Every finding on record at Norview Heights Rehabilitation and Nursing

Based on resident interview, staff interviews, clinical record review, and review of facility documents, the facility staff failed to ensure a resident was free from staff coercion and harassment for 1 of 2 residents (Resident #1), in the survey sample. The findings included: Resident #1 was originally admitted to the facility 6/22/23 and had not been discharged from the facility. The resident's diagnoses included Major depressive disorder, recurrent, mild, generalized anxiety disorder, borderline personality disorder, PTSD and stroke with right hemiplegia. The annual Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 5/3/24 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #1's cognitive abilities for daily decision making were intact. The active care plan had a problem dated 8/2/23 which stated the resident has an ADL self-care performance deficit related to CVA. The goal stated the resident will improve his current level of function in activities of daily living (ADL) through the review date, 8/6/24. The interventions included the resident is totally dependent on staff to provide bath/shower as necessary. The resident requires contact guard assist by staff to turn and reposition in bed as necessary. The resident is totally dependent on staff for dressing. The resident requires extensive assist to maximize independence with personal hygiene and oral care. The resident is totally dependent on staff for toilet use and the resident requires contact guard assist by staff for transferring. On 7/15/24 at approximately 6:27 PM an interview was conducted with Resident #1 upon the resident's request. The resident was observed to be extremely restless, shifting his body greatly, speaking rapidly and forcefully as he described his experiences regarding harassment by the some of the facility's staff. The resident stated Licensed Practical Nurse (LPN) #1 belittled him (talked about his inability to provide specific services for himself as a negative deficit) in the corridor where other residents and visitors could hear her. The resident stated the administrative staff separated LPN #1 from employment within the facility. Resident #1 stated LPN #1 currently had a daughter (Certified Nursing Assistant (CNA) #2 who is employed in the facility and the daughter continuously does things to coerce him to react. Resident #1 stated CNA #2 is not assigned to provide care to him anyone because he made a [NAME] not to have her assigned to him and it was honored. Resident #1 stated CNA #2 made remarks about him such as he was having frequent incontinence episodes so staff would have to provide incontinence care for him because he enjoys it sexually, he had threatened her, he had a gun in the facility, and she filed a criminal complaint against him. Resident #1 also stated that on 6/11/24 the Administrator had his room deep cleaned, which included removing all his personal effects from the room for cleaning and then called the facility staff had the police to take him from the facility to the hospital for a mental evaluation. The resident stated the hospital transfer made it impossible for him to secure his personal effects so others could not take them. The resident also stated he was discharged back to the facility at approximately 10:00 PM with no identified findings concerning his mental health and no new medications. The resident stated after an inventory many of his personal items were identified as missing and the facility's staff failed to take responsibility for them. Resident #1 stated that the Administrator had consistently made attempts to discharge him from the facility first for non-payment and once his spouse obtained the Medicaid benefits, the Administrator issued another discharge to him dated 6/14/24 to a local hotel for which the facility was to pay for two days. The 6/14/24 discharge notice stated the reason for the discharge was to maintain safety for other residents in the facility. Resident #1 stated the Administrator did not expound on how he was endangering other individuals in the facility. An interview was conducted with CNA #1 on 7/16/24 at 1:16 PM. CNA #1 stated she had not observed Resident #1 with alcohol, marijuana, or a gun in the facility but, she had overheard other staff talking about the resident having a gun in his room. An interview was conducted with CNA #2 on 7/16/24 at 1:29 PM. CNA #2 began crying when asked if she felt safe while working in the facility. CNA #2 stated she did not feel safe because Resident #1 harasses her every day by makes dog sounds when he sees her, talks about gang members, puts his middle finger up when he sees her coming in to work, and talks about suiting her. CNA #2 stated she obtained a restraining order against the resident because she fears he may stand and grab her and break her neck or his spouse may have a gun in the large bags she brings into the facility. CNA #2 concluded with she felt Resident #1 had a personal vendetta against her. A review of CNA #2's educational records revealed that she had not been educated on dealing with residents with disruptive or challenging behaviors. An interview was conducted with the Staff Development Coordinator who stated CNA #2 had not received the in-service on working with residents with disruptive or challenging behaviors because it had not been offered since she was hired but it is due to be offered soon. An interview was conducted with CNA #3 on 7/16/24 at 1:44 PM. CNA #3 stated Resident #1 became angry because an LPN talked about his disability in the presence of others. CNA #3 stated she had recognized a change in the resident's behavior since the incident, approximately June 2024. CNA #3 stated going outside to smoke calms the resident down. CNA #3 stated if there was a gun in the resident's room they would have seen it by now as often as the staff goes in and out of his personal belongings. An interview was conducted with Licensed Practical Nurse (LPN) #2 on 7/16/24 at approximately 2:16 PM. LPN #2 stated Resident #1 stated he was going to purchase a gun and send it to his wife and some staff felt it was possible she would bring it to the resident. LPN #2 stated that LPN #1 and Resident #1 were cordial at first for she had been his nurse for a while, and she believes the resident felt disrespected by LPN #1 and ever since the event occurred Resident #1 had displayed an increase in negative behaviors. LPN #2 stated she had not observed a gun in the resident's room. On 7/17/24 a final interview was conducted with the Administrator, Director of Nursing (DON), Staff Development Coordinator, Unit Manager, and Regional Director of Nursing. The Administrator stated she asked CNA #2 on 7/16/24 not to obtain another restraining order against Resident #1 and she felt going forward they would be capable of developing strategies for working with the resident to achieve his goals.

Based on resident interview, staff interviews, clinical record review, and facility document review, the facility staff failed to provide routine wound care treatments for 1 of 3 residents (Resident #1) in the survey sample. The findings included: Resident #1 was originally admitted to the nursing facility on 07/10/21. Diagnosis for Resident #1 included but not limited to Quadriplegia, Type II Diabetes, Transmetatarsal Amputation (TMA - removal of toes) to the left and right foot, and morbid obesity. The Minimum Data Set (MDS - an assessment protocol) a quarterly assessment with an Assessment Reference Date (ARD) of 07/18/23 coded Resident #1 with a 15 out of a possible score of 15 on the Brief Interview for Mental Status (BIMS), indicating no cognitive impairment. The MDS coded Resident #1 total dependence of two with bathing and toilet use, total dependence of one with personal hygiene, extensive assistance of two with bed mobility and transfer, extensive assistance of one with dressing and supervision with eating for Activities of Daily Living (ADL) care. Resident #1's person-centered care plan revised on 10/10/2023 identified the resident has actual impairment to left medial TMA and right plantar foot. The goal set for the resident by the staff was that the resident would have no complications related to (r/t) surgical vascular wound of the right foot. Some of the interventions/approaches the staff would use to accomplish this goal was to follow facility protocols for treatment of injury, goes out to doctor for lower leg wounds, encourage good nutrition and hydration to promote healthier skin and weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate and any other notable changes or observations. An interview was conducted with Resident #1 on 10/11/23 at 10:00 a.m. He stated he did not receive wound care treatment to his feet from 07/05/23 until he was seen at the wound clinic on 07/11/23. On 10/11/23 at approximately 12:46 p.m., an interview was conducted with the Nurse Practitioner (NP). She stated she assessed Resident #1's vascular wound to his feet on 06/21/23. She stated the Resident #1's were being followed by the wound clinic. Resident #1 had agreed to allow the facility to take over wound care services to his feet on a 30-day trial basis. The NP stated she spoke with Resident #1 on 07/05/23 and was informed by the resident he no longer wanted the facility to care for the wound to his feet and would be going back to (name of wound clinic). She stated she signed off on the same day, rendering services back to the wound clinic. She stated Resident #1 did not allow her to assess his wounds to his feet on that day (07/05/23). She stated she never gave orders to discontinue wound care treatment. A review of Resident #1's Treatment Administration Record (TAR) for June 2023 revealed the following orders to be started on 06/21/23. -Left plantar 5th toe - apply collagen AG and foam dressing every night shift for wound healing. -Right plantar foot - apply carboxymethylecellulose (CMC) fiber, cover with ABD pad and wrap with kling every night shift. -Left dorsal foot - apply skin prep two times a day for wound healing. The June 2023 Treatment Administration Record (TAR) revealed the above wound care orders were implemented from 6/21/23 to 7/4/23, and discontinued on 07/05/23. Further review of the TAR revealed there were no additional orders put in place until 07/11/23. Based on the TAR, Resident #1 went six (6) days without having wound care treatments to his left plantar 5th toe, right plantar foot and left dorsal foot. An interview was conducted with Registered Nurse (RN) #1 on 10/11/23 at 2:08 p.m. She stated she discontinued wound care orders to Resident #1's feet on 07/05/23, but only after the NP had informed her that she would no longer be following the wounds to Resident #1's feet. She stated she thought Resident #1 still had active wound care orders that were previously ordered by the wound clinic. She stated she did not realize Resident #1 did not have an active wound care order from 07/05/23 to 07/11/23 until she reviewed Resident #1's TAR on 10/11/23. She stated according to the July 2023 TAR, Resident #1 missed receiving wound care treatment to his feet for six (6) days. A review of Resident #1's clinical record revealed a progress note written by (name of wound clinic) on 10/21/22 where the note indicated a skin graft had been done on the left dorsal foot. The documentation did not give a description of the wound prior to or after the wound graft was performed. Further review of the clinical indicated a skin graft had been to the same area (left dorsal foot) on 07/11/23. A final meeting was held with the Administrator, Director of Nursing (DON), and Regional Director of Clinical Services on 07/21/23. The DON stated Resident #1 should have had wound care treatments to the feet in place from 07/05/23-07/11/23. The facility policy titled Wound Treatment Management revised on 12/01/22. It is the facility's policy to promote wound healing of various types of wounds, it is the policy of this facility to provide evidence-based treatments in accordance with current standards of practice and physician orders. Policy Explanation and Compliance Guidelines: 1. Wounds treatments will be provided in accordance with physician orders, including the cleansing method, type of dressing, and frequency of dressing change. 2. In the absence of treatments orders, the license will notify physician to obtain treatment orders. This may be the treatment nurse, or the assigned licensed nurse in the absence of the treatment nurse.

Based on observation, staff interview, facility documentation review, the facility staff failed to inform the Resident and the resident's representative of the administration of expired insulin for 1 of 3 residents (Resident #2) in the survey sample. The findings include: The facility staff notify Resident #2 and her family that she was administered expired Insulin Lispro. Resident #2 was originally admitted to the facility [DATE] and readmitted [DATE] after an acute care hospital stay. The current diagnoses included Type 2 Diabetes Mellitus. The quarterly, Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of [DATE] coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 9 out of a possible 15. This indicated Resident #2 cognitive abilities for daily decision making were moderately impaired. In sectionG(Physical functioning) the resident was coded as requiring extensive assistance of one person with bed mobility, transfers, locomotion, dressing, eating, toileting, personal hygiene, requires physical assistance of one person with bathing, supervision after set-up help with eating. Resident #2's person-centered care plan revised on [DATE] identified the resident as having Diabetes Mellitus. The goal for resident was that he would have no complications related to diabetes through the review date. An intervention that the staff used to accomplish this goal was to administer Diabetes medication as ordered by the doctor, monitor, document for side effects and effectiveness. The current Physician Order Sheet (POS) for [DATE] read: HumaLOG Injection Solution 100 UNIT/ML (Insulin Lispro) inject as per sliding scale: if 150 - 199 = 2 UNITS; 200 - 249 = 4 UNITS; 250 - 299 = 6 UNITS. Inject ,d+[DATE] units beneath the skin 4 times a day subcutaneously before meals and at bedtime for diabetes 11:30 AM., 4:30 PM., 10:00 PM -Start Date [DATE], 4:30 PM. The August, September and [DATE] MAR/Medication Administration Record reflected the current POS orders for HumaLOG Injection Solution 100 UNIT/ML (Insulin Lispro) and that all doses of Insulin Lispro/HumaLOG were administered. On [DATE] at approximately 3:35 PM.,a cart audit was conducted with RN/Registered Nurse #4 on the skilled unit. An opened bottle of Lispro Insulin was observed with an opened date of [DATE] with an expiration date of [DATE], which was beyond the 28-day of usage. She said that Resident #2 was still receiving the insulin. The Unit Manager (UM) Registered Nurse (RN) #1 who was observing RN #4 said that the insulin the resident was receiving should be off the cart and a new bottle ordered. A review of the MAR for September and [DATE] show that Resident #2 was receiving the expired Lispro 100 units/ml., which should have been discarded by [DATE] but was continued to be administered until [DATE]. On [DATE] at approximately 12:45 PM., an interview was conducted with Resident #2. She said, No one mentioned anything to me about receiving expired insulin yesterday or today. On [DATE] at approximately 12:55 PM., a phone call was made to Resident #2's daughter/Emergency contact #1 concerning notification of expired Lispro insulin. She stated she had not received any phone calls from the facility regarding her loved one receiving expired insulin but wanted me to contact Resident's other daughter. On [DATE] at approximately 2:15 PM., a phone call was made to Resident #2's daughter/Emergency contact #2. She stated that she just received a phone call around 2:00 PM on [DATE] from a nurse explaining that her loved one received expired insulin. On [DATE] at approximately 3:00 PM while waiting for Registered Nurse (RN) #4 to be interviewed concerning expired insulin, the DON said that the RN was not feeling well. On [DATE] at approximately 4:15 PM., the above findings were shared with the Administrator, the Director of Nursing (DON) and Corporate Consultant. The DON said that she should have written an incident report, notified the family, and discarded the expired insulin. An opportunity was offered to present additional information but no additional information was provided. Insulin Lispro injection products are used to treat type 2 diabetes (condition in which the body does not produce insulin and therefore cannot control the amount of sugar in the blood). Opened insulin Lispro solution (Admelog, Humalog) cartridges and pens may be stored at room temperature for up to 28 days; do not refrigerate them. Opened pens containing Humalog ,d+[DATE] or Humalog ,d+[DATE] may be stored at room temperature for up to 10 days; do not refrigerate them. Opened insulin Lispro solution pens can be stored at room temperature for up to 28 days (https://medlineplus.gov/druginfo/meds/a697021.html).

Based on the facility's medication storage review of 1 medication cart and 1 medication room; the facility staff failed to ensure expired insulin was discarded after the use by date (28 days) and that they predated 2 vials of insulin before use. The findings included; On [DATE] at approximately 3:35 PM a medication cart audit was conducted with Registered Nurse (RN) #4 on the Skilled unit. Stored inside of the medication cart were two unopened bottles of predated Lantus Insulin, one predated unopened Lantus Insulin Pen and one opened bottle of expired, beyond the 28-day usage insulin that had been administered to a resident. RN #4 said that she would usually date the insulin as they are delivered by pharmacy to the unit. The Unit Manager (UM) Registered Nurse (RN) #1 was observing RN #4 said that the insulin should not be predated until it's opened and the expired insulin should be off the cart and a new bottle ordered. [DATE] at approximately 4:15 PM., the above findings were shared with the Administrator, the Director of Nursing (DON) and Corporate Consultant. The DON said that insulin vials and pens should not be predated before initial use and expired insulin removed off the cart and discarded.

Based on resident interview, staff interviews, clinical record review, and facility document review, the facility staff failed to ensure a Resident was administered the correct insulin for 1 of 3 residents (Resident #1) in the survey sample. The findings included: Resident #1 was originally admitted to the nursing facility on 07/10/21. Diagnoses for Resident #1 included but not limited to Quadriplegia and Type II Diabetes. For Resident #1, the facility staff failed to ensure he received the correct insulin. Resident #1 was originally admitted to the nursing facility on 07/10/21. Diagnosis for Resident #1 included but was not limited to Quadriplegia and Type II Diabetes. The Minimum Data Set (MDS - an assessment protocol) a quarterly assessment with an Assessment Reference Date (ARD) of 07/18/23 coded Resident #1 with a 15 out of a possible score of 15 on the Brief Interview for Mental Status (BIMS), indicating no cognitive impairment. The MDS coded Resident #1 total dependence of two with bathing and toilet use, total dependence of one with personal hygiene, extensive assistance of two with bed mobility and transfer, extensive assistance of one with dressing and supervision with eating for Activities of Daily Living (ADL) care. Resident #1's person-centered care plan revised on 10/10/2023 identified the resident as having Diabetes Mellitus. The goal set for the resident by the staff was that the resident would have no complications. One of the interventions included giving diabetic medication as ordered by the physician. Monitor and document for side effects and effectiveness. According to the April 2023 Physicians Order Summary (POS), Resident #1 was ordered to be administered 10 units of Humalog/Lispro (short-acting) insulin before each meal. A review of the April 2023 Medication Administration Record (MAR) indicated that Resident #1 was ordered and used Humalog/Lispro 10 units subcutaneously (subq) before meals at 6:30 AM, 11:30 AM, and 4:30 p.m. Resident #1 was also on a sliding scale of Humalog/Lispro per the sliding scale with an order date of 3/24/23 which indicated the following: 0 - 149 = 0 units; 150 - 200 = 6 units; 201 - 250 = 8 units; 251 - 300 = 10 units; 301 - 350 = 12 units; 351 - 400 = 14 units; 401 - 450 = 16 units call Physician if blood glucose level above 401 subq before meals and at bedtime. Also, according to the April 2023 POS Resident #1 was ordered to be administered Lantus (long-acting) insulin 45 units once daily at 9:00 AM. A review of the April 2023 MAR indicated that Resident #1 was ordered and used Lantus Insulin 45 units subq once a day at 9:00 a.m. and 10 units of Lantus insulin subq at 9:00 p.m. On 4/10/2023, Resident #1 should have received 45 units of Lantus Insulin at 9:00 AM, but instead was injected with 45 units of Humalog/Lispro insulin. A review of the MAR/Medication Administration Record showed the following Blood Sugar readings on 4/10/23: 10:15 AM, BS (Blood Sugar)=285, 10:30 AM=285, 10:45 AM=169, 11:00 AM=172, 11:30 AM=124, 12:00 PM=171, 12:30 PM=207, 1:00 PM=191. The BS reading ranged from 124-285 throughout the day. An interview was conducted with Resident #1 on 10/11/23 at 12:30 p.m. He said that he was given incorrect medication by a nurse. He said that LPN #1 came back to him saying she had injected him with 45 units of Humalog (Short-acting Insulin) instead of 45 units of Lantus (Long-acting Insulin). He said if he had not eaten a high-carbohydrate (carb) meal last night he might have gotten worse. On 10/10/23 at approximately 1:30 PM., an interview was conducted with Licensed Practical Nurse (LPN) #1 concerning insulin. The LPN said that she gave Resident #1 Humalog (Short Acting Insulin) instead of Lantus (Long-Acting Insulin). The LPN also said that she immediately contacted the NP (Nurse Practitioner) and was given orders to give resident OJ (Orange Juice) multiple times at the bedside and frequent blood sugar checks. LPN #1 said the order received from the NP was 15 minutes for an hour twice for 30 minutes then every hour. Resident #1's BS/Blood Sugar did not drop below 100. A nurse's note dated 4/10/23 at 1:12 PM read the following: Upon coming back to the medication cart, I noticed only short-acting insulin was put away, I then realized the patient had received short-acting insulin 45 units. I went to the Director of Nursing (DON) looking for the Nurse Practitioner (NP). When I found the NP, I told her that the resident received 45 units of short-acting insulin instead of long-acting insulin. I received a verbal order to check the pt (patient) every 15 mins for 1 hour and to educate pt on hypoglycemia and if any changes and if pt isn't feeling well to let the nurse know. I informed the resident while at bedside I would be checking him for 1 hour every 15 min, then every 30 for the next 4 hours. Noted BS (Blood Sugar) 285 skin warm to the touch and dry. A nurse's note dated 4/10/23 at 1:00 PM, read the following: He is seen today after nursing reported giving patient the wrong dose of Humalog. Pt was given 45 units of short-acting Humalog by mistake. This is his normal Lantus dose. Pt has an implanted blood sugar monitoring device. Check and document blood sugar Q15 x4 and then Q30 x4 Give patient a snack. A review of the incident report dated 4/10/23 at 10:00 AM., showed that Resident #1 was alert, oriented to place, time, person, and situation, and was not taken to the hospital after receiving the wrong insulin, Humalog short-acting 45 units at 9:00 a.m. On 10/11/23 at approximately 10:55 AM., an interview was conducted with the DON concerning Resident #1. The DON said, I was at the facility working when the LPN came to me and said that she made a mistake. The Nurse Practitioner (NP) was already in the building at the time. The NP gave guidance to monitor the resident's cognitive status, blood sugars, give orange juice, and record the blood sugar readings as ordered. I was not aware of the resident's blood sugar levels dropping below 200 points in three hours. The DON further stated, This incident happened in April of 2023. He wears a glucose device and uses a Dexacom to provide blood sugar readings. The resident would not allow the LPN to administer medications to him after the insulin mix-up incident. We would have to get a nurse from another team to administer the insulin. If the other nurse is busy, I would administer the Resident's medications. During the survey from 10/10/23-10/12/23 several additional residents including Resident #1 were observed administering insulin by the licensed nurses. No errors were observed. On 10/12/23 at approximately 4:15 p.m., the above findings were shared with the Administrator, Director of Nursing and Corporate Consultant. An opportunity was offered to the facility's staff to present additional information but no additional information was provided. Humalog(R) ([NAME]-ma-log) and Insulin Lispro Injection are fast-acting insulins used to control high blood sugar in adults and children with diabetesv ( https://www.humalog.com/). Prescription LANTUS is a long-acting man-made-insulin used to control high blood sugar in adults and children with diabetes mellitus. LANTUS is not for use to treat diabetic ketoacidosis ( https://www.lantus.com/).

Based on a complaint investigation, clinical record review, staff interviews and facility document review the facility staff failed to ensure there was no delay in the treatment and services to include medications upon admission for 1 of 2 residents in the sample, Resident #2. The facility staff failed to ensure Resident #2's admission medications were reviewed timely by the attending physician personally. The findings included: Resident #2 was admitted to the facility on [DATE] with diagnoses to included but not limited to Diabetes Mellitus, Hypertension and Urinary Tract Infection. Resident #2 was never actually admitted to the hospital from 4/30/21 to 5/4/21, but was under observation only in the emergency room because of no bed availability due to covid. Since Resident #2 was not admitted to the hospital no discharge summary was provided to the facility upon admission. The facility only received a emergency department after care summary report for the resident. Under the covid waiver that was in place, a 3 day qualifying hospital stay was waived for a medicare skilled admission. Resident #2's most recent comprehensive Minimum Data Set (MDS) was a 5-day assessment with an Assessment Reference Date (ARD) of 5/11/21. The Brief Interview for Mental Status for Resident #2 was unable to be completed however, the staff assessment indicated the resident's short and long term memory was intact. Resident #2's Emergency Department After Care Summary Report for the emergency room stay from 4/30/21-5/4/21 was reviewed and is documented in part, as follows: Your Medication List: Cephalexin (antibiotic) 500 mg(milligrams) take 1 capsule by mouth every 8 hours for 7 days. ASK your doctor about these medications: Glipizide 5 mg take 1 tablet by mouth twice a day. Hydrocortisone 25 mg insert 1 suppository rectally twice a day. Ditropan XL 5 mg take 1 tablet by mouth once a day. Flomax 0.4 mg take 1 capsule by mouth daily after supper. Tramadol 50 mg take 1 tablet every 6 hours as needed. Instructions: Today, Name (Resident #2) was treated for his urinary tract infection, Today's Visit: Diagnoses: Acute cystitis with hematuria, weakness, confusion, frequent falls, and finger fracture. Resident #2's Progress Notes were reviewed and are documented in part, as follows: 5/5/2021 00:10 a.m. Nursing Admission Note: Pt (patient) arrived at 9:30 pm sleeping, hard to arouse, vs (vital signs) wnl (within normal limits) b/p (blood pressure)-125/80, temp(temperature)-97.3, pulse- 67, res-20, and o2 stats- 98%. Noted bruising on both knees and back of right hand. Pt 78 y/o (year old) male diagnosis weakness, confusion, frequent falls, UTI(urinary tract infection), unable to asses pt mental state and conduct any additional assessment due to pt being sleep all shift. No known allergies. Will continue to monitor. 5/6/2021 16:27(4:27 p.m.) daily nursing charting Note: vital signs T(temperature) 96.9, P(pulse) 75, Regular Respirations 18, BP (blood pressure) 156/69, O2(oxygen) 97 % - Room Air a. LEVEL OF CONSCIOUSNESS Alert 2. ORIENTATION Resident is alert and oriented to the following person,place, time 3. COGNITION intact Respiratory observation: lung sounds- left lung: clear lung sounds- right lung: clear Describe locations and details of right lung sounds: Are there changes in residents Respiratory status? no EDEMA Pitting 0 - none 5/7/2021 06:17 a.m. Nursing Progress Note: RESIDENT IS CURRENT ON ABT R/T UTI. NO ADVERSE REACTION NOTED BY THIS WRITER AT THIS TIME. RESIDENT IS CURRENTLY IN HIS ROOM RESTING. 5/7/2021 13:58(1:58 p.m.) Nursing Progress Note: Resident remains on abt(antibiotic) for uti(urinary tract infection) with no adverse reactions noted. He remains afebrile. 5/8/2021 11:53 a.m. Nursing Progress Note: Resident remains in bed resting comfortable easy to arousal denies pain no s/s (signs or symptoms) of acute distress remains on Keflex/uti no s/s of adverse reaction resident mains afebrile easy to arousal call bell remains in place. 5/10/2021 20:34 (8:34 p.m.) Nursing Progress Note: Resident cont on Keflex r/t(related to) UTI. No s/s of adverse reactions observed. Temp 97.8. Will cont to monitor. 5/13/2021 02:51 a.m. daily nursing charting Note: vital signs T 97.8, P 97, Regular R 19.0, BP 179/80, O2 99.0 Room Air. a. LEVEL OF CONSCIOUSNESS Alert 2. ORIENTATION Resident is alert and oriented to the following person 3. COGNITION Short-term memory loss Respiratory observation: Lung sounds- left lung Auscultate upper and lower lobes of lungs: Clear Lung sounds- right lung Auscultate upper and lower lobes of lungs: Clear Are there changes in residents Respiratory status? no EDEMA Pitting 0 - none 5/13/2021 18:58 (6:58 p.m.) eINTERACT SBAR(situation, background, assessment and recommendation) Summary for Providers Situation: The Change In Conditions reported on this Evaluation are/were: Other change in condition At the time of evaluation resident/patient vital signs, weight and blood sugar were: - Blood Pressure: BP 168/90 -Position: Lying r/arm - Pulse: P 100 -Pulse Type: Regular - RR: R 18.0 - Temp: T 98.2 -Route: Oral - Weight: W 168.0 lb -18:17 Scale: Standing - Pulse Oximetry: O2 98.0 % - Method: Room Air - Blood Glucose: BS 513 - 5/13/2021 19:00 Resident/Patient is in the facility for: Post Acute Care Outcomes of Physical Assessment: Positive findings reported on the resident/patient evaluation for this change in condition were: - Mental Status Evaluation: No changes observed - Functional Status Evaluation: No changes observed Primary Care Provider Feedback: Primary Care Provider responded with the following feedback: A. Recommendations: send to ER (emergency room ) for eval(evaluation) B. New Testing Orders: - Blood Tests 5/13/2021 20:34(8:34 p.m.) Progress Note: Resident sent to ER via 911 per on call orders. blood sugar above 600. DON (Director of Nursing), and residents sister RP (responsible party) made aware. Resident #2's Blood Sugar Summary tab was reviewed and is documented in part, as follows: 5/13/2021 19:00 p.m.: 513.0 mg/dL. Resident #2's Physician Orders were reviewed and are documented in part, as follows: traMADol HCl Tablet 50 MG No directions specified for order. Pharmacy Struck Out 5/5/2021. glipiZIDE Tablet 5 MG No directions specified for order. Struck Out 5/5/2021. Hydrocortisone Acetate Suppository 25 MG No directions specified for order. Struck Out 5/5/2021. Obtain cbc w diff (complete blood count), and BMP(basic metabolic panel) one time only: Order Date: 5/12/2021. Resident #2's Admission History and Physical dated 5/12/21 that was completed by the Medical Director was reviewed and is documented in part, as follows: History and Physical: Chief Complaint: History and Physical Medication List: glipizide 10 mg oral daily. Vital Signs: Pulse: 95, Blood Pressure: 188/89, O2 (oxygen) saturation: 100% on room air. Temperature: 97.6, Respiratory Rate: 18. Physical Exam: General: Well-groomed in no acute distress. Respiratory: Vesicular sounds heard throughout both anterior and posterior lungs. Psych: Pleasant cognitive impairment. Diagnosis, Assessment and Plan: Diabetes: CBC with Diff and BMP. Resident #2's Lab Results dated 5/13/21 were reviewed and are documented in part, as follows: Collected: 5/13/21 at 5:40 a.m. Reported: 5/13/21 at 18: GLUCOSE: 513 (CH) (critical high) WBC (white blood count) 15.8 H (high) On 4/6/22 at 3:34 p.m. a phone interview was conducted with RN (Registered Nurse) #1. RN #1 was asked what to explain what orders the Resident #2 arrived to the facility with on 5/4/21 and if she was aware he was a diabetic. RN #1 stated, All I had when he (Resident #2) came in was an after care visit summary from the hospital. There was no discharge summary because the the resident was never admitted . He was in the emergency room for his whole stay, because of covid there were no beds. I reviewed the orders on the after care summary and entered them into PCC (point click care) so all his nurse had to do was verify them with the attending when they called back. I wasn't his nurse that night but was just helping the other nurse out. When he came in he was alert and oriented to self and could follow directions, but he thought he was still in the hospital. No family members were with him. I had no idea from what the hospital send with him that he was a diabetic on admission. Before I left I called on-call to have the provider call back so the admission orders could be verified, then I left. I also help send him out to the hospital on 5/13/21. The lab called a little after 6 p.m. with a critical high glucose of 513 and his wbc's were also high. The attending was called with the values and ordered for the resident to be sent to the emergency room . He (Resident #22) was alert to person and there was no physical or mental changed noted with him. On 4/7/22 at 2:53 p.m. a phone interview was conducted with LPN (Licensed Practical Nurse) #1 who was the admitting nurse for Resident #2 on 5/4/21. LPN #1 was asked about the three admission medications (glipizide, anusol and tramadol) that she struck out on Resident #2's admission orders on 5/5/21. LPN #1 stated, It's hard to remember that far back, but when I strike a medication out on a new admission it is because the on-call provider did not approve the medication order for some reason. If I remember correctly, he (Resident #2) did not come in with a discharge summary only a aftercare summary from the emergency room . The summary only had a few meds on it and a no diabetes diagnosis. When the NP (Nurse Practitioner) #1 called back she only verified some of the orders. Name (NP#1) is very cautious and since there was no discharge summary she did not verify all of the orders since there were no diagnoses. She said to put the aftercare summary in the physician book to be reviewed by the physician when he came in to see the resident. On 4/7/22 at 2:07 p.m. a phone interview was conducted with the Medical Director regarding Resident #2's facility stay. The Medical Director stated, Name (Resident #2) was admitted late on 5/4/21 from the hospital emergency department after stay from 4/30/21 to 5/4/21. when the resident arrived there was no discharge summary from the hospital only an emergency room encounter summary since the resident was never admitted . I have met with the hospital board to make sure that all residents come with a discharge summary upon discharge. Due to covid we were a little behind seeing this resident, so I came in to see the resident on 5/12/21. When I got there we had finally been able to get some of the emergency room records that I reviewed and saw the resident had been on glipizide. I did assess the resident and he was in no acute distress and his vital signs were stable. I ordered a CBC and a BMP to be done before I restarted any diabetic medications to ensure the resident's kidneys were functioning properly. When the critical labs came back on the evening on 5/13/21 the resident was sent out 911 to the emergency room . The Medical Director was asked if NP #1 could call this surveyor. The Medical Director stated, She (NP #1) was out of the country and was only available via a text application The Medical Director sent this surveyor a screen shot of him asking NP #1 if she could remember holding Resident #2's glipizide upon admission due to no hospital discharge summary and diagnoses. NP #1 responded via text stating, I may have. The facility policy titled Admission Orders: last revised 1/4/22 was reviewed and is documented in part, as follows: Policy: A physician must personally approve, in writing, a recommendation that an individual be admitted to a facility. A physician, physician assistant or nurse practitioner must provide orders for the residents' immediate care and needs. Policy Explanation and Compliance Guidelines: 2. The orders should allow facility staff to provide essential care to the resident consistent with the resident's mental and physical status on admission. On 4/7/22 at 4:20 p.m. a pre-exit debriefing was held with the Administrator, the Director of Nursing, the Regional Director of Operations and the Regional Director of Clinical Services where the above information was shared. The Regional Director of Operations stated, We have reached out to the hospital and they are aware that all residents must be accompanied with a discharge summary upon admission. Our Medical Director has also met with the hospital board regarding this as well. Prior to exit no further information was shared. This is a Complaint Deficiency.

Based on observations, resident interview, staff interviews and clinical record review, the facility staff failed to provide necessary care and services to prevent development of pressure injuries for 2 of 23 residents (Resident #8), in the survey sample. The findings included: 1. Resident #8 was originally admitted to the facility 8/29/20 and had never been discharged from the facility. The current diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 10/11/21 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #8's cognitive abilities for daily decision making were intact. In section H0100 the resident was coded for having an indwelling catheter. In section M0100 was coded resident had no pressure ulcer/injury, a scar over bony prominence, or a non-removable dressing/device. The last Braden Scale completed on behalf of the resident was dated 5/11/21 and it indicated she had a moderate risk for a pressure injury. The weekly skin assessment were very inconsistent and there was no weekly documentation. The 8/6/21, skin assessment indicated the resident had open areas to the right hip and groin; 9/16/21 open areas to the right hip and groin; 9/23/21 right thigh opening; 10/14/21, skin intact; 10/21/21, peripheral intravenous to left forearm; 10/28/21, skin intact. Review of the clinical record revealed a progress note dated 9/2/2021 which read; No dressing to the right inner thigh applied, area resolved. Area cleaned and dried. Review of the clinical notes revealed a noted dated 10/18/21 at 19:02 which read; New area noted by Certified Nursing Assistant to resident's right inner leg, physician on call notified no feedback or new treatment ordered as yet. Physician notified and Power Of Attorney notified. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the treatment administration record revealed the treatment had not been signed off as completed since the order was obtained. Another physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A 10/26/21 care plan problem read; (name of resident) has a Pressure Ulcer. The goal read; Pressure Ulcer will decrease in size by the next review date 12/19/2021. The interventions included; Followed by wound NP. Assess for signs and symptoms of worsening, of infection or complications daily. Treatment as ordered by physician to the wound care area. An interview was conducted with Registered Nurse (RN) #1 on 10/27/21 at approximately 11:50 a.m. RN #1 stated the resident's catheter should be anchored because she had developed a pressure injury before because of positioning problems with the catheter tubing. After observation of the resident's catheter and tubing; RN #1 stated the resident's catheter tubing wasn't anchored and she would be back to secure the catheter as ordered, as well as assess the open area to the resident's right inner leg. RN #1 stated Resident #8 had previously had an open area to the right inner leg which had been assessed by the wound care Nurse Practitioner as a stage three pressure injury for it was caused by pressure from the catheter tubing. RN #1 further stated the right inner leg pressure injury had healed approximately two months ago. RN #1 also stated the wound care Nurse Practitioner was scheduled to see the newly opened area to the resident's right inner leg today but she learned she wasn't coming to the facility today therefore she would make the assessment. An interview was conducted with An interview was conducted with Licensed Practical Nurse (LPN) #1 on 10/28/21 at approximately 3:45 p.m. LPN #1 stated a Certified Nursing Assistant notified her at the end of her shift that Resident #8 had an open area to her right inner leg and she made an observation, contacted the on call physician and treated the open area as well as documented it for that was her responsibility. LPN #1 further stated the facility doesn't allow LPN's to assess and stage open areas therefore when the next RN was on duty the wound was to be assessed, measured and thoroughly documented on. On 10/28/21, at approximately 5:00 p.m., the above information was shared with the Administrator, Director of Nursing and two corporate consultants. The Director of Nursing stated the assessment of Resident #8's open area to the right inner leg should have been conducted prior to today and the indwelling catheter should have been secured at all times to prevent further opportunities for skin breakdown. 2. Resident #10 was originally admitted to the facility 10/11/2017 and readmitted [DATE] after an acute care hospital stay. The resident's current diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The significant change Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 9/30/21 coded the resident as not having the ability to complete the Brief Interview for Mental Status (BIMS). The staff interview was coded for long and short term memory problems as well as severely impaired daily decision making abilities. In section G (Physical functioning) the resident was coded as requiring total care of two people with bed mobility and transfers, total care of one person with locomotion, dressing, eating, toileting, personal hygiene and bathing. In section M the resident was coded for having one stage 3 pressure injury and one stage 4 pressure injury. During the initial tour on 10/26/21 at approximately 2:00 p.m., Resident #8 was identified as a vulnerable resident; unable to express herself verbally or non-verbally and ill-positioned in bed. No Braden scales could be located in the clinical record as completed for the resident. The clinical record revealed the following note; Resident seen by wound nurse 4/13/21;Unstageable wound to right lower buttocks noted to be resolved as of 4/13/21; no skin issues currently noted. A weekly skin assessed completed 7/23/21 read; 0.5 x 0.5 area to the buttock reopened. The 7/30/21, weekly skin assessment indicated all skin was intact; the 8/16/21, weekly skin assessment indicated all skin was intact; 8/23/21, weekly skin assessment indicated all skin was intact; 8/30/21, weekly skin assessment indicated all skin was intact; on 9/6/21, the weekly skin assessment indicated all skin was intact. On 9/13/21, the weekly skin assessment revealed a open area to the right gluteal fold with a treatment in place; on 9/20/21, the weekly skin assessment revealed a opening to the right buttock and a skin tear (site not identified); the weekly skin assessment dated [DATE] a stage 2 to the right buttock and a progression of the right heel pressure injury from a stage 1 to a stage 2, with an update to the treatment orders. The next weekly skin assessment was dated 10/13/21, indicated the resident had pre existing wounds to the right buttock and right heel, and treatments were in place for both and they were showing signs improvement; the 10/20/21, weekly skin assessment indicated the resident had pre existing wounds to the right buttock and right heel, and the 10/27/21, weekly skin assessment indicated the resident had open areas to the right gluteal fold and the left heel and to continue treatment as ordered; the current dressing was clean, dry and intact. Further review of the resident's clinical record revealed the resident was identified on 7/23/2021, with a 0.5 x .05 centimeter opening of the right buttocks. The area was cleansed with normal saline, [MEDICATION(S)] was applied and a border dressing. Notation was made for the Nurse Practitioner (NP) to follow-up. On 7/28/21 the NP assessed the right buttock pressure injury as a stage 3 which had reopened. Recommendations included pressure reduction and turning precautions and use of heel protection and pressure reduction to bony prominence's. The clinical record further revealed on 9/15/2021 and a right posterior ankle, stage I pressure injury. Another clinical record note dated 9/26/2021 at 17:36 read; during wound care, this nurse noted that the stage I pressure injury on right heel has progressed to a stage II with slight necrosis. No drainage, no odor. The treatment order was changed to clean with dermal wound cleanser (DWC), apply Santyl and cover daily. A new order was also written to ensure the resident always had a protective barrier between contracted points, and cushioning/repositioning to prevent breakdown of bony prominence's. A message was left with on the on call physician, and notification was put in the in physician's communication book for follow-up with the NP on Monday. The resident's sister was notified. On 9/29/21 the right heel pressure injury was assessed by Registered Nurse #1. The Weekly Pressure Wound Observation Tool revealed the resident had a stage 3 pressure injury to the right heel measuring 1.09 by 1.17 by 0.2 centimeters. A new order was obtained as follows; cleanse with normal saline, apply Iodosorb to wound bed followed by a dry dressing daily. A care plan problem dated 9/21/2021 read; (name of resident) has actual skin impairment to her right buttocks. The goal read; will have intact skin, free of redness, blisters or discoloration by/through review date, 12/19/2021. The interventions included; administer treatments as ordered and monitor for effectiveness. Educate the resident/family/caregivers as to causes of skin breakdown; including: transfer/positioning requirements; importance of taking care during ambulating/mobility, good nutrition and frequent repositioning. A care plan problem dated 10/7/21 read; (name of resident) has a stage 3 pressure ulcer to the right heel related to contractures. The goal read; Pressure injury will show signs of healing and remain free from infection by/through review date, 12/19/2021. The interventions included; reposition at least every 2 hours, more often as needed or requested. Resident has bolster to be used while in bed to prevent heel from applying pressure to her buttocks. An interview was conducted with Registered Nurse (RN) #1 on 10/28/21 at approximately 1:20 p.m. RN #1 also stated had she was aware of the inconsistencies in weekly skin reviews, assessment of new areas identified and institution of treatments. RN #1 further stated the process is for LPN's not to make wound care assessments but to complete a change in condition form indicating the location, appearance, drainage if any and size of the identified area and put a referral in to have her and the NP assessment the area further. RN #1 stated the wound care NP didn't assess the Resident #8's pressure injury until 9/29/21, fourteen days after the initial observation of skin changes identified by the LPN and during the NP assessment the wound was determined to be a stage 3 pressure injury not a stage I. RN #1 stated they instituted use of a pillow between the resident's right heel and right buttock to reduce the pressure from the right leg contracture to reduce the opportunity for increased skin breakdown but it was ineffective therefore; therapy was asked to evaluate and develop a plan for pressure relief. They instituted use of a wedge designed for Resident #8. On 10/28/21, at approximately 5:00 p.m., the above information was shared with the Administrator, Director of Nursing and two corporate consultants. The Director of Nursing stated the plan was to have more education on pressure ulcer prevention, treatment and promotion of healing.

Based on information gleamed during a complaint investigation, resident interview, staff interviews, and clinical record review, the facility staff failed to ensure clinical information and physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The findings included: Resident #9 was originally admitted to the facility 7/12/20, and was discharged from the facility 12/23/20, return not anticipated returning to the facility 9/22/20. Resident #9 diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The admission Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 7/17/21 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #9's cognitive abilities for daily decision making were intact. In section G (Physical functioning) the resident was coded as requiring total care of one person with transfers and bathing, extensive assistance of one person with bed mobility and toileting, limited assistance with personal hygiene, supervision of one person with locomotion and dressing and supervision after set-up with eating. During an interview with Resident #9 on 10/27/21 at approximately 10:30 a.m., the complainant elaborated on the care he had received at the facility since his admission which he felt was neglectful. The resident stated he transferred to the facility because he required intravenous antibiotic therapy and wound care utilizing a wound vacuum to his right plantar foot. Resident #9 stated he wasn't satisfied with application of the wound vacuum (vac) and the number of times it had be removed because he felt the nursing staff weren't competent in use of the wound vac. The resident also stated on 10/5/21 a nurse completed the right foot wound care by spraying it first with peri-fresh. He also reported on 10/7/21 another nurse attempted to remove the old dressing from his right foot but it had adhered to the wound, the nurse applied saline soaked gauze to loosen the dressing but it continued to adhere therefore the nurse pulled the dressing off and removed about 80% of the skin graft. Review of the clinical record revealed no progress notes or orders from the foot and wound specialist provider therefore Registered Nurse (RN) #1 was interviewed for clarification. On 10/27/21, the facility staff received all of the resident's progress notes from the foot and ankle specialty group the resident had seen multiple times since admission to the facility. This was their first time the facility staff had contacted the provider's office and received the progress notes from visits. August 9, 2021 was the resident's first visit to the foot and ankle providers since admission to the nursing facility. It also was the resident's post-operative visit after the fourth toe amputation, surgical debridement of the right plantar foot wound and diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the recently acquired foot and ankle specialty provider progress notes revealed the wound care orders were not consistent with what was ordered by the provider and they were changed more frequently without the specialty practice notification. An interview was conducted with Registered Nurse (RN) #1 on 10/27/21 at approximately 2:50 p.m. RN #1 stated Resident #9 preferred to arrange his appointments and transportation to all offsite physician appointments and he did. RN #1 further stated the resident faxes information to the staff regarding all appointments after he makes them to ensure they are aware and he attends appointments and returns to the facility. RN #1 stated they had never received any documents from the providers regarding the resident's appointments and they didn't telephone the providers for information they simply relied on details from the resident. RN #1 stated the orders were clearly documented in the progress notes from the specialty provider but because the resident never provided them with documents they managed the wound in-house using what information the resident provided. RN #1 stated she knew now that wasn't what they should have done but as a result the resident didn't suffer any deterioration in the right plantar foot wound. An interview was conducted with the Director of Nursing on 10/28/21 at approximately 1:40 p.m. The Director of Nursing stated she was aware the resident made his own appointments ad arranged transportation and that he never provided them with documentation of the visit but going forth they would ensure they communicated with the resident and the provider to ensure they had up to date information for their expectation is coordination of care. The Director of Nursing stated they determined continuity of care wasn't established for Resident #9 because he received treatment and orders for the right plantar foot wound from an outside provider and no written information from the provider was given to the facility's staff by the resident or the provider and the facility nurses were not communicating with the outside provider. This allegation was addressed with the Administrator, Director of Nursing and two corporate consultants on 10/28/219 at approximately 5:00 p.m. The Administrator stated she hadn't received any grievances on the resident's behalf but; she would work towards establishing effective communication with the resident and the facility staff. The Administrator also stated it was the expectation of the Licensed Nursing staff to obtain all consultation reports and orders related to the resident visits from the outside provider especially since they knew when each appointment took place and explain to the resident their need to obtain the reports for continuity of care. COMPLAINT RELATED DEFICIENCY

The facility staff failed to ensure one resident (Resident #6) in the survey sample of twenty four residents was allowed the opportunity to formulate an Advance Directive. The Findings included: Resident #6 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility staff failed to assist Resident #6 with formulating an Advance Directive. A Quarterly Minimum Data Set (MDS) dated [DATE] assessed this resident in the area of Cognitive Patterns (Brief Interview for Mental Status) BIMS as a 9. A Care Plan dated 10/26/21 indicated that this resident received [CONDITION(S)] services. A facility form dated 09/03/2021 indicated: Advance Care Planning Tracking Form - residents/patients and or their responsible health care decision makers should be provided the opportunity to discuss advance care planning with appropriate staff members and medical providers within the first few days of admission to the facility, at the times of change in condition, and periodically for routine updating of care plans. During an interview on 10/30/21 at 2:30 P.M. with the facility Social Worker, she was asked if Resident #6 had formulated an Advance Directive. The social worker stated no, and presented the Advance Care Planning Tracking form dated 09/03/2021. When asked for evidence that Resident #6 was provided the opportunity to formulate an Advance Directive, the social worker stated she did not have any other proof. A facility policy dated December 2016 indicated: Advance Directives- Policy Statement Advance directives will be respected in accordance with state law and facility policy. Policy Interpretation and Implementation 1. Upon admission, the resident will be provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advance directive if he or she chooses to do so.

Based on a medical record review, facility document review and staff interviews the facility staff failed to ensure a Notice of Medicare Non-Coverage was given timely prior to the last covered skilled day of 1/14/21 for one of 24 residents in the survey sample, Resident #20. The findings included: Resident #20 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #20's Notice of Medicare Non-Coverage (NOMNC) document with Skilled Nursing Services ending on 1/14/21 was reviewed and is documented as follows: I have been notified that coverage of my services will end on the effective date indicated on this notice and that I may appeal this decision by contacting my QIO (Quality Improvement Organization). The SNF (Skilled Nursing Facility) ABN (Advanced Beneficiary Notice) form CMS- was not provided to the resident due to an oversight. Written on the signature line for patient or representative was the following: POA notified of OT (occupational Therapy) ending. Dated: 1/12/21. On 10/27/21 at approximately 3:10 PM an interview was conducted with the Facility's Social Worker. She stated. The ABN should have been done because Resident #20 was in long term care. On 10/28/21 at approximately 4:25 p.m., the above findings were shared with the Administrator and Corporate Consultant. An opportunity was offered to the facility's staff to present additional information but no additional information was provided.

The facility staff failed to provide one resident (Resident #22) in the survey sample of twenty four residents with a Bed Hold Policy upon discharge to the hospital. The findings included: Resident #22 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #22 was discharged to the hospital on 09/29/21. He was not provided with a bed hold policy. A nursing note dated 09/29/21 indicated: Resident had a fall oob (out of bed) and evaluation of right groin surgical incision - due to increased swelling with purulent drainage. Resident sent to the hospital. A review of the clinical records did not indicate a Bed Hold Policy was provided upon discharge. During an interview on 10/29/21 at 11:15 A.M. with the Social Worker she was asked if Resident #22 received a bed hold policy/notice upon discharge to the hospital. The social worker stated, no. A Bed Hold Policy was requested during the survey but no policy was provided.

Based on observation, resident interview, staff interview, clinical record review, and review of facility documents, the facility's staff failed to monitor daily weights and Blood Sugar checks per physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The findings included: Resident #15 was originally admitted to the facility on [DATE] and readmitted on [DATE] after an acute care hospital stay. The current diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly, Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 10/05/2021 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #15 cognitive abilities for daily decision making were intact. In section G(Physical functioning) the resident was coded as requiring limited assistance of two persons for bed mobility, transfers and dressing. Requiring extensive assistance with eating and toileting. Requires supervision with personal hygiene. The Care plan dated 7/28/21 reads: Resident has a history of Diabetes Mellitus. Goal: Resident will have no complication through the review date. Interventions: Fasting serum blood sugar as ordered by the doctor. The Care plan dated 10/21/21 reads: Resident #15 requires tube feedings r/t (relating/to) Dysphagia and chewing problems. Goals: Resident will be free of aspiration through the review date. Interventions: Discuss with resident/family /caregivers any concerns about tube feeding. The Care plan dated 9/28/21 reads: Resident #15 has a swallowing problem r/t swallowing assessment results. Goal: The resident will maintain weight and nutritional balance through the review date. Interventions: Refer to Speech Therapist for swallowing evaluation. The October 2021 MAR (Medication Administration Record) Reads: Weekly weights every Wednesday Day shift. Start date 9/15/21 at 7:00 AM. A review of Resident's weight summary in the clinical record show that Resident #15 was weighed only on Wednesday 9/15/21. A review of the September 2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . No additional recorded after 9/22/21. The MAR for September was initialed by staff on 9/22/21 and 9/29/21 but no weight recordings were found in the clinical record. A review of the October 2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] .) The staff initialed the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The October 2021 POS (Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Dated 9/10/21. Start date: 9/15/21. The October 2021 POS (Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Dated 7/03/21. A review of the September 2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . At 11:30 AM and at 4:30 PM. No Blood Sugar Checks were conducted on 9/06/21. On 10/26/21 at approximately 12:12 PM. Resident was seen resting in bed. He stated that he receives tube feedings sometimes but is allowed to eat pureed foods. On 10/27/21 at approximately 4:10 PM an interview was conducted with Resident #15 concerning his weight. He stated. If I eat more than 50% of my meals I don't get any tube feedings. They check my weight sometimes. My appetite is pretty good. On 10/28/21 at approximately 2:25 PM an interview was conducted with RN (Registered Nurse) #1. Concerning Resident #15 weights and Blood Sugar checks. She stated. We have issues with our scales. He should have receive weekly weights. The resident was here so he should have received blood sugar checks. On 10/28/21 at approximately 4:25 p.m., the above findings were shared with the Administrator and Corporate Consultant. An opportunity was offered to the facility's staff to present additional information but no additional information was provided.

Based on observation, resident interview, staff interview, clinical record review, and review of facility documents, the facility's staff failed to monitor one resident after sustaining an injury after falling by obtaining neurological checks. For 1 of 24 residents (Resident #16), in the survey sample. The findings included: Resident #16 was originally admitted to the facility on [DATE] after an acute care hospital stay. The resident has never been discharged from the facility. The current diagnoses included; Cerebral Infarction Unspecified and Muscle weakness. The admissions Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 10/13/2021 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 13 out of a possible 15. This indicated Resident #16 cognitive abilities for daily decision making were intact. In section G(Physical functioning) the resident was coded as requiring extensive assistance of one person for bed mobility, transfers, dressing, eating and personal hygiene. Requiring total assistance with toileting. The care plan dated 10/27/21 reads: Resident #16 is at risk for falls r/t (related/to) Incontinence, [CONDITION(S)], [CONDITION(S)], Medications and history of [CONDITION(S)] (Cerebral Vascular Accident). Goal: The resident will not sustain serious injury through the review date (12/27/21). Interventions: Every 1 hour checks, Follow facility fall protocol (10/27/21). During the initial tour on 10/26/21 at approximately 11:55 AM., Resident #16 stated that he fell recently injuring his right inner eye and had another fall scratching his left elbow. (An area on Resident's left elbow was observed by the said surveyor. Appears to be healed). A review of the progress notes dated 10/15/21 at 11:07 PM., Reads: Resident found on floor in room. Patient was face up and had skin tear to right elbow. Vital signs were taken. Small reddened area noted under the right eye. Arm was cleaned and bandage applied. MD was notified and wife was called and a message was left. On 10/28/21 at approximately 2:10 PM RN (Registered Nurse/Unit Manager) #1 was asked to provide neuro checks (Neurological Checks) documentation for Resident #16. On 10/28/21 at approximately 2:15 Pm., an interview was conducted with RN #1 concerning Resident #16 neuro checks documentation concerning fall with an injury sustained on 10/15/21. She stated. No neuro checks were not done. He should have had them done. Neuro checks are done initially then every 15 minutes x 4, then every 30 minutes x 2. Then hourly for 4 hours then every 4 hours x 6 then every shift. We have a check list for neuro checks. Residents should have a full set of vital signs done after falling to make sure they don't have brain injury of have suffered any kind of injury after a fall. His falls occurred while he was on the quarantine unit. We have measures in place on this unit. Fall mats, frequent rounding, resident is placed next to the nurses station. On 10/2821 at approximately, 2:55 PM., RN #1 presented surveyor with The Facility's Fall Expectations Document. The document reads: Date of Incident, Time of Incident, Name of resident. Initial Risk management, Change of Condition, MD (Medical Doctor) notification, RP (Responsible Party) notification, Care Plan Update, Fall assessment, Pain assessment, Initiate neuro checks, Any Injuries, Treatment Orders if applicable. If head injury or major injury notify Unit Manager ASAP if no injury can notify in the morning. On 10/28/21 at approximately 4:25 p.m., the above findings were shared with the Administrator and Corporate Consultant. An opportunity was offered to the facility's staff to present additional information but no additional information was provided.

Based on observation, staff interview, and clinical record review, the facility's staff failed to ensure appropriate care and services were provided to prevent/reduce trauma to the urethra and bladder, and other complications such as pressure ulcer development while utilizing an indwelling catheter for 1 of 32 residents (Resident #8), in the survey sample. The findings included: Resident #8 was originally admitted to the facility 8/29/20 and had never been discharged from the facility. The current diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 10/11/21 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #8's cognitive abilities for daily decision making were intact. In section H0100 the resident was coded for having an indwelling catheter. Resident #8 had a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Resident #8 also had a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The current care plan had a problem dated 6/15/21 read; (name of the resident) has Indwelling Foley Catheter: failed voiding trials after catheter removal, diagnosis [CONDITION(S)]. The goal read; (name of the resident) will not develop any complications associated with catheter use through next review, 12/19/2021. The interventions included; Position catheter bag and tubing below the level of the bladder and away from entrance room door. Change catheter and bag as per policy. Observe/record/report to MD for signs/symptoms of a UTI: pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp, Urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns. On 10/26/21 at approximately 3:50 p.m., a bedside drainage bag was observed attached to the bed frame. The resident state she was unable to pass her water without the catheter and she was told approximately five days ago the catheter tubing had cause another open area to the groin. The resident further stated she wasn't aware of it because she can't feel the tubing when it rolls in to the groin area. The resident further stated it had happened before and healed but Resident #8 stated take a look yourself as she pushed the bed linens back. The catheter tubing was not anchored and it was lodged between the folds of skin under her stomach and right thigh. An interview was conducted with Registered Nurse (RN) #1 on 10/27/21 at approximately 11:50 a.m. RN #1 stated the resident's catheter should be anchored because she had developed a pressure wound when it's wasn't. After observation of the resident's catheter and tubing; RN #1 stated the resident's catheter tubing wasn't anchored and she would be back to secure the catheter as ordered as well as assess the open area to the resident's right inner leg. Taping the catheter is a frequent method used for stabilization. The drainage tube attached to the catheter is taped to the person's thigh or abdomen. The area of the thigh is the best site for taping with women. Men to secure the catheter use the site of the thigh or lower abdomen. (http://www.public.asu.edu/) On 10/28/21, at approximately 5:00 p.m., the above information was shared with the Administrator, Director of Nursing and two corporate consultants. The Director of Nursing stated the resident's indwelling catheter should have been secured and it had since been secured.

The facility staff failed to ensure ongoing communication and collaboration with the [CONDITION(S)] facility for one resident (Resident #6) in the survey sample of twenty four residents. The findings included: Resident #6 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility staff failed to ensure Resident #6 daily [CONDITION(S)] communication book was available. A Quarterly Minimum Data Set (MDS) dated [DATE] assessed this resident in the area of Cognitive Patterns (Brief Interview for Mental Status) BIMS as a 9. A Care Plan dated 10/26/21 indicated that this resident received [CONDITION(S)] services. [CONDITION(S)] - AV fistula shunt- palpate gently over area with fingertips or palm of hand. Check complete [CONDITION(S)] communication log record on return from [CONDITION(S)] appointments for any reports. Collaborate with RD at [CONDITION(S)] center about weights, outcomes of biochemical tests, nutrition education and nutrition counseling. A Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . On 10/27/21 at 3:45 P.M. during an interview with the Unit Manager, she was asked for Resident #6's [CONDITION(S)] communication book. The Unit Manager stated, the communication book was not returned from [CONDITION(S)] following his Tuesday appointment. A request was made to the Unit Manager and the Administrator for a [CONDITION(S)] communication policy. No policy was provided during the survey.

Based on the facility's medication storage review of 1 medication cart and 1 medication room; the facility staff failed to ensure two opened containers of eye drops included the opened date. The findings included; On 10/26/21 at approximately 1:15 PM a medication cart audit was conducted with LPN (Licensed Practical Nurse) #1. Stored inside of the medication cart were two opened bottles of eye drops without open dates written on the bottles. ([MEDICATION(S)] 0.095% expires 7/20/22 and Opthalmic Ultra eye drops expire 7/20/22). LPN #1 stated. They should put a date on them. On 10/26/21 at approximately 2:00 PM an interview was conducted with RN (Registered Nurse/Unit Manager) #1 concerning the above eye drops. She stated. When they open a bottle they should put a date on them. If no date they should discard and reorder the medications. On 10/28/21 at approximately 4:25 p.m., the above findings were shared with the Administrator and Corporate Consultant. An opportunity was offered to the facility's staff to present additional information but no additional information was provided.

Based on observation, staff interview and facility documentation review the facility staff failed to provide a safe, functional, sanitary, and comfortable environment for residents by not removing debris from two storage shed fires. The findings included; On 10/26/21 at approximately 1:15 PM an observation of the facility's dumpster area was conducted with the Food Service Director (FSD). Located near the dumpsters were the charred remains from two storage sheds. The first storage shed was completely burned to the ground and the second storage shed was partially burned. Located on the grounds were charred medical equipment, binders, scattered papers, Wheel chairs, several gallon jugs of water. An existing tree was located near the charred remains of the first shed with charred marks about 100 feet high upon it. There were two separate piles of wooden pallets near the charred remains. Some of the Charred debris was scattered beyond the parameters of the storage sheds near the sidewalk and building. The Food Service Director stated that the first shed was burned completely down on one day and that the second shed was partially burned on the next day. She stated that she found out about the fires when she returned to work. On 10/26/21 at approximately 3:30 PM a second observation of the grounds near the storage sheds were made. The area remains unchanged. Debris still scattered on the grounds. Debris located inside or near the storage sheds. On 10/26/21 at approximately 3:40 PM an interview was conducted with the Administrator concerning the two storage sheds. She stated, We're doing surveillance for four weeks. We asked for increased surveillance after the fires. We're trying to get a security system for the front and back of facility for additional lighting. A Pad lock was placed on the kitchen door. We have not gotten the police report but have secured the gate. The investigation is ongoing. It May be an arsonist in the area. One suspect is in custody. I have the name of the fire investigator. The fire department inspector is conducting the investigation. They wouldn't give me anything. They were old sheds that haven't been used for years. We didn't use them actively now. Water bottles, some debris, wheel chairs, files remnants of papers. I don't know of patient or employee information. Corporate reported it to the insurance. We are going to have it cleaned up. I think the insurance adjuster came out but I don't have anything to do with it. I will certainly ask Regional to give you the information. On 10/27/21 at approximately 9:13 AM., a telephone interview was conducted with the [NAME] Fire Inspector. He was asked about the fire reports for two fire incidents. He stated, The first fire incident occurred on 9/24/21 around 3:00 A.M. The second fire incident occurred on 9/25/21 around 10:00 P.M. The Fire Inspector stated a report could be issued to the facility if they requested one. The Fire Inspector stated the facility had a private insurance investigator looking into the matter but had since stopped all pursuit due to the deductible of the insurance policy. The Fire Inspector stated there is an ongoing investigation of arson for both incidents. The Fire Inspector stated the fire scene has been released back to the facility. All evidence regarding the arson suspicion has been collected. The scene was released over to the facility several weeks ago. No specific time frame was given. On 10/27/21 at approximately, 3:45 PM a third observation of the grounds near the storage sheds were made. The area remains unchanged. (Still with debris scattered throughout the grounds). On 10/28/21 at approximately 10:50 AM an interview was conducted with the maintenance Director concerning the sheds. He stated, I came in 2 weeks ago (Started Employment). I went out to see what was going on. I tried to figure out how I could clean it up. The administration said the fire department will come out. Wait until the investigation is over before you clean up. There's pallets, different papers are burnt up. On 10/28/21 at approximately 12:30 PM an interview was conducted with the Acting Director of Nursing (ADON) concerning the incident involving the sheds. She stated, On 9/24/2, I received a phone call from the staff saying there was a fire. I asked them if they had called the Fire Department (FD). They had called 911. I arrived fifteen minutes later. The back shed was being put out by the FD. The FD interviewed me. I made sure the residents were ok. They evacuated two patients on the green Hall (Near the kitchen). They were brought to the main nurses' station. Fire safety precautions were followed by the staff. The FD stated there was an arsonist in the area. A gentleman came to the door and said your building is on fire. I got my phone call at 2 am. The first shed had items like bedside tables, storage containers. There wasn't anything of value. I tried to do an incident report but couldn't put them in PCC (Point Click Care). The fire re-ignited. I called the FD back and they put out the fire. On the next night (9/25/21) I got a call about 10:00 PM., from the nurse saying the second shed is burning but contained by the FD. I didn't come out this time. The second shed contained old furniture. The papers on the ground may be old maintenance receipts, buckets. Those pallets are there because of a shipment of beds that came in. This was after the fire. On 10/28/21 at approximately 1:15 PM a phone call was made to Certified Nursing Assistant (CNA) #1. A message was left for staff to return call. On 10/28/21 at approximately, 1:20 PM an interview was conducted with CNA #2 concerning the incident involving the two sheds. He stated, I was working the 7:00 PM to 7:00 AM shift. When a man was at the front door, ringing the door bell, yelling, Fire. We got the patients safe and secure. I didn't see but smelled the smoke at first because I was busy getting the patients. I saw the flames from the unit closest to the kitchen. This was the first fire on September 24th. On 10/28/21 at approximately 1:25 PM a telephone interview was conducted with CNA #3. Concerning the shed incidents. She stated, I was rounding. We got a knock at the front door from policemen and the FD were here. They said they had an arson in the area. The residents were safe. The residents were located in the front. I saw some wheel chairs and other personal items outside on the ground. On 10/28/21 at approximately 2:00 PM a returned phone call was received from CNA #1 concerning the storage shed incidents. She stated, On the first night (9/24/21), we were at the nurses' station when someone rang the bell and stated there's a fire out back. I called 911. I went to the recreation room to get help. I saw the fire. I called code red. You could see it through the window. We closed the doors. I grabbed the fire extinguisher. On 10/28/21 at approximately 4:25 p.m., the above findings were shared with the Administrator and Corporate Consultant. The administrator stated, We will have the outside cleaned up, storage barn demolished and tree limbs removed.

Based on observations, staff interviews and facility document review the facility staff failed to ensure that infection control surveillance screening was conducted on each staff member prior to the start of their shift on 9/7/21 and 9/8/21. The findings included: On 9/9/21 the Covid-19 Sign In/Out Entry Logs were audited using the facility as worked schedules with the facility's Infection Preventionist present. The Covid-19 Sign In/Out Entry Logs revealed that on 9/7/21 one dietary staff member who was identified on the as worked schedule for 9/7/21 had not been screened prior to the start of their shift Also on 9/8/21 based on the as worked schedules for 9/8/21 there were 2 additional dietary staff members that were not listed on the Covid-19 Sign In/Out Entry Logs as being screened prior to the beginning of their shift. On 9/9/21 at 12:30 p.m., an interview was conducted with Dietary Aide OSM (other staff member) #2 regarding Covid screening on 9/7/21 prior to the beginning of her shift. OSM #2 was asked to review the Covid-19 Sign In/Out Entry Logs for 9/7/21 and indicate if her screening for that day was documented. OSM #2 stated, I don't think I did the screening that day, it wasn't intentional. I usually screen every day I work. I kept ringing the doorbell and no one answered the door, so I went around to the back door and went to work. On 9/9/21 at 2:15 p.m., an interview was conducted with Dietary Aide OSM #4 regarding Covid screening on 9/8/21 prior to the beginning of her shift. OSM #4 was asked to review the Covid-19 Sign In/Out Entry Logs for 9/8/21 and indicate if her screening for that day was documented. OSM #4 stated, No, I don't see where I signed in. I probably got distracted at the front door with questions about [CONDITION(S)] lunches. I should do the screening every day, it was just one of those days. On 9/9/21 at 2:30 p.m., an interview was conducted with Dietary Aide OSM #5 regarding Covid screening on 9/8/21 prior to the beginning of his shift. OSM #5 was asked to review the Covid-19 Sign In/Out Entry Logs for 9/8/21 and indicate if his screening for that day was documented. OSM #5 stated, No, I'm not on it. I did not sign-in and screen. I was running late from my other job. I came to work and went to the kitchen and forgot to sign-in on the logs. I should have recorded everything when I got here. On 9/9/21 at 2:41 p.m., an interview was conducted with the facility Infection Preventionist regarding the above findings and was asked if these 3 staff member had tested positive for Covid-19 in the last 2 weeks. The Infection Preventionist was also asked what were the expectations of staff in regards to Covid screening. The Infection Preventionist stated, No, they were tested yesterday and everyone was negative. I expect all staff members to enter through the front door only. They ring the bell, are let in then they put their mask on. Then they are to take their temperature, log it into the screening logs and answer the screening questions. All staff should be screening upon entering the facility. I need to do some training, because I see now that all staff have not been screened. The facility policy titled, Coronavirus Surveillance last reviewed 10/29/20 was reviewed and is documented in part, as follows: Policy: This facility will implement heightened surveillance activities for coronavirus illness during periods of transmission in the community and/or during a declared public health emergency for the illness. Policy Explanation and Compliance Guidelines: 2. Heightened surveillance activities will be implemented to limit the transmission of COVID-19. These include, but are not limited to, screening visitors, staff and residents. 3. Screening for visitors and staff: a. Signs or symptoms of a respiratory infection, such as fever, cough, shortness of breath, or sore throat or other symptoms of coronavirus. b. In the last 14 days, has had contact with someone with a confirmed diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . c. Travel within the last 14 days to geographic areas with sustained community transmission. d. Residing in a community where community-based spread of COVID-19 is occurring. On 9/9/21 at 4:00 p.m., a prexit debriefing was conducted with the Administrator the Director of Nursing, the Infection Preventionist and the Regional Director of Clinical Services where the above findings were share. The Administrator stated, Everyone that comes into the building is to be screened. No further information was shared from the facility staff prior to survey exit.

Based on resident interview, staff interview, clinical record review, facility document review, and in the course of a complaint investigation, it was determined that facility staff failed to notify the physician and/or responsible party of an incident of unusual occurrence for one of 11 residents in the survey sample, Resident #2; of a change in resident condition related to a PICC line for one of 11 residents, Resident #1; AND regarding missed medications per physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The findings include: 1. Facility staff failed to notify the responsible party when a stranger outside the facility had entered the building and handed Resident #2 a weapon in the form of a shank (1). Resident #2 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #2's most recent Minimum Data Set (MDS) assessment was a quarterly assessment with an Assessment Reference Date (ARD) of 6/8/21. Resident #2 was coded as being moderately impaired in cognitive function scoring 11 out of possible 15 on the Brief Interview for Mental Status Exam (BIMS). Resident #2 was coded as not having any behaviors during the 7 day look back period. On 8/17/21 at 10:55 a.m., an interview was conducted with Resident #1, another sampled resident. Resident #1 stated that last Sunday on 8/22/21 at approximately 6 p.m., a stranger from off the street was able to enter the building with what appeared to be a shank in his hand. Resident #1 stated that he was in the hallway when he saw the gentleman come onto the nursing unit, walk down the hall and hand the shank to a resident (Resident #2) who was sitting in her wheelchair on the hallway. Resident #1 stated that a nursing aide who was also a witness to this incident, immediately intervened and removed the shank from the resident. Review of the Facility Reported Incidents (FRIS) revealed no evidence that this incident has occurred. On 8/18/21 at 11:15 a.m., an interview was conducted with Certified Nursing Assistant (CNA) #3, the CNA who was witness to the above incident per Resident #1. When asked what had occurred on Sunday 8/22/21, CNA #3 stated that a gentleman was seen on the nursing unit with what appeared to be a shank in his hand. CNA #3 stated that she witnessed the man hand the shank to a resident sitting in her wheelchair on the hallway. When asked if the resident and man knew each other, CNA #3 stated that she was not sure. CNA #3 stated that she immediately removed the shank from the resident's (Resident #2's) hands. CNA #3 stated that the Director of Nursing (DON) was also present in the building and a witness. CNA #3 stated that the DON called the police immediately and the man had left the building before the police had arrived. CNA #3 stated that she wasn't sure what door the man entered from, but that the front lobby was always locked. CNA #3 denied having to write a witness statement. CNA #3 could not recall the exact time the man had entered the building. On 8/18/21 at 1:17 p.m., an interview was conducted with Administrative Staff Member (ASM) #2, the Director of Nursing (DON). When asked if a FRI or incident report was completed regarding an incident on Sunday, 8/22/21 regarding a man entering the building with a weapon, ASM #2 stated, No, because I took care of it immediately. When asked if she figured out what door the man entered from, ASM #2 stated, No. On 8/18/21 at 2:24 p.m., further interview was conducted with ASM #2. When asked if she could recall the events on 8/22/21, ASM #2 stated that she was in the building working on a medication cart because a nurse had called out. ASM #2 stated that at approximately 6 p.m., she was sitting at the nurses station when she saw an unidentified gentleman enter the nursing unit and walked down the green hall. ASM #2 stated that she quickly got up to follow the man as he was walking really fast. ASM #2 stated that she kept asking Can I help you with something? and he continued to walk to the therapy department and then turned around and walked quickly to the end of the pink hall. ASM #2 stated that the man kept saying that he was looking for someone, that it was personal. ASM #2 stated that (Name of Resident #2) was sitting in her wheelchair at the end of the pink hall when she introduced herself to the man. ASM #2 stated that was when the man handed the resident a screwdriver. ASM #2 stated that the nursing aide was right there and immediately took the screwdriver away. ASM #2 stated that she was calling the police and that the man then stated, Go ahead, I am leaving and I am walking toward tidewater drive. ASM #2 stated the man then left the building. ASM #2 stated that the police had arrived and she gave a description to the police. ASM #2 stated that the police told her to just throw the object away. When asked if this object was more like a shank and not a screwdriver, ASM #2 stated, It was very pointy and sharp. When asked the orientation of Resident #2, ASM #2 stated that Resident #2 was pleasantly confused and had dementia. When asked if the resident could have potentially harmed herself with this object, ASM #2 stated that it was taken out of her hands immediately; that it wasn't even in her hands for a second. When asked if Resident #2 could have hurt herself if staff were not present, ASM #2 stated, Possibly if no one was there. When asked if she had notified Resident #2's responsible party (RP), ASM #2 stated that she did not because staff had immediately intervened. When asked if Resident #2's RP would probably want to know if someone had handed her mother a weapon, ASM #2 stated, Yes, she would probably want to be aware of that. On 8/19/21 at 2:49 p.m., Administrative Staff Member (ASM) #1, the Administrator, ASM #2, the DON (Director of Nursing), ASM #3, the Regional Director of Clinical Services, and ASM #5, the corporate nurse were made aware of the above concerns. Facility policy titled, Notification of Changes did not address the above concerns. No further information was presented prior to exit. (1) Shank- a makeshift, knife like weapon. This information was obtained from https://lawenforcementmuseum.org/2010/01/20/contraband-weaponsshivs-and-[NAME]-a/. 2. The facility staff failed to notify the physician of a change in Resident #1's condition realated to his peripherally inserted central catheter (PICC) line on 7/23/21. Resident #1 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #1's most recent Minimum Data Set (MDS) assessment was an admission assessment with an assessment reference date (ARD) of 7/10/21. Resident #1 was coded as being intact in cognitive function scoring 15 out of possible 15 on the Brief Interview for Mental Status Exam (BIMS). Resident #1 was coded in Section N (Medications) as receiving antibiotics. Resident #1 was coded in Section O (Special Treatments and Programs) as receiving intravenous (IV) medications. Review of Resident #1's July 2021 POS (Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] 1) [MEDICATION(S)] (1) (antibiotic) 3-0.375 grams (GM). Use 3.375 gram intravenously every 6 hours for infection for 150 administrations. This order was discontinued on 8/12/21. 2) [MEDICATION(S)] Lock Flush (2) solution 1 UNIT/ML (unit/milliliter). Use 1 unit intravenously every 6 hours for PICC (3) maintenance. This order was discontinued on 7/23/21. This order was changed to PRN (as needed) on 7/23/21. On 8/17/21 at 10:55 a.m., an interview was conducted with Resident #1. Resident #1 had discussed his concern that he didn't feel like in the beginning of his stay, staff were properly flushing, clamping and monitoring his PICC line. Resident #1 had stated that on the evening of 7/23/21, the 7 am to 7 pm nurse; who he could not identify forgot to clamp his PICC line. Resident #1 stated as a result of this incident, a large amount of blood had come out of his line and went all over his bed, siderail and floor. Resident #1 denied any further episodes of bleeding prior to and after 7/23/21. Review of Resident's #1 clinical record revealed no documentation regarding the incident on 7/23/21; 7 a.m. to 7 p.m. shift. Review of Resident #1's care plan dated 7/25/21 documented in part, the following: (Name of Resident #1) has potential for infection related to catheter direct access to blood r/t (related to) PICC IV .Monitor for hemorrhage due to dislodgement of catheter, broken or disconnected lines. Report any abnormal findings to physician . Further review of Resident #1's clinical record revealed vital signs were obtained on 7/23/21 at 2:02 p.m. The following was recorded: BP (blood pressure): 124 / 63 mmhg; 67 beats per minute, 96 percent room air oxygen saturation. No further vital signs were recorded for 7/23/21. A nursing note dated 7/23/21 night shift (7 p.m. to 7 a.m.) documented in part, the following: Continues IV Pip/Tazo 3.375 ([MEDICATION(S)]). no adverse reactions. double lumen picc to RUE (Right Upper Extremity), patent. blood return present. no s/s (signs and symptoms) of irritation or infection noted. blood noted to bedsheets (sic), per patient site was bleeding earlier. this nurse insisted on changing sheets more than once, patient declined multiple times. Further review of Resident #1's clinical record revealed no prior incidences of bleeding from his PICC line. There was no evidence of any bleeding from his PICC line after 7/23/21. There was no evidence of an assessment done on Resident #1 regarding the incident or any follow-up assessments thereafter. A physician note could not be found in Resident #1's clinical record regarding the above incident on 7/23/21. On 8/18/21 at approximately 2:30 p.m., an interview was conducted with Licensed Practical Nurse (LPN) #1, the nurse who worked on 7/23/21 7 a to 7 p shift. When asked if she could recall an incident where Resident #1's had blood coming out of his PICC line and had leaked all over his bed, bed rail and floor, LPN #1 stated that this had happened on one occasion. LPN #1 stated that she could not recall the exact time she saw the blood but that the blood was dried on the floor, bed rail and on his sheets. LPN #1 stated it was a large amount of blood that had leaked from his PICC line. LPN #1 stated that she was not sure if this had happened on the previous shift 7 p to 7 a and she walked into his room on her first rounds or if it had happened later on her shift. LPN #1 was not quite sure because she stated her first rounds may have been late. LPN #1 did not recall making rounds prior to seeing the blood all over the resident's bed, floor and rail. LPN #1 stated that she recalled cleaning up the blood with bleach from the floor and rail. LPN #1 stated that she assessed the PICC line and stated that it was clamped at that time. LPN #1 stated that the PICC line was not actively bleeding at the time of her assessment. LPN #1 stated that she flushed the line with normal saline and she had no issues with the flush. LPN #1 stated that Resident #1 was also had no changes to his mental status or anything that would alert her that he was having a change in condition. LPN #1 stated that the bleeding may have been from the [MEDICATION(S)] flushes that were scheduled every shift and now were ordered for PRN (as needed). When asked if she had documented her assessment in the clinical record, LPN #1 stated that if it wasn't in the clinical record then she didn't document her assessment. When asked if she had notified the physician of this incident, LPN #1 stated that she did not because the Resident was not having any changes in his condition. LPN #1 stated that she kept checking on the resident to see if he had any changes. When asked what checking entailed, LPN #1 stated she would pop in his room and check in on him. When asked if vital signs were obtained at the time she discovered the blood or thereafter for monitoring, LPN #1 stated she just looked at the vital signs that were already obtained earlier in the shift by the Certified Nursing Assistant. When asked if the discontinued [MEDICATION(S)] flushes were in response to the bleeding episode on 7/23/21, LPN #1 stated that she thought that may have already been an order prior to the incident. On 8/19/21 at 2:49 p.m., Administrative Staff Member (ASM) #1, the Administrator, ASM #2, the DON (Director of Nursing), ASM #3, the Regional Director of Clinical Services, and ASM #5, the corporate nurse were made aware of the above concerns. Facility policy titled, Notification of Changes documents in part, the following: The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician; and notifies, consistent with his or her authority, resident's representatives when there is a change requiring notification .Circumstances requiring notification include: Significant change in the resident's physical, mental, or psychosocial condition such as deterioration of health, mental or psychosocial status. This may include .Clinical Complications .b. discontinuation of current treatment due to adverse consequences. (1) [MEDICATION(S)]- also known as Tazocin® [MEDICATION(S)]/tazobactam is an intravenously administered antibiotic. This information was obtained from The National Institutes of Health. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC 59/. (2) [MEDICATION(S)] Lock Flush- [MEDICATION(S)] flush belongs to the family of drugs called anticoagulants. This is used to prevent blood from clotting or stopping up your intravenous (IV) line. [MEDICATION(S)], in the doses used to flush IV lines, should not normally keep your blood from clotting elsewhere in your body. This information was obtained from https://cookchildrens.org/SiteCollectionDocuments/HomeHealth/Education/InfusionTherapy/CCHH_Infusion_HeparinandSodiumChlorideFlush.pdf. (3) PICC (peripherally inserted central catheter)- Central catheter is a venous access device that ultimately terminates in the superior vena cava (SVC) or right atrium (RA). They can be inserted centrally (centrally inserted venous catheter; CICC) or peripherally (PICC). PICCs are placed through the basilic, brachial, cephalic, or medial cubital vein of the arm. This information was obtained from The National Institutes of Health. https://www.ncbi.nlm.nih.gov/books/NBK 8/> 3. The facility staff failed to notify the physician when medication was not administered for nerve pain on 7/26/21; scheduled insulin on 8/2/21; and sliding scale insulin on 8/6/21 for Resident #1 per physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Resident #1 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #1's most recent Minimum Data Set (MDS) assessment was an admission assessment with an assessment reference date (ARD) of 7/10/21. Resident #1 was coded as being intact in cognitive function scoring 15 out of possible 15 on the Brief Interview for Mental Status Exam (BIMS). Resident #1 was coded in Section N (Medications) as receiving insulin injections. On 8/17/21 at 10:55 a.m., an interview was conducted with Resident #1. Resident #1 stated that he was out of his medication for nerve pain for two days and also that facility staff sometimes forget to check his blood sugar or give him insulin prior to his meals. Resident #1 stated he sometimes misses his scheduled insulin injections. Review of Resident #1's July 2021 orders revealed the following medication for nerve pain: [MEDICATION(S)] (1) Tablet 600 mg (milligrams) Give 1 tablet by mouth two times a day for pain. Review of the narcotic logs for [MEDICATION(S)] revealed that 30 tablets arrived to the building on 7/12/21 from pharmacy. The count went to 0 (zero) on 7/26/21 at 9:00 a.m. Further review of the narcotic logs revealed that 60 tablets were sent to the building on 7/27/21. The first dose administered from this pack was on 7/28/21 at 9:00 a.m. Further Review of Resident #1's July MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the emergency STAT box list revealed that [MEDICATION(S)] 300 mg (milligrams) was a medication in the STAT box. Review of the emergency STAT box pull list from pharmacy revealed that the only time staff had accessed the STAT box for the [MEDICATION(S)] was on 7/27/21 for both the morning and evening shifts. 2 tablets were pulled to equal 600 mg. There was no evidence that staff attempted to access the emergency STAT box list on 7/26/21 at 5 p.m. There was no evidence that Resident #1 experienced any pain or negative outcomes on 7/26/21 when his [MEDICATION(S)] was missed x 1 dose. On 8/18/21 at 12:53 p.m., an interview was conducted with Other Staff Member (OSM) #6 the lead pharmacist. OSM #6 confirmed that the only time facility staff tried to access the STAT box was on 7/27/21. OSM #6 stated that staff did not access the STAT box on 7/26/21. On 8/18/21 at 1:31 p.m. and 4:22 p.m. an interview was attempted with the nurse who failed to administer the [MEDICATION(S)] on 7/26/21 at 5 p.m. She could not be reached for an interview. Review of Resident #1's August 2021 POS (Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] [MEDICATION(S)] [MEDICATION(S)] Solution Pen Injector (2) 100 Unit/ML Inject 4 units subcutaneously with meals for DM (Diabetes Mellitus. [MEDICATION(S)] [MEDICATION(S)] Solution Pen Injector 100 Unit/ML (Insulin [MEDICATION(S)] (1 Unit Dial) Inject as per sliding scale; if 201-250 = 2 units; 251-300 = 4 units; 301-350 = 6 units; 351-400 = 8 units; 401-550 = 10 units of not resolved in 2 hours, call MD (medical doctor). Subcutaneously (under the skin) before meals and at bedtime for diabetes, low blood sugar. Review of Resident #1's August 2021 MARs revealed that his scheduled insulin was missed on 8/2/21 at 4:00 p.m. Resident #1's sliding scale insulin and blood sugar check was not completed on 8/2/21 as well at 4:30 p.m. Resident #1's blood sugar was documented at 301 at the next glucose check on 8/2/21 at 10:00 p.m. Further review of Resident #1's August 2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The nurse who failed to administer the scheduled and sliding scale insulin on 8/2/21 and 8/6/21 had passed away suddenly and could not be reached for an interview. On 8/18/21 at 11:38 a.m., an interview was conducted with Licensed Practical Nurse #2, a nurse who worked 7 p to 7 a with Resident #1 frequently. When asked what blanks or no signatures meant on the MAR, LPN #2 stated that no signatures meant the medication was not given. When asked if Resident #1 had ever made her aware that the 7 a to 7 p shift forgot to administer insulin, LPN #2 stated that she did recall the resident making her aware of that. LPN #2 stated that the nurse who failed to administer the insulin had suddenly passed away but she recalled that he was slower with passing out medications and may not have had the time to do a blood sugar check and administer insulin before the resident's meals. When asked if she ever recalled the resident having a high blood sugar level related to his insulin being missed the shift prior, LPN #2 stated that she couldn't recall. When asked if a blood sugar level of 300 was high for Resident #1, LPN #2 stated, That is pretty high for him. When asked if the physician should be made aware of any missed medication, LPN #2 stated that the physician should be made aware and a note should be documented of all missed medications. On 8/19/21 at 2:49 p.m., Administrative Staff Member (ASM) #1, the Administrator, ASM #2, the DON (Director of Nursing), ASM #3, the Regional Director of Clinical Services, and ASM #5, the corporate nurse were made aware of the above concerns. Facility policy titled, Medication Errors documents in part, the following: .The facility will consider factors in medication administration, including but not limited to, the following: a. Medication administered not in accordance with the prescriber's order. Examples include .Medication omission .If a medication error occurs, the following procedure will be initiated: a. The nurse assesses and examines the resident's condition and notifies the physician or health care practitioner as soon as possible . (1) [MEDICATION(S)] is commonly used to treat neuropathic pain (pain due to nerve damage). This information was obtained from the National Institutes of Health. https://pubmed.ncbi.nlm.nih.gov/ 471/. (2) [MEDICATION(S)] [MEDICATION(S)] Solution Pen Injector- is a rapid-acting human insulin analog indicated to improve glycemic control in adults and pediatric patients 3 years and older with type 1 diabetes mellitus and adults with type 2 diabetes mellitus. This information was obtained from The National Institutes of Health. https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=0691def8-4a7b-4de3-866f-a 9f47f1. 4. Facility staff failed to notify the physician that all 9 p.m. medications were not administered to Resident #3 on 12/26/20 per physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Resident #3 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #3's most recent Minimum Data Set MDS (assessment) was a quarterly assessment with an Assessment Reference Date (ARD) of 5/5/21. Resident #3 was coded as being severely impaired in cognitive function scoring 06 out of possible 15 on the Brief Interview for Mental Status (BIMS) Exam. During the course of a complaint investigation, it was alleged that residents did not receive medications and treatments on 12/26/20 night shift due to the lack of staffing. Review of Resident #3's December 2020 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] 1) Atorvastin Calcium ([MEDICATION(S)]) 40 mg (milligrams) Give 1 tablet by mouth at bedtime for high cholesterol. 2) [MEDICATION(S)] Tablet Give 6 mg by mouth at bedtime for [CONDITION(S)]. 3) [MEDICATION(S)] 15 MG Give 1 tablet by mouth at bedtime for depression. 4) Trazadone HCl Tablet 50 MG Give 1 tablet at bedtime for depression. 5) [MEDICATION(S)] HCL 500 MG Give 1 tablet by mouth two times a day for diabetes mellitus. Further review of Resident #3's December 2020 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The following order was documented: [MEDICATION(S)] Solution (Insulin [MEDICATION(S)]) Inject as per sliding scale: If 150-199 = 2 units give 2 units; 200-249 = 4 units give 4 units; 250-299 = 6 units give 6 units; 300-349 = 10 units give 10 units; 350-399 = 12 units 12 units; 400 - 450 = 14 units 14 units; subcutaneously three times a day for diabetes mellitus call md (Medical Doctor) if blood sugar is greater or equal to 400 mg/dl. Review of Resident #3's December 2020 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . 4 units of [MEDICATION(S)] were administered. There was no evidence in his clinical record of any negative outcome related to the above missed medications. There was no evidence that the physician was notified regarding the above medication missed. On 08/19/21 at approximately 9:10 a.m., an interview was conducted with the Director of Nursing (DON.) The December 2020 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON stated that she was not employed with the facility in December and was not sure why the medications were not administered. The DON stated she expected staff to notify the physician and resident representative of all medications not administered. On 8/19/21 at 2:49 p.m., Administrative Staff Member (ASM) #1, the Administrator, ASM #2, the DON (Director of Nursing), ASM #3, the Regional Director of Clinical Services, and ASM #5, the corporate nurse were made aware of the above concerns. 5. Facility staff failed to notify the physician that all 9 p.m. medications were not administered to Resident #4 on 12/26/20 per physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Resident #4 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #4's most recent Minimum Data Set (MDS) assessment was an annual assessment with an Assessment Reference Date of 6/4/21. Resident #4 was coded as being intact in cognitive function scoring 15 out of possible 15 on the Brief Interview for Mental Status (BIMS) Exam. During the course of a complaint investigation, it was alleged that residents did not receive medications and treatments on 12/26/20 night shift due to the lack of staffing. On 8/18/21 an interview was conducted with Resident #4. She could not recall if she missed medications on 12/26/20 and 12/27/20. She could not recall not having a nurse on that day. Review of Resident #3's December 2020 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] 1) Atorvastin Calcium ([MEDICATION(S)]) 20 mg (milligrams) Give 1 tablet by mouth at bedtime for high cholesterol. 2) Lantanprost 0.005 % (percent) Instill 1 drop in both eyes at bedtime for [CONDITION(S)]. 3) [MEDICATION(S)] 30 MG Give 1 tablet by mouth at bedtime related to Major Depressive Disorder. 4) Tylenol 8 hour Tablet Extended Release 650 MG Give 2 tablets by mouth every 8 hours for pain related to LOW BACK PAIN. The Tylenol 8 hour tablet was missed at 10 p.m. and at 6:00 a.m. on 9/27/20. Further review of Resident #3's clinical record revealed no negative outcomes related to the above medications not being administered. On 08/19/21 at approximately 9:10 a.m., an interview was conducted with the Director of Nursing (DON.) The December 2020 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON stated that she was not employed with the facility in December and was not sure why the medications were not administered. The DON stated she expected staff to notify the physician and the resident representative of all medications not administered. On 8/19/21 at 2:49 p.m., Administrative Staff Member (ASM) #1, the Administrator, ASM #2, the DON (Director of Nursing), ASM #3, the Regional Director of Clinical Services, and ASM #5, the corporate nurse were made aware of the above concerns. 6. The facility staff failed to notify the physician and Resident Representative (RR) that Resdient #5 was not administered the following medication on 12/26/20 at 9:00 p.m,: [MEDICATION(S)] insulin 40 units, Atarvastatin Calcium 10 mg, Trazadone 25 mg, Trazadone 50 mg and [MEDICATION(S)] Extended Release (ER) 60 mg for Resident #5. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #5's Minimum Data Set (MDS - an assessment protocol) a quarterly assessment with an Assessment Reference Date of 07/09/21 coded Resident #5's Brief Interview for Mental Status (BIMS) scored a 15 out of a possible score of 15 indicating no cognitive impairment. Resident #5's person-centered care plan with a revision date 12/41/19 documented resident is an insulin dependent diabetic. The goal: will remain adequate glucose levels and experience no signs/symptoms (s/s) of hypo/[CONDITION(S)] episodes. One intervention/approaches to manage goal included: please give me medication as ordered. The care plan also included Resident #5 at risk for complications related to my high blood pressure. The goal: will remain free from my complications related to high blood pressure. One intervention/approaches to manage goal included: give the medications as ordered by the physician/nurse practitioner. During the review of Resident #5's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] Insulin [MEDICATION(S)] Solution - inject 40 units subcutaneously at bedtime for (Type II Diabetes.) Atarvastatin Calcium tablet 10 mg - give 1 tablet by mouth at bedtime for (hyperlipidema.) Trazadone 50 mg - give 0.5 mg (25mg) by mouth at bedtime for ([CONDITION(S)].) Trazadone 50 mg - give 1 tablet by mouth at bedtime for ([CONDITION(S)].) [MEDICATION(S)] Extended Release (ER) - give 60 mg every 12 hours for (high blood pressure.) Further review of the December 2020 MAR, revealed evidenced there were no initials by the nurse; indicating the mentioned medications above were not administered on 12/26/20 at 9:00 p.m. On 08/19/21 at approximately 9:10 a.m., an interview was conducted with the Director of Nursing (DON.) The December 2020, MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . A pre-exit conference was conducted with the Administrator, Director of Nursing and Cooperate on 08/19/21 at approximately 3:30 p.m. The Administration team were informed of the above findings; no further information was provided prior to exit. 7. The facility staff failed to notify Resident #11's Responsible Party (RP) and physician of a missed dose of medication ([MEDICATION(S)] nebulizer treatment) on 04/10/20. Resident #11 was originally admitted to nursing facility on 05/24/19. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] .) Resident #11's Minimum Data Set (MDS - an assessment protocol) a quarterly assessment with an Assessment Reference Date (ARD) of 11/30/19 coded Resident #11's Brief Interview for Mental Status (BIMS) scored a 15 out of a possible score of 15 indicating no cognitive impairment. Resident #11's person-center comprehensive care plan with a revision date of 09/14/20 documented resident with [CONDITION(S)] and at risk for exacerbation and respiratory distress. The goal: will not experience any signs or symptoms of respiratory distress such as restlessness, shortness of breath, crackles, [CONDITION(S)] or show symptoms of being cyanotic (turning blue). Some of the intervention/approaches to manage goal include: give me my medications as ordered by my physician/nurse practitioner and monitor me for adverse effects and/or effectiveness of my medications and report adverse effects to my physician/nurse practitioner. Review of Resident #11's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of the April 2020 MAR, revealed evidenced there were no initials by the nurse; indicating the mentioned medication was not administered on 04/10/20 at 4:00 p.m. On 08/19/21 at approximately 9:10 a.m., an interview was conducted

Based on observation, resident and staff interviews and clinical record review the facility staff failed to ensure 3 of 11 residents (Resident #6, Resident 11 and Resident #8) in the survey sample who were unable to carry out activities of daily living (ADL) receives the necessary care services. The findings included: 1. The facility staff failed to ensure Resident #6 received showers twice a week. Resident #6 was originally admitted to the nursing facility on 05/11/21. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] .) Resident #6's Minimum Data Set (MDS - an assessment protocol) an annual assessment with an Assessment Reference Date of 05/18/21 coded Resident #6's Brief Interview for Mental Status (BIMS) scored a 13 out of a possible score of 15 indicating no cognitive impairment. In addition, the MDS coded Resident #6 total dependence of one with bathing, extensive assistance of one with bed mobility and dressing, limited assistance of one with transfer, eating, toilet use and personal hygiene for Activities of Daily Living (ADL) care. The care plan dated 05/27/21 identified Resident #6 with ADL self-care performance deficit. The goal set for the resident by the staff was that the resident will maintain and improve current level of function. One of the interventions/approaches the staff would use to accomplish this goal for a dependent resident is that staff is to provide bath/shower (specify frequency) and as necessary. On 08/17/21 at approximately 11:05 a.m., an interview was conducted with Resident #6 who stated, I have only had one shower since I've been admitted to the facility. The resident proceeded to say, I have never refused my showers and the staff don't ask. Review of Resident #6's documentation survey report for bathing revealed the following: Showers were not given for the entire month of July 2021 and has not been given for the month of August as of 08/17/21. On 08/18/21, the facility provided documentation of resident #6's shower scheduled: Resident #6 was scheduled to receive showers every Tuesday and Friday (7a-7p shift). An interview was conducted with Certified Nursing Assistant (CNA) #5 on 08/19/21 at approximately 8:30 a.m. The CNA was assigned to provide Resident #6 her shower on 08/13/21. She stated, I don't remember if Resident #6 refused her shower but if she did, the refusal was reported to the charge nurse so it could be charted in her record. During the review of Resident #6's clinical record for July and August 2021 revealed that Resident #6 has never refused her showers. On 08/19/21, an interview was conducted with CNA #6 at approximately 8:52 a.m. CNA #6 was assigned to provide a shower to Resident #6 on 08/17/21. The CNA said Resident #6 is usually sleepy and will sometimes refuse her showers. The CNA stated, If a resident refuse their shower, it's reported to the nurse and they will document the refusal. Review of Resident #6's clinical record revealed there were no refusal of care to include showers for Resident #6. An interview was conducted with the Director of Nursing (DON) on 08/19/21 at approximately 9:13 a.m. The DON said she expect for the CNA's to follow the resident's shower schedule and notify the charge nurse if the resident refuses. The CNA is also to document the refusal in Point Click Care (PCC) and the nurse is to document the refusal in the resident's clinical record. 2. The facility staff failed to ensure Resident #11 received showers twice a week. Resident #11 was originally admitted to the nursing facility on 05/24/19. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #11's Minimum Data Set (MDS - an assessment protocol) a quarterly assessment with an Assessment Reference Date (ARD) of 11/30/19 coded Resident #11's Brief Interview for Mental Status (BIMS) scored a 15 out of a possible score of 15 indicating no cognitive impairment. In addition, the MDS coded Resident #11 limited assistance of one with bed mobility and toilet use, supervision with dressing, toilet use, personal hygiene and bathing for Activities of Daily Living (ADL) care. The care plan dated 05/25/19 with a revision date identified Resident #11 requiring assistance with ADL's at times. The goal set for the resident by the staff was that the resident abilities will be maximized, remain clean and free of body odor, will be groomed and well-nourished with your assistance. One of the interventions/approaches the staff would use to accomplish this goal is that staff to assist bathing when needed. Review of Resident #11's documentation survey report for bathing revealed the following: Showers were not given for the entire month of December 2020 and only given twice for the month of November 2020; on 11/03 and 11/22/20. An interview was conducted with the Director of Nursing (DON) on 08/19/21 at approximately 9:13 a.m. The DON said she expect for the CNA's to follow the resident's shower schedule and notify the charge nurse if the resident refuses. The CNA is also to document the refusal in Point Click Care (PCC) and the nurse is to document the refusal in the resident's clinical record. 3. The facility staff failed to ensure that fingernail care was provided to Resident #8. Resident #8 was originally admitted to the facility on [DATE]. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The current Minimum Data Set (MDS) a quarterly assessment with an Assessment Reference Date (ARD) of 07/06/21 coded Resident #8 with a 15 out of a possible score of 15 on the Brief Interview for Mental Status (BIMS) indicating no cognitive impairment. In addition, the MDS coded Resident #8 requiring total dependence of one with bathing, extensive assistance of two with transfer and toilet use, limited assistance of two with bed mobility and dressing, limited assistance of one with personal hygiene. The care plan with a revision date of 10/23/20 identified Resident #8 with ADL self-care performance deficit related to fatigue and impaired balance. The goal set for the resident by the staff was that the resident will maintain current level of function with ADL's. One of the interventions/approaches the staff would use to accomplish this goal is during bathing/showering to check nail length and trim and clean on bath day as necessary; report any changes to the nurse. Resident #8's showers days are scheduled every Monday and Thursday (7a-7p) shift. During the initial tour on 08/17/21 at approximately 10:50 a.m. Resident #8 was observed lying in bed with her hands on the outside of her covers. The surveyor observed Resident #8's fingernails were very long with a brown substance under the nails. On the same day at approximately 1:42 p.m., Resident #8 fingernails remained unchanged. Resident #8 said my fingernails are long and nasty, they need to be cut/soaked and filed. Resident #8 stated, Can someone cut my fingernails? On the same day at approximately 1:50 p.m., License Practical Nurse (LPN) #4 assessed Resident #8's fingernails with the surveyor present. The LPN stated, Yes, Resident #8's fingernails need to be cleaned/cut and trimmed, I'll take care of it today. On 08/18/21 at approximately 9:10 a.m., Resident #8's fingernails had be cleaned/cut and filed. Resident #8 stated, Thank you for getting my fingernails taken care of so quickly, I've been trying for weeks to have the staff cut my fingernails. A pre-exit conference was conducted with the Administrator, Director of Nursing and Cooperate on 08/19/21 at approximately 3:30 p.m. The Administration team were informed of the above findings; no further information was provided prior to exit. Complaint deficiency

Based on observation, resident interview, staff interview, facility documentation review, clinical record review, the facility staff failed to ensure one resident (Resident #36), of 18 residents in the survey sample, remained free of accident hazard that resulted in a fall with fracture that resulted in harm of past non compliance. The findings included: Resident #36 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Resident #36's Admission Minimum Data Set (an assessment protocol) with an Assessment Reference Date of 11/4/16 coded Resident #36 with a BIMS (Brief Interview for Mental Status) score of 8 out of a possible 15 indicating a moderate cognitive impairment. Resident #36 required extensive assistance with 2 staff member assist for bed mobility and transfers as documented on the Admission Minimum Data Set with an Assessment Reference Date of 11/4/16. Resident #36 was hosptalized on [DATE] after being found lying on the floor, on the right side of her bed by a CNA, the bed was in a high position per a 3/16/18 Late Entry 16:03 (4:03 PM) (nursing note). An emergency room note dated 3/15/18 documented the following discharge Diagnosis: [REDACTED]. Nondisplaced fracture of second cervical vertebra, unspecified, fracture 2. Closed fracture of [MEDICATION NAME] process of cervical vertebra Fall Resident was released back to the facility on [DATE] with discharge education/instructions for a Broken Neck and a cervical collar. A facility Event Occurrence Report dated 3/15/18 documented the following: After event: Date of Event: 3/15/18 Time of event: 14:15 (2:15 PM) Type of event: fall Cognitive Status: Alert, Able to understand others ADL (Activity Daily Living): Transfer Mood: Apathetic Details of Incident: found lying on floor next to bed per CNA. Reported to nurse. Lying on floor on right side of her bed. RN assessed the patient and asked me to call 911 to send to hospital. Resident was complaining of neck pain. The bed was in high position. The CNA was doing ADLs and walked away. The fall occurred Type of Injury: Discomfort/pain Identify the location of known injury or pain: Left side of neck MD notified 3/15/18 14:15 (2:15 PM) RP notified: 3/15/18 14:20 (2:20 PM) A 3/15/18 Nursing note Late Entry Created 3/16/18 16:03 (4:03 PM), for effective date 3/15/18 14:41 (2:41 PM) documented the following: Resident was found lying on the floor, on the right side of her bed by CNA, the bed was in a high position. She was assessed, complained of neck pain, I was instructed to call 911, and send to hospital, the paramedic arrived and assessed the resident and transported to (hospital) she was alert and responsive, to all verbal command. Resident #36's Fall Risk assessment dated [DATE] documented a score of 15 indicating a high fall risk. A review done on 5/17/18 at approximately 3:35 PM, of an Event Occurrence Report dated 3/15/15 Resident #36, documented a fall on 3/15/15. Resident #36's person centered care plan dated 10/28/17 with a revision on 12/28/18 documented the Focus area: Focus Area: has the potential for fall related injury related to history of falls, incontinence, Alzheimer's Goal: Will not injure themselves in a fall through next review Interventions: Anticipate and meet Resident's needs Be sure Resident call light is within reach and encourage resident to use it for assistance as needed Focus Area; has an injury related to fall with major injury Goal: Resident will show sign symptoms of healing by next review date Interventions: 911 called for ER 3/15/18 Be sure call light is within reach and encourage Resident to use it for assistance as needed bi lat floor mats follow MD orders for injury Keep C collar on all the time A letter from the Facility's Administrator included with the Facility Reported Incident, dated 3/20/18 sent to the Office of Long Term Care and received 3/21/18 documented: .The CNA stepped out of room to get a fitted sheet for 10-15 seconds and in that time, (Resident #36) rolled off the bed onto the floor mat which was in place on her floor. To deter reoccurrence of fall during ADL care, Staff have been re-educated on bed position and ADL safety during care. Redirect patient as needed. The Facility Policy titled, Accidents/Incidents - Medical Director Review of, with a revision date of 2008 documented the following: As part of the QA process, the Medical Director will work with the Director of Nursing Services, Administrator, and other departments to evaluate trends, patterns, and interventions: for example, reduction of medications that may increase fall risks and ways to improve evaluation of individual's safety risk factors. The Director of Clinical Services presented a Corrective Action Plan dated 3/16/18. The Action plan documented the following: Bed in Highest position Variance: All residents have the potential to be affected. a. Resident's beds have been observed to be left elevated. b. Resident's have been left in elevated bed alone c. Resident rolled out of bed while CNA left her in an elevated bed position Corrective Action Plan: documented the following 1. 1 Resident had an event that resulted in a fracture. 2. Resident's beds need to be lowered prior to the staff member leaving the room 3. All nursing staff to be re-educated on Policy and Procedure of Resident safety 4. Charge nurse on duty to be responsible for ensuring beds are in lowest position. 5. Nursing Administration to audit rooms each shift daily for 4 weeks, then daily for 4 weeks then monthly thereafter. On 5/27/18 at approximately 4:15 PM, the education log from the Corrective Action Plan was reviewed. The education was titled, Bed In Lowest Position, and was conducted on 3/16/18. Review of the Facility's fall book documented 1 fall resulting in a fractured nose on 3/30/18, however no deficient practice was identified. On 5/17/18, the Director of Clinical Services stated that she knew the Resident's fracture was because she was left in a high position when the aide left out of the room for a few seconds to get a fitted sheet. The DCS stated, It's on us. The Facility Policy titled, Accidents and Incidents - Investigating and Reporting with a revision date of 2014 documented: All accidents or incidents involving residents occurring on our premises shall be investigated and reported to the administrator. The Facility Policy titled, Preventing Resident Abuse, with a revision date of 8/2011 documented the following: Identifying areas with the facility that may make abuse and or neglect more likely to occur and monitoring these areas regularly. The facility administration was informed of the findings during a pre-exit-briefing on 5/17/18 at approximately 5:45 PM. The facility did not present any further information about the findings. Past non-compliance: The fall from a high bed position resulted in a neck fracture that constituted harm of past non compliance for Resident #36.

Based on staff interviews, clinical record review and facility document review the facility staff failed to implement interventions consistent with the resident's needs, goals and person-centered care plan to reduce an avoidable accident for 2 of 20 residents in the survey sample, Resident #17 and #15. 1. On 5/11/17 Resident #17 was manually transferred from the bed to a shower chair with two staff when the resident's legs gave out. The resident was lowered to the floor and the resident's right leg got caught underneath her which resulted in a fracture to the right ankle resulting in harm. The staff failed to implement the appropriate transfer approach to prevent injuries per the resident's person-centered plan of care. The resident was to have been transferred using a mechanical lift (Hoyer). 2. The facility staff failed to provide supervision for Resident #15 to prevent a fall. The findings included: 1. Resident #17's last admitted to the facility was 2/5/13. The resident's [DIAGNOSES REDACTED]. The MDS (Minimum Data Set) a quarterly with an assessment reference date of 4/6/17 coded the resident as scoring a 3 out of a possible 15 on the Brief Interview for Mental Status (BIMS), indicating the resident's cognition was severely impaired. The resident was coded as requiring two person physical assistance with transfers. The comprehensive person-centered care plan initiated on 12/20/15 identified the resident has an ADL (Activities of Daily Living) Self Care Performance Deficit due to Alzheimer's and contractures. The goal was that the resident will receive appropriate staff support with all ADLs. One of the interventions listed was to transfer the resident with a mechanical lift. The Progress Notes dated 5/11/17 timed for 10:26 am, read, Resident has a hematoma (2) to right outer ankle. Blue in color. Resident c/o (complaint of) pain. NP (Nurse Practitioner) notified and order was given for x-ray of right ankle,. Resident was medicated prn (as needed) for pain. Mobile X-ray called. The Progress Notes dated 5/11/17 timed for 9:54 pm, authored by the night shift Licensed Practical Nurse (LPN#5) read, in part: At 0630 (6:30 am) when transferred resident to the chair to get shower, resident can't keep her balance, the CNA (Certified Nurse Aide #4) needed to slide her to sit on the floor . The Progress Notes dated 5/11/17 timed for 11:00 pm, read, in part: NP (name) made aware of X-ray of (R) ankle Incomplete fracture of medial malleolus (ankle). Patient to have a splint until seen by Ortho. blue boot used as immobilizer tonight . The Radiology Report dated 5/11/17 Conclusion read: Findings suggesting recent incomplete fracture of the medial malleolus. On 5/12/17 the resident was sent to the ER (emergency room ) for an Orthopedic evaluation. The resident was evaluated and discharged back to the facility the same day. The discharge [DIAGNOSES REDACTED]. The resident's discharge instructions were for a splint, no boot, and to continue the PRN Ibuprofen 600 mg (milligrams) by mouth every six (6) hours as needed for pain and to schedule a follow up appointment with the Orthopedic physician. The follow up appointment with the Orthopedic physician occurred on 5/18/17. The resident was placed in a cast and was to have another follow up in 3 weeks for removal of the cast. In response to the fall, the facility faxed a Facility Reported Incident (FRI) to the appropriate agencies to include the State Survey Agency and initiated an investigation. The facility's follow up investigation report dated 5/18/17 , authored by the Administrator, documented the resident was being transferred from the bed to the shower chair when the residents legs gave out. The resident was then lowered to the ground and subsequently sustained an incomplete fracture of the right ankle. In response to the incident a 100% quality review was completed on all residents transfer/mobility status. Direct care staff were re-educated on proper low lift technique and how to identify what means and mode of transfer for residents' plan of care. Lift competency skills review were initiated with all direct care staff. An interview was conducted with the Director of Clinical Services (DCS) on 6/1/17 at approximately 4:00 pm. The DCS was asked about the resident's fall with injury. She stated that the resident was a total lift transfer and required the use of a mechanical lift. She stated the CNA (Certified Nurse Aide #4) who transferred the resident that morning had knowledge that the resident required a Hoyer (mechanical) lift yet transferred the resident without one. The DCS stated that when interviewing CNA #4 she denied knowing the resident was a Hoyer lift and stated she had not been educated on the facility's Low Lift policy. The DCS stated all staff are educated on the facility's Low Lift policy during orientation. The DCS stated the resident had a red sticker at the entrance of the resident's room that identified her as a total lift (TL) at the time of the fall. The DCS also stated the resident's transfer requirements are also noted in the CNA Kardex that is maintained on the tablets used daily by the direct care staff. When asked what was the root cause of the fall that resulted in the fracture, she stated, Used the wrong lift. When asked if a Hoyer lift was available and operational for staff use at the time of the fall, she stated, Yes. Both CNA #4 and LPN #5 were given a final written warning due to utilizing an unapproved lift when getting a resident out of bed. Resident fell fracturing her ankle. The DCS stated LPN #5 failed to inform the oncoming staff of the fall and failed to fill out an incident report. On 6/1/17 at 2:45 pm, the direct care staff (CNA #6) assigned to care for Resident #17 today was interviewed. The CNA was asked how is the resident transferred, she stated, A two (2) person Hoyer lift. When asked why the resident was a total Hoyer lift she stated, She (the resident) can't weight-bear because both of her legs are contracted. When asked if she was aware of how the resident fell she stated, (Name of CNA #4) tried to use the sit to stand. On 6/1/17 at 3:10 pm, a second CNA was interviewed (CNA #5). She was asked how Resident #17 was transferred. She stated that the resident has been a Hoyer lift transfer for at least the last two years. She stated a sit to stand lift would not be appropriate for Resident #17 due to the resident's contractures and inability to weight-bear. On 6/2/17 at 9:45 am, CNA #4 was interviewed on the phone. She stated she was preparing the resident for a shower. While transferring the resident from the bed to the shower chair her and the charge nurse (LPN #5) grabbed the resident under both arms. They could not complete the transfer and lowered the resident to the floor. The CNA stated, (Name of LPN #5) couldn't bear the resident's weight .she couldn't lift her . Another CNA came into the room to assist with transferring the resident from the floor to the shower chair. CNA #4 stated she took the resident to the shower room and completed the shower. Afterwards the resident was then transferred to the bed with the use of a sit to stand and assistance of another CNA. CNA #4 stated she was not aware the resident was a Hoyer lift and further stated, I have never seen anyone use a lift (mechanical-Hoyer) with the resident, they normally use a 2 person lift with her. She stated, The Hoyer lift would have been a better transfer. A telephone call was placed to LPN #5 on 6/2/17 at 10:00 am., for an interview. The phone was not answered. The resident had been observed several times during the survey in bed with her eyes closed, on 6/1/17 and 6/2/17. Observed on the resident's name plate was a sticker with the symbol TL (total lift). The facility's Low Lift Program with a revision date of 01/11 Purpose read: Improve working conditions by eliminating 85%-90% of all manual resident transfers by utilizing mechanical lifting devices and aids, and to provide appropriate training for all employees on proper body mechanics and lifting techniques. Under Procedure read, in part: (3) The transfer requirement should be documented on the resident's care plan. (4) A sticker should be placed on each resident's nameplate. The sticker should include one of the following symbols-IND-individual, 1-Assist of One, 2-Assist of two, S/SST-Invacare Sit to Stand with Standing Sling, S/STR-Invacare Sit to Stand with Transfer Sling, TL-Invacare Total Lift (Hoyer). The 5 Point Corrective Action Plan dated 5/12/17 included the following with a corrective action completion date of 5/19/17 read as follows: 1. Identified staff members were not using lifts that are required to safely transfer residents. 2. All residents had a new mobility assessment performed. Identifying lift dots placed outside rooms bedside room numbers. 3. All staff members were re-educated on policy of a low lift facility and no resident is to be transferred without lift identified. Staff members were also in-serviced on kardex and how to verify lift necessary. 4. 100% compliance by 5/19/17 with all staff members able to verbalize proper use of all lifts. Also the staff has been in-serviced regarding appropriate transfer status for each resident. 5. Each staff member will have completed a lift competency and safe transfer techniques. Audit will be conducted on all three shifts on proper technique 1 time a week (total of 3 audits per week) for 30 days and random checks for 1 month after and will have annual competency thereafter. Based on the aforementioned interviews with facility staff, review of the corrective action plan and that the deficient practice did not reoccur after 5/19/17 or exist during the current survey, it was determined the facility met Past Non Compliance for this specific regulatory requirement. The following medical Definitions were obtained from Taber's Cyclopedic Medical Dictionary Edition #20: (1) Contracture-Fibrosis of connective tissue in skin, fascia, muscle, or a joint that prevents normal mobility of the related tissue or joint. (2) Hematoma- A swelling comprising a mass of extravasated blood (usually clotted) confined to an organ, tissue, or space and caused by a break in a blood vessel. 2. The facility staff failed to provide Resident #15 with supervision to prevent a fall. Resident #15 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the closed clinical records indicated: Resident #15 had a fall on 9/5/16-(resident fell out of bed) possible have 1 on 1 supervision, to ensure residents safety. 9/7/16 (resident found on floor by CNA) (certified nursing assistant). request lab work. 9/30/16 resident found on floor on right side in pink solarium in front of w/c. Unwitnessed fall. No visibly apparent injuries. Found unattended. Fall with pain to right hip x-ray requested to rule out fracture. X-ray determined no fracture. The clinical records indicated the physician as well as family were contacted after each incident. An Initial Minimum (MDS) data set [DATE] assessed this resident in the area of hearing as adequate. This resident was able to make her self understood sometimes and sometimes she was able to understand others. This resident was not able to complete the Brief Interview for Mental Status (BIMS). This resident was assessed as having short and long memory problems. This resident was assessed as having behaviors which impacted others. In the area of Activities of Daily Living (ADL'S) this resident was coded as requiring Extensive assistance of one person physical assist in the areas of Transfer, walk in room, locomotion on unit, dressing, eating toilet use and personal hygiene. This resident was assessed as having a history of falls. A Care Plan dated 8/30/16 indicated focus- Impaired balance, Alzheimer, restlessness and agitation. Interventions- Assitive devices (wheelchair). Explain all procedures/tasks before starting and converse with resident while providing care. Monitor and report decline in abilities. Screen for physical therapy, occupational therapy and speech therapy. Resident requires assistance to turn and reposition in bed. Transfer with assistance. Focus- potential for fall related injury history of seizures, falls, Alzheimer, non compliant. Interventions- Resident needs a safe environment with even floors free from spills and/or clutter, adequate glare-free light; a working and reachable call light, bed in low position at night, hand rails on walls, persona items within reach. Wear appropriate footwear when ambulation or mobilizing in wheelchair. Needs activities that minimize the potential for falls while proving diversion and distraction Non-drug interventions- enjoys sitting at the nurses station and watching everyone buzz around. A Four Point Falls Plan- indicated: Resident with poor safety awareness was left unsupervised in pink solarium. Interventions include providing supervision at all times for residents with high fall risk. During an interview on 6/3/17 at 11:15 A.M. with the administrator, she stated Resident #15 was very restless and would get up unassisted. The facility staff failed to provide Resident #15 with supervision to prevent a fall. Complaint Deficiency