I need something done. LN 6 stated, I know. LN stated to Resident 83, Take your pills. The medications administered at 11:47 a.m. did not included a pain pill. Once Resident 83 took his 8 a.m. medications LN 6 walked out of the room. LN 6 had not answered Resident 83's question regarding what would happen next regarding the wound care. A Certified Nursing Assistant (CNA) entered the room with Resident 83's lunch tray and Resident 3 stated, I can't eat in this position and I can't go on my back because my wound is open and uncovered. I need something done about my wound. The CNA walked out of the room with the uneaten lunch meal. Resident closed his eyes and put his head against the side rail grimacing. During an interview with Resident 83, on 2/3/18, at 12 p.m., the resident stated he was admitted to the facility on [DATE] for wound care. Resident 83 stated, The doctor (surgeon) did a great job on my wound. I don't want it to get worse and I don't want it to get infected. The nurse removed the wound dressing and the machine ([DEVICE]) this morning and put some gauze in my wound and left it uncovered. I have to stay on my side because I don't want to cause any more problems on my wound. From the first day I came here the nurses keep saying they don't know how to do the wound care. One nurse will come and do the treatment and in a few hours or by the next shift a nurse will come and say the machine (NPWT) is not working and they remove the wound bandages and leave it with nothing on. It's horrible, why did they bring me here if the nurses don't know how to care for my wound. During an interview with Family Member (FM) 1, on 2/3/18, at 12 p.m., FM 1 stated the nurses would tell her and Resident 83 they don't have the treatment supplies for the wound and they don't know how to perform the treatment. FM 1 stated she did not understand why the facility accepted Resident 83 if the staff did not know how to care for his needs. During a concurrent interview and observation of the treatment cart supplies, on 2/3/18, at 12:28 p.m. with LN (6), LN 6 stated, At around 10 a.m., I noticed the wound vac (NPWT) was not working properly. I checked it and noticed the suction tubing was placed on the healthy skin area and not on the wound. The wound had a tan colored soaked wound dressing. LN (6) stated she removed the wound vac and the dressing and packed the wound with a wet- to- dry dressing (a moist saline gauze dressing is put in the wound and allowed to dry.) LN 6 stated that's what he has on the wound at this time. I have not called the doctor because I have been busy with my medication pass. She reviewed the wound supplies in the treatment cart and stated, We do not have the wound supplies to perform the wound care. I don't know why they (Facility) accepted (Resident 83) when we (Licensed Nurses) don't know how to perform the wound vac treatment. LN 6 stated she had not been trained on how to perform a wound treatment using the [DEVICE]. LN 6 stated, I don't know what I'm doing with that (NPWT). During an interview with LN 6, on 2/3/18, at 12:50 p.m., LN 6 stated Resident 83 was being sent to the hospital because the facility did not have wound supplies and trained staff to perform the wound treatment. Resident was transferred to the hospital by ambulance at 12:50 p.m. on 2/3/18 (Nine days after the resident was admitted to the facility for treatment of [REDACTED]. During a review of the clinical record for Resident 83, the Face Sheet (Resident 83 Demographics) indicated Resident 83 was admitted to the facility on [DATE]. Review of Resident 83's Minimum Data Set, (MDS) assessment -(a comprehensive assessment tool used to identify physical and psychosocial abilities of the resident), dated, 2/1/18, indicated under Brief Interview for Mental Status (BIMS) a score of 15 (a score of 13 to 15 means no cognitive impairment in memory or judgement). Review of the hospital transfer form dated 1/25/18, indicated, Reason for placement: Wound care . LUQ (left upper quadrant) [MEDICAL CONDITION], abdominal; incision, st. (stage) 4 perianal (area around the anus) full thickness wound. Review of Resident 83's physicians order dated 1/25/18, indicated, apply nickel-thick [MEDICATION NAME] santyl ointment (is a sterile enzymatic [MEDICATION NAME] ointment) to the devitalized (weakened) necrotic (dead) tissue and wound bed. Apply white versa foam (dressing used to help promote graft take, for tunnels and undermining, while protecting delicate tissue) to the wound base and undermining (is deep tissue (subcutaneous fat and muscle) damage around the wound margin) covered by black [MEDICATION NAME] (a wound dressing that promotes wound healing) NPWT-125 mm hg (millimeter of mercury is a manometric unit of pressure) low intensity continues suction. Change on Monday, Wednesday and Friday. The treatment record indicated the treatment was completed on Monday 1/29/18, Tuesday 1/30/18, and Wednesday 1/31/18 with no documented reason why the physicians order was not followed. A second order indicated, Monitor (17) stitches for signs and symptoms of infection (mid lower abdomen) by shift starting 1/25/18. The document contained information the monitoring was not conducted for nine of 19 shifts from 1/25/18 to 2/3/18. During an interview and concurrent record review with LN 6, on 2/3/17, at 2:07 p.m., LN 6 reviewed Resident 83's clinical record. LN 6 was unable to find documentation of a wound assessment and a documented Braden skin risk assessment for Resident 83. She stated the Braden (a scale for Predicting Pressure Ulcer Risk, is a tool to identify the risk for a resident's development of a pressure ulcer) assessment was not completed and it should have been completed on assessment and the weekly skin assessments were completed weekly and none were completed for Resident 83. During a review of the clinical record for Resident 1, the Clinical Notes Report dated 1/25/18, at 9:13 p.m., indicated, Resident admitted . Resident (83) alert and oriented X3, able to make needs know(n) .has Dx (diagnosis) of perirectal [MEDICAL CONDITION] . [MEDICAL CONDITION] pouch intact, 17 stitches to lower mid abdomen . Resident (83) has wound vac (NPWT) to peri-anal . wound vac working well . The Clinical Notes Report dated 1/29/18, indicated, Order calls for versa type foam to wound bed and tunneling. None available at this time. MD (medical doctor) stated was okay to still change wound vac dressing at previously ordered intervals (Monday, Wednesdays, and Fridays) using black foam only until versa foam is available. The Clinical Notes Report dated 2/2/18, indicated, Resident 83 returned from wound clinic (with) n.o. (new order) on wed (Wednesday) 1/31/18 n.o. to begin today . Q (every) Monday and Every Friday. The Treatment Administration Record dated 2/1/18, indicated Resident 83 had not received the prescribed treatments on 2/2/18 as prescribed by the physician. During an interview with LN (6), on 2/3/18, at 12:17 p.m., she stated, I noticed the wound vac wasn't suctioning, so we removed it . and put a wet-to-dry gauze. LN 6 stated she removed the prescribed treatment and changed it without calling for a doctor's order. She stated, I don't know why they admitted him (Resident 83). We don't know how to do the dressing. At least I have never done one. We haven't received training on the wound vac and we don't have nurses that know how to do that (NPWT). During an interview with LN 10, on 2/3/18, at 3:30 p.m., No sorry she stated, I was never trained on that (NPWT), so I would not know how to do the treatment. During an interview with LN 3, on 2/3/18, at 3:39 PM, she stated, I have never been trained and I am not comfortable doing the (NPWT) dressing change. During an interview with the Proctor (P 3) she reviewed the education training records and stated, We do not have where the licensed nurses were educated on how to perform the (NPWT) treatment. During an interview with the Director of Nurses (DON), on 2/4/18, at 12:43 p.m., she stated the facility had not educated the LNs on how to perform the NPWT treatment. Review of Resident 83's medical record from the acute care hospital titled, History and Physical (H&P) dated 2/3/18, indicated, Patient (Resident 83) Presents with wound infection. The H&P indicated Resident 83 was started on two antibiotics to treat the perirectal Stage IV wound infection of the sacrum. 2. During a concurrent observation and interview with Licensed Nurse (LN 6), on 2/4/18, at 11:34 a.m., Resident 82 was laying on her bed turned to her right side. There was no pressure relieving device observed on the bed. LN 6 informed Resident 82 she was ready to perform the treatment to the pressure ulcer on the left buttock. LN 6 asked CNA 1 to hold Resident 82 onto her right side, and the residents bottom was then exposed. A wound was observed on the left side of Resident 82's bottom, and a second wound on the right side of her bottom. LN 6 began to clean a white ointment from both wounds using warm soapy water. LN 6 stated the treatment order on the indicated the treatment was to apply zinc oxide to the left (buttock) stage II pressure sore. She stated she would stage Resident 82's right buttocks wound as a stage II. LN 6 stated Resident 82 did not have a treatment order for the stage II wound to the right buttocks. LN 6 measured both wounds and stated, The left buttocks stage II measures 4 cm (centimeter) X (by) 2 cm and the right stage II measures 2 cm X 2 cm. LN 6 stated she would apply zinc oxide to the right buttocks pressure ulcer and to the left pressure ulcer. LN 6 stated she would call the doctor when I get a chance, I will call the doctor to inform him of the new wound to the right buttocks. LN 6 applied zinc oxide to the new pressure ulcer without a physician order. LN 6 stated she did not know when the right buttocks wound had developed. LN 6 further stated the facility did not have a treatment nurse and treatments and wound assessments were not being performed. During an interview with Resident 82, on 2/4/18, at 11:47 a.m., she stated, I have had the two sores for over two months . Resident 82 stated she stayed positioned on her side the majority of the time in an attempt to heal the wounds and because of the pain. She stated, I started with one wound now I have two. I don't want more. The nurses come once or twice a week and put something on my sores. But most of the time no one does anything for them, that's why they don't heal. It's horrible you can't get anyone to help you. I have to stay in bed. I can't get up or do anything because of the pain (of the pressure ulcer). During an interview with Certified Nursing Assistant (CNA) 2, on 2/6/18, at 9:05 a.m., CNA 2 stated, She (Resident 82) has had those wounds on her bottom for a long time. But they are getting worse. They are bigger and she has pain when we clean her or move her. She will ask us to not touch or press on that area because she says she hurts. We offer to get her up and she refuses. She hurts. During a review of the clinical record for Resident 82, the Clinical Notes Report dated 1/24/18, at 11:14 p.m. indicated, Writer was notified by CNA that Resident (82) has open area. Upon assessment Resident has pressure ulcer stage 2 to left butt. MD was notified and writer received order to cleanse with warm soap and water and apply zinc oxide BID (twice a day). Review of Resident 82's Minimum Data Set (MDS) assessment dated [DATE] indicated, the Brief Interview for Mental Status (BIMS) score was 13 (on a scale of 0-15 with 15 indicating no cognitive memory deficit). The section under, Functional Status Section G indicated Resident 82 required extensive assistance, one person assistance with bed mobility, transfers, moving to and from areas, dressing, toilet use, personal hygiene, and bathing. Section G, 0400, indicated Resident 82 had a functional limitation in Range of Motion to her upper and lower extremities, and uses a wheelchair for mobility. Section H0300/ H0400, indicated under urinary, Always incontinent and frequently incontinent of bowel. Section M0300 under skin conditions indicated the current number of unhealed Pressure ulcers as 2 present since 11/2/17. The facility weekly skin breakdown report dated 11/22/17, indicated, Stage II pressure ulcer healed to left and right buttocks. The Treatment Record dated 2/1/18 indicated Pressure Ulcer- (stage II Left Buttocks) cleanse left buttocks wound with warm soapy water, pat dry apply thin layer of zinc oxide 20% ointment twice a day and PRN (as needed) for incontinence episodes for 14 days then re-evaluate. The Treatment Record for 2/1/18, 2/2/18 and 2/3/18 contained no nurse signatures, indicated the treatment to the left buttocks stage II was not completed on 2/1/18, 2/2/18 and 2/3/18. There were no nurse initials or entries documented for these dates. LN 6 confirmed these findings and stated, The treatment was not done. LN 6 reviewed the clinical record and was unable to find documentation of the wound on the record of the right buttocks wound. LN 6 stated someone had to know about the right buttocks wound and no one notified the physician the wound was left untreated. During an interview with LN 6 on 2/3/18, at 11: 47 a.m., LN 6 confirmed the treatment record for Resident 82 was missing documentation of monitoring for nine shifts and stated, The treatment was not done. During an interview with LN 6, on 2/4/18, at 11:42 a.m., she reviewed the clinical record and was unable to find documentation of the weekly pressure ulcer reports (assessments) and Braden Risk Scale (skin breakdown assessment) document for Resident 82. LN 6 stated a weekly pressure ulcer report and a Braden Risk Scale assessment was not completed. The facility policy and procedure titled, Pressure Injury Prevention dated 8/12/16 indicated, To provide interventions for residents identified as high risk for developing pressure injuries. I. A risk assessment (Braden Scale) for developing pressure injuries will be completed upon admission and weekly for four weeks after admission, quarterly and when there is a significant change in condition. The facility policy and procedure titled, Pressure injury and Skin Integrity Treatment dated 8/12/16, indicated, To provide guidelines for the treatment of [REDACTED]. Treatments to pressure injuries and other skin integrity problems will be proven as ordered by the physician . A licensed Nurse will initiate a Pressure Report (SK- 02- form A) when a resident is admitted with a pressure injury or if a pressure injury develops. A licensed Nurse will initiate a Skin Ulcer Progress Report when a resident is admitted with . skin ulcer. A Skin integrity Progress Report will be initiated when a resident is admitted with or develops a skin problem such as . surgical wound. The Pressure Injury Progress Report, Skin Ulcer Progress Report or Skin Problem Progress Report will be updated weekly by the Licensed Nurse. Treatments to pressure injuries or other skin integrity problem will be ordered by the physician. The physician and family will be notified when there is a change in the condition of the pressure injury or skin integrity problem in order to insure that treatments and interventions are appropriate. Treatments administered will be documented on the Treatment Administration Record.

Based on observation, interview and record review, the facility failed to provide sufficient Licensed Nursing (LN) staff with specific competencies required for one of 87 sampled residents, Resident 83, when LN staff was not trained how to care for Resident 83's physician ordered Negative Pressure Wound Treatment (NPWT, a specialized wound treatment system that utilizes negative pressure and a pump device to promote wound healing of severe wounds). This failure resulted in delayed wound healing, infection of the wound bed, pain, stress and anxiety for Resident 83, when physician ordered treatment of [REDACTED]. Findings: Resident 83's clinical record titled, Face Sheet (Resident 83 Demographics) indicated Resident 83 was [AGE] years old and was admitted to the facility on [DATE]. Resident 83's clinical record titled, Physician order [REDACTED]. Resident 83's transfer form from the GACH to the Skilled Nursing Facility (SNF) dated 1/25/18, indicated Reason for placement: wound care . st. (stage) 4 (wound extends through the skin, through the muscle, down to the bone) perianal (area around the anus) full thickness wound. Review of Resident 83's clinical record titled, Clinical Notes Report dated 1/25/18, at 9:13 p.m., indicated Resident (Resident 83) admitted .Resident alert and oriented X 3 (knows who he is, where he is and what time it is), able to make needs known .Resident has wound vac (NPWT) .wound vac working well . Resident 83's clinical record titled, Minimum Data Set, (MDS, a resident assessment tool), dated 2/1/18, indicated under Brief Interview for Mental Status (BIMS) a score of 15 out of a possible 15 points which indicated Resident 83 was cognitively intact (memory and reasoning ability was intact). On 2/3/18, at 11: 47 a.m., during an observation and concurrent interview in Resident 83's room, Resident 83 was lying on his right side, holding himself off his backside by grabbing onto the hospital bedside rail. At the foot of his hospital bed were three packages of black foam wound dressing, gauze and a treatment cart with multiple wound dressings on top of the cart. Resident 83 was observed grimacing (facial expression of severe pain) and stated he was worried about his wound dressing as LN 6 administered his 8 a.m. medications(over three hours after the medications were due). Resident 83 stated to LN 6, I need something done to my wound. I can't stay like this. I don't want my wound to get worse or infected. Please, I need something done. LN 6 stated, I know. LN 6 stated Resident 83 had requested pain medication. Once Resident 83 took his 8 a.m. medications LN 6 walked out of the room without providing Resident 83 an explanation of what was going to happen with his open wound. At that time a Certified Nursing Assistant (CNA) entered the room with Resident 83's lunch tray and Resident 3 stated I can't eat in this position and I can't go on my back because my wound is open and uncovered. I need something done about my wound. The CNA walked out of the room with the uneaten lunch meal. Resident 83 closed his eyes and put his head against the side rail grimacing. On 2/3/18, at 12 p.m., during a concurrent interview with Resident 83 and Resident 83's Family Member (FM) 1, Resident 83 stated he was admitted to the facility on [DATE] for wound care. Resident 83 stated The doctor (surgeon) did a great job on my wound. I don't want it to get worse and I don't want it to get infected. The nurse removed the wound dressing and the machine this morning and put some gauze in my wound and left it uncovered. I have to stay on my side because I don't want to cause any more problems on my wound. From the first day I came here the nurses keep saying they don't know how to do the wound care. One nurse will come and do the treatment and in a few hours or by the next shift a nurse will come and say the machine (NPWT) is not working and they remove the wound bandages and leave it with nothing on. It's horrible. Why did they bring me here if the nurses don't know how to care for my wound? FM 1 stated the nurses tell her and Resident 83 they don't have the treatment supplies for the wound and they don't know how to perform the treatment. FM 1 stated she did not understand why the facility accepted Resident 83 if the staff did not know how to care for his needs. On 2/3/18 at 12:17 p.m. during an interview, LN 6 stated, At around 10 a.m., I noticed the wound vac (NPWT) was not working properly. I checked it and noticed the suction tubing was placed on the healthy skin area and not on the wound and the wound had a tan colored soaked wound dressing. LN 6 stated, I removed the wound vac (NPWT), the dressing, and packed the wound with a wet to dry dressing (saline soaked gauze covered with a dry dressing) and that's what he has on the wound at this time. I have not called the doctor because I have been busy with my medication pass. LN 6 reviewed the wound supplies in the treatment cart and stated, We do not have the wound supplies to perform the wound care. I don't know why they (Facility) accepted (Resident 83) when we (Licensed Nurses) don't know how to perform the wound vac (NPWT) treatment. I have never been educated on how to perform a wound treatment like that. I don't know what I'm doing with that (NPWT). We haven't received training on the wound vac and we don't have nurses that know how to do that (provide care for a resident with a NPTW). Resident 83's physicians order dated 1/25/18, indicated Apply nickel-thick [MEDICATION NAME] santyl ointment (is a sterile enzymatic [MEDICATION NAME] ointment) to the devitalized (poor blood flow) necrotic (dead) tissue and wound bed. Apply white versa foam (dressing used to promote tissue growth) to the wound base and undermining (deep tissue damage around the wound margin) covered by black [MEDICATION NAME] (a wound dressing that promotes wound healing) NPWT-125 mmhg (millimeter of mercury - a measurement of pressure) low intensity continuous suction. Change on Monday, Wednesday and Friday. Resident 83's treatment record indicated the treatment was completed on Monday 1/29/18, Tuesday 1/30/18, and Wednesday 1/31/18 with no documented reason why the physicians order was not followed. Resident 83's clinical record titled, Treatment Record dated (MONTH) (YEAR) indicated Resident 83's NPWT dressing change was scheduled for Friday 2/2/18. The Treatment Record was not initialed by the LN for 2/2/18 which indicated the wound treatment was not completed on 2/2/18 by the LN. On 2/3/17, at 2:07 p.m., during a concurrent interview and record record, LN 6 reviewed Resident 83's clinical record and was unable to find documentation of wound assessment and Braden (a scale for predicting a resident's risk for developing pressure ulcers) skin risk assessments. LN 6 stated the Braden skin risk assessment was not completed and it should have been completed by a LN on admission and the weekly skin assessments should be completed weekly and none were completed for Resident 83. Review of Resident 83's Clinical Notes Report dated 2/3/18 at 2:07 p.m. indicated, Upon Med pass resident (Resident 83) wound vac was not draining, wound vac dressing was removed and covered with clean wet to dry dressing. MD was made aware and gave orders to transfer resident out to acute hospital for wound management. The Clinical Notes Report entry was electronically signed by LN 6. Review of Resident 83's Physician order [REDACTED]. Review of Resident 83's GACH clinical record titled, ED (Emergency Department) Provider Notes dated 2/3/18 at 2:39 p.m., indicated, Discussion: Large sacral wound not getting proper wound care. Concerned for infection. Elevated [MEDICAL CONDITION] markers (laboratory results that indicate infection and inflammation). Will need IV (intravenous, medication is injected into a vein) abx (antibiotics) and will consult surgery. On 2/3/18 at 3:30 p.m., during an interview, LN 10 stated, I was never trained on that (NPWT), so I would not know how to do the treatment. On 2/3/18 at 3:39 p.m., during an interview, LN 3 stated, I have never been trained and I am not comfortable doing the (NPWT for Resident 83) dressing change. On 2/3/18 at 5:50 p.m., during an interview, Proctor (P) 4 reviewed the facility LN education records and stated, We do not have where the licensed nurses were educated on how to perform the (NPWT) treatment. P 4 stated he was unable to find any in-service training records that indicated LNs were trained to provide care to residents with a NPWT system. On 2/4/18 at 12:43 p.m., during an interview, the Director of Nurses (DON) stated the facility did not educate the LNs on how to perform the wound care using the NPWT system. Review of Resident 83's GACH clinical record titled, Progress Notes dated 2/5/18 indicated, Assessment and Plan .BIBA (brought in by ambulance) from SNF (skilled nursing facility) for a sacral wound that patient says is not being taken care of at the nursing home .Not currently taking any antibiotics .Patient (Resident 83) stated for last 2 to 3 days there is worsening drainage and foul smelling odor from wound .Decubitus ulcer (pressure ulcer) of coccygeal (tailbone) region, stage 4 with infection. Plan: IV [MEDICATION NAME] (an antibiotic) and [MEDICATION NAME] (an antibiotic) .wound consult placed, surgery (MD) consulted .will likely need wound vac once infection clearing and healing and also plastic surgery referral .

Based on observation, resident/staff interviews, and clinical record and administrative document review, the facility failed to prevent the formation of a pressure sore for one of eighteen sampled residents and one random resident (Resident 9). Resident 9 acquired two pressure sores (partial skin loss due to a pressure ulcer) located on her buttocks during her stay at the facility. This failure resulted in not implementing necessary interventions to prevent pressure sores and led to avoidable wound care to heal skin breakdown for Resident 9. Findings: Resident 9's clinical record indicated she was re-admitted on [DATE] with [DIAGNOSES REDACTED]. The facility document titled, Minimum Data Set ((MDS) a comprehensive assessment used for screening, clinical and functional status elements for nursing home residents) dated 8/20/15 indicated Resident 9 had a BIMS (Brief Interview for Mental Status is a test given by medical professionals to determine cognitive understanding on a scale of 1-15 with 15 being the highest score) of 15. Section H of the MDS indicated Resident 9 scored a 2/2 for bowel and bladder indicating she was incontinent (inability to control function of urination or defecation). Section M for pressure sores indicated 0 meaning Resident 9 had no pressure sores present on admission. On 9/22/15 at 2:30 p.m., during an interview and concurrent observation, Resident 9 stated she had a pressure sore on her bottom (referring to her buttocks). Resident 9 stated four to five hours went by before someone came to turn her. When asked about how she measured the time interval, Resident 9 stated she looked at the clock on the wall in front of her. The clock was observed on the wall in front of her and Resident 9 was observed to tell the correct time. On 9/22/15 at 2:40 p.m., Certified Nursing Assistant (CNA) 4 was observed repositioning Resident 9. During a concurrent interview after the observation, CNA 4 stated Resident 9 could assist with turning in bed but she was is a two person assist. CNA 4 stated Resident 9 had a pressure sore on her coccyx (tailbone). CNA 4 stated the pressure sore was reported to the nurse. On 9/23/15 at 3 p.m., during an interview Licensed Nurse (LN) 1 stated normally Resident 18 turned herself and she was able to verbalize her needs. LN 1 stated, She is on a turning schedule now since the pressure sores but she wasn't before. When asked if the pressure sore was avoidable, LN 1 responded, Yes, the pressure sore was avoidable . We could have done a better job. On 9/23/15 at 3/15 p.m., during an observation and concurrent interview in Resident 9's room, she was observed to be turned on her left side. During the observation it was pointed out to LN that Resident 9's upper body was turned to her left side but her bottom was lying flat on the bed. There was about a foot in length measurement on each side of Resident 9 between her arms and upper rails. Resident 9 was asked to describe where she felt the weight of her shoulders and she replied it was on her left side. Resident was asked where she felt the weight of her lower body and she replied it was on her bottom. LN 1 confirmed the observation and stated she could she how her upper body was turned but her bottom was flat on her back. LN 1 stated that's because most of her weight is in the middle; she needed a bigger bed. On 9/25/15 at 10:30 a.m., during an observation of Resident 9's dressing change to the coccyx area, a nickel size, reddened area and sore to the left inner fold and a smaller reddened sore to the right buttock inner fold. On 9/25/15 at 2 p.m., during an interview the Director on Nurses (DON) stated she went in to look at the pressure sores and they were circular. The DON stated, It looked like it was moisture related . When asked what do you think caused the pressure sore, the DON replied, If she has been laying in one place too long. On 9/25/15 at 3 p.m., during an interview with the Administrator regarding Resident 9's pressure sore, the Administrator stated if Resident 9 needed a bigger bed then they would get her a bigger bed. Review of clinical record titled, Skin Breakdown Report dated 9/24/15, indicated, Date of onset: 9/22/15, Occurrence: Acquired, Site: Left Buttock, Stage 2, Size: Length = 1.9 centimeter (cm) Width = 2.3 cm, Depth = 0.1 cm and another pressure sore noted on the same date on the right buttock measuring: Length = 1.5 centimeter (cm) Width = 1.5 cm, Depth = 0.1 cm. Review of clinical record titled, SBAR/COC (Situation-Background-Assessment-Recommendation/Change of Condition - a written tool to document a change of condition) Assessment dated 9/23/15 indicated, The resident has a Stage II pressure sore to right and left inner buttocks. Things that make the condition or symptoms worse: unrelieved pressure, moisture incontinence. Things that make the condition or symptom better: Keep site clean and dry, turning and repositioning every 2 hours and as needed. Location of pain: Bilateral Inner Buttock. Cause of pain: Pressure sore, Frequency: Intermittent. Treatment: [MEDICATION NAME] dressing every 3 days and as needed for dislodgement. Review of clinical record titled, Care Plan Report dated 8/24/15 indicated, Problem: (Resident 9) at risk of pressure ulcer secondary to impaired mobility, obesity, frequent B&B (Bowel and Bladder) incontinence and Diabetes. Interventions: turn and reposition every 2 hours and as needed. Review of Care Plan titled Urinary Continence: created 8/24/15, indicated, Problem: (Resident 9) is frequently incontinent secondary to impaired mobility, use of diuretic (water pill), and [DIAGNOSES REDACTED]. Review of facility administrative document titled, Pressure Ulcer Management dated 1/1/12 indicated, Cause of pressure (sore): A. Bony prominences - Areas of high risk are: Spine especially coccyx/sacrum, C. Maceration, Contributing factors: Overweight, Chronic disease (e.g. diabetic), Chronic incontinence.

Based on interview, clinical record and administrative document review, the facility failed to ensure transfer and discharge was necessary for the residents welfare, and failed to permit residents to remain in the facility when one of 18 sampled residents and one random sampled resident (Resident 18) was discharged to a lower level of care without medical justification. This failure resulted Resident 18's displacement from his home and resulted in an emergency room visit and subsequent hospitalization . Findings: Review of Resident 18's Face Sheet (document containing resident's profile information) indicated Resident 18 was admitted to the skilled nursing facility (SNF) on 11/24/2014 with [DIAGNOSES REDACTED]. The responsible party was noted to be Resident 18's sister. The physician's orders [REDACTED]. On 9/17/15 at 9:45 a.m., during an interview, Licensed Nurse (LN) 1 stated Resident 18 required one-to-one care because of behaviors, and was developmentally delayed. LN 1 stated Resident 18 needed prompting and required supervision while eating; was on a pureed diet (food had a consistency of a thick pudding) because of the difficulty with swallowing. LN 1 stated Resident 18 was not capable of administering own medications. On 9/17/15 at 9:45 a.m., during an interview with Social Services Director (SSD), the SSD stated Resident 18 had been in a Board and Care home (lower level of care home without nursing services provided in the home) prior to being admitted to the facility (11/24/14). The SSD stated Resident 18 had at that time had difficulty swallowing, and as a result had been admitted to the acute care hospital. On 9/17/15 at 9:45 a.m., during an interview with Resident 18's family member (FM)(sister who was the designated Responsible Party), FM stated, Resident 18 had been a resident in the SNF for 6 months and then was transferred to a board and care home. The sister stated the facility had been trying to find a place for Resident 18 for the past several months. The sister stated she was told at a resident Care Conference the facility staff thought the resident was better suited in a smaller place and needed one-to-one care. The sister stated she had not thought the facility meant to transfer the resident back to a board and care home, as that was where he had been admitted from. Resident 18's sister stated prior to 2012 Resident 18 had been in a board and care, but when he began to have problems swallowing there, he was then transferred to the hospital. Resident 18's sister stated following that hospitalization Resident 18 had then been admitted to the SNF for nursing care. The sister stated the facility called her the day before Resident 18 had been transferred to the board and care home on ,and told her they had found a place for Resident 18. Resident 18's sister stated the facility shipped him off the next day (9/2/15). The sister stated, He needs nursing care. Review of the document titled, InterDisciplinary Team Conference Attachment D, indicated a date of 9/1/15 with a discussion Resident 18 was accepted by a Board and Care Home. Review of the facility form titled, Physician's Report for Residential Care Facilities for the elderly undated, contained a stamp with the MD's name, address and license number. It was unsigned. The form contained a printed fax date at the top of the form 9/20/15 at 10 a.m. The document indicated Resident 18 required supervision, a pureed pudding thick liquid diet and medications must be administered by staff. The report also indicated Resident 18 had a wound to the left buttock. A second copy of this report was faxed to the medical director on 9/20/15 was stamped with medical director's name and license number but undated. Review of the facility document, untitled and undated, typed with a statement, Resident was discharged to Board and Care this am via (by) .medical transportation . On 9/23/15 at 3:30 p.m., during an interview the Medical Director (MD) stated physicians do not perform the assessment for residents who are being discharged . The MD stated, We depend on other people to do that. The MD stated, Sometimes we only see the residents once a month. 9/24/15 at 10:49 a.m., during an interview, the SSD placed a call to the primary care physician responsible for Resident 18's care. The phone call was not returned. On 9/25/15 a second telephone call was placed to the primary care physician. A message was left on the physician's voice mail requesting a return call. A message requesting a return call was left on the physician's voicemail with a phone number referenced for a return call. The physician did not return the call. On 9/24/15 at 8:15 a.m., during an interview with the Director of the Board and Care to which Resident 18 was transferred to stated in a room and board they are not allowed to administer medications. The Director stated they (facility) didn't tell him anything about the diet and he did not know what a pureed diet was. The Director stated, I noticed that when he (Resident 18) was eating he was choking a little bit. The Director stated he took Resident 18 to the emergency department. The Director stated the hospital case manager called him and told him; Resident 18 needed a higher level of care. The Director stated Resident 18 was admitted to the hospital. On 9/24/15 at 10:15 a.m., during an interview the Speech Therapist (ST) stated Resident 18 had a severe swallowing deficit, thin liquids were not safe for him, he needed the thick (pudding like consistency) liquids. The ST stated the Administrator conferred with him upon Resident 18's discharge and wanted to know if Resident 18 could eat independently. The ST stated he told the Administrator Resident 18 needed care on a 24/7 basis and needed one-to-one supervised care. The ST stated Resident 18 needed to stay on a pureed diet because he had difficulty swallowing. Resident 18's clinical record contained the document, Notice of Proposed Transfer and Discharge, dated, 9/1/15. The document contained, Reason for Discharge was blank and had not indicated why Resident 18 was being transferred to a lower level of care. Resident 18's Discharge Summary dated 9/1/14 indicated Resident 18 was admitted on [DATE] and was discharged on [DATE]. The section on the document, Safety Needs/Precautions: (Fall risk, Assistive, Sensory Aides was left blank. Resident 18's physician's orders [REDACTED]. No medical justification was noted on the discharge order by the primary care physician (P) 2. . Review of Acute care hospital record regarding the residents emergency contact, undated, indicated Resident 18 was admitted into the Emergency Department (ED) on 9/3/15 at 8:36 a.m., The record indicated Resident 18 presented with an abscess on right buttock and was unable to provide a history due to being non-verbal. The Acute care record indicated, Clinical Impression: Psychiatric disorder, Left buttock lesion (healing old abscess), Gravely disabled. The record indicated, Hospital Course: Patient was evaluated by speech/swallow for dysphagia and recommended to get alternate mean of feeding based on video fluoroscopic study (VFSS) (A study done by using x-ray to produce real-time video images. After the x-rays pass through the patient, instead of using film, they are captured by a device called an image intensifier and converted into light. The light is then captured by a TV camera and displayed on a video monitor.) The VFSS performed on 9/8/15 indicated, Severe oropharyngeal dysphagia with evidence of silent penetration and aspiration with puree solids and honey thick liquid. As per Speech Language Pathologist (SLP) patient is at high risk for aspiration . Disposition: Skilled nursing facility. Resident 18 was discharged to another (a different) SNF on 9/24/15. The active discharge [DIAGNOSES REDACTED]. Review of clinical document titled Speech Therapy dated 7/30/15 indicated, Precautions: Aspiration, Pudding liquids and Puree diet. Swallowing abilities= Moderate to severe level of impairment. Discharge Plan: Patient to reside in this long term care facility. Continued skilled SLP service is necessary to assess/evaluate least restrictive oral intake .reduce aspiration w/training in postural maneuvers . safely consume least restrictive diet . Review of a letter from the acute care hospital dated 9/5/15 at 10:30 a.m., by ED case manager, indicated, Patient was discharged from SNF on 9/2/15 to a room and board Patient was pounding on wall, got into refrigerator during night and was eating food and almost choked on food . Patient also has a healing abscess on left buttock . Patient appears to be inappropriate for room and board level of care, is incontinent (inability to control function of urination or defecation). Has wound on buttock that patient does not appear to be able to manage wound care. Felt to be unsafe discharge from facility. Review of Administrative document titled, Discharge and Transfer of Residents dated 1/1/12, indicated, Purpose- To ensure that discharge planning is complete and appropriate . Section titled, Discharge Documentation VIII. indicated The medical record will contain written documentation from the resident's Attending Physician if the resident is discharged because: ii. The resident's health has improved and he/or she no longer needs the Facility's services .