Every finding on record at Northern Cardinal Rehabilitation and Nursing

Based on staff interview, clinical record review and facility document review, it was determined the facility staff failed to provide complete and accurate documentation for one of eight residents, R3. The findings include: The facility staff failed to evidence complete and accurate documentation for turning and repositioning for R3. R3 was admitted to the facility on [DATE] with diagnosis that included but were not limited to fracture right femur, CVA (cardiovascular accident) and hemiplegia/hemiparesis. R3's most recent MDS (minimum data set) assessment, an admission assessment, with an ARD (assessment reference date) of 10/7/24, coded the resident as scoring a 11 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was moderately cognitively impaired. A review of the MDS Section G-functional status coded the resident as maximal assist for bed mobility/transfer, toileting and eating/hygiene. A review of R3's comprehensive care plan dated 10/7/24 revealed, FOCUS: The resident is at risk for weight loss or malnutrition related to CVA, hemiplegia, hemiparesis and loss of mobility. INTERVENTIONS: Monitor for trouble chewing/swallowing and amount of meal eaten. A review of the physician progress notes 10/12/22 at 1:00 AM revealed, SKIN: No redness, rashes, or ulcerations, temperature is warm and dry. Poor appetite. Severe protein-calorie malnutrition. A review of the progress note dated 10/12/22 at 9:04 PM revealed, SKIN Are their changes in residents skin integrity? No. ADLs: bed mobility - how residents move to/from lying position, turns side to side and positions body while in bed alternate sleep furniture: Extensive Assistance - Staff Support Provided, One-person physical assist. A review of the progress note dated 10/18/22 at 11:29 AM revealed, SKIN: Are there changes in residents skin integrity? No. ADLs- bed mobility - how residents move to/from lying position, turns side to side and positions body while in bed alternate sleep furniture, Total Dependence - Two+ persons physical assist. A review of two current resident medical records, R6 (BIMS of 14, indicating no cognitive impairment) and R7 (BIMS of 9, indicating moderate cognitive impairment), documentation of wound care, skin assessments and turning, repositioning were all documented without issues. Both R6 and R7 wounds were resolved during survey. An interview was conducted on 1/8/25 at approximately 8:15 AM with ASM (administrative staff member) #1, the administrator. When asked about documentation for turning and repositioning R3, ASM #1 stated, we had bought this facility and they changed from the previous EMR to our current EMR, we found out in auditing the documentation after the install that not all of the ADL (activities of daily living) documentation fields were installed. An interview was conducted on 1/8/25 at approximately 8:40 AM with R6. When asked about wound care, R6 stated, they have done a really good job with wound care and turning me, which is not easy as I have cerebral palsy and I cannot stay in one position too long. An interview was conducted on 1/8/25 at approximately 9:24 AM with RN (registered nurse) #1, when asked about the EMR, RN #1 stated, we were changing EMR systems on 10/1/22 to PCC and it evidently was not set up with all pieces. An interview was conducted on 1/8/25 at 1:25 PM with CNA (certified nursing assistant) #1. When asked about turning residents, CNA #1 stated, we turn every 2 hours and document in the ADL record, if it is not documented it could be documentation issue, instead of it not being done. An interview was conducted on 1/8/25 at 1:45 PM with CNA #2. When asked about turning residents, CNA #2 stated, the residents are turned every two hours. If there is missing documentation, the care was probably provided but just not charted. No, the chart is not complete and accurate. On 1/8/25 at approximately 3:25 PM, ASM (administrative staff member) #1, the administrator and ASM #5, the regional director of clinical services was made aware of the findings. No further information was provided prior to exit.

Based on interview, record review, and facility policy review, the facility failed to ensure that the facility accurately reflected the advance directive status for three of 12 sampled residents (Resident (R) 1, R73, and R109) reviewed for advance directives. Advance directive forms were not present for residents who were identified as DNR (do not resuscitate) status. Although physicians signed forms indicating code status, the forms were not signed by the resident or a health care surrogate named in an advance directive form. The failure to ensure that the facility has current, complete advance directive documentation places residents at risk of not receiving the end of life care they desire and/or having their wishes for code status honored. Findings include: Review of the facility's policy titled, Advance Directives, revised on [DATE], revealed, It is the policy of this facility to support and facilitate a resident's right to request, refuse and/or discontinue medical or surgical treatment and to formulate an advance directive .Upon admission, should the resident have an advance directive, copies will be made and placed on the chart as well as communicated to the staff .Decisions regarding advance directives and treatment will be periodically reviewed as part of the comprehensive care planning process, the existing care instructions and whether the resident wishes to change or continue these instructions. 1. Review of the Face Sheet, found in R109'2 electronic medical record (EMR) under the Face Sheet tab, revealed R109 was admitted to the facility on [DATE] with diagnoses including syncope and collapse, low back pain, falls, malaise, adult failure to thrive, and muscle weakness. Review of the previous hospital records in the Misc[ellaneous] tab revealed R109 was a Full Code prior to being admitted to the facility. Review of R109's Admission Minimum Data Set (MDS), found in the EMR under the RAI (Resident Assessment Instrument) tab, with an Assessment Reference Date (ARD) of [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of ,d+[DATE], indicating the resident had no cognitive impairment regarding daily decision making. Review of a Physician Progress Note, under the Misc tab dated [DATE], indicated Code Status of: Full Scope of Treatment. Review of quarterly MDS assessments with ARDs of [DATE] and [DATE] revealed the resident continued to be cognitively intact, based on BIMS scores of ,d+[DATE]. Review of Progress Notes under the Prog. Note tab dated [DATE] indicated, Pt. [patient] seen today for overall decline, no interventions have been successful .continued with failure to thrive and overall decline .Palliative care options were discussed. Review of the Misc tab revealed no evidence an Advanced Directive for R109 was in place. However, review of a Physician Order under the Orders tab dated [DATE] indicated a new order for, DNR [Do Not Resuscitate] with the Order Type listed as: Advanced Directives. Review of Progress Notes under the Prog. Note tab dated [DATE] indicated, Nurse was called into resident room at 1032. Resident was unresponsive. No heart or breath sound noted. No code was called due to resident DNR order sign in resident chart .Postmortem performed. Dr. [Doctor] was notified and next of kin notified. Review of Progress Notes under the Prog. Note tab dated [DATE] indicated, Resident assessed by writer. Absent pulse and respirations. Time of death 1039. DNR/Comfort care. During an interview on [DATE] at 9:03 AM, the Medical Records Director was questioned regarding any evidence of an Advanced Directive in R109's medical record. The Medical Records Director stated, We don't have any thinned charts. If the Advanced Directive has not already been scanned in, then we don't have it. She then stated, I don't know why we don't have anything. The nurses are responsible for getting that paperwork. Our Admissions person usually gets all paperwork from the hospital, then it goes to the nurse's station and the nurses go through that information. She stated, If there is any DNR (Do Not Resuscitate) documentation that is not uploaded, then I will check the computer to see if it's uploaded. I think it's the nurse's job to get that information. I don't see any advanced directives scanned into the chart. No During an interview on [DATE] at 9:11 AM, the Director of Nursing (DON) stated, When someone is admitted to the facility, they come with orders from the hospital, and we make sure what their code status is. We would clarify with the RP [Responsible Party] or POA [Power of Attorney]. The DON then stated, If the hospital paperwork says a full code, then they are a full code. Regarding the code status change for R109, the DON stated, The doctor orders for her code status was changed to a DNR on [DATE]. Prior to that she was a full code until it was changed on [DATE]. The DON stated, It was entered into our system on [DATE] as full code. She came in with a full code status and the doctor changed it on [DATE]. The DON then stated, When someone goes from a full code to a DNR, we usually have a DNR form that is filled out. If the resident is not cognitively aware, then we will talk to the POA. I don't see any further documentation such as the DNR form, any Advanced Directive, or a Power of Attorney in her chart. I just see a note where the family agreed to it [changing the resident's code status]. When asked what documentation the facility staff would use in the event there was an emergency (need to determine code status), the DON stated, We will rely on the physician order. That is what we will go by. During an interview on [DATE] at 9:55 AM, the Admission Concierge stated, Our process is, I give them a form regarding code status and Advanced Directives, and they sign it when they come in. If there is an Advanced Directive, we will have a copy of it. When asked if she could locate any documentation of an Advanced Directive for R109, she stated that she was unable to find any documentation of an Advanced Directive in R109's medical record. During an interview on [DATE] at 10:42 AM, regarding Advanced Directives for R109, the Social Worker (SW) stated, I know we obtain code status from our admissions. They are supposed to scan them in along with any doctor orders. We should be obtaining POA, living will and any Advanced Directives. The SW then stated, An Advanced Directive is a document that would explain what the wishes are of a person. What they want or don't want. Regarding R109, the SW stated, I don't see an Advanced Directive in her file. 2. Review of R73's Admission Record, located in the EMR under the Profile tab, indicated the resident was admitted to the facility on [DATE] with diagnoses that included Alzheimer's Disease with late onset. The Advance Directive status on the Admission Record stated, Advanced Directive: Do Not Resuscitate (DNR). Review of R73's Care Plan, dated [DATE], located in the EMR under the Care Plan tab, indicated he had an advanced directive in place for DNR status. Review of R73's Physician Orders, located in the EMR under the Orders tab and dated [DATE], stated, Advanced Directive: Do Not Resuscitate (DNR). Review of R73's Durable Do Not Resuscitate Order located in the EMR under the Misc [miscellaneous] tab, dated [DATE], stated, The patient is INCAPABLE of making an informed decision about providing, withholding, or withdrawing a specific medical treatment or course of medical treatment because he/she is unable to understand the nature, extent or probable consequences of the proposed medical decision, or to make a rational evaluation of the risks and benefits of alternatives to that decision .While capable of making an informed decision, the patient has executed a written advanced directive which directs that life-prolonging procedures be withheld or withdrawn . The document was dated [DATE] and was signed by a physician; however, there was no resident or responsible party's signature. R73 was not interviewed regarding advance directive status due to severe cognitive impairment. During an interview on [DATE] at 2:57 PM, the DON confirmed that R73 had an order for DNR and that the form titled, Durable Do Not Resuscitate Order signed by the physician and dated [DATE] did not include a resident or responsible party signature. The DON stated that this form was only a communication tool used by transportation services in the event the resident had a medical emergency. The DON stated that as long as the facility had a Do Not Resuscitate order on file, signed by the physician, it was acceptable to not have a signed advanced directive document signed by the resident/responsible party on file. During an interview on [DATE] at 3:40 PM, the SW confirmed that a Durable Do Not Resuscitate Order was not an advanced directive. During an interview on [DATE] at 3:40 PM, R73's responsible party stated that upon admission, she provided a copy of the resident's advanced directive to the Social Worker of the hospice agency he received services from, and they were supposed to pass it along to the facility. During multiple interviews on [DATE] between 4:00 PM-4:51 PM with Certified Nursing Assistant (CNA) 1, CNA2, and CNA3, they stated that if they found a resident unresponsive, they would call for a nurse immediately. During an interview on [DATE] at 4:09 PM, Licensed Practical Nurse (LPN3) stated if she found a resident unresponsive, she would call the clinical manager, a staff nurse, or look in the EMR to locate the resident's code status. If the resident had DNR listed as their code status, no cardiopulmonary resuscitation (CPR) would be performed. During an interview on [DATE] at 4:19 PM, LPN4 stated if she found a resident unresponsive, she would look in the EMR to locate the resident's code status. If the resident had DNR listed as their code status, no CPR would be performed. During an interview with the Administrator and Registered Nurse (RN1) on [DATE] at 12:39 PM, they stated they were both fairly new to the facility and that there was not a binder or paper copies of advance directives for each resident on the unit at this time, however, copies should be uploaded into the EMR for any resident's that have a signed advance directive. If there is no advance directive on file and a resident was having a medical emergency or was found unresponsive, the nurse would need to call the emergency contact/responsible party to let them know the facility would have to send the resident to the hospital. Neither the Administrator nor RN1 stated if the residents would receive CPR without a signed advance directive on file indicating DNR code status. During an interview on [DATE] at 12:57 PM, the SW stated code status should be obtained during the admission process and confirmed within 48 hours of admission. The SW stated the resident's advance directive should be scanned into the EMR and verified during quarterly care conferences, and all advance directives should match the physician's order in the EMR. The SW added that she was new to the facility, and she was in the process of starting a binder to include paper copies of all resident's advance directives. The SW confirmed that R73 did not have advance directives on file in the EMR. 3. Review of R1's Admission Record, located in the EMR under the Profile tab, indicated the resident was admitted to the facility on [DATE] with diagnoses that included metabolic encephalopathy, stage three chronic kidney disease, anxiety disorder, and dementia with other behavioral disturbances. The Advance Directive status on the Admission Record stated, Advanced Directive: Do Not Resuscitate (DNR). Review of R1's Care Plan dated [DATE], located in the EMR under the Care Plan tab indicated she had an advanced directive in place for DNR. Review of R1's Physician Orders, located in the EMR under the Orders tab and dated [DATE], stated, Advanced Directive: Do Not Resuscitate (DNR). Review of R1's Durable Do Not Resuscitate Order, located in the EMR under the Misc tab and dated [DATE], stated The patient is INCAPABLE of making an informed decision about providing, withholding, or withdrawing a specific medical treatment or course of medical treatment because he/she is unable to understand the nature, extent or probable consequences of the proposed medical decision, or to make a rational evaluation of the risks and benefits of alternatives to that decision. There was no other documentation to indicate R1 had executed a written Advanced Directive that directs whether life-prolonging procedures should be withheld or withdrawn, whether she appointed another responsible party to make those decisions on her behalf, or if she had chosen to not execute a written Advanced Directive. This section of the document was left blank. The document was signed by a physician, had no resident signature, and had written on it verbal consent by [her daughter (Power of Attorney) and grandson]. During an interview on [DATE] at 12:57 PM, the SW confirmed that R1 did not have advance directives on file in the EMR.

Based on interview, record review, and review of facility policy, the facility failed to notify the resident and/or the resident's representative, as well as the Ombudsman of transfers and the reason for the move in writing for two (Resident (R) 19 and R69) of three residents reviewed for hospitalization . The facility failed to provide a written notice, containing all required information, including the reason, date, and location to which the resident was transferred, as well as information about appeal rights, when R19 and R69 were transferred to the hospital for emergency care. Findings include: 1.Review of the Progress Note tab in R69's electronic medical record (EMR) revealed a progress note dated 09/23/22 and timed 12:23 AM. The note stated that at 10:45 PM, the resident was having a seizure that lasted 10 minutes and, as a result, 911 was called and the resident was sent to the emergency room . An additional progress note dated 09/23/22 and timed 8:07 AM revealed the resident was admitted to the hospital. An admission progress note, dated 09/30/22 at 8:35 PM, revealed the resident was readmitted from the hospital. The resident's EMR was reviewed in its entirety and provided no evidence that the facility provided a written transfer notice when the resident was transferred to the hospital. Review of R69's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/03/23, revealed the resident was moderately cognitively impaired, based on a Brief Interview for Mental Status (BIMS) score of 8/15. On 04/14/23 at 5:21 PM, a telephone interview was conducted with R69's daughter/responsible party, based on the resident's cognition. She stated she did not receive any written notices when her father went to the hospital. On 04/13/23 at 3:56 PM, interview with the Director of Nursing (DON) confirmed a written transfer notice was not sent to the resident's representative, nor to the Ombudsman, when the resident was transferred to the hospital. The DON stated they did not know the resident and their representatives were not being notified in writing about the transfers. The DON stated that she, the Administrator, and the Social Worker were all fairly new and did not know who was supposed to send the notices out. 2. Review of the Progress Note tab in R19's EMR revealed she had a nursing note, dated 03/27/23 and timed 12:54 AM, which stated that 911 was called because the resident could not breathe. A further note, dated 03/27/23 and timed 5:35 AM, revealed the resident was admitted to the hospital due to dyspnea. A Progress Note, dated 03/29/23 and timed 6:16 PM, revealed the resident arrived back to the facility via stretcher and was readmitted from the hospital. The resident's EMR was reviewed in its entirety and provided no evidence that the facility provided a written transfer notice when the resident was transferred to the hospital. Review of the quarterly MDS, with an ARD of 04/02/23, revealed R19 had a BIMS of 13/15, indicating the resident was cognitively intact. On 04/11/23 at 02:01 PM, an interview with R19 revealed that she had been in the hospital recently. When asked if she received a written notice at the time she was transferred to the hospital, she stated she had not. On 04/13/23 at 3:56 PM the DON confirmed a written transfer notice was not sent to the resident's representative nor the Ombudsman. Review of the Transfer and Discharge policy, with a revised date of 12/01/22, revealed it did not address that a written notice was required when a resident experiences an emergency/nonplanned transfer to the hospital.

Based on resident and staff interviews, clinical record review and facility documentation review, the facility staff failed to invite 3 residents to attended their person-centered care plan and failed to update and revise one resident care plan who had a change in their code status for 4 of 57 residents (Resident #73, #63, #161 and #109) in the survey sample. PARTICIPATION IN CARE PLANNING 1. a. Review of R73's Admission Record, located in the electronic medical record (EMR) under the Profile tab, indicated the resident was admitted to the facility on [DATE] with diagnoses that included Alzheimer's Disease with late onset. Review of R73's quarterly Minimum Data Set (MDS) located in the EMR under the MDS tab with an Assessment Reference Date (ARD) of 03/20/23, revealed the resident had a Brief Interview for Mental Status (BIMS) score of three out of 15, indicating the resident was severely cognitively impaired. Review of R73's AHR- Multidisciplinary Care Conference- V 2 document located in the EMR under the Assessments tab, revealed it was dated 10/23/22 and 03/30/23 to indicate that care conferences were held. Review of R73's Care Conference invitation record located in the EMR under the Misc [miscellaneous] tab indicated a care conference was held on 03/30/23. No other invitations to care conferences were available for review. Because R73 could not be interviewed regarding frequency of care conferences due to severe cognitive impairment, an interview was conducted on 04/11/23 at 3:03 PM with R73's responsible party (RP). The RP indicated she had one care conference on 07/31/22 and no others since that time. During an interview on 04/14/23 at 12:39 PM, the Director of Nursing (DON) stated that residents and their representatives have the right to attend and participate in their care, including care conferences. All care conferences are coordinated by the Social Worker (SW) who is responsible for verbally notifying the resident and providing a printed invitation. The DON stated that prior to her employment starting 02/27/23, she was not sure what system was in place for care conferences, but since that time they had started having care plan meetings. During an additional interview on 04/14/23 at 1:47 PM, the DON stated that documentation of any care conferences that were held would be located in the EMR under the assessments tab. The DON confirmed that a care conference was held on 10/13/22 and on 03/30/23 for R73, adding that every resident should have a care conference quarterly. During an interview on 04/14/23 at 12:12 PM with the Administrator, she stated that during the COVID-19 epidemic, the facility's care conferences were hit and miss, and she was not sure if the facility quit doing them all together. b. Review of R63's quarterly MDS, with an ARD of 01/27/23, revealed the resident was admitted to the facility on [DATE]. On 04/14/23 at 9:30 AM, an interview with R63's responsible party revealed she had only been invited to one care conference and that was over one year ago. She stated she would like to be invited so she could attend the meetings. R63's EMR was reviewed in its entirety. There was no information related to the facility holding care conferences in the past year nor evidence that either the resident or their responsible party was invited to participate in care planning. On 04/14/23 at 10:37 AM, an interview with the Administrator confirmed there was no information in the record to indicate the facility held a care conference for the resident in the past year or invited the resident and responsible parties to participate in care planning. She stated she, the DON, and the SW were all new to the facility and they were unable to locate any information related to a care conference. c. During a telephone interview on 04/13/23 at 2:00 PM, an interview with R161's daughter revealed she was not invited to any care conferences for the resident after the COVID-19 pandemic. Review of R161's 07/07/22 quarterly MDS with an ARD of 07/07/22 revealed the resident was admitted to the facility on [DATE]. Review of R161's discharge EMR revealed he passed away on 08/29/22. R161's EMR was reviewed in its entirety. There was no information related to the resident or their family member being invited to participate in care planning in the year prior to his death. On 04/14/23 at 10:37 AM the Administrator verified there was no information in the record to indicate the facility invited the resident and their responsible party to participate. She stated that she, the DON, and the SW were all new to the facility and they were unable to locate any information related to this issue. REVISION OF CARE PLANS 2. Review of the facility's policy titled, Care Plan Revisions Upon Status Change, revised 12/01/22, revealed, The purpose of this procedure is to provide a consistent process for reviewing and revising the care plan for those residents experiencing a status change. It further indicated, 1. The comprehensive care plan will be reviewed and revised as necessary . 2. Upon identification of a change in status, the nurse or any member of the interdisciplinary team will notify the MDS Coordinator, the physician, and the resident representative .The team meeting discussion will be documented in the nursing progress notes .The care plan will be updated with the new or modified interventions .Care Plans will be modified as needed by the MDS Coordinator or other designated staff member . Review of the Face Sheet found in R109's EMR, under the Face Sheet tab, revealed R109 was admitted to the facility on [DATE]. Review of a Care Plan found in R109's EMR under the Care Plan tab, initiated on 07/27/22, revealed, Advance Directive- Full Code, indicating the resident was to receive life saving measures, including cardiopulmonary resuscitation, if needed. Review of a Physician Progress Note under the Misc[llaneous] tab dated 08/17/22 confirmed the resident's Code Status of: Full Scope of Treatment. Review of a Physician Order under the Orders tab dated 01/20/23 the resident's code status was changed, with an order given for, DNR [Do Not Resuscitate]. Further review of the Care Plan found in R109's EMR under the Care Plan tab revealed no evidence of revisions or updates to the care plan to reflect R109's changed code status from Full Code Status to DNR. Review of the care plan revealed, Full Code was still listed. Review of additional Nursing Progress Notes under the Prog Note tab, dated 02/21/23, indicated, Nurse was called into resident room at 1032 [10:32 AM]. Resident was unresponsive. No heart or breath sound noted. No code was called due to resident DNR order sign in resident chart. (Cross-reference F578.) During an interview on 04/14/23 at 9:11 AM regarding the care plan for R109, the DON stated, The doctor orders for code status were changed on 01/20/23 to DNR. Prior to 01/20/23, she was a Full Code. The DON then stated, With her care plan, I see where she was listed as a full code on the care plan dated 07/26/22, but the care plan was not updated to reflect the new orders and code status of a DNR. During an interview on 04/14/23 at 10:42 AM, regarding care plan revisions, the Administrator stated, When we have our morning meetings every day, our MDS Coordinator should be making those revisions when we are talking about them. They are supposed to be updating the care plans. During a second interview on 04/14/23 at 12:42 PM, regarding care plan revisions, the DON, who indicated she was new to the facility, stated, The care plans should be updated and/or revised during our IDT [Interdisciplinary Team] meetings. The nurse managers and MDS are the ones who would revise the care plans. We would review any notes, then update the care plan during that meeting because that would be a change. That is our process now. I can't speak to what the process was before. When the DON was asked if there was any documentation to show the care plan for R109 was ever updated/revised to reflect the change in code status, the DON stated that there was none and confirmed the care plan was not updated and/or revised.

Based on interview, record review, and review of facility policy, the facility failed to ensure one (Resident (R) 63) of five residents reviewed for unnecessary medications received their medication in accordance with accepted professional standards. The facility failed to administer medications in a timely manner as ordered on four of four weekends that were reviewed. Findings include: Review of the Medication Administration policy, revised 12/01/22, revealed it is the facility policy to administer medications within 60 minutes prior to or after the scheduled time. On 04/14/23 at 9:30 AM, a telephone interview with R63's family member (FM63) revealed her mother called her about her medications being late on the weekends. FM63 stated her mother frequently gets her 9:00 AM medications at 12:00 PM on the weekends. Review of the Diagnosis tab in R63's electronic medical record (EMR) revealed her diagnoses included chronic obstructive pulmonary disease, hypertension, Diastolic (congestive) heart failure, major depressive disorder, anxiety disorder, peripheral vascular disease, pain, and diabetes mellitus with diabetic neuropathy. Review of R63's quarterly Minimum Data Set (MDS). with an Assessment Reference Date (ARD) of 01/27/23, located in the MDS tab of the EMR. revealed she had a Brief Interview for Mental Status (BIMS) score of 15/15. indicating she was cognitively intact. Review of Medication Administration Audit Reports for four weekends verified the resident was not given her medications in a timely manner in accordance with physician's orders and the facility policy. Review of the Medication Administration Audit Reports revealed the following: a. On 03/18/23, R63 was scheduled/ordered to receive Xarelto tablet 2.5 milligrams (mg), Metoprolol Tartrate Tablet 25mg, Fluticasone Propionate nasal suspension nose spray, Januvia oral tablet 100 mg, Lexapro tablet 10 mg, and amlodipine besylate 5 mg at 9:00 AM. According to the Medication Administration Audit Report, the resident did not receive each of these medications until 11:57 AM, 2 hours and 57 minutes past the ordered time. b. On 03/25/23, R63 was scheduled/ordered to receive Xarelto, Metoprolol Tartrate, Fluticasone Propionate nasal suspension, Januvia, Lexapro, amlodipine besylate, and Roflumilast. According to the Medication Administration Audit Report the resident did not receive the Metoprolol Tartrate, Fluticasone Propionate, Januvia, Lexapro, and amlodipine besylate until 11:54 AM, 2 hours and 54 minutes past the ordered time. The resident did not receive the Xarelto and Roflumilast until 12:05 PM, 3 hours and 5 minutes past the physician ordered time. c. On 03/25/23, R63 was scheduled/ordered to receive Meclizine HCL tablet 25 mg, Duloxetine HCL capsule delayed release particles 60 mg, Anor Ellipta aerosol powder breath activated, Plavix tablet 75mg, and Brimonidine Tartrate eye drops at 2:00 PM. Review of the Medication Administration Audit Report revealed she did not receive each of the medications until 3:35 PM, 1 hour and 35 minutes past the ordered times. d. On 03/25/23, R63 was scheduled/ordered to receive Xarelto, a Lidoderm patch 5%, Mirtazapine tablet 7.5 mg, Lipitor tablet 20 mg, Vitamin C 250 mg, zinc oral tablet 50 mg, and Vitamin D 1000 unit at 9:00 PM. Review of the Medication Administration Audit Report revealed she did not receive each of the medications until 11:54 PM, 2 hours and 54 minutes past the ordered times. e. On 03/26/23. R63 was scheduled/ordered to receive Januvia, Fluticasone Propionate nasal suspension, amlodipine besylate, Lexapro, Xarelto, and Metoprolol Tartrate at 9:00 AM. Review of the Medication Administration Audit Report revealed she did not receive each of the medications until 10:41 AM, 1 hour and 41 minutes past the ordered times. f. On 03/26/23, R63 was scheduled/ordered to receive Xarelto, a Lidoderm patch, Lipitor, and Mirtazapine at 9:00 PM. Review of the Medication Administration Audit Report revealed she did not receive these medications until 11:05 PM, 2 hours and 5 minutes past the ordered time. g. On 03/31/23 R63 was scheduled/ordered to receive Xarelto at 9:00 AM. According to the Medication Administration Audit Report, she did not receive the Xarelto until 2:59 PM, 5 hours and 59 minutes past the ordered time. h. On 03/31/23, R63 was scheduled/ordered to receive Roflumilast at 10:00 AM. According to the Medication Administration Audit Report, she did not receive it until 2:59 PM, 4 hours and 59 minutes past the ordered time. i. On 03/31/23, R63 was scheduled/ordered to receive Humalog solution 100 units/milliliters (ml) on a sliding scale. According to the Medication Administration Audit Report she did not receive it until 2:59 PM, 2 hours and 29 minutes past the ordered time. j. On 03/31/23, R63 was scheduled/ordered to receive Xarelto, a Lidoderm patch, Mirtazapine, Lipitor, Brimonidine tartrate eye drops, and Meclizine HCL at 9:00 PM. According to the Medication Administration Audit Report, she did not receive each of the medications until 04/01/23 at 5:01 AM, 8 hours and one minute past the ordered time. k. On 04/08/23, R63 was scheduled to receive Xarelto, a Lidoderm patch, Mirtazapine, Lipitor, and Brimonidine eye drops at 9:00 PM. Review of the Medication Administration Audit Report, she did not receive each of these medications until 04/09/23 at 3:10 AM, 6 hours and 10 minutes past the ordered time. l. On 04/09/23, R63 was scheduled/ordered to receive Xarelto, Metoprolol Tartrate, amlodipine besylate, Lexapro, and Januvia at 9:00 AM. Review of the Medication Administration Audit Report revealed she did not receive each of these medications until 10:27 AM, 1 hour and 27 minutes past the ordered time. m. On 04/09/23, R63 was scheduled/ordered to receive Plavix 75 mg, Duloxetine HCL 60 mg, and Meclizine HCL 25 mg at 2:00 PM. According to the Medication Administration Audit Report, she did not receive the medications until 4:31 PM, 2 hours and 31 minutes past the ordered time. On 4/14/23 at12:47 PM, the Director of Nursing (DON) was interviewed and said she expected resident medications to be administered within one hour of the ordered time (per the facility policy.). The above Medication Administration Audit Reports were reviewed with the DON and the EMR was reviewed with the DON for possible documented reasons to explain why the medications were not administered timely. The DON verified the medications were not administered timely and there was no documented reason for the delay. She stated that she did not even know that the facility had Medication Administration Audit sheets (prior to surveyor intervention) and this was the first time she was made aware that medications were not administered timely.

Based on observation, interview, record review, and policy review, the facility failed to ensure that three of 57 sampled residents (Resident (R) 32, R73, and R94) were free of potential accidents while residing in the facility. Specifically, the facility failed to verify placement and function of wander guards (device worn to prevent elopements) for the three residents, who had wandering and/or exit-seeking behaviors. This failure placed the resident at risk for elopement and potential injury. In addition, the facility failed to thoroughly assess one resident (R211) after a fall, as well as conduct a thorough investigation with a root cause analysis to determine the reason for the resident's fall so as to initiate steps to prevent further accidents. Findings include: 1. Review of the facility's policy titled, Elopements and Wandering Residents, revised on 12/01/22, stated, This facility ensures that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents, and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk .4. Monitoring and Managing Residents at Risk for Elopement or Unsafe Wandering a. Residents will be assessed for risk of elopement and unsafe wandering upon admission and throughout their stay by the interdisciplinary care plan team e. Charge nurses and unit managers will monitor the implementation of interventions, response to interventions, and document accordingly. F. The effectiveness of interventions will be evaluated, and changes will be made as needed. Any changes or new interventions will be communicated to relevant staff. a. During observations on 04/11/23 at 6:01, 04/13/23 at 12:19 PM, and 04/14/23 at 10:14 PM, R73 was noted to have a wanderguard bracelet in place to the left ankle. During an interview on 04/13/23 at 9:46 AM, Registered Nurse (RN)1 confirmed the presence of a wander guard to R73's left ankle. RN1 stated she had not seen him attempt to wander or elope from the premises. Review of R73's Admission Record, located in the electronic medical record (EMR) located under the Profile tab, indicated the resident was admitted to the facility on [DATE] with diagnoses that included Alzheimer's Disease with late onset. Review of R73's current Order Summary Report, located in the EMR under the Orders tab, revealed that since 11/16/21, staff were to, Apply Secure Care Bracelet/WanderGuard for safety (Check for placement every shift. Check for functioning once per week [sic] Review of R73's Care Plan, dated 11/29/21, located in the EMR under the Care Plan tab, indicated the resident was at risk for elopement as evidenced by wandering and that he had a Secure Care Wander Guard in place for safety. Interventions included checking the device for functioning weekly and checking the device for placement every shift. Review of R73's Treatment Administration Record (TAR) for the months of 03/2023 and 04/2023 did not include documentation for placement of the wanderguard every shift and checking the functioning once weekly. b. During observations on 04/11/23 at 6:01, 04/13/23 at 12:19 PM, and 04/14/23 at 10:14 PM, R94 was noted to have a wanderguard bracelet in place to the left ankle. Review of R94's Admission Record located in the EMR under the Profile tab indicated the resident was admitted to the facility on [DATE] with diagnoses that included dementia and comorbidities including metabolic encephalopathy, restlessness, and agitation. Review of R94's Care Plan dated 03/06/23, located in the EMR under the Care Plan tab indicated the resident had a behavior problem related to wandering through the hallways. Interventions included medication administration and positive interactions with caregivers. The care plan did not include use of a wanderguard bracelet. Review of R94's current Order Summary Report located in the EMR under the Orders tab revealed orders to check wanderguard placement every shift and to check wanderguard functioning every Monday as of 04/14/23. Review of R94's Treatment Administration Record (TAR) for the month of April 2023 did not include documentation for placement of the wanderguard every shift and checking the functioning once weekly During an interview 04/14/23 at 10:14 AM, Licensed Practical Nurse (LPN) 7 demonstrated that the TAR was where the nurses were to document verification of wander guard placement every shift. Further interview with LPN7 confirmed that R73's and R94's TARs did not have a prompt to document the wander guard's functioning or placement. During an interview on 04/14/23 at 10:21 AM, LPN8 reviewed the TARs for R73 and R94 and confirmed that no monitoring was in place for their wander guards even though there were orders in place to monitor the placement and functioning of their devices. During an interview on 04/14/23 at 1:38 PM, the Director of Nursing (DON) verified that R73, and R94 had wander guards in place. The DON confirmed that R73's progress note dated 11/12/21 indicated a wanderguard was placed to the left ankle; she was not aware that the orders for wanderguard monitoring were not added to the TAR. The DON also confirmed that R94 had a wander guard in place since 04/03/23; however, there was no evidence that they had monitored for its placement or function, and the need to do this monitoring had not been added to the TAR until 04/14/23, after the initiation of the survey. 2. During observations on 04/11/23 at 6:01, 04/13/23 at 12:19 PM, and 04/14/23 at 10:14 PM, R32 was noted to have a wanderguard bracelet in place to the left ankle. Review of R32's Admission Record, located in the EMR under the Profile tab, indicated the resident was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease and comorbidities including schizophrenia and dementia. Review of R32's quarterly Minimum Data Set (MDS) located in the EMR under the MDS tab with an Assessment Reference Date (ARD) of 01/20/23 had a Brief Interview for Mental Status (BIMS) score of six out of 15, indicating the resident was severely cognitively impaired. The MDS indicated the resident required one personal physical assistance with transfers, supervision for locomotion off/on the unit, and a wander/elopement alarm was used daily. Review of R32's current Order Summary Report, located in the EMR under the Orders tab, revealed an order dated 08/09/21 which stated, Apply and Secure Care Wander Guard for safety (Check for placement every shift) Check for functioning once per week, every shift for Elopement and Wandering [sic] Review of R32's Treatment Administration Record (TAR) for the months of March and April 2023 included documentation for placement of the wanderguard every shift and checking the functioning once weekly. Although R32's TAR documented that staff were checking the wander guard's function each week, interviews with staff revealed that this could not be verified: During an interview 04/14/23 at 10:14 AM, LPN 7 stated that once weekly, the nurse assigned to the resident was to check the functioning of the wanderguard bracelet. However, LPN7 continued, she did not have a device to check the functioning of any of the residents' wander guards. LPN7 stated she had not notified anyone of not having device for monitoring of wanderguard functioning. LPN7 also stated that she was not aware of any other means of checking the devices for proper functioning. During an interview on 04/14/23 at 10:29 AM, LPN5 stated she was an agency nurse and she was not familiar with R32, R73, or R94. LPN5 checked the nursing cart for a device to check the wanderguard's functioning and was not able to locate the device. LPN5 indicated she was not familiar with which residents were at risk for elopement/wandering or how to check their wander guard devices, should they have one. During an interview on 04/14/23 at 1:38 PM, the DON verified that R32 had a wander guard in place. The DON stated she was not aware that the nurses did not have a device to check the functioning of wander guards, and stated they should have to ensure that the devices are functioning properly. Further interview with DON revealed she was not aware of any other means of checking the devices for proper functioning and could provide no evidence that the facility had checked the devices for proper functioning. During an interview on 04/14/23 at 10:45 AM, the Administrator stated that the floor nurses should have a device to check the functioning of the wanderguard, and she was not aware that they did not have a device for verifying proper functioning. The Administrator stated that the Maintenance Director should have a way to check the doors proper functioning for alarms to sound when a wanderguard bracelet sets off the alarm. However, the Administrator could not provide evidence that the Maintenance Department was checking for proper functioning of alarms. Additionally, the Administrator could provide no evidence, prior to exit from the facility, that the facility had checked the functioning of the alarms to ensure that residents were free from the risk of elopement. 2. Review of the facility's policy titled, Fall Risk Assessment, revised on 12/01/22, indicated, The Morse Fall Scale risk assessment will be completed by the MDS [Minimum Data Set] Coordinator or designee upon admission, quarterly. The policy further indicated, An Actual Fall will result in a Post Fall assessment tool in [name of facility computer charting] along with a Post Fall Follow up note. Review of the facility's policy titled, Fall Prevention Program, revised on 12/02/22, indicated, Each resident will be assessed for the risks of falling and will receive care and services in this facility with the level of risk to minimize the likelihood of falls. Definitions: A fall is an event in which an individual unintentionally comes to rest on the ground, floor, or other level. The event may be witnessed, reported, or presumed when a resident is found on the floor or ground, and can occur anywhere. The policy further indicated, When any resident experiences a fall, the facility will: a. Assess the resident. b. Complete a Post-fall review and a Post Fall Follow Up note in [name of facility computer charting]. c. Complete an incident report. d. Notify the physician and family. e. Review the resident's care plan and update as indicated. f. Document all assessment and actions .i. Begin neurologic assessment using Neurologic Record assessment tool in [name of computer charting]. Review of a Face Sheet, found in R211's EMR under the Face Sheet tab, revealed R211 was admitted to the facility on [DATE] with diagnoses to include hemiplegia, unspecified affecting left nondominant side, cerebral infarction, and weakness. Review of an AHR-Morse Fall Scale Assessment found in R211's EMR under the Assessment tab dated 12/19/21, indicated R211 was identified as a Low Risk for Falling upon admission. Review of R211's quarterly MDS, found in the EMR under the RAI (Resident Assessment Instrument) tab with an ARD of 03/19/22, revealed the resident had a BIMS score of 15/15, indicating no cognitive impairment. The MDS further indicated R211 required limited assistance with one-person physical assist for bed mobility, toilet use and transfers. The MDS indicated R211 was Not steady, and only able to stabilize with staff assistance for moving from a seated to standing position, walking, surface-to-surface transfers, and moving on and off the toilet. Review of a Progress Note, found in R211's EMR under the Prog Note tab and dated 04/22/22, indicated, Note Text: @ around 0930 [9:30 AM] resident found sitting on floor in front of his wheelchair. Stated he tried to get OOB [out of bed] to wheelchair and it rolled from him. No apparent injury denied hitting head. 3 staff members to get up with sit and stand Reeducated on importance if [sic] calling for help OOB also reeducated on making sure brakes engaged on wheelchair with transfer. Review of the EMR revealed no documentation of additional progress notes regarding this fall. Review of the EMR revealed no evidence of an incident report, post-fall assessment, AHR-Morse Fall Scale assessment, or root cause analysis completed to determine the possible cause of the fall and identify steps needed to prevent further accidents after the fall on 04/22/22. In addition, there was no evidence that neuro checks were completed per facility policy. During a phone interview on 04/12/13 at 2:30 PM, R211 stated, I had a stroke. From what I recall, I was falling. I fell off the bed once and I needed help off the floor. I don't remember any specifics of that fall. During an interview on 04/13/22 at 8:35 AM, when reviewing R211's medical record with the DON, she stated, It says he [R211] had a fall at around 9:30 AM on 04/22/22 where he was found sitting on the floor in front of his wheelchair. The DON stated, Our process is there should be a Morse Fall scale assessment completed upon admission and after each fall. I see one was completed on 12/19/21, but not any others completed. The DON stated, I'm seeing he had a fall on 04/22/22. When asked if there was an incident report, neuro checks completed, post fall assessments or any root cause analysis completed after this fall, she stated, I'm not seeing anything. The DON stated, The process is, an assessment should be done at the time of a fall, a skin assessment completed, pain assessment, and a post fall review attached to our IDT [Interdisciplinary team] team. The DON stated, If it was an unwitnessed fall, we automatically do neurochecks q [every] 15 minutes, then q [every] 30 minutes, then every 4 hours x4 for three days. We should be doing post fall documentation. That would be under our post fall assessment to show what they [the resident] was doing at the time of the fall, when was the last time staff saw them, footwear they were wearing, any devices used at the time of the fall and any interventions we have. Then we take it to the IDT team and start our investigation. We are supposed to do a post review of the fall as to what happened, and if neurochecks were done. The DON stated, R211 had no further falls since 04/22/22 and since it was unwitnessed and we don't know what happened, it would be my expectation staff initiate neurochecks because we don't know if he hit his head or not. I'm not seeing anything documented in the chart. That would be my expectation of the staff to be documenting. There was also no incident report that I could find. No root cause analysis of the fall. Nothing.

Based on observation, interview, record review, and review of facility policy, the facility failed to ensure staff washed their hands/performed hand hygiene as required during wound care for one (Resident (R) 28) of 57 sampled residents. In addition, soap dispensers needed for handwashing in three resident bathrooms were not functioning properly. This failure involved six (Resident (R) R3, R5, R17, R19, R69, and R162). Findings include: 1. Review of the facility's policy titled, Hand Hygiene, provided by the facility and revised 12/01/22 stated, All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility .Hand hygiene is indicated and will be performed under the conditions listed in, but not limited to, the attached hand hygiene table .The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves. Review of the facility's document titled, Hand Hygiene Table, provided by the facility and dated 2020, stated to use alcohol based hand rub (ABHR) before and after handling clean or soiled dressings . before performing resident care procedures . after handling items potentially contaminated with blood, body fluids, secretions, or excretions .when, during resident care, moving from a contaminated body site to a clean body site. Review of R28's Admission Record, located in the electronic medical record (EMR) under the Profile tab, indicated R28 was originally admitted to the facility on [DATE] and readmitted to the facility on [DATE]. with a primary diagnosis of protein calorie malnutrition and co-morbidities including cerebral infarction, congestive heart failure, dependence on supplemental oxygen, and pulmonary disease. Review of R28's quarterly Minimum Data Set (MDS), located in the EMR under the MDS tab with an Assessment Reference Date (ARD) of 03/14/23, had a pressure ulcer/injury, and had one or more unhealed pressure ulcers/injuries, and had two Stage III pressure ulcers. Review of R28's Care Plan, revised on 04/11/23, indicated the resident was at risk for pressure ulcer development related to history of stroke and had interventions including maintaining universal precautions while providing care, included skin treatment and preventative as ordered, follow facility protocols for treatment of injury. Review of R28's Order Summary Report, located in the EMR under the Orders tab and dated 04/12/23 included: 1. 04/08/23- cleanse behind left ear with normal saline, pat dry, apply bacitracin ointment (antibacterial ointment) and cover with a small foam dressing every day shift for skin tear until healed then discontinue. 2. 03/24/23- Santyl External Ointment 250 UNIT/GM [gram] (Collagenase) Apply to Right Heel topically every day shift for Stage 3 Pressure Injury. Cleanse area to Right heel with Dakins solution, pat dry, apply nickel thick layer of Santyl, followed by Dakin's moist gauze, gently wrap with kerlix daily and as needed for soiling or removal AND apply to right heel topically as needed for Stage 3 Pressure Injury. 3. 04/08/23- Calcium Alginate External Miscellaneous (Calcium Alginate) Apply to left buttock topically every day shift for wound care. Cleanse open area with Dermal wound cleanser, pat dry, gently pack with Calcium Alginate daily, cover dry dressing or foam dressing. 4. 04/08/23 Apply to left buttock topically as needed for soiled or loose dressing Cleanse open area with Dermal wound cleanser, pat dry, gently pack with Calcium Alginate daily and cover dry dressing or foam dressing. During an observation on 04/12/23 at 10:35 AM, Licensed Practical Nurse (LPN) 1 was providing wound care to R28. LPN1 used hand sanitizer prior to placing all wound care supplies on R28's over the bed table. A barrier was placed on the table, supplies were laid on the table, and LPN1 then removed a soiled dressing from R28's left buttock, removed soiled gloves, donned clean gloves, and cleansed the wound with dermal wound cleanser. LPN1 then doffed soiled gloves, donned clean gloves, applied calcium alginate dressing, and covered the area with a dry dressing. LPN1 then doffed the soiled gloves, donned clean gloves, checked R28's posterior [NAME] (ear), applied bacitracin ointment, applied a dry dressing to the area, doffed soiled gloves, donned clean gloves, and then dressed the resident in his personal clothing. LPN1 exited the room to obtain wound care materials for a wound to the heel, and at that time she used hand sanitizer that was in a dispenser on the wall next to the door. During an interview on 04/12/23 at 11:17 AM with LPN1, she confirmed that she did not perform hand hygiene (either handwashing or sanitizing) between glove changes but should have while performing wound care for R28 on 04/12/23 at 10:35 AM. During an interview on 04/14/23 at 6:40 PM, the Assistant Director of Nurses/Infection Preventionist (ADON/IP) confirmed that nurses should perform hand hygiene between donning and doffing gloves during routine patient care and during wound care. 2. a. On 04/11/23 at 1:17 PM, R162 stated the soap dispenser in her bathroom had not worked since she was admitted five days prior and, as a result, she could not wash her hands. Observation revealed the soap dispenser was an electronic dispenser which should have dispensed hand soap when an individual's hand was placed under it. The soap dispenser did not function/dispense soap on 04/11/23 at 1:17 PM and 5:26 PM, on 04/12/23 at 10:35 AM, and on 04/13/23 at 10:46 AM. The bathroom with this non-functioning soap dispenser was off of R162 and R19's room. b. Observations on 04/11/23 at 1:08 PM, 04/12/23 at 9:19 AM and 12:07 PM and on 04/13/23 at 10:46 AM revealed the soap dispenser in R69 and R3's bathroom did not function properly, as it did not dispense soap. c. Observation on 04/11/23 at 1:10 PM, on 04/12/23 at 9:26 AM, and on 04/13/23 at 4:00 PM, revealed the soap dispenser in R5 and R17's bathroom did not function properly, as it did not dispense soap. On 04/13/23 at 10:46 AM, the Registered Nurse (RN) Manager for the 200 unit (RN1) verified the soap dispensers in R162 and R19' room, as well as R69 and R3's room, were not dispensing soap when her hand was placed under them. She stated the aides and nurses should have been using them and should have reported the dispensers did not work. She stated she was not aware of the broken dispensers prior to 04/13/23 at 10:46 AM, after surveyor intervention. On 04/13/23 at 4:02 PM, the Director of Nursing (DON) verified the soap dispenser in R5 and R17's room was not working and did not dispense soap when she placed her hand under it. She stated the staff should have noticed and reported it because they are expected to wash their hands after assisting the residents with toileting and/or after completing incontinence care. On 04/13/23 at 9:20 AM, the Maintenance Supervisor stated he was made aware of the issue with the soap dispenser in R162's bathroom and he was planning to put a battery in it. He stated it was the responsibility of the Housekeepers to check the soap and sanitizer dispensers and to report to him if they were not working. He stated he was not made aware of any malfunctioning soap dispensers until that morning. On 04/14/23 at 3:04 PM, LPN10 stated R162 used the bathroom independently; R17 and R19 were assisted with toileting by staff; and R3, R5, and R69 were incontinent and receive incontinent care.

Based on interview, record review, and review of the Facility Assessment, the facility failed to provide training/education on the required topic of dementia for five of five Certified Nurse Assistants (CNAs) reviewed under the Sufficient and Competent Nursing Staff facility task. This failure had the potential to leave staff unprepared to meet the needs of residents in the facility with a diagnosis of dementia. Findings include: Review of the Facility Assessment-Northern Cardinal, reviewed 02/2023, revealed, The purpose of the assessment is to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. Use this assessment to make decisions about your direct care staff needs, as well as your capabilities to provide services to the residents in your facility. Using a competency-based approach focuses on ensuring that each resident is provided care that allows the resident to maintain or attain their highest practicable physical, mental, and psychosocial well-being .it is to document common diagnoses or conditions in order to identify the types of human and material resources necessary to meet the needs of resident's living with these conditions or combinations of these conditions .Alzheimer's Disease, Non-Alzheimer's Dementia. During an interview on 04/14/23 at 12:30 PM, the Administrator stated the facility utilizes an online training system titled SNF [Skilled Nursing Facilities] Clinic to assist in providing the nursing staff with their annual and competency trainings. The Administrator provided training documentation for five sampled CNAs to be reviewed. Review of the training records for CNA8, CNA9, CNA10, CNA11, and CNA12 revealed these staff did not complete training on dementia care/management. The Administrator was asked to review and confirm if this documentation was correct. During an additional interview on 04/14/23 at 4:15 PM, the Administrator confirmed that there was no dementia training for the five sampled CNAs whose files were reviewed. Further interview with the Administrator revealed that she had been in the position since 11/2022 and there had not been any dementia trainings completed since she had been there because it was not included on the list of topics that staff were required to be trained on.

Based on interview, record review, and review of facility policy, the facility failed to provide the resident and/or resident representative with a written bed hold notice upon transfer to the hospital for two (Resident (R) 19 and R69) of three residents reviewed for hospitalization . Findings include: Review of the facility policy titled, Bed Hold Notice Upon Transfer, revised 12/01/22, revealed the facility will provide the resident and/or representative with a written notice which specifies the duration of the bed-hold policy and addresses information explaining the return of the resident to the next available bed. 1.Review of the Progress Note tab in R69's electronic medical record (EMR) revealed a progress note, dated 09/23/22 and timed 12:23 AM, which stated that at 10:45 PM, the resident was having a seizure that lasted 10 minutes. As a result, 911 was called and the resident was sent to the emergency room . An additional progress note, dated 09/23/22 and timed 8:07 AM, revealed the resident was admitted to the hospital. An admission progress note, dated 09/30/22 at 8:35 PM, revealed the resident was readmitted from the hospital. The resident's EMR was reviewed in its entirety and there was no evidence that a written bed-hold notice was provided at the time of the transfer to the hospital. Review of R69's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/03/23 revealed the resident was moderately cognitively impaired, based on a Brief Interview for Mental Status (BIMS) score of 8/15. Based on the resident's cognition, on 04/14/23 at 5:21 PM, R69's daughter/responsible party was called for an interview. She stated she did not receive any written notices when her father went to the hospital. On 04/13/23 at 3:56 PM the Director of Nursing confirmed a written bed hold notice was not provided when the resident was transferred to the hospital. The DON stated that she did not know the reason the required notice was not provided, adding that she, the Administrator, and Social Worker were all new to the facility. 2. Review of the Progress Note tab in R19's EMR revealed she had a nursing note, dated 03/27/23 at 12:54 AM, which stated 911 was called because the resident could not breathe. An additional progress note, dated 03/27/23 at 5:35 AM, revealed the resident was admitted to the hospital due to dyspnea. A progress note dated 03/29/23 at 6:16 PM revealed the resident was readmitted from the hospital. The resident's EMR was reviewed in its entirety and there was no evidence that a written bed-hold notice was provided for the time of the transfer to the hospital. Review of R19's quarterly MDS, with an ARD of 04/02/23, revealed R19 had a BIMS of 13/15, indicating the resident was cognitively intact. On 04/11/23 at 02:01 PM, R19 was interviewed. During the interview R19 stated she had been in the hospital recently. When asked if she received a written bed-hold notice, she stated she had not. On 04/13/23 at 3:56 PM the Director of Nursing confirmed a written bed hold notice was not provided to the resident/resident representative when the resident was transferred to the hospital.

Based on record review and interview, the facility failed to ensure the Minimum Data Set assessment accurately reflected the resident's status for three (Resident (R) 28, R73 and R211) of 55 sampled residents. The facility failed to ensure that alarm use, oxygen therapy, and falls were accurately coded to reflect the residents' devices, needs, and/or history. This failure placed the resident at risk for unmet care needs. Findings include: 1. Review of the Resident Assessment Instrument (RAI) 3.0 User's Manual revised 10/2019, stated The intent of this section [Section P] is to record the frequency that the resident was restrained by any of the listed devices or an alarm was used, at any time during the day or night, during the 7-day look-back period. Assessors will evaluate whether or not a device meets the definition of a physical restraint or an alarm and code only the devices that meet the definitions in the appropriate categories . Steps for Assessment: 1. Review the resident's medical record (e.g., physician orders, nurses' notes, nursing assistant documentation) to determine if alarms were used during the 7-day look-back period. 2. Consult the nursing staff to determine the resident's cognitive and physical status/limitations. 3. Evaluate whether the alarm affects the resident's freedom of movement when the alarm/device is in place. For example, does the resident avoid standing up or repositioning himself/herself due to fear of setting off the alarm . Coding Instructions: Identify all alarms that were used at any time (day or night) during the 7-day look-back period. After determining whether or not an item listed in P0200 was used during the 7-day look-back period, code the frequency of use . Code 0, not used: if the device was not used during the 7-day look-back period. Code 1, used less than daily: if the device was used less than daily. Code 2, used daily: if the device was used on a daily basis during the look-back period . Coding Tips .Wander/elopement alarm includes devices such as bracelets, pins/buttons worn on the resident's clothing, sensors in shoes, or building/unit exit sensors worn by/attached to the resident that activate an alarm and/or alert the staff when the resident nears or exits a specific area or the building. This includes devices that are attached to the resident's assistive device (e.g., walker, wheelchair, cane) or other belongings. Review of R73's Admission Record, located in the electronic medical record (EMR) located under the Profile tab, indicated the resident was admitted to the facility on [DATE] with diagnoses that included Alzheimer's Disease with late onset. Review of R73's Health Status Note dated 11/12/21 indicated a wander guard was placed to the resident's left ankle. Review of R73's Order Summary Report located in the EMR under the Orders tab revealed that since 11/16/21, the resident had an order for staff to Apply Secure Care Bracelet/WanderGuard for safety (Check for placement every shift. Check for functioning once per week [sic]. Review of R73's current Care Plan, located in the EMR under the Care Plan tab, revealed that since 11/29/21, the resident was assessed as at risk for elopement as evidenced by wandering and that he had a Secure Care Wander Guard in place for safety. Review of R73's quarterly Minimum Data Set (MDS) located in the EMR under the MDS tab with an Assessment Reference Date (ARD) of 03/20/23, revealed the resident was severely cognitively impaired, as evidenced by a Brief Interview for Mental Status (BIMS) score of three out of 15. Section G of the MDS indicated the resident required one personal limited assistance with transfers, and supervision for locomotion off/on the unit. Per Section P (Restraints and Alarms) of the MDS, a wander/elopement alarm was not used. Observations on 04/11/23 at 6:01 PM, 04/13/23 at 12:19 PM, and 04/14/23 at 10:14 PM revealed the current physician orders and care plan were being followed and R73 continued to have a wanderguard bracelet alarm in place to the left ankle. Interview with Registered Nurse (RN) 1 on 04/13/23 at 9:46 AM, Licensed Practical Nurse (LPN) 7 on 04/14/23 at 10:14 AM, and the Director of Nursing (DON) on 04/14/23 at 1:38 PM, confirmed that R32 had a wanderguard in place. During an interview on 04/14/23 at 10:05 AM, the MDS nurse (LPN10) stated that the facility uses the RAI manual for its policies and procedures. During the interview, LPN10 stated she overlooked R73 having a wanderguard in place (when coding the MDS) because its placement was not being signed off by nurses. LPN10 indicated that when the order was initially entered in the EMR, it was not marked for the nurses to document on the medication administration record (MAR) or treatment administration record (TAR) The MDS was not coded to indicate an alarm as it was their practice to review the MAR/TAR but not the physician's orders. 2. Review of the RAI 3.0 User's Manual, dated 10/2019, under Section J1800 revealed, Any Falls since Admission/Entry or Reentry or Prior Assessment, whichever is more recent- Coding Instructions-Code 1, yes: if the resident has fallen since the last assessment. The RAI Manuel further indicated, on Section J1900: Number of Falls Since Admission/Entry or Reentry or Prior Assessment- Steps for Assessment: Review all available sources for any fall since the last assessment .include medical records .nursing home incident reports .for falls and level of injury. Coding Instructions- Code 1, one: if the resident had non-injurious fall since .prior assessment. Review of a Face Sheet, found in R211's EMR under the Face Sheet tab, revealed R211 was admitted to the facility on [DATE] with diagnoses to include hemiplegia, unspecified affecting left nondominant side, cerebral infarction, and weakness. Review of R211's Quarterly MDS found in the EMR under the RAI tab with and ARD of 03/19/22 revealed the resident had no falls since admission to the facility. Review of a Progress Note found in R211's EMR under the Prog Note tab dated 04/22/22 indicated, Note Text: @ around 0930 [9:30 AM] resident found sitting on the floor in front of his wheelchair. Stated he tried to get OOB [out of bed] to wheelchair and it rolled from him. No apparent injury. Denied hitting head. 3 staff members to get up with sit and stand .Reeducated on importance if [sic] calling for help OOB also reeducated on making sure brakes engaged on wheelchair with transfer. Review of R211's Quarterly MDS found in the EMR under the RAI tab with an ARD date of 06/19/22 revealed on Section J1800- Any Falls since .Prior Assessment. No. The MDS further indicated on Section J1900- Number of falls since Admission/Entry or Prior Assessment: None. The MDS did not include reflect the fall that R211 sustained on 04/22/22. During a phone interview on 04/12/23 at 2:30 PM, regarding the fall that took place on 04/22/22, R211 stated, I had a stroke. From what I recall, I was falling. I fell off the bed once and I needed help off the floor. I don't remember any specifics of that fall. During an interview on 04/13/23 at 10:21 AM, regarding the inaccurate coding of the MDS, the MDS Coordinator stated, If we are doing a quarterly MDS, we are supposed to look at all information such as nurse's notes, and any risk management notes that are completed. If the resident is alert and oriented, we will talk with them as well. We try to keep it as factual what was actually seen. The MDS Coordinator then stated, With the Quarterly MDS dated [DATE] on Section J, it says no falls. We would expect to see that fall he [referring to R211] had on 04/22/22 coded on the 06/19/22 quarterly assessment. A modification will need to be done to the MDS because it's incorrectly coded. The MDS Coordinator stated, Our process is, if that resident was still here and I were here at the time, I would have had a correction made. She then indicated, I didn't see any additional notes and this quarterly should have been coded correctly. 3. Review of the RAI 3.0 User's Manual revised 10/2019, stated O0100C, Oxygen therapy - Code continuous or intermittent oxygen administered via mask, cannula, etc., delivered to a resident to relieve hypoxia in this item. Code oxygen used in Bi-level Positive Airway Pressure/Continuous Positive Airway Pressure (BiPAP/CPAP) here. Do not code hyperbaric oxygen for wound therapy in this item. This item may be coded if the resident places or removes his/her own oxygen mask, cannula. Observations on 04/11/23 at 1:12 PM, 04/12/23 at 10:35 AM, 04/12/23 at 11:22 AM, and 04/13/23 at 11:13 AM revealed R28 was receiving oxygen via nasal cannula. Review of R28's current Order Summary Report located in the EMR under the Orders tab revealed an order since 12/22/22, for oxygen continuous at two liters per minute (LPM) via nasal cannula every shift for medical diagnosis of wheezing and shortness of breath. Review of R28's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/14/23 revealed it did not include the use of oxygen therapy. During an interview on 04/12/23 at 11:22 AM with R28's family member, they stated that R28 had had a stroke prior to admission in 2022, then was hospitalized from 03/27/23-04/01/23 with a diagnosis of pneumonia. The family member confirmed that R28 had been on oxygen prior to his initial admission in 2022 and continued on oxygen throughout his stay in the facility. During an interview on 04/14/23 at 10:05 AM, the MDS nurse (LPN10) stated that the facility uses the RAI manual for its policies and procedures.

Based on interview, record review, and facility policy reviews, the facility failed to ensure that three (Resident (R) 38, R62, and R414) of five residents reviewed for vaccine administration, were offered and/or received the pneumococcal series and/or influenza vaccination. Specifically, R38 was not educated or offered the pneumococcal series or influenza vaccination, R62 was not educated or offered the pneumococcal series, and R414 was not offered the influenza vaccination. Findings included: Review of the facility's Immunization Informed Consent Record, revised 2020, revealed a statement that said, I certify that I have received relevant Vaccine Information Statements (VIS) that provide current CDC [Center for Disease Control] information about the vaccine(s) I have elected to receive. I further certify that the benefits and potential side effects of such immunization(s) have been thoroughly explained to me and I do understand such information . Place the original signed and dated copy of this form in the individual's permanent medical record. If requested, provide photocopy of this record to the individual or his/her legal representative. Review of the facility's policy titled, Influenza Vaccination, revised 12/01/22, revealed, It is the policy of this facility to minimize the risk of acquiring, transmitting or experiencing complications from influenza by offering our residents, staff members, and volunteer workers annual immunization against influenza . 2. Influenza vaccinations will be routinely offered annually from October 1st through March 31st unless such immunization is medically contraindicated, the individual has already been immunized during this time period or refuses to receive the vaccine . 4. Prior to the administration of the influenza vaccine, the person receiving the immunization, or his/her legal representative, will be provided with a copy of CDC's current vaccine information statement relative to the influenza vaccination . 6. Individuals receiving the influenza vaccine, or their legal representative, will be required to sign a consent form prior to the administration of the vaccine. The completed, signed, and dated record will be filed in the individual's medical record . 8. The resident's medical record will include documentation that the resident and/or the resident's representative was provided education regarding the benefits and potential side effects of immunization, and that the resident received or did not receive the immunization due to medical contraindication or refusal . Education regarding immunizations has been implemented. Review of the facility's policy titled, Pneumococcal Vaccine (Series), revised 12/01/22, revealed, It is our policy to offer our residents and staff immunization against pneumococcal disease in accordance with current CDC (Center for Disease Control) guidelines and recommendations . 8. The resident's medical record shall include documentation that indicates at a minimum, the following: a. The resident or resident's representative was provided education regarding the benefits and potential side effects of pneumococcal immunization. b. The resident received the pneumococcal immunization or did not receive due to medical contraindication or refusal. Review of the facility's Admission Packet provided by the facility revealed it did not include information provided to the resident or responsible party regarding immunizations. 1. Review of R38's Admission Record, located in the electronic medical record (EMR), under the Profile tab, revealed the resident was admitted to the facility on [DATE] with a primary diagnosis of sepsis. Review of R38's EMR under the Immunizations tab revealed no immunization history. Review of documents under the Misc[ellaneous] tab also revealed no evidence that this resident was offered, accepted, or declined the influenza or pneumococcal vaccine series. Review of R38's Snapshot, located in the EMR under the Misc tab, indicated that the influenza vaccine and pneumococcal series were never given while the resident was hospitalized [DATE]-[DATE]. On 04/12/23 at 8:31 AM, R38 declined an interview. During an interview on 04/14/23 at 5:29 PM, the Assistant Director of Nurses/Infection Preventionist (ADON/IP) was unable to locate R38's admission packet or declination forms to determine if R38 was educated and offered the influenza vaccine and pneumococcal series. The ADON/IP confirmed that R38 should have been offered and educated on the influenza vaccine due to her being admitted before March 31st. In addition, per the ADON/IP, the resident should have been offered the pneumococcal series due to her being over age 65. 2. Review of R62's Admission Record, located in the EMR under the Profile tab, indicated that the resident was admitted to the facility on [DATE] with a primary diagnosis of sepsis. Review of R62's EMR under the Immunizations tab revealed that a tuberculosis screening was given on 04/04/23. There was no documentation to indicate that the resident was offered, accepted, or declined the pneumococcal series. Review of R62's Hospital History and Physical, located in the EMR, under the Misc tab and dated 04/03/23, did not contain any immunization history. R62 was lethargic and unable to be interviewed regarding immunization status on 04/11/23 at 1:33 PM, 04/11/23 at 5:12 PM, and 04/12/23 at 2:55 PM. During an interview on 04/14/23 at 6:27 PM, the ADON/IP was unable to locate R62's admission packet or declination forms to determine if R62 was educated and offered the pneumococcal series. The ADON/IP confirmed that R62 should have been offered and educated on the pneumococcal series due to him being over age 65. 3. Review of R414's Admission Record, located in the EMR under the Profile tab, indicated the resident was admitted to the facility on [DATE] with a primary diagnosis of fractured left femur. Review of R414's Snapshot, located in the EMR under the Misc tab, indicated that the influenza vaccine was never provided while hospitalized [DATE]-[DATE]. Review of R414's EMR under the Immunizations tab revealed no immunization history. In addition, review of documents under the Misc tab revealed no evidence that the resident was offered, accepted, or declined the influenza vaccine. R414 was not available for interview on 04/14/23 during immunization review due to having been discharged from the facility on 04/13/23. During an interview on 04/14/23 at 6:39 PM, the ADON/IP confirmed that R414 had no documentation available to confirm that she had been educated or offered the influenza immunization. The ADON/IP confirmed that R414 should have been offered and educated on influenza immunizations. During the interview conducted on 04/14/23 at 6:39 PM, the ADON/IP stated that the Admission Coordinator who works off-site was responsible for asking new admissions if they would like to receive immunizations to include pneumococcal and influenza vaccinations Additionally, the clinical nurse performing the resident's admission would ask the resident or their responsible party if they would like to receive any appropriate immunizations to include pneumococcal, and influenza vaccines. The ADON/IP stated that it had not been her practice to offer pneumococcal or influenza immunizations for residents that were not currently vaccinated against the viruses. The ADON/IP did not give an explanation as to why she did not follow up with residents regarding their immunization status. During an interview on 04/14/23 at 6:46 PM, Licensed Practical Nurse/ Unit Manager (LPN2) stated that any resident that agreed to receiving an immunization would sign a consent form; if the resident was non-verbal the family would be contacted to receive consent or declination of vaccinations, Per LPN2, during flu season all residents are offered the influenza immunization, and all residents over 65 are offered the pneumococcal vaccine. LPN2 stated that, in addition, the Social Worker or Admission Coordinator would have the resident fill out the consent or declination forms; however, she was not sure where the forms were kept after obtaining signatures from residents or responsible parties. LPN2 was not able to locate R414's admission packet to determine if education or declination of the and influenza immunization was provided. The Admission Coordinator was not available for interview during the survey process. During an interview on 04/13/23 at 2:46 PM, the Social Worker stated that she had only worked at the facility for about a week and was supposed to be receiving training this week regarding her responsibilities during the new admission process. As of the time of the interview, the Social Worker stated that she had not been involved in the admission process.

Based on interview, record review, and review of facility policy, the facility failed to timely notify the families of two (Resident (R) 63 and R73) of 57 sampled residents by 5:00 PM the following day when the residents tested positive for COVID-19. Findings include: Review of the facility policy titled, Coronavirus Prevention and Response revised 07/18/22, stated, Notify physician, Director of Nursing, Infection Preventionist, and family. Review of the facility's document titled COVID-19 Action Plan revised 02/15/22. stated, Facility will notify and document Medical Director, attending physician, resident and family of positive COVID-19 case/s in the facility as well as emergency plans initiated. Notifications to be documented in PCC [Point Click Care electronic medical record] for residents . Communication plan is activated, and staff are assigned to contact family members at least weekly with updates. Review of the policy titled Notification of Changes with a revised date of 12/01/22 revealed it was the facility's policy to notify the family member/legal representative when there is a change in the resident's condition. 1. Review of the facility document titled Resident Line List of resident's testing positive for COVID-19 revealed R73 tested COVID-19 positive on 02/21/22. Review of R73's Progress Note located in the EMR under the Progress Notes tab, dated 02/24/22 and 02/25/22 indicated R73's spouse was notified that all staff tested negative for COVID-19 and that two residents tested positive for COVID-19. However, there was no evidence that R73's spouse was notified by 5:00 PM the following day when the resident tested positive for COVID-19 on 02/21/22. During an interview on 04/11/23 at 3:03 PM with R73's responsible party, she stated she was not informed when her husband testing positive for COVID-19 in February 2022. She stated she did not find out about the results until her son told her about it. The RP stated that currently the facility sends out notifications via text messages when there is a positive COVID-19 case in the building. During an interview on 04/12/23 at 9:29 AM with the Director of Nursing (DON), she stated the facility was currently using the Care Feed program through the Electronic Medical Record (EMR) that calls the phone number on file for the resident's responsible party, also has option to send a text message. During an interview on 04/14/23 at 3:32 PM, the Assistant Director of Nurses (ADON) confirmed that R73 tested positive for COVID-19 on 02/21/22. The ADON also confirmed that although the spouse was notified on 02/24/22 that all staff tested negative and two other residents tested positive, there was no evidence to indicate staff notified the spouse when her husband tested positive for COVID-19 on 02/21/22. The ADON stated that it was the facility's policy for the nurses to report any changes in condition/COVID-19 cases on the 24 hour report document and to report to the responsible party (as well as the physician) any positive results. During an interview on 04/14/23 at 4:00 PM, the Regional Director of Operations (RDOR) stated that the facility started using Care Feed on 08/26/22 (after R73's COVID-19 diagnosis.). Per the RDOR, prior to that date, Eastern Healthcare Group purchased the facility on 12/01/21 and they were doing phone notifications when a resident or staff was diagnosed with COVID-19. During an interview on 04/14/23 at 4:14 PM with the Administrator, she stated she would provide a copy of the 24 hour report to see if there was evidence that the nurse on duty reported when R73 tested positive for COVID-19. However, the document was not provided prior to exit. 2. Review of the Progress Notes tab in the EMR revealed that on 03/14/23 at 12:13 PM, a nurse stated that R63 tested positive for COVID 19 and the physician was notified. There was no evidence that the family/responsible party was also notified that the resident tested positive. Interview on 04/14/23 at 9:30 AM with R63's responsible party confirmed that on 03/14/23, her mother tested positive for COVID and no one called her and informed her. On 04/14/23 at 10:48 AM the Administrator stated the family/responsible party should have been notified when the resident tested positive for COVID 19, and confirmed there was no documentation available to show that this occurred.

Based on observation, staff interviews and facility documentation review the facility staff failed to ensure a bottle of medication (Aspirin 81 mg) was stored in a secured location, accessible to designated staff only. The findings included: On 04/12/23 at 11:25 a.m., a bottle of medication was observed on top of Medication Cart two (2) on the Chesapeake Unit. The nurse assigned to Cart 2 was not in view of the medication cart. The bottle of medication was observed for 4 minutes on top of the medication cart as residents, staff and visitors walked past. On the same day, the Assistant Director of Nursing (ADON) and Unit Manager arrived at the medication cart at 11:29 a.m. They were asked if the bottle of medication left on top of the cart unattended contained any medication. The ADON picked up the bottle of medication; shook the bottle and stated, Yes, there's medication inside the bottle. The ADON stated the medication was Aspirin 81 mg tablets. The ADON stated mediation should never be left on top of the medication when not in direct view. She stated the medication should have been placed inside the medication cart and the cart always locked when in view of the nurse. The ADON stated by the medication left on top of the medication cart and not in view of the nurse puts the residents at risk for harm. An interview was conducted with the Director of Nursing (DON) on 04/14/23 at 12:30 p.m. She was informed that a bottle of Aspirin was left unattended on top of the medication cart of the Chesapeake Unit. On 04/14/23 at 7:45 p.m., the Administrator was informed of the above findings. No further information was provided prior to exit. The facility's policy titled Medication Storage revised on 12/01/22. It is the policy of the facility to ensure all medications housed on our premises will be store in the pharmacy and/or medication rooms. Policy Explanation and Compliance Guidelines 1. General Guidelines: (a.) All drugs and biological's will be stored in locked compartments) i.e., medications carts, cabinets, drawers, refrigerators, medications rooms.)

Based on interview, record review, and facility policy review, the facility failed to provide required education and offer immunization to one (Resident (R) 414) of five residents reviewed for immunizations. Specifically, the facility failed to provide education and offer the COVID-19 vaccine to the resident. Findings include: Review of the facility's policy titled, Coronavirus Prevention and Response, revised 07/18/22, revealed, 11. Vaccination Planning a. All facility staff and residents will be encouraged to get vaccinated against SARS-CoV-2. Review of the facility's policy titled, COVID-19 Action Plan, revised 02/15/22, revealed, All residents are to be offered and provided a COVID-19 vaccination(s) as indicated. Any resident who refuses vaccination must have a declination form documented. Education regarding vaccinations must also be offered and recorded in the medical record. Review of R414's Admission Record, located in the electronic medical record (EMR) under the Profile tab, indicated the resident was admitted to the facility on [DATE] with a primary diagnosis of fractured left femur. Review of R414's Snapshot, located in the EMR under the Misc[ellaneous] tab, indicated that the COVID-19 vaccine was never provided while the resident was hospitalized [DATE]-[DATE]. Review of R414's EMR under the Immunizations tab revealed no immunization history; review of documents under the Misc tab revealed no evidence that the resident was offered, accepted, or declined the COVID-19 vaccine. R414 was not available for interview on 04/14/23 during immunization review due to having been discharged from the facility on 04/13/23. During an interview on 04/14/23 at 6:39 PM, the Assistant Director of Nurses (ADON)/ Infection Preventionist (IP) stated that the Admission Coordinator that works off-site was responsible for asking new admission residents if they would like to receive immunizations, including the COVID-19 vaccination. Additionally, the clinical nurse performing the resident's admission was to ask the resident or their responsible party if they would like to receive any appropriate immunizations, including the COVID-19 vaccine. The ADON/IP stated that it had not been her practice to offer COVID-19 immunizations for residents that were not currently vaccinated against the virus. The ADON/ IP confirmed that R414 had no documentation available to confirm that she had been educated or offered the COVID-19 vaccine. The Admissions Coordinator was not available for interview on 04/14/23 at 6:39PM. During an interview on 04/14/23 at 6:46 PM, Licensed Practical Nurse (LPN) 2 stated that any resident that had agreed to receiving an immunization would sign a consent form; if the resident was non-verbal the family would be contacted to receive consent or declination of vaccinations. Additionally, the Social Worker or Admission Director would have the resident fill out the consent or declination forms; however, she was not sure where the forms were kept after obtaining signatures from residents or responsible parties. LPN2 was not able to locate R414's admission packet to determine if education was provided, the vaccine was offered, and the resident accepted or declined the vaccine. During an interview on 04/13/23 at 2:46 PM, the Social Worker stated that she had only worked at the facility for about a week and was supposed to be receiving training this week regarding her responsibilities during the new admission process. As of the time of the interview, the Social Worker stated that she had not been involved in the admission process.

Based on resident and staff interview, clinical record review and facility document review, the facility staff failed to ensure 1 of 57 residents (Resident #312) in the survey sample were free of significant medication errors. The findings included: The facility staff failed to ensure the following significant medication Seroquel was administered as ordered to Resident #312. Diagnosis included but not limited to dementia without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety. A review of the Brief Interview for Mental Status (BIMS) admission assessment scored a 13 out of a possible 15 indicating moderate cognitive skills for daily decision-making. Resident #312's care plan created on 04/11/23 identified the resident uses anti-psychotropic medications. The goal set for the resident by the staff was that the resident will be/remain free of psychotropic drug related complications, including movement disorder, discomfort, hypotension, gait disturbance, constipation/impaction, or cognitive/behavioral impairment. Some of the interventions/approaches the staff would use to accomplish this goal is to administer psychotropic medications as ordered by the physician, monitor for side effects and effectiveness every shift. During the review of Resident #312's Medication Administration Record (MAR) for April 2023 revealed the following medication (Seroquel) to be administered twice a day at 9:00 a.m., and 9:00 p.m. Further review of the April 2023 MAR, revealed evidence the medication Seroquel was not administered on 04/08/23 at 9:00 a.m., 04/09/23 at 9:00 a.m., and 9:00 p.m. An interview was conducted with the Director of Nursing (DON) on 04/14/23 at 12:30 p.m. She stated when a new admission comes into the facility and pharmacy had not delivered the residents medication, the first thing the nurse should do is check the Cubex machine to see if the medication is available. She stated if the medication is available, the medication is to be pulled and administered to the resident. If the medication is not available in the Cubex, pharmacy is to be contacted to see when the medication is going to be delivered. She said the physician is to be informed the medication was not available to be administered. She said Resident #312 is taking an antipsychotic medication which cannot be suddenly stopped especially with her admitting diagnosis. The DON reviewed the list of all medications in the Cubex. After the list was reviewed, the DON stated there were 14 tablets of Seroquel 25 mg available to be administered. On 04/14/23 at 7:45 p.m., the Administrator was informed of the above findings. No further information was provided prior to exit. The facility's polity titled Medication Administration revised on 12/01/22. It is the facility policy for medications are administered by license nurses, or other staff who are legally authorized to do so in the state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. Definitions: -Seroquel tablets and extended-release tablets are also used alone or with other medications to treat episodes of mania (frenzied, abnormally excited or irritated mood) or depression in patients with bipolar disorder (manic depressive disorder; a disease that causes episodes of depression, episodes of mania, and other abnormal moods) ( (https://medlineplus.gov/ency/article/007365.htm).

Based on interview, record review, and facility policy review, the facility failed to ensure that medication irregularities identified by the consultant pharmacist were acted upon for two (Resident (R)35 and R80) of five residents reviewed for unnecessary medication use. The failure to ensure that the physician reviewed and responded to the pharmacist's recommendations placed the residents at risk for unnecessary medications and associated side effects. Findings include: Review of an undated document provided by the facility titled Addressing Pharmacy Recommendations revealed Step 1: Pharmacy recommendations are given to the prescriber/physician. The Director of Nursing (DON) or designee ensure that pharmacy recommendations are delivered to the prescriber/attending physician in a timely manner .Step 2: Nursing to follow through per prescriber's response. DON or designee ensures that recommendations signed by the prescriber are acted upon in the medical record .Step 3: Maintaining a record of addressed pharmacy recommendations. DON or designee ensures that all pharmacy recommendations, once acted upon, are included in the patient's medical record .A copy of all pharmacy recommendations, once acted upon, should also be maintained by the DON. 1. Review of R35's Admission Record, located in the electronic medical record (EMR) under the Profile Tab, indicated the resident was admitted to the facility on [DATE] with medical diagnosis of encephalopathy and dementia with other behavioral disturbances. Review of R35's Pharmacy Notes under the Progress Notes tab revealed the following statement under every monthly medication review for the last year: Pharmacy Note: MRR [Medication Regimen Review] completed: Medical Record Reviewed including orders, progress notes, labs: See consultant pharmacist report for consult on any noted irregularities and/or recommendations. There was no other documentation found in R35's EMR to indicate the specifics of what the pharmacist recommended or the physician's response. 2. Review of R80's Admission Record, located in the EMR under the Profile tab indicated the resident was admitted to the facility on [DATE] with diagnosis of paraplegia, acute kidney failure, anxiety disorder, and major depressive disorder. Review of R80's Pharmacy Notes under the Progress Notes tab revealed the following statement under every monthly medication review for the last year: Pharmacy Note: MRR completed: Medical Record Reviewed including orders, progress notes, labs: See consultant pharmacist report for consult on any noted irregularities and/or recommendations. There was no other documentation found in R80's EMR to indicate what the recommendations were or the physician's response to each recommendation. During an interview on 04/13/23 at 10:29 AM with the Director of Nursing (DON), she was asked to provide the consultant pharmacy reports that were referenced in the resident's EMRs. Interview with the DON revealed that the facility did not have evidence of any pharmacy recommendations for these residents. An additional interview was conducted with the DON on 04/13/23 at 4:07 PM during which the facility's Regional Director of Clinical Services (RDCS) was also present. The DON confirmed that the facility could not find any evidence of physician response to pharmacy recommendations prior to March 2023, when the DON began employment. The DON stated that in response to the survey team's request for pharmacy recommendation, they contacted the pharmacist, who was able to provide some documentation regarding her recommendations. Review of the documentation the DON provided from the pharmacist revealed that a recommendation for a gradual dose reduction (GDR) was made on 12/21/22 to reduce R35's Seroquel 25 milligrams from twice to once a day. The DON stated that The doctor must not have agreed to this because [R35's] medications have not changed. However, the DON could provide no evidence that the physician responded to this recommendation and provided a rationale as to why a GDR was clinically contraindicated. Review of R35's EMR revealed no documentation to determine the doctor's response and R35 continued to take the Seroquel as originally prescribed from December 2022 through the present. During the interview on 04/13/23 at 4:07 PM, the DON also provided information from the pharmacist that a GDR recommendation was made on 12/21/22 to reduce R80's Xanax, Effexor, and Risperdal. The DON stated the doctor must not have agreed with the Xanax recommendation because there was no change to the medication; however, the DON could provide no evidence that the physician responded to this recommendation and documented why a GDR was not indicated. During an interview on 04/14/23 at 10:38 AM, the Administrator confirmed the importance of having documentation of the physician's response to pharmacy recommendations, stating, I know. They really need a system. During a phone interview on 04/14/23 at 2:29 PM with the facility's pharmacist, she stated that the process for her recommendations should go as follows: She completes the medication review and gives it to the facility. The facility then gives it to the physician, and he will agree or disagree with the recommendation and respond on the document the pharmacist gave to the facility. The facility is then supposed to either keep the signed response in a binder or scan it into the resident's EMR. During a phone interview on 04/14/23 at 3:55 PM with the facility's Medical Director (MD), he revealed how he responds to the pharmacist's MMRs. He stated he receives the reports monthly and either agrees or disagrees with the recommendations and documents his rationale on the form provided by the pharmacy. The MD stated either the DON or pharmacist places the forms in folders located behind the receptionist's desk until he signs them. The forms are then given to the DON to scan or file. During an additional interview on 04/14/23 at 4:15 PM with the DON, she verified the physician's folder did not contain the physician's responses to the pharmacist's recommendations. The DON provided a binder she began when she started employment; however, it only contained one physician response. The DON verified she did not have the other physician's responses requested.

Based on observation, interview, record review, and facility policy review, the facility failed to provide oxygen therapy as needed for one (Resident (R) 28) of two residents reviewed who required respiratory care received out of a total sample of 57 residents. Oxygen was not continuously delivered at the rate ordered by the physician and was removed by staff who were not qualified to perform this task. Findings include: Review of the facility's policy titled, Oxygen Administration, revised 12/01/22, revealed, Oxygen is administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plans, and the residents' goals and preferences . 2. Personnel authorized to initiate oxygen therapy include physicians, RNs [Registered Nurse], LPNs,[Licensed Practical Nurse] and respiratory therapists. Review of R28's Admission Record, located in the electronic medical record (EMR) under the Profile tab, indicated R28 was originally admitted to the facility on [DATE] and readmitted to the facility on [DATE]. The resident had primary diagnosis of protein calorie malnutrition and co-morbidities including cerebral infarction, congestive heart failure, dependence on supplemental oxygen, and pulmonary disease. Review of R28's current Order Summary Report located in the EMR under the Orders tab revealed an order dated 12/22/22 for oxygen continuous at two LPM via nasal cannula every shift for medical diagnosis of wheezing and shortness of breath. Review of R28's initial admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) RD of 12/27/22 indicated the resident required oxygen therapy prior to admission and while a resident at the facility. Review of R28's quarterly Minimum Data Set (MDS) located in the EMR under the MDS tab with an Assessment Reference Date (ARD) of 03/14/23 had a Brief Interview for Mental Status (BIMS) score of 11 out of 15 indicating the resident was moderately cognitively impaired. The quarterly MDS did not include the use of oxygen therapy. (Cross-reference F641.) Review of R28's Care Plan revised on 01/03/23 included use of oxygen therapy related to ineffective gas exchange. Interventions included monitoring for signs/symptoms of respiratory distress, use of accessory muscles, oxygen settings at 2 liters per minute (LPM) via nasal cannula, positioning resident to facilitate ventilation, and proper positioning. Review of R28's AHR- Admission/Re-Admission Screening- V5 document located in the EMR under the Assessment tab and dated 04/01/23 revealed R28 required oxygen at 3 LPM via nasal cannula. During an observation on 04/11/23 at 1:12 PM, R28 was in bed receiving wearing oxygen via nasal cannula at 3.5 LPM. A therapist was working with R28 at the time of this observation. During an observation and interview on 04/12/23 from 10:35 AM-11:17, AM R28 was receiving wound care from LPN1. Certified Nursing Assistant (CNA) 1 had just finished providing a bed bath to R28. R28 was noted to be lying on his left side, unclothed, with the bed flat. The resident's oxygen concentrator was on; however, the oxygen tubing with the nasal cannula was lying on the mattress near the side rail to the resident's right side and was not in use. LPN1 completed wound care, and the two staff members dressed the resident, and repositioned him in bed. When LPN1 was asked how long R28 had been without his oxygen, she stated she did not know. CNA1 stated the resident had been off of his oxygen for approximately 20 minutes prior to the nurse arriving in the room at 10:35AM. CNA1 stated she had removed the resident's oxygen tubing so she could provide a bed bath and forgot to put it back on. At 11:02 AM, LPN1 obtained a pulse oximeter from the nursing cart, checked R28's oxygen saturation levels, and obtained a reading of 83%. At 11:07 AM R28's oxygen saturation levels had increased to 93% when he was provided 4 LPM oxygen via nasal cannula. At 11:17 AM, LPN1 stated she had not noticed R28's oxygen was not in place due to him being turned over for wound care. Interview with the two staff revealed that neither staff was familiar with the oxygen policy at the time of this interview. During an interview on 04/13/23 at 11:05 AM, CNA4 stated that CNAs are not allowed to disconnect or reconnect oxygen tubing for any resident and that this was a nursing task only. Per CNA4, CNAs were allowed to reposition the cannula if it was loose in the nares, but that was the only exception. During an interview on 04/11/23 at 11:08 AM, CNA5 also stated that CNAs are not allowed to disconnect any oxygen tubing from residents. During an interview on 04/13/23 at 4:00 PM, CNA2 stated that CNAs are not allowed to disconnect any oxygen tubing from residents and if needed, it would need to be done by a nurse. During an interview on 04/13/23 at 4:09 PM, LPN3 stated that only nurses are allowed to connect and disconnect oxygen for a resident, and CNAs are not allowed to do so. During an interview on 04/13/23 at 4:37 PM, CNA3 stated that CNAs were allowed to temporarily remove oxygen tubing from a resident and then immediately put it back on, such as when they are changing their shirt/hospital gown; otherwise, the nurse would have to start or stop oxygen administration. During an additional interview on 04/13/23 at 4:51 PM with CNA1, she stated that the facility allows for the CNAs to remove and reapply oxygen tubing. When asked about the observation on 04/12/23, CNA1 confirmed that R28 was off of his oxygen for at least 20 minutes while she was performing a bed bath. CNA1 stated that after the bath, the wound care nurse and surveyor came into the room and she forgot to put the oxygen back on R28. During an interview on 04/14/23 at 1:30 PM, the Director of Nursing (DON) stated that CNAs were not allowed to connect or disconnect oxygen tubing for any resident and that was a clinical nurse's responsibility.

Based on observation, staff interview and clinical record review the facility staff failed to ensure 2 residents out of 57 (Resident #57 and 74) in the survey sample who was unable to carry out activities of daily living receives the necessary services to maintain fingernail care and showers. The findings included: 1. Resident #57 was admitted to the facility on [DATE]. Diagnosis included but not limited to Alzheimer's disease, dementia, cerebrovascular accident (CVA) with right sided hemiplegia and hemiparesis. The current Minimum Data Set (MDS) a quarterly assessment with an Assessment Reference Date (ARD) of 02/03/23 coded the resident with a 00 out of a possible score of 15 on the Brief Interview for Mental Status (BIMS), indicating severe cognitive impairment. The MDS coded Resident #57 required total dependence of one with dressing and bathing, extensive assistance of one with bed mobility, transfer, toilet use and personal hygiene and supervision with eating for Activities of Daily Living (ADL) care. Resident #57's comprehensive care plan revised on 07/30/22 indicated the resident has ADL care performance deficit related to CVA with left and right hemiparesis and hemiplegia. The goals the facility staff set for the resident will improve current level of functioning in bed mobility, transfers, eating, dressing, toilet use and personal hygiene. Some of the interventions included but are not limited the resident requires extensive staff participation with personal hygiene and oral care. During the initial tour on 04/11/23 at approximately 2:11 p.m., Resident #57 was in her wheelchair sitting in the doorway of her room. The residents' fingernails were very long and rigged with a brown substance under each fingernail. The resident held out her hands while shaking her head back and forth. When asked if she wanted her fingernails cut and cleaned, she stated, Oh yes. On 04/12/23 at 10:15 a.m., Resident #57's fingernails remained unchanged. On 04/13/23 at 9:30 a.m., Resident #57's fingernails remained long and rigged with a brown substance under each fingernail. On the same day at approximately 3:00 p.m., the resident fingernails were assessed with Certified Nursing Assistant (CNA) #3. The CNA said Resident #57's fingernails are long and dirty; she will take care of them right now. The resident replied, Thank you, thank you, thank you. An interview was conducted with the Director of Nursing (DON) on 04/14/23 at 1:05 p.m. She stated the CNAs are to inspect the resident's fingernails during ADL care every day; that is part of the resident daily hygiene. On 04/14/23 at 7:45 p.m., the Administrator was informed of the above findings. No further information was provided prior to exit. The facility's policy titled Activities of Daily Living (ADL's) revised on 12/01/22. Policy: The facility will ensure a resident's abilities in ADL's do not deteriorate unless deterioration is unavoidable this included but is not limited to bathing, dressing, and grooming. Policy Explanation and Compliance Guidelines: 3. A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal care oral hygiene. 46585 2. The facility failed to ensure that one (Resident (R) 74) resident who was dependent on staff for assistance with Activities of Daily Living (ADL) received care in accordance with assessed preferences and needs. R74, who needed assistance from staff with bathing, did not receive showers as scheduled. Review of the policy titled, Activities of Daily Living, dated 12/1/22, revealed, A resident who is unable to carry out activities of daily living will receive the necessary services to maintain .grooming, and personal and oral hygiene. Review of the policy titled, Bathing a Resident, dated 12/1/22, revealed It is the practice of this facility to assist residents with their choice of bathing/hygiene options to maintain proper hygiene and help prevent skin issues .Complete the Resident Body Scan Tool and give to nurse .Record care provided in Point Click Care Point of Care. Review of R74's electronic medical record (EMR) Admission Record, located under the Profile tab. indicated the resident was admitted to the facility on [DATE] with diagnoses including colostomy, morbid (severe) obesity due to excess calories, muscle weakness, difficulty in walking, chronic obstructive pulmonary disease, and anxiety disorder. Review of R74's annual 09/21/22 Minimum Data Set (MDS), with an Assessment Reference Date (ARD) located under the MDS tab, revealed that the resident's bathing preferences (choice between showers, bed baths, etc.) were very important. A quarterly MDS with an ARD of 02/27/23 revealed a Brief Interview for Mental Status (BIMS) score of 15/15, indicating R74 was cognitively intact. The assessment indicated R74 required extensive assistance for showering/bathing. Per the MDS, the resident had no rejection of care during the assessment period. Review of R74's Progress Notes under the Progress Notes tab from 04/14/23 through 03/01/22 (over one year) revealed R74 has only refused a shower on two occasions. During an interview on 04/11/23 at 5:20 PM, R74 and his wife both stated they have a concern regarding him not receiving enough showers. R74 stated I feel like I've only had about two or three full showers since I was admitted . R74's wife stated she had brought this concern to the attention of staff on at least one other occasion. R74 stated he had probably received a bed bath approximately fifty percent of the days he was supposed to. R74 stated he would like to have more showers. During the interview, the resident was observed to be wearing clean clothes. He had no odor but was observed to need a shave. Interview on 04/13/23 at 9:26 AM with Registered Nurse (RN) 1, (the Unit Manager), revealed R74 is to receive a shower on Mondays and Thursdays between the hours of 7:00 AM and 7:00 PM. RN1 stated the Certified Nurse Aides (CNAs) are supposed to offer R74 a bath/shower and document the outcome on the resident's shower sheet (Resident Body Scan Tool). RN1 stated the CNAs are supposed to write on the form if the resident refused a shower, or if a bed bath was preferred. RN1 stated that if the form has no additional documentation, that means the resident received a shower. RN1 observed there were only three shower sheets in the binder for R74, indicating he received a shower on 03/30/23, 04/03/23, and 04/06/23. RN1 stated the facility just recently started completing these forms again, so she then looked up R74's showers/baths in his EMR under the Tasks tab titled, Showering/Bathing. Review of this tab revealed R74 had only had nine showers/baths since 09/15/21. RN1 stated, Well that's not good. She stated she had only been at this facility since 03/06/23 and was aware the CNAs were not good at documenting showers prior to her arrival. When RN1 was asked if she thought this was an acceptable number of showers to receive, she stated Maybe. During an interview on 04/13/23 at 9:45 AM with CNA7 and CNA8, they stated they are both responsible for R74's showers. Both CNA7 and CNA8 stated R74 gets a bed bath every day per his choice. They stated R74 will sometimes refuse showers due to his colostomy bag because he doesn't want to get it wet. CNA8 said [the showers] get documented on the shower sheets if it's on his scheduled shower day. If it's in between [R74's] scheduled shower days, it gets documented in PCC [Point Click Care]. CNA8 stated that [R74's] PCC is all messed up because there's no ADLs in there. Both confirmed there were only 3 shower sheets for this resident in the binder. During an additional interview on 04/14/23 at 8:15 AM with R74, he stated he did not get his scheduled shower on Monday, 04/10/23. R74 stated that he did not get one on Thursday, 04/13/23 either because staff told him We can't find the shower bed. The shower bed was observed in the hallway on 04/13/22 throughout the morning, including 10:30 AM, on the day R74 was scheduled for his shower. During an interview on 04/14/23 at 5:32 PM, the Director of Nursing (DON) stated the facility has recently discussed the topic of properly documenting showers. The DON stated R74's chart was not set up properly to document showers in his EMR. The DON stated the facility recently re-implemented the shower sheets in March, so perhaps that was why there are only three forms. She stated the only time shower/bathing information gets documented in a resident's Progress Notes is when they refuse their shower/bath. The DON verified there were only nine showers/bath documented under the Tasks tab under Showers or Bathing for R74 since 09/15/21 and confirmed there was very little documentation in R74's EMR or shower binder to dispute the resident's claim that he was not getting his showers.

Based on observation, staff interviews and clinical record review and during the course of a complaint investigation the facility staff failed to ensure 1 of 12 residents (Resident #1, a closed record review) who was unable to carry out activities of daily living (ADL) received the necessary services to include showers and or Baths. The Findings Included; Resident #1 was admitted to the facility on [DATE], readmitted on [DATE] and discharged on [DATE] to the community. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The current Minimum Data Set (MDS), a discharged assessment with an Assessment Reference Date (ARD) of 8/06/21 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 12 out of a possible 15. : This indicated Resident #1 cognitive abilities for daily decision making were moderately impaired. In section G(Physical functioning) the resident was coded as requiring extensive assistance of two persons with bed mobility. Requiring extensive assistance of one person with transfers, dressing and toilet use. Requiring the supervision of one person with personal hygiene. Requiring Set-up help only with eating and requiring the assistance of one person with bathing. The Care Plan dated 2/02/21 reads: Resident #1 has trouble with her day to day activities related to her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Nansemond Unit Bath Schedule Show that Resident #1 should have received baths on scheduled days/evenings according to her assigned room. The Chesapeake Unit Bath Schedule show that Resident #1 should have received baths on scheduled days/evenings according to her assigned room. A review of the ADL documentation for the month of May 2021 reveal that Resident #1 did not receive a bath or shower. A review of the ADL documentation for the month of June 2021 reveal Resident #1 did not receive a bath or shower. A review of the ADL documentation for the month of July reveal that Resident #1 did not receive a bath or shower. On 9/09/21 at approximately 4:45 PM an interview was conducted with LPN (Licensed Practical Nurse) #2 concerning resident #1. She stated, She was upset and non-compliant with care. Before she left the facility she was compliant with her care. She was able to do her upper body and the aides would set her up with the basin, wash cloths and towels She was here doing COVID-19 and bathing changed. They were not able to get showers. On 09/10/21 at approximately 2:45 PM., the above findings were shared with the Administrator and the Director of Nursing (DON). The DON stated, According to ADL LOOKBACK report, there was no bathing documented for the months in questions (May, June, July, August). An opportunity was offered to the facility's staff to present additional information but no additional information was provided. Complaint deficiency

Based on clinical record review, staff interviews and review of facility documentation, it was determined the facility staff failed to inform residents, their representatives, and or families of those residing in facilities by 5 p.m. the next calendar day following the occurrence of a single confirmed infection of COVID-19 from testing results of 10/24/20, 10/26/20 and 11/2/20. Although it was determined that the facility staff did not inform any of the facility's residents, and/or representatives of COVID-19 cases by 5:00 p.m. the next calendar day, a random sample of 6 residents were put in the survey sample for documentation purposes. The findings included: 1. A review of Resident #1's clinical record did not reveal that the resident, who was his own responsible party, was made aware of a COVID-19 case by 5 p.m. on the next calendar day following the facility's knowledge of a confirmed case of COVID-19 that resulted on 10/24/20 and 10/26/20. Resident #1 was admitted to the nursing facility on 10/8/20 with [DIAGNOSES REDACTED]. On 11/2/20, the facility had knowledge that the resident tested positive for COVID-19 and was aware of his own test results. The most recent Minimum Data Set (MDS) assessment dated [DATE] coded the resident with a score of 15 out of a possible score of 15 on the Brief Interview for Mental Status (BIMS) which indicated the resident was cognitively intact in the skills for daily decision making. On 11/13/20 at approximately 5:00 p.m., during an interview that was conducted with the Administrator and the Director of Nursing (DON), they stated they did not have a process in place to inform the facility's residents, representatives or families by 5 p.m. the next calendar day after their awareness of confirmed COVID-19 cases to include those that resulted on 11/24/20 and 11/26/20 or 11/2/20. 2. A review of Resident #2's clinical record did not reveal that the resident, who was his own responsible party, was made aware of a COVID-19 case by 5 p.m. on the next calendar day following the facility's knowledge of a confirmed case of COVID-19 that resulted on 10/24/20, 10/26/20 and 11/2/20. Resident #2 was admitted on [DATE] with [DIAGNOSES REDACTED]. Resident #2's most recent Minimum Data Set ((MDS) dated [DATE] coded the resident with a score of 15 out of a possible score of 15 on the Brief Interview for Mental Status (BIMS) which indicated the resident was cognitively intact in the skills for daily decision making. On 11/13/20 at approximately 5:00 p.m., during an interview that was conducted with the Administrator and the Director of Nursing (DON), they stated they did not have a process in place to inform the facility's residents, representatives or families by 5 p.m. the next calendar day after their awareness of confirmed COVID-19 cases to include those that resulted on 11/24/20, 11/26/20 and 11/2/20. 3. A review of Resident #3's clinical record did not reveal that the resident or responsible party was made aware of a COVID-19 case by 5 p.m. on the next calendar day following the facility's knowledge of a confirmed case of COVID-19 that resulted on 10/24/20, 10/26/20 and 11/2/20. Resident #3 was admitted on [DATE] with [DIAGNOSES REDACTED]. Resident #3's most recent Minimum Data Set ((MDS) dated [DATE] coded the resident with a score of 11 out of a possible score of 15 on the Brief Interview for Mental Status (BIMS) which indicated the resident was moderately impaired in the cognitive skills for daily decision making. On 11/13/20 at approximately 5:00 p.m., during an interview that was conducted with the Administrator and the Director of Nursing (DON), they stated they did not have a process in place to inform the facility's residents, representatives or families by 5 p.m. the next calendar day after their awareness of confirmed COVID-19 cases to include those that resulted on 11/24/20, 11/26/20 and 11/2/20. 4. A review of Resident #4's clinical record did not reveal his responsible party was made aware of a COVID-19 case by 5 p.m. on the next calendar day following the facility's knowledge of a confirmed case of COVID-19 that resulted on 10/24/20, 10/26/20 and 11/2/20. Resident #4 was admitted on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Resident #4's most recent Minimum Data Set ((MDS) dated [DATE] coded the resident with a score of 5 out of a possible score of 15 on the Brief Interview for Mental Status (BIMS) which indicated the resident was severely impaired in the cognitive skills for daily decision making. On 11/13/20 at approximately 5:00 p.m., during an interview that was conducted with the Administrator and the Director of Nursing (DON), they stated they did not have a process in place to inform the facility's residents, representatives or families by 5 p.m. the next calendar day after their awareness of confirmed COVID-19 cases to include those that resulted on 11/24/20, 11/26/20 and 11/2/20. 5. The facility staff failed to inform Resident #6 or her family by 5 p.m. of the next calendar day following the occurrence of a single confirmed infection of COVID-19. Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #6 nor her family/representatives were informed of confirmed infection of COVID-19. A review of a 11/10/20 Quarterly Minimum Data Set (MDS) Brief Interview for Mental Status (BIMS) assessed this resident as an 11 which indicated moderate cognitive impairment. A review of the clinical records indicated one resident had a positive confirmed infection of COVID-19 on 10/24/20, 10/26/20 and 11/2/20. A review of the clinical record did not indicate the facility staff had informed the resident, her family or representatives by 5 P.M. the next calendar day. 6. The facility staff failed to inform Resident #7 or her family or representatives by 5 p.m. of the next calendar day following the occurrence of a single confirmed infection of COVID-19. Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #7 nor her family/representatives were informed of confirmed infection of COVID-19. A review of a 11/10/20 Quarterly Minimum Data Set (MDS) - Brief Interview for Mental Status (BIMS) assessed this resident as an 00 which indicated severe cognitive impairment. A review of the clinical records indicated one resident had a positive confirmed infection of COVID-19 on 10/24/20, 10/26/20, and 11/2/20. A review of the clinical record did not indicate the facility staff had informed the resident, her family or representatives by 5 P.M. the next calendar day. On 11/13/20 at approximately 5:00 p.m., during an interview that was conducted with the Administrator and the Director of Nursing (DON), they stated they did not have a process in place to inform the facility's residents, representatives or families by 5 p.m. the next calendar day after their awareness of confirmed COVID-19 cases to include those that resulted on 11/24/20, 11/26/20 and 11/2/20.

Based on staff interviews, clinical record review and during the course of a complaint investigation the facility staff failed to follow the physician orders [REDACTED].#237. The facility staff failed to follow the physician order [REDACTED]. The symptoms reoccurred on [DATE] at 3:30 a.m., the nurse did not send the resident to the ER as ordered, two hours later the resident was deceased , constituting harm. The findings included: Resident #237 was admitted to the facility on [DATE] for short-term skilled services with [DIAGNOSES REDACTED]. The admission MDS (Minimum Data Set) with an assessment reference date of [DATE], coded the resident as scoring a 15 out of a possible 15, indicating the residents cognition was intact. The resident required limited assistance with one person physical assist with bed mobility, transfers, walking in room and corridor,dressing, toileting, personal hygiene and supervision with set up help only for eating. The resident was a full code. Resident #237's care plan with an initiated date of [DATE] included: I have a [MEDICAL CONDITION] disorder; Goal-I will remain free of [MEDICAL CONDITION] activity through review date, [DATE]; I will maintain lab values within therapeutic range per MD, through next review date [DATE]; Interventions included, but not limited to: Give medications as ordered, [MEDICAL CONDITION] documentation, post [MEDICAL CONDITION] treatment, [MEDICAL CONDITION] precautions. On [DATE] the clinical record evidenced the resident had a change in condition that required physician intervention to include evaluation and orders. The nursing health status note dated [DATE] timed at 12:09 p.m., read Res (resident) is very shaky this am. He needed help w/eating (with) breakfast and needed 2 person assist getting out of bed. Dr. (name of physician) saw him and increased his [MEDICATION NAME] (anti-anxiety medication) to 3 x day prn (as needed) and said to give him a dose now. He also ordered labs and said that if the shakiness does not improve to send him to the ER. VSS (vital signs stable). The vital signs obtained closest to this entry were timed for 12:08 p.m., blood pressure ,[DATE], pulse 57, respirations 16. The physician orders [REDACTED]. The clinical record evidenced on [DATE] the resident was administered the now dose of [MEDICATION NAME] 0.5 mg at 11:58 a.m., and another dose was administered at 8:48 p.m. The 7 a.m.-7 p.m., skilled daily nursing notes dated [DATE] at 3:33 p.m., read, in part: Mood Indicator: Tired/has little energy. Staff provided limited assistance with bed mobility. Staff provided set up help only with bed mobility. Resident requires limited assistance from staff for transfers .Neuromuscular status is not within normal clinical limits this shift. Tremors . The 7 p.m.-7 a.m., skilled daily nursing noted dated [DATE] at 10:31 p.m , read, in part: .required one person assist with transfers this shift. The clinical record evidenced that early the next morning on [DATE], the resident exhibited the shaking symptoms; the staff failed to follow the physician orders [REDACTED]. Within two hours of the identified symptoms (shaking) at 3:30 a.m., the resident was deceased . Licensed Practical Nurse (LPN#4) documented the following at 6:41 a.m., on [DATE]: @ approximately 03:30 (a.m.), CNA (certified nursing assistant) reported to writer that resident was shaking and was not able to get himself ready as he normally does. Writer went in to assess resident and check his vital signs. Resident was alert, answering questions, speaking coherently. Writer asked resident if he still wanted to go to [MEDICAL TREATMENT] or if he would like the MD to be notified. Resident stated he still wanted to go to [MEDICAL TREATMENT] and that he has had shakes before. Vital signs were as follow 96.8 axillary, 52, ,[DATE], 18, 97%. Routine medication was administered, vitals were checked after about 30 minutes and were as follows 97.3 oral, 57, ,[DATE], 20, 99%. Resident's brothers arrived to transport him to [MEDICAL TREATMENT]. Resident's brother stated he wasn't sure if they should transport him and asked him if he wanted to go to the ER instead, resident stated yes, I'll go to the ER @ 0500, writer called EMS, gave report @0510. MD was called, answering service stated MD would be notified. @ 0520 EMS arrived, @ 0525 MD called back, report was given, and he stated that resident should go out to ER. Writer informed MD that 911 had already been called and was in room with resident. EMT technician came to desk and requested nursing staff to come to resident's room. CPR (cardiopulmonary resuscitation) was administered by EMS as nursing stood by to assist however needed. Resident was pronounced deceased by EMT at 0540. On [DATE] at 11:15 a.m., LPN #4 was interviewed via phone. LPN #4 was asked if she was aware of the physician order [REDACTED]. She stated the change in condition physician order [REDACTED]. When asked If you had been aware of the physician order [REDACTED].? She stated, Absolutely. On [DATE] at 12:00 p.m., the physician was interviewed via phone. He stated he had discussed with the day shift nurse on his order to send the resident to the ER if the resident still had symptoms. When asked if he would have expected the nurse (LPN#4) to have sent the resident to the ER at 3:30 a.m., when the symptoms continued, he stated, Yes .if he was still having any symptoms any shaking go to the ER. He also stated the nurse could have called him at that time if she had any questions. He also stated that he had a discussion with the nursing staff that his orders have to be passed from one nurse to another. An interview was conducted on [DATE] at 2:45 p.m., with one of two of Resident #237's brothers who was at the bedside on [DATE]. The brother stated he and his other brother arrived at the facility at approximately 5:00 a.m. on [DATE] to transport the resident to [MEDICAL TREATMENT]. Upon arrival he noted Resident #237 was not sitting up in the wheelchair at the nurses station as normally expected. They headed to the resident's room and were met by LPN #4. He stated upon entering the resident's room the resident was having a terrible [MEDICAL CONDITION], the nurse asked if they were going to take the resident to [MEDICAL TREATMENT] and he stated No .he will never make it to [MEDICAL TREATMENT], he stated he told the nurse that she needs to call 911. He stated EMS arrived approximately ten minutes later and began to work on the resident. The EMS report dated [DATE] evidenced the EMS service was dispatched at 5:06 a.m., and made it to Resident #237's bedside at 5:18 a.m. The report read, in part: M5 arrived scene to find a (age and gender) lying in bed. Patient was pulseless and apenic (not breathing) up (sic) arrival. Skin is warm and dry. Pupils are fixed and dilated. Verified with staff that no DNR (do not resuscitate) was present then began CPR. Staff called due to hypertension and tremors. Patient's brothers were present and they stated that he had not been responding to them for about 15 minutes prior to M5 arrival .working through ACLS protocols .airway established .M5 called dispatch for a engine due to [MEDICAL CONDITION] .Epi was given every ,[DATE] minutes . Initial rhythm was asystole. Rhythm never changed, down time was approximately 15 minutes prior to arrival. Contacted medical control, gave (name of physician) the report and he concurred with the decision to terminate efforts. The above findings was shared with the Administrator and the Director of Nursing during the pre-exit meeting conducted on [DATE] at 7:30 p.m. Complaint deficiency.

Based on observation, resident interview, staff interview, facility documentation review, and clinical record review, the facility staff failed to maintain a safe environment for 2 of 41 residents in the survey sample (Resident #25 and Resident #4). This citation was originally found at a level four isolated and upon acceptance of the plan of correction, it was lowered to a level two isolated. During initial tour, an oxygen E tank was observed in Resident #40's room. The tank was unsecured. There was approximately 2000 PSI (pounds-force per square inch) reading on the gauge of the tank. It was sitting, without a stand or holder, left of the door going out to the hall. The observation constituted the notification of immediate jeopardy. An additional unsecured oxygen tank was observed sitting in the corner of Resident #4's room. There was approximately 2000 PSI reading on the gauge of the tank. The oxygen tank was in a black sleeve but was not secured at the time of the observation. The findings included: 1. Resident #25 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Resident #5's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date of assessed the resident with 15 out of a possible 15 BIMS (Brief Interview for Mental Status), indicating no cognitive impairment. The Resident required two staff person assistance with bed mobility and required one staff person assistance with transfers, locomotion on unit, dressing, toilet use and personal hygiene. The Comprehensive Person Centered Care Plan revised on 10/27/17 identified a focus area of oxygen therapy related to [MEDICAL CONDITION]. The goal was to have no signs/symptoms of poor oxygen absorption through the review date. Two interventions included oxygen via nasal canula 2 Liters continuously and oxygen supplies and tubing changes/cleaning per facility protocol. Physician order [REDACTED]. On 03/12/18 at approximately 11:40 AM, during the initial tour, Resident #25 stated he gets short of breath when going to the bathroom because his portable oxygen tank for his wheel chair is not in the holder. An oxygen concentrator was observed in the Resident's room. Resident #25 was asked where his portable tank was. He stated he didn't know, that it was over there somewhere. A free standing oxygen type E tank was found to the left of the door going out to the hall. The tank was not secured in a holder to prevent it from falling over. On 03/12/18 at approximately 11:45 AM, two additional surveyors were asked to come into the room. The surveyors turned on the portable oxygen tank and found there to be 2000 PSI left in tank. On 03/12/18 at approximately 12:05 PM, the survey team met and a call was placed to the State Agency. After discussion with the State Agency Supervisors, the decision was made to call Immediate Jeopardy. On 03/12/18 at approximately 12:10 PM the Survey Team met with the Administrator and the Director of Nursing (DON) to discuss concern of Immediate Jeopardy. On 03/12/18 at approximately 12:20 PM, this surveyor walked to Resident #25's room and showed the freestanding oxygen E tank to the Administrator and Director of Nursing (DON). It remained sitting in the corner by the door going to the exit, without a stand to secure it. The oxygen E tank was lifted by the DON and taken to the nurses station where LPN#31 took the oxygen E tank and held it while the DON was directing her to take the tank and place in in the Resident's wheel chair oxygen caddy. On 03/12/18 at approximately 4:35 PM, the facility's initial Plan of Correction (P[NAME]) was received from Administrator and DON was reviewed by the Surveyor. On 03/12/18 at approximately 4:37 PM the DON and Administrator were informed of changes required prior to the acceptance of P[NAME] and at 4:45 PM, the P[NAME] was denied due to being incomplete. On 3/13/18 at approximately 11:05 AM, the P[NAME] was received from the Administrator and DON. The P[NAME] was reviewed by survey team but not accepted after interviewing 7 staff members who stated they were never in-serviced on the proper storage of oxygen E tanks as part of the P[NAME]. On 3/13/18 at 11:30 AM, the supervisor at the State Agency was informed that the P[NAME] was received from Administrator but not accepted by survey team. On 3/13/18 at 11:59 AM, two staff members were interviewed about being in-serviced on proper storage of oxygen E tanks. Staff stated they were not in-serviced. On 3/13/18 at approximately 12:04 PM, the P[NAME] was again denied. On 3/13/18 at approximately 12:46 PM, the Survey Team received the P[NAME] from the Administrator and DON. The P[NAME] was reviewed by survey team and denied and returned to the Administrator for additional information. On 3/13/18 at approximately 1:00 PM, the P[NAME] was accepted and the Immediate Jeopardy was abated. The P[NAME] documented the following: 1. 3/12/18 surveyor noted that unsecured oxygen cylinder was left in resident room, said tank was removed from resident room by DON at 1220 PM. Resident's oxygen tank will be secured in an oxygen tank holder or oxygen tank cart, designed for carrying and storage of oxygen E cylinder canisters. Surveyor identified that oxygen tank was found to be sitting in corner of room unsecured, was in black sleeve to secure to wheelchair was found not to be at this time, was removed from corner of room by DON and secured to back of wheelchair at 1226 PM. 2. All residents with orders for oxygen will be reviewed to determine if oxygen tanks are in use on a continuous basis or as needed basis, completed 3/12/18 at 1400 (2:00 PM); 100% physical inspection of facility to identify and remove unsecured oxygen canisters in all areas, completed 3/12/18 at 1300 (1:00 PM). 3. Nursing, housekeeping, facilities, activities, therapies will be in-serviced in the safe use of portable E oxygen cylinders including the securing of tank in device designed for that use per policy, 3/12/18; staff coming into facility through agency will read and sign policy for proper use and storage of oxygen prior to start of their shift beginning 3/12/18; new employee orientation will include review of safe oxygen storage procedures and securement in alignment with policy - records of signatures to be kept by education department. 4. Nursing Supervisor and/or Charge Nurse will make rounds on residents with portable oxygen tanks and will observe each designated oxygen storage area on their unit every shift for 7 days. Any observed variances will be immediately corrected and noted as such on audit sheet; daily audit sheet will be given to DON who is responsible for ensuring that audits are completed and will analyze for trends, patterns and further actions necessary; upon completion of the first 7 day audits, the trends will be analyzed and audits may be reduced to 3 times per week for 7 days. The results of the 2 week audits will be reported to QAPI (Quality Assurance and Performance Improvement) Committee for additional oversight and recommendation for the frequency of continued audits. 5. Responsible - DON/Night Supervisor/Nurse Administrator 6. Implementation 3/12/18 On 03/15/18 at approximately 04:13 PM, Resident # 25 was observed lying in bed, oxygen E tank cylinder was observed in a secure location in the wheelchair oxygen tank holder. On 3/16/18 at approximately 3:49 PM, Resident #25 was observed in his room, oxygen E tank cylinder safely secured in wheel chair oxygen holder. The facility administration was informed of the findings during a pre-exit briefing on 3/20/18 at approximately 3:55 PM. The facility did not present any further information about the finding. 2. On 3/12/18 at 12:20 P.M. an unsecured oxygen tank was observed sitting in the corner of Resident #4's room. The oxygen tank was in a black sleeve which to be secured to a wheelchair. The oxygen tank was found not to be secured at the time. Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #4's unsecured oxygen tank was noted to have 2000 PSI remaining in the tank. A Quarterly Minimum Data Set ((MDS) dated [DATE] assessed this resident in the areas of Hearing, and Speech as having no concerns. This resident was assessed in the area of Vision as requiring glasses. In the area of Cognitive Patterns this resident was coded in the area of Brief Interview for Mental Status (BIMS) as a 15. This resident had no concerns in the area of Mood, or Behaviors. In the area of Activities of Daily Living (ADL) this resident was assessed as requiring supervision or limited assistance in the areas of transfer, dressing, eating, toilet use and personal hygiene. This resident was assessed as using a walker and wheelchair as mobility devices. In the area of Special Treatments, Procedures and Programs no concerns were assessed. A Revised Care Plan dated 10/16/17 indicated: Focus- History of [MEDICAL CONDITION] Intervention- Oxygen 2 L (liters) via nasal canula PRN (as needed) as ordered. O/2 sats (oxygen saturation) to be obtained every shift as ordered. Focus- History of falls Interventions- The Resident needs a safe environment with even floors free from spills and or clutter. Focus- I use Oxygen Therapy at times because of [MEDICAL CONDITION] and History of [MEDICAL CONDITION]. Sometimes I have shortness of breath. Goal- I will have no s/sx (signs/symptoms) of poor oxygen absorption. Intervention- Change residents position every 2 hours to facilitate lung secretion movement and drainage. Give medications as ordered by physician. Monitor/document side effects and effectiveness. If the resident is allowed to eat, oxygen still must be given to the resident but in a different manner (e.g. changing from mask to a nasal canula). Return resident to usual oxygen delivery method after the meal. Oxygen Settings -Oxygen 2 L via nasal canula to keep SpO2 > 93% as needed as ordered. Oxygen supplies and tubing changes /cleaning per facility protocol. A physician's orders [REDACTED]. oxygen 2/L via nasal canula (Dyspnea) to keep Sp02>93% as needed. The Administrator and the Director of Nursing were called to Resident #4's room on 3/12/18 at 12:26 P.M. at which time the oxygen tank was removed from the room. During an interview on 3/12/18 at 12:30 P.M. with the Administrator and the Director of Nursing, they were asked if the oxygen tank was secured as first observed. They both stated, No. The DON stated the oxygen tank should have been secured in the black sleeve and attached to Resident #4's wheelchair. 03/13/18 at 1:04 PM the facility Policy and Procedure titled, Oxygen Tank Storage with an effective date of 1/2018 ws reviewed and documented the following: Oxygen tanks will be stored in compliance with safety regulations, thus keeping residents and staff safety at a priority. Rationale The facility establishes and maintains a safe, functional environment: interior spaces meet the need of the resident population and are safe and suitable to the care, treatment and services provided. The primary source of oxygen for resident use is the oxygen concentrator. However, there are times when the resident may require the use of an oxygen e-cylinder for transportation to appointments within or outside the facility. Procedure: O2 (Oxygen) tanks must be stored in a safe and consistent manner. 1. All O2 tanks must be stored in an approved Ox tank storage rack. 2. All O2 tank storage racks must be approved by Facility Services. 3. Empty O2 tanks must be in a separate rack from Full or Mid-Range filled O2 tanks. B. Other O2 tank safety items: 1. All O2 tanks are to be placed only in an approved O2 tank holder when in use. a. Wheelchair holders as appropriate or in wheeled storage devices if resident is ambulatory. 5. O2 tanks will not be left in free-standing position.

Based on observation, staff interviews, clinical record reviews, facility document reviews and in the course of a complaint investigation the facility staff failed to ensure that the appropriate lift device and or lift was provided during transfers according to the residents comprehensive person-centered care plan to prevent accidents for 2 of 2 residents in the survey sample, Resident #1 and #2. 1. Based on physical functional limitations Resident #1 required the utilization of a total mechanical lift for all transfers. On 9/19/17 the facility's total lift equipment was not maintained in safe operating condition; therefore, the staff (Certified Nurse Aide/CNA #2) elected to use a sit to stand mechanical lift to transfer the resident from the wheelchair to the bed. The resident did not meet the criteria for the use of the sit to stand lift due to non-weight bearing status and inability to fully grasp both handle bars due to right sided weakness from a stroke. During the transfer, the sit to stand lift malfunctioned. The resident was suspended by the lift straps. The resident's weight pulled her down causing the lift belt to rise under the resident's neck and the right shoulder, as a result the resident sustained [REDACTED]. 2. Based on physical functional limitations Resident #2 required a pivot transfer with one staff or use of a total mechanical lift for transfers. The resident did not meet the criteria for a sit to stand mechanical lift due to inability to fully grasp both handle bars due to right arm contracture and weakness from a stroke. On 10/4/17 CNA#3 transferred the resident from the bed to a wheelchair using a sit to stand mechanical lift. The findings included: 1. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The current MDS (Minimum Data Set) at the time of the incident was an annual with an assessment reference date of 7/10/17. The resident scored a 13 out of a possible 15 on the Brief Interview for Mental Status, indicating the resident's cognition was intact. The resident required extensive assistance of two staff for bed mobility and transfers. The resident was not steady and was only able to stabilize with staff assistance during transitions from surface to surface (transfer between bed and chair or wheelchair). Functional limitation of range of motion was identified due to impairment on both upper and lower extremities on one side. The resident's weight was 187 pounds. The comprehensive person-centered care plan initiated on 9/23/13 identified the resident had ADL (activities of daily living) self care performance deficit due to [DIAGNOSES REDACTED]. Several of the interventions listed was for the resident to wear a right hand orthotic at bedtime for contracture management, a right half lap tray for upper extremity support while seated in a wheelchair, bed mobility extensive of assistance of two, and for transfers the resident required extensive to total and two assist. The CNA Kardex Report/ care plan at the time of the incident identified for transfers Resident #1 required, extensive to total and two assist with Hoyer lift (total mechanical lift). One staff member during transfer with Hoyer is to support/monitor right side paresis to ensure resident's safety. The State Survey Agency received an initial Facility Reported Incident (FRI) on 9/20/17. The report stated that on 9/19/17 two of two Hoyer lifts in the facility (total mechanical lifts) were not working. The CNA used a sit to stand mechanical lift to assist the resident. When assisting the resident with the sit to stand device, the device stopped working. The CNA called out for assistance and the nurse came into the room as well as another CNA. During this process the resident was suspended by the lift straps, resulting in a displaced humeral neck fracture and non-displaced fracture of the olecranon process. The resident was lowered to the bed and the straps were disconnected. The resident was assessed and complained of pain to the right shoulder, therapeutic medication was administered. The physician and the family were notified. an order for [REDACTED]. The resident was sent to the ED (emergency department) for evaluation. An investigation was started and equipment was evaluated. The X-ray reports dated 9/20/17 read: 1. Shoulder- Acute minimally displaced right humeral neck fracture. 2. Elbow Right-Questionable non-displaced fracture of the olecranon process. The resident was evaluated at the ED on 9/20/17 and returned back to the facility that same day. The ED discharge [DIAGNOSES REDACTED]. The Orthopedic follow up dated 9/22/17 read, in part: .positive Right humeral neck fracture with minimal displacement. Plan: Sling to right UE (upper extremity). See orders. No use (R) UE, caution when transferring. F/U (follow up) 3 weeks. The final facility internal investigation report dated 9/25/17 concluded the following: 1. Equipment evaluation was completed and there were no malfunctions. The batteries had not been properly charged on the mechanical lifts resulting in the 2 Hoyer lifts not working and the sit to stand which did not have an adequately charged battery to manage the transfer. 2. Choice of the sit to stand lift for this transfer was incorrect based on resident functional status. Corrective measures implemented to prevent recurrence were: 1. In-service staff on properly charging mechanical lifts between use. 2. In-service staff on alternative measure for transferring a resident if lift is not functioning. 3. One to one in-service and disciplinary action taken with CNA who initiated the transfer with the incorrect type of lift. On 10/3/17 at 1:50 p.m., CNA#1 assigned to care for Resident #1 was interviewed. She was asked how do you determine the transfer status of your resident, she stated, the care plan inside the closet door, if the resident is not a one person assist you get someone to help. She stated Resident #1 was a total lift resident who required the Hoyer lift. When asked, when and where are mechanical lifts charged, she stated, for myself, I put it on the charger in the clean supply room, sometimes I come in and they are not charged. She stated that this past Saturday (9/30/17) when she went to get the sit to stand to use on a resident it was beeping, indicating that it was not fully charged. She stated each lift has 2 batteries. CNA #1 was asked if she had been inserviced recently on mechanical lifts, sit to stand lifts and manual lifting that was provided by the facility on 9/28/17 and 9/29/17 as part of the corrective measure, she stated, No. The care plan located inside Resident #1's closet dated 8/29/17 indicated the resident required a mechanical Hoyer lift for transfers. On 10/3/17 at 8:41 p.m., an interview was conducted via telephone with CNA #2 who transferred Resident #1 with the incorrect lift on 9/19/17. Per the interview and CNA #2's written statement she stated that at approximately 8:30 p.m., the resident was sitting up in a wheelchair in her room. The resident requested to be placed back into bed. The CNA obtained the total lift from the shower room, took it into the residents room and at that time discovered it was not working. She then went to the other unit to obtain the other total lift. This lift was not working either, she stated,the battery was not working. She then went back to the unit and asked a coworker how was she was supposed to transfer the resident to bed if the both total lifts were not working, the coworker stated to transfer the resident using the sit to stand as they had used this lift on the resident before and everything went well. She then went to get the sit to stand lift. After applying the waist guard she began to lift the resident. The lift kept going in and out-stopping and starting back up. She stated once she realized the lift was beginning to go out she quickly tried to proceed, the resident asked to be put down, stating, Put me down. At that time she saw the nurse across the hall and alerted her that she needed help. The nurse came in to assist. They both attempted to lift the resident up but could not. The nurse left the room to get more assistance. While waiting the waist guard had quickly went up causing her stroke arm to lift as well. She stated, during the whole transfer (name of resident) was calm but was saying her arm was hurting. When asked what was the root cause of the resident obtaining a fracture from the transfer, she stated, The machines, if they had been working properly I would have used the appropriate equipment .I did what I thought was best. The written statement dated 9/20/17 from the nurse involved with the incident read, in part: .I entered the room and noted (Resident #1's name) with a lift belt under her neck and around her R shoulder. I rushed to help but the (Resident name) was too heavy and I had to run and scream for someelse {sic} to come help. Then I ran back into the room to help (CNA#2) support (Resident name) till helped arrived so she would not choke on the belt. The patients weight was pulling her down and the belt was under her chin . If I had released the belt around her neck, she would have fallen to the floor and possibly sustained more injury, and her shoulder was still caught in the belt as well . (name of CNA#2) stated that the patient should have been moved with a different type of lift but she had tried the two we have and they were not working at all. So the lift used in the incident was the only one she had available to use to get this non weight bearing, non ambulatory bariatric patient from wheelchair to her bed and the lift just stopped working mid transfer. On 10/3/17 at 12:25 p.m., the resident was in bed attempting to eat lunch. The resident's speech was slurred. The right arm was not in a sling, the right hand was contracted. At 2:15 p.m., and 5:00 p.m., the resident was observed in bed. The right arm sling was still not on as ordered by the physician. On 10/3/17 at 4:00 p.m., an interview was conducted with the Administrator. When asked what was the root cause of the incident that resulted in the resident's fracture, she stated, The CNA used poor judgement in selecting the sit to stand. The findings was shared with the Administrator, the Corporate Nurse, the Interim Director of Nursing, and the Nansmond Unit Manager at the pre-exit meeting conducted on 10/4/17. The facility policy titled Lift Machine Using, undated, read in part: Purpose: The purpose of this procedure is to help lift residents using a manual lifting device. Preparation: 1. Review the resident's care plan to assess for any special needs of the resident. 2. Assemble the equipment and supplies as needed. General Guidelines: The portable lift can be used by one nursing assistant if the resident can participate in the lifting procedures. If not, two (2) nursing assistants will be required to perform the procedure. The following information was obtained from Interior Health Patient Handling Procedure Stand Assist-Sit Stand Lift Criteria provided by the facility, in part, but not limited to: The Patient Must: 2. Be able to hold onto both handles on the machine. Reason-Sling will place too much pressure in patient's armpits. 3. Be able to keep both feet flat on the footplate of the lift throughout the transfer. Reason-Patient could fall off the lift. This position is painful for patients who have stiff of contracted knees or hips. Patient lifts are designed to lift and transfer patients from one place to another (e.g., from bed to bath, chair to stretcher). The powered models generally require the use of a rechargeable battery and the manual models are operated using hydraulics. These medical devices provide many benefits, including reduced risk of injury to patients and caregivers when properly used. However, improper use of patient lifts can pose significant public health risks. Patient falls from these devices have resulted in severe patient injuries including head traumas, fractures, and deaths. Source www.fda.gov The FDA (U.S. Food & Drug Administration) Patient Lift Safety Guide read, in part: 3. Check Patient's Condition-Before using a patient lift, check: to see if patient can assist with transfer, make sure you have correct lift and sling for patient's condition, ensure lift will not make patient's condition worse. 9. Perform Safety Check-Before lifting the patient, perform safety checks: For electric lifts, make sure batteries are always charged. 2. Based on physical functional limitations Resident #2 required a pivot transfer with one staff or use of a total mechanical lift. The resident did not meet the criteria for a sit to stand mechanical lift due to the inability to fully grasp both handle bars due to right arm contracture and weakness from a stroke. On 10/4/17 CNA #3 transferred the resident from the bed to a wheelchair using a sit to stand mechanical lift. Resident #2 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The current MDS a quarterly with an assessment reference date of 9/4/17 assessed the resident as having unclear speech. The resident was coded as having both long and short term memory deficits and moderately impaired cognitive skills for daily decision making. The resident's self performance during transfers required extensive assistance and support of two staff. Under Balance During Transitions and Walking the resident was not steady and only able to stabilize with staff for moving from seated to standing position and surface-to-surface transfer (transfer between bed and chair or wheelchair). The resident had functional limitation of range of motion to one side of the body effecting both upper and lower extremity. The comprehensive person centered care plan dated 11/7/13 identified the resident had ADL performance deficit related to [DIAGNOSES REDACTED]. The goal was that the resident will maintain current level of ADL function. Under Transfers the approach was the resident required extensive assistance of 2 staff members. The CNA kardex/ care plan under 'transfer' indicated the resident required extensive assistance of 2 staff members. On 10/4/17 at approximately 10:30 a.m., this inspector along with the Administrator and Nansmond unit manager were inside the Nansmond unit shower room inspecting the mechanical lifts. CNA #3 (an agency staff) entered the shower room to place the sit to stand lift back inside for storage and then left the room. The CNA was followed out by this inspector and asked what resident was this sit to stand lift used for, she stated (resident #2's name). The CNA was asked if this lift was appropriate for this resident, she stated, This is the second time I've worked with him, I had a problem getting him up . they (other staff) were busy . When asked if she had asked for help as the resident is a two person assist she stated, No. I didn't see anyone at that time. The closet door kardex was reviewed and indicated the resident was a two person lift. The CNA stated, the sit to stand is a one person lift as long as the resident is able to sit and hold on to the bar to stand. The Nansmond unit manager was interviewed immediately following the interview with CNA #3. The above finding of Resident #2 being transferred with a sit to stand lift was shared. She was asked how is Resident #2 supposed to be transferred. She stated when she gets him up he can pivot transfer with two staff. When asked if a sit to stand lift was an appropriate lift for this resident, she stated, I don't know if anyone uses a lift with him .I don't know. When asked does Resident #2 meet the criteria for the sit to stand, she stated, No, due to his weakness. When asked if it was okay to use a sit to stand with one staff, she stated, No, not if you don't have a second person .a second person is there to prevent possible injury. The unit manager was asked are agency staff trained on the facility's lift policy, she stated, It's pretty standard in most facilities that you use two people . The unit manager stated she would have therapy screen the resident for transfers. Following this interview the rehab therapy department conducted a screening on the resident for safe transfers. The Screening Form dated 10/4/17 concluded the resident does not require a lift for transfers, however, if a lift is used for safety, it must be a Hoyer (total lift) with assist of 2 staff. On 10/4/17 at 2:30 p.m., the rehab manager was interviewed. She stated the resident was not appropriate for the sit to stand lift due to the resident's right hand contracture that hinders him from grabbing onto the hand bar. The following information was obtained from Interior Health Patient Handling Procedure Stand Assist-Sit Stand Lift Criteria provided by the facility, in part, but not limited to: The Patient Must: 2. Be able to hold onto both handles on the machine. Reason-Sling will place too much pressure in patient's armpits. The findings was shared with the Administrator, the Corporate Nurse, the Interim Director of Nursing, and the Nansmond Unit Manager at the pre-exit meeting conducted on 10/4/17. COMPLAINT DEFICIENCY

Based on staff interview, clinical record review, facility document review and during the course of a complaint investigation the facility staff failed to provide the necessary care and services to promote the healing of a pressure ulcer for 1 of 8 residents in the survey sample, (Resident #8). Resident #8 acquired a left heel pressure ulcer. The facility staff failed to obtain physician orders [REDACTED]. The pressure ulcer worsened. Facility staff failed to accurately assess the wound. On [DATE] the treatment nurse initiated an antibiotic treatment without obtaining an order from the physician. The resident subsequently was admitted to the hospital on [DATE] and required a sharp's debridement of the pressure ulcer. The findings include: Resident #8 an [AGE] year old was admitted from the hospital to the facility on [DATE] with [DIAGNOSES REDACTED]. The facility's clinical record to include the physician progress notes [REDACTED]. The admission MDS (Minimum Data Set) with an assessment reference date of [DATE] assessed the resident as scoring a 2 of 15 for the Brief Interview for Mental Status (BIMS). The resident required extensive assistance of two staff for bed mobility, transfers and toileting. The resident was wheelchair bound. Resident #8 was frequently incontinent of bladder and occasionally incontinent of bowel. The resident's admission weight was 196. Under section M. Skin Conditions assessed the resident was being at risk for the development of pressure ulcers. The resident's skin did not present with any pressure ulcers. Other skin problems included moisture associated skin damage (MASD). The resident was on a pressure reducing device for the bed. The Care Area Assessment (CAA) Summary triggered for #16 pressure ulcers. The analysis of findings indicated the resident was at risk for the development of pressure ulcers related to impaired mobility. The resident was to be maintained on an Atmos 4000 pressure-relieving mattress and wheelchair cushion per protocol. Skin checks were to be maintained weekly and during any ADL (activities of daily living). The resident was to be repositioned every two hours and as needed for comfort and /or pressure relief. Review of the comprehensive plan of care dated [DATE] identified the resident was at risk for the development of a pressure area and /or skin breakdown related to [DIAGNOSES REDACTED]. The goal set was the resident will not experience skin breakdown as evidenced by intact skin during the next 90 days. Several approaches included: Atmos air 4000 mattress, reposition every two hours, monitor toes nails and feet during weekly skin checks-refer to podiatry as needed, and skin checks weekly by wound care nurse. The weekly skin assessments were scheduled for every Tuesday during the day shift. On [DATE] the care plan was revised to include as a problem the following: an area to the right upper buttocks, the coccyx and the left heel. Treatments were added. Review of the weekly skin checks evidenced on [DATE] the nurse identified the resident had a 1.5 cm (centimeter) x 0.5 cm purplish-blue area intact to the left lateral heel. The nurse indicated the heels were elevated on pillows to float, and the treatment nurse was made aware of the area. Further investigation of the clinical record evidenced the wound/ treatment nurse did not assess the left heel from [DATE] through [DATE]. The treatment administration records (TAR) did not evidence any treatment for [REDACTED]. The weekly skin checks for [DATE] read; the area to the left heel remains, but intact. The weekly skin checks for [DATE] by the treatment nurse read ; MASD to left hip, with an area to coccyx and a discolored area to left heel. The initial documentation of the left heel by the wound/ treatment nurse was dated [DATE] on the weekly wound report dated [DATE]. The report documented the resident acquired a left heel pressure ulcer measuring 4 cm x 7.6 cm x 0 cm, stage-unstageable. The pressure ulcer was described as "new with an intact blister fluid filled with evaporation loose gray color flap intact". The treatment was to clean with wound cleanser, apply calcium alginate dressing, and wrap with kerlix daily for 14 days. A stage II pressure ulcer is described as a partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough. May also present as an intact or open/ruptured serum filled or serosanguinous (blood tinged fluid) filled blister. An unstageable pressure ulcer is described as full thickness of tissue loss in which actual depth of the ulcer is completely obscured by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black)Pressure Ulcer Prevention Quick Reference Guide, National Pressure Ulcer Advisory Panel (NPUAP 2009) Eschar is hardened dead tissue. The recommended used of alginate dressings is for treatment of [REDACTED]. Pressure Ulcer Treatment Quick Reference Guide, (NPUAP 2009) This was coded on the significant change MDS with an assessment reference date of [DATE] as an unstageable-suspected deep tissue injury in evolution. Deep tissue injury is defined as purple or maroon localized area of discolored skin - or blood filled blister due to damage of the underlying soft tissue from pressure and/or shear. Pressure Ulcer Prevention Quick Reference Guide, (NPUAP 2009) Review of the TAR for [DATE] evidence the left heel treatment was administered on ,[DATE] and ,[DATE], there was no evidence of treatment administered on ,[DATE] or ,[DATE]. The treatment was signed as administered on ,[DATE] thru ,[DATE]. This completed the 14 day course of treatment. Another physician order [REDACTED]. This treatment was administered from ,[DATE] thru [DATE]. There was no other physician order [REDACTED]. On [DATE] the treatment nurse requested a podiatrist consult. The clinical record failed to evidence Resident #8 was seen by a podiatrist. On [DATE] orders were received to administer vitamin C 500 mg twice a day for 45 days, a multivitamin with minerals every day for 45 days and Prostat 30 ml twice a day for 45 days, per the registered dieticians (RD) recommendations to aid in wound healing. On [DATE] the RD documented on the nutritional screening & assessment record the following; "resident with SC (significant change) in status decline. Has breakdown to coccyx and rt buttocks... The RD's assessment did not include the left heel pressure ulcer. The weekly wound assessment dated [DATE] evidenced the coccyx and right upper buttock pressure areas were healed as of [DATE]. The wound/ treatment nurse documented; "left heel 4 cm x 7 cm x 0 cm, unstageable, flap remains intact air filled." The [DATE] calcium alginate treatment for 14 days was carried over onto the June medication administration sheet (MAR). The treatment was signed off as administered on ,[DATE], ,[DATE], and ,[DATE]. Next to this last entry was a handwritten note reading,"See TX book", no other treatment was signed off after this. The treatment book (TAR) for June did not evidence an entry for the calcium alginate treatment or any other treatment for [REDACTED]. The weekly skin assessment sheet dated [DATE] documented by the floor nurse read as follows; Tx (treatment) continue to (L) heel, no new areas notes. The weekly wound assessment by the treatment nurse documented the following: [DATE]-left heel, 4 cm x 7.6 cm x 0 cm, unstageable, blister flap intact with decreasing fluid. Left heel clean with wound cleanser apply calcium alginate dressing wrap with kerlix. ,[DATE] weight 188.25 lbs. [DATE]-left heel, 4 cm x 7.4 cm x 0 cm, unstageable, blister flap intact flexible gray tissue. Left heel clean with wound cleanser apply calcium alginate dressing wrap with kerlix. ,[DATE] weight 188.25 lbs. [DATE]-left heel, 4.1 cm x 7.2 cm x 0 cm, unstageable, gray flexible intact flap no drainage. Left heel clean with wound cleanser apply calcium alginate dressing wrap with kerlix. ,[DATE] weight 188.25 lbs. [DATE]-left heel, 4.1 cm x 7.2 cm x 0 cm, unstageable, no change in size a dry flexible gray flap. Left heel clean with wound cleanser apply calcium alginate dressing wrap with kerlix. ,[DATE] weight 188.25 lbs. [DATE]-left heel, 4 cm x 7 cm x 0 cm, unstageable, flap removed intact dark tissue some decrease in size because of removal of flap some non-[MEDICAL CONDITION]. (*request for oral antibiotic). [DATE] clean left heel with wound cleanser apply santyl with [MEDICATION NAME] powder cover with 4 x 4 and wrap with kerlix once daily. The assessment indicated the resident was seen by the physician on [DATE] and [DATE]. The physician note dated [DATE] indicated the resident had a stage II decubitus ulcer. The site was illegible. The weekly skin assessments by the floor nurse documented the following: [DATE]- Tx (treatment) continue to (L) heel. [DATE]-Tx continue to (L) heel. [DATE]- (L) heel necrotic ulcer noted. Receiving daily treatment. Drsg (dressing) in place. [DATE]- Dressing intact to (L) heel. Review of the clinical record physician orders, nurses notes or TAR's failed to evidence a physician order [REDACTED]. According to the weekly wound assessments documentation a treatment was administered on ,[DATE] and ,[DATE]. There is no evidence on the TAR's of a treatment order or that a treatment was administered daily from [DATE] through [DATE]. Review of the [DATE] TAR's did not evidence a treatment order for the left heel, until [DATE]. On [DATE] at 5:42 P.M., the wound/ treatment nurse documented in the nurses notes the following;" Patient's treatment continues to left heel chronic with the healing matrix. Dr. (name of physician) office contacted via fax with request for oral antibiotic the patient's blister had ruptured to heel flap removed, some dark tissue exposed with this foot and ankle showing some [MEDICAL CONDITION]. The heel will float when in bed. Will await response from (name of physician). A telephone order was noted in the clinical record dated [DATE] and timed as received at 5:32 P.M., by the treatment nurse. The order read; " Clean left heel with wound cleanser apply Santyl (an enzymatic debridement ointment) with [MEDICATION NAME] powder cover with a 4 x 4 and wrap with kerlix once daily." This order was transcribed onto the TAR and signed as administered on [DATE]. The faxed physician request was sent by the treatment nurse to the physician's office. It was dated [DATE] and read as follows; "Comments: (Using SBAR), Situation, Background, Assessment, Recommendation; "Patient continues treatment to left heel unstageable the area's flap has been removed and dark flexible tissue remains as well as some [MEDICAL CONDITION] to ankle. To continue to treat and close the area would you consider a oral antibiotic? "The treatment nurse continued her comments under the physician response section that read; "Topical treatment: Clean left heel with wound cleanser apply Santyl with [MEDICATION NAME] powder cover with a 4 x 4 with kerlix once daily." Further investigation evidenced the physician did not respond to the fax until [DATE]; three (3) days after the resident had been discharged to the hospital. He wrote the following physician order; " Keflex 500 mg 1 cap po (by mouth) Q (every) 6 hours x 10 days". On [DATE] at 12:10 P.M., the treatment nurse documented, " Treatment to patients heel this shift. Afloat when in bed, (sign for no) complications. Will continue to monitor". On [DATE] the resident was noted to have a change in condition. The SBAR nurses notes read as follows; "10:30 am, Observed resident in bed breathing but non-responsive. Unable to wake up. BP ,[DATE], 99 (temp), 93 (pulse), 30 (respirations), O2 sat on room ar 87, BS (blood sugar) 305. Called (on call MD name). 11 am, received order to send to ER for evaluation. POA (name) called...911 transported resident to (name of hospital ER), report called." On arrival to emergency room #1 at 11:23 A.M., the resident's blood sugar was 438, a repeat was conducted and also read 438, (normal lab reference is ,[DATE]). The physical exam documented: "Dry oral membranes. Looks dehydrated. Ulcer to left heal {sic} with pus drainage, foul odor...Pt looks septic. Immediately started goal directed therapy. Started IV vanc ([MEDICATION NAME],) [MEDICATION NAME] and [MEDICATION NAME] (antibiotics). A urinalysis was obtained. The resident was diagnosed with [REDACTED]. The ER nurse documented the following;" On arrival to ER pt left heel necrotic with a foul odor. Wound with moderate amount of drainage. Also noted with right heel to be boggy. Also noted to have area approx 2 cm on right buttocks stage I purplish in color slow to blanch." A culture of the left heel wound was obtained. The culture was positive for the following: 1. Proteus Mirabilis-moderate 2. Pseudomonas Aeruginosa-moderate 3. [DIAGNOSES REDACTED] Pneumoniae-moderate 4. [MEDICATION NAME] Faecalis-moderate group D. The responsible party (RP) requested the resident be transferred to another hospital for further care. The resident was transferred to Hospital #2 at 2:59 P.M., on [DATE] and admitted directly to the ICU. The attending physician documented; " Suspect a combination of [MEDICAL CONDITION] and severe [MEDICAL CONDITION] (elevated sodium=175- normal lab reference is ,[DATE]). Upon admission the left heel wound was assessed and described as; "Stage IV decubitus ulcer on left heel with necrotic surrounding tissue as well as skin breakdown on her sacrum. Will consult general surgery for [REDACTED]. The senior resident comments read as follows; "Impression: Ulceration secondary to pressure with possible diabetic ulcer component". The attending physician documented his conversation with the RP about the left heel pressure area; "...is OK with bedside debridement of decub (I explained that antibiotics alone would likely be ineffective). The general surgery consult documented, "Approx 7 cm x 8 cm unstageable decubitus to left heel with large central area of necrosis and degloving of the skin around the periphery. Slight undermining around wound edges." At 10:00 P.M. on [DATE] the general surgery physician documented the left heel pressure ulcer was debrided, "The area was cleaned in sterile fashion with chloraperp and the excess skin was excised. No drainage or bleeding was noted during the procedure". A Stage IV pressure ulcer is described as a full thickness of skin tissue loss with exposed bone or muscle. Slough or eschar may be present. Often includes undermining and and tunneling. Pressure Ulcer Prevention Quick Reference Guide, (NPUAP 2009) On [DATE] at 10:00 A.M., the initial interview with the wound/ treatment nurse was conducted. She was asked who did the wound care in the building? She stated, " I do the treatments Monday through Friday, the floor nurses do them on the weekends". She indicated she had been the "treatment" nurse for approximately 4 years. She stated she is responsible for the weekly assessments of all wounds including pressure ulcers. She indicated she is the point of contact with the physician for any changes and recommendations for pressure ulcer treatments. On [DATE] at 11:20 A.M., a second interview was conducted with the treatment nurse and surveyor #2 in attendance. The treatment nurse was asked if she had assessed the left heel and notified the physician after it was identified as an area of breakdown on [DATE]. She stated the protocol is, "Whoever saw it first notifies the doctor...if it is a new area an incident report is filled out...then you start the protocol... such as float the heel." When asked if the physician was notified she stated, " It would be on the incident report". The director of nurses (DON) was then asked to locate the incident report, several minutes later the DON reported back to the surveyors that there was no incident report filed for this newly identified area. The nurses notes did not indicate the physician was notified of the left foot skin breakdown initially identified on [DATE]. During the interview the treatment nurse (Tx) indicated she had not assessed the wound prior to [DATE]. The Tx nurse was asked why she recommended the calcium alginate as the choice of treatment after her initial assessment on [DATE] evidenced the wound did not have any drainage or exudate and was intact. She stated, " I didn't say it was "wet or nothing... I don't know...the blister had started to rupture it was gray". Review of the calcium alginate insert read it is indicated for the management of moderately to heavily -exudating, partial and full thickness wounds. The treatment nurse was asked why a change in treatment had not been implemented when there was no change in the wound according to her assessment for 5 weeks. She stated, "When something looks wrong...doesn't get better you can change the treatment". The facilities Skin and Wound management obtained from Med-Pass dated 2010 read as follows; If wound does not improve in ,[DATE] weeks notify physician. Consider a skin consult with a wound specialist. The treatment nurse was asked if she had notified the physician that the wound was not improving. She stated she had not. When asked if she had requested a consult with a wound clinic, she indicated the facility did not use a wound clinic. When asked why she had requested a podiatrist consult on [DATE] she stated it was so the left heel pressure ulcer would be evaluated. When asked if the podiatrist had consulted, she stated "No...it is brutal trying to get a podiatrist in here", and indicated the family members had not provided a name of a podiatrist to contact. When asked if she had followed up with this she stated she had not. She stated the podiatrist visits the facility approximately every 3 months. The Tx nurse indicated she had not called the physician and asked him to come and examine the resident's pressure ulcer at this point. The treatment nurse was asked if the resident had received treatment for [REDACTED]. She stated, "When an order stops you generate another order by getting an order from the physician". When questioned why there was no order for [DATE] she stated, "I didn't write nothing?...I can't believe I missed that...." The treatment nurse was asked if Resident #8's was a diabetic. She stated, "No...those things matter when you try to nurse a heel...I didn't see any of that (DM diagnosis) in the chart...this is just a whole mess." The treatment nurse was asked why she requested an oral antibiotic on [DATE]. She stated, "Because I saw some [MEDICAL CONDITION] in the leg, the blister was leaking and it had a faint odor...if you have [MEDICAL CONDITION] around the wound it could be a sign of infection...the leg was warm to touch...I faxed it over to see if I could get it something from the pharmacy...it was a holiday weekend and I knew I had to get something for her...". The treatment nurse faxed a note to the physician's office at approximately 5:30 P.M., on [DATE] to notify him of a change in condition of the wound with suspected infection. The physician did not respond or address this fax until [DATE], after the resident had been discharged . After further questioning the Tx nurse indicated she had written the telephone order for the [MEDICATION NAME] powder without waiting for a response from the physician. The telephone order was then faxed to the pharmacy, and treatment was initiated with the [MEDICATION NAME]. The treatment nurse stated she did not call the oncall physician after no response was recieved from the physician for medical intervention. [MEDICATION NAME] is an antibiotic used to treat superficial infections caused by susceptible organisms, according to the Specialized Long-Term Nursing Drug Handbook 2008. The facilities policy for Skin and Wound Management dated 2010 read as follows: "The physician will help identify medical interventions to wound management; for example, treating a soft tissue infection surrounding an ulcer, removing necrotic tissue..." The pharmacy was contacted on [DATE]. They informed the surveyor that they were no longer being supplied with [MEDICATION NAME] powder, and had been out of it for several months. The pharmacy tech stated the pharmacy canceled the [MEDICATION NAME] order and had notified the facility on the evening of [DATE]. The treatment cart was inspected on [DATE] with the unit manager and the treatment nurse in attendance. A bottle of [MEDICATION NAME] powder was located inside Resident #8's cassette. There was no pharmacy label, it had been removed. A strip of paper tape had been applied and handwritten on it was Resident #8's last name. The treatment nurse then indicated that she had taken this bottle from another resident who had been discharged , wrote the resident's name on it and used it on Resident #8 on [DATE]. Through conversations with the director of nurses (DON) on ,[DATE] and ,[DATE] the above findings was shared. She stated the [MEDICATION NAME] powder had been obtained from a resident who had been discharged , stating, "It (the [MEDICATION NAME]) hadn't expired...it was the holiday week and she (the Tx nurse) wanted her (Resident #8) to have something instead of nothing". When asked what was the standard of treatment for [REDACTED]. When asked if the facilities utilizes a wound clinic she stated, "No...the hospital has a wound nurse that is available." The DON was asked if the resident had a [DIAGNOSES REDACTED].

2. Facility staff failed toprovide interventions to Resident #6 to prevent further falls in this resident with a history of falls. Resident #6 was [AGE] years old at the time of the survey. He was admit to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. The resident's 9/10/2012 quarterly Minimum Data Set (MDS) and the Brief Interview for Mental Status (BIMS) evidenced the resident scored a 2 of 15 possible points evidencing cognitive impairment. For transfers the resident required the assistance of one person and for bed mobility required the assistance of two persons. The resident did not walk in his room or off the unit. The resident was not steady moving from seated to standing position, surface to surface transfer and movement on and off the toilet, and was only able to stabilize with staff assistance. Review of the resident's care plan identified a problem of, "Resident is a risk for injury from fall." The problem was first identified on 6/11/2009. The goal was the resident will be free of falls/injury during the next 90 days. The current care plan's next review date was 12/20/2012. The current care plan listed the resident's falls since 6/25/2012. On 1/17/2012 the approach of, "Resident to have safety devices while in/out of bed to help in the prevention of falls" was added. The devices were not identified. The original approach of "bed in lowest position when resident in bed" was amended to read "high/low bed with mat and bed against the wall." No date was included. During the survey the bed was noted to be adjustable in height, against the wall and a mat on the floor. The use of a Pommel cushion was also added, without a date and the effectiveness was not assessed. The next seven approaches had not been updated since 6/11/2009 and included: complete risk assessment on admission and after each fall, complete three night fall risk assessments on admit, encourage resident to remain in an observable area when up and out of bed, keep call bell in reach and answer call for assist promptly, monitor for changes in cognitive status (i.e. sleepiness, confusion, agitation, pain ect). Notify MD, monitor resident while in bathroom/shower for personal safety awareness remain with resident if exhibiting confusion or agitation, and physical therapy to evaluate and treat to increase functional mobility and personal safety awareness. Review of the resident's clinical record evidenced a fall on 2/24/2012 while the resident was attempting to transfer from the bed to the wheelchair without shoes, it was an observed fall. On 3/7/2012 the resident was found on his knees in front of the wheelchair. Resident #6 fell three times in April 2012. On 4/3/2012 he fell at 6:30 a.m. and was found in front of the toilet, he fell again at 6:20 p.m. and was found on the floor. On 4/20/2012 the resident was found on the floor in his room with the wheelchair at his side. On 5/8/2012 (10 p.m.)the resident was found on the floor in his room attempted to transfer self. On 5/19/2012 he was found on the floor in his bathroom, the fall investigation report evidenced that he was non compliant with using the call bell and asking for assistance. However, this approach remained on his care plan. On 6/3/2012 the resident was found on the floor by the bed. On 6/13/2012 he was found on the floor next to the wheelchair and bed. On 6/25/2012 this resident was found again on the floor beside his bed. On 8/7/2012 the resident was found on the floor in the hall next to his w/c. On 8/25/2012 Resident #6 was found on the floor in his bathroom. On 8/29/2012 this resident was found on the floor next to his bed. It was determined that the alarm did not sound because the battery was not working. In September the resident fell twice, on 9/17/2012 the bed alarm sounded and the resident was found on the floor by his bed. On 9/22/2012 the resident was found in his bathroom on the floor. On 10/11/2012 the resident had an observed fall, he leaned forward and slipped out of his chair. Following the falls the resident was assessed and did not suffer injuries. On the afternoon of 11/27/2012 the facility staff was requested to provide evidence of care plan interventions following each falls for Resident #6. Information was received 11/28/2012 mid morning. The information included a check list, "Extended Care Fall Risk Assessment Fall Prevention Interventions" that is completed on everyone who falls. The interventions included room free of clutter, call bell in reach, night light, non skid strips, non slip foot wear, personal items in reach, education on use of assistive equipment, observation every two hours, moving resident closer to the nursing station, alarm to bed and chair, special equipment, facility programs, PT/OT, blood pressure and /or oxygen saturation, pain management, rest periods, Hi-Lo bed, ADL review, CNA Fall Prevention Program, and a request for a physician review. The form did not indicate when the approach had been indicated or was it effective During the survey the resident was observed with a chair and bed alarm but only two of the falls evidenced if the alarm was functional at the time of the fall or if it allowed staff time to reach the resident prior to a fall. The check list had been completed for all falls, but during interview with the DON mid morning on 11/28/2012 she was unable to tell the surveyors what intervention had been placed following each fall. No individualized interventions were identified. The DON also provided a "trending book" for falls that identified residents, number of falls, and staff assigned to care for the resident. Further review of the information provided to the team did not evidence documentation that the possible precipitating factors contributing to the falls were assessed/considered. The documentation addressed what occurred after the falls. Behavior, need for toileting, hunger, staff/resident interactions observed occurring prior to falls were not addressed. Resident #6 is severely cognitively impaired and would not be reliable interview for reasons associated with the falls. On the morning of 11/30/2012 the DON and Administrator were requested to review the information provided to the team and to provide information related to each fall and intervention. Later that afternoon the DON returned the previous documents but stated there was no additional information. Based on observation, clinical record review, staff interview and facility document review, the facility staff failed to monitor and implement new interventions to prevent falls for 2 of 23 residents in the survey sample, Resident # 2 and Resident # 6 1. The staff failed to monitor and implement interventions to prevent a fall resulting in an fracture to the right hip and repair for Resident #2. 2. Facility staff failed toprovide interventions to Resident #6 to prevent further falls in this resident with a history of falls. Findings included: 1. The staff failed to monitor and implement interventions to prevent a fall resulting in a fracture to the right hip and repair for Resident #2. Resident # 2 was re-admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. Review of both Resident # 2's MDS (Minimum Data Set) assessment done as an initial assessment with an ARD date of 3/12/12 and the last quarterly review with an ARD date of 8/27/12, coded resident # 2 as a 0 of 15 on the BIMS Scale (Brief Interview for Mental Status). The resident was coded as being understood by others and usually understanding others. Resident # 2 was coded as needing extensive assistance of at least 2 staff for bed mobility, transfers and toilet use. The resident was coded as demonstrating frequent urinary incontinence. The resident was coded as not walking "in the room or corridor". Resident #2 was coded as "not steady, only able to stabilize with human assistance" in moving from a seated to a standing position and moving on and off the toilet. The resident was coded as having two falls since "admission or previous assessment". On the 3/12/12 assessment, Resident # 2 was coded as demonstrating delirium / an altered level of consciousness. Review of Resident #2's Clinical Record revealed an interdisciplinary Progress Note entry at 8:45 pm on 10/29/12 that read "Resident found on floor in Act (Activities) Area. Clip alarm intact. Assisted back in wheelchair at which time resident complained of pain in back. Resident was lying on right side when found. Call out to MD (Medical Doctor) for order for X-ray to rule out fracture. Son made aware of fall, c/o pain... Resident now sitting at nurses station..ordered X-ray of R hip..". Review of a Progress Note entry at 3:40 am on 10/30/12 indicated the resident had been admitted to an acute care facility with a right hip fracture. Review of a discharge note from the acute care facility on 11/1/12, revealed Resident # 2's X-ray of the pelvis showed " a displaced, impacted fracture of the neck of the right femur". Review of Resident # 2's Clinical Record, Fall Investigations, the extended Care Fall Risk Assessment forms and 24 hour reports, provided by the facility, indicated the resident had had a total of 17 falls from 3/11/12 to 10/29/12 including : 4 falls in resident room 10 falls in Activities/Day room or Nursing Station 1 fall in hallway 2 falls without a setting documented. Review of the facility information as provided, revealed the following falls and related interventions: Review of Resident # 2's Admission Care Plan, 3/7/12, in place at the time of the 10/29/12 fall and fracture, indicated 9 interventions had been put in place on 3/7/12. Target dates for review were listed as 6/15/12, 9/14/12 and 12/6/12. All 17 falls occurred after the 3/7/12 Care Plan Date. 3/9/12 Risperdal (antipsychotic) was ordered BID (twice a day) for agitation 3/11/12 at 23:00 (11:00 PM) Fall Activities /Day Room. Attempting to get up on own from W/C and fell . (No documentation found of new interventions since 3/7/12 Care Plan). 3/12/12 at 4:45 am Fall Bedroom. "Roommate called and said resident trying to get up and put on shoes. When staff arrives resident had removed clip alarm and was sitting in middle of floor. The investigation stated "Pt needs a pressure alarm and possibly a lap buddy or something to keep her maintained. Possibly a 1-1 sitter. Patient knows how to remove the clip alarm". No indication was found in the clinical record or through interview that these recommendations were discussed. 3/15/12 at 9:30 am - Fall Activities/Day Room from "slid out of WC. Resident was trying to stand and gait unsteady". 3/30 12 at 1:00 am - Fall Hallway. "Resident string that was attached to chair alarm was lengthy. The block labeled "Nursing observation frequency increased" was marked. 4/30/12 at 2:20 am - Fall Activities/Day Room - Found on Floor 5/12/12 at 2:00 am, Fall Nursing Station. "... Scooting in Wheelchair and slipped to floor". "...W/C not locked" 5/15/12 at 2:45 am - Fall Bedroom. Woke up and got up out of bed. Bed alarm turned on but did not sound. Delayed reaction. 5/21/12 at 1:25 pm - Fall Nursing Station. "Was trying to move W/C and slipped from Chair". Skin Tear hand. 6/14/12 at 11:30 pm - Fall Nursing Station (front of W/C. Found on Floor.in front of W/C...No injuries". "Chair alarm attached. Didn't alarm". "Alarm attached to blanket, not resident". 6/15/12 Revision Date of Care Plan 6/21/12 at 6:55 am Fall Bedroom. "Bed alarm wet off. ...Resident found on mat , on floor with no injuries". 6/24/12 Hoyer 6/25/12 at 9:50 pm Fall Nursing Station. 6/28/12 10:50 am/pm (?) Fall Nurses Station. Resident ..."stood up fromW/C and tried to take a step and fell down on buttocks". "Alarm patent and intact". 7/16/12 Ativan (sedative) was ordered 7/30 12 10:30 pm - Fall Activities/Day Room. Resident "stood up in Activities Area. Her knees buckled and she went to the floor. She did not hit her head and there was no apparent Injury". 9/1/12 7:45 pm - Fall Activities/Day Room. "Appeared to have slipped down on floor from chair. Taken to Dining Room after fall" 9/5/12 "Clip alarm in place for safety" noted in Care Plan" 9/14/12 Revision Date of Care Plan 10/19/12 1:00 pm: Fall (Lowered to floor) 10/29/12 8:45 pm: Fall Activities/Day Room (to Acute Care Facility / Fractured Hip), Found on Floor. "Heard W/C alarm. Found resident lying on floor on right side. The Care Plan included two interventions prior to the fall and fracture on 10/29/12. One of the two interventions on the Care Plan read "Ensure bed and chair alarms are on and functioning properly when resident in bed or in wheelchair". The intervention had no date or time that related the intervention to a specific fall. An intervention dated 9/5/12, following 15 falls, read "Clip alarm in place for safety". Review of the 2nd fall investigation, dated 3/12/12, indicated a clip alarm was in place at that time. A review of fall investigations for Resident #2 revealed an entry following the second fall on 3/12/11 which included a recommendation for "a pressure alarm and possibly a lap buddy or something to keep her maintained. Possibly a 1:1 sitter. Patient knows how to remove clip alarm". The Care Plan did not reveal if any of the other interventions suggested were initiated. Of the 10 fall investigation forms reviewed, a total of 9 forms indicated Resident # 2 was not on any medications that might have been associated with the falls, although Resident #2 had been on an antipsychotic and a sedative/hypnotic at night. an order for [REDACTED]. The order was no longer on the Physician order [REDACTED]. The Pummel Cushion was not listed as an intervention on Resident # 2's Care Plan. No indication was found the Pummel Cushion was used. On 11/28/12 the director of nursing (DON) was unable to provide this surveyor with any detail on the use of the Pummel Cushion. On 11/28/12 at 3:00 pm the Director of Nurses stated the (IT) Interdisciplinary Team met Monday thru Friday at 9:30 am and discussed all falls listed on the 24 hour report. The DON stated the interventions might be found on notes from the Team Meetings or possibly from the 24 hour reports. The DON provided this surveyor with a copy of the 24 hour reports however no specific interventions were identified for Resident # 2. The DON provided this surveyor with a list of interventions for Resident #2, however, the interventions were not fall specific. The DON was unable to provide any documentation that indicated falls were being monitored resulting in specific interventions related to each fall. On 11/29 12 at 10:30 the Administrator was made aware of the lack of assessment of current interventions or identification of new interventions following each fall as expected. The DON stated "on the old forms" they identified the interventions.