Every finding on record at Oak Ridge Health and Rehabilitation

Number of residents sampled: Number of residents cited: Based on record reviews, observations, interviews, and facility policy review the facility failed to ensure oxygen was administered at the flow rate ordered by the Physician to reduce the potential for respiratory complications for one (Resident #74) of one resident reviewed. The findings include: Review of Resident #74's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/14/2026, revealed Resident #74 had diagnoses which included chronic obstructive pulmonary disease (COPD) [disease of the lungs with damaged or inflamed airways and air sacs making it difficult to breathe], respiratory failure and sleep apnea. The MDS revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 15 which indicated Resident #74 was cognitively intact. The MDS also revealed Resident #74 could transfer, ambulate 10 feet and propel in a wheelchair independently. The MDS also indicated Resident #74 received oxygen therapy. Review of an Order Summary Report dated 03/18/2026, revealed Resident #74 had a Physician's Order for oxygen as needed for shortness of breath at two liters per minute per nasal cannula with a start date of 07/15/2025. The Order Summary Report also indicated Resident #74 had an order to check pulse oximetry (ox) every shift with a start date of 07/15/2025. Review of Resident #74's Care Plan with a revised date of 01/07/2026, revealed Resident #74 had altered respiratory status/difficulty breathing related to COPD. The Care Plan included interventions to administer medications/puffers as ordered with a goal indicating the residents pulse oximetry would remain above 90%. The Care Plan did not indicate Resident #74 was able to, or been known to, adjust the oxygen flow rate independently. Review of Resident #74's March 2026 Medication Administration Record (MAR) did not indicate the resident had used oxygen and did not show any pulse oximeter results. Review of Nurse's Progress Notes for Resident #74 from 02/01/2026 to 03/19/2026, revealed no documentation that Resident #74 had previously adjusted the oxygen flow rate themselves. During an observation and concurrent interview on 03/16/2026 at 12:23 PM, Resident #74 was observed lying on the bed with oxygen in use at a rate of four liters per minute by nasal cannula. Resident #74 stated they wore oxygen all the time. During an observation and concurrent interview on 03/17/2026 at 9:14 AM, Resident #74 was observed sitting up in bed with oxygen in use at a rate of four liters per minute by nasal cannula. Resident #74 stated they used oxygen all the time except when they went out to smoke. The resident was asked if she puts the oxygen on herself and she stated she did. This surveyor asked Resident #74 if the resident set the rate of oxygen themselves and Resident #74 stated, no I put it on, but it is already set up for me. During an observation on 03/18/2026 at 12:00 PM and 03/19/2026 at 11:40 AM, Resident # 74 was in their room on the bed with oxygen in use at four liters per minute by nasal cannula. During an interview on 03/19/2026 at 11:46 AM, Licensed Practical Nurse (LPN) #1 observed Resident #74's oxygen flow rate and indicated to the surveyor that it was set at four liters per minute. LPN #1 indicated Resident #74 used oxygen all the time and that all the nurses were responsible for routinely checking the oxygen flow rate. LPN #1 stated the rate should be checked every shift. LPN #1 was asked what the Physicians Order indicated Resident #74's oxygen flow rate should be set at. After reviewing the electronic record LPN #1 stated it should be set at two liters. LPN #1 was asked if Resident #74 changed the oxygen flow rate themselves and she stated the resident puts the oxygen on and takes it off, but she was not aware that the resident alters the rate. LPN #1 stated that she needed to correct the flow rate because Physicians Orders were very important and should be followed. During an interview on 03/19/2026 at 11:57 AM, LPN #2 indicated the nurse was responsible for ensuring the oxygen was set at the correct flow rate and the flow rate should be checked whenever the nurse goes in to see the resident. LPN #2 stated, when residents were on oxygen continuously the resident's oxygen saturation was checked every shift and the nurse should check the rate when she was checking the residents' oxygen saturation. LPN #2 indicated Physicians Orders regarding oxygen flow rate should be followed to ensure that the resident does not get too much oxygen and to make sure they get enough oxygen. During an interview on 03/19/2026 at 12:02 PM, the Director of Nursing (DON) indicated Resident #74 used oxygen on an as needed basis when they were in their room and the resident would take it off when they went out to smoke. The DON was asked what Resident #74 oxygen flow rate should be set at and after looking at the electronic record the DON stated the oxygen flow rate should be set at two liters as needed. This Surveyor asked the DON who was responsible for ensuring oxygen was set at the correct flow rate and the DON indicated the nurses should be checking the flow rate. The DON stated, It is especially important when residents are taking their oxygen on and off. The residents that take their oxygen off or adjust it should be checked multiple times per day. The DON was asked if Resident #74 adjusted their own oxygen flow rate and the DON stated the resident turns it on and off, but she had not seen the resident adjust the flow rate. The DON was informed that during the surveyor's observations of the resident the oxygen flow rate had been set at four liters per minute and the DON stated, she would have to investigate to see if the resident was adjusting it, but it was not Care Planned for the resident to self-administer the oxygen. The DON stated, I will be looking into it, interviewing and watching, but I will go now and ensure it is on the correct rate. The DON was asked for a policy on oxygen use. Review of a facility policy titled, Oxygen Administration with a revised date of October 2010, indicated that the purpose of this procedure is to provide safe guidelines for oxygen administration. The staff should verify there is a physician's order for oxygen and adjust the oxygen delivery device so that the proper flow of oxygen is being delivered. After completing the oxygen set up the oxygen flow rate, route, and residents' tolerance of procedure should be documented in the resident's medical record. Review of the American Association for Respiratory Care Clinical Practice Guidelines for use of Oxygen in the Home and Alternative Site Health Care Facility such as Skilled Care Facilities or Extended Care Facilities indicated oxygen is a medical gas and should only be administered in accordance with doctor's orders. Measurements of baseline oxygen tension and/or saturation is essential before oxygen therapy is begun and these measurements should be repeated when clinically indicated or to follow the course of the disease as determined by the attending physician. There is a potential in patients with chronic obstructive pulmonary disease that oxygen administration may lead to respiratory problems due to altered carbon dioxide levels in the blood.

Based on observations, record review, and interview, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety. The finding are: On 9/23/24 at 10:16 AM, and again on 9/24/24 at 10:15 AM, a half-cut watermelon dated 9/18/24 was observed stored on the top shelf of the refrigerator. On 09/23/24 at 10:18 AM, the surveyor observed two boxes of ice cream that were not dated. The Dietary Manager (DM) dated the boxes and said they were for activity. On 09/24/24 at 10:15 AM, the surveyor observed eggs stored on the 2nd shelf of the refrigerator with a large bin of prepared potato salad sitting below the eggs. The Dietary Consultant (DC) moved the eggs to the bottom shelf and stated they should not be stored on that shelf but should be stored on the bottom shelf. On 9/25/24 at 9:50 AM, the DM informed the surveyor the eggs were regular eggs and were used for baking. On 9/23/24 at 10:20 AM, the surveyor observed a freezer bag of frozen waffles sitting on the shelf in the freezer were not sealed, leaving the waffles exposed. On 9/23/24 at 10:21 AM, and again on 9/23/24 at 11:47 AM, the surveyor observed 9 bowls of prepared dry cereal were sitting on the pantry shelf not sealed. On 9/23/24 at 10:22 AM, the surveyor observed a large bin of sugar sitting in the pantry with the bin lid not secured to the container, leaving the sugar exposed. On 9/23/24 at 10:22 AM, and again at 11:35 AM, the surveyor observed a dented can of evaporated milk sitting on the shelf in the pantry that was used to store food intended to be served to the residents. On 9/23/24 at 10:45 AM, the surveyor and DM checked the ice machine. The DM wiped the top of the inside of the ice machine with a white napkin. A black substance came off on the white napkin. The DM stated the substance was mold. A sign on the right side of the ice machine indicated the ice machine had been cleaned on 8/20/24. On 09/23/24 at 12:41 PM, Certified Nurse Assistant (CNA) #3 was observed serving a cup of orange drink in the unit dining room to Resident #61 with 2 fingers resting on the rim of the cup and the right palm was resting over the fluid. CNA #3 stated she has not been told a process for serving residents but confirmed she probably should have held the cup from the bottom sides to prevent the resident from drinking where her fingers had been, because it put the resident at risk for cross contamination. On 9/24/24 at 11:04 AM, the [NAME] conducted a sanitization test of the 3-compartment sink with the Parts Per Million specific disinfectant strip, then took bread from the meal prep area and began to prepare peanut butter and jelly sandwiches holding the bread slices with his bare hands. The [NAME] did not wash his hands between the task of testing the sanitizer in the sink and preparing the bread with peanut butter. The [NAME] then went to the pantry area and brought back a container of jelly. The [NAME] did not wash his hands. The [NAME] picked up the bread slices with his bare hands and began to spread the jelly on the bread. The surveyor interviewed the [NAME] and asked him if he had washed his hands between the task, the [NAME] said he had not. The DM informed the [NAME] he could not use his bare hands to prepare the sandwiches. On 9/24/24 at 10:29 AM, the Dietary Aide (DA) was stacking the resident dinner plates in the plate cart with her bare hands. The DA picked the plates up with her fingers on the surface of the plate. The surveyor asked her why it was a problem to pick the plates up with her fingers. The DA said it can cause cross contamination because the residents have to eat out of them. On 09/24/24 at 2:47 PM, the DM checked the inside of the ice machine. She swiped the inside of the ice machine with a white paper towel. A black-pinkish substance came off on the white paper towel. The DM said her concern was cross contamination for the residents. On 9/24/24 at 10:39 AM, the wall adjacent to the dishwasher room, inside the kitchen was covered with a rust-colored substances running down the wall behind a shelf containing the cleaned dishes and tea pitchers.

Based on observation, and interview it was determined that the facility failed to ensure the tub room door on the Memory Unit was locked to ensure vulnerable residents were free from accidents and injuries, affecting 5 (Resident #25, #41, #56, #61, and #73) sampled residents. Findings include: A review of a policy titled Secure Neighborhood Policy & Procedure Manual, revealed that doors to the exits, janitor closets, mechanical rooms, and shower rooms will not be left unlocked, disengaged, or propped open. On 09/23/24 at 11:21 AM, the tub room door across from the nurse's station in the Memory Unit was observed ajar with one resident considered an elopement risk wandering the hallway. Licensed Practical Nurse (LPN) #1 accompanied the surveyor to the tub room door, and LPN #1 revealed dirty linens are stored in the tub room, and stated the door is supposed to be locked to keep the residents out, because a resident could fall in the tub, or otherwise get hurt in the tub room. During an interview with Director of Nursing (DON), she revealed the process for maintaining the tub and shower rooms were to keep them clean, and locked so that residents do not have access. The DON confirmed there are dirty linens stored in the tub room that residents should not be touching, and if the door shuts residents may not be able to get out, they could fall in the floor or the tub and harm themselves.

Based on observation, record review and interview, the facility failed to ensure menus were prepared and followed for 1 of 2 meals observed. The findings are: On 9/24/24 at 1:10 PM, the menu for the noon meal was barbeque beef tips, baked potato salad, fried okra, Texas toast and ice cream. The surveyor observed the meal service of the noon meal. The [NAME] reported the kitchen had run out of barbeque beef tips before all residents were served the lunch meal. The last 4 meal trays prepared from the food line were served chicken nuggets. The Surveyor interviewed Resident #76, who was served chicken nuggets instead of the beef tips indicated on the menu, and the resident said they would rather have had the barbeque beef. The Dietary Manager said she did not know how they ran out of beef tips because they prepared the same number of beef packages as always. On 9/24/24 at 1:45 PM, the surveyor asked the [NAME] why is it important to ensure you have enough food prepared to serve all residents the planned meal. The [NAME] said residents are supposed to get what is on the menu, as this is their home. The [NAME] said he did not know what why they ran out of food because he had prepared the same amount of food he always did.

Based on observation, and interview, the facility failed to ensure a qualified dietitian was utilized in overseeing meal preparation, menu planning, and managing dietary operations to prevent foodborne illnesses, and sanitation. This failed practice had the potential to affect 72 residents that receive meals from the kitchen according to a list provided by the administrator on 11/02/23 at 3:34PM . The findings are: 1. On 11/01/23 at 02:32 PM The Dietary Manager [DM] told the surveyor that she is not a certified dietary manager. DM said, I'm currently in classes for Safe Serve then I'll take other classes. 2. On 11/01/23 at 02:32 PM The surveyor spoke with the Administrator and asked what their process was for ensuring the dietary manager received certification. The Administrator told the surveyor that the DM was in the process of getting the certification. 3. On 11/03/23 a form titled Job Description, Director of Food Service/Dietary Manager/ Supervisor . Education: Be a graduate of an accredited course in dietetic training approved by the American Dietetic Association . Must be registered as a food service Director in the state .

Based on observation, record review and interview, failed to ensure dented food cans were promptly removed/ discarded to prevent the growth of bacteria; 1of 1 ice scoops were maintained in a clean and sanitary condition to prevent potential contamination of residents' beverages for residents who received meals from 1 of 1 kitchen; foods stored in the freezer, refrigerator and dry storage area were covered, sealed, and dated to minimize the potential for food borne illness for residents who received meals from 1 of 1 kitchen; expired food items were promptly removed /discarded on or before the expiration or use by date to prevent the growth of bacteria; fan in preparation area and air conditioner above clean dish washing area were not maintained in a clean and sanitary condition to prevent potential contamination of residents' food for residents who received meals from 1 of 1 kitchen, ensure the three compartment sink dishwashing temperatures were at level to kill and prevent the growth of bacteria for 1 of 1 kitchen and hot food was maintained at 135 degrees or above to prevent potential food borne illness for residents who received meals from 1 of 1 kitchen. These failed practices had the potential to affect 72 residents who receive meals from the kitchen (total census: 77) as documented on a list provided by Administrator on [DATE] at 3:34 PM. The findings are: 1. On [DATE] at 10:48 AM The following observations were made on a shelf in the stand-up refrigerator. a. 3 premade and wrapped sandwiches with no preparation date b. pitcher covered with aluminum foil of pear slices dated [DATE]. c. sliced turkey in plastic zipper bag with bag not sealed. d. chopped lettuce in plastic bag not sealed and open to air. e. Prepared (flavored drink) in pitcher without a preparation date f. raw bacon stored on top shelf of refrigerator in 2 plastic zipper storage bags and in box. g. bag of 5 premade waffles stored directly on top of raw bacon. h. 7 bowls of prepared salads with no date on any bowl i. lettuce and tomatoes dated [DATE] stored under raw bacon. 2. On [DATE] at 10:55 AM The following observations were made on a shelf in the stand-up freezer. a. Plastic zipper storage bag of smoked sausage open and not sealed. b. plastic bag of chicken patties open and not sealed. c. bag of veggies that have been refrozen with no opening date. d. banana and chocolate cream pie has no receive date on package. e. Three Quart containers of orange sherbet without receive date. f. Three packages of raw cookie dough with no receive date. 3. On [DATE] at 10:59 AM The following observations were made on a shelf in the walk-in refrigerator. a. large bag of spinach laying on shelf not sealed open to air. b. One pound block of butter in box with cabbage no receive date On [DATE] at 11:02 AM The following observations were made on a shelf in the dry storage room. a. a one gallon can of cream style corn dented in rack and mixed with other cans. b. a one gallon can of diced potatoes dented in rack and mixed with other cans c. Nine 46 oz jugs of honey thickened tea with an expiration date of [DATE] d. Open package of cherry gelatin wrapped in plastic wrap without an open date and not bagged. e. Open package of lemon pudding wrapped in plastic wrap without an open date and not bagged. f. large bag of vanilla wafers no open date and not in a sealed bag g. 8 tortilla shells without an open date wrapped in plastic wrap. On [DATE] at 11:05 AM The dietary manager was asked, What do you do when you receive dented cans from the supplier? Dietary Manager replied, We place the dented cans to the side and let the truck driver know. Dietary Manager was then asked, How often do you or your staff check for expired items? Dietary Manager replied, Supposed to check for expired items with truck on Mondays and Thursdays. On [DATE] at 11:08 AM The following observations were made on a shelf in the walk-in freezer. a. bag of breaded squash not sealed and open to air b. an opened box of uncooked chicken on top of an open box of cooked diced chicken c. Three gallon container of orange sherbet without an open date, appears to have been melted and refroze with ice crystals on top On [DATE] at 10:31 AM Dietary Worker #1 washed 2 pans, spatula, whisk, and ladle in premade dish water in 3 compartment sink. Dietary Worker #1 did not rinse the dishes after washing but went straight to the sanitizer before the drying rack. Surveyor asked the Dietary Manager to obtain temperatures of the dish water and sanitizer water. The findings were wash water was 108.3 and sanitizer water was 91.2. Surveyor also asked the Dietary Manager to use the Quaternary Ammonium Compounds (QAC) test strip to test the sanitizer water. The findings revealed the parts per million was between ,d+[DATE]. The surveyor asked the Dietary Manager What is the wash and sanitizer water temp supposed to be? Dietary Manager replied I'm not sure. Also there was supposed to have been a rinse in the middle with sanitize in the third compartment. On [DATE] at 10:40 AM Surveyor made observation with Dietary Manager and observed the ice scoop in metal rack on the wall beside the ice machine. The scoop is open to air and not covered. A jug of sliced pears with aluminum foil over the top in the refrigerator dated [DATE]. On [DATE] at 11:04 AM Multiple dietary staff noted using the ice scoop to serve ice for the lunch meal pass for drinks. On [DATE] at 11:36 AM The temperature of the food items when checked on the steam table by the Dietary Employee (DE) #1 was chicken fritters 133.1 degrees Fahrenheit, Pureed Carrots 130.1 degrees Fahrenheit, Pureed Noodles 133.1 degrees Fahrenheit. The above food items were not reheated before being served to the residents. On [DATE] at 11:40 AM The air conditioner in the dish washing area and ceiling fan above the preparation table near the stove and fryer are thickly coated with a black/grey substance. On [DATE] at 02:27 PM Dietary worker #3 was asked, how should food be stored after being opened? Dietary Worker #3 replied in a container with a lid with name, date, initials and expiration date. Surveyor asked, how are hazardous foods stored such as raw meat? Dietary Worker #3 replied, covered on the bottom shelf dated and labeled. Surveyor asked, What is the process for dented cans? Dietary Worker #3 replied, date and set to the side. Surveyor asked, once food is brought out of the freezer and thawed how should it be re -stored? Dietary Worker #3 replied, refrigerate the food. Surveyor asked, how often is the deep fryer cleaned? Dietary Worker #3 replied, the deep fryer is cleaned one time a week. Surveyor asked, how is the ice scoop stored? Dietary Worker #3 replied, the ice scoop should be placed in the holder. Surveyor asked, how often do you check the food storage area for expiration dates? Dietary Worker #3 replied, expiration dates are checked daily. Surveyor asked, how long is leftovers stored before being discarded? Dietary Worker #3 replied, left overs are stored for three days. Surveyor asked, In a three department sink when washing dishes what should the temperatures be for wash, rinse and sanitize? Dietary Worker #3 replied, wash 160 degrees Fahrenheit, rinse 140 degrees Fahrenheit, I do not know the temperature of the sanitize solution. Surveyor asked, what should the parts per million (ppm) for the rinse solution be? dietary worker #3 replied, 200 ppm. On [DATE] at 02:31 PM Surveyor asked Dietary Manager, how should food be stored after being opened? Dietary Manager replied, in a plastic bag and dated. Surveyor asked, how are hazardous foods stored such as raw meat? Dietary Manager replied, all raw meats on bottom shelf and all other foods stored above the raw meats. Surveyor asked, once food is brought out of the freezer and thawed how should it be re -stored? Dietary Manager replied, raw veggies from freezer should be stored in a bag in the refrigerator and not back in the freezer. Surveyor asked, how often is the deep fryer cleaned? Dietary Manager replied, the deep fryer is cleaned on Wednesday or Thursday. Surveyor asked, How is the ice scoop stored? dietary manager replied, the ice scoop should be stored facing the wall in a rack. We used to have a bucket with a top on it. Surveyor asked, how long is leftovers stored before being discarded? dietary manager replied, leftovers are stored for three to seven days. Surveyor asked, what should the temperature of foods be at serving time? dietary manager replied, The beef should be greater than 155 degrees Fahrenheit, pork should be 160 degrees Fahrenheit, veggies 140 to 155 degrees Fahrenheit or higher, fish 150 degrees Fahrenheit or higher. Cold deserts should be less 41 degrees Fahrenheit.

Based on observation, interview, and record review the facility failed to ensure that the facility provided privacy to promote dignity for 1 (R#58) of 1 sampled resident who had a catheter and for 1 (R#228) of 7 (R#228, 17, 35, 23, 27, 72, and 13) sampled residents who reside on section D hall. The findings are: 1. a. On 10/30/23 at 12:23 PM, Resident #58 had a foley catheter bag hanging on the side of the bed with no privacy cover. The urine drainage bag was visible from the door for visitors and other residents to see. b. On 10/31/23 at 08:17 AM, Resident #58 had a foley catheter bag hanging on the side of the bed with no privacy cover. The urine drainage bag was visible from the door for visitors and other residents to see. c. On 11/01/23 at 08:28 AM, Resident #58 had a foley catheter bag hanging on the side of the bed with no privacy cover. The urine drainage bag was visible from the door for visitors and other residents to see. d. According to annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) dated 09/22/2023 states under section H0100. Appliances, resident has an indwelling catheter. e. A physician order dated 08/24/2023 states Foley french 18 FR [French] and bulb 30 cc [cubic centimeters]: change foley cath [catheter] Q [every] 30 days PRN [as needed] leakage obstruction or patient removal every day shift every 30 day 2. a. On 10/30/23 at 11:49 AM, Resident #228 in bed uncovered with brief undone wearing only a T-shirt with multiple staff and residents going past room in hallway. b. On 10/30/23 at 12:04 PM, Resident #228 remained in bed uncovered with brief undone. Resident across the hall was staring at resident exposed. Multiple staff members had walked past the resident room. c. On 10/31/23 at 08:23 AM, Resident #228 was sitting up on the side of the bed with only a T-shirt and brief on and uncovered. The door was open with other residents going by and staff walking up and down the hall. d. A care plan with initiation date of 10/23/2023 stated, The resident has impaired cognitive function/dementia or impaired thought processes as evidenced by .related to Dementia. e. On 10/30/23 at 12:50 PM, during representative interview Resident #228 family member stated, I dressed him when I got here. On 11/02/2023 at 2:40 PM, the Surveyor asked the certified nursing assistant (CNA) #2, how should a residents foley catheter drainage bag be placed? The CNA replied, placed on the side of the bed below the bladder or under the wheelchair with a privacy bag. The surveyor asked, why should the catheter bag be placed in a privacy bag? The CNA replied, it's a dignity issue, they don't want others to see a bag of pee under them. The Surveyor asked, what would your expectation be for a resident who is in their room and not fully clothed? The CNA replied, ask them why their clothes are not on if they can answer and if they cannot then cover them up or put clothes on them. The Surveyor asked, what is the reason you would cover them or put clothes on? The CNA replied, It's a dignity issue they can be in their room undressed with their door we don't want others to see to the naked in their room. On 11/02/2023 at 2:42 PM, the Surveyor asked the Licensed Practical Nurse (LPN) #3, how should a residents foley catheter drainage bag be placed? The LPN replied, the foley catheter should be placed below the bladder. The surveyor asked, should the catheter bag have a privacy cover? The LPN replied, Yes, it should have a privacy cover. The Surveyor asked, why should it have a privacy cover? The LPN replied, for resident privacy. The surveyor asked, what would your expectation be for a resident who is in their room and not fully clothed? The LPN replied, go in there and give them privacy so others don't see them. The Surveyor asked the Director of Nursing (DON), how should a residents foley catheter drainage bag be placed? The DON replied, placed below the bladder. The surveyor asked, should the catheter bag have a privacy cover? The DON replied, yes, it should have a privacy cover over bag. The Surveyor asked, why should it have a privacy cover? The DON replied, there should be a privacy cover for the resident's privacy. The surveyor asked, what would your expectation be for a resident who is in their room and not fully clothed? The DON replied, provide privacy for dignity and pull curtain or close door. On 11/02/2023 at 3:34 PM, A policy titled, Quality of Life-Dignity states .10. Staff shall promote, maintain, and protect resident privacy, including bodily privacy .a. helping the resident to keep urinary catheter bags covered .

Based on observation, and interview, the facility failed to ensure expired and unlabeled medications were removed from the medication cart and placed into an area for destruction to prevent potential administration to residents. This failed practice had the potential to affect 19 residents who receive medications from the D hall medication cart, according to a list provided by the Administrator on 11/03/23 at 8:39AM. The findings: 1. On 11/02/23 at 2:11pm., the facility's medication room was inspected with Assistant Director of Nurses (ADON) and Licensed Practical Nurse (LPN) #1. There were 2 (two) pens of Basaglar Insulin, opened with the expiration dates of 03/03/23 and 10/04/23. A bottle of Latanoprost without a resident's name opened with no opened date and a 3-ounce bottle (half full) of Saline Nasal Spray without a resident's name or open date on the bottle. 2. On 11/02/23 at 2:38PM, LPN #2 was asked if expired medications and medications without a resident's name be stored in the medication cart. LPN #2 stated 'No, because expired medications can cause an adverse reaction and if there is no label on the medication then someone could get the wrong medication or wrong dose. 3. On 11/02/23 at 3:11PM, the Director of Nursing (DON) was asked to explain the importance of keeping the medication carts inspected. The DON stated to ensure its clean, organized, and expired meds removed so new ones could be ordered. The DON was asked why it is important to remove all expired medication and medications without names on them be removed from the cart. The DON stated, there could be issues if given the wrong resident and expired meds could cause issues. 5. A facility policy titled, Storage of Medication, received from the Administrator on 11/02/23 at 3:34 p.m., documented, .1 Drugs and biologicals shall be stored in the packaging containers or other dispensing systems in which they are received.3 Drug containers that have missing, incomplete . Labels shall be returned to the pharmacy for proper labeling and storing.#4. The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed .

Based on record review and interview, the facility failed to provide pneumococcal immunizations as required or appropriate for 3 (Resident #49, #51, #62) of 5 (#49, #51, #62, #42, #65) sampled residents whose records were reviewed for the receipt of pneumococcal immunizations. The findings are: 1. On 11/01/23 at 03:10 PM, Review of Resident #49's electronic record documented a Participation in Immunization Programs consent form signed by the representative with no date. The form documented, .I authorize the facility to administer a one time pneumococcal vaccine to me . The resident's record did not document the receipt of a Pneumococcal vaccine. 2. On 11/01/23 at 03:20 PM, Review of Resident #51's electronic record documented a Participation in Immunization Programs consent form signed by the representative with no date. The form documented, . I authorize the facility to administer a one time pneumococcal vaccine to me . The resident's record did not document the receipt of a Pneumococcal vaccine. 3. On 11/01/23 at 03:30 PM, Review of Resident #62's electronic record documented a Participation in Immunization Programs consent form initialed by the resident with no date. The form documented, .I authorize the facility to administer a one time pneumococcal vaccine to me . The resident's record did not document the receipt of a Pneumococcal vaccine. 4. On 11/01/23 at 04:02 PM, the Director of Nursing (DON) was asked to provide the dates in which Resident #49, 51 and 62s' Participation in Immunization Programs Consent forms were signed or initialed and documentation of the receipt of Resident #49, 51 and 62's Pneumococcal vaccines. 5. On 11/02/23 at 10:24 AM, the DON provided Resident #49's Participation in Immunization Program Consent form dated 5/9/23. The DON did not provide documentation of the administration of a pneumococcal vaccine for Resident #49. The DON also provided Resident #51's Participation in Immunization Program Consent form dated 5/2/23. The DON did not provide documentation of the administration of a pneumococcal vaccine for Resident #41. The DON also provided Resident #62's Participation in Immunization Program Consent form dated 12/8/22. The DON did not provide documentation of the administration of a pneumococcal vaccine for Resident #62. 6. On 11/02/23 at 03:07 PM, the DON was asked to review Resident #49's record and was asked, when was their pneumococcal vaccine given? She answered, We gave it today. She was asked to review Resident #51's record and was asked, when was their pneumococcal vaccine given? She answered, We gave it today. She was asked to review Resident #62's record and was asked, when was their pneumococcal vaccine given? She answered, We gave it today. I came here in January. I am trying to get things in place. I was going to do a vaccine audit but you came before I could get it done. She was asked, do you know that your policy states that you will give the pneumococcal vaccines within 30 days of their admission? She answered, Yes. 7. A Policy titled, Pneumococcal Vaccine which was provided by the Administrator on 10/30/23 at approximately 3:00 PM documented, Prior to or upon admission, residents will be assessed for eligibility to receive the Pneumovax (pneumococcal vaccine) and when indicated, will be offered the vaccination within thirty (30) days of admission to the facility unless medically contraindicated or the resident has already been vaccinated .

Based on record review and interview, the facility failed to comprehensively assess the resident's physical, mental and psychosocial needs to identify risks and impact of the resident function for 1 (Resident #51) of 16 (Resident #49, 51, 42, 44, 30, 14, 16, 67, 35, 228, 58, 70, 27, 62, 72, 13) sampled residents whose comprehensive assessments were reviewed. The findings are: 1. A Progress Note for Resident #51 dated 7/24/23 at 14:23 (2:23 PM) documented, Incident Description: This nurse and CNAs [Certified Nursing Assistants] clearing tables after noon meal service when alerted by dietary manager that resident had fallen. Resident seen lying on left side on floor with blood oozing from forehead, rollator walker within reach and resident wearing non-skid socks. The Dietary Manager stated that resident was attempting to get up from dining table when her legs got crossed up and she fell . Immediate Intervention: CNA retrieved towels to contain flow of blood. Head to toe assessment and ROM [range of motion] done to upper and lower extremities before resident assisted from floor and into wheelchair by this nurse and CNA. While this nurse and CNA were assisting resident, dietary manager called DON [Director of Nursing] who came to assist. Neuro check was performed and 2 cm [centimeter] skin tear noted to left forehead was cleaned with skin cleanser. Resident taken to room to be cleaned up and helped to bed during which she c/o [complaint of] left hip pain. Resident transported to (Named Hospital) for evaluation. 2. A Progress Note for Resident #51 dated 7/30/23 at 21:29 (9:29 PM) documented, Note Text: Received report from nurse on 3rd floor at (Named Hospital) around 12:20 that resident would be returning to [Named Facility] via non emergency transport. Nurse reports resident underwent a Endoprosthesis Hip Replacement surgery on August 26, 2023 . 3. A History and Physical form dated 7/24/23 documented, .She complained of left hip pain after a fall. She was brought to the ER [emergency room ] and had x-rays which revealed that she has a fracture to their left hip . 4. The Significant Change in Status (SCSA) Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/6/23 documented Resident #51 had no falls since prior assessment. Recent surgery requiring active SNF (skilled nursing facility) care - hip replacement. 5. A Care Plan with a revision date of 7/25/23 documented, The resident has had an actual fall on 05/16/2023 . I had an actual fall on 07/11/2023 . I had an actual fall on 07/15/2023 . I had an actual fall on 07/21/2023 . I had an actual fall on 07/24/2023 . I had another fall on 07/24/2023 . I had another fall on 10/31/2023 . 6. A Care Plan initiated on 7/31/23 documented, The resident has an alteration in musculoskeletal status R/T [related to] left hip fracture . 7. On 11/02/23 at 04:13 PM, MDS Coordinator #2 was asked, what is the purpose of the MDS? She answered, To set a plan of care that is individualized based on the diagnosis and the resident needs. She was asked, should the MDS be accurate? She answered, Yes. She was asked to review Resident #51's SCSA MDS with ARD 8/6/23 and was asked, did the resident have a fall since prior assessment? She answered, Yes. I should have caught that. 8. The Centers for Medicare & Medicaid Services Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual Version 1.18.11 October 2023 documented, .Medicare and Medicaid participating LTC facilities are required to conduct comprehensive, accurate, standardized and reproducible assessments of each resident's functional capacity and health status. To implement this requirement, the facility must obtain information from every resident. This information is also used by the Centers for Medicare & Medicaid Services (CMS) to ensure that the facility meets quality standards and provides appropriate care to all residents. 42 CFR S483.20, requires LTC facilities to establish a database, the Minimum Data Set (MDS), of resident assessment information .

Based on observation, record review and interview, the facility failed to complete a Significant Change in a Minimum Data Set (MDS) after a decline in two or more Activities of daily living (ADL) for 1 resident (R#35) of 17 sampled residents (R#s, 44, 30,14, 16, 67, 35, 228, 58, 49, 70, 51, 24, 27, 62, 72, 13, & R#42) whose MDS's were reviewed. This failed practice had the potential to affect 77 residents in the facility as documented on the Resident Listing Report provided by the Administrator on 10/30/23 at 10:37 AM. The findings are: 1. On Resident #35's quarterly, MDS with an assessment reference date (ARD) of 04/27/23, it was documented that the resident required no help for bed mobility, independent with set up help only with eating. Resident was independent with no help needed for transfers and Supervision with 1 person assist for toileting. 2. On Resident #35's quarterly, MDS with an ARD date of 07/28/23 it was documented that resident #35 was a limited assist with 1 person assist with bed mobility, independent with setup help only with eating. Resident is an extensive assistance with 2- person assistance with transfers and extensive assistance with 1 person assist with toileting. 3. On 11/2/23 at 9:50 AM, the Surveyor asked the Minimum Data Set Coordinator (MDSC) if she could look in the electronic record at the last 2 (two) MDS in section G (4/27/23 and 7/28/23). The MDSC was asked to explain when a significant change should be done. The MDSC stated, when you notice a change in 2 (two) or more areas, then you monitor for 14 days then if there is no returning to normal baseline then you do a significant change. He had a decline in 3 (three) areas actually. The MDSC was asked if a significant change would have been necessary. The MDSC stated, Yes, we should have done one, it's been 3 months. 4. On 10/2/23 at 02:55 PM, the Director of Nurses (DON) was asked if she expected the MDSC to accurately code the MDS. The DON stated, Yes. The DON was asked to explain when a Significant Change should be completed. DON stated, when there is a decline in 2 or more areas. The DON was asked if a MDS was done in April then again in July and there were declines, what should have occurred. The DON stated, a significant change MDS. 5. On 10/2/23 the Surveyor asked the MDSC for a policy on Significant Changes, the policy provided did not meet the criteria needed. 6. Documented from, LONG-TERM CARE FACILITY RESIDENT ASSESSMENT INSTRUMENT 3.0 USER'S MANUAL- Version 1.17.1 October 2019, A significant Change is a major decline or improvement in a resident's status that will not normally resolve itself without intervention . A significant change is appropriate if there are either two or more areas of improvement or decline .

Surveyor: [NAME], [NAME] Based on observation, interview and record review the facility failed to ensure the Minimum Data Set (MDS) was coded accurately to reflect the resident's restraint status for 1 sampled resident (R#27). This failed practice had the potential to affect 77 residents who required MDS assessments, according to the Resident Listing Report provided by the administrator on 10/30/2023 at 10:37 AM. The findings are: a. Resident #27 had a diagnosis of unspecified Sequelae of Cerebral Infarction, and Cerebrovascular Disease, unspecified. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/22/23 documented the resident was coded for Physical Restraints under Section P0100. The restraints coded were bed rails used in bed daily. b. On 10/31/2023 at 08:53 AM Surveyor entered resident #27's room and made observation that the resident did not have side rails on the bed. c. On 11/01/23 at 09:02 AM Minimum Data Set Coordinator (MDSC) was asked to access resident #27's Minimum Data Set (MDS) and look in the restraint section. MDSC stated Resident #27 should not have any restraints coded. Surveyor asked, What is coded for restraints on the MDS? MDSC stated, Bed rails is coded as used daily. Surveyor asked MDSC, Does Resident #27 use side rails? MDSC replied, No, Resident #27 does not use side rails. Surveyor then asked, Should side rails be coded on the MDS? MDSC replied, No, side rails should not be coded on the MDS. d. On 11/01/23 at 09:22 AM Director of Nurses (DON) was asked to explain the process of building an MDS. DON replied, The nurse assesses the resident when admitted and build the MDS from there. Surveyor asked the DON, Should the MDS be coded accurately? Why? DON replied, Yes, it should be coded correctly because it is an assessment for billing and for residents care. Surveyor asked, If a resident is coded for side rails on the MDS and they don't use them, is that a coding error? DON replied, Yes, that is an MDS coding error. e. According to the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual. It states .Medicare and Medicaid participating LTC (Long-term care) facilities are required to conduct comprehensive, accurate, standardized and reproducible assessments of each resident's .

Based on observation, record review and interview, the facility failed to reassess the effectiveness of interventions and review and revise the care plan to meet the resident's needs for 1 (Resident #42) of 16 (#49, 51, 42, 44, 30, 14, 16, 67, 35, 228, 58, 70, 27, 62, 72, 13) sampled residents whose care plans were reviewed. The findings are: 1. On 10/30/23 at 12:29 PM, Resident #42 was sitting in a wheelchair in the room with facial hair measuring approximately 1/4 of an inch on the chin area. 2. On 10/30/23 at 04:41 PM, Resident #42 was sitting in a wheelchair in the room with facial hair measuring approximately 1/4 of an inch on the chin area. 3. On 10/31/23 at 08:16 AM, Resident #42 was sitting in a recliner eating breakfast with facial hair measuring approximately 1/4 of an inch on the chin area. 4. On 11/01/23 at 08:40 AM, Resident #42 was sitting in a recliner eating breakfast with facial hair measuring approximately 1/4 of an inch on the chin area. The resident's left middle fingernail was broken and jagged. 5. The resident was asked, do the staff care for your nails? The resident stated, Yes. I broke my nail and I need to have them file it. The resident was asked, do you want the staff to remove your facial hair? The resident answered, They do it when I tell them to do it. 6. The Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/18/23 documented independent with no staff assistance for personal hygiene. 7. The Quarterly MDS with an ARD of 8/21/23 documented the resident required supervision with set up assistance only for personal hygiene. 8. The Care Plan with a revision date of 5/15/21 documented the resident required .extensive assist x 1 person for personal hygiene . 9. On 11/02/23 at 11:15 AM, the Nurse Consultant provided Resident #42's Personal Hygiene Documentation Survey Report which documented personal hygiene/oral care was performed every shift during the month of October and November and no documented refusals of care. 10. On 11/01/23 at 11:01 AM, CNA #1 was asked, do you provide care for Resident #42? The CNA answered, Yes. I try but she is her own person and I do things the way she wants me to. She asks me to do things when she gets ready. 11. On 11/02/23 04:13 PM, MDS Coordinator #2 was asked, what is a care plan? The nurse answered, The plan of care that involves the interdisciplinary team. We adjust it to make it patient centered. She was asked, how often should the care plan be reviewed and revised? She answered, With any change, or any time we add something, or if there is a change in condition or at least every quarter. She was asked to review Resident #42's care plan for personal hygiene. She stated, It says extensive assistance from 1 staff. She was asked to review the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/21/23, how what assistance is documented for personal hygiene? She answered, It says supervision and 1 person assistance. She was asked to review the Annual MDS with the ARD of 2/18/23, what assistance is documented for personal hygiene? She answered, Independent with no setup. She was asked, which one is accurate? She answered, It depends on the day. Some days she is more independent than others. I should have made a progress note. She was asked, should the care plan be reviewed and revised with accurate information? She answered, Yes. 12. A Policy titled, Care Plans, Comprehensive Person Centered which was provided by the Administrator on 11/2/23 at 3:34 p.m. documented, .Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change .

Based on observation, record review and interview, the facility failed to ensure a resident who wore an (electronic wander management device), did not exit the building unattended for 1 (Resident #1) of 3 (Residents #1, #2 and #3) case mix residents and had the potential to affect 14 residents who wore an (electronic wander management device) and were at risk for elopement. This failed practice resulted in past noncompliance at the level of Immediate Jeopardy, which caused or could have caused serious harm, injury, or death for Resident #1. The Administrator was notified of the Past Immediate Jeopardy on 09/13/23 at 11:28 AM. The findings are: 1. On 09/12/23 at 11:07 AM, observed the Main Dining Room was on the parking side of the facility and was noted to have an exit door with a keypad. The door exits out into a parking lot with a paved road beside the back of the building. The pavement had cracks and potholes. The road runs down an incline to the main street with a speed bump. The facility dumpsters were at the end of the driveway next to the main street. This street is used by the large apartment complexes nearby and goes around to the front of the facility. 2. Resident #1's clinical record noted the resident had diagnoses of Catatonic Schizophrenia, Alzheimer's Disease, Vascular Dementia and Mild Intellectual Disabilities. 3. Resident #1's Physicians Order dated 09/18/19 noted the resident was to wear an (electronic wander management device) due to poor safety awareness with placement and function checked every shift. 4. A Care Plan with an initiated date of 08/24/18 and a revision date of 04/14/21 noted Resident #1 was an elopement risk and was to be observed for exit seeking behaviors and was to wear a (electronic wander management device) on his left ankle. Other interventions included offering pleasant diversions, structured activities, food, conversation, television and or a book to distract him from wandering. 5. The Nursing Elopement Risk with Care Plan dated 08/16/21 indicated Resident #1 had a history of wandering, was above high risk to wander and was to wear a (electronic wander management device) on his left ankle. 6. The Nursing Admit/Readmit Assessment and Care Plan dated 07/17/23 and 08/01/23 indicated Resident #1 was a high risk to wander and was an elopement risk and was to wear a (electronic wander management device) on his left ankle. 7. A Nursing Note dated 09/7/2023 at 12:38 PM noted the facility received a call around 6:30 AM that Resident #1 sustained a fall outside. Staff nurses and the Housekeeping Supervisor immediately responded to the resident's side where he was assessed and had superficial abrasions to his face. Emergency Medical Services (EMS) were called. Physician Assistant and family member were notified Resident #1 was being sent to the emergency room (ER) for evaluation and treatment. Resident #1 stated to staff that he used the numbers to exit the facility and showed staff that he exited the small dining exit door. The (electronic wander management device) remained in place and was verified that it was functioning. 8. A Nursing Note dated 09/07/23 at 12:45 PM noted Resident #1 arrived back to facility from the ER around 11:30 AM with abrasions noted on the left side of his head and face and steri-strips on his forehead. 9. A Witness Statement dated 09/07/23 at 7:00 AM written by LPN #1 noted around 7:00 AM, maybe 6:30 AM, she answered the phone, and was informed by a lady that one of the residents was outside by the dumpsters and had fallen. She ran out to the dumpsters and saw Resident #1 lying on the ground and he had an abrasion to the left side. Resident #1 got up and was brought back into the building in a wheelchair. 10. A Witness Statement dated 09/07/23 by the Housekeeping and Laundry Supervisor noted she asked Resident #1 how he got out of the building and Resident #1 told her he got out of the Dining Room door. 11. A Witness Statement dated 09/07/23 by the LPN/Minimum Data Set (MDS) noted she asked Resident #1 how he got out of the door and if he used the code. Resident #1 stated, I pushed the code. She then asked him for the code, and he stated, [Numbers] and I didn't push the [Number]. 12. A Nursing Note dated 09/12/23 at 12:17 PM, noted Resident #1 had the (electronic wander management devices) in place, and they were working properly. The passcode to the doors was reset and Resident #1 no longer required one on one. 13. On 09/12/23 at 11:22 AM, the Administrator stated the Secure Care System for the Dining Room was not set correctly. It had an override. The system is supposed to lock when an (electronic wander management device) is close to the door and not open even when the code is entered. The main dining door did not lock when the resident pushed the code in, and he was able to exit the door due to the override. 14. A facility policy titled, Wandering and Elopements, provided by the Administrator on 09/12/23 at 2:24 PM documented, .Policy Statement The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. Interpretation and Implementation 1. If identified as at risk for wandering, elopement, or other safety issues, the residents care plan will include strategies and interventions to maintain the resident's safety .

Based on interview and record review, the facility staff failed to report an elopement to the Office of Long Term Care for 1 (Resident #1) of 3 (Residents #1, #2 and #3) case mix residents who were an elopement risk. The findings are: 1. On 09/12/23 at 10:45 AM, the Surveyor asked the Administrator if she had completed a reportable on the elopement for Resident #1. The Administrator stated no, it was discussed, and it was decided not to report. Cross Reference F689. 2. On 09/12/23 at 2:05 PM, the Surveyor asked the Nurse Consultant why the facility did not report the elopement to the Office of Long-Term Care. She stated we had 24 hours to decide if it was neglect, and after reviewing the incident, it was decided the facility didn't deviate from the Plan of Care, so it was not neglect. So, we decided not to report it. She further stated they did call the police about the incident. 3. A Nursing Note dated 09/12/23 at12:17 PM noted Resident #1's (electronic wander management device) was in place and working properly and that Resident #1 no longer required one on one due to an override of the doors and the passcode being reset. 4. On 09/12/23 at 11:22 AM, the Administrator stated the Secure Care System for the Dining Room was not set correctly. It had an override. The system is supposed to lock when an (electronic wander management device) is close to the door and not open even when the code is entered. The main dining door did not lock when the resident pushed the code in, and he was able to exit the door due to the override. 5. On 09/12/23 at 2:24 PM, the Administrator provided a policy titled, Abuse Investigations, documented, Policy Statement All reports of resident abuse, neglect and injuries of unknown source shall be promptly and thoroughly investigated by facility management. Policy Interpretation and Implementation .15. The Administrator will provide a written report of the results of all abuse investigations and appropriate action taken to the state survey and certification agency, the local police department, the ombudsman, and others as may be required by state or local laws, within five (5) working days of the reported incident .

Based on observation and interview, the facility failed to ensure dietary staff washed their hands before handling clean equipment or food items to prevent potential food borne illness for residents who received meals from 1 of 1 kitchen, failed to ensure food items stored in the freezer and storage room were dated, covered/sealed and monitored for mold to prevent the potential for food bone illness; convention oven was clean; expired food items were promptly removed/ discarded by the expiration or use by dates, hot foods were maintained at or above 135 degrees Fahrenheit on the steam table to prevent potential food borne illness for residents who received meals from 1 of 1 kitchen. These failed practices had the potential to affect 72 residents who received meals from the kitchen (total census:74) as documented on a list provided by the Administrator The findings are: 1. On [DATE] at 12:54 PM, an opened ziplock bag that contained open bags of gravy was stored on a shelf below the cart. The bags were not sealed. 2. On [DATE] at 1:00 PM, the following observations were made in the Storage Room on the bread rack: a. An 8 count bag of hamburger buns with an expiration date of [DATE]. b. An 8 count bag of hamburger buns was in a box on the bread rack with an expiration date of [DATE]. c. There were 8 six count bags of hoagies in a box on the bread rack, 4 of the 8 bags had mold on them. 3. On [DATE] at 1:24 PM, an opened box of pork fritters was stored on a shelf in the walk-in freezer. The box was not covered or sealed. 4. On [DATE] at 1:28 PM, an opened box of dinner rolls was stored on a shelf in the freezer. The box was not covered or sealed. 5. On [DATE] at 1:43 PM, the following observations were made in the kitchen cabinet: a. An 8 count bag of jumbo [MEDICATION(S)] buns with an expiration date of [DATE]. b. A bag of bread with Best by [DATE]. c. An 8 count bag of hot dog buns with, Best by [DATE]. d. A bag of hamburger buns with no date. 6. On [DATE] at 1:59 PM, the floor of the convention oven was covered with caked on corroded burnt food items. Five of five oven racks were covered with buildup of black residue. The Surveyor asked Dietary Employee (DE) #1, How often do you clean the oven? She stated, It has been 3 ½ weeks since the last time I cleaned it. 7. On [DATE] at 4:07 PM, DE #2 was wearing gloves on her hands. She united a bag of bread and without washing her hands, removed slices of bread from the bag and placed them on the plate to be used in preparing ham and cheese sandwich to be served the residents who requested a sandwich with their supper meal. 8. On [DATE] at 4:11 PM, DE #2 was wearing gloves on her hands. She took a knife from DE #3 and placed it on the counter. Without changing gloves and washing her hands, she picked up a plate and placed it on the counter with her fingers inside the plate to be used in positioning ham and cheese sandwich to be served to the residents who requested a ham and cheese sandwich with their supper meal. At 4:13 PM, she picked up bowls from the cabinet and placed them on the counter to be used in portioning dessert to be served to the residents for supper meal. 9. On [DATE] at 04:18PM, DE #2 turned off the sink faucet. Without washing her hands, she picked up a clean blade and attached it to the base of the blender to be used in pureeing food items to be served to the residents for supper. 10. On [DATE] at 04:21 PM, DE #7 took out a bowl of fruit fluffy from the refrigerator and placed it on the counter. Without washing her hands, she picked up a clean blade and attached it to the base of the blender to be used in pureeing food items to be served to the residents on pureed diets. The Surveyor immediately asked DE #7, What should you have done after touching a dirty object and before handling food items? She stated, I should have washed my hands 11. On [DATE] at 4:35 PM, the temperature of the Pureed Italian vegetables when tested and read from the steam table by DE #1 was as follows: a. Pureed Italian vegetables - 107 Degrees Fahrenheit. The above food was not reheated before being served to the residents on pureed diet. 12. On [DATE] at 7:15 AM, DE #3 was wearing gloves, she picked up oven mitts and placed them on her gloved hands contaminating the gloves. She then removed a pan of biscuits from the oven and placed them on the steam table. Without changing gloves and washing her hands, she unwrapped foil and removed pieces of bacon and placed them on the steam table to be served to the residents for breakfast. At 12:41 PM, The Surveyor asked DE #3, What should you have done after touching dirty objects before handling food items? She stated, I should have taken the gloves off and washed my hands 13. On [DATE] at 7:28 AM, DE #5, who was on the serving line, was wearing a glove on her right hand. She used her left hand to pick up the tray cards and placed them on the trays, without washing her hands, she picked up clean plates and placed them on the tray to be used in portioning food to be served to the residents for breakfast with her thumb inside the plate. At 12:42 PM, the Surveyor asked DE #5, What should you have done after touching dirty object before handling food items? she responded, I guess, wash my hands. 14. The facility policy titled, Employee Cleanliness and Handwashing Technique, provided by the Registered Dietician on [DATE] at 4:30 PM documented, .Dietary department employees are required to wash their hands on the occasions listed below: .f. after disposing or handling of trash or food g. after handling dirty dishes . any other time deemed necessary .

Based on record review and interview, the facility failed to ensure an effective system was in place for residents who have authorized the facility to manage their personal funds to access their personal funds after hours and on weekends. This failed practice had the potential to affect 48 residents in the facility who had authorized the facility to manage their personal funds according to a list provided by the Business Office Manager (BOM) on 8/17/22 at 2:05 PM. The findings are: a. On 08/16/22 at 1:01 PM, Resident #19 was in her room. The Surveyor asked, Who takes care of your money. Resident #19 stated, The facility does. The Surveyor asked, Are able to access her money when you need to? Resident #19 stated, Yes, during the week but not on weekends. I try to ask by Friday, because no one is here to handle the money on the weekends. I call my husband if I need something on the weekends and he takes care of it. b. On 8/17/22 at 11:13 AM, during Resident Council Meeting, the Surveyor asked the residents, Do you have access to your personal funds? Two of the five residents stated, they can get money Monday through Friday during the day, but not after hours or on weekends. c. On 08/17/22 11:30 AM, the Surveyor asked the Administrator, Who is responsible for the management of the residents personal funds? She stated, The Business Office Manager. The Surveyor asked the Administrator, Does the facility have a process in place for residents to request their funds that are managed by the facility after hours and on weekends? The Administrator stated, Yes. The staff can call me, and I will come up here and get the money for the resident. The Surveyor asked the Administrator, Is there a process in place if you are not available? The Administrator stated, I am on call 24/7 [24 hours a day, 7 days a week]. The Surveyor asked the Administrator, Are staff aware of this process? The Administrator stated, Yes. d. On 08/17/22 at 11:35 AM, the Surveyor asked the BOM and the Business Office Consultant, Are you responsible for getting the residents their money when they request it? She said, Yes. The Surveyor asked the BOM, Is there a process in place for residents to have access to their money after hours and on weekends? She stated, I'm not sure. I just started in this position. The Business Office Consultant stated, There is a policy for residents to have access to their money after hours and on weekends. The Surveyor informed her that during the Resident Council Meeting this morning two of the five residents in attendance stated they do not have access to their money after hours and on weekends. The Business Office Consultant stated, There should be money in a lock box, a resident list showing who has money, and a sheet showing who requested money and how much, on a nurse's cart for after hours and weekends. e. On 08/17/22 at 11:45 AM, the Surveyor asked Licensed Practical Nurse (LPN) #1, Do you ever work weekends or evenings when the office staff are gone? LPN #1 stated, Yes sir. The Surveyor asked LPN #1, What is the process on how residents access personal funds after hours or on weekends? LPN #1 stated, I don't know of one. The Surveyor asked LPN #1, What would you do if a resident came to you on the weekend and asked for some money to purchase a coke from the vending machine? LPN #1 stated, The office isn't open one the weekends, so I would buy the resident a coke with my own money. f. On 8/17/22 at 1:10 PM, the Surveyor asked Registered Nurse (RN) #2, Do you ever work on the weekends or during the week after the office staff are gone for the day? RN #2 stated, Yes, I work on Saturdays. The Surveyor asked RN #2, Do you know the process for residents that have their money managed by the facility to receive money on the weekends if a resident request it? RN #2 stated, We don't have one, because residents are supposed to get money on Fridays before the office closes. g. On 8/17/22 at 1:45 PM, the Surveyor asked RN #1, What is the process for residents whose money is managed by the facility to request money after hours and/or on the weekends? RN #1 stated, There is not currently a process in place. The facility policy and procedure titled, Patient Trust, received by the Administrator on 8/19/22 at 9:42 documented, .Policy: This facility manages patient personal funds as requested and in accordance with any and all applicable law. Procedure: The facility will manage patient personal funds via an interest-bearing account in the name of the facility with Patient Trust in the title. The following procedures are followed in managing patient trust accounts. Patient Trust Accounting: 10. Trust Cash-On-Hand must be available for patient cash requests. a. The balance of the cash-on-hand should be between $50-$250 at all times .

Based on record review and interviews, the facility failed to ensure care plan meetings were held and residents and families were invited to the Care Plan meetings to participate in treatment options for 2 (Residents #34 and #57) of 2 sampled residents. This failed practice had the potential to affect all 79 resident who resided in the facility as documented on the Resident Census and Conditions of Residents provided by the Administrator on 08/15/22 at 10:32 AM. The findings are: 1. Resident #57 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly MDS with an ARD of 06/18/22 documented the resident scored 15 (13-15 indicates cognitively intact) on a BIMS. a. On 8/16/22 at 9:30 AM, the Surveyor asked Resident #57, Have you or your family been invited to Care Plan meetings where your care and future plans for your care is discussed? He stated, I don ' t know anything about having a Care Plan meeting. 2. Resident #34 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/09/22 documented the resident scored 15 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status (BIMS). a. On 8/16/22 at 10:30 AM, the Surveyor asked Resident #34, Have you or your family been invited to Care Plan meetings where your care and plans for your care is discussed? He stated, No I used to be asked about them, but it ' s been a long time. 3. On 8/18/22 at 11:02 AM, the Surveyor asked the MDS Coordinator, Have you had any Care Plan meetings for [Resident #34] and [Resident #57]? She stated, To be honest with you it has been 3 or 4 months since we had any Care Plan meetings. The Surveyor asked, Can you tell me why? She stated, I'm not really sure the Social Director schedules those meetings. 4. On 8/18/22 at 11:06 AM, the Surveyor asked the Social Director, Have you had any Care Plan meetings for [Resident #34] and [Resident #57]? She stated, Well yes, we are having Care Plan meetings. The Surveyor asked, When was the last Care Plan meeting for [Resident #34]? She stated, Well I guess it has been a while, it was December of 2019. The Surveyor asked, When was the last Care Plan meeting for [Resident #57]? She stated, Well I guess it has been a while, it was March of 2021. The Surveyor asked, Can you tell me why? She stated, Well I got behind with COVID, but I'm caught up now. 5. On 08/19/22 at 9:45 PM, the Surveyor asked the Director of Nursing, How often should Care Plan meetings be held? She stated, Quarterly and as needed. The Surveyor asked, Have Care Plan meetings been held? She stated, I am new to this position, so I'm unsure about the Care Plan meetings. 6. On 08/19/22 at 9:55 PM, the Surveyor asked the Administrator, How often should Care Plan meetings be held? She stated, Quarterly or as needed. The Surveyor asked, Have Care Plan meetings been held? She stated, I thought we were until the survey started, then I found out we weren't

Based on observation, interview and record review, the facility failed to ensure fingernails were cleaned and groomed to promote good personal hygiene and grooming for 2 (Residents #11 and #34) of 16 (Resident #4, #6, #9, #11, #18, #21, #26, #34, #40, #48, #52, #55, #63, #77, #82 and #333) sampled residents who required staff assistance with nail care. This failed practice had the potential to affect 42 residents who resided in the facility and required staff assistance with nail care according to a list provided by Director of Nursing (DON) on 8/18/22 at 5:05 PM. The findings are: 1. Resident #11 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/12/22 documented the resident scored 9 (8-12 indicates moderately cognitively impaired) on the Brief Interview for Mental Status (BIMS) and required extensive physical assistance of one person with personal hygiene and was totally dependent of one person for bathing. a. The Care Plan with a revision date of 7/10/22 documented, .The resident has an ADL [activities of daily living] self-care performance deficit r/t [related to] Dementia . BATHING/SHOWERING: Check nail length and trim and clean on bath day and as necessary . b. On 08/15/22 at 12:47 PM, Resident #11 was wheeling himself down the hall in his wheelchair. The resident's fingernails were short, and had a black substance under them. c. On 08/16/22 at 8:55 AM, Resident #11 was lying in bed. His fingernails were short and had a black substance under them. d. On 08/17/22 at 12:10 PM, Resident #11 was propelling himself in his wheelchair from the dining room. The Surveyor asked the resident if she could look at his fingernails and he held up his left hand. The nails were short and had a black substance under them. The Surveyor asked, Have the staff cleaned your nails lately? He stated, I am not sure. e. On 08/18/22 at 10:45 AM, Resident #11 was in the hall in his wheelchair. His fingernails were short and had a black substance under his nails. The Surveyor asked Resident # 11, Do you let the staff clean your fingernails? Resident #11 stated, I just let them do what they want. f. On 08/18/22 at 10:50 AM, the surveyor asked Licensed Practical Nurse (LPN) #1, Are you [Resident #11's] nurse? LPN #1 stated, Yes, I am his nurse. The Surveyor asked LPN #1 to accompany the surveyor to where Resident #11 was sitting in his wheelchair and the Surveyor asked, Can you look at [Resident #11's] fingernails and describe them to me? LPN #1 looked at Resident #11's fingernails and quietly said to Resident # 11, I need to clean your fingernails. Resident #11 stated, Okay. LPN #1 stated to the surveyor, There is a dark matter under the nails on the right hand. His nails don't need to be cut, but they do need to be cleaned. The Surveyor asked LPN #1, How much assistance does [Resident # 11] require with his ADL's? LPN #1 stated, He is maximum staff assistance with ADL's The Surveyor asked LPN #1, Who is responsible for nail care? LPN #1 stated, The CNA [Certified Nursing Assistant] staff for nondiabetic residents. The aide caring for him is responsible. That is part of getting him ready for the day. The Surveyor asked LPN #1, How often should nail care be done? LPN #1 stated, Daily and as needed. If it is needed 5 times a day, we should do it that often. The Surveyor asked LPN #1, Does [Resident # 11] refuse care? LPN #1 stated, He can be difficult to do ADL care on at times. The Surveyor asked LPN #1, Do you know if it is care planned that he refuses ADL care? LPN #1 stated, I am not sure if that is care planned or not. The Surveyor asked LPN #1, Why is it important that a residents nails are kept groomed and clean? LPN #1 stated, It is important for the appearance and so as not to risk the resident ingesting a contaminant. I am going to get gloves and take care of this right now. g. On 08/18/22 at 11:40 AM, the surveyor asked CNA #1, Do you take care of [Resident # 11]? CNA #1 stated, Yes I have his hall today, but it is not my usual hall. The surveyor asked CNA #1, How much assistance with ADL's does [Resident # 11] need? CNA #1 stated, He is extensive assistance. He will try to help with putting on his clothes and transferring. The surveyor asked CNA #1, Who is responsible for doing nail care? CNA #1 stated, We had an aide going around earlier this week doing nail care. I do not know if he just would not let her do his nails. The CNA's do nail care unless the residents are diabetic. The surveyor asked CNA #1, How often should nail care be done? CNA #1 stated, It is supposed to be done on bath days. His bath day was yesterday. It should have been done then. The surveyor asked CNA #1, Does [Resident # 11] refuse care? CNA #1 stated, He will refuse care at times. When he says no, he means no. I have not tried today to clean his nails, but the nurse came to me and told me that you had shown her that they were not clean earlier. I will go in a little while and see if he will let me soak his hands in some warm soapy water. The surveyor asked CNA #1, Why is it important that residents nails are kept groomed and clean? CNA #1 stated, When they are feeding themselves, they are using their hands and fingers and if they are dirty that is not sanitary. They could be consuming germs. h. On 08/18/22 at 3:55 PM, the Surveyor asked the DON, Who is responsible for doing nail care? The DON stated, Our CNA's and our nurses are responsible. The Surveyor asked the DON, How often should nail care be done? The DON stated, It should be done weekly. The Surveyor asked the DON, Why is it important that the residents nails are kept groomed and clean? The DON stated, Keeping nails clean and groomed cuts down on infection control issues. Long nails could cause self-inflicted wounds such as skin tears. The Surveyor asked the DON, Did the nurse tell you that I spoke to her about [Resident # 11's] nails not being clean? The DON stated, No she did not. The DON was informed that the nurse the surveyor spoke with about Resident #11's nails said that the resident does resist care at times. The DON stated, I do know he will cuss at times and can get belligerent. I will go and make sure that they did get his nails cleaned though. 2. Resident #34 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly MDS with an ARD of 05/19/22 documented the resident scored 15 (13-15 indicates cognitively intact) on a BIMS and was totally dependent of one person for personal hygiene and totally dependent of two persons for bathing. a. The Care Plan with a revision date of 05/05/22 documented, .The resident has an ADL self-care performance deficit . BATHING/SHOWERING: Check nail length and trim and clean on bath day and as necessary. Report any changes to the nurse . b. On 8/15/22 at 12:38 PM, Resident #34's fingernails were greater than ½ inch long with debris underneath. Resident #34 stated he would like his nails trimmed. c. On 8/18/22 at 9:17 AM, the Surveyor asked CNA #2, When is nail care done? She stated, On Sunday or when needed. The Surveyor asked, Who does nail care? She stated, The CNA's unless they are diabetic, then the nurse does it. d. On 8/18/22 at 9:33 AM, the Surveyor asked CNA #3, When is nail care done? She stated, On Sunday or when needed. Resident refuses most of the time. The Surveyor asked, Who does nail care? She stated, The CNA's unless they are diabetic, then the nurse does it. e. On 8/18/22 at 1:55 PM, the Surveyor asked LPN #2, Who trims [Resident #34's] nails? She stated, He only lets the 3 to 11 nurse trim his nails. Sometimes he says he wants them trimmed then when you go to do it, he refuses. 3. The facility policy titled, Activities of Daily Living (ADL's), Supporting, provided by the DON on 08/18/22 at 05:05 PM documented, .Policy Statement: Resident will be provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADL's). Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene .

Based on observation, record review and interview, the facility failed to ensure a physician-ordered narcotic pain medication was available for administration as ordered to provide pain management, promote comfort, and wellbeing for 1 (Resident #27) of 5 (Residents #7, 26, 27, 34 and 82) sampled residents who had physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The findings are: Resident #27 has diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/12/2022 documented the resident scored 15 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status (BIMS) and received scheduled and PRN (as needed) pain medication and experienced very severe, horrible pain over the last 5 days. a. The Physicians Order dated 05/07/22 documented, .[MEDICATION(S)] [[MEDICATION(S)]] 30mg [milligram] tablet Give 1 tablet by mouth every 6 hours related to Chronic Pain Syndrome, give one tablet po every six hours b. On 8/15/22 at 11:30 AM, during initial rounds Resident #27 stated, I am hurting so bad. They ran out of my pain medicine over the weekend. c. On 8/15/22 at 11:45 AM, the Surveyor asked Licensed Practical Nurse (LPN) #2, Do you have pain medication for [Resident #27]? She stated, We ran out over the weekend. I tried to call the doctor, but all I got was an answering machine and you can't leave a message. The Surveyor asked, Isn't this doctor your Medical Director? She stated, Yes. The Surveyor asked, Don't you have a number other than the office number, should you have an emergency? She stated, I don't have it. The Surveyor asked, When did he last have his pain meds [medications]? She pulled out the narcotic book and the last entry was 12:00 PM on 8/14/22. She stated, The pharmacy is in [City] and they should deliver his meds by 2:00 PM today. The Surveyor asked, Did you notify the Registered Nurse (RN) charge nurse? She stated, No, I didn't. On 8/15/22 at 1:00 PM, the Surveyor asked RN #1, Were you notified that [Resident #27] was out of a scheduled narcotic? She stated, No I wasn't. I would have made arrangements to get the medication locally if I had known. On 8/19/22 at 9:45 AM, The Surveyor asked the Director of Nursing (DON), Were you aware that narcotics for [Resident #27] were not available over the weekend? She stated, No not until the surveyors arrived. The Surveyor asked, What is being done to prevent this from happening again? She stated, I will be having a nurses meeting and in-service for the nurses, and I have counseled the nurse.

Based on observation, record review, and interview the facility failed to ensure care planned interventions to prevent unsupervised smoking were implemented and failed to provide adequate supervision to prevent excessive exposure to the sun for 1 (Resident #2) of 3 (Resident #2, #3 and #4) sampled residents that required supervision for smoking. The failed practice resulted in actual harm for Resident #2 who was left outside unsupervised in temperatures ranging from 94.5 degrees Fahrenheit to 96.7 degrees Fahrenheit for an extended period of time resulting in the resident experiencing a temperature of 104 degree Fahrenheit and subsequent skin eruptions with blistering of skin, and had had potential to cause more than minimal harm to 13 residents who required supervision for smoking as documented by a list provided by the administrator on 07/25/22 at 1:05 PM. The Administrator was notified of the past harm situation on 7/27/22 at 9:33AM. The findings are: 1. Resident #2 had a Diagnoses of Heart Failure, [CONDITION(S)], and None-Alzheimer's Dementia. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/12/22 showed that the resident scored 9 (8-12 indicates moderate impairment) on the Brief Interview for Mental Status (BIMS) and required extensive assistance with bed mobility, transfer, toileting, personal hygiene, dressing and was independent with locomotion and eating. The resident was a smoker. a. The care plan with a revision date of 10/20/21 showed .Focus: The resident is a smoker (sometimes) .Goal: The resident will not smoke without supervision . Intervention/Tasks: . The resident requires SUPERVISION while smoking . b. A Physicians Order dated 7/13/22 showed, . [MEDICATION(S)] Tablet 800-160 MG ([MEDICATION(S)]-[MEDICATION(S)]) Give 1 tablet by mouth two times a day related to URINARY TRACT INFECTION, SITE NOT SPECIFIED (N39.0) until 07/18/22 23:59 x 5 days . c. On 7/20/22 at 00:54 AM Resident #2 temperature summary in the electronic record showed, . 98.3 °F Forehead (non-contact) . (Manual) . d. Weather: Underground's weather history report for El Dorado, Arkansas: https://www.wunderground.com/dashboard/pws/KARELDOR18/table/2022-07-20/2022-07-20/daily The temperature on 7/20/22 was 94.5 degrees Fahrenheit (F.) at 1:04 PM and 96.7 degrees F. at 2:59 PM. e. On 7/20/22 at 3:05 PM, a Nsg (Nursing) General Note documented, . Resident noted slumped over while smoking. Redness noted to forehead and resident has on sweater. Taken back into facility [Blood Pressure] B/P 137/58, Pulse 100, Resp 24, Temperature 104. Cool towels applied under arms and around neck and head area. Sweater removed. Given water to drink. Resident began to be more responsive and mumbled. Temperature continued to drop back down to 100. Resident put into bed. Advanced Practice Nurse (APN) called and made aware with NON (New Orders Noted). Called wife, ( .), on both phones with no answer and no voice mail set up. Wife returned call and made aware of new orders and that Rapid COVID-19 test was negative . f. On 7/20/22 at 4:18 PM, a Nsg General Note showed, .Continues to come around and temperature noted at 98.9. Will continue to monitor . g. On 7/21/22 at 10:19 AM, a Nsg General Note showed, . Late entry - Resident noted to have several fluid filled blisters on body related to having recently completed [MEDICATION(S)] which is very photosensitive. He enjoys smoking and had exposure while smoking despite being in long sleeves, jeans, and having shoes on. Resident's fluid filled blisters remain intact. Nurses are aware and are monitoring for changes as needed. He denies pain and/or discomfort currently. NP (Nurse Practitioner) aware . h. A Physician's Order dated 7/23/22 showed, .[MEDICATION(S)] Capsule 150 MG [milligrams] Give 3 capsule by mouth three times a day for Prophylaxis until 08/06/2022 23:59 for a total of 450 MG . i. A Physicians order dated 7/23/22 showed, . [MEDICATION(S)] HCL [Hydrochlorozide] tablet 50 MG *Controlled Drug* Give 1 tablet by mouth every 6 hours as needed for pain - Moderate . j. A Physician's order dated 7/25/22 showed, . [MEDICATION(S)] table 100 MG give 1 tablet by mouth two times a day related to Urinary Tract Infection, site not specified for 10 days . k. A Physician's Order dated 7/25/22 showed, . Monitor blister to the top of scalp for drainage or if it has ruptured every day shift . l. A Physician's order dated 7/25/22 showed, Cleanse areas to the front of the left thigh with NS (Normal Saline) and apply [MEDICATION(S)] and cover with silicone adhesive dressing and change daily and PRN [As Needed] every day shift and as needed when soiled or missing . m. A Physicians order dated 7/25/22 showed, .Cleanse area to left shoulder with NS and apply [MEDICATION(S)] and cover with silicone adhesive dressing and change daily and PRN every day shift and as needed when soiled or missing . n. A Physicians order dated 7/25/22 showed, . Cleanse area to left dorsum foot and left 3rd [third] toe with NS apply [MEDICATION(S)] and ABD (Abdominal pad) and wrap in rolled gauze and change every day and PRN every day shift and as needed when soiled or missing . o. A Physician's order dated 7/26/22 showed, Cleanse area to left side of neck with NS and apply [MEDICATION(S)] and cover with adhesive dressing and change every day and PRN every day shift and as needed when soiled or missing . p. A Physicians order dated 7/26/22 showed, . Cleanse area to right upper inner thigh with NS and apply [MEDICATION(S)] and cover with silicone adhesive dressing and change every day and PRN every day shift and as needed when soiled or missing . q. On 7/26/22 at 9:10 AM, Resident #2 was lying in bed with his eyes open. There was a blistered area on the top of his head that appeared to be dry with no weeping noted. White substance was noted on the blistered area. The Surveyor asked Resident #2, does the area on your head hurt? Resident #2 stated, No. The Surveyor asked, Does your foot or any other area hurt? Resident #2 stated, No. The Surveyor asked, Do you remember being left outside last week for a long-time during smoke break? Resident #2 stated, No. r. On 7/25/22 at 10:55 AM, the Treatment Nurse perform wound care on Resident #2's wounds. Wound care was performed to wounds on residents left foot, left side neck, left shoulder, and left thigh. No concerns with wound care procedure, technique, or infection control procedures. The resident still has some blisters on his left thigh that have not ruptured. The wounds did not appear infected, but there was some [CONDITION(S)], white/yellow slough, and loose skin from where the blister had ruptured in the wound on the foot. The Surveyor asked the Treatment Nurse, How long have you been the Treatment Nurse? The Treatment Nurse stated, I have been the Treatment Nurse here for about [AGE] years, but I did it for 6 years at another facility before I worked here. The Surveyor asked, Can you tell me how the resident got these wounds? The Treatment Nurse stated, The resident was taking [MEDICATION(S)] and he likes to go out to smoke. He was out smoking and got very hot. I think it was the combination of his getting hot and a reaction to the [MEDICATION(S)] he had just finished taking. I was his nurse that evening after he had gotten hot by being outside. I can tell you that he was fully dressed. He had two shirts on, jeans and sneakers. When we took his clothes off there were areas of his skin that were flushed. He did not have any blisters at first, but blisters appeared on most of the places that appeared red and flushed beginning the following day. He had a large area on his abdomen, but that area did not blister. It has mostly been on his left side of his body. Two new blisters were found today. The Surveyor asked, do you know who was supervising the smoke break that day that the resident got overheated? The Treatment Nurse stated, No. I am not sure who it was. s. On 7/26/22 at 12:10 PM, The Surveyor informed the Pharmacy Consultant that a resident who had taken [MEDICATION(S)] had been outside smoking and became overheated and although staff stated he was fully dressed he had flushed area's that went on to become blisters. The Surveyor asked, Can [MEDICATION(S)] cause a reaction that results in the residents skin blistering? The Pharmacy Consultant stated, Yes. [MEDICATION(S)] can cause photosensitivity. One of the most common reactions to [MEDICATION(S)] is a rash and blisters can occur. The combination of the heat with the medication could have helped to bring out the rash and the blisters. I also work in a commercial pharmacy and that kind of reaction is the most common reaction that you see with [MEDICATION(S)]. t. On 7/26/22 at 12:15 PM, a progress note provided by the Nurse Consultant dated 7/25/22 at 11:32 AM by the APRN [Advanced Practice Registered Nurse] showed, . Today's visit is medically necessary to assess blistered area's to pt's (patients) head, left shoulder, LLE [Left Lower Extremity] and left foot . Assessment and Plan: Patient was examined in his room today. It was noted that he has multiple open and closed blistered areas on this left extremity, left shoulder, top of left foot and left third toe. He also has a water filled blister on the top of his head. It was reported on 7/20/22 at 4:05 PM when the DON [Director of Nursing] phoned this provider to report patient's condition. It was reported by DON that patient previously had a temp of 104 but currently during the correspondence it was down to 100.0. She reported that his vital signs were within normal limits and stated he had previously been outside . At that time orders were given to provide a rapid COVID-19 exam and labs were ordered CBC (Complete Blood Count) and BMP (Basic Metabolic Profile). On 7/23/22 Registered Nurse (RN) Supervisor notified this provider and was concerned about multiple opened and closed blisters across patient's head, left shoulder, left leg and toe. It was noted at the time he had just completed [MEDICATION(S)] antibiotic therapy on 7/18/22 for his [CONDITION(S)] (Urinary Tract Infection) Orders were given to start [MEDICATION(S)] 450 MG TID (Three times Daily) x 14 days at that time and to apply [MEDICATION(S)] to open areas where the blisters have erupted, keep areas covered until healed. Order given for [MEDICATION(S)] 50 MG q (every) 6 hours PRN (as needed) for pain. Today areas were noted, and it appears these blisters were from a drug eruption more than likely d/t [due to] the combination of heat and recent [MEDICATION(S)] antibiotic therapy . Since these areas appear to be from a drug eruption. [MEDICATION(S)] will be discontinued, and Sulfa antibiotics will be added to his list of drug allergies. New order for [MEDICATION(S)] 100 MG twice a day for 10 days given . u. On 7/26/22 at 12:35 PM, The Surveyor asked the Nurse Consultant, Who was supervising the smoke break on 7/20/22 when (Resident #2) became overheated? The Nurse Consultant stated, Licensed Practical Nurse (LPN #1) was the nurse supervising the smoke break, but the nurse got called away because of an emergency and did not get someone to take her place. The Nurse Consultant was asked, Is (LPN #1) working today? The Nurse consultant stated, No. I was working this weekend and I sent her home because I started a full investigation into the incident. We wanted to be sure this could not happen again. She has written a statement that you can read, or you can call her and talk with her. The NP (Nurse Practitioner) came and saw the resident on Monday, and she stated that she believed that the blisters occurred because of a reaction to the [MEDICATION(S)]. The nurse is an excellent nurse and was very upset by what happened. I felt that we needed to investigate to be sure that what happened did not cause any harm to the resident. The Surveyor asked, How long was (Resident #2) outside? The Nurse Consultant stated, He was out there for too long. The best we could tell he was outside from about 1:05 PM until 2:40 PM. Normally if the nurse must leave during the smoke break, she should have gotten someone to take her place and that is what should have happened. We have done a QA assessment of what happened, and we have put things in place so that it never happens again. The Surveyor asked, Was it usual for (Resident #2) to sit outside by himself? The Nurse consultant stated, No it was not usual for (Resident #2) to sit outside by himself. v. On 7/26/22 at 1:15 PM, During a telephone interview with LPN #1 the Surveyor asked, How long have you worked for the facility? LPN #1 stated, I have worked for the facility for about 2 years. The Surveyor asked, How long have you been a nurse? LPN #1 stated, I have been a nurse about [AGE] years. The Surveyor asked, Were you the nurse supervising the smoke break on 7/20/22 when (Resident #2) went outside on smoke break? LPN #1 stated, Yes. I took him out on smoke break about 1:05 PM - 1:10 PM. I had (Resident #2) at the door to smoke his cigarette then I was going to wheel him back inside, but one of the resident's sisters came to the door and said her sister was having a panic attack and asked me to come and see if she had something I could give her. I think that was about 1:15 PM. Normally I would get someone else to go outside with the residents. When I got to the resident (resident having panic attack) the assistants were cleaning her up and she had some bumps on her vaginal area. We were being paged to (Administrators) office for an in-service and I was trying to do something about the resident's bumps on her vaginal area. (Resident #2) just slipped my mind. The Surveyor asked, Can (Resident #2) wheel himself in his wheelchair? LPN #1 stated, Yes he uses his legs to push himself. The Surveyor asked, What was (Resident #2) wearing that day? LPN #1 stated, He was wearing a black long sleeved thermal shirt, blue jeans, socks and black shoes with Velcro straps. The Surveyor asked, Who else was sitting outside? LPN #1 stated, Only the smokers. I usually take them out and let them smoke then bring them back in. (Resident #2) was sitting right by the door. I was planning on pushing him in when he finished his cigarette. The Surveyor asked, Who told you that (Resident #2) was still outside? LPN #1 stated, I came out of (Administrators) office at about 2:30 PM-2:45 PM. One of the assistants told me that the Terminix Employee reported someone was outside. I went immediately and got him inside. I assessed him and got him something to drink. The Surveyor asked, Was he responsive when you went outside? LPN #1 stated, Yes. He responded to me. He was awake and spoke. He drank the water that I gave to him. The Surveyor asked, Who did you report what happened to? LPN #1 stated, I took him straight to the Administrator's office. The DON was in the office. The Surveyor asked, Did Administration do an investigation into what happened? LPN #1 stated, Yes they did. The Surveyor asked, Did you call the doctor? LPN #1 stated, The DON did. The Surveyor asked, Did you get suspended during the investigation? LPN #1 stated, I got sent home on Saturday and I have been at home since. I am so sorry this happened. I have never left the residents outside before. The Surveyor asked, How did the other residents get back inside the building? LPN #1 stated, I do not know who brought them in, but they can open the door and come back inside. w. On 7/26/22 at 2:00 PM, the Surveyor asked the DON, When did you first find out that (Resident #2) had not been brought back inside after the 1 PM smoke break on 7/20/22? The DON stated She (LPN #1) bought him straight to the alcove that is between mine and The Administrators office when she bought him back in the building. The Surveyor asked, What was the resident wearing? The DON stated, He was wearing a black thermal long-sleeved shirt, jeans, socks and shoes. The Surveyor asked, Was he responding when she brought him to you? The DON stated, Yes he was responding. I put cold tepid towels on him to help him cool down. The Surveyor asked, How quickly did his temperature come down? The DON stated, It came down quickly with the compresses and the water he was drinking. The Surveyor asked, Did he have any blisters on his skin at that time? The DON stated, No. The Surveyor asked, What did his skin look like? The DON stated, He looked hot. His skin had a red tinge to it. The Surveyor asked, What did his head look like? The DON stated, His head was flushed but there were no blisters. The Surveyor asked, Did you call the doctor immediately? The DON stated, Yes. The Surveyor asked, Did the doctor give you orders at that time? The DON stated, She gave orders for a CMP (Complete Metabolic Profile) CBC (Complete Blood Count) and COVID-19 test was ordered at that time. The Surveyor asked, When did blisters start to appear on the resident? The DON stated, The blisters started appearing the next day. The Surveyor asked, Did you immediately start an investigation into the incident? The DON stated, Yes, I took the resident back to his room, while the Administrator called the Certified Nursing Assistant (CNA) to find out what time she had seen the resident last. The Surveyor asked, When did the NP (Nurse Practitioner) come and see the resident? The DON stated, I was not here Friday, so I am on sure if she saw him Friday, but I know for sure she saw him Monday. The Surveyor asked, Do you know what the NP thinks caused the blisters on the resident? The DON stated, My understanding is she thinks the blisters were caused by the antibiotic that he had been on for the [CONDITION(S)] [ Urinary Tract Infection]. The Surveyor asked, What have you done to try and make sure this never happens again? The DON stated, We have a check off list and the staff members have to write down who goes out and mark the resident off once they go back inside after smoking. We are now taking water out with each break and offering it to the residents. We have in-serviced the staff about the check off list. The staff have been in-serviced that they have to get someone to replace them if they are called away when they are supervising smoke break. The Surveyor asked, How are you monitoring to be sure this is happening? The DON stated, I am going out and checking that it is being done and writing it on a monitoring sheet. The Surveyor asked, Has anything like this ever happened before? The DON stated, No Ma'am it has not. The Surveyor asked, What are going to do with the nurse that left the smokers unsupervised? The DON stated, She has been suspended. She is a very good nurse. She was extremely upset when it happened. She immediately told what had happened so the resident could be taken care of. She will be in-serviced and counseled before she returns to work. On 7/27/22 at 8:50 AM, the Surveyor asked DON, Do you know what the temperature was on the 7/20/22 when Resident #2 was left outside? The DON stated, I am not sure exactly. I knew we were under a heat advisory that week. The Administrator who heard the question came into the DON office and stated, I went back and looked it up after the incident because I wanted to know what the temperature was, and it was between 96- and 98-degree Fahrenheit. x. On 7/27/22 at 9:02 AM, the Surveyor asked the Nurse Consultant, Can the residents open the door to get in from the smoke area? The Nurse consultant stated, If they continue to push on the door, it will open and it will alarm to alert staff, so the residents can open the door and get back in if they keep pushing on it. The Surveyor asked, Could (Resident #2) have opened the door himself and got back inside the building? The Nurse Consultant stated, Yes he could have if he pushed on the door, but I am not aware of him ever having done that. y. On 7/28/22 at 9:10 AM, The policy titled Smoking Policy - Residents, with a revision date of July 2017, provided by the Administrator showed, .Policy Statement: This facility shall establish and maintain safe resident smoking practices . Policy Interpretation and Implementation: . 11. All residents will have the direct supervision of a staff member, family member, visitor or volunteer worker at all times while smoking or vaping . 2. The facility removed the harm and corrected the failed practices on 07/24/2022, prior to the survey, as evidenced by the following: a. The QA Plan provided on 7/26/22 at 3:15 PM by the Nurse Consultant showed: 1. On 07/20/22 Pest Control Staff notified facility staff that there was a resident located outside. Facility staff immediately responded to the area and charge nurse ., assisted the resident into the facility where he was assessed and assisted to drink water, and cooled with wet tepid cloths. He was wearing long sleeved shirt, long pants, socks, and shoes: skin assessment revealed patches of reddened flushed appearing areas; initial tympanic surface temp registered at 104 however was decreasing with temp check done at frequent intervals by nurses at bedside. (Resident #2) who initially appeared sleepy when brought into the facility immediately began to interact per his baseline with staff. He was noted to consume multiple glasses of water, punch and Ensure. Increased oral intake of fluids continued throughout the evening shift per staff including designated treatment nurse. Resident's family and the Nurse Practitioner were notified of increased temp and new lab orders were obtained and processed appropriately. Medication review identified the resident had completed [MEDICATION(S)] on 7/18/22. The nurse identified as assisting resident outside for smoking at 1:00 PM was suspended pending in house investigation as to why the resident remained outside for an extended period. 2. All other residents with the potential to be affected were identified by the Administrator and DON by reviewing resident smoking status and by identifying whether any 'smokers' were currently or had recently completed [MEDICATION(S)]. All residents identified revealed no additional resident as having remained outside for an extended period and no other resident demonstrated any complications from being outside smoking. A checklist of all residents who smoke was implemented to document any residents who go out to smoke and that each are assisted back inside the facility within an appropriate period. 3. In services were initiated re: appropriate supervision of residents while smoking safely outside as well as on utilizing the smokers list to be cognizant that all residents outside for smoking are indeed back inside within an appropriate period. Inservice will be ongoing to encompass all staff who may supervise smoking. 4. Administrator/Designee to round outside in the smoking area 2 x [times] per day, 5 x per week to ensure there are no residents outside for too long a period. These rounds will continue for 4 weeks or until substantial compliance is achieved. 5. All findings will be reported to the QAA Committee for review and recommendations. b. A statement provided by the Nurse Consultant on 7/26/22 at 3:15 PM, that was signed by the Treatment Nurse showed, .7/20/22 R(Residents) assmt (assessment) all smokers . (Resident #2) Flushing of skin in various areas; abdomen, shoulder, head, leg, feet on the left side of body . All other smokers had no new skin issues identified related to being outside smoking. c. A copy of the staff in-service provided by the Nurse Consultant on 7/26/22 at 3:15 PM showed, .Date:7/24/22 .As smokers are taken out to smoke, they are to be checked off as going out and checked back in when they come in to ensure that everyone who goes out comes back inside . d. A form titled Rounds in Smoking Area provided by the Nurse Consultant on 7/26/22 at 3:15 PM showed, . AM and PM and initials on 7/21/22, 7/22/22, 7/23/22, 7/24/22, 7/25/22., and AM with initials for 7/26/22 .

Complaint # (AR 785) was substantiated (all or in part) with these findings: Based on record review and interview, the facility failed to ensure necessary care and services were provided after a fall with injury, as evidenced by failure to ensure new onset hip pain with range of motion was evaluated to rule out a serious fall-related injury; failure to ensure the severity of pain and limitations in range of motion were thoroughly assessed by nursing as ordered for 72 hours following a fall; failure to ensure nursing staff communicated to Physical Therapy staff that the resident had sustained a fall so that therapy staff would take the necessary precautions to prevent potential exacerbation of any existing injury; failure to ensure Therapy staff immediately stopped therapy and communicated the resident's complaints of pain with range of motion to licensed nursing staff; failure to ensure the physician was immediately provided with complete radiology results, which resulted in a delay in treatment for [REDACTED].#5) of 7 (Residents #1 through #7) case mix residents who were at risk for falls. The failed practices resulted in Immediate Jeopardy, which caused or could have caused serious harm, injury or death to Resident #5, who experienced a fall that resulted in fractures and did not receive treatment for [REDACTED]. The failed practices also had the potential to cause more than minimal harm to 26 residents who had falls in the past 60 days, as documented on a list provided by the Director of Nursing (DON) on 12/15/17. The facility was informed of the Immediate Jeopardy condition on 12/14/17 at 4:45 p.m. The findings are: 1. The facility's policy and procedure titled, Accidents and Incidents - Investigating and Reporting, provided by the Director of Nursing (DON) on 12/15/17 at 11:25 a.m., documented, All accidents or incidents involving residents . occurring on our premises shall be investigated and reported to the Administrator. Policy Interpretation and Implementation 1. The Nurse Supervisor/Charge Nurse and/or the department director or supervisor shall promptly initiate and document investigation of the accident or incident. 2. The following data, as applicable, shall be included on the Report of Incident/Accident form: .k. Any corrective action taken; l. Follow-up information; m. Other pertinent data as necessary or required . 2. A policy titled, Change in a Resident's Condition or Status, received on 12/15/17 from the Director of Nursing (DON), documented, Policy Statement Our facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident's medical . condition . Policy Interpretation and Implementation . 1. The nurse will notify the resident's Attending Physician or physician on call when there has been a (an): .d. Significant change in the resident's physical .condition . g. need to transfer the resident to a hospital/treatment center; h. specific instruction to notify the Physician of changes in the resident's condition . 3. Prior to notifying the Physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider, including (for example) information prompted by the Interact SBAR (Situation Background, Assessment, Recommendations) Communication Form .7. The nurse will record in the resident's medical record information relative to changes in the resident's medical . condition or status . 3. Resident #5 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The Admission 5-Day Minimum Data Set (MDS) with an assessment reference date (ARD) of 11/11/17 documented the resident scored 10 (8-12 indicates moderately impaired) on a Brief Interview for Mental Status (BIMS), required extensive assistance with transfer, did not ambulate, was not steady with balance for surface-to-surface transfer, had functional limitation in range of motion of lower extremity and had 1 fall since admit with no injury. a. A hospital record dated 11/3/17 documented, Orthopedic Daily Rounding Note . Subjective .Additional information Patient is s/p (status [REDACTED]. b. A Fall Risk Evaluation dated 11/4/17 documented the resident's total fall risk score was 10, with a total score of 10 or greater indicating a high risk for falls. c. An Unusual Occurrence Report dated 11/11/17 at 11:00 p.m. and written by Licensed Practical Nurse (LPN) #1 documented, .Resident found lying on floor beside bed lying on left side. ROM (range of motion) WNL (within normal limits). Assisted up per 2 staff members to bed. (No) apparent injuries noted . Type of Injury 1. None Apparent . d. A Patient Fall Analysis Tool form dated 11/11/17 documented, .Additional Pertinent Facts/Comments: She has been more confused the past few days . Immediate Action taken for Patient: She was assessed for pain (and) injury . There was no documentation that a thorough post-fall investigation was conducted. e. The SBAR Communication form dated 11/11/17 (not timed) documented, The Change in condition, symptoms, or signs . Fall - found on floor. This started on 11/11/17 . Primary [DIAGNOSES REDACTED]. Other pertinent history . dementia . Nursing Notes . Resident found lying on floor in room beside bed, lying on her left side. ROM WNL. Assisted up per 2 staff members to bed. (On call physician) for (Attending physician) called (with) N.O. (new order) to monitor (times) 72 (hours) for complications from fall . f. A Physician's Telephone Order dated 11/11/17 at 11:20 p.m. and signed by LPN #1 documented, Monitor (times) 72 (hours) for complications from fall . g. The Medicare Daily Skilled Charting dated 11/12/17 and written by Licensed Practical Nurse (LPN) #1 documented, 2 A (2:00 a.m.) Res (resident) c/o (complains of) rt (right) hip pain 7/10 (pain level 7 on a scale of 1 to 10) [MEDICATION NAME] 5/325mg (milligrams) po (by mouth) given. (3:00 a.m.) Res cont (continues) to be awake but states, 'the pain is better.' (3:45 a.m.) Resident c/o pain to rt hip - res currently in bed lying on her rt side. Repositioned resident at this time off of her rt side . 4:50 A (4:50 a.m.) Res cont to be awake (and) on the call light inquiring about her children . 11/12/17 (6:00 a.m.) Res cont to be awake. There was no documentation the right hip was assessed for injury, or that the lower extremity was checked for swelling, bruising or range of motion limitations to evaluate the cause of the resident's pain. h. The Interdisciplinary Progress Notes dated 11/12/17 and written by LPN #2 documented, 8 AM C/O (complains of) (right) hip pain (2) [MEDICATION NAME] 325/5 given po (by mouth) (at) this (time). Husband (at bedside) 9 AM (No) further c/o pain (at) this (time). Husband states 'She is in (and) out of sleep'. There was no documentation the right hip was assessed for injury, or that the lower extremity was checked for swelling, bruising or range of motion limitations to evaluate the cause of the resident's pain. i. An Occupational Therapy Treatment Encounter Note dated 11/12/17 and written by the Certified Occupational Therapy Assistant (COTA) documented, .Bed mobility at Max A (assistance) supine to sit this afternoon due to increased pain from fall last night. Had increased fear of falling, resulting in 4 attempts to get up and T/F (transfer). Pt did better once a second person to help. Mod A (assistance) (times) 2 to stand/pivot. T/F back to bed after therapy was much better due to pain pill. Able to use trapeze bar and left leg to push self up in bed . Comments: Subjective/Objective: Pt and husband report her falling late last night. Noted right knee swelling and increased pain to right hip and knee. Talked to nurse and requested an x-ray be done . Comments Subjective/Objective: Pt has had increased confusion and poor memory. Unsafe with functional mobility due to poor safety awareness. Pt was making progress toward stated goals but had a fall over the weekend hindering her abilities to participate in standing activities and various ADLs (activities of daily living). Increased pain noted with movement of RLE (right lower extremity). This therapist requested X-rays be done to check status of right hip and knee. X-Rays were ordered and done this day . There was no documentation the COTA stopped the transfer attempts and reported the resident's increased pain and difficulty transferring to a licensed nurse or therapist; the resident was transferred on the fourth attempt, with 2 people assisting, then was transferred back to bed after Occupational Therapy was completed. j. A Physical Therapy Treatment Encounter Note dated 11/12/17 written by Physical Therapy Assistant (PTA) #1 documented, .Comments Subjective/Objective: Nursing reports patient had a fall last night and waiting x-ray to R (right) hip and knee. Increased swelling noted to LLE (left lower extremity) and patient is keeping her R leg in ER (extended rotation). When attempting to move her R leg into neutral position has increased pain. Pain medication prior to therapy session. No exercises or weight bearing to RLE (right lower extremity). k. The Interdisciplinary Progress Note dated 11/12/17 at 1:20 p.m. and written by LPN #2 documented, Therapy here, called to gym, resident (right) knee (with) (plus) 1 [MEDICAL CONDITION] (and) bruising. Therapy informed this nurse that resident was having increased difficulty (with) use of (right) leg. (Physician) on call for (Attending Physician) call placed to (Medical Clinic), (with) N.O. (new order) for (right) hip (and) (right) knee x-rays. Supervisor notified . Awaiting onsite imaging (at) this (time). l. A Physician's Telephone Order dated 11/12/17 at 1:20 p.m. and signed by LPN #2 documented, X-ray Right hip (and) Right knee Indication - DX (diagnosis) fall (increased) pain . m. The Interdisciplinary Progress Notes dated 11/12/17 at 4:45 p.m. and written by LPN 2 documented, Still waiting onsite imaging for x-rays call placed for status informed was between (2 city names) (and) would be here soon. An additional note at 6:05 p.m. documented, Onsite (imaging) here for x-rays awaiting results. n. The Radiology Report dated 11/12/17 at 6:14 p.m. documented, Exam: XR (x-ray) Right Hip with Pelvis . 2 or 3 views . Clinical History: .Signs and symptoms; Swelling or effusion of joint; Right . Findings: Bones/joints: Right hip arthroplasty. Femoral component traverses the proximal femoral fracture. Soft tissues: Surgical staples project over soft tissues of right hip . Right Hip Arthroplasty. Femoral Component Traverses the Proximal Femoral Fracture . Exam: XR Right Knee . Clinical History . Pain . Findings: Linear band of [MEDICAL CONDITION] extending to the cortex in what appears as the lateral femoral condyle, only seen on the lateral view, may represent a compression fracture . Soft tissues: Prominent soft tissue swelling around the knee. There was a handwritten notation on each page of the report, signed by LPN #2, which documented, Faxed 11/12/17 at 8:35 p.m. o. The Interdisciplinary Progress Notes dated 11/12/17 at 8:20 p.m. and written by LPN #2 documented, Results of x-rays here results called to (Nurse Practitioner). N.O.N. (new order noted) to hold therapy until (Physician) notified of results . p. A Physician's Telephone Order dated 11/12/17 at 8:20 p.m. documented, 1. Hold therapy until (physician) is contacted about x-ray reports. 2. Call (physician) in A.M. (morning) for further orders . Indication - DX (diagnosis) possible fracture . q. A Medicare Daily Skilled Charting note dated 11/13/17 at 9:30 a.m. and written by Registered Nurse (RN) #1 documented, (Physician) called (and) stated to send to ER (emergency room ) for evaluation . Resident taken via w/c (wheelchair) van to ER . admitted to (hospital). r. A form dated 11/13/17, provided by the Assistant Director of Nursing (ADON) on 12/14/17 at 3:45 p.m., documented, From: (Facility name) Date: 11/13/17 8:25 a.m. Subject: (Resident #5) had fall over the weekend. Showed possible compression fx (fracture) of knee, x-ray done of hip also. She had previous hip surgery in Little Rock. Just let me know if want us to send to (local hospital) for second opinion . s. A Physician telephone order dated 11/13/17 (not timed) documented, Send to ER for evaluation of (right) hip/knee t. The Emergency Department (ED) record documented, ED Nurse Documentation . Arrival Date: 11/13/17 Time: 11:49. Diagnosis: [REDACTED]. Triage Assessment: .Complains of pain in right knee and hip pain does not radiate. Pain currently is 8 out of 10 on a pain scale . The ED Physician Documentation form documented, .11/13 the patient presents with decreased range of motion, an injury, pain, that is acute. The complaints affect the right knee. Context: The problem was sustained at a nursing home . facility, resulted from the patient falling, the patient is not able to bear weight, and the patient is not able to ambulate. Onset: The symptoms/episode began/occurred 2 day(s) ago. Associated signs and symptoms: Pertinent positives: swelling. Pt sent over from (facility) nursing home for right knee injury. Pt is at (facility) for therapy after having right hip replacement surgery Nov (November) 2 in LR (Little Rock). 2 days ago she fell in her room. NH (nursing home) reports since then she has been unable to ambulate with assistance like she has been doing. They did an x-ray of the right hip and right knee and the report on the hip was normal, but the report on the knee said possible fracture so they sent her to the ER . Extremity: Positive for decreased range of motion, pain, swelling, tenderness. All other systems reviewed are negative . Extremities: grossly normal except noted in the right knee: [MEDICAL CONDITION], noted in the right hip: decreased ROM, pain, leg shortened and rotated . Differential Diagnosis: [REDACTED]. Disposition: 11/13 .Patient's condition represents a certified medical emergency .11/13/17 14:45 (2:45 p.m.) Transfer ordered to (large metropolitan hospital). [DIAGNOSES REDACTED]. Reason for transfer: Orthopedics - Higher Level of Care. u. The hospital record x-ray imaging report dated 11/13/17 at 12:56 p.m. documented, .Impression: Soft tissue swelling and large knee joint effusion. No acute fracture of right knee identified. v. The hospital x-ray imaging report dated 11/13/17 at 2:08 p.m. documented, .Impression: Acute fractures of right ilium and superior lateral acetabulum and proximal femur in patient status [REDACTED]. w. The hospital Operative Report dated 11/15/17 documented, .Preoperative Diagnosis: [REDACTED]. Postoperative Diagnosis: [REDACTED]. Procedure: Revision right total-hip of femoral component only with fixation of peri-prosthetic fracture . Anesthesia: General . x. A hospital Discharge Summary dated 12/5/17 documented, .Course of hospitalization : .had right hip surgery 2 weeks prior to a recent repeat surgery. She was at the nursing home, fell , sustained a right peri-prosthetic [MEDICAL CONDITION] and was referred to (other hospital). She underwent revision of the right total hip femoral component with fixation of peri-prosthetic fracture on November 15, 2017. 2 days post, she was referred for therapy and medical management.She does have history of multiple medical problems. She has had significant confusion postop. She states that her confusion was worse following her second surgery . Discharge Diagnoses: [REDACTED]. 2. Diabetes Mellitus. 3. Hypertension. 4. [MEDICAL CONDITION]. 5. [MEDICAL CONDITION]. 6. Dementia. 7. Anxiety and Depression . 10. Postop [MEDICAL CONDITION] . y. On 12/13/17 at 3:00 p.m., the Physical Therapy Assistant (PTA) was asked if the resident had been seen by therapy on 11/12/17 and stated, Yes she was. The PTA was asked how the resident was taken to the therapy department on that date and stated, Wheelchair. The PTA was asked who took the resident to the therapy department and stated, I did; she was up in a wheelchair, and I did put her to bed with assist, and it did take 2 of us. The PTA was asked who assisted in putting the resident to bed and stated, A CNA (Certified Nursing Assistant). The PTA was asked when she initially became aware of the resident's 11/11/17 fall and stated, Came in to see her (on 11/12/17), and the nurse told me she had a fall. The PTA was asked if she was informed the resident had fallen before the resident was taken to therapy. The PTA stated, Yes, and she was up in a wheelchair. The PTA was asked why therapy continued and stated, Because I didn't have a hold order to hold PT, so I held PT to the right leg, that particular leg, so all I could do was document what I saw and not mess with that leg. The PTA was asked if the resident had complained of pain and stated, She was in pain. I asked the nurse to check her. The PTA was asked how long the resident was in therapy and stated, 60 minutes. The PTA was asked if the resident had said if she was in pain and stated, You could tell in her face, grimacing. She didn't really say much. She wasn't herself. The PTA was asked if there was movement to the left leg and stated, Not other than I put her to bed; when you have a total hip, you have to abide by hip precautions. The PTA was asked if she reported the resident's pain to the nurse and stated, The nurse did come in there because of the rotation and swelling. The PTA was asked what part of the resident's leg was swollen and stated, The whole leg; the thigh was swollen. The PTA was asked what was rotated and stated, Her hip, her knee was rotated outward. She did have swelling from the surgery, but this was more so that particular day. The PTA was asked if the nurse had made any recommendations and stated, They were just waiting on x-ray. I reported it to nursing and, if I suspect something, you don't make them weight bearing. z. On 12/13/17 at 3:37 p.m., LPN #2 was asked, After the resident fell on [DATE], was an assessment done? The LPN stated, Yeah, checked her out; checked her dressing. The pain was about the same. Therapy came in. (Certified Occupational Therapy Assistant) got her up and took her to PT (Physical Therapy). The LPN was asked when the resident was assessed and stated, When in therapy, we noticed the change. I didn't notice a change 'til called to the gym. The LPN was asked what was then done and stated, Immediately notified my supervisor . doctor on call, got order for x-rays . called APN (Advanced Practice Nurse) and he gave the order. It was like around 8:30 p.m. (Nurse Practitioner's name). Gave him the x-ray results, and he told me to call (Attending physician name). Gave pain med, got her vital signs. LPN #2 was asked if there was any further assessment of the resident and stated, I went in and it didn't look any worse. The LPN was asked, When the x-ray results were given (nurse practitioner), why was there no referral to the emergency room for evaluation and the LPN stated, Because the x-rays were inconclusive. aa. On 12/14/17 at 4:24 a.m., LPN #1 was asked who found the resident when the resident fell on [DATE] and stated, I found resident on the floor. The LPN was asked what was done for the resident. The LPN stated, I came to the desk and called the doctor first, (Doctor name). She said to monitor her 72 hours for complications . The LPN was asked what monitoring was done and stated, Like if she had any increased pain, swelling, anything out of the norm. The LPN was asked where this monitoring was documented and stated, In my nurse's notes. The LPN was asked how often the resident was monitored and stated, I was in there like every time to check on her. The LPN was asked what could prove that assessments were done and stated, You chart it. LPN #1 was asked when she last assessed the resident on the morning of 11/12/17 and stated, Between 6 and 6:30 a.m. The LPN was asked if range of motion was checked when the resident was seen after being put back to bed and stated, No I did not again. The LPN was asked if range of motion should have been checked intermittently as part of the ongoing monitoring and stated, I would think so. LPN #1 was asked if the ongoing monitoring should be documented and stated, Yes. bb. On 12/14/17 at 11:00 a.m., the Certified Occupational Therapy Assistant (COTA) was asked if she had worked on 11/12/17 in the therapy department and stated, I believe so. The COTA checked the schedule and stated, Yes. The COTA was asked if she had assisted the resident to get out of bed on 11/12/17 and stated, I did. The COTA was asked if any staff had assisted and stated, It was a CNA, later. She (the resident) was really confused . When I got there, her husband told me she had had a fall the night before, and it was harder for her to get her leg out of bed and to move it, so I helped her go from supine to sit. The COTA was asked if the resident had complained of pain and stated, It was really bad when she moved. The COTA was asked if the resident could bear weight and stated, Weight bearing as tolerated. Once I went to get her up and she was having more difficulty, I told her don't put any weight down. We attempted to stand the first time with a gait belt, and I went to stand her that time and the fear set in. She said 'I can't, I can't' and I sat her back down and I reassured her. I'm in front of her and I reiterated 'you don't have to put any weight on the right leg'. I attempted again to stand her up by myself. I don't know if it was more of a fear issue or pain .A CNA came in and I asked if she could help and, I can't remember if we used the walker or not. I know it was 4 attempts. She seemed to be more scared. The COTA was asked if she had reported to the nurse that the resident was having pain and difficulty getting up. The COTA stated, I can't remember. The COTA reviewed the therapy notes for 11/12/17 and stated I can't remember if it was before or after I got her to stand to the wheelchair . The COTA was asked who the nurse was and stated, I think it was (LPN #2) between 12:30 and 1:00 (p.m.), after I got her up. The COTA was asked, if a resident has new complaints of pain with movement, especially after a fall, should you proceed with a transfer. The COTA stated, I can't remember. The COTA was asked, When there had been 4 attempts to get the resident up, should that should have been reported to the nurse? The COTA stated, I felt like it was okay for her to get up. Her behavior exhibited more fear. I know I asked (LPN #2) if they had done an x-ray. There was not an x-ray. The COTA was asked if the nurse had checked the resident and stated, Got her down there and told her (LPN #2) she needed an x-ray. The COTA was asked if the resident should have gotten up in the wheelchair and stated, As long as she doesn't bear weight. The COTA was asked if the resident had stayed up in the wheelchair and stated, Yes. The COTA was asked how long the resident had been in the therapy department and stated, 90 minutes. cc. On 12/14/17 at 12:50 p.m., the Director of Nursing (DON) was asked when a resident had a fall what was to be done afterwards and stated, It depends on what their range of motion is, if they had a shortening of the leg. We have a monitoring protocol and do fall tracking. The DON was asked when to monitor the resident after a fall and the DON stated, 72 hours. The DON was asked what the monitoring consisted of and stated, They check range of motion, vital signs, recheck for bruising, abrasions, skin tears. The DON was asked where this was to be documented and stated, In the nurses' notes. The DON was asked how often nurses were to check the resident during the 72 hour period and stated, At least every couple of hours. The DON was asked, If a resident has sustained a fall, and staff goes to get the resident out of bed, and the resident complains of pain, should they continue to get the resident out of bed? The DON stated, No. The DON was asked if resident falls were to be communicated to therapy staff and stated, Yes. The DON was asked if therapy staff should notify the nurse when a resident complains of pain with range of motion/movement after a fall. The DON stated, They should alert the nurse immediately. The DON was asked if there was documentation that indicated the resident was evaluated after the fall on 11/11/17. The DON referred to the nurses notes and stated, No, just that she was agitated. The DON was asked if that indicated that the resident had been assessed and stated, No it doesn't. The DON was asked if the nurse's notes are where assessments and monitoring should be documented and stated, Yes. The DON was asked if there was any documentation that noted the resident had been monitored and assessed following the fall during the time from 8:00 a.m. to 1:20 p.m. on 11/12/17. The surveyor referred the DON to the nurse's notes, and the DON stated, No. The DON was asked if the therapy department should have continued, with 4 attempts, to get the resident out of bed with the resident complaining of pain. The DON stated, No. The DON was referred to the 11/12/17 x-ray report results that indicated a fracture. The DON was asked what time the physician was called with those results and stated, 9:30 (a.m.). The DON was asked what time the physician should have been notified of the x-ray report and stated, To be honest, I think they open at 9. The DON was asked if the nursing staff should have called the physician before 9:30 a.m. and stated, Yes. At 2:40 p.m., the DON was asked if there was a fracture to the right hip on the x-ray reports on 11/12/17. The DON reviewed the x-ray results and stated, It says [MEDICATION NAME] the proximal femoral fracture so that's a fracture. The DON was asked if the physician should have been notified sooner of the x-ray results and the DON stated, When there is a fracture. They should have called. The DON was asked if the nurse is responsible for assessing the resident and notifying the physician of a change after a fall and stated, Yes. dd. On 12/14/17 at 2:00 p.m., Registered Nurse (RN) #1 was asked when she came on duty on 11/13/17, if she was made aware that the resident had fallen and had x-ray reports with results. The RN stated, They filled me in that she had fallen and they got x-rays the night before. The RN was asked when the physician was notified and stated, I'm going to guess they did. We faxed it to him. The RN was asked when she had made the physician aware on the morning of 11/13/17 of the x-ray results and stated, He (physician) called. I was under the impression (Assistant Director of Nursing (ADON)) had (called the physician) that she (resident) had fallen and she wasn't complaining of pain and they hadn't ordered to send to the ER. They had gotten x-rays done on Sunday. The RN was asked if she was made aware of the x-ray results when she came to work and stated, (I) spoke with her night nurse. The RN was asked what an assessment after a fall consisted of and stated, Like a head to toe, me checking her out, vital signs, listen to breath sounds, bowel sounds. The RN was asked how she had transported the resident to the emergency room and stated, By wheelchair van. When he told us to send her to ER for evaluation of the hip/knee, when I came on that morning, she was complaining of knee pain. The RN was asked why the resident was sent in the van in a wheelchair and not the ambulance. The RN gave no response. The RN was asked why she had determined that the resident should be transported by van instead of an ambulance and stated, In my mind, thinking that she was already up in the wheelchair. The RN was asked if she had reviewed the x-ray results and stated, Yes. The RN was asked if she was aware that the resident had a fracture to the hip and stated, Yes. RN #1 was asked if the resident should have been transferred to the ER in a wheelchair in the facility van with a newly [MEDICAL CONDITION] and stated, No. ee. On 12/14/17 at 2:38 p.m., the ADON was asked when she became aware that the resident had x-ray results that showed a fracture and stated, When I came in that morning. The ADON was asked if she had reviewed all the x-ray reports and stated, I can't say. The ADON was referred to the incident report dated 11/11/17 at 11:00 p.m. when the resident had fallen and was asked if there had been an investigation and if any measures were put in place at that time to prevent a recurrence of the failure to assess and the delay in treatment. The ADON stated, No I missed it. The ADON was asked why the resident went out of the facility via van and stated I'm not sure. The ADON was asked if she had investigated why the resident was transported to the emergency room via facility van in a wheelchair and stated, No. At 2:40 p.m., the ADON was asked if she had conducted an investigation for any aspect related to the resident's fall and stated, No I did not. The ADON was asked if she was aware that the resident had a fracture to the right hip. The ADON stated, No, I was not. The ADON was asked if she had reviewed the hip x-rays and stated, No, I had not. The ADON was asked, after having found that the resident had sustained a fracture during the fall on 11/11/17, what was done about post fall care. The ADON gave no response. The ADON was asked when she was made aware of the resident's fall and stated, I guess it was Monday (11/13/17). The ADON was asked, after the resident was sent out of the facility, if any investigation was done regarding a review the post-fall assessment, the delayed treatment and care for a fracture, and the transport of the resident in a wheelchair in the facility van. The ADON stated, I don't recall. The ADON was asked if there had been any review or investigation that resulted in any measures being put in place to prevent a recurrence of the failure to assess and monitor, the lack of documentation, the delays in treatment, and the transportation via facility van for an injury classified as a medical emergency. The ADON stated, Again, we didn't do anything. I don't recall specifically, we didn't. The ADON was asked if there should be thorough investigations of post fall circumstances to ensure all aspects of post fall care, especially if there was any delay in treatment. The ADON stated, Should. ff. On 12/14/17 at 3:12 p.m., the Advanced Practice Nurse (APN) was asked if he recalled being informed of the resident's x-ray results on 11/12/17 with a [MEDICAL CONDITION]. The APN stated, No I don't. I feel like (I) would remember that. The APN was asked, If you were informed that there was a fracture on the x-ray report, would you have given an order for [REDACTED]. 4. The immediate jeopardy was removed, and the scope/severity reduced to H on 12/15/17 at 3:30 p.m., when the facility implemented the following Plan of Removal: a. Identification: On 12/14/17 the DON/designee identified 4 other residents who had experienced a Fall within the last 7 days. One resident had radiology exam pertaining to a Fall with negative findings which were reported to the physician. There were 3 of the 4 residents being monitored post fall per physician's orders [REDACTED]. b. Assessments: 1. On 12/14/17 (TRUNCATED)

Complaint # (AR 785) was substantiated (all or in part) with these findings: Based on record review and interview, the facility's nursing administration failed to ensure deficient practices that occurred after a fall with injury were investigated, identified and addressed. The facility failed to ensure necessary and appropriate care was provided post-fall, as evidenced by failure to ensure new onset hip pain with range of motion was evaluated to rule out a serious fall-related injury; failure to ensure the severity of pain and limitations in range of motion were thoroughly assessed by nursing as ordered for 72 hours following a fall; failure to ensure nursing staff communicated to Physical Therapy staff that the resident had sustained a fall so that therapy staff would take the necessary precautions to prevent potential exacerbation of any existing injury; failure to ensure Therapy staff immediately stopped therapy and communicated the resident's complaints of pain with range of motion to licensed nursing staff; failure to ensure the physician was immediately provided with complete radiology results, which resulted in a delay in treatment for [REDACTED].#5) of 7 (Residents #1 through #7) case mix residents who were at risk for falls. The failed practices resulted in Immediate Jeopardy, which caused or could have caused serious harm, injury or death to Resident #5, who experienced a fall that resulted in fractures and did not receive treatment for [REDACTED]. The failed practices also had the potential to cause more than minimal harm to 26 residents who had falls in the past 60 days, as documented on a list provided by the Director of Nursing (DON) on 12/15/17. The facility was informed of the Immediate Jeopardy condition on 12/14/17 at 4:45 p.m. The findings are: 1. The facility's Assistant Director of Nursing Services Job Description, provided by the Administrator on 12/19/17, documented, Assists the Director of Nursing Services in directing the activities of licensed and non-licensed personnel who provide health care and nursing services to residents at the home on a 24 hr (hour), 7 day per week basis. Nature and Scope: the Assistant Director of Nursing reports to the Director of Nursing Services. Reporting to this position are Shift Supervisors, Registered Nurses, Licensed Practical Nurses, and Certified Nurses Assistants. The Assistant Director of Nursing Services compliments the Director of Nursing Services in planning, developing, and supervising the activities of licensed and non-licensed personnel who provide health care and nursing services to nursing home residents. This position assists with the development and implementation of nursing services, objectives, policies, and procedures in accordance with Federal and State regulations.The Assistant Director of Nursing Services may confer with resident's physicians on an occasional basis to clarify medical orders and direct care. In the absence of the Director of Nursing Services, the Assistant Director of Nursing Services performs the duties of the Director . Principal Accountabilities . Oversees the clinical operations (i.e. (such as): monitoring residents conditions .) of the Nursing Department. Assists the Director of Nursing Services in the design, implementation and evaluation of nursing systems that ensure consistent delivery of care and maintains and promotes resident rights. Conducts nursing rounds on all units several times a day, including the beginning and end of shift. Provides reports/recommendations as needed/required for Director of Nursing Services concerning the operations of Nursing Services. Assists the Director of Nursing Services in the development, implementation and evaluation of facility policies, procedures and guidelines on an annual and ongoing basis (i.e.: nursing .etc (et cetera).) . Assists the Director of Nursing Services in ensuring nursing staff awareness and compliance with Federal and State regulations relative to resident rights issues . 2. The facility's Shift Supervisor Job Description, provided by the Administrator on 12/19/17, documented, Supervises and coordinates activities of nursing personnel on each unit, on an assigned shift, promoting high quality care; assesses the needs of residents and ensures services are consistent with needs. Essential Duties and Responsibilities: Serves as the primary safety net seven days per week, 365 days per year for any events occurring during the shift for which they are responsible that require the immediate attention of facility management . Communicates with Director or Assistant Director regarding pertinent issues related to each unit (ie: falls, negative outcomes, change in condition) .Performs other duties as assigned. Responsible for the supervision of all licensed and non-licensed personnel, who provide health care and nursing services, on an assigned shift. Qualifications: To perform this job successfully, an individual must be able to perform each essential duty satisfactorily .Must be proficient with the use of nursing skills.Ability to apply common sense understanding to carry out instructions furnished in written or oral form. Ability to deal with problems involving several variables in standardized situations. While performing the duties of this job, the employee is frequently required to talk or hear .The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job . 3. The facility's policy and procedure titled, Accidents and Incidents - Investigating and Reporting, provided by the Director of Nursing (DON) on 12/15/17 at 11:25 a.m., documented, All accidents or incidents involving residents . occurring on our premises shall be investigated and reported to the Administrator. Policy Interpretation and Implementation 1. The Nurse Supervisor/Charge Nurse and/or the department director or supervisor shall promptly initiate and document investigation of the accident or incident. 2. The following data, as applicable, shall be included on the Report of Incident/Accident form: .k. Any corrective action taken; l. Follow-up information; m. Other pertinent data as necessary or required . 4. A policy titled, Change in a Resident's Condition or Status, received on 12/15/17 from the Director of Nursing (DON), documented, Policy Statement Our facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident's medical . condition . Policy Interpretation and Implementation . 1. The nurse will notify the resident's Attending Physician or physician on call when there has been a (an): .d. Significant change in the resident's physical .condition . g. need to transfer the resident to a hospital/treatment center; h. specific instruction to notify the Physician of changes in the resident's condition . 3. Prior to notifying the Physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider, including (for example) information prompted by the Interact SBAR (Situation Background, Assessment, Recommendations) Communication Form .7. The nurse will record in the resident's medical record information relative to changes in the resident's medical . condition or status . 5. Resident #5 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The Admission 5-Day Minimum Data Set (MDS) with an assessment reference date (ARD) of 11/11/17 documented the resident scored 10 (8-12 indicates moderately impaired) on a Brief Interview for Mental Status (BIMS), required extensive assistance with transfer, did not ambulate, was not steady with balance for surface-to-surface transfer, had functional limitation in range of motion of lower extremity and had 1 fall since admit with no injury. a. A hospital record dated 11/3/17 documented, Orthopedic Daily Rounding Note . Subjective .Additional information Patient is s/p (status [REDACTED]. b. A Fall Risk Evaluation dated 11/4/17 documented the resident's total fall risk score was 10, with a total score of 10 or greater indicating a high risk for falls. c. An Unusual Occurrence Report dated 11/11/17 at 11:00 p.m. and written by Licensed Practical Nurse (LPN) #1 documented, .Resident found lying on floor beside bed lying on left side. ROM (range of motion) WNL (within normal limits). Assisted up per 2 staff members to bed. (No) apparent injuries noted . Type of Injury 1. None Apparent . d. A Patient Fall Analysis Tool form dated 11/11/17 documented, .Additional Pertinent Facts/Comments: She has been more confused the past few days . Immediate Action taken for Patient: She was assessed for pain (and) injury . There was no documentation that a thorough post-fall investigation was conducted. e. The SBAR Communication form dated 11/11/17 (not timed) documented, The Change in condition, symptoms, or signs . Fall - found on floor. This started on 11/11/17 . Primary [DIAGNOSES REDACTED]. Other pertinent history . dementia . Nursing Notes . Resident found lying on floor in room beside bed, lying on her left side. ROM WNL. Assisted up per 2 staff members to bed. (On call physician) for (Attending physician) called (with) N.O. (new order) to monitor (times) 72 (hours) for complications from fall . f. A Physician's Telephone Order dated 11/11/17 at 11:20 p.m. and signed by LPN #1 documented, Monitor (times) 72 (hours) for complications from fall . g. The Medicare Daily Skilled Charting dated 11/12/17 and written by Licensed Practical Nurse (LPN) #1 documented, 2 A (2:00 a.m.) Res (resident) c/o (complains of) rt (right) hip pain 7/10 (pain level 7 on a scale of 1 to 10) [MEDICATION NAME] 5/325mg (milligrams) po (by mouth) given. (3:00 a.m.) Res cont (continues) to be awake but states, 'the pain is better.' (3:45 a.m.) Resident c/o pain to rt hip - res currently in bed lying on her rt side. Repositioned resident at this time off of her rt side . 4:50 A (4:50 a.m.) Res cont to be awake (and) on the call light inquiring about her children . 11/12/17 (6:00 a.m.) Res cont to be awake. There was no documentation the right hip was assessed for injury, or that the lower extremity was checked for swelling, bruising or range of motion limitations to evaluate the cause of the resident's pain. h. The Interdisciplinary Progress Notes dated 11/12/17 and written by LPN #2 documented, 8 AM C/O (complains of) (right) hip pain (2) [MEDICATION NAME] 325/5 given po (by mouth) (at) this (time). Husband (at bedside) 9 AM (No) further c/o pain (at) this (time). Husband states 'She is in (and) out of sleep'. There was no documentation the right hip was assessed for injury, or that the lower extremity was checked for swelling, bruising or range of motion limitations to evaluate the cause of the resident's pain. i. An Occupational Therapy Treatment Encounter Note dated 11/12/17 and written by the Certified Occupational Therapy Assistant (COTA) documented, .Bed mobility at Max A (assistance) supine to sit this afternoon due to increased pain from fall last night. Had increased fear of falling, resulting in 4 attempts to get up and T/F (transfer). Pt did better once a second person to help. Mod A (assistance) (times) 2 to stand/pivot. T/F back to bed after therapy was much better due to pain pill. Able to use trapeze bar and left leg to push self up in bed . Comments: Subjective/Objective: Pt and husband report her falling late last night. Noted right knee swelling and increased pain to right hip and knee. Talked to nurse and requested an x-ray be done . Comments Subjective/Objective: Pt has had increased confusion and poor memory. Unsafe with functional mobility due to poor safety awareness. Pt was making progress toward stated goals but had a fall over the weekend hindering her abilities to participate in standing activities and various ADLs (activities of daily living). Increased pain noted with movement of RLE (right lower extremity). This therapist requested X-rays be done to check status of right hip and knee. X-Rays were ordered and done this day . There was no documentation the COTA stopped the transfer attempts and reported the resident's increased pain and difficulty transferring to a licensed nurse or therapist; the resident was transferred on the fourth attempt, with 2 people assisting, then was transferred back to bed after Occupational Therapy was completed. j. A Physical Therapy Treatment Encounter Note dated 11/12/17 written by Physical Therapy Assistant (PTA) #1 documented, .Comments Subjective/Objective: Nursing reports patient had a fall last night and waiting x-ray to R (right) hip and knee. Increased swelling noted to LLE (left lower extremity) and patient is keeping her R leg in ER (extended rotation). When attempting to move her R leg into neutral position has increased pain. Pain medication prior to therapy session. No exercises or weight bearing to RLE (right lower extremity). k. The Interdisciplinary Progress Note dated 11/12/17 at 1:20 p.m. and written by LPN #2 documented, Therapy here, called to gym, resident (right) knee (with) (plus) 1 [MEDICAL CONDITION] (and) bruising. Therapy informed this nurse that resident was having increased difficulty (with) use of (right) leg. (Physician) on call for (Attending Physician) call placed to (Medical Clinic), (with) N.O. (new order) for (right) hip (and) (right) knee x-rays. Supervisor notified . Awaiting onsite imaging (at) this (time). l. A Physician's Telephone Order dated 11/12/17 at 1:20 p.m. and signed by LPN #2 documented, X-ray Right hip (and) Right knee Indication - DX (diagnosis) fall (increased) pain . m. The Interdisciplinary Progress Notes dated 11/12/17 at 4:45 p.m. and written by LPN 2 documented, Still waiting onsite imaging for x-rays call placed for status informed was between (2 city names) (and) would be here soon. An additional note at 6:05 p.m. documented, Onsite (imaging) here for x-rays awaiting results. n. The Radiology Report dated 11/12/17 at 6:14 p.m. documented, Exam: XR (x-ray) Right Hip with Pelvis . 2 or 3 views . Clinical History: .Signs and symptoms; Swelling or effusion of joint; Right . Findings: Bones/joints: Right hip arthroplasty. Femoral component traverses the proximal femoral fracture. Soft tissues: Surgical staples project over soft tissues of right hip . Right Hip Arthroplasty. Femoral Component Traverses the Proximal Femoral Fracture . Exam: XR Right Knee . Clinical History . Pain . Findings: Linear band of [MEDICAL CONDITION] extending to the cortex in what appears as the lateral femoral condyle, only seen on the lateral view, may represent a compression fracture . Soft tissues: Prominent soft tissue swelling around the knee. There was a handwritten notation on each page of the report, signed by LPN #2, which documented, Faxed 11/12/17 at 8:35 p.m. o. The Interdisciplinary Progress Notes dated 11/12/17 at 8:20 p.m. and written by LPN #2 documented, Results of x-rays here results called to (Nurse Practitioner). N.O.N. (new order noted) to hold therapy until (Physician) notified of results . p. A Physician's Telephone Order dated 11/12/17 at 8:20 p.m. documented, 1. Hold therapy until (physician) is contacted about x-ray reports. 2. Call (physician) in A.M. (morning) for further orders . Indication - DX (diagnosis) possible fracture . q. A Medicare Daily Skilled Charting note dated 11/13/17 at 9:30 a.m. and written by Registered Nurse (RN) #1 documented, (Physician) called (and) stated to send to ER (emergency room ) for evaluation . Resident taken via w/c (wheelchair) van to ER . admitted to (hospital). r. A form dated 11/13/17, provided by the Assistant Director of Nursing (ADON) on 12/14/17 at 3:45 p.m., documented, From: (Facility name) Date: 11/13/17 8:25 a.m. Subject: (Resident #5) had fall over the weekend. Showed possible compression fx (fracture) of knee, x-ray done of hip also. She had previous hip surgery in Little Rock. Just let me know if want us to send to (local hospital) for second opinion . s. A Physician telephone order dated 11/13/17 (not timed) documented, Send to ER for evaluation of (right) hip/knee t. The Emergency Department (ED) record documented, ED Nurse Documentation . Arrival Date: 11/13/17 Time: 11:49. Diagnosis: [REDACTED]. Triage Assessment: .Complains of pain in right knee and hip pain does not radiate. Pain currently is 8 out of 10 on a pain scale . The ED Physician Documentation form documented, .11/13 the patient presents with decreased range of motion, an injury, pain, that is acute. The complaints affect the right knee. Context: The problem was sustained at a nursing home . facility, resulted from the patient falling, the patient is not able to bear weight, and the patient is not able to ambulate. Onset: The symptoms/episode began/occurred 2 day(s) ago. Associated signs and symptoms: Pertinent positives: swelling. Pt sent over from (facility) nursing home for right knee injury. Pt is at (facility) for therapy after having right hip replacement surgery Nov (November) 2 in LR (Little Rock). 2 days ago she fell in her room. NH (nursing home) reports since then she has been unable to ambulate with assistance like she has been doing. They did an x-ray of the right hip and right knee and the report on the hip was normal, but the report on the knee said possible fracture so they sent her to the ER . Extremity: Positive for decreased range of motion, pain, swelling, tenderness. All other systems reviewed are negative . Extremities: grossly normal except noted in the right knee: [MEDICAL CONDITION], noted in the right hip: decreased ROM, pain, leg shortened and rotated . Differential Diagnosis: [REDACTED]. Disposition: 11/13 .Patient's condition represents a certified medical emergency .11/13/17 14:45 (2:45 p.m.) Transfer ordered to (large metropolitan hospital). [DIAGNOSES REDACTED]. Reason for transfer: Orthopedics - Higher Level of Care. u. The hospital record x-ray imaging report dated 11/13/17 at 12:56 p.m. documented, .Impression: Soft tissue swelling and large knee joint effusion. No acute fracture of right knee identified. v. The hospital x-ray imaging report dated 11/13/17 at 2:08 p.m. documented, .Impression: Acute fractures of right ilium and superior lateral acetabulum and proximal femur in patient status [REDACTED]. w. The hospital Operative Report dated 11/15/17 documented, .Preoperative Diagnosis: [REDACTED]. Postoperative Diagnosis: [REDACTED]. Procedure: Revision right total-hip of femoral component only with fixation of peri-prosthetic fracture . Anesthesia: General . x. A hospital Discharge Summary dated 12/5/17 documented, .Course of hospitalization : .had right hip surgery 2 weeks prior to a recent repeat surgery. She was at the nursing home, fell , sustained a right peri-prosthetic [MEDICAL CONDITION] and was referred to (other hospital). She underwent revision of the right total hip femoral component with fixation of peri-prosthetic fracture on November 15, 2017. 2 days post, she was referred for therapy and medical management.She does have history of multiple medical problems. She has had significant confusion postop. She states that her confusion was worse following her second surgery . Discharge Diagnoses: [REDACTED]. 2. Diabetes Mellitus. 3. Hypertension. 4. [MEDICAL CONDITION]. 5. [MEDICAL CONDITION]. 6. Dementia. 7. Anxiety and Depression . 10. Postop [MEDICAL CONDITION] . y. On 12/13/17 at 3:00 p.m., the Physical Therapy Assistant (PTA) was asked if the resident had been seen by therapy on 11/12/17 and stated, Yes she was. The PTA was asked how the resident was taken to the therapy department on that date and stated, Wheelchair. The PTA was asked who took the resident to the therapy department and stated, I did; she was up in a wheelchair, and I did put her to bed with assist, and it did take 2 of us. The PTA was asked who assisted in putting the resident to bed and stated, A CNA (Certified Nursing Assistant). The PTA was asked when she initially became aware of the resident's 11/11/17 fall and stated, Came in to see her (on 11/12/17), and the nurse told me she had a fall. The PTA was asked if she was informed the resident had fallen before the resident was taken to therapy. The PTA stated, Yes, and she was up in a wheelchair. The PTA was asked why therapy continued and stated, Because I didn't have a hold order to hold PT, so I held PT to the right leg, that particular leg, so all I could do was document what I saw and not mess with that leg. The PTA was asked if the resident had complained of pain and stated, She was in pain. I asked the nurse to check her. The PTA was asked how long the resident was in therapy and stated, 60 minutes. The PTA was asked if the resident had said if she was in pain and stated, You could tell in her face, grimacing. She didn't really say much. She wasn't herself. The PTA was asked if there was movement to the left leg and stated, Not other than I put her to bed; when you have a total hip, you have to abide by hip precautions. The PTA was asked if she reported the resident's pain to the nurse and stated, The nurse did come in there because of the rotation and swelling. The PTA was asked what part of the resident's leg was swollen and stated, The whole leg; the thigh was swollen. The PTA was asked what was rotated and stated, Her hip, her knee was rotated outward. She did have swelling from the surgery, but this was more so that particular day. The PTA was asked if the nurse had made any recommendations and stated, They were just waiting on x-ray. I reported it to nursing and, if I suspect something, you don't make them weight bearing. z. On 12/13/17 at 3:37 p.m., LPN #2 was asked, After the resident fell on [DATE], was an assessment done? The LPN stated, Yeah, checked her out; checked her dressing. The pain was about the same. Therapy came in. (Certified Occupational Therapy Assistant) got her up and took her to PT (Physical Therapy). The LPN was asked when the resident was assessed and stated, When in therapy, we noticed the change. I didn't notice a change 'til called to the gym. The LPN was asked what was then done and stated, Immediately notified my supervisor . doctor on call, got order for x-rays . called APN (Advanced Practice Nurse) and he gave the order. It was like around 8:30 p.m. (Nurse Practitioner's name). Gave him the x-ray results, and he told me to call (Attending physician name). Gave pain med, got her vital signs. LPN #2 was asked if there was any further assessment of the resident and stated, I went in and it didn't look any worse. The LPN was asked, When the x-ray results were given (nurse practitioner), why was there no referral to the emergency room for evaluation and the LPN stated, Because the x-rays were inconclusive. aa. On 12/14/17 at 4:24 a.m., LPN #1 was asked who found the resident when the resident fell on [DATE] and stated, I found resident on the floor. The LPN was asked what was done for the resident. The LPN stated, I came to the desk and called the doctor first, (Doctor name). She said to monitor her 72 hours for complications . The LPN was asked what monitoring was done and stated, Like if she had any increased pain, swelling, anything out of the norm. The LPN was asked where this monitoring was documented and stated, In my nurse's notes. The LPN was asked how often the resident was monitored and stated, I was in there like every time to check on her. The LPN was asked what could prove that assessments were done and stated, You chart it. LPN #1 was asked when she last assessed the resident on the morning of 11/12/17 and stated, Between 6 and 6:30 a.m. The LPN was asked if range of motion was checked when the resident was seen after being put back to bed and stated, No I did not again. The LPN was asked if range of motion should have been checked intermittently as part of the ongoing monitoring and stated, I would think so. LPN #1 was asked if the ongoing monitoring should be documented and stated, Yes. bb. On 12/14/17 at 11:00 a.m., the Certified Occupational Therapy Assistant (COTA) was asked if she had worked on 11/12/17 in the therapy department and stated, I believe so. The COTA checked the schedule and stated, Yes. The COTA was asked if she had assisted the resident to get out of bed on 11/12/17 and stated, I did. The COTA was asked if any staff had assisted and stated, It was a CNA, later. She (the resident) was really confused . When I got there, her husband told me she had had a fall the night before, and it was harder for her to get her leg out of bed and to move it, so I helped her go from supine to sit. The COTA was asked if the resident had complained of pain and stated, It was really bad when she moved. The COTA was asked if the resident could bear weight and stated, Weight bearing as tolerated. Once I went to get her up and she was having more difficulty, I told her don't put any weight down. We attempted to stand the first time with a gait belt, and I went to stand her that time and the fear set in. She said 'I can't, I can't' and I sat her back down and I reassured her. I'm in front of her and I reiterated 'you don't have to put any weight on the right leg'. I attempted again to stand her up by myself. I don't know if it was more of a fear issue or pain .A CNA came in and I asked if she could help and, I can't remember if we used the walker or not. I know it was 4 attempts. She seemed to be more scared. The COTA was asked if she had reported to the nurse that the resident was having pain and difficulty getting up. The COTA stated, I can't remember. The COTA reviewed the therapy notes for 11/12/17 and stated I can't remember if it was before or after I got her to stand to the wheelchair . The COTA was asked who the nurse was and stated, I think it was (LPN #2) between 12:30 and 1:00 (p.m.), after I got her up. The COTA was asked, if a resident has new complaints of pain with movement, especially after a fall, should you proceed with a transfer. The COTA stated, I can't remember. The COTA was asked, When there had been 4 attempts to get the resident up, should that should have been reported to the nurse? The COTA stated, I felt like it was okay for her to get up. Her behavior exhibited more fear. I know I asked (LPN #2) if they had done an x-ray. There was not an x-ray. The COTA was asked if the nurse had checked the resident and stated, Got her down there and told her (LPN #2) she needed an x-ray. The COTA was asked if the resident should have gotten up in the wheelchair and stated, As long as she doesn't bear weight. The COTA was asked if the resident had stayed up in the wheelchair and stated, Yes. The COTA was asked how long the resident had been in the therapy department and stated, 90 minutes. cc. On 12/14/17 at 12:50 p.m., the Director of Nursing (DON) was asked when a resident had a fall what was to be done afterwards and stated, It depends on what their range of motion is, if they had a shortening of the leg. We have a monitoring protocol and do fall tracking. The DON was asked when to monitor the resident after a fall and the DON stated, 72 hours. The DON was asked what the monitoring consisted of and stated, They check range of motion, vital signs, recheck for bruising, abrasions, skin tears. The DON was asked where this was to be documented and stated, In the nurses' notes. The DON was asked how often nurses were to check the resident during the 72 hour period and stated, At least every couple of hours. The DON was asked, If a resident has sustained a fall, and staff goes to get the resident out of bed, and the resident complains of pain, should they continue to get the resident out of bed? The DON stated, No. The DON was asked if resident falls were to be communicated to therapy staff and stated, Yes. The DON was asked if therapy staff should notify the nurse when a resident complains of pain with range of motion/movement after a fall. The DON stated, They should alert the nurse immediately. The DON was asked if there was documentation that indicated the resident was evaluated after the fall on 11/11/17. The DON referred to the nurses notes and stated, No, just that she was agitated. The DON was asked if that indicated that the resident had been assessed and stated, No it doesn't. The DON was asked if the nurse's notes are where assessments and monitoring should be documented and stated, Yes. The DON was asked if there was any documentation that noted the resident had been monitored and assessed following the fall during the time from 8:00 a.m. to 1:20 p.m. on 11/12/17. The surveyor referred the DON to the nurse's notes, and the DON stated, No. The DON was asked if the therapy department should have continued, with 4 attempts, to get the resident out of bed with the resident complaining of pain. The DON stated, No. The DON was referred to the 11/12/17 x-ray report results that indicated a fracture. The DON was asked what time the physician was called with those results and stated, 9:30 (a.m.). The DON was asked what time the physician should have been notified of the x-ray report and stated, To be honest, I think they open at 9. The DON was asked if the nursing staff should have called the physician before 9:30 a.m. and stated, Yes. At 2:40 p.m., the DON was asked if there was a fracture to the right hip on the x-ray reports on 11/12/17. The DON reviewed the x-ray results and stated, It says [MEDICATION NAME] the proximal femoral fracture so that's a fracture. The DON was asked if the physician should have been notified sooner of the x-ray results and the DON stated, When there is a fracture. They should have called. The DON was asked if the nurse is responsible for assessing the resident and notifying the physician of a change after a fall and stated, Yes. dd. On 12/14/17 at 2:00 p.m., Registered Nurse (RN) #1 was asked when she came on duty on 11/13/17, if she was made aware that the resident had fallen and had x-ray reports with results. The RN stated, They filled me in that she had fallen and they got x-rays the night before. The RN was asked when the physician was notified and stated, I'm going to guess they did. We faxed it to him. The RN was asked when she had made the physician aware on the morning of 11/13/17 of the x-ray results and stated, He (physician) called. I was under the impression (Assistant Director of Nursing (ADON)) had (called the physician) that she (resident) had fallen and she wasn't complaining of pain and they hadn't ordered to send to the ER. They had gotten x-rays done on Sunday. The RN was asked if she was made aware of the x-ray results when she came to work and stated, (I) spoke with her night nurse. The RN was asked what an assessment after a fall consisted of and stated, Like a head to toe, me checking her out, vital signs, listen to breath sounds, bowel sounds. The RN was asked how she had transported the resident to the emergency room and stated, By wheelchair van. When he told us to send her to ER for evaluation of the hip/knee, when I came on that morning, she was complaining of knee pain. The RN was asked why the resident was sent in the van in a wheelchair and not the ambulance. The RN gave no response. The RN was asked why she had determined that the resident sho (TRUNCATED)

Complaint # was substantiated, all or in part, with these findings. A. Based on record review and interview, the facility failed to ensure that the physician was immediately consulted regarding episodes of significant [DIAGNOSES REDACTED] and [MEDICAL CONDITION] for 2 (Residents #21 and #24) of 4 (Residents #2, #18, #21 and #24) case mix residents who were at risk for low/high blood sugar levels. The failed facility practices caused or could have caused serious injury or death to Resident #21, who was unresponsive with severe low blood sugar on [DATE] and required admission to the Intensive Care Unit, and was likely to affect 9 residents who were at risk of low blood sugar levels, according to a review of all Medication Administration Records (MARs) for residents with diabetes provided by the Director of Nursing (DON) on [DATE]. The facility was informed of the Immediate Jeopardy on [DATE] at 2:25 p.m. The findings are: 1. Resident #21 had a [DIAGNOSES REDACTED]. The 5-day Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE] documented the resident was cognitively intact per a staff assessment of mental status and had Diabetes Mellitus. a. The physician's orders [REDACTED]. [MEDICATION NAME] 75 units sq (subcutaneous) q (every) am (morning). [MEDICATION NAME] 50 units sq q HS (bedtime). Humalog SSI (Sliding Scale Insulin) < (less than) 100 = 0 units. 101 - 150 = 10 units. 151 - 200 = 15 units. 201 - 300 = 20 units. 301 - 400 = 25 units. > (greater than) 400 call MD (medical doctor). FSBS (Finger Stick Blood Sugar) AC (before) meals & (and) HS." There were no ordered parameters to notify the physician in the event of low blood sugars. There were no ordered interventions for the treatment of [REDACTED]. b. The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]"0". The FSBS result on [DATE] at 8:00 p.m. was documented as 59. There was no documentation on the MAR indicated [REDACTED]. c. The Nurse's Note dated [DATE] documented, "Mood State/Behaviors: 7a - 3 p (7:00 a.m. - 3:00 p.m.) Shift: Cooperative, Pleasant, sleeps a lot. 3p - 11p (3:00 p.m. - 11:00 p.m.) Shift: Cooperative, Pleasant, sleeps a lot." The last Nurse's Note entry documented, "5:30 (p.m.) Doctors to remove ctures (sutures) on the 30th and change appointment." There was no documentation of the resident's status at 8:00 p.m. and no documentation of any intervention to address the low blood sugar reading. There was no documentation that the physician was notified of the low blood sugar. d. On [DATE] at 12:15 p.m., Licensed Practical Nurse (LPN) #4 was asked, "(Resident #21) had a blood sugar of 59 on [DATE] at 8:00 p.m. Can you tell me what happened?" LPN #4 stated, "I went to check the blood sugar. It was 59. I gave her juice and re-checked her blood sugar. It was 193. I went ahead and gave her the insulin." LPN #4 was asked, "Where did you document that?" LPN #4 stated, "It should be in the Nurses' Notes." LPN #4 was asked, "I have looked at the Nurses' Notes and the last entry was at 5:30 p.m.?" LPN #4 stated, "I should have documented it in the Nurses' Notes." LPN #4 was asked, "Did you call the physician?" LPN #4 stated, "No. You first try to get the sugar up. If you can't, then you call the doctor." e. The Nurse's Note dated [DATE] documented, "4:55 a.m.: called to resident room. Resident not responsive. Foam at the mouth. Resident FSBS check result 33. VS (vital signs) B/P (blood pressure) ,[DATE]. P (pulse) 104. R (Respiration) 24. Resident unable to take in PO (oral) intake. 5A (5:00 a.m.) (Hospital) called to page Att (Attending physician) on call. (Physician) called back. New order given. [MEDICATION NAME] 1 mg (milligram) now given as order. 5:50 a.m. Resident finger stick blood sugar check 82. Resident moving hands + (and) mouth making snoring noise but still not opening eyes or talking. (Physician) repaged D/T (due to) Resident condition not responding ... Awaiting return ..." The Nurses' Notes dated [DATE] at 6:15 a.m. documented, "(Clinic) paged again thru (Hospital)." The note dated [DATE] at 6:15 a.m. documented, "( Physician) returned call. Let her know resident current condition & previous treatments. Order to send to ER (emergency room ). Ambulance called notified of transfer. ER called notified of resident being transported to ER." f. The History and Physical from the Hospital dated [DATE] documented, "Chief Complaint: Altered Mental Status. History of Present Illness: This is a [AGE] year old female known with diabetes, high blood pressure, [MEDICAL CONDITION], and [DIAGNOSES REDACTED] disease. She had back surgery 2 weeks ago for spinal fusion. Last week, she had I&D (incision and drainage) for infection at the site of incision and she was started on [MEDICATION NAME]. Two days ago, she got in (Nursing Home). This morning, in the nursing home, they found her in the bed with altered mental status and her blood sugar was 34. They called the physician on call, who recommended [MEDICATION NAME]. After [MEDICATION NAME], her blood sugar improved, but her mental status did not improve. They called again and the decision to drive her to the emergency room was taken. On the way to the hospital, she received in ambulance D50 ([MEDICATION NAME] 50%)... Assessment and Plan: ... We admitted the patient with: ... 3. Wound infection ... 4. Diabetes. She was on [MEDICATION NAME] and [MEDICATION NAME] sliding scale. According with the records, she was receiving 76 units of [MEDICATION NAME] in a.m. and 50 units at p.m. and Humalog. We will hold the insulin treatment. She will have insulin sliding scale if BS (blood sugar) will be higher than 200..." g. The Nurse's Note dated [DATE] at 10:00 a.m. documented, "Spoke with nurse @ (at) (Hospital) ER. Stated (Resident) was being admitted to ICU (Intensive Care Unit)." The Nurse's Note dated [DATE] at 10:20 a.m. documented, "( Hospital) called: notified pt. (patient) has expired." 2. Resident #24 had [DIAGNOSES REDACTED]. The annual MDS with an ARD of [DATE] documented the resident scored 6 (,[DATE] indicates severely impaired) on the Brief Interview for Mental Status and had Diabetes Mellitus. a. The [DATE] physician's orders [REDACTED].= 2 units, ,[DATE] = 4 U (units) , 300 - 349 = 6 units, ,[DATE] = 8 U, 400 - 450 = 10 units and call MD ..XXX[DATE]: [MEDICATION NAME] ([MEDICATION NAME]) Gel. Give 15 grams for initial dose if blood sugar < (60. Repeat in 15 minutes after initial dose. Then may repeat in 30 minutes. If no response, call MD. [DATE]: [MEDICATION NAME] 5 units SQ AC meals. [DATE]: [MEDICATION NAME] 30 units SQ HS. FSBS Finger Stick Blood Sugar at 12 Midnight. [MEDICATION NAME] is an antidiabetic medication that acts to lower the blood sugar." b. The [DATE] Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. On [DATE] the blood sugar was 46. On [DATE] the blood sugar was 47. On [DATE] the blood sugar was 39. On [DATE] the blood sugar was 38. On [DATE] the blood sugar was 37. On [DATE] the blood sugar was 37. On [DATE] the blood sugar was 48. There was no documentation in the Nurses Notes that the resident's physician was consulted regarding the low blood sugars. c. On [DATE] at 2:00 p.m., the DON was asked, "Was the physician notified?" there was no documentation provided of any physician notifications. The back of the MAR indicated [REDACTED] Date Medication Reason Result [DATE] [MEDICATION NAME] (Low) BS 48 12:30 a.m. effective (up)72 [DATE] [MEDICATION NAME] (Low) BS 46 12:40 a.m. effective (up) 68 [DATE] [MEDICATION NAME] (Low) BS 47 12:20 a.m. effective (up) 72 [DATE] [MEDICATION NAME] (Low) BS 39 12:30 a.m. effective (up) 69 [DATE] [MEDICATION NAME] (Low) BS 38 12:30 a.m. effective (up) 77 [DATE] [MEDICATION NAME] (Low) BS 35 12:30 a.m. effective (up) 68 [DATE] [MEDICATION NAME] (Low) BS 37 12:30 a.m. effective (up) 73 [DATE] [MEDICATION NAME] (Low) BS 49 12:30 a.m. effective (up) 64. There was no documentation that the physician was notified of the low blood sugars. d. The Nurse's Notes dated [DATE] documented, "... Resident often has low FSBS @ 12 AM. Given Orange Juice to sustain blood sugars during the night .. e. The [DATE] MAR indicated [REDACTED]. 10 units of [MEDICATION NAME] R Insulin was documented for each of the blood sugar readings. There was no documentation in the Nurse's Notes that the physician was notified of the high blood sugar readings. f. On [DATE] at 3:00 p.m., the DON stated, "They (the nurses) fax the blood sugars for the week to the MD." 3. On [DATE] at 1:45 p.m., the Director of Nursing (DON) was asked, "What is the protocol if a resident has low blood sugar?" The DON stated, "We give orange juice, then re-assess, and on until we send them to the emergency room ." The DON was asked, "Does the physician get notified?" The DON stated, "No." The policy, "treatment of [REDACTED]. The DON was asked, "The policy states there are interventions for low blood sugar, but that the physician is not notified until the resident is bad enough to require the emergency room ?" The DON stated, "That's what it says." 4. On [DATE] at 2:15 p.m., the Medical Director was asked, "If a resident has a blood sugar less than 60, what should the facility do?" The Medical Director stated, "Contact the primary care physician." The Medical Director was asked, "When should the physician be notified?" The Medical Director stated, "If the resident is symptomatic, you should call immediately." The Medical Director stated, "Most primary care physicians leave orders or guidelines what to do if the blood sugar is low or high and when to notify them." 5. The Immediate Jeopardy was removed on [DATE] at 3:55 p.m. when the facility submitted the following Plan of Removal: The DON/designee will immediately notify the physician for Resident #24 to report the resident's low blood sugar results with date & time of each episode. The DON/designee will immediately identify the other 7 residents who have blood sugar testing ordered by reviewing all MARS and then immediately check their finger stick blood sugar results to see if the results include any levels below 60. The DON/designee will notify the physician of those low levels. The DON/designee will contact the facility Medical Director immediately to verify parameters for a new policy and procedure regarding physician notification of low and high finger stick blood sugar results. The DON/designee will immediately implement physician orders [REDACTED]. The DON/designee will implement a new facility policy & procedure for blood sugar parameters treatment and physician notification to include follow-up assessment of the resident and physician notification. The DON/designee will immediately begin inservice training with all nurses present on: Procedure: 1. Nurse completes glucometer check as ordered by physician or if resident a diabetic and exhibiting signs/symptoms of hyper/[DIAGNOSES REDACTED]. 2. If glucometer result is less than 60, no insulin will be given and one of two treatment options implemented below with a blood sugar recheck completed in 15 minutes. If the glucometer result remains less than 60, one of the treatment options will be repeated and the physician will be notified for further treatment. TREATMENT: a. Give 15 Gm (grams) or one single use tube of glucose gel if the resident is symptomatic with signs/symptoms of [DIAGNOSES REDACTED], such as ? confusion, [MEDICAL CONDITION], dizziness are more common in the elderly ? sweating (almost always present). Check for sweating on the back of neck at hairline. ? Nervousness, shakiness, and weakness. ? Extreme hunger and slight nausea. ? Dizziness and headache. ? Blurred vision. ? A fast heartbeat and feeling anxious. ? b. Give food snack if the resident is NOT symptomatic with signs/symptoms of [DIAGNOSES REDACTED]. 3. If glucometer result is greater than 400, insulin will be administered as ordered and blood sugar recheck completed in 30 minutes. If glucometer result remains greater than 400, the physician will be notified for further treatment. 4. The physician will be notified after necessary treatment is given for blood sugars less than 60 or greater than 400 for further orders. The new policy regarding blood sugar parameters for physician notification. The DON/designee will continue inservice training until all nurses have been inserviced to be completed. No nurses will begin their work shift until the DON/designee has inserviced them regarding the assessment, treatment, and physician notification for low blood sugars. The DON/RN Supervisor will monitor finger stick blood sugar results every shift to ensure the proper assessment, treatment, and physician notification was completed by the Charge Nurse as needed for low blood sugars. Any discrepancies will be corrected immediately by the DON' RN Supervisor with further 1:1 training with the Charge Nurse." B. Based on observation, record review and interview, the facility failed to ensure the physician was promptly consulted for treatment orders and the family was notified of an injury to a toe for 1 (Resident #1) of 1 case mix resident who was dependent on staff for transfers and lost a toenail. This failed practice was likely to cause more than minimal harm to 39 residents who were dependent on staff for transfers, as documented on the Resident census and Conditions of Residents dated [DATE]. The findings are: Resident #1 had a [DIAGNOSES REDACTED]. a. On [DATE] at 3:45 p.m., during transfer of the resident from her geri-chair to her bed via lift, a dark reddish stain was visible on the left outer small toe area of the resident's sock. b. On [DATE] at 8:58 a.m., the Treatment Nurse was asked who was to notify her of changes in resident's skin conditions. She stated, "The CNAs (Certified Nursing Assistants) do and the 7:00 a.m.to 3:00 a.m. nurses do the weekly skin audits." c. On [DATE] at 9:00 a.m., as the treatment nurse removed the resident's left sock for the body audit, the resident's left small toe was covered with a bloody bandage and the toenail was missing. The nurse stated, "I didn't know." d. On [DATE] at 9:14 a.m., after the Treatment Nurse checked the physician's orders [REDACTED]. At this time, the nurse notified the physician for orders to treat the toe and notified the resident's family. e. On [DATE] at 9:15 a.m., the Registered Nurse (RN) Supervisor was asked if she was notified that the resident's toe was injured and the toe nail was missing. The RN stated, "No." f. On [DATE] at 9:15 a.m., LPN #3, the charge nurse for the resident, was asked if she was notified that the resident's toe was injured and the toe nail was missing. The LPN stated, "No."

Complaint # was substantiated all or in part with these findings. A. Based on record review and interview, the facility failed to ensure that Resident #21 and #24 received and the facility provided the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. The facility failed to ensure residents with low blood sugar levels were thoroughly assessed, the physician was consulted, interventions were implemented and the resident's condition monitored for further incidents of [DIAGNOSES REDACTED] for 1 (Resident #21) of 4 (Residents #2, #18, #21 and #24) case mix residents who were at risk for low blood sugar levels. The facility failed to ensure residents with episodes of [DIAGNOSES REDACTED] or [MEDICAL CONDITION] were thoroughly assessed and re-assessed after intervention, and that the physician was consulted regarding [MEDICAL CONDITION] as planned and regarding repeated episodes of [DIAGNOSES REDACTED] for 1 (Resident #24) of 4 (Residents #2, #18, #21 and #24). The failed facility practices caused or could have caused serious injury or death to Resident #21, who was unresponsive with severe low blood sugar on [DATE] and required admission to the Intensive Care Unit, and was likely to affect 9 residents who were at risk of low blood sugar levels, according to a review of all Medication Administration Records (MARs) for residents with diabetes provided by the Director of Nursing (DON) on [DATE]. The facility was informed of the Immediate Jeopardy on [DATE] at 2:25 p.m. The findings are: 1. Resident #21 had a [DIAGNOSES REDACTED]. The 5-day Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE] documented the resident was cognitively intact per a staff assessment of mental status and had Diabetes Mellitus. a. The physician's orders [REDACTED]. [MEDICATION NAME] 75 units sq (subcutaneous) q (every) am (morning). [MEDICATION NAME] 50 units sq q HS (bedtime). Humalog SSI (Sliding Scale Insulin) < (less than) 100 = 0 units. 101 - 150 = 10 units. 151 - 200 = 15 units. 201 - 300 = 20 units. 301 - 400 = 25 units. > (greater than) 400 call MD (medical doctor). FSBS (Finger Stick Blood Sugar) AC (before) meals & (and) HS." There were no ordered parameters to notify the physician in the event of low blood sugars. There were no ordered interventions for the treatment of [REDACTED]. b. The Plan of Care dated [DATE] documented, "Problem: DM (Diabetes Mellites). Interventions: 1. FSBS (with) Humolog per sliding scale. 2. Scheduled insulin per physician's orders [REDACTED]. 4. Labs as ordered. Fax results to physician." c. The Nutritional Progress Notes dated [DATE] documented, "... Diet: Regular, NAS, NCS (no concentrated sweets), No fried foods ... Estimated 24 hr (hour) body needs are 2182 - 2618 K calories (kilocalories) ... Current diet is appropriate to provide 1800 - 2000 K cal (kilocalories) and diet may result in some weight loss which is desirable to achieve suggested body weight and appropriate BMI (body mass index)." d. The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]"0". The FSBS result on [DATE] at 8:00 p.m. was documented as 59. There was no documentation on the MAR indicated [REDACTED]. e. The Nurse's Note dated [DATE] documented, "Mood State/Behaviors: 7a - 3 p (7:00 a.m. - 3:00 p.m.) Shift: Cooperative, Pleasant, sleeps a lot. 3p - 11p (3:00 p.m. - 11:00 p.m.) Shift: Cooperative, Pleasant, sleeps a lot." The last Nurse's Note entry documented, "5:30 (p.m.) Doctors to remove ctures (sutures) on the 30th and change appointment." There was no documentation of the resident's status at 8:00 p.m. and no documentation of any intervention to address the low blood sugar reading. There was no documentation that the resident was re-assessed and no documentation that the physician was notified of the low blood sugar. On [DATE] at 12:15 p.m., Licensed Practical Nurse (LPN) #4 was asked, "(Resident #21) had a blood sugar of 59 on [DATE] at 8:00 p.m. Can you tell me what happened?" LPN #4 stated, "I went to check the blood sugar. It was 59. I gave her juice and re-checked her blood sugar. It was 193. I went ahead and gave her the insulin." LPN #4 was asked, "Where did you document that?" LPN #4 stated, "It should be in the Nurses' Notes." LPN #4 was asked, "I have looked at the Nurses' Notes and the last entry was at 5:30 p.m.?" LPN #4 stated, "I should have documented it in the Nurses' Notes." LPN #4 was asked, "Did you call the physician?" LPN #4 stated, "No. You first try to get the sugar up. If you can't, then you call the doctor." f. The Nurse's Note dated [DATE] documented, "4:55 a.m.: called to resident room. Resident not responsive. Foam at the mouth. Resident FSBS check result 33. VS (vital signs) B/P (blood pressure) ,[DATE]. P (pulse) 104. R (Respiration) 24. Resident unable to take in PO (oral) intake. 5A (5:00 a.m.) (Hospital) called to page Att (Attending physician) on call. (Physician) called back. New order given. [MEDICATION NAME] 1 mg (milligram) now given as order. 5:50 a.m. Resident finger stick blood sugar check 82. Resident moving hands + (and) mouth making snoring noise but still not opening eyes or talking. (Physician) repaged D/T (due to) Resident condition not responding ... Awaiting return ..." The Nurses' Notes dated [DATE] at 6:15 a.m. documented, " (Clinic) paged again thru (Hospital)." The note dated [DATE] at 6:15 a.m. documented, "( Physician) returned call. Let her know resident current condition & previous treatments. Order to send to ER (emergency room ). Ambulance called notified of transfer. ER called notified of resident being transported to ER." g. The History and Physical from the Hospital dated [DATE] documented, "Chief Complaint: Altered Mental Status. History of Present Illness: This is a [AGE] year old female known with diabetes, high blood pressure, [MEDICAL CONDITION], and [DIAGNOSES REDACTED] disease. She had back surgery 2 weeks ago for spinal fusion. Last week, she had I&D (incision and drainage) for infection at the site of incision and she was started on [MEDICATION NAME]. Two days ago, she got in (Nursing Home). This morning, in the nursing home, they found her in the bed with altered mental status and her blood sugar was 34. They called the physician on call, who recommended [MEDICATION NAME]. After [MEDICATION NAME], her blood sugar improved, but her mental status did not improve. They called again and the decision to drive her to the emergency room was taken. On the way to the hospital, she received in ambulance D50 ([MEDICATION NAME] 50%)... Assessment and Plan: ... We admitted the patient with: ... 3. Wound infection ... 4. Diabetes. She was on [MEDICATION NAME] and [MEDICATION NAME] sliding scale. According with the records, she was receiving 76 units of [MEDICATION NAME] in a.m. and 50 units at p.m. and Humalog. We will hold the insulin treatment. She will have insulin sliding scale if BS (blood sugar) will be higher than 200 ..." h. The Nurse's Note dated [DATE] at 10:00 a.m. documented, "Spoke with nurse @ (at) (Hospital) ER. Stated (Resident) was being admitted to ICU (Intensive Care Unit)." The Nurse's Note dated [DATE] at 10:20 a.m. documented, "( Hospital) called: notified pt. (patient) has expired." 2. Resident #24 had [DIAGNOSES REDACTED]. The annual MDS with an ARD of [DATE] documented the resident scored 6 (,[DATE] indicates severely impaired) on the Brief Interview for Mental Status and had Diabetes Mellitus. a. The [DATE] physician's orders [REDACTED].= 2 units, ,[DATE] = 4 U (units) , 300 - 349 = 6 units, ,[DATE] = 8 U, 400 - 450 = 10 units and call MD ..XXX[DATE]: [MEDICATION NAME] ([MEDICATION NAME]) Gel. Give 15 grams for initial dose if blood sugar < (60. Repeat in 15 minutes after initial dose. Then may repeat in 30 minutes. If no response, call MD. [DATE]: [MEDICATION NAME] 5 units SQ AC meals. [DATE]: [MEDICATION NAME] 30 units SQ HS. FSBS Finger Stick Blood Sugar at 12 Midnight. [MEDICATION NAME] is an antidiabetic medication that acts to lower the blood sugar." b. The Plan of Care dated [DATE] documented, "Problem: At risk for hyper/[DIAGNOSES REDACTED], and other complications, related to Diabetes Mellitus. Approaches: Obtain and monitor related lab as ordered. Report Abnormal Results promptly. Monitor for signs shakiness, hunger, nervousness, weakness, sweating, drowsiness, unsteadiness and confusion. Record and report. If signs of [DIAGNOSES REDACTED] occur, give [MEDICATION NAME] 1 mg IM (intramuscular) or Glucose tab (tablet)1 po Q 15 minutes. Notify MD and record in Nurses Notes. Medication as ordered by Physician..." c. The [DATE] Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. On [DATE] the blood sugar was 46. On [DATE] the blood sugar was 47. On [DATE] the blood sugar was 39. On [DATE] the blood sugar was 38. On [DATE] the blood sugar was 37. On [DATE] the blood sugar was 37. On [DATE] the blood sugar was 48. There was no documentation in the Nurses' Notes that the resident's condition was assessed and no documentation that the resident's physician was consulted regarding the low blood sugars. On [DATE] at 2:00 p.m., the DON was asked, "Was there any intervention to address the low blood sugars at midnight? The MAR indicated [REDACTED]?" The DON stated, "I didn't copy the back of the MAR, I'll go see." At 2:15 p.m., Registered Nurse (RN) #1 brought a copy of the back of the MAR. There was no documentation provided of any physician notifications. The back of the MAR indicated [REDACTED] [DATE] [MEDICATION NAME] (Low) BS 48 - 12:30 a.m. effective (up)72; [DATE] [MEDICATION NAME] (Low) BS 46 - 12:40 a.m. effective (up) 68; [DATE] [MEDICATION NAME](Low) BS 47 - 12:20 a.m. effective (up) 72; [DATE] [MEDICATION NAME] (Low) BS 39 - 12:30 a.m. effective (up) 69; [DATE] [MEDICATION NAME] (Low) BS 38 - 12:30 a.m. effective (up) 77; [DATE] [MEDICATION NAME] (Low) BS 35 - 12:30 a.m. effective (up) 68; [DATE] [MEDICATION NAME] (Low) BS 37 - 12:30 a.m. effective (up) 73; [DATE] [MEDICATION NAME] (Low) BS 49 - 12:30 a.m. effective (up) 64. There was no documentation of the dosage of [MEDICATION NAME] administered, no documentation of the resident's status or symptoms and no documentation that the physician was notified of the low blood sugars. There was no documentation of whether the resident was symptomatic and no documentation that any monitoring of the resident's status was completed. d. The Nurse's Notes dated [DATE] documented, "... Resident often has low FSBS @ 12 AM. Given Orange Juice to sustain blood sugars during the night... e. The [DATE] MAR indicated [REDACTED]. 10 units of [MEDICATION NAME] R Insulin was documented for each of the blood sugar readings. There was no documentation in the Nurse's Notes that the resident's condition was assessed and no documentation that the physician was notified of the high blood sugar readings. f. On [DATE] at 2:20 p.m., Resident #24 was asked, "Do you ever feel weak and shaky?" Resident #24 stated, "Sometimes". Resident #24 was asked, "Do they give you orange juice when you're weak and shaky?" Resident #24 stated, "Yes, they do." Resident #24 was asked, "Does that make you feel better?" Resident #24 stated, "Yes." Resident #24 was asked, "Do you get enough to eat?" Resident #24 stated, "Yes. I have enough to eat. The glucose shakes help." g. On [DATE] at 3:00 p.m., the DON stated, "They (the nurses) fax the blood sugars for the week to the MD." 3. The facility's policy and procedure titled "treatment of [REDACTED]. 1. Perform initial assessment including accucheck (if blood sugar < 60, continue with administration of 8 oz (ounces) orange juice and wait 30 minutes. If remains give snack of at least 4 crackers and 1 oz cheese or ,[DATE] peanut butter sandwich. 2. Perform focused assessment and documentation of resident to include: * Level of Consciousness. *Orientation. *Vital Signs. * Onset. * Duration. 3. Determine last meal, last medication dose, and related illness. 4. In the event the patient should lose consciousness, administer [MEDICATION NAME] SQ into thigh or abdomen, roll patient onto side to avoid aspiration in the event of vomitting. 5. Record actions, continue to monitor and transport to ED (Emergency Department) if necessary." 4. On [DATE] at 1:45 p.m., the Director of Nursing (DON) was asked, "What is the protocol if a resident has low blood sugar?" The DON stated, "We give orange juice, then re-assess, and on until we send them to the emergency room ." The DON was asked, "Does the physician get notified?" The DON stated, "No." The policy, "treatment of [REDACTED]. The DON was asked, "The policy states there are interventions for low blood sugar, but that the physician is not notified until the resident is bad enough to require the emergency room ?" The DON stated, "That's what it says." 5. On [DATE] at 2:15 p.m., the Medical Director was asked, "If a resident has a blood sugar less than 60, what should the facility do?" The Medical Director stated, "Contact the primary care physician." The Medical Director was asked, "When should the physician be notified?" The Medical Director stated, "If the resident is symptomatic, you should call immediately." The Medical Director stated, "Most primary care physicians leave orders or guidelines what to do if the blood sugar is low or high and when to notify them." 6. The Immediate Jeopardy was removed on [DATE] at 3:55 p.m. when the facility submitted the following Plan of Removal: The DON/designee will immediately notify the physician for Resident #24 to report the resident's low blood sugar results with date & time of each episode. The DON/designee will immediately identify the other 7 residents who have blood sugar testing ordered by reviewing all MARS and then immediately check their finger stick blood sugar results to see if the results include any levels below 60. The DON/designee will notify the physician of those low levels. The DON/designee will contact the facility Medical Director immediately to verify parameters for a new policy and procedure regarding physician notification of low and high finger stick blood sugar results. The DON/designee will immediately implement physician orders [REDACTED]. The DON/designee will implement a new facility policy & procedure for blood sugar parameters treatment and physician notification to include follow-up assessment of the resident and physician notification. The DON/designee will immediately begin inservice training with all nurses present on: Procedure: 1. Nurse completes glucometer check as ordered by physician or if resident a diabetic and exhibiting signs/symptoms of hyper/[DIAGNOSES REDACTED]. 2. If glucometer result is less than 60, no insulin will be given and one of two treatment options implemented below with a blood sugar recheck completed in 15 minutes. If the glucometer result remains less than 60, one of the treatment options will be repeated and the physician will be notified for further treatment. TREATMENT: a. Give 15 Gm (grams) or one single use tube of glucose gel if the resident is symptomatic with signs/symptoms of [DIAGNOSES REDACTED], such as ? confusion, [MEDICAL CONDITION], dizziness are more common in the elderly ? sweating (almost always present). Check for sweating on the back of neck at hairline. ? Nervousness, shakiness, and weakness. ? Extreme hunger and slight nausea. ? Dizziness and headache. ? Blurred vision. ? A fast heartbeat and feeling anxious. b. Give food snack if the resident is NOT symptomatic with signs/symptoms of [DIAGNOSES REDACTED]. 3. If glucometer result is greater than 400, insulin will be administered as ordered and blood sugar recheck completed in 30 minutes. If glucometer result remains greater than 400, the physician will be notified for further treatment. 4. The physician will be notified after necessary treatment is given for blood sugars less than 60 or greater than 400 for further orders. The new policy regarding blood sugar parameters for physician notification. The DON/designee will continue inservice training until all nurses have been inserviced to be completed. No nurses will begin their work shift until the DON/designee has inserviced them regarding the assessment, treatment, and physician notification for low blood sugars. The DON/RN Supervisor will monitor finger stick blood sugar results every shift to ensure the proper assessment, treatment, and physician notification was completed by the Charge Nurse as needed for low blood sugars. Any discrepancies will be corrected immediately by the DON/RN Supervisor with further 1:1 training with the Charge Nurse." B. Based on observation, interview and record review, the facility failed to ensure that indwelling catheters were kept clean and free from powder which causes irritation and potential infection for 1 (Resident #3) of 4 (Residents #3, #6, #9 and #12) case mix residents with indwelling urinary catheters. These failed practices were likely to cause more than minimal harm to 4 residents with indwelling urinary catheters, as documented on the Resident Census and Conditions of Residents form provided by the Administrator on [DATE]. The findings are: Resident #3 had [DIAGNOSES REDACTED]. The quarterly MDS with an ARD of [DATE] documented the resident scored 3 (0 - 7 indicates severely impaired) on the BIMS, had an indwelling urinary catheter and was incontinent of bowel. a. The [DATE] physician's orders [REDACTED]." b. The Plan of Care dated [DATE] documented, "Continence: At risk for complications related to indwelling catheter. Approaches: Cleanse area with soap and water Q shift and PRN (as needed). Assess tissue for signs of redness, discoloration, or swelling. Report abnormal findings to charge nurse ..." c. On [DATE] at 9:40 a.m., Certified Nursing Assistant (CNA) #2 and CNA #3 removed the resident's brief. The resident was covered with a white substance over the abdomen and groin area and the suprapubic catheter was covered with the white substance from the stoma outward for approximately 7 inches of the length of the catheter. A wet area was noted around the suprapubic catheter and along the abdominal crease above the pubic area to the right side of the resident and down to the hip area. CNA #3 was asked, "What is this (wet area)?" CNA #3 stated, "Looks like it's leaking." CNA #3 was asked, "What is that (pointing to white substance on the resident)?" CNA #3 stated, "That's powder." CNA #3 was asked, "Why do you put powder on the resident?" CNA #3 stated, "He likes to stay covered up and he sweats." CNA #2 and CNA #3 cleaned the stoma, suprapubic catheter tubing, abdomen, right side and hip of powder and urine and placed a clean brief under the resident. CNA #2 shook a large amount of powder from a container into the brief up to the front waistline of the brief. The CNA placed the brief containing the powder over the resident's abdomen and suprapubic catheter and then fastened the sides. d. The Lippincott Manual of Nursing Practice, Ninth Edition, page 783, documented, "Management of the Patient with an Indwelling (Self-Retaining) Catheter and Closed Drainage System ... Care of the indwelling catheter: ... Nursing Action: 2. Avoid using powders and sprays on the perineal area. Rationale: 2. Powder can encrust and cause soreness and infection ..."