Every finding on record at Oak Grove Health & Rehab Center, LLC

Based on record review, interviews, and review of facility policy, the facility failed to ensure consistent and comprehensive management of nutritional services for one out of 11 residents (Resident (R) 67) reviewed for nutrition. The facility's failure to ensure consistent nutritional interventions were provided for R67 created the potential for this and other residents to experience significant/unanticipated weight loss or nutritional deficits. A total of 31 residents were reviewed in the sample. Review of the Resident Face Sheet, dated 02/19/26 and found in the electronic medical record (EMR) under the Profile tab, revealed R67 was admitted to the facility on [DATE]. The resident's diagnoses included rheumatoid arthritis, history of stroke, and malnutrition. Review of R67's Physician's Order Report, dated 02/19/26 and found in the EMR under the Orders tab, revealed orders, with an initial order date of 12/12/25 for the resident to receive a regular mechanical soft diet with nectar thick liquids and an order with an original order date of 09/04/25, for the resident to receive fortified foods with breakfast and dinner and for the resident to receive a 2-Cal Nutritional Supplement twice daily. The orders did not include any specific frequency for monitoring the resident's weight. R67's Vital Signs Report, dated 02/19/26 and found in the EMR under the Vital Signs Tab, revealed the following weights (which indicated a significant weight loss of 20.9% in two months): 12/05/25: 102.4 poundsNo weight was recorded in January of 202602/04/26: 81.0 poundsThe record did not indicate anything to show a re-weight had ever been obtained for R67 after her significant weight loss was recorded on 02/04/26.Review of R67's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/04/26 and found in the EMR under the MDS tab, revealed a Brief Interview for Mental Status (BIMS) assessment could not be completed due to the resident's poor cognition. The assessment indicated the resident had short and long-term memory deficits. The assessment indicated the resident had not experienced significant weight loss or gain during the assessment reference period and indicated the resident was dependent on staff to eat her meals. Review of R67's Nutrition Note, dated 02/09/26 and found in the EMR under the Notes tab, revealed Nutrition Note: [R67] is a 90 y.o. [year old] female who remains at increased nutritional risk related to PMH [Past Medical History]: dysphagia [difficulty swallowing], protein-calorie malnutrition, HTN [hypertension], hypothyroidism, iron-deficiency anemia, dementia, metabolic encephalopathy, and anxiety. She continues with a regular, mech [mechanical] soft diet, nectar thick liquids with fortified foods at breakfast and dinner. Additionally she gets House 2 Cal Med Pass 180 mL [milliliters] twice daily (720 kcal [calories], 32 g [grams] protein). Her intake is good with > [greater than] 75% of most meals consumed, although she is noted with some varied intake. Today she did eat most of her breakfast as I observed her finishing her meal. She does do well with the ONS [supplement] although she is also noted to refuse that at times as well. Current weight: 81 lb [pounds] (02/04/26), previous weight: 102.4 lb (12/5/25), 98 lb (11/3/25), and 102.4 lb (8/5/25). This is noted for significant weight loss of 17% weight loss over previous 3 months and 20% weight loss over previous 6 months. Resident is noted to remain underweight during this admission. She is noted with a skin tear, but no pressure injury at this time. She was seen earlier this month for her quarterly review, but there was no monthly weight yet. Recommend to re-check resident's weight. Additionally recommend to increase fortified foods to be at all meals. Recommend to continue with regular, mech soft diet with nectar thick liquids. Continue with House 2 cal HN [supplement], 180 mL, twice daily. Recommend to check weight weekly x4 [four times]. If weight continues downward trend even with additional fortified foods recommend to increase House 2 cal HN, Med Pass to three times daily. Will continue to monitor intake, weight, labs, and skin integrity, and follow-up per protocol.R67's Nutrition/Hydration Risk Care Plan, dated 02/16/26 and found in the EMR under the Care Plan tab, indicated the resident was at risk for significant weight loss related to her history of stroke and rheumatoid arthritis and was receiving a calorie enhanced diet. Interventions included: provide diet per physician's order, honor resident's dietary preferences, weigh per facility protocol, provide supplements as ordered, monitor dietary intake, and monitor need for increased nutritional intervention related to diagnosis, medications, and listed problems. Review of R67's Medication and Treatment Administration Records (MARs/TARS), dated 02/01/26 through 02/19/26 and found in the EMR under the Orders tab, revealed the resident received her supplement twice daily and fortified foods at meals twice daily.Review of R67's dietary meal cards revealed she received fortified foods at all three meals.Review of R67's record revealed nothing to indicate the resident had been re-weighed or that the resident's weight had been obtained weekly according to the recommendations in the 02/09/26 nutrition note. During an interview with the Registered Dietician (RD) on 02/18/26 at 12:58 PM, she indicated R67 should have been weighed in January, and she was unsure of why that had not been done. She indicated if the resident had refused to be weighed in January, the weight should have been re-attempted, and documentation should be in the resident's record to indicate a refusal/reason for the missed weight if the weight was not able to be obtained. The RD indicated a re-weight had been requested and should have been done after R67 was weighed on 02/04/26 and a significant weight loss had been recorded on that date. She stated her expectation was her nutritional recommendations would be followed.During an interview with the Director of Nursing (DON) on 02/19/26 at 12:27 PM, she confirmed R67 had not been weighed in January per facility protocol, and her expectation, and confirmed the resident's weights had not been increased to weekly per the RD's 02/09/26 recommendation. She stated she was not sure why these things had been missed. The DON further indicated a re-weight should have been obtained for R67 on 02/04/26 after the result indicated a significant loss of weight.Review of the facility's policy titled, Resident Weight Policy, dated last revised/reviewed on 03/23/25, indicated, Weights will be obtained routinely in order to monitor nutritional health over time.The facility's policies related to the maintenance of nutritional health were requested by the survey team on 02/19/26 at 10:00 AM; however, the policies were not received prior to survey exit on 02/19/26.

Based on review of facility policy, record review, observations, and interviews, the facility failed to ensure a splint was applied routinely for one out of one resident (Resident (R) 11) reviewed for position and mobility. The facility's failure to ensure R11's splint was routinely applied created the potential for this and other residents to experience avoidable decline in range of motion (ROM). A total of 31 residents were reviewed in the sample. Review of R11's Resident Face Sheet, dated 02/19/26 and found in the electronic medical record (EMR) under the Admissions tab, revealed the resident was admitted to the facility on [DATE]. The resident's diagnoses included history of stroke and reduced mobility. Review of R11's Occupational Therapy Discharge summary, dated [DATE] and found in the EMR under the Documents tab, revealed facility staff had been trained to ensure the application of the resident's right upper extremity splint/brace for three hours daily. Review of R11's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/16/25 and found in the EMR under the MDS tab, revealed a Brief Interview for Mental Status (BIMS) assessment could not be completed due to the resident's poor cognition and inability to communicate. The assessment indicated the resident had limited range of motion (ROM) to his upper and lower extremities bilaterally and indicated a brace/splint was not being applied for the resident. Reviewed of R11's Splint/Brace Care Plan, dated 02/12/26 and found in the EMR under the Care Plan tab, revealed R11 required the use of a splint/brace to his right upper extremity for three hours per day to improve ROM to the extremity. The care plan indicated the resident's splint/brace was to be applied every day from 8:00 AM until 11:00 AM. Review of R11's Physician's Order Report, dated 02/19/26 and found in the EMR under the Orders tab, revealed no orders for the resident's use of a splint/brace.R11's record revealed no documentation to indicate his splint/brace was being applied per his plan of care.Observations of R11 lying in his bed or seated in his wheelchair conducted on 02/18/26 at 9:25 AM and 10:55 AM, and on 02/19/26 at 10:15 AM, revealed R11 did not have his care planned brace applied to his right upper extremity. R11 was observed along with Licensed Practical Nurse/Unit Manager (LPN/UM1) and the Director of Nursing (DON) on 02/19/26 at 11:17 AM. Both confirmed R11 was not wearing his care planned splint/brace and that they were not able to locate the brace. Both indicated R11 was expected to have the care planned splint/brace applied daily for three hours between 8:00 AM and 11:00 AM. During a follow-up interview with the DON on 02/19/26 at 12:16 PM, she confirmed that although R11 was expected to have had his care planned brace/splint applied, the application of the resident's brace had not been added to the resident's daily care documentation and so had never been applied. The DON confirmed R11 should have been wearing the splint/brace daily and stated education would be provided to staff to begin applying the splint/brace immediately. Review of the facility's policy titled, Splint Issuance Policy, dated last revised/reviewed on 03/24/25, indicated, Splints shall be issued or fabricated with a provider's order and therapist must evaluate patient to determine need for splint, fit and issuance and Patient splint schedule will be communicated to the multidisciplinary team and documented in the care plan.

Based on record review, observations, interviews, and review of facility policy, the facility failed to ensure a medication error rate of less than five percent. Two errors occurred during the administration of one Resident's (Resident (R) 134) medications out of 30 observed opportunities, resulting in an error rate was 6.67 percent. The facility's failure created the potential for R134 and other residents to experience negative physical and/or psychosocial effects related to improper medication administration. A total of 31 residents were reviewed in the sampleReview of R134's Resident Face Sheet, dated 02/19/26 and found in the electronic medical record (EMR) under the Profile tab, revealed the resident was admitted to the facility on [DATE]. The resident's diagnoses included congestive heart failure and malnutrition. Review of R134's Physician's Order Report, dated 02/19/26 and found in the EMR under the Orders tab, revealed an order, with an original order date of 02/13/26, for the resident to receive MiraLAX (a stool softening medication) 17 grams by mouth daily and an order, with an original order date of 02/13/26, for the resident to receive a multivitamin one tablet daily for supplement. Review of R134's Medication Administration Record (MAR), dated 02/13/26 through 02/19/26 and found in the EMR under the Orders tab, revealed the resident was receiving her MiraLAX and multivitamin as ordered. Review of R134's admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/19/26 and found in the EMR under the MDS tab, revealed a Brief Interview for Mental Status (BIMS) assessment score of three out of 15, which indicated the resident was severely cognitively impaired. R134 was observed receiving her medication administered by Registered Nurse (RN) 1 on 02/18/26 at 9:38 AM. The resident's MiraLAX was mixed and administered with approximately two to three ounces of water (less than the required four to eight ounces of fluid to ensure full effect of the medication) and a multivitamin with minerals was administered instead of the resident's ordered multivitamin (without added minerals). During an interview with RN1 on 02/18/26 at 9:43 AM, she stated she administered the multivitamin with minerals because it was the only form of the vitamin available in the facility and stated she thought MiraLAX was to be administered in about eight ounces of water. She stated she did not realize the cup used to mix the resident's MiraLAX in was only a four-ounce cup. No larger cups were available on the medication cart. During an interview with the Director of Nursing (DON) on 02/19/26 at 10:57 AM, she stated medication was expected to be administered in the correct form/dose, and MiraLAX was expected to be administered in at least four to eight ounces of fluid to ensure proper effect.Review of the facility's policy titled, Bowel Tracking Policy, dated 10/06/25, indicated, If 48 hours without a bowel movement: Step 1: Give Miralax 17 grams in 4 - 8 ounces liquid. Review of the facility's policy titled, General Dose and Preparation and Medication Administration Policy, dated 11/15/24, indicated, 3. Prior to administration of medication, facility staff should take all measures required by facility policy and applicable law, including, but not limited to the following: 3.1 Verify each time a medication is administered that it is the correct medication, at the correct dose, at the correct route, at the correct rate, at the correct time, for the correct resident.

Based on a family interview, staff interviews, clinical record review, and review of facility documents, the facility staff failed to notify the Physician and/or Practitioner of an abnormally elevated blood pressure reading, the inability to procure a newly ordered blood pressure medication and of identified changes in mentation which progressed to a serious and life-threatening hypertensive emergency and a large left-brain bleed for 1 of 5 residents (Resident #1), in the survey sample, which constituted harm. Past Non-Compliance was given to this citation. The Findings Included: Resident #1 was no longer a resident of the facility; therefore, a closed record review was conducted. Resident #1 was originally admitted to the facility on [DATE] and she was last discharged from the facility to a local hospital on 6/21/23 after a change in condition. Resident #1's diagnoses included a stroke, high blood pressure, and heart failure. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 3/28/23 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 11 out of a possible 15. This indicated Resident #1's cognitive abilities for daily decision-making moderately impaired. In section G (Physical functioning) the resident was coded as requiring extensive assistance of two or more people with bed mobility, transfers, toileting, and bathing, extensive assistance of one person with personal hygiene, dressing, and locomotion in the room and she was independent after set-up with eating. CNA #1 stated on 6/20/23 at approximately 7:30 AM, she went into Resident #1's room to provide AM care prior to breakfast and the resident declined care. CNA #1 stated this was not a normal response from Resident #1, so she asked her if she was feeling okay and the resident stated she did not get enough sleep. CNA #1 stated Resident #1 received her regular go to meal of waffles and sausages for breakfast but she did not eat the breakfast meal, the Resident stated she was not hungry. CNA #1 stated she went into Resident #1's room at approximately 9:45 AM to provide hygienic care and again the resident declined care. CNA #1 stated she reported to the charge nurse that Resident #1 had refused hygienic care twice that morning and she did not eat breakfast and the charge nurse gave her no instructions. CNA #1 stated Resident #1 did not eat lunch and again she stated she was not hungry. CNA #1 stated at between 5:15 PM - 5:30 PM she observed the resident had only consumed two eight-ounce soft drinks over the course of the day and a few bites of the dinner meal. CNA #1 stated she was not asked to, and she did not obtain vital signs or blood pressure on Resident #1 at any time during her shift on 6/20/23. On 8/9/23 at approximately 11:35 AM an interview was conducted with Licensed Practical Nurse (LPN) #2. LPN #2 stated she was the licensed nurse assigned to Resident #1 on 6/20/23 from 7:00 AM - 7:00 PM. LPN #2 stated on 6/20/23 at approximately 10:00 AM she recognized the resident was not herself because she did not carry on her normal conversation. LPN #2 stated between 3:30 PM - 4:00 PM she obtained a blood pressure reading of 218/94 when obtaining the resident's vital signs and she did not report the 218/94 blood pressure reading to the Doctor of Nursing Practice (DNP) when she spoke with her about the confusion. On 6/20/23 between 3:30 PM- 4:00 PM, LPN #2 said the DNP gave STAT (now) orders for urine analysis with culture and sensitivity, and other STAT blood labs. The DNP told the LPN she would be at the nursing facility to see Resident #1 in approximately one hour. During the interview with the DNP that was conducted on 8/8/23 at 3:50 PM, she stated she evaluated Resident #1 on the evening of 6/20/23 and stated after leaving the resident's room she reviewed the resident's record and noticed a severely elevated blood pressure reading of 218/94 recorded for 6/20/23 at 3:55 PM. The DNP stated the blood pressure reading caused alarm because she was not made aware by the nursing staff of the abnormally elevated blood pressure reading. The DNP further stated that based on the Resident's blood pressure readings a decision was made to add another antihypertensive medication to the resident's regimen to achieve better blood pressure control. The DNP stated Norvasc 5 milligram (mg) tablet was ordered, and one tablet was to be given by mouth at bedtime starting 6/20/23. She stated she requested the nursing staff to obtain another BP which at this time was at 7:00 p.m. with a reading of 151/66 which may have been lower due the resident administered the regularly scheduled BP medication around 6:00 p.m. On 8/9/23 at approximately 10:30 AM an interview was conducted with Registered Nurse (RN) #1. RN #1 stated she assumed care for Resident #1 from 7:00 PM -11:00 PM on 6/20/23. RN #1 stated she administered resident #1's medications to her between 8:30 PM and 9:30 PM and she recognized the Resident continued with confusion. RN #1 also stated the DNP left new orders for resident #1 but she did not have the opportunity to take the orders off until 10:30 PM. RN #1 stated the ordered medication (Norvasc 5 mg) was not available in the E-Kit or the Omnicell and she reviewed other resident medication profiles to determine if any other residents had the medication available to utilize. RN #1 stated after she exhausted all methods to obtain the ordered medication, she reported the inability to obtain the newly added antihypertensive to the oncoming nurse, LPN #3. RN #1 further stated she did not notify the Physician and/or Practitioner that the newly ordered antihypertensive was not available to be administered and she did not obtain a blood pressure reading. On 8/9/23 at approximately 5:52 PM an interview was conducted with LPN #3. LPN #3 stated on 6/20/23 she worked the 11:00 PM -7:00 AM shift and Resident #1 was included in her assignment. LPN #3 stated the newly ordered antihypertensive medication, Norvasc showed on the Medication Administration Record (MAR), but it did not show up in Resident #1's profile in the Omnicell, therefore the antihypertensive medication (Norvasc 5 mg) was not available to be administered. LPN #3 stated at 11:00 PM Resident #1 was not her normal bubbly self and for each question she asked, the Resident answered with an incorrect response. LPN #3 stated she completed the Resident's neuro checks at 11:00 PM and the resident stated it was 1980 and she was in a nearby city. LPN #3 stated the 4:00 AM neuro checks were completed, and the Resident's responses were delayed approximately ten seconds before she answered. LPN #3 stated at 6:30 AM the Resident's temperature was 100.3, and Tylenol 325 mg two tablets were administered. LPN #3 stated she did not report the Resident's delayed responses, the elevated temperature, or that the newly ordered antihypertensive was not available to the Physician and/or Practitioner. There was no evidence in the clinical record that a BP reading was obtained on Resident #1. The hospital's emergency room (ER) assessment dated [DATE] read, upon the resident's arrival to the ER at 8:53 AM, she was suffering a hypertensive emergency exhibited by a systolic blood pressure in the two hundreds and the abnormally elevated blood pressure requiring treatment with an antihypertensive medication (Cardene) delivered by intravenous drip to achieve control of the resident's blood pressure. The hospital's emergency room summary dated 6/21/23 read that the resident was intubated (a tube inserted through the mouth into the airway to aid with breathing) and the computerized tomography (CT) scan images revealed the resident suffered a hemorrhagic stroke, a large left-brain bleed with extensions into the spaces between her brain and the brain's outer covering making the resident's prognosis for recovery very poor. The hospital urinalysis indicated the resident did not have a urinary tract infection (UTI) based on a urine specimen obtained at the hospital. Hemorrhagic stroke occurs when a blood vessel in the brain leaks or ruptures. Brain hemorrhages can result from many conditions that affect the blood vessels. Factors related to hemorrhagic stroke included: uncontrolled high blood pressure Overtreatment with blood thinners (anticoagulants) and Bulges at weak spots in your blood vessel walls (aneurysms) https://www.[NAME].com/search?q=hemorrhagic+stroke+and+high+blood+pressure+mayo+clinic&qs=n&form=QBRE&sp=-1&lq=0&pq=hemorrhagic+stroke+and+high+blood+pressure+mayo+clinic&sc=0-54&sk=&cvid=300C4048B7EA49999866C84326E930BC&ghsh=0&ghacc=0&ghpl= The facility developed the following action plan secondary to Resident #1's change in condition on 6/20/23: Change in Condition Risk Tool/Abatement Plan: (Resident #1's name) 1. The facility failed to notify to the physician of resident's blood pressure increase to 218/94 during change in condition on 6/20/2023 at approximately 3:45PM. Following the physician visit on 6/20/2023, and new order's received by facility, the facility failed to notify the physician of increased confusion as noted on the neuro-checks completed at 11:00PM on 6/20/2023, 4:00AM on 6/21/2023, and a change in vital signs noted at 6:30AM on 6/21/2023 for 1 resident (MC) during physician ordered monitoring of a change in condition. The facility also failed to notify the physician that the Norvasc as ordered on 6/20/2023 was unavailable to be administered at bedtime on 6/20/2023 as the physician ordered. Resident MC was discharged from the facility to the hospital per physician orders. 2. All residents have the potential to be affected with altered mental status. An audit was done to identify residents with changes in condition related to altered mental status or abnormal labs or vital signs. No other residents were found during this audit which was completed on 6/27/23. 3. Nursing Administration was educated on Notification of Changes including injury/decline as well as Competent Nursing Staff as related to F-580 and F-726 by the Administrator on 6/29/23. The DON and/or Designee completed the training with all licensed nursing staff, CNAs and licensed therapists by 6/30/23. 4. DON or designee will complete audits on changes in condition and transfers to ED x4 weeks by way of the 24HR Report. Aggregate findings will be analyzed, and any adverse findings immediately corrected. Findings and any applicable corrections will be presented and recorded in the monthly Quality Assurance and Performance Improvement (QAPI) meeting. Facility Administrator will be responsible for ensuring compliance. 5. Completion Date: June 30, 2023 On 8/9/23 at approximately 1:54 PM a final interview was conducted with the Administrator and Corporate Consultant. The Administrator presented action started on 6/23/23 by the Director of Nursing (DON) and the Administrator (ADM) as they began interviewing staff which assisted them to develop their education plan. The ADM also stated on 6/29/23 the tabletop exercise commenced and training on competent nursing staff was taught by the DON. The training focused on prioritizing care and recognizing everything is not a urinary tract infection. After a review of the facility's action plan titled Change in Condition Risk Tool/Abatement Plan and a review of four additional resident records of residents who experienced a change in condition, it was determined that the facility implemented its plan. There was sufficient evidence that the facility corrected the noncompliance and was in substantial compliance at the time of the current survey for the regulatory requirement, F-580 Past Non-Compliance (PNC).

Based on compliant investigation, staff interviews, clinical record review and facility documentation review, the facility staff failed to follow professional standards of nursing for 1 of 34 residents (Resident #47) in a survey sample. The findings included: The facility staff failed to ensure blood pressures were taken prior to the administration of medication ([MEDICATION(S)]) as ordered by the physician Resident #47 was admitted to the nursing facility on 06/03/21. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #47's Minimum Data Set (an assessment protocol) a quarterly assessment with an Assessment Reference Date (ARD) of 12/10/21 coded the resident's Brief Interview for Mental Status (BIMS) score 08 of a possible 15 with moderate impairment for daily decision-making. In section G (Physical functioning) the MDS coded Resident #47 requiring total dependence of one with bathing, extensive assistance of one with bed mobility, transfer, dressing, toilet use and personal hygiene and set-up help only with eating for Activities of Daily Living (ADL) care. Review of Resident's #47's Order Summary Report for January 2022 revealed the following order: [MEDICATION(S)] tablet - give 2 mg tablet by mouth three times a day for muscle relaxer; hold for altered mental status/sedation or systolic blood pressure less than 100. During the review of Resident #47's blood pressure for the month of July 2022 revealed blood pressure was not taken three times a day prior to the administration of the medication [MEDICATION(S)] on the following days: (01/02, 01/03, 01/04, 01/05, 01/06, 01/07, 01/08, 01/09, 01/11, 01/13, 01/14, 01/16, 01/18, 01/19 and 01/22/2022). An interview was conducted with License Practical Nurse (LPN) #5 on 01/26/22 at approximately 3:50 p.m. The LPN reviewed the above mentioned physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . On 01/27/22 at approximately 1:10 p.m., an interview was conducted with the Director of Nursing (DON). The DON reviewed the [MEDICATION(S)] order and stated, Resident #47's blood pressure should have been taken prior to giving each dose of the [MEDICATION(S)]. On the same day at approximately 3:00 p.m., the DON said she had spoken with Resident #47's physician who stated, Resident #47's blood pressure should have been taken prior to giving each dose of [MEDICATION(S)] because she was having low blood pressures during that time. A debriefing was held with the Administrator and Director of Nursing on 01/27/22 at approximately 4:50 p.m. The Administration team were informed of the above findings; no further information was provided prior to exit. Definitions: -[MEDICATION(S)] is used to relieve the spasms and increased muscle tone caused by [CONDITION(S)] (MS, a disease in which the nerves do not function properly and patients may experience weakness, numbness, loss of muscle coordination and problems with vision, speech, and bladder control), stroke, or brain or spinal injury. [MEDICATION(S)] is in a class of medications called skeletal muscle relaxants. It works by slowing action in the brain and nervous system to allow the muscles to relax (https://medlineplus.gov/druginfo/meds/a 1.html). -[CONDITION(S)] is a disease that causes weakness in your voluntary muscles. These are the muscles that you control. For example, you may have weakness in the muscles for eye movement, facial expressions, and swallowing. You can also have weakness in other muscles. This weakness gets worse with activity, and better with rest(https://medlineplus.gov/druginfo/meds/a 1.html). Complaint deficiency

Based on information gleamed during a complaint investigation, staff interviews, and review of facility documents, the facility staff failed to have a procedure in place to ensure that a presumed Graduate Nurse (GN) had a license or authorization to practice in the state prior to hiring, starting orientation and rendering care to residents in the facility. The findings included: An interview was conducted with the Director of Nursing and Administrator on 1/28/21 at approximately 5:45 p.m. regarding the complaint that they had nurses right out of school without proper credentials working in the facility. The Director of Nursing stated they didn't have anyone working as a nurse who didn't meet the requirements to work as a graduate Nurse. Review of one presumed Graduate Nurse (GN) Personnel record revealed the staff was originally hired 10/18/21 and rehired 12/20/21. Further review of the personnel records didn't reveal a license to practice as a practical Nurse neither a letter from the Department of Health Professions authorizing the individual the right to practice as a Practical Nurse applicant for 180 days or until results were received from the first licensing examination. An interview could not be conducted with the Human Resource Director for she was out of town during the survey. On 1/28/21 at approximately 2:25 p.m., an interview was conducted with the staff who currently held the proper credentials to practice as a practical nurse applicant as of 1/19/22 with a testing date of 3/9/22. The staff member stated he was supposed to complete his nursing classes October 2021 but he hadn't completed all clinical hours necessary for he had been out sick. He stated he had to wait for the specific clinical rotation to come back around therefore; there was a delay in completion of the practical nursing program. The staff stated he completed the graduate practical nurse orientation in the nursing facility and staff taught him to complete wound care, pass medications, obtain vital signs, conduct a fall assessment and other competent nurse duties. The staff stated sometime in November he resumed the practical nurse program to complete the required clinical rotation at which time he stopped working in the nursing facility. The staff stated it was approximately 12/19/21 that he was rehired as a graduate Nurse by the nursing facility and he has worked continuously since then. On 1/28/21 at approximately 2:30 p.m., the above findings were shared with the Director of Nursing. An opportunity was offered to the facility's staff to present additional information but no additional information was provided and no concerns were voiced. The below information was obtain from the following website on 2/7/22: https://law.[NAME].virginia.gov/admincode/title18/agency90/chapter19/section110/ A. The board shall authorize the administration of the (National Council Licensure Examination) NCLEX for registered nurse licensure and practical nurse licensure. B. A candidate shall be eligible to take the NCLEX examination (i) upon receipt by the board of the completed application, the fee, and an official transcript or attestation of graduation from the nursing education program and (ii) when a determination has been made that no grounds exist upon which the board may deny licensure pursuant to § 54.1-3007 of the Code of Virginia. C. To establish eligibility for licensure by examination, an applicant for the licensing examination shall: 1. File the required application, any necessary documentation and fee, including a criminal history background check as required by § 54.1-3005.1 of the Code of Virginia. 2. Arrange for the board to receive an official transcript from the nursing education program that shows either: a. That the degree or diploma has been awarded and the date of graduation or conferral; or b. That all requirements for awarding the degree or diploma have been met and that specifies the date of conferral.

Based on observations, resident interview, family interview, staff interviews, and clinical record review, the facility staff failed to to ensure a resident exhibiting resistive behaviors secondary to a history of pain related trauma received person-centered services to support and promote mental and physical well-being which resulted escalated behaviors and a significant decline in mental and physical functioning for 1 of 34 residents (Resident #36), in the survey sample. The findings included: Resident #36 was originally admitted to the facility 10/11/21, and readmitted [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 12/9/21 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 14 out of a possible 15. This indicated Resident #36'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 bathing and locomotion, extensive assistance of two people with bed mobility, transfers, personal hygiene and dressing, extensive assistance of one person with toileting, supervision after set-up with eating. During an interview with Resident #36 on 1/25/22 at approximately 1:35 p.m., the resident began to cry and speak very rapidly because she felt the staff doesn't answer her call bell timely, doesn't speak to her, her friend or parents appropriately The resident also stated the staff is causing her mental anguish because of their attitudes towards her. The resident further stated she came to the facility to strengthen her body so she could return home requiring one person assistance with bed mobility, activities of daily living (ADL) and transfers from the bed to a chair. The resident further stated at some point during the hospitalization prior to admission to the nursing facility she sustained a right [CONDITION(S)] and later other fractures in which she was unaware of until she experienced excruciating pain during turning and repositioning. The resident also stated on one occasion she was put in the Hoyer lift while she was fractured and the pain was indescribable. The resident expressed since the fractures and the Hoyer lift events she has had great fear of excruciating pain when staff approaches her and often prior to staff touching her to provide any type of care. The resident further stated she occasionally uses the call bell to ask for assistance because she knows she needs ADL care but because of fear of pain she rejects the care when the staff finally arrives. The resident also stated sometimes she requests pain medication prior to receiving care but most of the time she simply rejects care for fear of experiencing great pain. The resident stated her most recent method for dealing with having staff assistance has been to eat very little and decrease her fluid intake so she will not eliminate very often but; as a result she has suffered frequent episodes of constipation. Observations were made on the resident on 1/25/21 at approximately 1:35 p.m., and again on 1/27/28 at approximately 4:45 p.m., the resident appeared unbathed, sweaty, with dishevel hair and the bed linens were notably soiled. The window was opened because the resident stated she was too warm. A care plan had a problem dated 12/7/21 which read; resident has behaviors: as evidenced by; refuses Adl care, turn and reposition, dressing changes, weights, Physician orders, hair facial hairs removed, to be changed when soiled, can be accusatory, skin assessment related to severe anxiety that debilitates her functional status. The goal read; resident will have fewer episodes of refusal by the review date, 5/22/22. The interventions included; Anticipate and meet the resident's needs. Caregivers to provided opportunity for positive interaction, attention. Stop and talk with him/her as passing by. Educate and encourage of the risk verses benefits of skin assessments, of being accusatory, of being changed when soiled of removing facial hairs, of refusing MD orders, encourage and allow the resident to express feelings appropriately. Explain all procedures to the resident before starting and allow the resident to adjust to changes. Intervene as necessary to protect the rights and safety of others. Approach/Speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed. Another care plan problem dated 12/7/21 read; resident has potential for acute/chronic pain related to Chronic Physical Disability [CONDITION(S)], and a right femur fracture. The goal read; the resident will verbalize adequate relief of pain or ability to cope with incompletely relieved pain through the review date 5/22/22. The interventions included; Administer analgesia/medications per orders. Anticipate the resident's need for pain relief and respond to any complaint of pain as needed. Assess/document for probable cause of each pain episode. Remove/limit causes where possible. Assess/record/report to nurse loss of appetite, refusal to eat and weight loss. Assess/record/report to nursing any signs/symptoms of non-verbal pain. Implement non-pharmacological interventions to release the pain like Distraction techniques, Relaxation and Breathing exercises, music therapy, Re-position. Observe and report changes in usual routine, sleep patterns, decrease in functional abilities, decrease ROM, withdrawal or resistance to care. Notify MD as needed with changes. Report to Nurse any change in usual activity attendance patterns or refusal to attend activities related to signs/symptoms or complaints of pain or discomfort. Review of the clinical record revealed Resident #36 had rejected care since admission to the facility and when the resident was initially approached by Social Services to receive support from a psychologist the therapy was rejected but agreed upon on at a later date. Further review of the clinical record revealed volumes of documentation of the resident's episodes of rejecting services yet interventions; such as staff education to encourage resident trust and acceptance of services or professional services such as increased psychotherapy with a focus on the resident's indicators of distress using a person-centered approach were not documented, neither were referrals to provide ongoing assessment and symptom management, and emotional/spiritual support documented. The clinical record had a progress note from the Psychological practitioner which indicated on 10/27/21 the resident wasn't available to be seen. Another opportunity to treat the resident wasn't made until 1/26/22. Review of the 1/26/22 notes resulted in no recommendations for changes in therapy, medications of the treatment plan even with the constant rejection of care, screaming, and other indicators of mental distress. An interview was conducted with the Occupational Therapist (OTR) on 1/27/22 at approximately 1:00 p.m. The OTR stated the resident received occupational therapy services 10/11/21 through 10/22/21 and 10/29/21 through 11/8/21 and because the resident was currently long term care she wasn't receiving any type of therapy but could be screened for physical therapy services. The OTR also stated the resident's dad wanted her to roll in bed with one person originally but it wasn't possible for sometimes it required three to four people here to roll the resident. The OTR stated she recognized the resident's greatest obstacle was her anxiety therefore; she talked about techniques to control the her anxiety using singing, praying, the resident offering cues and the resident's anxiety got better but not rolling still wasn't doable with one person. The OTR stated she continued to work with the resident in strengthening to assist with rolling and desensitization related to having the immobilizers in place for the fractures. The OTR finally stated the resident's anxiety prevented further progression in occupational therapy for the resident wasn't capable of getting past her anxiety exhibited as pain to warrant continued therapy services and she stated based on her interactions with the resident she didn't believe as long as the resident was with the level of anxiety she currently exhibits therapy services could be rendered. 01/28/22 07:59 a.m., an interview was conducted with the parents of Resident #36. They expressed their concerns that the facility had plans to discharge the resident and hadn't worked effectively towards their goal of one person assistance for bed mobility and transfers in the community. The parents expressed their desire for their daughter to leave the nursing facility but at the currently level of dependence they didn't have to community resources to meet her needs. They felt the therapist provided the services they felt were appropriate for the resident such as speech therapy instead of physical therapy. On 1/27/22 at approximately 2:55 p.m., an interview was conducted with the primary physician for Resident #36. The physician stated the resident has had great anxiety related to pain when staff touches her resulting in the resident's inability to receive needed care and services. The physician further stated this anxiety had been overshadowing her entire stay at the facility therefore the primary physician stated he would institute a team approach to maximize resident's relief of her pain which seems to be exacerbated by her overall anxious disposition. His plans and options of treatment included treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . The physician also stated he would request input for ongoing chronic pain management from a physician of physical medicine and rehabilitation and he would review the medication for changes. On 1/27/22 at approximately 5:45 p.m., the above findings were shared with the Administrator, Director of Nursing. An opportunity was offered to the facility's staff to present additional information but no additional information was provided and neither were concerns voiced.

Based on observation, clinical record review, staff interview the facility, the failed to ensure 1 of 34 Residents (#92) in the survey sample was seen by the pharmacist for Medication Regimen Review (MRR) on a monthly basis. The findings included: The facility staff failed to review Resident #92's medication regimen for the month of August 2021. Resident #92 was admitted to the facility on [DATE]. Diagnosis for Resident #92 included but not limited to Major Depressive disorder and Anxiety disorder. Resident #92's Minimum Data Set (MDS), a quarterly Assessment Reference Date (ARD) of 01/09/22 coded the resident with a 09 out of a possible score of 15 on the Brief Interview for Mental Status (BIMS) indicating moderate cognitive impairment. The MDS coded Resident #92 requiring extensive assistance of one with bed mobility, transfer, dressing, eating, toilet use, personal hygiene and bathing for Activities of Daily Living (ADL) care. Resident #92's comprehensive care plan documented Resident #92 is on a antipsychotic therapy related to depression. The goal set for the resident by the staff is to remain free from adverse effects of antipsychotic therapy. One of the interventions/approaches the staff would use to accomplish this goal is to consult with the pharmacist, physician and the Medical Director for a gradual dose reduction if appropriate. Review of Resident #92's Order Summary Report revealed the resident was taking 14 scheduled medication to include [MEDICATION(S)] and [MEDICATION(S)]. Review of Resident #92's clinical record did not include a pharmacy progress note for August 2021. The DON said she was not able to locate the pharmacy review for August 2021. A debriefing was held with the Administrator and Director of Nursing (DON) on 01/27/22 at approximately 4:50 p.m. The DON stated, The pharmacist is expected to the resident on a monthly basis. Definitions: [MEDICATION(S)] is used alone or in combination with other medications to control certain types of seizures. It is also used to relieve panic attacks (sudden, unexpected attacks of extreme fear and worry about these attacks). [MEDICATION(S)] is in a class of medications called benzodiazepines. It works by decreasing abnormal electrical activity in the brain (https://medlineplus.gov/drug). [MEDICATION(S)] tablets and extended-release tablets are also used alone or with other medications to treat episodes of [CONDITION(S)] (frenzied, abnormally excited or irritated mood) or depression in patients with [CONDITION(S)] disorder (manic depressive disorder; a disease that causes episodes of depression, episodes of [CONDITION(S)], and other abnormal moods) (https://medlineplus.gov/drug).

Based on observation, staff interviews and clinical record review the facility staff failed to ensure 1 resident (Resident #35), in the survey sample of 34 Residents who was unable to carry out activities of daily living receives the necessary services to maintain toenail care. The findings included: Resident #35 was originally admitted to the facility on [DATE]. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The most recent Minimum Data Set (MDS) an annual with an Assessment Reference Date (ARD) of 12/04/21 coded the resident on the Brief Interview for Mental Status (BIMS) with a score of 9 which indicated moderate cognitive impairment for daily decision-making. Resident #35 was coded to require limited assistance of one staff with personal hygiene. The Care Plan revealed the following: I have an ADL Self Care Performance Deficit r/t my cognition. Goal: I will maintain current level of function in my adls (Activities of Daily Living) through the review date. Interventions: Check nail length and trim and clean on bath day and as necessary. Report any changes to the nurse. During the initial tour on 1/26/2022 at approximately 10:29 AM., an interview was conducted with Resident #35. The surveyor asked the Resident if his toenails needed to be trimmed. He stated, Yes. The surveyor then asked the resident if she could see his feet. He stated, Yes. The Resident's nurse, LPN (Licensed Practical Nurse) #1 was asked to assist in removing the covers and socks from off of the Resident's feet. An observation of the resident's toenails on the right great toe revealed his toenails were long, thick and jagged. The toenails on the resident's left great toe appeared Jagged and long. His fourth toenail (on the left foot) appeared long and jagged and his second toenail appeared jagged (on the left foot). LPN #1 stated that she will put him on the podiatry list. On 01/26/22 at 12:19 PM. The surveyor was approached by LPN #1. She stated, The Podiatrist comes on a case by case basis. We can put him (Resident #35) on the list. I talked to MDS (Minimum Data Set) staff about getting him on the list for an appointment. Received the podiatry list dated 11/09/21 from the administator via email on 1/28/22. A notation at the bottom of the podiatry list reads: Next earliest appointment date 2/07/22. Resident #35's name was not on the list. On 1/28/22 at 2:15 PM a pre-exit interview was conducted via telephone with the administrator and the DON. The surveyor asked what are your expectations concerning Resident #35 and is your nursing staff allowed to cut residents' toenails if they're non diabetic. The administrator stated, The SW (Social Worker) is notified and schedules ancillary services. Yes. (nurses are allowed to provide toenail care if a resident is not diabetic).

Based on observations, record review and staff interviews, the facility staff failed to ensure one Resident (Resident #45) in the survey sample of 28 residents did not smoke inside the facility. The findings included: Resident #45 had a re-admitted [DATE]. Resident #45 was readmitted with diagnoses which included muscle weakness, [CONDITION(S)], neuromuscular dysfunction of bladder, [CONDITION(S)] disorder, and adjustment disorder. Resident #45 was assessed as requiring maximum assist with Activities of Daily living. Resident was noted to have a [CONDITION(S)]. Resident #45 had a care plan dated 11/05/21 which indicated: Focus- Smoking paraphernalia no-complaint with smoke free facility; Goal- The resident will have an understanding of the effects of being non complaint with smoke free facility. Interventions- Educate and encourage of the risk verses benefits of not following non-smoking facility policy. Resident #45 was observed on 1/25/22 at 2:35 p.m. in bed. Resident #45 was able to speak and carry on a conversation. Resident #45 was observed in bed on 1/26/22 at 9:15 a.m. in bed. Resident had completed his breakfast meal and ate 100%. A Social Worker's note dated 1/24/22 at 13:29 (1:29 p.m.) indicated: SW spoke with admin who informed resident was smoking again in his room. Guardian was made aware. Non emergent (police) were called out, they were unable to assist in room search but did stand outside the door as backup. Administrator, Unit Manager and SW entered the room to assist in a room search. Resident was informed he wasn't smoking but had a vape pen in his hand. Once pointed out by SW, Administrator informed resident he will need to had over. Resident refused stated that he does not see why he needs to stop doing the things he likes to do. The administrator continued to educate resident that smoking is prohibited in the facility. SW informed resident that the guardian is still working on restoring his rights. SW also informed that multiple group homes and no beds or he is on there do not readmit list because of his behaviors. When requested to hand over his smoking device resident refused and stated he wanted to be sent out to he hospital, when asked why he stated it was his bladder. A call was placed to guardian to make him aware. Resident refused to be sent out. A Social Worker's note dated 1/18/222 at 17:20 (5:20 p.m.) indicated: SW called no emergent police line, per police officers there is nothing that they can do at a state level because marijuana is legal in the state of Virginia. Per officers this would be something that needs to be handled at an administrative level. Cops wouldn't even assist with room search they only stood outside door, while an attempt to search room. Resident informed he was not smoking and he was only burning SAGE. Resident refused search. Social worker requested the red lighter that was on the bed and the sage. Resident handed over both items. SW educated resident that this a non-smoking facility and we will be initiating a 30 day dc notice. SW will issue a 30 day notice once a place for him to go, SW have been working diligently these last couple of days to find placement for this gentlemen but once they see the behavior notes facilities are very apprehensive. Officers suggest if you get into a physical altercation with resident file a police report. Build a case. During an interview on 1/27/22 at 2:36 p.m. with the SW, she stated, the doctor had completed a competency assessment on Resident #45 and resident is competent. SW stated getting full support from Guardian had been troublesome. When asked how resident receive smoking material, the SW stated, they can not figure it out. Resident have wounds and refuse to be treated. They think he has items hidden under his bottom. During an interview on 1/27/22 at 3: 10 p.m. with the administrator she was asked how resident was able to get smoking material into the building since he was not able to get up on his own. The administrator, stated she was not sure because resident did not have that many visitors. During an interview on 1/28/22 at 9:21 a.m. with the Unit Manager she was asked how resident got smoking material into building. the Unit Manager stated, they do not know. Cameras set up out side did not capture the area where Resident #45's room is located. A facility Smoking Policy: indicated- This facility is a non- smoking facility.

Based on observation, resident and staff interviews, clinical record review and during the course of a complaint investigation the facility staff failed to follow the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The findings included: Resident #23 was originally admitted to the nursing facility on 03/11/21. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #23's Minimum Data Set (MDS-an assessment protocol) a quarterly revision assessment with an Assessment Reference Date (ARD) of 11/17/21 coded Resident #23 an 8 out of a possible score of 15 on the Brief Interview for Mental Status (BIMS), indicating moderate cognitive skills for daily decision-making. In addition, under respiratory treatments was coded for the use of oxygen therapy. Resident #23's person centered care plan had a focus which read; Resident #23 is on oxygen therapy. The goal read; will be free from signs and symptoms of [CONDITION(S)]. One of the interventions included; administer oxygen as ordered. The care plan also reads: The resident has a behavior problem: Turns up 02. Goals: Resident #23 will have an understanding of the effects of turning up 02 thru the next review date. 2/13/22. Initiated on 11/19/21. Interventions: Educate and encourage the risk verses the benefits of the 02 setting. Review of Resident #23's Order Summary Report for January 2022 included the following order: Oxygen at 4 LPM Via nasal cannula every 24 hours as needed for Shortness of Breath with a start date of 12/29/21. Change O2 tubing and set-up weekly every night shift every Monday for SOB (Shortness of Breath) Label tubing with date when changed. Order date: 10/14/21. Start Date: 10/18/21. During the initial tour on 1/26/22 at approximately 4:34 PM., Resident #23 was observed lying in bed with oxygen on at 7 liters per minute via nasal cannula (n/c) with humidification. No label/Date seen on O2 tubing On 1/27/22 at approximately 8:51 AM., Resident lying in bed with his oxygen at 7 liters per minute via n/c with humidification. No label/Date seen on O2 tubing. On 1/27/22 at approximately 8:57 AM an interview was conducted with LPN (Licensed Practical Nurse) #3 concerning resident #23's 02 level. He stated, It should be 4 liters. On 1/27/22 at approximately 1:36 PM., an interview was conducted with LPN (Licensed Practical Nurse) #4. She stated, Resident #23 turns up his own O2. He is care planned as being non-compliant with his O2. She was asked by surveyor if Resident's oxygen flow rate should be monitored due to his behavior. She stated, Yes. Policy: Oxygen Administration (all routes) Policy. Department: Clinical: Respiratory. Effective Date: 1/23/2017. Last Revision Date: 12/16/2019. Policy: Licensed clinicians with demonstrated competence will administer oxygen via the specified route as ordered by a provider. In an emergency situation, clinicians may administer oxygen and obtain a provider's order as soon as practicably possible after patient stabilization or transfer. Equipment: Regulator/Flow meter. Procedure: Verify Provider order. Preparation and Equipment: Connect the regulator and flow meter, open set to desired flow. Administration via nasal cannula: Set flow rate. Cleaning: Change tubing, mask, and cannula weekly and document according to facility policy. On 1/28/22 at approximately 9:25 AM a telephone interview was conducted with the administrator and DON concerning the above. The facility staff did not present any further information. This is a complaint deficiency!

Based on staff interview, clinical record review and in the course of a complaint investigation, it was determined that facility staff failed to maintain a complete record for one of 34 residents in the survey sample; Resident #298. During the course of the survey from 1/25/22 through 1/28/22 a surveyor was not able to retrieve records for one closed record resident through the facility's current eMAR (Electronic Medication Administration Records) system called My Unity. The administrator assured the surveyor that she would be able to get the requested records for Resident #298. The records were received upon request. However, when requesting wound care information the records provided by the facility did not contain adequate information. A conclusion was made concerning Resident #298's stage 2 pressure ulcer once hospital records were requested and received by VDH/OLC (Virginia Department of Health/Office of Licensure and Certification). On 1/28/22 at 9:25 AM the administrator stated, With the user rights for the eMAR (Electronic Medication Administration Records) system at each Sentara building was given to one person on sight. They are not able to add additional users. We are not able to do that through my Unity. The findings included: Resident #298 was admitted to the facility on [DATE]. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The current Minimum Data Set (MDS), an admission assessment with an Assessment Reference Date (ARD) of 07/20/20 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15.This indicated Resident #298's cognitive abilities for daily decision making were intact. In section G (Physical functioning) the resident was coded as total dependence of two persons with bed mobility, dressing, toilet use and personal hygiene. Resident was coded as Independent with eating-set up help only. In section M (Skin Conditions). Risk of Pressure Ulcers/Injuries? Coded as 1, meaning Yes. The Medical Records Custody Agreement reads: This Medical Records Custody Agreement is entered into to be effective as of November 1, 2020 by and between the entities set forth on the signature page under the heading [NAME] (Collectively, [NAME]), and the entities set forth on the signature page under the heading Sentara (Collectively, Sentara). On 1/28/22 at approximately 9:25 AM a telephone interview was conducted with the Administrator and DON concerning the above. The facility did not present any further information.

Based on staff interviews and facility documentation review the facility staff failed to ensure 1 of 3 Resident representatives (for Resident #1) was notified of a positive COVID-19 test result timely. The findings included: Resident #1 was originally admitted to the facility on [DATE] and was discharged to the hospital on [DATE]. Resident #1 was readmitted to the facility on [DATE], discharged to the hospital on [DATE] and readmitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Resident #1's Minimum Data Set (MDS - an assessment protocol) with an Assessment Reference Date of 09/17/2020 coded Resident #1 with a BIMS (Brief Interview for Mental Status) score of 15 indicating no cognitive impairment. On 09/30/2020 at approximately 12:00 p.m. a copy of the facility COVID-19 positive Line Tracker was received from the Administrator and revealed the following information regarding Resident #1: Date tested : 08/10/2020 Date of Result Notification: Resident was asymptomatic. Date of Negative Result: BLANK SPACE STATUS: Resident recovered and is now LTC (Long Term Care) (9/17). On 09/30/2020 review of Resident #1's clinical record revealed the following: Review of Providers Narrative Progress Note revealed the following: Date of Visit: 08/08/2020 Reason For Visit: Progress Note Progress Note: Resident seen in medical follow up for COVID-19 testing. It was noticed today that she is in the same suite as a patient who just tested positive for COVID-19. The patients have been in their separate rooms without sharing the bathroom however given the proximity and sharing of staff members we wanted to test (Resident Name) to make sure she was not compromised .COVID-19 testing. Review of Physician Clinical Notes Report E-Signed (Electronically Signed) 08/20/2020 revealed the following: Effective Date Author: 08/14/2020 NEW DIAGNOSIS / INTERVAL HX (History) / TEST: *** regarding patient's recent lab results. Patient noted to be COVID 19 positive on 08/10/20. Patient currently in isolation and appropriate steps being taken with staff. Clinical Notes Report for the period of 08/08/2020 through 08/12/2020 was reviewed and no evidence that resident representative was notified of Resident #1's positive COVID-19 test results. Review of Daily Skilled Nurse's Notes for the period of 08/08/2020 through 08/15/2020 was reviewed and there was no evidence that the resident representative was notified of Resident #1's positive COVID-19 test results. On 09/30/2020 at approximately 2:00 p.m., an interview was conducted with the Administrator regarding Outbreak Testing. When asked if the staff document when residents test negative the Administrator stated, They are inconsistent unless on the COVID Unit. The staff notify the responsible party, family when the resident test positive and they document in the nurse note. On 09/30/2020 at approximately 2:45 p.m., an interview was conducted with the Clinical Manager. When asked who contacts the family, resident representative when a resident test positive for COVID-19, the Clinical Manager stated, If a resident is positive I think the doctor or Administrator calls the family. On 10/01/2020 requested copy of Policy and Procedure on Notification of Resident Changes. On 10/02/2020 received the facility policy and procedure titled Life Care - Notification of Changes in Condition. Review of the policy and procedure revealed the following: Revision Date: 02/11/2020 Required Action Steps: 3. The nurse on duty will notify the Practitioner and Resident / Legal Representative / Family Member when there is a need to alter treatments or a change in condition is noted. On 10/05/2020 at approximately 2:00 p.m., an interview was conducted over the telephone with the Clinical Manager. When asked if she was able to find any documentation stating that Resident #1's representative was notified of her positive COVID-19 test results, the Clinical Manager stated, I did not see it in the nurses notes. I don't remember seeing anything on (Resident Name). On 10/05/2020 at approximately 3:25 p.m., during a briefing the Administrator was made aware of finding. No further information was presented about the finding.

Based on observations, staff interview, clinical record review and facility documentation review, the facility staff failed to ensure infection control measures were consistently implemented to prevent the development and/or transmission of a communicable disease (COVID-19). The facility staff failed to conduct active screening of staff for COVID-19 when entering the facility. The findings included: On 09/30/2020 at approximately 10 a.m., requested that the Clinical Manager provide directions to the entrance where staff enter when coming into work. The Clinical Manager accompanied the surveyor to the back entrance of the facility. At the back entrance was an area with overbed tables lined up against the wall along with a tracking log. Observed a staff member cleaning a thermometer with wipes. When the Clinical Manager was asked who was screening staff at the back entrance when entering the facility, the Clinical Manager stated, Staff are checking their own temperatures. The Clinical Manager also stated, The Infection Control Nurse goes around and checks the staff's temperatures again at noon and their temperature is checked before they leave work. Surveyor requested copy of the tracking log for the period of 09/29/2020 and 09/30/2020. Received a copy of Daily Internal Tracking Facility Access Log on 09/30/2020. Review of the log revealed the following: Column Time In not consistently documented; Column Outcome (Cleared to enter, Not cleared to enter, Employee Health Notified) not consistently documented; Column TEMP (Temperature) at 1/2 (Half) Way point of shift not consistently documented; Column Time Out not consistently documented; Column RECORD TEMPERATURE TAKEN not consistently documented. On 09/30/2020 at approximately 3:15 p.m., an interview was conducted with the Clinical Manager with the Administrator present, when asked if the Clinical Manager stated that the staff check their own temperature and screen themselves when they come in to work, the Clinical Manager stated, Yes, they've been doing it so long they know what to do. On 09/30/2020 a copy of facility policy and procedure on staff screening process was requested and received. The facility policy titled - Life Care - Staff and Non-Staff Screening for COVID-19 Procedure Original Date: 04/15/2020 Revision Date: 07/16/2020 Purpose: To provide further guidelines on how to effectively conduct staff and non-staff screenings for Covid-19. Refer to Policy for overall commitments. On 10/05/2020 at approximately 3:25 p.m., during briefing the Administrator was made aware of finding. No further information was presented about the finding.

Based on resident interview, staff interview, facility document review, and clinical record review, it was determined that facility staff failed to ensure medications were available for one of 18 residents in the survey sample, Resident #105. The findings include: Resident #105 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A comprehensive assessment had not yet been completed. Resident #105 was documented as being alert and oriented x 4 in his clinical record. Review of Resident #105's clinical record revealed that he was admitted to the facility on [DATE] at 12:45 p.m. Review of Resident #105's (MONTH) 2019 POS (physician order [REDACTED].Diabetic [MEDICAL CONDITION] (2). Review of Resident #105's MAR (Medication Administration Record) revealed he missed three doses of his [MEDICATION NAME] 600 mg (milligrams) on 8/31/19 (the next day) at 12:00 a.m., 8 a.m. and 4 p.m. The note sheets on the MAR indicated [REDACTED]. Review of Resident #105's nursing notes failed to evidence a reason why his [MEDICATION NAME] was not available. Resident #105's clinical record failed to evidence any uncontrolled pain or negative outcome related to his missed doses of [MEDICATION NAME]. Review of the facility's STAT box list revealed that [MEDICATION NAME] 600 mg was in the STAT box. On 9/5/19 at 9:23 a.m., interviews were attempted with the nurses who documented: Not administered on the MAR indicated [REDACTED]. On 9/5/19 at 9:46 a.m., an interview was conducted with RN (Registered Nurse) #3, the unit manager. When asked the process of ensuring newly admitted residents receive their scheduled medications, RN #3 stated that nurses should enter the orders into the computer system, verify orders with the physician and fax any hard scripts to pharmacy for medications that require hard scripts. RN #3 stated that if a medication was needed right away, she would call the pharmacy to have them STAT the medication or pull the medication from the emergency STAT box. When asked if [MEDICATION NAME] 600 mg was in the STAT box, RN #3 stated that she didn't think so. RN #3 also stated that [MEDICATION NAME] required a hard script as of (MONTH) 1st 2019. When asked if a resident was admitted on [DATE] in the afternoon if she would expect the resident to get all their medications for the next day (8/31/19), RN #3 stated that she would expect that resident to receive all of their medications for the next day. RN #3 stated that if the medication was not available when the nurse went to administer the medication, she would expect the nurse to check the STAT box to see if the medication was available, or call pharmacy to have the medication sent STAT. RN #3 stated that she would also expect the nurse document in the clinical record why a medication was not available. RN #3 stated that she was not sure what happened with Resident #105's [MEDICATION NAME]. On 9/5/19 at 9:54 p.m., an interview was conducted with Resident #105. When asked if he received all his medications when he first arrived to the facility, Resident #105 stated that he was not sure. When asked if he was in pain when he had first arrived to the facility due to his [MEDICATION NAME] being unavailable, Resident #105 stated that he was always in some type of pain whether it be nerve pain or gas pain. Resident #105 could not recall if he had an increase in pain on 8/31/19. On 9/5/19 at 11:05 a.m., ASM (administrative staff member) #1, the Administrator and ASM #2, the DON (Director of Nursing) were made aware of the above concerns. ASM #1 stated that they did have a policy regarding the above concerns but had an instruction sheet for the nurses on ordering medications. The following was documented: Before 8 PM M-F or Before 4 PM on Sat-Sun: Enter the order in vision. It must be activated, not draft format. Orders will be processed same day and delivered on next run. If still no meds, call Pharmacy. After 10 PM M-F or after 5 PM Sat-Sun: Call back up pharmacy (pharmacy number) If still no meds: Call on call pharmacist: (number). No Medication orders should go unfilled and no patient should ever have to wait for pain meds. (1) [MEDICATION NAME] ([MEDICATION NAME])- recommended for chronic neuropathic pain. This information was obtained from The National Institutes of Health. https://www.ninds.nih.gov/Disorders/Patient-Caregiver-Education/Fact-Sheets/Peripheral-[MEDICAL CONDITION]-Fact-Sheet. (2) Diabetic [MEDICAL CONDITION]-is a type of kidney disease caused by diabetes. This information was obtained from The National Institutes of Health. https://www.niddk.nih.gov/health-information/diabetes/overview/preventing-problems/diabetic-kidney-disease.

Based on observation, staff interviews and facility documentation review, the facility failed to ensure medications were labeled and stored in accordance with currently accepted professional principles on 2 out of 4 units. The findings included: 1. The facility staff failed to ensure one bottle of Aspirin 81 mg (milligrams) was removed from the medication cart once expired. On [DATE] at approximately 4:00 p.m., an inspection of the medication cart on Unit (2) was conducted with Licensed Practical Nurse (LPN) #2. During the inspection of the medication cart was an open bottle of Aspirin 81 mg with an expiration date of ,[DATE]. The surveyor asked LPN #2, Should the bottle of Aspirin still be stored inside the medication cart after the expiration time has lapsed she replied, No, I am going to remove the Aspirin as soon as you are finished inspecting the cart. An interview was conducted with Director of Nursing (DON) on [DATE] at approximately 5:05 p.m. She said expired medication should be removed from the medication cart immediately. 2. The facility staff failed to ensure medication cart was locked when not in direct site on 1 of 4 units (Unit 3). On [DATE] at approximately 4:50 p.m., the surveyor observed the medication cart on Unit 3 (middle cart) unlocked and left unattended when not in direct site of the nurse. The medication nurse, Licensed Practical Nurse #1 arrived to the medication cart at approximately 4:53 p.m. The surveyor asked LPN #1, if the medication cart should be locked when not in her direct view, she replied, I should have locked my cart before I went into the resident's room. On the same day at approximately 5:05 p.m., an interview was conducted with the Director of Nursing (DON). The DON stated, Before the nurse left her medication cart, she should have made sure it was locked. 3. The facility staff failed to ensure medication (Tylenol) was stored in a secured location, accessible to designated staff only. On [DATE] at approximately 4:50 p.m., the surveyor observed an open bottle of Tylenol (325 mg) sitting on top of the medication cart unattended. The medication nurse, Licensed Practical Nurse (LPN) #1 arrived to the medication cart at approximately 4:53 p.m. The surveyor asked LPN #1, if she was aware, an open bottle of Tylenol was left on top of her medication cart unattended. She replied, I meant to put the Tylenol inside the cart before I went into the resident's room. She removed the Tylenol, placed it inside the cart then locked her cart. On the same day at approximately 5:05 p.m., an interview was conducted with the Director of Nursing (DON). The DON stated, Medications should never be left on top of the cart unattended. The nurse should make sure all medication are stored inside the cart before leaving the medication cart. 4. The facility staff failed to ensure liquid [MEDICATION NAME] was stored as recommended by the manufactures guidelines on 2 of 4 units (Units 2 and 3) and failed to ensure a multi dose vial of insulin (Humalog R) was dated once opened. On [DATE] at approximately 4:00 p.m., this surveyor inspected the medication cart on Unit (2) with License Practical Nurse (LPN) #2. Stored inside the narcotic controlled box was a multi dose vial of liquid [MEDICATION NAME]. The surveyor asked, Should liquid [MEDICATION NAME] be stored on the medication cart she replied, No, liquid [MEDICATION NAME] should be stored in the refrigerator. On the same day at approximately 4:53 p.m., this surveyor inspected the medication cart on Unit (3) with Licensed Practical Nurse (LPN) #1. Stored inside the narcotic controlled box was two multi dose vials of liquid [MEDICATION NAME] and an open vial of Humalog insulin not dated when opened. The surveyor asked, Should liquid [MEDICATION NAME] be stored on the medication cart she replied, Liquid [MEDICATION NAME] is stored in the refrigerator. The LPN said insulin should always be dated once open. The surveyor asked, How long is insulin good for once open she replied, 30 days. An interview was conducted with Director of Nursing (DON) on [DATE] at approximately 5:05 p.m. The DON said liquid [MEDICATION NAME] is stored in the medication refrigerator and insulin is good for 28 days after opening. The DON stated, The nurse is to date the insulin once open along with their initials. The Administrator and Director of Nursing was informed of the finding during a briefing on [DATE] at approximately 11:15 a.m. The facility staff did not present any further information about the findings. -The facility's policy titled Life Care - Storage of Medications (Last Revision [DATE]). Policy Statement: Medications, treatments, and biological are stored safely, securely, and properly following manufacture's recommendations or facility policy. The medication supply is accessible only to license nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. -Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, unlabeled, or without secure closures are immediately removed from stock, disposed of according to procedures for medication destruction, and reorder from the pharmacy if a current order exists. The facility's policy titled Life Care - Medication Administration (Revision date: [DATE].) -Purpose: Safe and accurate administration of medications. General Guidelines include but not limited to: -The medication Cart is to be locked at all times, unless in direct view of the license nurse. Life Care - Medication: Expiration Dates: (Last Reviewed date: [DATE].) -Policy statement: All Timed-Dated medications have an expiration date printed on the container. Refer to the Manufacture Product Information or Contact Dispensing Pharmacy. -Expiration Dates (Suggested): -Once opened; all insulin kept in the refrigerator in the medication cart expires 28 days after opening. -Other bulk medications expire on manufacture regardless of opening.

Based on observation, staff interviews, clinical record review and review of the facility's policy, the facility staff failed to ensure the necessary treatment, care and services were provided to promote healing, prevent infection and to prevent development of new foot ulcer for 1 of 39 residents (Resident #75) in the survey sample. The findings included: The facility staff failed to prevent, identify, and treat Resident #75's foot ulcer to the back of left heel prior to being found at an advance stage (unstageable) resulting in harm. The ulcer was first identified as a black crusty scabbed measuring 2 cm x 2 cm. Resident #75 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED].*Dementia with behavioral disturbance, *Diabetes Mellitus and involuntary movements (not done by choice; done unwillingly). Resident #75's quarterly Minimum Data Set (MDS-an assessment protocol) with an Assessment Reference Date of 06/24/19 coded a 05 out of a possible score of 15 on the Brief Interview for Mental Status (BIMS), indicating severely impaired cognitive skills for daily decision-making. In addition, the MDS coded Resident #75 requiring total dependence of one with bathing, extensive assistance of two with bed mobility, transfer and personal hygiene, extensive assistance of one with dressing, eating and toilet use. Under section M (Skin Condition - M0100) of the MDS, it was coded: Resident has a stage 1 or greater pressure ulcer. Section (M0150) at risk for developing *pressure ulcers was coded: yes; Section (M0210) for unhealed pressure ulcers was coded: yes; Section (M0300) for having *unstageable (1) pressure ulcer was coded: yes. Section (M1200) for skin and treatments was coded for having pressure reducing device for chair and bed, nutrition or hydration intervention to manage skin problems and pressure ulcer care. Resident #75's person-centered comprehensive care plan revised 7/16/19 documented Resident #75 with actual skin breakdown to left heel diabetic ulcer. The goal: ulcer will not worsen during the next 90 days. Some of the intervention/approaches to manage goal included to provide care according to physician orders-see Treatment Administration Record (TAR), use pressure reducing mattress and use pillows, pads, or wedges to reduce pressure on heels and pressure points (turn/reposition), assess and record the size (L x W x D) of skin discoloration, [MEDICAL CONDITION] and pain status. There were no preventative measures in place prior to the development of the unstageable ulcer. A Braden Risk Assessment Report was completed on 01/02/19; resident scored a 16 indicating mild risk for the development of pressure ulcers. During the initial tour of the facility on 07/16/19 at approximately 4:32 p.m., Resident #75 was observed in bed lying on his right side with his heels position directly on the mattress. A pair of prevalon boots were observed on the floor beside Resident #75's nightstand. Review of the clinical record revealed the current treatment to the left heel as of 07/12/19 read as follows: Cleanse with normal saline gauze, dry area after cleaning, apply allevyn dressing; dressing to be changed every other day. Review of the Treatment Administration Record (TAR) for (MONTH) 2019 revealed on 07/06/19, the treatment was not completed for late afternoon or evening shift due to Resident #75 not being cooperative, moving left/foot all over and yelling at nurse. On 07/17/19 at approximately 11:00 a.m., wound care observation was conducted with Licensed Practical Nurse (LPN) #1. Resident #75 was lying in bed on his right side. Prior to starting wound care, LPN #1 washed her hands x 21 seconds and donned a pair of gloves. The LPN removed the old dressing from the left heel wound. The left heel pressure ulcer was observed with black *eschar (hard black dead tissue) with red peri wound edges, no drainage or odor noted. The wound was cleaned with saline soaked gauze x 2; gloves removed, hand sanitizer applied, a new pair of gloves donned. The LPN measured left heel wound; area measured at 4 cm x 2.5 cm, gloves removed, hand sanitizer applied, donned new glove then applied allevyn dressing. Through the entire dressing change, Resident #75 was thrashing his left leg/foot around with his left heel rubbing continuously on the mattress. On 07/17/19 at approximately 2:05 p.m., Resident #75's bilateral heels were observed positioned directly on the sheet/mattress and a pair prevalon boots were observed on the over bed table. The review of the clinical nurse note evidenced an entry dated 04/30/19 at 10:35 a.m., written by LPN #1 indicated the following: Resident kicking left shoe off. Noted 2 cm x 2 cm black crusty scabbed area to back of heel, area cleanse with normal saline dermal wound cleanser (DWC) and skin prep applied, no drainage present. Reached out to Programs of All-Inclusive care for the Elderly (PACE) concerning the wound to back of left heel. On the same day at approximately 11:09 a.m., a clinical note written by LPN #1 indicated the following documentation: Follow-up with PACE related to ulcer to left heel and the Nurse Practitioner (NP) from PACE will be in this afternoon to evaluate Resident #75's foot. Resident #75's progress note written by the podiatrist on 07/01/19 revealed the following documentation: Assessment: Wagner - Stage 1 Ulcer to left heel. (Staging the seriousness of a [MEDICAL CONDITION]; Stage 1=ulcer is present but no infection. www.healthline.com). Plan: He needs to wear a Prevalon boot on both feet. Vascular Exam: Within Normal Limits (WNL) to left foot. Integument/Skin: Ulcer posterior left heel with stable eschar. The progress note included: Patient presents to the office on 07/01/19 for Annual Diabetic Foot Exam and foot care. Patient was brought in by care giver from PACE. An interview was conducted with Licensed Practical Nurse (LPN) #1 on 07/17/19 2:10 p.m. The surveyor asked, Since Resident #75 has an unstageable ulcer to his left heel, when should the prevalon boots to be applied? The LPN replied, I cannot answer that; how Resident #75 is to wear the prevalon boots is up to PACE, they approve all orders for Resident #75. The LPN looked in the computer for the order on how and when Resident #75 is to wear the prevalon boots. After the LPN finished looking for the prevalon boot order she replied, I do not see an order for [REDACTED]. An interview was conducted with CNA #1 on 07/17/19 at approximately 2:20 p.m. The surveyor asked When does Resident #75 wear his prevalon boots she replied , I removed them when he goes to bed but put them back on when I get him out of the bed. The surveyor asked, When is Resident #75 to wear his prevalon boots she replied, I really do not know. The surveyor asked, Were you ever told when to apply the prevalon boots she replied, No. The surveyor asked, What is the purpose of prevalon boots, she replied, To take the pressure of the heels and ankles the surveyor asked, Is the pressure being relieved when the resident is in bed without his prevalon boots on, she replied No. On 07/18/19 at approximately 2:20 p.m., the above information was shared with the Administrator and the Director of Nursing. The Director of Nursing stated, Resident #75's left heel pressure ulcer is assessed and monitored under the care of PACE physician and staff. She said the ulcer should have been assessed with [REDACTED]. The resident's left heel pressure ulcer wound was being cared for by PACE, and assessed at the PACE clinic on a weekly basis and included the following: 1. 04/30/19 - Resident #75 was first identified with an unstageable to his left heel on 04/30/19 at approximately 10:35 a.m., at the nursing facility by LPN #1. However, on the same day at approximately 2:19 p.m., a skin assessment was completed at the PACE clinic. The assessment did not show evidence that the left heel unstageable pressure ulcer was present or assessed. 2. 05/02/19 - Under skin integrity/wound assessment for did not include documentation the left heel (unstageable) pressure ulcer was assessed (no documentation.) 3. There was no skin assessment completed for week of (MONTH) 5, 2019 by PACE or the facility. 4. 05/14/19 - left heel with unstageable wound approximately 2 x 2 with redness around edges PACE (NP) to enter orders to cleanse with normal saline, apply *[MEDICATION NAME] and dry dressing daily. 5. 05/21/19 - Note: participant was seen today for weekly assessment. Participant skin remains intact at this time without skin breakdown. Will continue to follow weekly and report skin concerns to MD (missing last page.) 6. 05/28, 06/04, 06/11 and 6/18/19 - Participant was seen in the clinic today for wound care Cleanse the wound to the back of the left heel with normal saline, pat dry, and painted the area with [MEDICATION NAME] (no measurements documented.) 7. 07/02/19 - Participant was seen in the clinic for wound care Eschar area noted to left heel is currently being followed by Podiatry; area measured approximately 2.5 cm x 2.5 cm, no odor or drainage noted. Applied allevyn to left heel as ordered (no measurements documented.) 8. 07/09/19 - Participant was seen in the clinic today for wound care to left heel. Cleansed with normal saline and covered with an allevyn dressing; area is dry and intact (no measurements documented.) 9. 07/16/19 - Participant was seen in the clinic today for wound care to left heel. Cleansed with normal saline and covered with an allevyn dressing; area is dry and intact (no measurements documented.) 10. 07/18/19 - Participant was seen in the clinic today for wound care. No dressing present. Area to left heel is dry with eschar present; wound is not open, wound cleansed with normal saline and covered with an allevyn dressing (no measurements documented.) The Administrator and Director of Nursing and were informed of the finding during a briefing on 07/18/19 at approximately 2:20 p.m. The surveyor asked, What preventative measures were put in place to prevent the left heel pressure ulcer from worsening once it was first identified on 04/30/19. The Administrator said there should be a preventative care plan in place. The surveyor presented Resident #75's care plan to the Administrator for review. The Administrator reviewed the care plan then stated, This is a poorly written care plan; he does not have a preventative care plan in place. The surveyor informed the Administrator and DON that the podiatrist made a recommendation on 07/01/19 for the use of prevalon boot due to the left heel ulcer but the order was never transcribed. The DON said, PACE should have received the podiatrist recommendations and they should have either approved or declined the recommendation. The surveyor asked, What is the purpose of prevalon boots. The DON stated, To give off load to the heels; the prevalon boots form as a cradle to keep the heels from touching the bed. On the same day at approximately 5:35 p.m., the DON presented a physician order [REDACTED]. Boots to be worn at all times except for cleaning and care. An interview was conducted with Director of Nursing (DON) on 07/18/19 at approximately 5:45 p.m. The surveyor stated, Resident #75's pressure ulcer was first identified on 04/30/19 with a black scab measuring 2 cm x 2 cm but later clarified as an unstageable pressure ulcer to his left heel. After the review of the Resident #75's clinical record showed evidence that a treatment was not started until 05/14/19; 14 days later; it that acceptable. The DON stated, No, absolutely not acceptable. The surveyor asked, What stage should a pressure ulcer be first identified and what can happen if a wound treatment was not started or seen by a physician for evaluation for 14 days after first being identified, she replied, At a stage 1 and worse case scenario; gangrene, amputation, shock,[MEDICAL CONDITION] or death could occur, treatment should have been started right away. Definitions: *Pressure Injury: A pressure injury is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear (http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-injury-stages/). *Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss. Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar (i.e. dry, adherent, intact without [DIAGNOSES REDACTED] or fluctuance) on the heel or ischemic limb should not be softened or removed (http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-injury-stages/). *Allevyn Adhesive [MEDICATION NAME] Foam Dressing allows for the formation and maintenance of a moist wound healing environment, preventing eschar formation and promoting rapid, trouble-free healing (http://www.hightidehealth.com/allevyn-adhesive-foam-dressings-home.html). *Prevalon helps minimize pressure, friction and shear on the feet, heels and ankles of non-ambulatory individuals. By off-loading the heel, it delivers total, continuous heel pressure relief (www.hdis.com/prevalon-boot-heel-protector.html). * [MEDICATION NAME] swab stick helps reduce bacteria that can potentially cause skin infection (www.drugs.com). *Diabetes is a complex disorder of carbohydrates, fat, and protein metabolism that is primarily a result of a deficiency or complete lack of insulin secretion (Mosby's Dictionary of Medicine, Nursing & Health Professions 7th Edition).

Based on staff interviews, resident interview, and clinical record review, and in the course of a complaint investigation, the facility staff failed to provide pain management consistent with professional standards of practice for one (Resident #84) of 39 residents in the survey sample, resulting in harm. The resident was not assessed for pain from the time of admission until the following day during occupational therapy. There was no evidence that once pain was identified that it was treated timely. The findings include: Resident #84 was admitted to the facility 08/16/2018. Resident #84 left the facility, AMA (Against Medical Advice) on 08/27/2018. [DIAGNOSES REDACTED]. Resident #84's Admission Minimum Data Set (an assessment protocol) with an Assessment Reference Date of 08/23/2018 coded the resident with a BIMS (Brief Interview for Mental Status) score of 13 indicating no cognitive impairment. In addition, the Minimum Data Set coded Resident #84 as requiring extensive assistance of 1 with bed mobility, transfer, dressing, toilet use and personal hygiene, and limited assistance of 1 with eating. Per documentation in the clinical record, the resident was scheduled to go to outpatient [MEDICAL TREATMENT] on Mondays, Wednesdays and Fridays (time undetermined). On 07/19/2019 Resident #84's closed record was reviewed and revealed the following: Resident #84's Hospital Discharge Summary was reviewed and revealed that the resident was discharged from the hospital on [DATE] and prior to discharge the resident was administered [MEDICATION NAME] ([MEDICATION NAME]) 6 mg (milligrams) oral at 6:33 p.m. [MEDICATION NAME] is used to relieve pain .[MEDICATION NAME] is in a class of medications called opiate (narcotic) [MEDICATION NAME] . Source (https://medlineplus.gov/druginfo/meds/a 3html). Resident #84 was admitted to the facility on [DATE] at 7:50 p.m. The resident's Admission Physician order [REDACTED]. [MEDICATION NAME] ([MEDICATION NAME]) 2 mg. tablet (1 tab) oral As Needed Every Four Hours-chronic pain, starting 08/16/2018; [MEDICATION NAME] 2 mg. tablet (2 tab) oral As Needed Every Four Hours-chronic pain, starting 08/16/2018; [MEDICATION NAME] ([MEDICATION NAME]) 2 mg. tablet (1 tablet) oral Four Times Daily-chronic pain, starting 08/17/2018; Tylenol 8 Hour 650 mg. tablet, extended release (1 tablet) tablet oral chronic pain-Three Times Daily starting 08/17/2018. There was a care plan dated 8/18/18-8/27/18 however there was no plan of care for pain management. There was no pain assessment documented upon admission or during the night. The first pain assessment revealed in the clinical record was during the Occupational Therapy evaluation dated 8/17/19 as follows: Review of OT (Occupational Therapy) Evaluation and Plan of Treatment notes dated 08/17/2018 at 10:52 a.m., which revealed the following: Behaviors: Patient behaviors: tearful due to pain. Pain at Rest: Intensity = 10/10; Frequency/Duration = Constant; Location : left side: Pain Description/Type: ache. Pain With Movement: Intensity = 10/10; Frequency/Duration = Constant; Location: left side; Pain Description/Type: ache. There was no documentation indicating what was done about the severe pain assessed by OT. Review of the Clinical Note entry dated 08/17/2018 at 7:20 p.m., was documented in part, as post [MEDICAL TREATMENT] as follows: Medicated x2 for pain to left lower extremities 8/10 with pain medication only giving relief. There was no indication of when the resident went to, or returned from the [MEDICAL TREATMENT] center. Review of eMedStat (an electronic locked medication storage unit) transactions revealed [MEDICATION NAME] Tab 2 mg was dispensed on 08/17/2018 at 10:03 a.m. however, there was no documentation of administration on the Medication Administration Record [REDACTED] Review of the Medication Administration Record [REDACTED] [MEDICATION NAME] 2 mg. tablet (2 tabs) As Needed Every Four Hours was administered on 08/17/2018 at 2:15 p.m. and was effective; [MEDICATION NAME] 2 mg. tablet (1 tab) oral As Needed Every Four Hours was administered on 08/17/2018 at 6:50 p.m. and was effective; [MEDICATION NAME] 2 mg. tablet (1 tablet) oral Four Times Daily was documented as administered on 08/17/2018 at the evening dose; [MEDICATION NAME] 2 mg. tablet (1 tablet) oral Four Times Daily was documented as administered on 08/17/2018 at bedtime; Tylenol 8 Hour 650 mg. tablet, extended release (1 tablet) was administered at bedtime on 08/17/2018. There was no time included on the MAR indicated [REDACTED]. There was no documented evidence that Resident #84 received or was offered pain medication prior to above. On 07/19/2019 at 11:30 a.m., a telephone interview was conducted with Pharmacy Technician and she stated that the pharmacy received the order for [MEDICATION NAME] ([MEDICATION NAME]) on 08/17/2018 at 8:13 a.m., the orders were entered into their system at 8:30 a.m. and then the medication was packaged at 10:30 a.m. and the driver left the pharmacy at 11:00 a.m. to make deliveries. [MEDICATION NAME] was in the eMedStat machine on 08/16/2018 but required a hard script for the [MEDICATION NAME] to be released. (There are 4 eMedStat machines in the facility and each machine has 20 [MEDICATION NAME]'s.) The Pharmacy Technician stated that the resident came in from the hospital with a hard script for [MEDICATION NAME] on 08/16/2018 for a quantity of 60 however, the pharmacy was not made aware until 08/17/2018. The Pharmacy Technician stated that the nurses can notify the Pharmacy at anytime if they need a medication that is not available to them. The Pharmacy Technician stated that four (4) [MEDICATION NAME]'s were made available in the eMedStat machine at the facility on 08/17/2018 at 8:30 a.m. after receiving the order and sent the remaining 56 tablets to the facility on [DATE]. The Pharmacy technician stated that the facility pulled 2 [MEDICATION NAME]'s from the eMedStat machine at 9:56 a.m. No documentation of administration was revealed on the Medication Administration Record. On 07/19/2019 at 2:20 p.m., an interview was conducted with the Administrator and she was asked, What are your expectations of the nurses when new residents are admitted and they have new medication orders? The Administrator stated, I expect the nurses to process the orders immediately and if they are unable to process then the order should be escalated to the pharmacist and if needed escalated to the Director of Nursing. On 07/19/2019 at 4:00 p.m., a telephone interview was conducted with the complainant and she was asked, What time did you receive your first dose of pain medication after admission to the facility on [DATE]? The complainant stated, I did not get anything for pain until after I returned from [MEDICAL TREATMENT] the next day. I went to [MEDICAL TREATMENT] and my leg was hurting. The complainant was asked, What was you pain intensity on a rate of 1-10 that morning? The complainant stated, My pain was a 10! I had even called my son that morning at 3:00 a.m. crying, my leg hurt. Complaint deficiency.

Based on staff interview, facility document review, and clinical record review, it was determined that facility staff failed to maintain an effective antibiotic stewardship program. The findings include: Review of the facility Infection Control Log, from (MONTH) 2019 until (MONTH) 2019 revealed the following: On multiple occasions from (MONTH) of 2019 through (MONTH) 2019, there was no documentation (left blank) under the column, culture/test obtained Y/N (yes/no), to determine if a test or culture was collected for those residents diagnosed with [REDACTED]. On 7/16/19 at 3:11 p.m., an interview was conducted with the infection control nurse (other staff member) #5. When asked the process for tracking and trending infections, OSM # 5 stated that she tracks infections using a computer program called Vision. OSM #5 stated that she obtains her information from residents charts and documents the following on the infection control log: If the infections were acquired at the facility or present upon admission or re-admission, any cultures/tests obtained, the culture results if indicated, the antibiotic used for treatment and the resolve date of the infection. When asked why there were so many blanks (no documentation) under column culture/test obtained, and culture, OSM #5 stated that most of the columns were blank because when residents were admitted or readmitted to the facility with infections, she did not have access to any cultures or tests that were obtained in the hospital. When asked if the history and physical and d/c (discharge) summary from the hospital were sent with residents upon admission to facility, OSM #5 stated that at times, the hospital paperwork did not contain that information. When asked if she could call the hospital to obtain that information, OSM#5 stated, I guess we could, yes. When asked why it was important for document if a culture was obtained and the organism causing the infection if a culture/test was obtained; OSM #5 stated that it was important to document that information to ensure the resident was on the appropriate antibiotic. On 7/17/19 at approximately 5:30 p.m., ASM (administrative staff member) #1, the Administrator was made aware of the above concern. Facility policy titled, Infection Prevention and Control Program, documents in part the following: Surveillance: [NAME] The facility tracks infections among residents upon admission and throughout their stay; collecting information necessary for evaluation to determine whether present upon admission or health care associated, analyzing and reporting monthly and quarterly to QAPI as required .C. The facility remains alert for potential outbreaks by the following methods: 1. Daily, weekly and monthly review and analysis of surveillance data, looking for any increase in particular types of infections and any clustering patterns. 2. Review lab findings for the isolation of uncommon or unusual organisms such as opportunistic pathogens and communicable disease agents.

Based on observation and staff interview, the facility staff failed to enhance and promote dignity during medication administration for one resident, Resident #57 in a survey sample of 39 residents. The findings included: The facility staff failed to knock upon entering Resident #57's room during medication on the Garden Spring Unit. Resident #57 was admitted to the facility on [DATE] from the community and has never been discharged . [DIAGNOSES REDACTED]. The annual Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 03/15/19 coded the resident as having short-term and long- term memory problems. Cognitive skills for decision making coded the resident as being severely impaired never/rarely making decisions. On 07/17/19 at approximately 4:30 PM Licensed Practical Nurse (LPN) #3 entered the resident's room to administer medications on two occasions without knocking before entering. On 07/18/19 at approximately 3:44 PM an interview was conducted with Licensed Practical Nurse #5 and she was asked if it was important to knock before entering into a resident's room. She stated Yes, this is considered their home and each room is considered their apartment. On 07/18/19 at approximately 3:58 PM an interview was conducted with Licensed Practical Nurse #3 concerning her entering the resident's room without knocking. Her response was, I should have knocked. It's a dignity issue. It's their home. On 07/18/19 at approximately 4:02 PM an interview was conducted with Certified Nursing Assistant (CNA) #2, when asked if it's important to knock before entering resident's rooms she stated, Yes, because it's a dignity and privacy issue. On 7/18/19 at approximately 4:12 PM, a pre-exit interview was conducted with the Administrator and the Director of Nursing concerning the above. No comments were made.

Based on observations, staff interviews, clinical record reviews and facility document review the facility staff failed to ensure the resident environment was free from hazards which constituted IJ (Immediate Jeopardy) for one resident (Resident #58) and appropriate assistance devices were utilized to prevent subsequent falls for one resident (Resident #63) of 26 sampled residents to prevent accidents over which the facility has control. This citation was originally found at a level four isolated and upon acceptance of the plan of correction, it was lowered to a level two isolated. 1. On 12/4/17 at 3:44 PM, a full portable cylinder oxygen tank was observed leaning freely against a wheelchair inside Resident #58's room. The oxygen tank was not stored in a cylinder stand and had the potential for being knocked over or damaged. A determination of Immediate Jeopardy (IJ) was confirmed at 4:15 PM on 12/4/17. 2. The facility staff failed to ensure appropriate assistance devices, to include use of gait belt, were used for transfers in order to prevent opportunities for subsequent falls for Resident #63. The findings included: 1. Resident #58 was admitted to the facility on [DATE] with active current [DIAGNOSES REDACTED]. The current MDS (Minimum Data Set) a quarterly with an assessment reference date of 10/19/17 coded the resident as scoring a 13 out of a possible 15 on the Brief Interview for Mental Status, indicating at the time of the assessment the resident's cognition was intact. The resident was able to ambulate in the room and corridor independently and at times used a wheelchair for mobility. Physician orders [REDACTED]. On 12/4/17 at 3:44 PM, the resident was observed sitting in a recliner at the bedside. On the opposite side of the room a full portable cylinder oxygen tank was observed leaning against a folded wheelchair. The oxygen tank was not stored in a cylinder stand and had the potential for being knocked over or damaged. There was no other source of oxygen such as an oxygen concentrator in the room. The identification of the hazard was immediately bought to the attention of the State Survey Agency team at 4:00 PM. After consultation with the State Agency office a determination of Immediate Jeopardy (IJ) was confirmed at 4:15 PM on 12/4/17. After determination of Immediate Jeopardy a meeting was held with the Administrator and the Director of Nursing (DON) to inform them of the IJ on 12/4/17 at 4:15 PM. The survey team conducted a 100% sweep of the resident's rooms and common areas to ensure safe storage of portable oxygen cylinder tanks was adhered to. No additional concerns of safe storage were identified. On 12/4/17 at 4:35 PM, the Administrator presented a corrective action plan to the state survey team. After careful review and discussion the action plan was denied at 4:55 PM. The immediacy was abated at 4:20 PM as the oxygen tank in Resident #58's room was removed by the Director of Nursing and secured appropriately in an oxygen storage room. On 12/4/17 at 6: 29 PM, the Administrator presented a second corrective action plan to the state survey team. After careful review and discussion the action plan was denied at 6:55 PM. The survey team left the facility at this time. On 12/5/17 at 9:35 AM, the Administrator presented a third corrective action plan to the state survey team. After careful review and discussion the action plan was accepted at 9:53 AM. The Corrective Action Plan titled Q[NAME] (Quality of Care) Environment read, as follows: 1. The oxygen tank noted in room [ROOM NUMBER] on 12/4/17 for (Resident #58's name) was placed in a tank holder at 4:20 pm by the DON. 2. The following residents are at risk if the oxygen tank is improperly stored: (name of 19 residents). 3. An inservice was completed on 12/4/17 at 6 pm regarding the policy and procedure titled Storage of Hazardous Materials revised on 8/28/17 (see attached), for all facility staff currently in the building. The remainder of the facility staff will be inserviced on this policy before returning to work in person and via campus wide email. !00% of all resident rooms in the facility, common spaces, rehabilitation gym, and storage areas were checked to assure oxygen tanks were stored appropriately at 5:45 pm on 12/4/17. 4. The Clinical Managers or designee will audit all resident rooms, common spaces, rehabilitation gym, and storage areas with oxygen tanks to assure proper storage daily x 90 days. Audits will be reviewed by the DON and summarized weekly and presented to the QAPI committee for additional oversight or recommendations. 5. Date Certain: 12/4/17 at 4:20 pm Oxygen tank was placed in a holder 12/4/17 at 4:30 pm staff inservices initiated 12/4/17 5:45 pm resident rooms, common spaces, rehabilitation gym, and storage areas with oxygen tanks have been checked 12/19/17 QAPI committee to review audits After accepting the plan for removal of Immediate Jeopardy from the Administrator, and determining that the Immediate Jeopardy was removed, the deficiency was assigned a Scope and Severity level of J, isolated. Attached to the action plan was a note dated 12/4/17 authored by the DON that read: At 1620 this writer went to room [ROOM NUMBER] and found 02 tank leaning up against wheelchair on the right-hand side of the room. O2 tank was full and not in a holder. Tank was immediately removed and placed in O2 tank holder. Staff that was present on unit at that time was immediately in-serviced. An interview was conducted with the Clinical Manager on 12/7/17 at 9:45 AM., to determine time frame that the oxygen cylinder had remained in the resident's room unsecured. She stated she could not determine this but did state that when the resident goes on leave of absents (LOA) from the facility the family members usually request an oxygen tank to be provided. She stated she believes the resident went on LOA over the Thanksgiving holiday. The Clinical Manager was asked how many cylinder tank stands are available on the unit. She stated she is aware of one that was currently in use. She further stated some are stored in the rehab gym. When asked if the staff have access to the gym on off hours, she stated she was not sure. A review of the clinical notes dated 11/23/17 read, in part: Resident went LOA with daughter (RP-Representative Party) at 0635 .Oxygen tank was also given per family request. In response to the above findings the Clinical Manager contacted the RP on 12/5/17 and documented the following: Spoke with RP today to educate about having oxygen canisters given to a nurse upon return from LOA for safety purposes. If resident needs to take oxygen with her on outings, the canister will need to be secured and taken in a rolling holder. RP voiced understanding. The facility policy titled Storage of Hazardous Materials revised 8/28/17 read, in part: Policy Statement- It is the policy of Sentara Life Care Corporation to establish guidelines for the proper storage of all Hazardous Materials. *Flammable liquids, combustible gases, etc., will not be stored in areas where intense heat or open flame devices could ignite matter. Note: Oxygen cylinders are stored in upright position and are kept in E-tank holder. According to the National Institute of Health article titled Compressed Gas Cylinder Storage and Handling dated 3/2013 read, in part: Due to the nature of compressed gas cylinders, special storage and handling precautions are necessary. Storage: Gas cylinders should be properly secured at all times to prevent tipping, falling or rolling. They can be secured with straps or chains connected to a wall bracket or other fixed surface, or by use of a cylinder stand. Cylinders should be stored where they will not be knocked over or damaged. Take precautions so that gas cylinders are not dropped or allowed to strike each other or other objects. Damaging the cylinder valve could turn the cylinder into a dangerous missile with the potential to destroy property and injure personnel. 2. Resident #63 was identified with a history of falls and is at risk for falls. The facility staff failed to ensure appropriate assistance devices, to include use of gait belt, were used for transfers in order to prevent opportunities for subsequent falls. Resident #63 was admitted to the nursing facility on 1/19/16 with [DIAGNOSES REDACTED]. The resident was readmitted to hospice care on 7/25/17 due to failure to thrive. The most recent Minimum Data Set Assessment (MDS) was a quarterly dated 10/26/17 coded the resident impaired with short and long term memory and severely impaired with the skills for decision making. The resident was coded to required total assistance from one staff for transfers. The assessment indicated the resident was not steady to move from a seated to standing position without assistance. This assessment coded the resident to be at risk for falls and to have fallen two or more times without injury. The Significant Change in Status Assessment MDS dated [DATE] coded the resident to be walking in the room and in the corridors with assistance of one staff. The resident was assessed to have fallen two or more times without injury and one time with injury. The Significant Change in Status Assessment MDS dated [DATE] coded the resident to have fallen within the last month, within 2-6 months and sustained a fracture related to a fall in the last 6 months. The care plan dated as revised on 11/22/17 identified the resident to have fallen out of a high back wheel chair, was at risk for falls in general with a history of falls with injures to include facility acquired fractures. A fall investigation identified a fall as recent as 12/2/17 to have fallen out of the same chair. This care plan identified the resident was at risk for continuous falls as dated 9/15/17. The care plan also identified the resident had a [DIAGNOSES REDACTED]. The care plan identified the resident was receiving hospice care. For transfers the care plan indicated the resident required assistance and supervision as needed. The care plan did not plan for the use of a Geri-lounger while out of bed, nor did the care plan plan for the use of a gait belt for resident safety during transfers. The resident no longer had a high back wheel chair. The hospice care plan dated 9/12/17 also identified the resident was at risk for falls and had falls in the facility with major injuries to include significant skull fracture, wrist and femur fracture. This care plan identified the resident was unsteady and remained at risk for falls especially if she were ambulating or attempting to ambulate without assistance. The hospice care plan identified the resident required assistance but never asks for it. Resident #63 was observed in the dining area of the locked unit, reclined in a Geri-lounger while out of bed, during the survey days of 12/4/17, 12/5/17, 12/6/17, 12/7/17, 12/8/17 and 12/11/17. She was not communicative in any way and was confused to person, place and time. On 12/11/17 at 10:10 a.m., two surveyors observed Certified Nursing Assistant (CNA) #1 to transfer Resident #63 from bed to Geri-Lounger. The resident was able to weight bear on both legs turn and pivot, but unsteady, to transfer to the lounger. The CNA stated this transfer techniques was the way he always transferred the resident, although all the ADL sheets recorded 4/2 (total assist with one staff). An interview was conducted with the unit's clinical manager Registered Nurse (RN) #1 on 12/11/17 at 1:30 p.m. She stated the resident was able to bear weight, turn and pivot to transfer from bed to chair and from chair to bed, and she had performed this transfer with the resident on many times. When asked why the MDS assessed the resident as a 4/2, indicating she did not participate in any way during transfers, she stated they were going by what the CNA's recorded which was incorrect and should be recorded as 3/2 (extensive assist of one staff). In addition the RN #1 stated a mechanical lift was never used to transfer the resident. A later interview with RN #1 on 12/11/17 at 3:09 p.m., she stated she spoke with CNA #1 and was informed by him, he mostly took the resident under her arms and transferred her to and from the chair and bed which was not an appropriate way to transfer the resident. She stated she expected the staff to use a gait belt as an assistance device, per the facility's policy, to ensure the resident's safety during all transfers in that she could bear weight, stand a pivot. On 12/8/17, at 11:19 a.m., a telephone interview was conducted with Resident #83's assigned hospice nurse. She stated in (MONTH) (YEAR), the resident was in a high back wheel chair and was leaning too far forward resulting in a fall out of that type of chair. She said, the Geri-lounger was used for rest from ambulating up until around (MONTH) (YEAR) where the Geri-lounger became the safest choice when out of bed. She stated the resident would probably still try to get out of bed and attempt to walk which would result in falling due to her unsteadiness. She said at this point, hospice services was not actively searching for any other chair. On 12/11/17 at 5:50 p.m., the aforementioned issue was brought to the attention of the Administrator and the Director of Nursing (DON). No further information was provided prior to survey exit. The facility's policy and procedure titled Gait Belt (Transfer Belt) dated 4/27/17 indicated the Purpose: Gait belt will be available to use as needed, to ensure the safety of staff and residents. Apply gait belt snugly to the resident's waist. To bring resident to standing position, keep your back straight and pull on the gait belt, holding on each side. After the resident is standing, use gait belt to assist, use gait belt to assist in stabilizing and turning resident. If resident begins to fall, draw resident close to your body using gait belt and slowly lower resident to floor .

Based on observations, record review, family, staff interview and facility policy the facility staff failed to provide treatment and care in accordance with professional standards of practice for 2 of 26 residents in the survey sample, Residents #147 and #358. 1. For Resident #147 the facility staff failed to: (1) obtain physician orders [REDACTED]. 2. The facility staff failed to ensure Resident #358 received pin care in accordance with professional standards of practice. The findings included: 1. Resident # 147 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The facility staff failed to have parameter for the use of insulin and the monitoring of glucose levels. The facility staff were not aware of the dosage of insulin administered or the blood sugar levels form [DATE] through [DATE]. Resident #147 wife stated she had been administering insulin twice a day and obtaining blood sugars levels since admission. She also stated that the facility did not inquire about the dosages administered or the blood sugars levels since admission. A determination of Immediate Jeopardy (IJ) was confirmed at 1643 P.M. (4:43 PM) on [DATE]. This citation was originally found at a level four isolated and upon acceptance of the plan of correction, it was lowered to a level two isolated. An Initial Minimum Data Set ((MDS) dated [DATE] assessed Resident #147 in the area of Cognitive Patterns - Brief Interview of Mental Status (BIMS) as a (15). In the area of Activities of Daily Living (ADL's) this resident was assessed as a (,[DATE] in the area of bed mobility, a (,[DATE]) in the area of transfer, a (,[DATE]) in the area of walk in room, (,[DATE]) in the area of dressing, a (,[DATE]) in the area of eating, a (,[DATE]) in the area of toilet use, and a (,[DATE]) in the area of personal hygiene. In the area of Medications this resident was assessed as receiving injections for (7) days. In the area of Insulin this resident was assessed as receiving insulin for (4) days. In the area of Orders for Insulin changes- this resident was assessed for (0) days. In the area of Medications Received - this resident was assessed as receiving Anticoagulant for (7) days. A Care Plan dated [DATE] indicated : Problem- Potential for hypo/hyperglygycemia r/t: DX of DM (resident [DIAGNOSES REDACTED]. Interventions- Administer medication per MD order, Disciplines -Nursing, Frequency - PRN (as needed). Intervention- monitor for effectiveness of medication, Disciplines- Skilled Nursing, Frequency - PRN. Intervention- monitor for side effects of medication, Disciplines- Skilled Nursing, Frequency - PRN. Intervention- observe for s/s of low blood sugar (sweating, headache, light headed, confusion, slurred speech, drowsiness, Intervention -Observe for s/s pf high blood sugar (polyuria, blurred vision, weakness, headache, anorexia, N & V, abdominal pain, [MEDICATION NAME] breath, mental changes, [MEDICAL CONDITION], intervention - Monitor accuchecks per MD order Intervention- serve diet per MD order, Disciplines - Dietary- Licensed Practical Nurse- Registered Nurse, Frequency -PRN. Intervention - Notify MD as needed, Disciplines - Skilled Nursing, Frequency - PRN. A review of the Care Plan did not indicate a Care Plan for the care and treatment and use of Anticoagulant medications. A review of the Care Plan did not indicate the care and treatment for [REDACTED]. A Clinical Note dated [DATE] at 02:48 AM indicated: [MEDICATION NAME] and [MEDICATION NAME] changed to [MEDICATION NAME] ,[DATE] per resident and wife request. Administration changed to PM on several meds. approved and ordered by physician. A Clinical Note dated [DATE] at 9:22 AM indicated: Patient stated wants wife to administer all insulin and obtain blood sugars for him. Wife and husband educated on risks, Wife signed paperwork to self administer insulin and pro air inhaler. Wife able to answer correctly all questions regarding insulin and pro air inhaler. A Medication Administration History print-out with a 11:46 A.M. ,[DATE] 17 run date indicated: [MEDICATION NAME] ,[DATE] 100 unit/ml subcutaneous suspension two times daily starting [DATE]. An Administration History form with a date administered column indicated: [DATE] (7:30) date documented (11:,[DATE] (08:23) Not administered, Notes: resident wife taking BS (blood sugar) and injecting insulin. An Administration History form indicated: date administered column [DATE] (7:30) - [DATE] (8:23) Blood Sugar Site - Value (Blank). [DATE] (16:30) -[DATE] - [DATE] (17:34) Blood Sugar value 129, Insulin not administered wife administered. An Administration History form dated [DATE] (7:30) - [DATE] (8:51) blood sugar site Value (blank) Notes - Resident wife stated she does BS and administer insulin. There is no further documentation of [MEDICATION NAME] or Blood Sugar levels being shared or documented by the facility staff. A facility form for Resident Self Administration of Medication Review dated [DATE] was presented: The form indicated: Resident Name: and date - [DATE]. List of medications for self-administration: Insulin, blood sugars. 1. Can the resident name all of his/her medications? (Circle Yes or No)- Yes. 2. Does the Resident know what the medications are used for? Yes 3. Does the Resident follow writer and oral instructions? Yes 4. Is the Resident aware of adverse reactions? Yes 5. Does the Resident know to report all adverse reactions immediately to the nurse? Yes 6. Does the Resident give his/her medications to anyone else? No 7. Is the resident familiar with the rules of the self-medication program? Yes 8. Are medications stored according to the label? Yes 9. Are over the counter medications in the resident's room, not prescribed by the physician? No 10. Has the resident returned all unused, old, expired and extra medication(s) to the nurse? Yes 11. Are medications stored, and secured, to prevent access by other residents? Yes 12. Does the resident return the medication container for refills? Yes 13. Has the resident's status changed, so that he/she should have the nurse medicate him/her? No The resident was observed self-administering medication appropriately. The resident has been interviewed and appears to be adhering to the rules for the self-administration program and should be allowed to continue the program. Comments: Wife to Self Administer Insulin and and return demonstration completed - do patients blood sugars and pro air [MEDICATION NAME]. This form was signed by Resident #147's wife and Unit 300 Nurse Manager. During an interview with Resident #147's wife on [DATE] at 3;10 P.M. when asked about the Self-Administration form she stated, I did not receive any training or over site for taking his blood sugars, giving him his insulin or giving him his breathing treatments. I signed the form, but there was no return demonstration or education. I signed the form because I wanted to be the one making sure his insulin and blood sugars were not going all over the place as they were when he was in the hospital. I told them (Facility staff and doctor) that I was going to give him his insulin. Resident #147 wife was asked, if staff asked had her about his blood sugar parameter and insulin dosage? She stated, staff never inquired about his blood sugar levels or insulin dosage. Resident #147 was observed to have Resident #147 blood sugar levels in a note book that she kept in a night stand drawer. During an interview with Resident #147's wife with a second surveyor at 3:17 P.M. on [DATE] she stated, I give ,[DATE], showed the insulin in a vial in the resident's top bedside drawer, not dated when opened. When it is finished I get another vial. The blood sugar in the hospital were up and down (240/ 68), so I wanted to have control when I came here, I wanted to do his insulin like I was at home. I signed a form so I could get control of doing blood sugar checks and administer the insulin. I was not educated by any nurse - I did not do a return demonstration. When asked how would she know how much insulin to give she stated, (i.e.), if blood sugar is 95, she stated 32 units. If 164 - I would give 35 units. I give between ,[DATE] units on a sliding scale. I take his blood sugars before he eats in the morning and before he eats his dinner. Resident #147 wife showed her book with blood sugar levels and stated, staff are not concerned. They don't inquire or ask. I don't share information with unit nurses. They don't act concerned. The wife was asked, if she did not come in to the facility on e day, how would staff know how Resident #147 blood sugars were running? She stated, they would not know. During an interview on [DATE] with Resident #147 doctor he stated, Resident #147's wife had talked with him and the facilities admission team while Resident #147 was in the hospital during discharge planning. Resident #147 wife had express that she would be doing his blood sugars levels and insulin administration at the nursing home due to the up and down levels Resident #147 experienced during his hospital stay. He stated, I was ok with her giving him the insulin and taking his blood sugars. She stated, she did it at home for Resident #147. The doctor was asked, Did he write an order indicating it was ok for Resident #147's wife to give insulin and take his blood sugars while a resident at the facility? The doctor stated, No. The doctor stated, he was new to long term care and had been working at the facility for a few weeks. The doctor was asked if Resident #147's wife would have been allowed to give insulin and take blood glucose levels in the hospital ? The doctor stated, No The doctor was asked, was he aware that nursing staff were not given Blood Sugar readings by Resident #147 wife? Also, nursing staff were not aware of how much insulin Resident #147's was receiving? The doctor answered, he was not aware that nursing staff did not know blood sugar readings. The doctor also, answered, he was not aware that nursing staff did not know how much insulin Resident #147's wife was giving him. The doctor was asked, was he aware of Resident #147's blood sugar levels and insulin dosage. The doctor stated, He was not aware. During a meeting on [DATE] at 2:47 P.M. with the 300 Unit Nurse Manager, The Director of Nursing and the Administrator, the Nurse Manager was asked if there was a physician's orders [REDACTED].#147's wife to administer insulin and obtain blood sugars. The Nurse Manager stated, No and preceded to hand over an revised Care Plan dated [DATE] at 1:53 PM. During this interview the Director of Nursing (DON) stated she was not aware of Resident #147's blood sugars were not being monitored by nursing staff. The DON was asked if Resident #147's wife have a physician's orders [REDACTED].? The DON stated, No. During this interview the Administrator stated, we were trying to be home like and allow the wife to care for her husband as she would at home. When asked was the doctor aware of Resident #147 wife administering insulin and taking his blood sugars, she stated, Yes, he knew we had talked about the wife providing his care prior to his discharge from the hospital. The doctor was ok with it. It is apparent that there is a disconnect. During an interview on [DATE] at 6:23 PM with the 300 Unit Nurse Manager, The DON, the Administrator and Regional Nurse Manager, the Regional Nurse Manager stated, We agree this is not good. The facility stated, there were no policy's and procedures for Resident family's to administer medications, provide treatments or take blood sugar levels. An acceptable Plan of Corrections was provide to the survey team at 6:48 P.M. on [DATE]. The Immediate Jeopardy was abated at that time. Immediate Jeopardy Plan of Corrections: Self-Administration of Medication 1. The physician orders [REDACTED].#147 in room [ROOM NUMBER] have been clarified for staff to complete blood glucose's and administer medications on [DATE]. (see attached) A new label has been secured to a new vial of [MEDICATION NAME] ,[DATE] insulin at 5:45 PM. The Director of Nursing and Clinical Manger spoke directly with the patient's wife regarding the facilities concerns with the current practice of her administering medications (see attached). The Clinical Manager, spoke with the physician who was not in agreement that the wife should manage his medications (see attached). 2. Any family who request to self-administer medications and or manage inhalers or blood glucose monitoring are at risk. At this time, no other families have requested to self -administer their own medications. At this time the facility does not have a policy to accommodate family administration of medications to residents. No medications will be administered or procedures will be completed without a physician's orders [REDACTED].>3. An inservice was initiated [DATE] at 5:50 PM regarding the policy and procedure titled Self-Administration of Medications revised on [DATE] ( see attached), for all licensed nursing staff currently in the building. The remainder of the licensed nursing staff will be inserviced on this policy before returning to work in person and via campus wide email. 4. The Clinical Managers or designee will audit new physician orders [REDACTED]. Any new orders identified will be evaluated by the Interdisciplinary Team for completion of resident education and monitoring to assure appropriateness of the order. Audits will be reviewed by the DON and summarized weekly and presented to the QAPI committee for additional oversight or recommendations. 5. Date Certain: [DATE] 4:30 PM: Clinical Manager spoke with MD and clarified his desire for staff to monitor blood glucose's and administer medications. [DATE] 4:56 PM: DON and Clinical Manager spoke to patients's wife, to address concerns with family administration of medications. Wife in agreement that facility may manage. [DATE] 5:30 PM: Insulin, blood glucose monitoring and inhaler administrator orders were clarified. A new vial of insulin was labeled and the inhaler was ordered and will be delivered by the pharmacy on the next delivery. [DATE] 5:30 PM staff inservices initiated [DATE] 5:45 PM chart audits initiated to evaluate new orders [DATE]: QAPI committee to review audits Resident #147 2. The facility staff failed to ensure Resident #358 received pin care in accordance with professional standards of practice. Resident #358 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED].* (1), Fracture of Right Tibia* (2), Chronic Pai[DIAGNOSES REDACTED]* (3), Anxiety Disorder* (4), Depression* (5), and [MEDICAL CONDITION]* (6). Resident #358's Admission Minimum Data Set (MDS - an assessment protocol) with an Assessment Reference Date of [DATE] coded Resident #358 with a BIMS (Brief Interview for Mental Status) with a 15 of 15 indicating no cognitive impairment. In addition, Resident #358 was coded as requiring limited assistance with one staff person assistance for transfer, toilet use and dressing. Resident #358 was coded as always continent of urinary and bowel functions. Resident #358's Hospital Discharge Instructions included the following: Discharge: Pin Care Instructions: page 5 of 6 Once a day wash around the pin sites with warm soapy water and anti bacterial soap and a wash cloth. If pin sites become more red and painful or have increased drainage then wash pin sites twice per day. If the redness/drainage/pain continue please call us. You may take a shower and wash your Ex-fix and/or K-wire sites in the shower with warm soapy water and antibacterial soap. Do not soak your extremity that has an Ex-fix and/or K-wires. No baths or hot tubs. Discharge: Wound Care: Daily dry dressing changes to medial and lateral incision/sutures on left lower leg and left arm. From the document (MONTH) (YEAR) Physician order [REDACTED]. Left leg: dry dressing: Left arm: dry dressing Pin Care to left arm fixator daily: Notes: Pin care to left arm fixator Pin sites daily Pin Care to left arm fixator daily: Notes: Pin care to left arm fixator pin sites daily cover left tibia surgical site with xeroform gauze cover with dry dressing cover with Kerlix daily A [DATE] 12:22 PM Physician order [REDACTED]. A [DATE] 19:31 (7:31 PM) Clarification Physician order [REDACTED]. A [DATE] 5:32 AM Clarification Physician order [REDACTED]. Resident #358's Treatment Administration Record (TAR) for (MONTH) (YEAR) documented the following: Left leg One time daily starting [DATE] dry dressing and was discontinued on [DATE] Left arm one time daily starting [DATE] dry dressing and discontinued on [DATE] Pin Care to Left arm fixator daily one time daily starting [DATE] and discontinued [DATE] Notes: Pin Care to left arm fixator Pin sites daily Cover left tibia surgical site with xeroform gauze cover with dry dressing cover with Kerlix daily one time daily starting [DATE] and discontinued on [DATE] Pin care to left tibia fixator daily one time daily starting [DATE] and discontinued [DATE] Left leg one time daily starting [DATE] dry dressing and discontinued [DATE] Left arm one time daily starting [DATE] dry dressing and discontinued [DATE] Resident #358's [DATE] to Present Care Plan documented the following: Problem: Impaired skin integrity related to left leg status [REDACTED]. Interventions included but were not limited to: Monitor nutrition parameters Assist resident to eat/drink adequate amount of nutrition Follow prescribed treatment regimen. Problem: Impaired skin integrity to left arm status [REDACTED]. Interventions included but were not limited to: Follow prescribed treatment regimen. On [DATE] 0 Resident #358 was observed at approximately 1:16 PM. She stated that she had Fracture to Left arm and left leg with pins and rod. The Resident stated the bones were crushed in a car accident a month ago. Resident #358 stated that the Nurses are supposed to do pin care in morning and night. Nurses aren't doing morning pin care always. The resident stated she is in a Bariatric bed. The Resident stated she talked to the Unit Manager #4 about 3 days, and reported that she stated she would talk to somebody. Resident #358 stated that she waits a long time for anyone to come in after I ring bell. Resident #358 stated, I've waited up to 2 hours. Resident stated she can get to potty by herself but she shouldn't. Resident #358 stated that if she waited I would wet her self. On [DATE] at approximately 10:30 AM, the Unit Manager #4 and surveyor entered Resident #358's room so that the surveyor could show the Unit Manager #4 Hydrogen Peroxide on the bedside table and Dermal Wound Cleanser in the drawer at the foot of Resident #358's bed. Surveyor informed the Unit Manager #4 that the Resident is performing her own wound care using hydrogen peroxide to pin sites and dermal wound cleanser to incision lines of lower left leg with steri strips. The Unit Manager #4 stated that the Educator Registered Nurse #5 had spoken to the resident about her wound care and attempted to removed the peroxide and the Resident would not allow it to be removed. The Unit Manager #4 was asked as the PIN care orders did not specify what to do, how would she perform pin care and she stated that she would clean with soap and water. On [DATE] at approximately 3:00 PM, the Director of Nursing (DON) was asked if it is the expectation that Resident #358's specific PIN care orders should be clarified and issues with the Care Plan be updated on the Resident's care plan. The DON stated, Yes. On [DATE] at approximately 4:30 PM, Unit Manager #4 stated that the Doctor had talked with Resident #358 about hydrogen peroxide and the Resident #358 agreed for it to be removed from her room. The Unit Manager was asked if she felt all the issues with Pin Care should be updated on the care plan, and asked if PIN care instructions should be clarified and Unit Manager #4 stated, Yes, and the orders have been clarified. The Facility was asked to provide a Policy and Procedure for PIN Care and the DON on [DATE] at approximately 3:00 PM stated, We have no specific PIN Care Policy. The facility administration was informed of the findings during a briefing on [DATE] at approximately 6:00 p.m. The facility did not present any further information about the findings. Definitions: 1. Fracture Radius: Fracture or break of the wrist bone 2. Fracture Tibia: Fracture or break of the leg shin bone 3. Chronic Pai[DIAGNOSES REDACTED]: Medline Plus documented the following: Pain is a signal in your nervous system that something may be wrong. It is an unpleasant feeling, such as a prick, tingle, sting, burn, or ache. Pain may be sharp or dull. You may feel pain in one area of your body, or all over. There are two types: acute pain and chronic pain. Acute pain lets you know that you may be injured or a have problem you need to take care of. Chronic pain is different. The pain may last for weeks, months, or even years. The original cause may have been an injury or infection. There may be an ongoing cause of pain, such as arthritis [MEDICAL CONDITION]. In some cases there is no clear cause. Environmental and psychological factors can make chronic pain worse. Many older adults have chronic pain. Women also report having more chronic pain than men, and they are at a greater risk for many pain conditions. Some people have two or more chronic pain conditions. 4. Anxiety Disorder: Medline Plus documented: Fear and anxiety are part of life. You may feel anxious before you take a test or walk down a dark street. This kind of anxiety is useful - it can make you more alert or careful. It usually ends soon after you are out of the situation that caused it. But for millions of people in the United States, the anxiety does not go away, and gets worse over time. They may have chest pains or nightmares. They may even be afraid to leave home. These people have anxiety disorders. 5. Depression: Medline Plus documented: Depression is a serious medical illness. It's more than just a feeling of being sad or blue for a few days. If you are one of the more than 19 million teens and adults in the United States who have depression, the feelings do not go away. They persist and interfere with your everyday life. 6. [MEDICAL CONDITION]: Medline Plus documented: [MEDICAL CONDITION] disorder is a mental condition in which a person has wide or extreme swings in their mood. Periods of feeling sad and depressed may alternate with periods of being very happy and active or being cross or irritable.

Based on observation, staff interview, clinical record review, and in the course of a complaint investigation, the facility staff failed to provide a safe environment for Resident #1 from abuse from her husband. The facility staff failed to implement safety measures to prevent Resident #1's husband from inflicting verbal and possible physical abuse on the Resident. Findings included: Resident #1, a [AGE] year old female, was admitted to the facility on [DATE] from a local acute care hospital, where she was hospitalized subsequent to spousal abuse. Her [DIAGNOSES REDACTED]. An MDS (Minimum Data Set) had not yet been completed for Resident #1. At 10/25/2016 at 1:10 PM Resident #1 was interviewed in her room while she was sitting in a wheelchair. She seemed oriented to person and place. She stated that she wished to stay in the facility long-term and that she did not want to live with her husband. Resident #1's hospital discharge summary dated 10/10/2016 read Chief complaint-intractable back pain, spousal abuse. The Chief Complaint section of the discharge summary also read presents to the emergency room after having a verbal altercation with her husband, who ended up pulling her to the floor. The patient ended up injuring her back. In addition, the summary read the patient's family is at bedside reporting that her husband is verbally and physically abusive to her. On 10/25/2016 at 2:00 PM Resident #1 's clinical record was reviewed. A nursing note written by LPN (Licensed Practical Nurse) B dated 10/16/2016 at 12:59 PM stated res (Resident) out of bed to gerichair sitting in front of the nurses' station. Res. Husband and son approached res. Res. could be heard saying you pushed me .Supervisor was called to the unit . An additional note was seen dated 10/25/2016 at 1:58 PM written by RN (Registered Nurse) B, who was the nursing supervisor, stating This nurse was called to the unit by a staff nurse. Resident husband and son talking to the resident. This RN walks over to the Resident and asks Are you alright? She shakes her head and nods affirmatively. Within moments RN hears (husband stating) you shouldn't have said that, you're the cause of all this, I didn't push you down, you're lying. Resident begins visibly shaking and makes constant eye contact with this RN. At this point this RN explained to the son that Resident #1 is under a protective order and that they would have to leave. Both were upset but compliant with the request. On 10/25/2016 at 2:00 PM an interview was conducted with Other A, Social Services Director who stated that the hospital did notify APS (Adult Protective Services) regarding Resident #1. APS declined to pursue a protective order since Resident #1 was now considered to be safe while in the facility. She further stated that Resident #1 had informed her on 10/21/2016 that she didn't want her husband to visit her at the facility. Other A also stated that on 10/21/2016 she informed the facility's corporate risk management staff of the situation, resulting in a directive from risk management that facility staff be informed that they are not to allow Resident #1's husband to be on facility property. Other A then submitted an email dated 10/21/2016 that she sent to the facility department heads and the unit managers informing them of the directive from risk management. When asked if she was aware of staff's having received and implemented the directive, she stated that, while she did not witness any communication with staff, she expected the staff to follow-up with a level of professionalism related to their respective positions. 10/25/16 at 1:25 P.M. an interview was conducted with CNA (Certified Nursing Assistant) A in the Activities Office. She stated that she remembered seeing Resident #1's husband in the facility on a weekend recently but couldn't remember when. When asked if she was aware if Resident #1's husband was allowed to be in the facility, CNA A stated, I don't know of any instructions regarding him visiting. My Unit Manager is supposed to inform us of any special instructions regarding visitors. She further stated that during the weekdays the receptionist should have every visitor sign the visitors log and wear a name tag. She stated that there was no receptionist coverage on weekends and that visitors were free to enter at will. On 10/27/2016 at 10:00 AM a review of the facility visitor log showed no entries for 10/16/2016, the date that Resident#1's husband visited. This date was a Sunday. On 10/25/16 at 1:35 P.M. an interview was conducted with LPN (Licensed Practical Nurse) A. When asked if Resident #1's husband was allowed to visit the facility, she stated, She (Resident #1) gets nervous when she hears visitors coming. I don't think he's allowed to come in or be with her, but there was nothing informing me of any visitor's restrictions. Her sister told me that she wasn't allowed to go to her sister's house to pick up any of (Resident #1's) belongings. She stated that the husband refused to release any of Resident #1's belongings. On 10/25/16 at 1:50 P.M. an interview was conducted with RN (Registered Nurse) A, Unit Manager. She stated that she remembered meeting Resident #1 on the day of her admission to the facility. Resident #1 told her that her husband pushed her down, resulting in a hospitalization , and that she didn't want to go back home and live with her husband. When asked if she was aware of Resident #1's husband's being restricted from entering the facility, the unit manager stated, I have not seen anything regarding him being banned from the building. I just heard that her sister wanted to get a restraining order. RN A stated that it would be difficult to keep Resident#1's husband away from the facility since his physical appearance is unknown. At 3:00 PM on 10/25/2016 the survey team determined that the facility was not offering Resident #1 sufficient protection from potential harm, and that Immediate Jeopardy (IJ) existed. 3:05 PM 10/25/2016-Call made to Virginia Department of Health, Office of Licensure and Certification informing supervisors of an Immediate Jeopardy situation since the facility could not assure Resident #1's safety at all times. 3:25 PM 10/25/2016- Supervisors agreed to Immediate Jeopardy. 3:40 PM 10/25/2016- Facility staff was informed of the IJ situation. This consisted of Administration A, Facility Administrator; Administration B, Director of Nursing; and Administration C, Corporate Nurse Executive. 5:15 PM 10/25/2016-POC (Plan of Correction) presented and returned for correction. 6:00 PM 10/25/2016-POC accepted. IJ lifted. The Plan of Correction consisted of the following points: 1. Patient was moved to another room under an alias name. Patient has agreed to be transferred to another facility within 24 hours under the alias name. Until transfer, the facility will provide 24 hour 1-1 care for the patient. The facility instructed the husband not to visit the wife per the wife's request. 2. All patients who are at risk from abuse have the potential to be affected. 3. Nursing staff has been educated regarding the resident's circumstances. Staff will be educated on facility visitation policy, including check in process after normal business hours. In addition, signs will be posted at each nurses' station directing visitors to check in at the nurses station after hours. Facility will communicate with APS (Adult Protective Services) regarding known active cases to request background information including a current photo and description of parties that may endanger residents. 4. Administrator and/or designee will randomly observe staff ensuring visitor log is completed. Social worker will maintain APS log and provide administrator with weekly updates. All findings will be reported to QAPI (Quality Assurance Process Improvement) monthly for the next 6 months. 5. Compliance date October 25, 2016. Resident #1's responsible Party has agreed to the details of relocating her to another facility.

Based on staff interview, clinical record review, facility document review and during the course of a complaint investigation the facility staff failed to provide the necessary care and services to attain or maintain the highest practicable physical well-being in accordance with assessment and plan of care for 1 of 22 residents in the survey sample, Resident #19. The facility staff failed to identify an abnormal vital sign, manage pain and follow physician orders [REDACTED]. The resident was found to be in [MEDICAL CONDITION] (an abnormal heart rhythm) requiring medical intervention, the resident's pain was managed with IV medication. The findings include: Resident #19 is a [AGE] year old admitted to and discharged from the facility on 12/31/12. The hospital discharge summary dated 12/31/12 indicated Resident #19 was discharged to the facility following a hospitalization due to a motor vehicle accident on 12/24/12. Discharge [DIAGNOSES REDACTED]. During the hospital course Resident #19 underwent surgical interventions for the fractured arm and hip. On hospital day 4 the resident developed SVT with rates in the 150-160's (normal rate is 100 or below). The resident converted initially on her own and then a second time responded to the medication [MEDICATION NAME] 6 mg (milligrams) IV. About 4 hours later she converted back to SVT and required [MEDICATION NAME] 12 mg and [MEDICATION NAME]. Cardiology was consulted and felt it was most likely a chronic type of event with an acute onset. The resident stayed one night in ICU (intensive care unit) and after converting and remaining stable she was transferred back to the floor. The resident was discharge from the hospital to the facility for further skilled therapy and after care to include pain management. The resident was weaned off the PCA pump (patient-controlled [MEDICATION NAME]; a computerized pump that gives the patient power to control their pain) and placed on oral liquid pain medication of [MEDICATION NAME] 5 mg/ 5 ml (milliliters) 5-10 ml every 4 hours as needed for pain. The resident could not swallow pills. Discharge additional instructions read: You have a broken rib. You may hear clicking of the ribs when reaching or moving. This is normal phenomenon. You are at high risk for pneumonia. Make sure your pain is well controlled enough to take deep breaths and to use you ICS (incentive spirometery) frequently. Do not allow yourself to run out of pain medications. The hospital records indicate the resident received her last dose of pain medication ([MEDICATION NAME]) prior to discharge at 1:44 P.M. The resident's last vital signs were B/P 116/55, pulse (P) 86, temperature (T) 96.7, respiratory rate (R)18 and pulse oximetry (PO) 96%. The resident was cooperative, alert and orientated X 4. The resident required assistance with bed mobility and transfers. The resident was discharged at approximately 3:30 P.M., via medical transport. The medical transport form indicated the resident was alert and orientated and did not have any pain. The resident's vital signs did not include a pulse, the B/P was 136/82, R-14. The time was 4:50 P.M. Review of the facility's clinical record failed to indicate the time of arrival to the unit for Resident #19. A nursing admission assessment dated [DATE] did not include the time of the assessment. The resident's vital signs were B/P 116/74, P-137, R- 20 and T-97.3, no O2 sat (pulse oximetry) was taken. The nursing assessment was completed by the night shift nurse (licensed practical nurse/ LPN #2), who according to the facility had come in early at 7:00 P.M., to relieve the day shift nurse. A Pain Assessment Tool form was completed by LPN#2. The resident indicated she has pain. The pain site was identified as the right upper and lower extremity and the right side of trunk. The pain was described by the resident as aching, continuous, daily pain. The pain lasted most of the day. The pain was made better by positioning and medication. The pain was worse in the evening and night time. The pain affected the resident's sleep and physical activity. The resident scored the pain a 10 out of 10, worst possible. An Initial Care Plan developed on 12/31/12 for Resident #19 evidenced the facility staff identified comfort related to pain due to femur, rib and wrist fracture as a problem. The goal was for the resident to have increased comfort as evidenced by verbal, nonverbal response; ability to rest. Approaches listed to achieve the goal was for position changes every 2 hours and as needed (PRN), positioning devices PRN, medicate per MD orders, monitor sleep PRN. The admission physician orders [REDACTED]. A hard script (prescription form) for the [MEDICATION NAME] was sent with the resident to the facility to fax to the pharmacy. The facility staff did not fax this prescription order to the pharmacy until 9:06 P.M. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The complainant alleges he accompanied the resident from the hospital to the facility on [DATE]. He stated the resident arrived at the facility at approximately 4:00 P.M., he indicated he stayed for awhile and then left for home. A few hours later he received a call from the resident. The resident stated, "Please come get me out of here, I've been pushing the button and no one has answered". The complainant indicated the resident sounded in distress and she stated she was in "extreme pain". He then came to the facility. Upon arrival to the facility the complainant stated "When I got there you could hear alarms going off..." He stated the resident was "scared, her eyes were wide open, she was in severe pain, she was crying and fearful...she looked like day one in the ER after the motor vehicle accident...she was in agony and distress...she looked almost yellow, she was sweaty...I spoke with the charge nurse who told me they were working on her pain medicine...my mom had been in pain for hours without any pain medicine...When I spoke with the head nurse she said we will get it under control...the head nurse did not check her vital signs...I told them I wanted her out of here...she needed to go to the emergency room ...I was not polite...I told them let's call 911...when the EMT's got here they rushed her out of here...her vital signs were bad..." Review of the nurses notes for 12/31/12 evidenced an initial entry timed at 11:00 P.M. documented by LPN#2 that read: "Resident stated that she was transported via stretcher at 16:30 from (name of hospital). She is A&O X 3 (alert and orientated) and able to voice all needs...respirations are elevated (secondary to) pain and movement....apical pulse elevated at 140 bpm (beats per minute)...resident is continent but used her brief (secondary to) bed pan being to {sic} painful to sit on...resident could not turn over (without) being in severe pain. Pain scale 10/10. No RX's (medication) delivered from pharmacy yet. Brief was changed by CNA (certified nurse aide). Vital signs -T-97.4, P-140, R-20, B/P 116/64." At 11:30 P.M., LPN #2 documented, "Resident's family arrived to facility and requested their mother be sent back to the hospital (secondary to) poor pain management. Resident's son stated "My mother was released too soon, she looks pretty bad! ". (Name of attending physician) and D.O.N (director of nursing) was advised of request and agreed resident should be transported back to hospital for evaluation. Medical transport was called and stated they would arrive in 30-40 minutes. 1 hour later, medical transport called & stated they couldn't be here for another hour. Canceled (with) medical transport & called 911. 911 transported resident @ 1030 pm via stretcher to (name of hospital) & family escorted resident to hospital (with) all her belongings). The emergency room documentation evidenced the chief complaint was rapid heart rate, diffuse pain, diaphoresis (sweating). The ER physician documented, "The family found the patient diaphoretic, rapid pulse rate, diffuse pain. EMS was called. Positive for diffuse pain at the postop sites as well as right rib pain. Vital signs B/P 98/70, pulse rate 140's to 150's, R-20, T-98.7, O2 saturation was in the lower 90's on room air, 97% on 2 liters per nasal cannula. Impression: [MEDICAL CONDITION], postop pain. Diagnostic studies: EKG and labs were obtained. The resident was treated with Adenocard 6 mg IV with subsequent improvement of her rhythm to a sinus [MEDICAL CONDITION] approximately 110. This was followed with [MEDICATION NAME] 2.5 mg IV as well as 50 mg by mouth dose. Pulse rate 99. Final Diagnoses: [REDACTED]. The triage nurse documented at 12:05 A.M.,"...pt (patient) states she needs liquid pain medication because she can not swallow pills and they (the facility) did nto {sic) have liquid form. pt is in severe pain and came to ED (emergency department) for pain control. Patient complains of pain, on a scale of 0-10 patient rates pain as 10, pain is constant. The resident was administered IV [MEDICATION NAME] 4 mg for pain management while at the emergency room at 3:16 A.M. The resident was transferred to another hospital at 4:00 A.M. for admission. LPN#1 received a final written warning on 1/2/13 for "failing to provide pain medication for a newly admitted resident (Resident #19)". LPN#1 refused to sign this counseling. LPN#1 was no longer an employee at the facility. There is no evidence in the clinical record of the nurse recognizing the abnormal vital sign (the elevated apical pulse) and/or implementation of ongoing monitoring and assessments. There is no evidence of the nursing staff notifying/ consulting with the physician about the abnormal apical pulse (vital sign) and the delay in getting the pain medication. There is no evidence of the nursing staff offering alternative pain medication or non pharmacological approaches to alleviate the resident's pain. The certified nurse aide (CNA#1) assigned to care for Resident #19 on 12/31/12 was interviewed on 11/14/13 at 3:30 P.M. The CNA indicated she remembered Resident #19 stating, "I remember spending significantly more time with her...I was repositioning her at least every hour...she didn't like being on her back". When asked if the resident had indicated to her that she was in pain, the CNA stated, "She did ask me about her pain meds...she did say she was uncomfortable...I explained to her my role as a CNA...I told her I can relay this to the nurse". The CNA stated the resident arrived on the unit before dinner, stating "Dinner is served around 5:00 P.M." The CNA recalled the family coming back to visit the resident that evening. CNA#1 stated, "She (Resident #19) would elaborate more when her family was here...she was more emotional". On 11/14/13 at 9:10 A.M., the administrator was asked about Resident #19. She recalled this incident. She stated, "When a new admission leaves within 7 days quality looks into it, or if a resident leaves within 24 hours or against medical advise (AMA) I look into it...it was a pain issue...the nurse could have gotten her (Resident #19) another pain medication like Tylenol, we have standing orders for it...I termed another employee who did not get anything for pain...they could have called the physician". On 11/14/13 at 9:40 A.M., the DON was interviewed. She indicated that Resident #19 had arrived at the facility at approximately 4:30 P.M. The DON stated, "I didn't know anything about it until January first, we were on holiday...this incident was discussed during morning meeting...the family felt she (the resident) was release too early from the hospital...we had a problem getting her pain medication...the nurse was given a final written warning." A second interview with DON was conducted on 11/15/13 at 2:00 P.M. The failure of the nurse to recognize and act upon the abnormal pulse was shared. The DON stated the [MEDICAL CONDITION] have been related to the pain. She stated," the nurse should have notified the physician for the abnormal pulse and for something (pain medication) that was available...in the meantime there was a standing order for Tylenol." The DON indicated the nurse could have contacted the on call nurse for assistance or herself. The DON indicated she was not notified of this event as documented by LPN#1 on 12/31/12. On 11/15/13 at 2:50 P.M., the staff development coordinator (SDC) was interviewed. She stated, "The nurse could have given Tylenol or called the physician". The SDC stated if the pain medication was not available another option was to have called the back up pharmacy, stating, "Pain is the fifth vital sign". The SDC indicated new admission assessments should be initiated and vital signs obtained within one hour of admission. 2. The complainant also alleged Resident #19 did not receive insulin as ordered by the physician on 12/31/12. The clinical record and Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Sliding scale insulin (Humalog) was ordered, 150-200=2 units, 201-250=4 units, 251-300=6 units, 301-350=8 units, 351-400=10 units, > (greater than) 400 give 14 units. There was no evidence the facility obtained the resident's blood sugar before dinner and at bedtime on 12/31/12. Upon admission to the emergency room the resident's blood sugar was 113, normal lab reference is 74-106. On 11/15/13 at 2:00 P.M., the above was shared with the director of nursing. She indicated the nursing staff should have obtained the resident's blood sugar as ordered by the physician. COMPLAINT DEFICIENCY

Based on staff interview, clinical record review and facility document review and during the course of a complaint investigation the facility failed to ensure that 1 resident (Resident #20) of 20 residents in the survey sample was positioned appropriately in an assistive device to prevent an avoidable injury. During transport of Resident #20 in a wheelchair the staff failed to ensure the resident's right foot was propped on the foot rest, the right foot got stuck behind the front wheel and the resident sustained [REDACTED]. Resident #20's clinical record was reviewed as a closed record; the resident was discharged from the facility on 8/03/09. The findings include: Resident #20 was an [AGE] year old originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Osteopenia is a generalized reduction in bone mass that is less severe than that resulting from osteoporosis, caused by the resorption of bone at a rate that exceeds bone synthesis. The current MDS (Minimum Data Set) a quarterly completed on 5/09/09 indicated the resident had long and short term memory deficits with severe impaired daily decision making skills and rarely/ never communicated. The resident was dependent on staff for bed mobility, transfers, feeding, personal hygiene and bathing and had partial loss of limitation on both upper and lower extremities. Resident #20 was wheelchair bound and dependent on staff for locomotion on and off the unit. Under skin conditions the resident was assessed as having desensitized skin to pressure and or pain. A complaint was received in the State Agency office on 5/11/10 alleging that Resident #20 obtained a fracture to the right lower extremity during transport in the wheelchair. Review of the facilities investigation of the incident revealed that the Director of Nurses (DON) interviewed the staff directly involved with the incident and written statements were obtained. The investigation was completed on 5/18/09; the facility determined that the resident obtained a non displaced fracture of the tibial plateau as a result of the resident's right foot getting stuck behind the front wheel of the wheelchair during transport on 5/15/09. The investigation report documented the following conclusion; "Based upon investigation of employees interviewed, it appears that patient (Resident #20) suffered injury during transport in wheelchair (secondary to osteopenia) on 5/15/09. All parties notified and appropriate follow-up care actions pursued". A written statement from the certified nurse aide responsible for placing and transporting Resident#20 in the wheelchair documented the following, "Pt (patient) 107-A was placed in Hoyer lift and then the wrong chair, without pommel cushion (name of second C.N.A) and I stopped when I saw her (Resident #20) leg stuck and dragged a little ..." This C.N.A was no longer an employee and not available for interview. On 9/01/10 at 10:47 A.M., the DON was interviewed. She stated that based on her investigation, "It appeared that the patient suffered an injury during transport in the wheelchair". Following this incident an in-service was conducted. The in-service dated for 5/20/09 was titled, "Positioning in Wheelchair" and focused on the following: 1. Positioning in the wheelchair 2. When pushing down the hallway make sure legs are up, in foot rests and off the floor. The DON stated the injury occurred due to the staff not "paying attention to where her (Resident #20's) legs went ...her foot should have been on foot rests". The DON provided a roster that showed only eleven of the C.N.A.s received the in-service (approximately 25 percent of the C.N.A.s on staff). The DON did not have evidence to show the rest of the C.N.A.s were re-educated. The DON also stated that LPN#2 did not do a thorough assessment of Resident #20's right leg after the C.N.A. reported the change in condition to her. The facilities investigation revealed that on 5/15/09 during the 3 p.m.-11 p.m. shift at approximately 10:30 p.m., the certified nurse aide (C.N.A.#1) had noted and reported to the licensed practical nurse (LPN#2) that the resident's right leg was "discolored". Review of the written statement from C.N.A. #1 stated, "I was doing my last rounds about 10:30 p.m. to 10:45 p.m. I notice her leg was discolored. I told the LPN and she told me to tell the charge nurse witch {sic} I did". Review of the clinical record nurses notes failed to evidence any nursing documentation or assessment on 5/15/09 of the change in condition of Resident #20's leg on the 3 p.m.-11 p.m. or 11 p.m.-7 a.m. shift. See F 281 and F 514 for further details. Resident #20's right leg was not thoroughly assessed until 5/16/09 at 8:45 A.M.. The nurse documented that the resident's right lower extremity was assessed and found to be "edematous (swollen)" with a large ecchymotic area (skin discoloration caused by escape of blood into the tissues from ruptured blood vessels) noted "anteriorally {sic} extending from the knee to above ankle, warmer to touch as compared to the left lower extremity with limited flexion noted. The resident grimaced and moaned when the right leg was manipulated ...the upper outer aspect of the right lower extremity was firm to touch". The physician was paged and an order was received to obtain an x-ray. Review of the x-ray report dated 5/16/09 evidenced that the resident had a non displaced fracture of the right tibial plateau. The resident was sent to out to the emergency room at 4:00 p.m. and returned at 7:00 p.m.. The resident returned with an immobilizer in place and orders for pain medication, Vicodin 5/500 mg one tablet every 6 hours as needed and a follow up orthopedic appointment for 5/18/09. Resident #20's representative party was contacted on 9/03/10 at 3:45 p.m., and interviewed. She stated that the DON reported to her that the resident sustained [REDACTED]. On 9/2/10 at 3:15 p.m., Resident #20's attending physician who is also the medical director was interviewed. When asked if the facility had reported to him their findings of the investigation of the fractured leg he stated he did not recall. The investigation results were reviewed with the physician, he stated, "if that is what the facility said happened (the resident's leg getting stuck behind the wheelchair wheel) it is possible to have obtained a fracture that way ". On 9/2/10 at approximately 4:00 p.m., an interview with the administrator and the DON was conducted. The administrator stated, "It happened ...we acknowledge it ...it was an unfortunate isolated occurrence". A list of incidences and accidents resulting from Hoyer lifts and wheelchairs was asked for to review. On 9/3/10 at approximately 9:00 a.m., the administrator provided to the surveyor a list of incidences involving Hoyer lifts and wheelchairs from 5/09 through 8/10. Two incidences from the Hoyer and one from the wheelchair were noted, each resulted in skin tears. During the survey other resident's in the survey sample were observed during Hoyer lift transfers and wheelchair transport without incidence. COMPLAINT DEFICIENCY