Every finding on record at Old Southwest Health and Rehabilitation

Based on staff interviews, clinical record reviews, and facility document reviews, the facility staff failed to ensure the Quality Assurance and Performance Improvement (QAPI) Program met the needs of the facility as evidenced by repeated deficiencies in the areas of: Resident Rights, Resident Transfers, Quality of Life, Quality of Care, Pharmacy Services, Infection Control, and Staff Training Requirements. The findings include: The facility's Quality Assurance and Performance Improvement (QAPI) program failed to implement measures/actions that corrected deficient practices cited in the previous surveys which resulted in deficient practices being cited during this revisit survey in the same areas of care. The facility's QAPI program failed to ensure residents and/or residents' responsible parties had an opportunity to develop advanced directives as evidenced by deficient practice in the area of Resident Rights. The facility's QAPI program failed to ensure that transferred residents were provided the required transfer and/or bed hold information as evidenced by deficient practice in the area of Admission, Transfer, and Discharge. The facility's QAPI program failed to ensure that residents' bathing needs were met as evidenced by deficient practice in the area of Quality of Life. The facility's QAPI program failed to ensure that residents received their medications as prescribed as evidenced by deficient practice in the areas of Quality of Care and Pharmacy Services. The facility's QAPI program failed to ensure (a) appropriate use and cleaning of a resident's glucometer and (b) residents were offered and/or received vaccinations as evidenced by deficient practices in the area of Infection Control. The facility's QAPI program failed to ensure an effective training program for its staff members as evidence by deficient practice in the area of Training Requirements. On 7/16/24 at 2:45 p.m., the survey team met with the facility's Administrator, Director of Nursing (DON), Assistant DON, Regional Director of Operations, MDS Coordinator, Regional MDS Coordinator, and Regional Director of Clinical Services. During this meeting, the failure of the facility's QAPI program to develop and/or implement action plans to prevent the aforementioned repeat deficiencies was discussed.

Based on observation, staff interview and facility document review the facility staff failed to ensure licensed nursing staff have the competencies and skill sets necessary to provide care for the residents. The findings included: Surveyor observed registered nursing (RN) #3 on 07/10/24 at 11:15 am performing a blood sugar check for a resident via glucometer. RN #3 did not fully remove the glucometer from the plastic storage bag while checking the residents blood sugar, then returned the glucometer to the bag without cleaning or disinfecting the glucometer. Surveyor spoke with the assistant director of nursing (ADON), who is also the facility staff development coordinator, on 07/11/24 at 1:40 pm regarding RN #3. Surveyor asked ADON if RN #3 had received training on infection control and specifically on cleaning/disinfecting glucometer. ADON stated, We don't have nurse competencies. We don't have a program for that but will be starting one soon. I do have education/in-service training on infection control, glucometer cleaning and others. ADON provided surveyor with a copy of RN #3's job description, signed and dated by RN #3 on 05/22/24. This job description read in part, Administer professional services such as: catheterization, tube feedings, suction, applying and changing dressings/bandages, packs, colostomy, and drainage bags, taking blood, giving massages and range of motion exercises, care for the dead/dying, etc., as required. ADON also provided a copy of an Education In-service Attendance Record for infection control dated 05/22/24, which RN #3 had signed. ADON provided surveyor with a New Hire Orientation form, which included a section for skills checklists and core competencies. These competencies included clean glucometer/PT-INR machine. Surveyor asked ADON to provide RN #3's checklist, and ADON stated, They get their competencies on the floor, and we do not have checklists for competencies. Surveyor requested and was provided with a facility policy entitled Competency Evaluation which read in part, It is the policy of this facility to evaluate each employee to assure appropriate competencies and skills for performing his or her job and to meet the needs of facility residents. 'Competency' is a measurable pattern of knowledge, skills abilities, behaviors, and other characteristics that an individual needs to perform work roles or occupational functions successfully. 3. Initial competency is evaluated during the orientation process. 4. Subsequent and/or annual competency is evaluated at a frequency determined by the facility assessment, evaluation of the training program, and/or job performance evaluations. 6. Checklists are used to document training and competency evaluations. 8. Employee competency forms are maintained in the Staff Development Coordinator's office for current training year, then forwarded to the Human Resources Director for placing into the employee's personnel file. The concern of not ensuring licensed nursing staff have the competencies and skill sets necessary to provide care for the residents was discussed with the administrator, director of nursing, ADON, minimum data set coordinator, regional director of operations, director of clinical reimbursement, and regional director of clinical services on 07/16/24 at 2:45 pm. No further information was provided prior to exit.

Based on staff interview, facility document review and during a medication pass and pour observation the facility staff failed to follow established infection control procedures during finger stick blood glucose monitoring for 1 of 4 observations. The findings included: For Resident #124 the facility staff failed to properly clean and disinfect a blood glucometer. Resident #124's face sheet listed diagnoses which included but not limited to type II diabetes mellitus without complications. Resident #124's comprehensive care plan was reviewed and contained a care plan for . has diabetes mellitus. On 07/10/24 at 11:15, surveyor observed registered nurse (RN) #3 during a medication pass and pour. RN #3 removed a plastic zip lock bag containing Resident #124's glucometer and placed it on top of the medication cart, then removed a glucometer test strip, opened the bag, and placed the strip in the glucometer. RN #3 removed a plastic container of Sani-wipes from the medication cart and placed them of top of the cart. RN #3 removed a wipe from the container, entered Resident #124's room, and wiped the overbed table. RN #3 returned to the medication cart, gathered an alcohol pad, cotton ball, lancet and glucometer in one hand and placed the plastic container of wipes under opposite arm. RN #3 returned to resident's room, placed all items on the overbed table, donned gloves, cleaned resident's finger with alcohol pad, wiped finger with cotton ball, pricked resident's finger with lancet, then applied a drop of resident's blood to test strip in glucometer, only removing part of the glucometer from the plastic bag. After checking resident's blood sugar, RN #3 removed test strip from the glucometer and slid glucometer back into the bag and placed it back onto overbed table. RN #3 picked up used lancet and removed gloves with lancet and used test strip inside. RN #3 then placed gloves in trash in resident's room, washed her hands, gathered the glucometer and container of wipes, and returned to the medication cart. RN #3 placed the plastic bag containing the glucometer on top of the medication cart, donned gloves, removed the glucometer, cleaned it with a wipe and placed it on a tissue to dry. RN #3 removed gloves and once glucometer was dry, returned it to the plastic bag, placed the bagged glucometer back into the medication cart, where it came in contact with three other bagged glucometers. Surveyor spoke with RN #3 on 07/10/24 at 4:25 pm regarding checking a resident's blood sugar. RN #3 stated, I clean surface of med cart, take bagged glucometer out of cart and place on top of cart. I then assemble my supplies (lancet, test strip, alcohol pad, cotton ball), knock on resident's door, wash my hands, put on gloves, clean resident's finger with alcohol, dry with cotton, stick with lancet, check blood sugar, take gloves off with strip inside, place lancet in sharps container. I then clean the glucometer and put back in bag. Surveyor asked RN #3 if they take the bagged glucometer into a resident room, and RN #3 stated, I take the whole thing in there, and place the bag on the bedside table. Surveyor asked RN #3 if they removed the glucometer from the bag when they checked Resident #124's blood sugar, and RN #3 stated, I shouldn't have checked his blood sugar with the glucometer in the bag. Surveyor spoke with the assistant director of nursing (ADON), who is also the facility infection preventionist (IP) on 07/10/24 at 6:55 pm regarding the handling of glucometers. ADON/IP stated, They should clean and disinfect it prior to and after using. Surveyor asked ADON/IP if the glucometer should be removed from the plastic bag prior to entering a resident room, and ADON/IP stated, They shouldn't take Ziploc bag into residents' rooms, and the wipes should stay on the cart. Surveyor asked ADON/IP what would happen if a glucometer were used while still partially inside the bag, and ADON/IP stated, They would have to get a new bag, because that one is considered contaminated. If it is returned to the cart, everything in the cart area is considered contaminated. They would have to clean the cart. Surveyor requested and was provided with a facility policy entitled Blood Glucose Monitoring which read in part, 3. The nurse will abide by the infection control practices of cleaning and disinfection of the glucometer as per the manufacturer's instructions and in accordance with the facility's glucometer disinfection policy. 4. Individual glucometers for residents, will be maintained in a separate plastic bag in the medication cart, and must have proper identification to distinguish between residents and these should not be shared between residents . Procedure: 6. Provide a clean surface for the glucometer to sit if needed (i.e. paper towel). 14. Discard the lancet in a puncture resistant sharps container. 15. Remove the strip and dispose of it properly. 18. Clean and disinfect the glucometer as per manufacturer's instructions. Surveyor spoke with ADON/IP on 07/11/24 at 1:23 pm regarding the disposal of glucometer test strips, and ADON/IP stated, Blood glucose strips should be placed in the sharps container. Surveyor requested and was provided with the manufacturer's instructions for cleaning the glucometer, which read in part, Cleaning and disinfecting can be completed by using a commercially available EPA-registered disinfectant detergent or germicide wipe. Many wipes act as both a cleaner and disinfectant, though if blood is visibly present on the meter, two wipes must be used; use one wipe to clean and a second to disinfect. Surveyor requested and was provided with a facility policy entitled Glucometer Disinfection which read in part, 1. The facility will ensure blood glucometers will be cleaned and disinfected after each use and according to manufacturer's instructions for multi-resident use. 3. The glucometers should be disinfected with a wipe pre-saturated with an EPA registered healthcare disinfectant that is effective against HIV, Hepatitis C, and Hepatitis B virus. Surveyor requested information on the disinfectant used to clean the glucometers and was provided with a copy of the label from a container of Super Sani-Cloth gemicidal disposable wipes. This container listed a dwell time of 2 minutes, and indicated the product was bactericidal, tuberculocidal, and virucidal. Surveyor requested and was provided with an Education In-Service Attendance Record dated 05/22/24 with a topic of glucometer use. This in-service covered the areas of glucometer usage/storage and cleaning, dwell time, purple sanitizer wipes, and infection control. RN #3 had signed this in-service form. ADON/IP provided the surveyor with a glucometer cleaning observation form dated 07/02/24 and signed by both ADON and RN #3. This form indicated that RN #3 demonstrated proficiency in glucometer cleaning. The concern of the facility staff failing to follow established infection control procedures during finger stick blood glucose monitoring was discussed with the administrator, director of nursing, ADON/IP, regional director of operations and regional director of clinical services on 07/16/24 at 2:45 pm. No further information was provided prior to exit.

Based on staff interviews, facility document review, and clinical record review, the facility staff failed to have written evidence of providing the bed hold policy to the resident and/or the resident representative when the resident was transferred for five (5) of five (5) residents reviewed for transfers (Resident #109, Resident #116, Resident #121, Resident #125, and Resident #126). The findings include: The facility staff was unable to provide written documentation to indicate the facility's bed hold policy was provided to the following residents at the time of their transfers to a local hospital: Resident #109, Resident #116, Resident #121, Resident #125, and Resident #126. The following information was found in a facility policy titled Transfer and Discharge (including AMA) (with a reviewed/revised date of 12/1/22): Emergency Transfers/Discharges - initiated by the facility for medical reasons, or for the immediate safety and welfare of a resident . Provide a notice of the resident's bed hold policy to the resident and representative at the time of transfer, as possible, [sic] but no later than 24 hours of the transfer. Resident #109's clinical documentation included a Discharge/Transfers form which was dated 6/20/24 and indicated the resident was transferred to a local hospital. No written evidence was found by or provided to the surveyor to indicate the resident and/or resident representative had been provided with written notice of the facility's bed hold policy. Resident #116's clinical documentation included a Discharge/Transfers form which was dated 6/19/24 and indicated the resident was transferred to a local hospital. No written evidence was found by or provided to the surveyor to indicate the resident and/or resident representative had been provided with written notice of the facility's bed hold policy. Resident #121's clinical documentation included a Discharge/Transfers form which was dated 6/27/24 and indicated the resident was transferred to a local hospital. No written evidence was found by or provided to the surveyor to indicate the resident and/or resident representative had been provided with written notice of the facility's bed hold policy. Resident #121's clinical record included a note, dated 6/29/24, indicating a voice mail had been left asking the resident's representative to call the facility about the bed hold policy. Resident #125's clinical documentation included a Discharge/Transfers form which was dated 6/12/24 and indicated the resident was transferred to a local hospital. No written evidence was found by or provided to the surveyor to indicate the resident and/or resident representative had been provided with written notice of the facility's bed hold policy. Resident #126's clinical documentation included a Discharge/Transfers form which was dated 6/17/24 and indicated the resident was transferred to a local hospital. No written evidence was found by or provided to the surveyor to indicate the resident and/or resident representative had been provided with written notice of the facility's bed hold policy. On 7/15/24 at 3:55 p.m., the Administrator reported they had no additional evidence of written bed hold information being provided; the Administrator indicated the bed hold information was provided verbally. On 7/16/24 at 2:45 p.m., the survey team met with the facility's Administrator, Director of Nursing (DON), Assistant DON, Regional Director of Operations, MDS Coordinator, Regional MDS Coordinator, and Regional Director of Clinical Services. During this meeting, the failure of the facility staff to have evidence of written notice of the facility's bed hold policy being provided, to the resident and/or the resident representative when a resident is transferred, was discussed.

Based on observations, resident interviews, staff interviews, and facility document review, the facility staff failed to ensure water temperatures were maintained at a level to decrease the risk for injuries. The findings include: The facility staff failed to ensure water temperatures were maintained at a level that would decrease the risk for injuries. On 7/10/24 at 11:30 a.m., a surveyor checked the water in the sinks of resident room [ROOM NUMBER] and #309; the water in both rooms was hot to the point that the surveyor could not hold their hand under the stream for more that 2-3 seconds. On 7/10/24 at approximately 11:45, this surveyor checked the water temperature in the sink of room [ROOM NUMBER]. This surveyor was unable to hold their hand under the stream without feeling discomfort from the hot water. On 7/10/24 at 12:05 p.m., this surveyor checked facility water temperatures with the facility's Maintenance Director in three (3) resident rooms. Only one (1) of the (3) resident rooms had a water temperature greater than 120 degrees Fahrenheit. At this time, a resident reported the water temperature in their room had been hotter prior to when the water temperature was checked; this resident also reported the water pressure was greater prior to when the water temperature was checked. Water temperatures checked, on 7/10/24 by the facility staff, indicated water temperatures in eight (8) resident rooms ranged between 121 - 125 degrees Fahrenheit. The facility staff provided the survey team with documentation to indicated they had the facility's plumbing checked and adjusted on 7/10/24. On 7/16/24 at 2:45 p.m., the survey team met with the facility's Administrator, Director of Nursing (DON), Assistant DON, Regional Director of Operations, MDS Coordinator, Regional MDS Coordinator, and Regional Director of Clinical Services. During this meeting, elevated water temperatures in residents' rooms were discussed.

Based on staff interview and facility document review, the facility staff failed to maintain an effective training program for existing staff consistent with their expected roles. The findings include: The facility staff failed to provide evidence of staff training for all their existing facility staff. On 07/11/24 at 3:10 p.m., during an interview with the current Staff Development Coordinator (SDC) this staff stated they had not started any competencies for current staff, they were waiting on Health Care Academy, and they did not know when the start date would be. On 07/11/24 at 4:30 p.m., during an end of the day meeting with the Administrator, Director of Nursing (DON), SDC, and Regional Director of Clinical Services (RDCS) the issue with the missing education/competencies was reviewed. The SDC stated they did not have any evidence of competencies for existing staff. The Administrator stated a training tool (Health Care Academy) was to be implemented in July 2024, the RDCS stated there was a delay in receiving supplies and they have been ordered. On 07/12/24 at 11:45 a.m., the SDC stated they did not have a policy on training requirements. The SDC provided the survey team with a copy of their policy titled, Competency Evaluation this policy read in part, It is the policy of this facility to evaluate each employee to assure appropriate competencies and skills for performing his or her job and to meet the needs of facility residents . On 07/16/24 at 2:45 p.m., during a meeting that included the survey team, Administrator, Registered Nurse #1, DON, SDC, Regional Director of Operations, RDCS, and Director of Clinical Reimbursement the issue regarding education for staff was reviewed. The DON stated the third week of July 2024 they would be having their first skills fair. The RDCS stated they had started competencies with staff and then stopped. The RDCS stated they had a lot of education to do with staff and they were going to start from scratch as some employees were no longer employed at the facility. When asked if they had a list of staff that had completed competencies the RDCS stated they did not. No further information regarding this issue was provided to the survey team prior to the exit conference.

Based on staff interview, clinical record review, and facility document review the facility staff failed to follow physician's orders for 4 of 24 residents, Resident #110, Resident #112, Resident #113, and Resident #104. The findings included: 1. For Resident #110 the facility staff failed to follow physician's order for the administration of the medications Gabapentin, Levothyroxine, Metolazone, and artificial tears. Resident #110's clinical record listed diagnoses which included but not limited to chronic pain syndrome, chronic diastolic (congestive) heart failure, essential hypertension, and dry eye syndrome of bilateral lacrimal glands. Resident #110's most recent minimum data set with an assessment reference date of 06/07/24 assigned the resident a brief interview for mental status score of 15 out of 15 in section C, cognitive patterns. This indicates that the resident is cognitively intact. Resident #110's comprehensive care plan was reviewed and contained care plans for . has chronic pingueculitis (feeling of something in the eye), . has potential fluid deficit/overload r/t (related to) Diuretic use d/t (due to) CHF (congestive heart failure), HTN (hypertension), and . at risk for pain d/t dx (diagnosis) of chronic pain and Gout. Interventions for these care plans include Administer medications per MD orders and Medicate as ordered. Resident #110's clinical record was reviewed and contained a physician's order summary which read in part, Artificial Tears Solution 1.4%. Instill 1 drop in both eyes three times a day for dry eyes, metolazone oral tablet 10 mg. Give 2 tablet (20 mg) by mouth one time a day for edema, Levothyroxine Sodium Oral Tablet 125 mcg. Give 0.5 tablet (62.5 mcg) by mouth one time a day for hypothyroidism, dose is 62.5, and gabapentin 300 mg. Give one capsule by mouth three times daily for neuropathy. Resident #110's electronic medication administration record (eMAR) for the month of May 2023 was reviewed and contained entries as above. These entries were not initialed as being administered on 05/29/24 at 6:00 am. Resident #110's eMAR for the month of June 2024 was reviewed and contained an entry for gabapentin 300 mg. Give one capsule by mouth three times daily for neuropathy. This entry was coded 9 on 06/28/24 at 6:00 am and 1:00 pm and coded 5 on 06/29/24 at 9:00 pm. Chart code 9 is equivalent to other/see nurse's notes. Chart code 5 is equivalent to Hold/See nurse's notes. Resident #110's nursing progress notes were reviewed and contained notes which read in part, 6/28/2024 05:10. Gabapentin Oral Capsule 300 mg. Give 1 capsule by mouth three times a day for Neuropathy. Texted MD, need script to pharmacy, 6/28/2024 13:47. Gabapentin Oral Capsule 300 mg. Give 1 capsule by mouth three times a day for Neuropathy. Waiting for drug from pharmacy, and 6/28/2024 20:47. Gabapentin Oral Capsule 300 mg. Give 1 capsule by mouth three times a day for Neuropathy. On hold, awaiting further instructions per pharmacy and MD. Surveyor spoke with Resident #110 on 07/10/24 at 11:30 am. Surveyor asked Resident #110 if there was ever a time when they did not get their medications, and Resident #110 stated, Sometimes, they tell me they don't have them. Surveyor spoke with the assistant director of nursing (ADON) on 07/11/24 at 10:45 regarding Resident #110's medications. ADON stated, Either the nurse didn't document, or didn't give it. But, if it's not documented, it's not done. Surveyor spoke with the director of nursing (DON) on 07/15/24 at 10:30 am regarding Resident #110's medications. DON stated, It's unknown if he got his meds or not. Surveyor requested and was provided with a facility policy entitled Medication Administration which read in part, Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. 17. Sign MAR (medication administration record) after administered. Surveyor requested and was provided with a facility policy entitled Medication Reordering which read in part, It is the policy of this facility to accurately and safely provide or obtain pharmaceutical services including the provision of routine and emergency medications and biologicals in a timely manner to meet the needs of each resident. 2. Acquisition of medications should be completed in a timely manner to ensure medications are administered in a timely manner. 3. Each time a nurse ia administering medications and observes (6) or less doses left of one kind, that nurse will reorder the medicaiton, time permiting. Surveyor requested and was provided with a facility policy entitled Unavailable Medications which read in part, 1. The facility maintains a contract with a pharmacy provider to supply the facility with routine, prn (as needed), and emergency medications. 2. A STAT supply of commonly used medications is maintained in-house for timely initiation of medications. Surveyor requested and was provided with a list of medications available in the STAT supply. This list included gabapentin 300 mg. The concern of not administering Resident #110's medications per the physician's orders was discussed with the administrator, DON, ADON, Regional Director of Operation, MDS coordinator, Director of Clinical Reimbursement, and Regional Director of Clinical Services on 07/16/24 at 2:45 pm. No further information was provided prior to exit. 2. For Resident #112 the facility staff failed to administer the resident's medications donepezil, atorvastatin, Semglee, tizanidine, trazodone, rivastigmine, Xarelto, and Lortab. Resident #112's clinical record listed diagnoses which included but not limited to diabetes mellitus, unspecified dementia, psychotic disturbance, peripheral vascular disease, and other chronic pain. Resident #112's most recent minimum data set assessment with an assessment reference of 06/27/24 assigned the resident a brief interview for mental status score of 12 out of 15 in section C, cognitive patterns. This indicates that the resident is cognitively intact. Resident #112's comprehensive care plan was reviewed and contained care plans which read in part, . has impaired cognitive function/dementia or impaired thought processes r/t (related to), . has peripheral vascular disease (PVD) r/t Diabetes, heart disease, HLD (hyperlipidemia), PAD (peripheral artery disease) with recent bypass surgery, 4th-5th toe amputation rt (right) foot, . has diabetes mellitus, .is at risk for pain d/t (due to) PAD/PVD and chronic pain, . is on anticoagulant therapy d/t hx (history) of bypass surgery, and . takes psychotropic medication d/t dx (diagnosis) of MDD (manic depressive disorder) and insomnia. Resident #112's clinical record was reviewed and contained a physician's order summary which read in part, donepezil HCl oral tablet 5 mg. Give 1 tablet by mouth at bedtime related to unspecified dementia, unspecified severity, with agitation, atorvastatin calcium oral tablet 20 mg. Give 1 tablet by mouth at bedtime for cholesterol, Semglee Solution Pen-Injector 100 unit/ml (insulin glargine). Inject 25 unit subcutaneously one time a day related to Type 2 diabetes mellitus with hyperglycemia, tizanidine HCl 4 mg. Give one tablet by mouth at bedtime for muscle spasms, trazodone HCL oral tablet 150 mg. Give 75 mg by mouth at bedtime for depression, rivastigmine tartrate oral tablet 1.5 mg. Give 1 capsule by mouth two time a day for related to unspecified dementia, unspecified severity, with agitation, Xarelto oral tablet 2.5. Give 1 tablet by mouth two time a day related to peripheral vascular disease, and Lortab tablet 5-325 mg. Give 1 tablet by mouth three times a day for chronic pain. Resident #112's electronic medication administration record (eMAR) for the month of May 2024 was reviewed and contained entries as above. These entries were not initialed as being administered on 05/26/24 at 9:00 pm. Resident #112's eMAR for the month of June 2024 was reviewed and contained an entry for donepezil HCl oral tablet 5 mg. Give 1 tablet by mouth at bedtime related to unspecified dementia, unspecified severity, with agitation. This entry was coded as 9 on 06/07/24. Chart code 9 is equivalent to other/see nurses notes. Resident #112's nurse's progress notes were reviewed, and surveyor could not locate a note related the medication. Surveyor spoke with the assistant director of nursing (ADON) on 07/11/24 at 10:45 regarding Resident #112's medications. ADON stated, Either the nurse didn't document, or didn't give it. But, if it's not documented, it's not done and If the medication is in the Cubex (stat supply), they should have pulled it. Surveyor spoke with the director of nursing (DON) on 07/15/24 at 10:30 am regarding Resident #112's medications. DON stated, It's unknown if he got his meds or not. Surveyor requested and was provided with a facility policy entitled Medication Administration which read in part, Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. 17. Sign MAR (medication administration record) after administered. Surveyor requested and was provided with a facility policy entitled Medication Reordering which read in part, It is the policy of this facility to accurately and safely provide or obtain pharmaceutical services including the provision of routine and emergency medications and biologicals in a timely manner to meet the needs of each resident. 2. Acquisition of medications should be completed in a timely manner to ensure medications are administered in a timely manner. 3. Each time a nurse is administering medications and observes (6) or less doses left of one kind, that nurse will reoder the medication, time permiting. Surveyor requested and was provided with a facility policy entitled Unavailable Medications which read in part, 1. The facility maintains a contract with a pharmacy provider to supply the facility with routine, prn (as needed), and emergency medications. 2. A STAT supply of commonly used medications is maintained in-house for timely initiation of medications. Surveyor requested and was provided with a list of medications available in the STAT supply. This list included the medication donepezil 5 mg. The concern of not administering Resident #112's medications per the physician's orders was discussed with the administrator, DON, ADON, Regional Director of Operation, MDS coordinator, Director of Clinical Reimbursement, and Regional Director of Clinical Services on 07/16/24 at 2:45 pm. No further information was provided prior to exit. 3. For Resident #113 the facility staff failed to administer the medications Lyrica, furosemide, and Levothyroxine were administered per the physician's orders. Resident #113's clinical record listed diagnoses which included but not limited to chronic pain syndrome, edema, and hypertension. Resident #113 most recent minimum data set with an assessment reference date of 06/27/24 assigned the resident a brief interview for mental status score of 15 out of 15 in section C, cognitive patterns. This indicates that the resident is cognitively intact. Resident #113's comprehensive care plan was reviewed and contained care plans for . is at risk for pain d/t (due to) decreased mobility, Resident has a dx (diagnosis) of chronic pain, and The resident is on diuretic therapy d/t hx (history) of edema. Resident #113's clinical record was reviewed and contained a physician order summary which read in part, Lyrica Capsule 100 mg (Pregabalin). Give 1 capsule by mouth three times a day for pain, Furosemide Oral Tablet 40 mg (Furosemide). Give 40 mg by mouth two time a day for edema, and Levothyroxine Sodium 300 mcg tablet. Give 300 mcg by mouth in the morning for thyroid dysfunction. Resident #113's electronic medication administration record (eMAR) for the months of June and July 2024 were reviewed and contained an entry which read in part, Lyrica Capsule 100 mg (Pregabalin). Give 1 capsule by mouth three times a day for pain. This entry was coded 5 on 06/29/24 at 2:00 pm, 07/01/24 and 07/02/24 at 9:00 am, and coded 9 on 07/02/24 at 9:00 pm, and 07/03/24 at 9:00 am, 2:00 pm, and 9:00 pm. Chart code 5 is equal to hold/see nurses notes and chart code 9 is equal to other/see nurses notes. Resident #113's nurse's progress notes were reviewed and contained notes which read in part, 6/29/2024 15:19. Lyrica capsule 100 mg. Give 1 capsule three times a day for pain. Do not exceed maximum daily dose of 300 mg. patient lethargic, 7/2/2024 20:27. Lyrica capsule 100 mg. Give 1 capsule three times a day for pain. Do not exceed maximum daily dose of 300 mg. not available, and 7/3/2024 20:19 Lyrica capsule 100 mg. Give 1 capsule three times a day for pain. Do not exceed daily dose of 300 mg. not available. Surveyor could not locate notes related to 07/01/24 and 07/02/24 for the 9:00 am doses or the 07/03/24 9:00 am or 2:00 pm doses. Surveyor could not locate an order hold the medication if the resident was lethargic. Resident #113's eMAR for the month of June 2024 contained an entry which read in part, Furosemide oral tablet 40 mg (Furosemide). Give 40 mg by mouth two times a day for edema. This entry was coded 9 on 06/29/24 at 6:00 am and 11 on 06/29/24 at 2:00 pm. Chart code 9 is equal to other/see nurses notes and chart code 11 is equal to Held per parameters. Resident #113's nurses progress notes were reviewed and contained a note which read in part, 6/29/2024 07:50. Furosemide oral tablet 40 mg. Give 40 mg by mouth two times a day for edema. Held for low BP (blood pressure). Surveyor could not locate a nurse's note for 06/29/24 at 2:00 pm. The order for this medication did not contain parameters. Resident #113's eMAR for the month of May 2024 contained an entry which read in part, Levothyroxine Sodium Oral Tablet 300 mcg. Give 1 tablet by mouth one time a day for thyroid management. This entry was blank on 05/30/24 at 6:00 am. Surveyor spoke with the assistant director of nursing (ADON) on 07/11/24 at 10:45 regarding Resident #113's medications. ADON stated, Either the nurse didn't document, or didn't give it. But, if it's not documented, it's not done, Medications shouldn't be held without an order, and If it the medication is in the Cubex (stat supply), they should have pulled it. Surveyor spoke with the director of nursing (DON) on 07/15/24 at 11:45 am regarding Resident #113's medications. DON stated the resident's Lyrica was on hold due to needing a new prescription sent to the pharmacy. Surveyor requested and was provided with a facility policy entitled Medication Administration which read in part, Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. 17. Sign MAR (medication administration record) after administered. Surveyor requested and was provided with a facility policy entitled Medication Reordering which read in part, It is the policy of this facility to accurately and safely provide or obtain pharmaceutical services including the provision of routine and emergency medications and biologicals in a timely manner to meet the needs of each resident. 2. Acquisition of medications should be completed in a timely manner to ensure medications are administered in a timely manner. 3. Each time a nurse is administering medications and observes (6) or less doses left of one kind, that nurse will reorder the medication, time permiting. Surveyor requested and was provided with a facility policy entitled Unavailable Medications which read in part, 1. The facility maintains a contract with a pharmacy provider to supply the facility with routine, prn (as needed), and emergency medications. 2. A STAT supply of commonly used medications is maintained in-house for timely initiation of medications. Surveyor requested and was provided with a list of medications available in the STAT supply. This list included the medications Lyrica 50 mg capsules, levothyroxine 100 mcg tablets and furosemide 20 mg tablets. The concern of not administering Resident #113's medications per the physician's orders was discussed with the administrator, DON, ADON, Regional Director of Operation, MDS coordinator, Director of Clinical Reimbursement, and Regional Director of Clinical Services on 07/16/24 at 2:45 pm. No further information was provided prior to exit. 4. For Resident #109, facility staff failed to adhere to the provider ordered maximum dose of 200mg in 24 hours for Imitrex (Sumatriptan Succinate), a medication to treat migraines. The resident received 400mg in 24 hours on 07/04/24 into 07/05/24 and 300mg in 24 hours on 07/10/24. Resident #109's minimum data set with an assessment reference date of 06/09/24 coded the brief interview for mental status summary score a 15 out of 15. The resident was coded as not having behaviors to include inattention, disorganized thinking, or altered level of consciousness. On 07/10/24 at 3:00 p.m. Resident #109 was observed and interviewed. The resident was clean, dressed and lying in her bed complaining of a migraine. The resident reported the staff were not giving her Imitrex for migraines as often as needed. Resident #109's clinical record contained a provider order dated 06/21/24 for Imitrex 100mg give one tablet by mouth every 2 hours as needed for migraine max dose 200mg in 24 hours. On 07/10/24 at approximately 6:40 p.m., Resident #109's July 2024 Medication Administration Record (MAR) was reviewed. The MAR revealed Imitrex 100mg was documented as administered four times for a total of 400mg in 24 hours starting on 07/04/24 into 07/05/24: 1. 07/04/24 at 12:49 p.m. 2. 07/04/24 at 15:14 (3:14 p.m.) 3. 07/04/24 at 19:35 (7:35 p.m.) 4. 07/05/24 at 09:51 (9:51 a.m.) The MAR revealed Imitrex 100mg was documented as administered three times for a total of 300mg in 24 hours on 07/10/24: 1. 07/10/24 at 04:43 a.m. 2. 07/10/24 at 08:24 a.m. 3. 07/10/23 at 13:47 (1:47 p.m.) On 07/10/24 at 7:05 p.m., the director of nursing (DON) was informed of the identified Imitrex doses that exceeded 200mg in 24 hours. The DON acknowledged Resident #109 received more than the ordered amount/dose of the as needed Imitrex. The DON notified the nurse practitioner (NP) via phone with new orders received. On 07/11/24 at 4:20 p.m., the facility's pharmacy returned the surveyor's call and acknowledged 200mg in 24 hours is the maximum dose of Imitrex. The pharmacist suggested contacting the resident's provider for further guidance. At the summary meeting on 07/11/24, the administrator and DON were informed of the Imitrex administration that exceeded the maximum dose in 24 hours. The administrator reported the concern will be taken to Risk/QA meeting. The DON reported putting in a new order (100mg every 2 hours for a maximum of two doses in 24 hours) and stated this was a unique case; the 100mg being ordered every 2 hours as needed. Attempted to interview Resident #109 on 07/12/24 at approximately 9:30 a.m. The resident was not in her room and staff reported she was out of the facility at an appointment. The NP was interviewed via phone on 7/12/24 at approximately 12:30 p.m. She reported being notified of the extra doses of Imitrex and stated she ordered bloodwork (CMP - comprehensive metabolic panel) and vital signs since the extra doses of Imitrex could cause bradycardia (low heart rate) and there had not been issues with bradycardia. The NP stated she was aware of some literature that said 300mg was the maximum dose in 24 hours. The NP's progress note dated 07/11/24 read the NP met with Resident #109 and discussed limiting the Imitrex to two doses per day and no more than 10 days/month. The resident acknowledged she had not known of that limited dose per day or per month prior to now and she would track the days on her phone. A different NP (NP #2) wrote a progress note dated 07/12/24 which read the NP's reason for visit was Drug GDR (gradual drug reduction) and allergy reconciliation. The note read, in part, the resident's allergy list included Zolmitriptan. She has been taking Imitrax [sic - Imitrex] for migraine headache, which has been tolerated well. The medication is effective and therapeutic, which is verified as not being a true allergy. Therefore, after discussing the issue with the patient, I preferred to keep the medication in her active medication list . After briefly speaking to Resident #109 in the hall in her wheelchair on 07/15/24 at approximately 11:00 a.m., this surveyor attempted to interview Resident #109 regarding her medications and migraines, but the resident was not in the facility. According to a progress note dated 07/15/24 at 1:52 p.m. the resident had been transferred to the hospital for right flank pain with dysuria (painful urination). A progress note dated 07/16/24 read the resident remained at the hospital. Registered Nurse (RN #4) was interviewed in person on 07/16/24 at 11:35 a.m. regarding the 07/05/24 as needed dose of Imitrex she administered to Resident #109 at 9:51 a.m. The nurse explained prior to administering the Imitrex dose, she would check the resident's allergies and make sure it had been two hours since the resident's last dose. After reading the order to include the maximum 200mg in 24 hours limit, RN #4 acknowledged the dose she had administered on 07/05/24 provided more than 200mg in 24 hours. RN #4 stated, I feel real bad about that, I try to pay close attention. The nurse stated she planned to speak with the DON to see what she needed to do now. These concerns were discussed with the administrator, regional director of clinical services (RDCS), assistant director of nursing (ADON) and DON on 07/11/24 at 4:28 p.m. during a summary meeting. The administrator, ADON, DON, regional director of operations, MDS coordinator, regional MDS coordinator, and RDCS #2 were informed of these concerns during a summary meeting on 07/16/24 at 2:46 p.m. No further information was provided prior to the exit conference.

Based on staff interviews, clinical record review and facility document review, the facility staff failed to ensure that a resident and/or resident representative had an opportunity to develop an advanced directive for three of three residents sampled, resident #101, resident # 103, and resident # 104. The findings included: 1. For resident # 10 (R103), the facility staff failed to provide the resident representative with written information concerning the right to accept or refuse medical or surgical treatment and the option to formulate an advance directive. R103's diagnoses included but were not limited to anoxic brain damage and chronic respiratory failure due to asphyxiation. R103 was not interviewable, and the electronic record indicated there was a parent acting as their representative with a sibling also listed. A progress note written by the social worker with a date of 6/18/24 read, Tried to reach both RP's (responsible party) for the care plan that was unable to leave a message for contact # 1, and left a voice message for contact # 2, waiting on response. On 7/10/24 at 3:33 PM this surveyor met with the Social Worker. When asked if resident #101 has been given the opportunity to develop an advanced directive they stated, During care plan meetings we are asking and reviewing them. They stated that the family did not respond to phone calls/messages and did not attend the care plan meeting, so the IDT (interdisciplinary team) reviewed code status during the most recent meeting. On 7/11/24 the Social Worker provided the surveyor with a copy of a form entitled, Advanced Care Planning Tracking Form with R103's name on it. The form was dated 9/21/22. The document read in part, Residents/patients and/or their responsible health care decision makers should be provided the opportunity to discus advance care planning with appropriate staff members and medical providers within the first few days of admission to the facility, at times of change in condition, and periodically for routine updating of care plans. The purpose of this tool is to document these discussions. Under the heading Describe the key aspects of the discussion the only thing written on was DNR, indicating that the discussion was solely about the resident having a do not resuscitate (DNR) order in place. There was no resident or resident representative signature on the form, the RP's name had been written in by the social worker and they had also written, per care plan conference call. 2. For resident # 101 (R101) the facility staff failed to provide the resident with written information concerning the right to accept or refuse medical or surgical treatment and the option to formulate an advance directive. R101's most recent minimum data set (MDS) assessment with an assessment reference date of 5/18/24 assigned the resident a brief interview for mental status (BIMS) score of 15 out of 15, indicating intact cognition. R101 was interviewed and stated they did not remember being provided with any specific information about advanced directives when they admitted or since then. On 7/11/24 the Social Worker provided this surveyor with the Advanced Care Plan Tracking Form for resident #101 that was dated 9/29/23. There was no resident signature on the form. The section entitled Describe the key aspects of the discussion was blank. A copy of the policy entitled, Advanced Directives with a revised date of 10/1/21 was provided. The policy read in part, Advanced Directive is a written instruction, such as a living will, durable power of attorney for health care, Do Not Resuscitate (DNR), physician orders for scope of treatment (POST) recognized by state law (whether statutory or as recognized by the courts of the state), relating to the provision of health care when the individual is incapacitated. Under the heading, Policy Explanation and Compliance Guidelines the document read in part, The facility will provide the resident or resident representative information, in a manner that is easy to understand, about the right to refuse medical or surgical treatment and formulate an advanced directive. On 7/11/24 at 11:30 AM surveyors met with the Administrator. They stated that the Advanced Care Planning Tracking Form is evidence of a discussion with the resident and/or the resident's RP about advanced directives. They were not able to provide evidence that written information was provided or that anything was discussed other than the resident's code status. This concern was reviewed with the Administrator, Regional Director of Operations, Regional Director of Clinical Services, Director of Nursing, Assistant Director of Nursing and MDS Coordinator on 7/16/24 at 2:40 PM. No further information was provided to the survey team prior to the exit conference. 3. For Resident #104 facility staff failed to provide written evidence the resident or resident representative agreed to or declined to develop an advance directive. Resident #104's admission Record listed diagnoses which included but were not limited to vascular dementia, dependence on respirator (ventilator), and persistent vegetative state. The annual minimum data set with an assessment reference date of 06/24/24 read the resident was in a persistent vegetative state/no discernible consciousness in Section B (Hearing, Speech, and Vision). Resident #104's clinical record was reviewed on 07/10/24 with no evidence of a written advanced directive noted. No written evidence of the resident or resident representative declining the opportunity to provide an advanced directive was found. A form titled; Advance Care Planning Tracking Form dated 09/29/23 was noted in the clinical record. The form, referred to as the tracking form, named the resident's spouse as the resident representative (RR) with the facility's director of social services being the only signature on the form. Under the area titled Advance Directive Documents in Place, only the box beside Full Code was checked. The tracking form indicated the document was to Review existing Advance Care Plan and the discussion was held with the RR. The director of social services (DSS) was interviewed on 07/11/24 at 9:05 a.m. The director reported the facility's form titled, Advanced Care Planning Tracking Form was available during the most recent survey and was presented to the federal surveyor. The DSS reported the facility plan was to review advance directives with residents and RRs at their next scheduled care plan meeting. On 07/11/24 at 11:30 a.m., this writer and another surveyor met the administrator per his request for clarification of the regulation expectation. After discussion, the administrator verbalized understanding that written evidence of the resident or RR being provided written information concerning the right to accept or refuse medical or surgical treatment and if desired, formulate an advance directive was required. The administrator reported the tracking form was evidence of a discussion and acknowledged he could not provide evidence the resident and/or RR had been provided written information regarding advance directives. The policy titled, Advance Directives with a reviewed/revised date of 10/01/21 read in part, Policy: It is the policy of this facility to support and facilitate a resident's right to request, refuse and/or discontinue medical or surgical treatment and to formulate an advance directive . 1. On admission, the facility will determine if the resident has executed an advance directive, and if not, determine whether the resident would like to formulate an advance directive. 2. The facility will provide the resident or resident representative information, in a manner that is easy to understand, about the right to refuse medical or surgical treatment and formulate an advance directive . During a summary meeting with the administrator, regional director of clinical services, director of nursing, and assistant director of nursing on 07/11/24, the concern regarding written evidence of advance directive options was discussed. No further information was provided prior to exit conference.

Based on staff interviews, facility document review, and clinical record review, the facility staff failed to ensure that written transfer notices included the required information when provided to five (5) of five (5) residents reviewed for transfers (Resident #109, Resident #116, Resident #121, Resident #125, and Resident #126). The findings include: The transfer notice information documented at the time of Resident #109's, Resident #116's, Resident #121's, Resident #125's, and Resident #126's transfers to a local hospital failed to include the required information. This transfer notice information stated the reason for the transfer was that the facility could not manage the residents' care but did not detail the specific care issues the facility was unable to manage. This transfer notice information failed to provide information about the residents' appeal rights. This transfer notice information failed to include the name, address (mailing and email) and telephone number of the Office of the State Long-Term Care Ombudsman. The following information was found in a facility policy titled Transfer and Discharge (including AMA) (with a reviewed/revised date of 12/1/22): Emergency Transfers/Discharges - initiated by the facility for medical reasons, or for the immediate safety and welfare of a resident . Provide transfer notice as soon as practicable to resident and representative. Resident #109's clinical documentation included a Discharge/Transfers form which was dated 6/20/24 and indicated the resident was transferred to a local hospital. This form was not signed by the staff member who completed the form. This form indicated the reason for the transfer was CANNOT MANAGE CARE AT THE FACILITY. This form did not detail the resident's condition that could not be managed at the facility. This form did not provide information related to the resident's appeal rights. This form did not provide the ombudsman contact information. Resident #116's clinical documentation included a Discharge/Transfers form which was dated 6/19/24 and indicated the resident was transferred to a local hospital. This form was not signed by the staff member who completed the form. This form indicated the reason for the transfer was CANNOT MANAGE CARE AT THE FACILITY. This form did not detail the resident's condition that could not be managed at the facility. This form did not provide information related to the resident's appeal rights. This form did not provide the ombudsman contact information. Resident #121's clinical documentation included a Discharge/Transfers form which was dated 6/27/24 and indicated the resident was transferred to a local hospital. This form was not signed by the staff member who completed the form. This form indicated the reason for the transfer was CANNOT MANAGE CARE AT THE FACILITY. This form did not detail the resident's condition that could not be managed at the facility. This form did not provide information related to the resident's appeal rights. This form did not provide the ombudsman contact information. Resident #125's clinical documentation included a Discharge/Transfers form which was dated 6/12/24 and indicated the resident was transferred to a local hospital. This form was not signed by the staff member who completed the form. This form indicated the reason for the transfer was CANNOT MANAGE CARE AT THE FACILITY. This form did not detail the resident's condition that could not be managed at the facility. This form did not provide information related to the resident's appeal rights. This form did not provide the ombudsman contact information. Resident #126's clinical documentation included a Discharge/Transfers form which was dated 6/17/24 and indicated the resident was transferred to a local hospital. This form was not signed by the staff member who completed the form. This form indicated the reason for the transfer was CANNOT MANAGE CARE AT THE FACILITY. This form did not detail the resident's condition that could not be managed at the facility. This form did not provide information related to the resident's appeal rights. This form did not provide the ombudsman contact information. On 7/15/24 at 3:36 p.m., the Administrator provided the surveyor with a blank copy of a form titled Notice of Transfer/Discharge. This form included sections for the aforementioned information not included in the residents' Discharge/Transfers forms. The Administrator reported they felt as if the required transfer notice information was different for emergency transfers and non-emergency transfers. The Administrator reported this form is not provided with every hospitalization or emergency transfer. On 7/16/24 at 2:45 p.m., the survey team met with the facility's Administrator, Director of Nursing (DON), Assistant DON, Regional Director of Operations, MDS Coordinator, Regional MDS Coordinator, and Regional Director of Clinical Services. During this meeting, the failure of the facility staff to ensure transfer notice information included the required information was discussed.

Based on observations, resident and staff interview, clinical record review and facility document review, the facility staff failed to provide the necessary activities of daily living (ADL) care to maintain appropriate grooming/bathing for three of 24 residents in the survey sample, resident # 101, resident # 103 and resident # 104. The findings included: 1. For resident # 101 (R101), the facility staff failed to provide adequate baths and/or showers. R101's diagnosis list includes but is not limited to the following: respiratory failure with hypoxia, chronic obstructive pulmonary disease, type II diabetes mellitus, morbid, severe obesity, bipolar disorder unspecified, generalized anxiety disorder, essential hypertension. R101's minimum data set with an assessment reference date (ARD) of 5/18/24 assigns the resident a brief interview for mental status score (BIMS) of 15 out of 15 indicating intact cognition. On 7/9/24 at 4:17 PM this surveyor interviewed R101 about bathing and showering. R101 stated, I guess. When asked if they get enough baths. They could not tell me when they got the last bath, I can't remember. When asked if they would like to have more baths they stated, it'd be okay. On 7/15/24 this surveyor was provided with a print off of R101's bathing records for June and July 2024. The document for June 2024 had bed baths documented for 6/8/24, 6/12/24, 6/13/24, 6/20/24, and 6/26/24 and a partial bath documented 6/16/24. The July record had bed baths documented on 7/2/24, 7/3/24, 7/6/24 and a partial bath on 7/13/24. R101's care plan was reviewed. A focus read, (Resident) has an ADL self-care performance deficit r/t Respiratory failure, COPD, Morbid obesity. One of the interventions read BATHING/SHOWERING: totally dependent 1-2 staff for shower 2x wkly (two times weekly) and prn (as needed). A policy entitled, Activities of Daily Living (ADLs) with a revised date of 12/1/22, read in part, 3. A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. On 7/15/24 at 1:38 PM this surveyor interviewed the Director of Nursing (DON). When asked what the expectation was for number of showers to be given to each resident they stated, There is no policy for that, we follow the standard of care for Virginia which is twice a week. When asked to verify the number of bed baths given in June and July, they agreed that R101 had five bed baths in June and three thus far in July. On 7/16/24 at 2:44 PM the survey team met with the Administrator, DON, Regional Director of Operations, Regional Reimbursement Specialist, MDS Coordinator, Assistant Director of Nursing and Regional Director of Clinical Services. This concern was discussed. No further information was provided prior to the exit conference. 2. For R103 the facility staff failed to maintain nail care. The findings included: On 7/10/24 at 8:30 AM this surveyor observed the resident in their bed. Fingernails and toenails noted to be long and jagged. Resident was not interviewable and is dependent on staff for all care. On 7/11/24 at 9:24 AM observed resident in their bed. Fingernails and toenails long and jagged. On 7/12/24 at 11:11 AM observed resident in their bed, fingernails and toenails long and jagged. This surveyor interviewed Licensed Practical Nurse (LPN) # 2. Surveyor asked when staff provides nail care for dependent residents, they stated, it's done as needed on bath days. They cut them a few weeks ago. They stated the certified nursing assistants provide fingernail care, but only the podiatrist can cut toenails. They stated that resident was seen by the podiatrist a month or so ago and they would find that documentation. LPN # 2 disagreed with surveyor that resident's fingernails were long, No, they're not too long. On 7/12/24 at 12:10 PM LPN # 2 stated to surveyor, I talked to my Regional (Director of Clinical Services) he/she said (name omitted) fingernails are too long, so we're going to cut them after lunch. Surveyor asked LPN #2 if they had located the documentation of the podiatrist visit as it was not in the clinical record. They stated, I'm going to bring you something but then you'll need to talk to the social worker, that's who takes care of all that. On 7/15/24 at 10:15 AM surveyor observed resident in their bed. Fingernails and toenails were still long and jagged. Surveyor spoke with the Director of Nursing (DON) about the concern and asked for documentation that resident had been seen by the podiatrist. The documentation provided indicated that resident had been seen by the podiatrist April 8, 2023. On 7/15/24 at 12:15 PM this surveyor interviewed the Social Worker. They stated, He/she was seen in April I gave that to (DON), did you not get it? This surveyor informed them the visit note provided by the DON was dated April 2023. They stated, That's not right, the podiatrist was here in May. I called them and they said he/she was seen last in April 2023 but that can't be right. When asked if they keep a copy of the podiatry list that gets sent to the provider, they stated they just email it and He sees who he wants to I guess. Social Worker did provide a copy of the list they sent to the podiatrist on April 30, 2024, with resident # 103's name included. The social worker could not explain why resident was not seen. They indicated that the podiatrist will be back July 29, 2024, and resident will be seen then. This surveyor met with the DON and confirmed that there is no evidence resident has been seen by podiatry since April 8, 2023. Asked DON if there is a policy that says nurses cannot trim toenails and they stated there was not. Informed DON that LPN # 2 had told surveyor fingernails would be trimmed after lunch on 7/12/24 but nails were still long. They stated, I'll take care of that right now. 7/16/24 9:00 AM, fingernails and toenails were observed to be trimmed. On 7/16/24 at 2:44 PM the survey team met with the Administrator, Regional Director of Operations, Regional Director of Clinical Services, Director of Nursing, Assistant Director of Nursing, MDS Coordinator and Regional Reimbursement Specialist. These concerns were discussed, and no further information was provided to the survey team prior to the exit conference. 3. For Resident #104 facility staff failed to provide bed baths twice a week. Resident #104's admission Record listed diagnoses which included but were not limited to vascular dementia, dependence on respirator (ventilator), and persistent vegetative state. The annual minimum data set with an assessment reference date of 06/24/24 read the resident was in a persistent vegetative state/no discernible consciousness in Section B (Hearing, Speech, and Vision). Resident #104 was observed on 07/09/24 at approximately 8:55 a.m. The resident was clean, lying in bed with clean sheets. The resident's clinical record and bathing sheets indicated that since his last admission, Resident #104 received bed baths on: 1. 06/21/24, 2. 06/26/24, 3. 07/05/24 - (eight days between baths) and, 4. 07/09/24. Partial baths were documented on: 5. 07/11/24 and, 6. 07/13/24. The administrator, regional director of clinical services, assistant director of nursing, and director of nursing (DON) were informed of the bathing frequency concern and request for any bathing documentation during a summary meeting on 07/11/24 at 4:28 p.m. On 07/15/24 at 1:38 p.m., the DON reported the facility had no specific bed bath policy; the DON's expectation was for bed baths to follow the state standard of care which was twice/week. No further information was provided prior to exit conference.

Based on staff interviews and clinical record review, the facility staff failed to ensure a medical provider was promptly notified of critical lab values for one (1) of four (4) residents sampled for laboratory review (Resident #114). The findings include: The facility staff failed to ensure Resident #114's critical laboratory results were promptly reported to a medical provider. Resident #114's Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 5/2/24, was signed as completed on 5/19/24. Resident #114 was assessed as usually being able to make self understood and as sometimes being able to understand others. Resident #114's Brief Interview for Mental Status (BIMS) summary score was documented as a six (6) out of 15; this indicated severe cognitive impairment. Resident #114's clinical record included the results of a CBC with auto Differential laboratory test dated 6/1/24. (A Complete Blood Count (CBC) is a laboratory test that measures various components of a blood specimen.) These results indicated the Resident's [NAME] Blood Count (WBC) and Hemoglobin (HGB) Level were critically low. This laboratory result included the following statement: After multiple unsuccessful attempts to notify facility of the critical value by phone, the result was released to be viewed in (system name omitted) and a follow up phone call will be placed in the AM. (WBC, HGB). These laboratory results were reported on 6/1/24 at 9:14 p.m.; the medical provider documented reviewing these results on 6/2/24 at 9:28 a.m. According to a nursing note dated 6/2/24 at 1:03 p.m., Resident #114 was transferred to the local emergency room on 6/2/24 for a blood transfusion. On 7/11/24 at 9:00 a.m., the surveyor interviewed, via telephone, a staff member of the laboratory which obtained and processed Resident #114's aforementioned laboratory test. This staff member reported their protocol is to attempt to notify the facility of a critical laboratory result via telephone three (3) times, after the third unsuccessful attempt to notify the facility, the results are released to be viewed by the facility staff. This laboratory staff member reported the laboratory staff would attempt an additional call during the morning of the next business day. On 7/12/24 at 9:29 a.m., the surveyor interviewed the Director of Nursing (DON) about the laboratory staff being unable to contact the facility with the aforementioned critical laboratory results. The DON reported staff members might be providing resident care and unable to hear the telephone; the DON gave the example of staff administering residents their medications. On 7/12/24 at 10:10 a.m., the DON reported the facility staff is starting to document outstanding diagnostic tests in a 'communication binder' which will allow for reporting of outstanding diagnostic tests between oncoming and outgoing nursing staff at shift change. On 7/16/24 at 2:45 p.m., the survey team met with the facility's Administrator, Director of Nursing (DON), Assistant DON, Regional Director of Operations, MDS Coordinator, Regional MDS Coordinator, and Regional Director of Clinical Services. During this meeting, the delay in medical provider notification of Resident #114's aforementioned critical laboratory results was discussed.

Based on staff interview, clinical record review and facility document review the facility staff failed to ensure 1 of 24 resident was free of significant medication error, Resident #110. The findings included: For Resident #110 the facility staff failed to administer the medication metoprolol per the physician's order. Resident #110's clinical record listed diagnoses which included but not limited chronic diastolic (congestive) heart failure, and essential hypertension. Resident #110's most recent minimum data set with an assessment reference date of 06/07/24 assigned the resident a brief interview for mental status score of 15 out of 15 in section C, cognitive patterns. This indicates that the resident is cognitively intact. Resident #110's comprehensive care plan was reviewed and contained care plans for . potential for altered cardiovascular status r/t (related to) hyperlipidemia, and CHF (congestive heart failure) with daily wts (weights) and . has potential fluid deficit/overload r/t (related to) diuretic use r/t CHF, HTN (hypertension). Interventions for these care plan included Monitor vital signs. Notify MD of significant abnormalities and administer medications as ordered. Resident #110's clinical record contained a physician's order summary which read in part, Metoprolol Tartrate Oral Tablet 25 mg. Give 0.5 tablet by mouth two times a day for HTN. Hold if systolic BP (blood pressure) is less than 100 and HR (heart rate) under 60. Resident #110's electronic medication record for the month of June 2024 was reviewed and contained an entry as above. This entry was coded 9 on 06/12/24. Chart code 9 is equivalent to other/see nurse's notes. Resident #110's nurse's progress notes were reviewed and contained a note dated 06/12/24 which read in part, 6/12/2024 09:46. Metoprolol Tartrate Oral Tablet 25 mg. Give 0.5 tablet by mouth two times a day for HTN. Hold id systolic BP is less than 100 and HR under 60. Medication reordered through pharmacy. Surveyor spoke with the assistant director of nursing (ADON) on 07/11/24 at 10:45 regarding Resident #110's medications. ADON stated, If the medication is in the Cubex (stat supply), they should have pulled it. Surveyor requested and was provided with a facility policy entitled Unavailable Medications which read in part, 1. The facility maintains a contract with a pharmacy provider to supply the facility with routine, prn (as needed), and emergency medications. 2. A STAT supply of commonly used medications is maintained in-house for timely initiation of medications. Surveyor requested and was provided with a list of medications available in the STAT supply. This list included metoprolol tartrate 25 mg. The concern of not ensuring Resident #110 was free from significant medication error was discussed with the administrator, DON, ADON, Regional Director of Operation, MDS coordinator, Director of Clinical Reimbursement, and Regional Director of Clinical Services on 07/16/24 at 2:45 pm. No further information was provided prior to exit.

Based on observation, staff interview, and clinical record review, the facility staff failed to maintain a clean, comfortable, homelike environment for 1 of 24 residents, Resident #118. The findings include: Resident #118's tube feeding pole was observed to have a dried brown substance on the bottom of the tube feeding pole. Resident #118's diagnoses included, but were not limited to, persistent vegetative state and cognitive communication deficit. Section B (hearing/speech/vision) of Resident #118's minimum data set (MDS) assessment with an assessment reference date (ARD) of 05/23/24 was coded to indicate Resident #118 was in a persistent vegetative state. Section K (swallowing/nutritional status) was coded to indicate this resident received nutrition via a feeding tube. On 07/10/24 at 11:00 a.m., the surveyor observed a brown dried substance on the bottom of this residents tube feeding pole. A second observation was made on 07/10/24 at approximately 2:35 p.m. the brown dried substance remained on the bottom of the tube feeding pole. On 07/11/24 at 4:30 p.m., during an end of the day meeting with the Administrator, Regional Director of Clinical Services, Director of Nursing, and Assistant Director of Nursing/Staff Development Coordinator the issue with Resident #118's tube feeding pole was reviewed. No further information regarding this issue was provided to the survey team prior to the exit conference on 07/16/24.

Based on staff interview and clinical record review, the facility staff failed to review and revise a comprehensive care plan (CCP) for 1 of 24 residents, Resident #115. The findings include: For Resident #115, the facility staff failed to review and revise the residents CCP to include their Do Not Resuscitate (DNR). Resident #115's diagnosis included adult failure to thrive. Section C (cognitive patterns) of Resident #115's significant change minimum data set (MDS) assessment with an assessment reference date (ARD) of 06/30/24 included a brief interview for mental status (BIMS) score of 6 out of a possible 15 points. Section O (special treatments and procedures) was coded to indicate this resident was receiving Hospice services. A review of Resident #115's clinical record revealed that the facility staff had not revised the CCP regarding the residents current code status. Under the focus area of Advance Directive, the facility staff documented this resident was a Full Code. Interventions included follow facility guidelines for full code. Resident #115's clinical record included the provider order for DNR dated 05/28/24. The clinical record also included a DDNR (durable do not resuscitate) order form dated 05/28/24 signed by the provider and authorized representative. On 07/11/24 at 9:30 a.m., during an interview with MDS nurse #1 this staff reviewed Resident #115's CCP and acknowledged their DNR status had not been updated on the CCP. MDS nurse #1 stated they would update the CCP today. On 07/11/24 at 4:30 p.m., during an end of the day meeting with the Administrator, Regional Director of Clinical Services, Director of Nursing, and Assistant Director of Nursing/Staff Development Coordinator the issue with Resident #115's CCP not being revised to include their current DNR status was reviewed. On 07/12/24 at 10:00 a.m., the Administrator provided the surveyor with an updated care plan indicating Resident #115's CCP had been revised to include their current DNR status. No further information regarding this issue was provided to the survey team prior to the exit conference.

Based on staff interview, clinical record review, facility document review, and a medication pass and pour observation the facility staff failed to follow professional standards of practice for the administration of medications for 2 of 24 residents, Resident #123, and Resident #110. The findings included: For Resident #123 the facility staff signed a medication as being administered when the medication was unavailable for administration. Resident #123's clinical record listed diagnoses which included but not limited to unspecified asthma, uncomplicated. Resident #123's most recent minimum data set with an assessment reference date of 05/28/24 coded the resident as 3 out of 15 in section C, cognitive patterns. This indicates that the resident is severely cognitively impaired. Resident #123's comprehensive care plan was reviewed and contained a care plan for . is at risk for ineffective breathing d/t (due to) dx (diagnosis) of COPD (chronic obstructive pulmonary disease). Interventions for this care plan include give medications as ordered. Surveyor observed registered nurse (RN) #3 on 07/10/24 at 8:35 am during a medication pass and pour. RN #3 prepared Resident #123's medications, then stated to surveyor that resident's inhaler was not on the cart. RN #3 stated, It was ordered on 07/07/24 and she probably hasn't had it for a few days. Resident #123's clinical record was reviewed on 07/10/24 and contained an order which read in part, Symbicort Aerosol 160-4.5 MCG/ACT (Budesonide-Formoterol Fumarate) 1 puff inhale orally two times a day for SOB (shortness of breath). Rinse mouth after use. Resident #123's electronic medication administration (eMAR) record was reviewed and contained an entry as above. This entry had been initialed for all administrations for the month of July, including 8 am on 07/10/24. Surveyor spoke with licensed practical nurse (LPN) #5 on 07/11/24 regarding Resident #123's Symbicort inhaler. LPN #5 looked in the medication cart, then stated the inhaler was not there, unless it came last night. Surveyor reviewed Resident #123's eMAR and observed that the inhaler had been initialed as administered by LPN #5. Surveyor asked LPN #5 if they had signed the inhaler as administered, and LPN #5 stated, Not sure, I can't remember honestly. Surveyor spoke with the assistant director of nursing (ADON) on 07/12/24 at 10:45 am regarding Resident #123's inhaler, and nursing staff initialing it as administered. ADON stated, they should not sign off if they don't have it. That's just common sense. It also goes to compliance and ethics. Surveyor requested a copy of the facility standards of practice for medication administration and was provided with a copy of a facility policy entitled Medication Administration which read in part, Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. 17. Sign MAR after administered. The concern of not following professional standards of practice was discussed with the administrator, director of nursing, assistant director of nursing, regional director of operations, minimum data set coordinator, director of clinical reimbursement, and regional director of clinical services on 07/16/24 at 2:45 pm. No further information provided prior to exit. 2. For Resident #110 the facility staff signed a medication as being administered when the medication was unavailable for administration. Resident #110's clinical record listed diagnoses which included but not limited to chronic pain syndrome. Resident #110's most recent minimum data set with an assessment reference date of 06/07/24 assigned the resident a brief interview for mental status score of 15 out of 15 in section C, cognitive patterns. This indicates that the resident is cognitively intact. Resident #110's comprehensive care plan was reviewed and contained a care plan for . at risk for pain d/t dx (diagnosis) of chronic pain and Gout. Interventions for this care plan included Administer medications per MD orders and 'Medicate as ordered. Resident #110's clinical record was reviewed and contained a physician's order summary which read in part, gabapentin 300 mg. Give one capsule by mouth three times daily for neuropathy. Resident #110's electronic medication administration record (eMAR) for the month of June 2023 was reviewed and contained an entry as above. This entry was initialed as being administered on 06/27/24 at 1:00 pm and 9:00 pm. Resident #110's nurse's progress notes were reviewed and contained a noted dated 06/27/24 which read in part, 6/27/2024 16:29 Gabapentin Oral Capsule 300 mg. Give 1 capsule by mouth three times a day for neuropathy. Med not available. Surveyor spoke with the assistant director of nursing (ADON) on 07/12/24 at 10:45 am regarding Resident #110's gabapentin and nursing staff initialing it as administered. ADON stated, they should not sign off if they don't have it. That's just common sense. It also goes to compliance and ethics. Surveyor requested a copy of the facility standards of practice for medication administration and was provided with a copy of a facility policy entitled Medication Administration which read in part, Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. 17. Sign MAR after administered. The concern of not following professional standards of practice was discussed with the administrator, director of nursing, assistant director of nursing, regional director of operations, minimum data set coordinator, director of clinical reimbursement, and regional director of clinical services on 07/16/24 at 2:45 pm. No further information provided prior to exit.

Based on observation, staff interview, and clinical record review, the facility staff failed to ensure physician ordered equipment (splint) was in place to ensure the resident maintained and/or improved their highest level of range of motion (ROM) and mobility for 1 of 3 current residents in the survey sample. Resident #118. The findings include: The facility staff failed to apply a provider ordered splint to the residents right hand. Resident #118's diagnoses included, but were not limited to, persistent vegetative state, muscle weakness, and cognitive communication deficit. Section B (hearing/speech/vision) of Resident #118's minimum data set (MDS) assessment with an assessment reference date (ARD) of 05/23/24 was coded to indicate Resident #118 was in a persistent vegetative state. Section GG (functional abilities and goals) was coded to indicate this resident had limitations in ROM in the upper and lower extremities. Resident #118's comprehensive care plan included the focus area has limited physical mobility related to neurological deficits. Interventions included apply splint per MD order. On 06/21/24 the provider transcribed an order to apply right and left hand splints during the day. When reviewing the clinical record, the surveyor was unable to find this order on the medication administration record (MAR) or the treatment administration record (TAR). During observations on 07/10/24 at 11:00 a.m. and again at 2:35 p.m. Resident #118 was not observed with a splint in place to their right hand. The clinical record did not include any documentation to indicate why this splint was not in place. On 07/11/24 at 10:55 a.m., Resident #118 was observed with their right-hand splint in place. During an interview with Licensed Practical Nurse (LPN) #4 this nurse was asked who had placed the right-hand splint on Resident #118. LPN #4 stated therapy had placed the splints on this resident. On 07/11/24 at 11:00 a.m., during an interview with therapy staff #1 and #2. These staff stated Resident #118's hand splints were the nursing staff's responsibility. On 07/11/24 at 4:30 p.m., during an end of the day meeting with the Administrator, Regional Director of Clinical Services, Director of Nursing, and Assistant Director of Nursing/Staff Development Coordinator the issue with Resident #118's splint not being in place was reviewed. No further information regarding this issue was provided to the survey team prior to the exit conference.

Based on staff interview, clinical record review, facility document review and during a medication pass and pour observation the facility staff failed to ensure medications were available for administration for 2 of 24 residents, Resident #123, #113 and failed to ensure the nursing staff correctly implemented the facility schedule control medication monitoring system for 5 of 5 medication carts. The findings included: 1. For Resident #123 the facility staff failed to ensure the medication Symbicort aerosol inhaler was available for administration. Resident #123's clinical record listed diagnoses which included but not limited to unspecified asthma, uncomplicated. Resident #123's most recent minimum data set with an assessment reference date of 05/28/24 assigned the resident a brief interview for mental status score of 3 out of 15 in section C, cognitive patterns. This indicates that the resident is severely cognitively impaired. Resident #123's comprehensive care plan was reviewed and contained a care plan for . is at risk for ineffective breathing d/t (due to) dx (diagnosis) of COPD (chronic obstructive pulmonary disease). Resident has SOB (shortness of breath) when lying flat. Interventions for this care plan include Give medications as ordered. Surveyor observed registered nurse (RN) #3 on 07/10/24 at 8:35 am during a medication pass and pour. While preparing Resident #123's medications, RN #3 informed surveyor that resident's inhaler was not in the medication cart. RN #3 stated that inhaler had been ordered on 07/07/24, and she probably hasn't had it for a few days. Resident #123's clinical record was reviewed and contained a physician's order summary which read in part, Symbicort Aerosol 160-4.5 MCG/ACT (Budesonide-Formoterol Fumarate). 1 puff inhale orally two times a day for SOB. Rinse mouth after use. Resident #123's electronic medication administration (eMAR) record was reviewed and contained an entry as above. This entry had been initialed for all administrations for the month of July, including 8 am on 07/10/24. Surveyor spoke with an order entry staff at the pharmacy regarding Resident #123's Symbicort inhaler on 07/10/24 at 2:00 pm. Order entry staff stated that they had tried to fill it, but insurance denied payment on 07/07/24. Order entry staff stated that a refill request on 06/29/24 had triggered to switch to generic, but medication was switched to generic on 10/16/23. Surveyor asked order entry staff when medication was last sent to facility, and order entry staff stated that a 30-day supply was sent on 06/06/24. Surveyor spoke with licensed practical nurse (LPN) #5 on 07/11/24 regarding Resident #123's Symbicort inhaler. LPN #5 looked in the medication cart, then stated the inhaler was not there, unless it came last night. Surveyor requested and was provided with a facility policy entitled Unavailable Medication which read in part, 1. The facility maintains a contract with a pharmacy provider to supply the facility with routine, prn, and emergency medications. 3. The facility shall follow established procedures for ensuring residents have a sufficient supply of medications. 5. If a resident misses a scheduled dose of the medication, staff shall follow procedures for medication errors, including physician/family notification, completion of a medication error report, and monitoring the resident for adverse reaction to omission of the medication. Surveyor requested and was provided with a facility policy entitled Medication Reordering which read in part, It is the policy of this facility to accurately and safely provide or obtain pharmaceutical services including the provision of routine and emergency medications and biologicals in a timely manner to meet the needs of each resident. 2. Acquisition of medications should be completed in a timely manner to ensure medications are administered in a timely manner. 3. Each time a nurse is administering medications and observes (6) or less doses left of one kind, that nurse will reorder the medication, time permiting. The concern of not ensuring residents medications were available for administration was discussed with the administrator, director of nursing, assistant director of nursing, regional director of operations, minimum data set coordinator, director of reimbursement, and regional director of clinical services on 07/16/24 at 2:45 pm. No further information was provided prior to exit. 2. For Resident #113 the facility staff failed to ensure the medications atorvastatin and semaglutide were available for administration. Resident #113's clinical record listed diagnoses which included but not limited to type 2 diabetes mellitus with hyperglycemia and morbid obesity due to excess calories. Resident #113 most recent minimum data set with an assessment reference date of 06/27/24 assigned the resident a brief interview for mental status score of 15 out of 15 in section C, cognitive patterns. This indicates that the resident is cognitively intact. Resident #113's comprehensive care plan was reviewed and contained care plans for . has diabetes mellitus and . has nutritional problem d/t (due to) dx (diagnosis) of obesity. Resident has dx of Type 2 diabetes, CHF (congestive heart failure), and anemia. Interventions for these care plans include Diabetes medication as ordered by doctor and Administer medications as ordered. Resident #113's clinical record was reviewed and contained a physician's order summary which read in part, Atorvastatin calcium oral tablet 10 mg (Atorvastatin calcium). Give 10 mg by mouth one time a day for hypercholesterolemia, and Semaglutide-Weight Management Subcutaneous Solution Auto-injector 0.25mg/0.5 ml (Semaglutide (Weight Management)). Inject 0.25 mg subcutaneously one time a day every 7 day(s) for Supramorbid obesity/DM. Resident #113's electronic medication administration records (eMAR) for the months of May, June and July 2024 were reviewed and contained entries as above. For the month of June 2024, the entry for atorvastatin was coded 9 on 06/28/24 at 8:00 am. For the month of July 2024, the entry for semaglutide was coded 9 on 07/01/24 and 07/08/24. Chart code 9 is equivalent to other/see nurses notes. Resident #113's nurses' progress notes were reviewed and contained progress notes which read in part, 6/28/2024 08:24. Atorvastatin Calcium Oral Tablet 10 mg. Give 10 mg by mouth one time a day for hypercholesterolemia. ordered from pharmacy, 7/1/2024 12:43. Semaglutide-Weight Management Subcutaneous Solution Auto-injector 0.25 mg/0.5 ml. Inject 0.25 mg subcutaneously one time a day every 7 day(s) for Supramorbid obesity/DM. Medication not available; MD notified and aware; pharmacy states that the medication delivery is on the way, and 7/8/2024 11:01. Semaglutide-Weight Management Subcutaneous Solution Auto-injector 0.25 mg/0.5 ml. Inject 0.25 mg subcutaneously one time a day every 7 day(s) for Supramorbid obesity/DM. Medication not available; MD notified and aware; Medication delivery on the way per Pharmacy. Surveyor requested and was provided with a facility policy entitled Unavailable Medication which read in part, 1. The facility maintains a contract with a pharmacy provider to supply the facility with routine, prn, and emergency medications. 3. The facility shall follow established procedures for ensuring residents have a sufficient supply of medications. 5. If a resident misses a scheduled dose of the medication, staff shall follow procedures for medication errors, including physician/family notification, completion of a medication error report, and monitoring the resident for adverse reaction to omission of the medication. Surveyor requested and was provided with a facility policy entitled Medication Reordering which read in part, It is the policy of this facility to accurately and safely provide or obtain pharmaceutical services including the provision of routine and emergency medications and biologicals in a timely manner to meet the needs of each resident. 2. Acquisition of medications should be completed in a timely manner to ensure medications are administered in a timely manner. 3. Each time a nurse is administering medications and observes (6) or less doses left of one kind, that nurse will reorder the medication, time permiting. The concern of not ensuring residents medications were available for administration was discussed with the administrator, director of nursing, assistant director of nursing, regional director of operations, minimum data set coordinator, director of reimbursement, and regional director of clinical services on 07/16/24 at 2:45 pm. No further information was provided prior to exit. 3. The facility nursing staff failed to accurately complete the shift change controlled substance inventory count sheets on 5 of 5 medication carts. The facility's shift change controlled substance inventory count sheet forms for 5 of 5 medication carts were noted to have incomplete information. These forms are part of the facility process where licensed nurses document the count of the facility's controlled medication at the time when access to the controlled medications is being transferred from one licensed nurse to another licensed nurse. These forms included the statement: Nurse signatures below denote that the control drug inventory was true and correct at the date and time [sic] shift change or key exchange. On 07/10/24 beginning at approximately 4:00 p.m., the surveyor reviewed the shift change controlled substance inventory count sheets on the narcotic books on each unit. Numerous sheets on each medication cart were observed to contain blanks where the oncoming and/or off going nurse had not signed these sheets. Several sheets were also observed to have no information in the areas designated for the facility name, station, and/or medication cart number. On 07/10/24 at 4:10 p.m., during an interview with the Unit Manager this staff stated the nursing staff had been in-serviced and re-educated on completing these forms. On 07/11/24 at 3:30 p.m., the DON provided the surveyor with a copy of their policy titled, Controlled Substance Administration & Accountability. This policy read in part, It is the policy of this facility to promote safe, high quality patient care, compliant with state and federal regulations regarding monitoring the use of controlled substances. The facility will have safeguards in place in order to prevent loss, diversion or accidental exposure . On 07/11/24 at 4:30 p.m., during an end of the day meeting with the Administrator, Regional Director of Clinical Services, Director of Nursing (DON), and Assistant Director of Nursing/Staff Development Coordinator the issue with the shift change controlled substance inventory count sheets being incomplete was reviewed. No further information regarding this issue was provided to the survey team prior to the exit conference.

Based on staff interviews, medical record review and facility document review, the facility staff failed to act on pharmacy recommendations for one of three residents in the survey sample, resident # 101. The findings included: For resident # 101 (R101) the facility failed to act upon the pharmacy recommendations from May 27, 2024, and June 26, 2024. Progress notes in the clinical record indicated that medication regimen reviews had been done May 27,2024 and June 26,2024. This surveyor could not locate the Consultant Pharmacist Recommendation to Physician for either month in the record. On 7/11/2024 this surveyor asked the Director of Nursing (DON) for the pharmacy recommendations for May and June. They brought blank copies of each one. The recommendation for May read, Federal guidelines state psychopharmacological drugs should have an attempt at a gradual dose reduction (GDR) twice per year for the first year in two different quarters with 1 month between attempts, then annually thereafter, when used to manage behavior, stabilize mood, or treat psych disorder. This resident has been taking Buspirone 20 mg TID since 5/12/23 without a GDR. Could we attempt a dose reduction at this time to perhaps Buspirone 15 mg TID to verify this resident is on the lowest possible dose? If not, please indicate response below. The June recommendation read, Federal guidelines state psychopharmacological drugs should have an attempt at a gradual dose reduction (GDR) twice per year for the first year in two different quarters with 1 month between attempts, then annually thereafter, when used to manage behavior, stabilize mood, or treat psych disorder. This resident has been taking Hydroxizine 50 mg TID since 12/7/2024 without a GDR. Could we attempt a dose reduction at this time to perhaps 25 mg TID to verify this resident is on the lowest possible dose? If not, please indicate response below. This surveyor clarified with the DON that I needed to see the completed recommendations that had been addressed by the physician. They stated they would return with them. On 7/15/24 this surveyor reminded the DON that I was still waiting to see the pharmacy recommendations for May and June. They provided the June 26, 2024, recommendation signed by the physician and dated 7/9/24. Surveyor asked if they had it on 7/9/24 why did they not provide it on 7/11/24. They stated, I just got it. I sent it to him/her the end of June but I had to call this morning, and this is what I got. Several hours later, they were able to produce the May 27 recommendations after asking their Nurse Practitioner (NP) to review it, as the other provider still had not sent it back. It was dated 7/16/24. They stated they were routinely having trouble getting the recommendations back timely from the psych provider. This concern was reviewed with the Administrator, Regional Director of Operations, Regional Director of Clinical Services, Director of Nursing, Assistant Director of Nursing, MDS Coordinator and Regional [NAME] Specialist on 7/16/24 at 2:44 PM. No further information was provided to the survey team prior to the exit conference.

Based on staff interview, clinical record review and facility documentation review the facility staff failed to ensure 1 of 24 residents was free from unnecessary medications, Resident #110. The findings included: For Resident #110 the facility staff administered the medication metoprolol without checking the residents blood pressure or pulse per the physician's order. Resident #110's clinical record listed diagnoses which included but not limited chronic diastolic (congestive) heart failure, and essential hypertension. Resident #110's most recent minimum data set with an assessment reference date of 06/07/24 assigned the resident a brief interview for mental status score of 15 out of 15 in section C, cognitive patterns. This indicates that the resident is cognitively intact. Resident #110's comprehensive care plan was reviewed and contained care plans for . potential for altered cardiovascular status r/t (related to) hyperlipidemia, and CHF (congestive heart failure) with daily wts (weights) and . has potential fluid deficit/overload r/t (related to) diuretic use r/t CHF, HTN (hypertension). Interventions for these care plan included Monitor vital signs. Notify MD of significant abnormalities and administer medications as ordered. Resident #110's clinical record contained a physician's order summary which read in part, Metoprolol Tartrate Oral Tablet 25 mg. Give 0.5 tablet by mouth two times a day for HTN. Hold if systolic BP (blood pressure) 100 and HR (heart rate) under 60. Resident #110's electronic medication administration record (eMAR) for the month of June 2024 was reviewed and contained and entry as above. From 06/17/24 through 06/28/24, there were no blood pressures or heart rates entered on the eMAR. Surveyor spoke with the director of nursing (DON) on 07/15/24 at 10:30 am regarding Resident #110's medications. DON stated that resident had daily vital signs taken, and if it wasn't recorded on the eMAR, it should be on the vital signs sheet. Surveyor reviewed Resident #110's daily vital signs and could not locate a blood pressure recorded for 06/21/24 and 06/27/24. Surveyor requested and was provided with a facility policy entitled Medication Administration which read in part, Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. 8. Obtain and record vital signs, whin applicable or per physician orders. When applicable, hold medication for those vital signs outside the physician's prescribed parameters. 17. Sign MAR after administered. For those medications requiring vital signs, record the vital signs onto the MAR . Medication requiring vital signs prior to administration: Anti-Hypertensives. The concern of not ensuring a resident was free from unnecessary medication was discussed with the administrator, DON, assistant director of nursing, regional director of operations, and regional director of clinical services on 07/16/24 at 2:45 pm. No further information was provided prior to exit.

Based on staff interview and clinical record review, the facility staff failed to provide laboratory services to meet the needs of the resident for 1 of 4 sampled residents (Resident #122). The findings included: For Resident #122, the facility staff failed to obtain a urinalysis as ordered by the medical provider. The urinalysis was ordered to be obtained between 11/11/22 and 11/12/22; however, it was not obtained until 11/14/22. This was a closed record review. Resident #122's diagnosis list indicated diagnoses, which included, but not limited to Acute and Chronic Respiratory Failure, Obstructive and Reflux Uropathy, Acute Congestive Heart Failure, Dementia, and Chronic Cystitis. The minimum data set (MDS) with an assessment reference date (ARD) of 2/03/23 assigned the resident a brief interview for mental status (BIMS) summary score of 3 out of 15 indicating the resident was severely cognitively impaired. A review of Resident #122's clinical record revealed a medical provider order dated 11/10/22 to obtain a urinalysis with culture and sensitivity (UA C&S) from 11/11/22 through 11/12/22. Surveyor was unable to locate the results of the ordered UA C&S in Resident #122's clinical record. Surveyor spoke with the Administrator, Director of Nursing (DON), Assistant DON, and Regional Director of Clinical Services (RDCS) on 7/11/24 at 4:27 PM and requested the results of the UA C&S. On 7/15/24, the DON provided the lab results for a UA C&S collected on 11/14/22 at 5:00 AM. The UA results were positive for 2+ nitrites, 4+ protein, 1+ urobilinogen, 11-26 red blood cells, 51-100 white blood cells, 5-16 squamous epithelial cells, amorphous crystals, mucus, and triple phosphate crystals. The final culture report revealed greater than 100,000 mixed flora with no predominant microorganisms present. On 7/15/24 at approximately 1:25 PM, surveyor spoke with the DON and inquired why the UA C&S ordered for 11/11/22-11/12/22 was not obtained until 11/14/22. The DON stated they were not sure as the timing did not make sense. Surveyor requested to speak with the medical provider who gave the UA C&S order and the nurse who entered the order on 11/10/22, however, neither were still employed by the facility. The facility was unable to provide the facility lab policy effective in November 2022. On 7/16/24 at 2:45 PM, the survey team met with the facility management team including the Administrator and DON and discussed the concern of the delay in obtaining the UA C&S for Resident #122. No further information regarding this concern was presented to the survey team prior to the exit conference on 7/16/24.

Based on staff interview, clinical record review, and facility document review, the facility staff failed to ensure that their quality program implemented a corrective action plan following an initial medication error which resulted in a resident (Resident #9) requiring transfer and treatment at an acute care hospital. After the failure of the facility's quality program to adequately address the initial medication error, Resident #9 was subsequently provided the same incorrect medication which resulted in the resident again requiring transfer and treatment at an acute care hospital. The findings include: For Resident #9, the facility staff applied Biofreeze gel (which contained aloe) instead of the ordered Voltaren ointment on two separate occasions, once in December 2023 and again in February 2024. Aloe was listed as one of Resident #9's allergies in the clinical record upon admission. Resident #9 required transfer to an acute care hospital for treatment of an anaphylactic reaction resulting in intubation with ventilator support after both medication errors. During an interview with the regional director of clinical services (RDCS - regional nurse) on 03/29/24, the nurse was unable to provide written evidence of the facility's plan of correction implemented in response to the first medication error in December 2023. The RDCS said that although the current administrative team had searched everywhere throughout this survey, documents which included evidence of implementing and/or completing their QAPI (quality assurance performance improvement) plan had not been found. The regional nurse acknowledged facility staff administered the same medication (Biofreeze) to Resident #9 in February 2024 which again resulted in an acute hospital admission for treatment of anaphylactic shock. The facility's 4-point plan of correction for the February 2024 medication error with supporting documentation was provided and reviewed. On 02/20/24, upon Resident #9 returning to the facility following the second medication error and subsequent hospital stay, the assistant director of nursing (ADON) added Biofreeze to Resident #9's allergy list. On 03/22/24, the current nurse practitioner (NP) wrote an order for Biofreeze External Gel 4% (topical analgesic), apply to affected leg area topically three times a day for leg pain. The order was discontinued on 03/23/24. A licensed practical nurse (LPN #11) documented on the MAR (medication administration record) that Biofreeze was administered on 03/22/24 at 9:00 p.m. Resident #9 was interviewed on 03/27/24 at approximately 11:30 a.m. The resident stated she had not received Biofreeze since February, If I had, I wouldn't be here. I've told everybody Biofreeze has aloe in it and I'm allergic. LPN #11 was interviewed via phone on 03/28/24 at 10:00 a.m. and reported knowing Resident #9 was allergic to Biofreeze and had anaphylactic reactions to it twice, therefore he knew not to administer it. After her first and second instances, she talks about her allergies. The nurse stated clicking on Biofreeze in the computer to indicate it was applied, was a mistake. The quality program failed to effectively implement a corrective action plan after the initial medication error. Subsequently, the facility staff repeated the same medication error. In addition, a recent provider order for that medication which Resident #9 had a documented allergy to, was shared with the regional director of operations, regional director of clinical services, director of nursing, and administrator during an end of day meeting on 03/28/24 at 3:22 p.m. No further information was provided prior to the exit conference. The identified deficient practice is detailed under the appropriate citation in this report.

Based on resident interview, staff interviews, clinical record review, and facility document review the facility staff failed to ensure 1 resident (Resident #9) was free of significant medication errors. For Resident #9, the significant medication error resulted in a transfer to a higher level of care for an anaphylactic reaction on two separate occasions, two months apart. The findings were: 1. For Resident #9, the facility staff applied Biofreeze gel (which contained aloe) instead of the ordered Voltaren ointment on two separate occasions, the first time in December 2023 and again in February 2024. Aloe was listed as one of Resident #9's allergies in the clinical record upon admission. Resident #9 required transfer to an acute care hospital for treatment of an anaphylactic reaction resulting in intubation with ventilator support after both medication errors. Resident #9's clinical record listed diagnoses to include, but not limited to, chronic obstructive pulmonary disease, fibromyalgia, chronic pain syndrome, COVID positive, Left Kidney Neprectomy (kidney removal) , anxiety disorder, asthma, recurrent major depressive disorder, and cognitive communication deficit. According to Resident #9's Clinical Profile document, the initial admitted was 12/6/23. The minimum data set assessment with an assessment reference date of 01/29/24, coded the resident's brief interview for mental status as 15 out of 15, indicating intact cognition. During an interview with Resident #9 on 03/25/24, the resident reported having an allergy to aloe and facility staff had applied Biofreeze (contains aloe) to the resident on two separate occasions. Resident #9 was aware Biofreeze would cause a severe allergic reaction and insisted on treatment and a shower. The resident was admitted to a hospital for treatment which included ventilator support for multiple days after both medication errors. Resident #9's clinical record contained a list of the resident's allergies which included aloe. The aloe allergy was dated the same day as the resident's admission to the facility. The admission order was for Voltaren External Gel 1%, apply to affected joints topically four times a day for pain with a discontinue date of 12/11/23. There was no admission order for Biofreeze. On 03/28/24, the surveyor observed the generic Biofreeze ointment tube located in the facility's medication room (a white bottle with green writing). Aloe was listed as an inactive ingredient. The regional director of clinical services (RDCS) recalled the December 2023 medication error and provided an email she sent two facility administrative employees, dated 12/11/23, which described how to develop and implement a plan of correction (POC). The RDCS acknowledged not having evidence that POC was completed. Neither of the two facility administrative employees currently worked at the facility and was not interviewed. Resident #9's clinical record was reviewed. The Respiratory Therapist's note was dated 12/9/23 at 5:41 A.M. It referred to an incident regarding Resident #9 earlier that shift at 8:35 P.M. It read, Approached by nurse for a nebulizer machine for resident post suspected allergic reaction. Delivered equipment to room and assessed her. Pt SpO2 99% on 6 L nasal cannula, RR 22, lungs clear, a small to moderate amount of upper airway wheezing/stridor. Resident stated she could feel blisters forming in her mouth and her throat was feeling a little tight, but at that time she could still swallow and breath ok. I looked in her mouth and saw some edema and redness in the back of the throat with some slight tongue swelling. I suggested racemic epi nebulized if we had any on hand at this facility. We did not have this medication. Nurse and I spoke to DON and AON about the situation and possibility of sending resident out to the hospital for assessment and steroids, especially in the setting of potential airway compromise. They agreed. While waiting for EMS to arrive, I was alerted by nurse that resident was having SOB and trouble swallowing. I gave resident a duo-neb to try to get her to take deep breaths and slow her breathing down. At that time vitals were still stable although she was slightly tachycardic and tachypneic with a HR of about 118 and RR of about 28. When EMS arrived, her breathing was more labored, she was SOB when trying to talk, her upper airway wheezing/stridor had increased, and she had some tongue swelling. I told them what I had observed and what I had done. I was present in the room until EMS took the resident to the hospital. The clinical record contained an SBAR (Change of Condition form). It read. Pt. (Resident #9) having an allergic reaction to aloe, epinephrine, benadryl not effective completely. Pt. received pain ointment on shoulders, knees and neck that contained aloe. Pt c/o [complains of burning where ointment was applied. Pt received shower, epinephrine and benadryl for difficulty breathing, blisters in mouth and wheezing. Pt still feeling sx.(signs/symptoms). MD notified, order to send to ER {emergency room } for further tx. Resident #9's clinical record contained an LPN (licensed practical nurse - LPN #12) progress note for 02/09/24 at 1:45 p.m. which read that the resident complained of pain in back and both legs. While the nurse applied bio freeze the resident started yelling, I cant [sic] have that The nurse checked the chart and did not see that the resident could not have Biofreeze but later noticed the resident was allergic to one ingredient (aloe) this is [sic] bio freeze. The resident was taken to shower to wash off the gel and received epinephrine for anaphylaxis. The resident was sent to the emergency room for observation. LPN #12 was interviewed via phone on 03/27/24 at 10:50 a.m. in the director of nursing's (DON) office. The nurse reported Resident #9 was complaining of muscle pain and the nurse could not find any Voltaren after checking the medication cart, the supply closet, and the medication room. When asked why she applied Biofreeze when Biofreeze was not ordered, LPN #12 stated, I didn't know . I thought they were same thing or next best thing since couldn't find Voltaren. LPN #12 was aware of allergies listed in red in the MAR (medication administration record) but said it did not list Biofreeze and the nurse was not aware aloe was an ingredient in Biofreeze. LPN #12 stated I'm aware now that Biofreeze and Voltaren are not the same. The nurse stated the facility had provided education in the form of inservices on medication administration, specifically Biofreeze vs Voltaren, and to administer medications per provider order. Resident #9's clinical record included a Voltaren External Gel 1% order to apply to affected joints topically four times a day for pain to start on 01/25/24 and was discontinued 02/20/24. The hospital discharge summary for the discharge date of [DATE] listed the discharge diagnoses to include but were not limited to, anaphylactic reactions s/p [status post] mechanical ventilation. On 02/20/24, upon Resident #9 returning to the facility following the second medication error and subsequent hospital stay, the assistant director of nursing (ADON) added Biofreeze to Resident #9's allergy list. The facility's nurse practitioner at the time wrote on 02/21/24, History of Present Illness: Resident recently readmitted after hospitalization for allergic anaphylaxis reaction to Biofreeze (again) and seen today for evaluation of medications, and treatments for accuracy and plan of care. Resident evaluated and assessed for any problems, concerns or needs. Resident denies pain or discomfort at this time and verbalizeds [sic]understanding of diagnosis and treatment plan. The RDCS acknowledged that the facility staff administered the same medication (Biofreeze) to Resident #9 in February 2024 as had been applied to Resident #9 in December 2023. This second medication error had again resulted in an acute hospital admission for treatment of anaphylactic shock. The RDCS provided evidence of the facility's completed plan of correction for the February 2024 medication error. On 03/27/24 at 4:30 p.m., an end of day meeting was conducted with the regional director of operations, regional director of clinical services, and the director of nursing. We discussed the medication errors that resulted in harm to Resident #9.

Based on staff interview, resident interview, and clinical record review, the facility staff failed to provide supervision to ensure resident safety for 1 of 6 residents, Resident #1. The findings included: For Resident #1 the facility staff failed to provide supervision which resulted in the resident being admitted to the hospital for treatment of heat stroke. On the date of this incident ([DATE]), the National Weather Service for the area reported a high temperature of 97 degrees, with a heat advisory in effect. Resident #1's face sheet listed diagnoses which included but not limited to hemiplegia, chronic obstructive pulmonary disease, hypertension, and cognitive communication deficit. Resident #1's most recent minimum data set with an assessment reference date of [DATE] assigned the resident a brief interview for mental status score of 15 out of 15 in section C, cognitive patterns. This indicates that the resident is cognitively intact. Section G, functional status, coded the resident as independent in locomotion on and off the unit. Resident #1's comprehensive care plan was reviewed and contained care plans for .enjoys and prefers independent leisure in room such as computer, phone, and TV. they wheels around hallways and talks to staff. They enjoy going outside to garden, .has potential to be physically/verbally aggressive r/t (related to) institutional incarceration. They were observed cutting prior roommates radio cord and is very argumentative with staff, and .is extremely resistant to any and all medical and clinical recommendations . Resident #1's clinical record was reviewed and contained a nurse's progress note dated [DATE], which read in part [DATE] 17:44:00 spoke with . (name omitted) at . (name omitted), they stated the the resident had heat stroke and would be admitted to hospital. Resident #1's clinical record contained an SBAR Communication Form dated [DATE] which read in part Situation: unresponsiveness. Background: Vital signs: BP: 95/55 Temp: 109. Appearance: resident was observed unresponsive sitting outside in the sun in courtyard upright in his/her wheelchair with head laid back, eyes fixed, rattle noted to breath sounds, shortness of breath/labored breathing noted, no sweating noted, multiple nurses assisted resident inside the building to an empty cool room and applied cool washcloth to forehead, 911 notified, resident left facility via ambulance staff x 5 at 1525. NP (nurse practitioner) . (name omitted) notified. Resident #1's clinical record contained a hospital ED (emergency department) provider note which read in part, Date of Service: [DATE] 3:59 PM Profound hyperthermia with 3+ hours of sun exposure in WC (wheelchair) and had previously just eaten lunch and at baseline with Left CVA (cerebrovascular accident) driving the SNF (skilled nursing facility) living. EMS (emergency medical services) enroute noticed a pretty abrupt change and suspect they had seized/aspirated. On arrival had a good respiratory drive and would moan, so elected to cool and bipap. Once down to 104, patient was more purposeful so attempted to engage him/her and they suddenly postured and went rigid with arm swinging and rigidity and appeared to have seized again, then had small amount of vomit that was cleared with suction. Elected to intubate. Previous stroke could make him/her high risk for PSE (portosystemic encephalopathy) though think exposure was cause given his/her +107 temp. There are no other decision makers. Prognosis is grim. This surveyor spoke with certified nurse's aide (CNA) #1 on [DATE] at 1:40 pm. Surveyor asked CNA #1 if they recalled Resident #1, and CNA stated they did. Surveyor asked CNA #1 if they recalled the incident with Resident #1, and CNA #1 stated they did, and that it happened after lunch. CNA #1 stated resident enjoyed being outside and came in and out on their own. CNA stated that Resident #1 is gonna do what they want to do, and they would tell you that. This surveyor spoke with CNA #2 on [DATE] at 3:10 pm. CNA #2 stated that resident loved to go outside to feed the squirrels. Surveyor asked CNA #2 if they recalled the incident with Resident #1 and CNA #2 stated they did, and that it happened prior to the start of their shift. This surveyor spoke with Resident #1 via telephone on [DATE] at 1:50 pm. Surveyor asked Resident #1 what they recalled about the incident, and Resident #1 stated that they usually go outside early to feed the birds and squirrels, but do not specifically remember anything about the day of the incident. This surveyor spoke with Resident #7 on [DATE] at 2:00 pm. Surveyor asked Resident #7 if they recalled the incident with Resident #1, and Resident #7 stated that they did. Resident #7 stated that Resident #1 was outside, washing the sidewalk with water hose, and that Resident #1 was already outside when they went out. Surveyor asked Resident #7 how long they were outside, and Resident #7 stated, around 45 min or an hour. Surveyor asked Resident #7 if any staff came out to check on them or offer fluids while they were outside, and Resident #7 stated no. The Director of Nursing (DON) provided this surveyor with a signed statement from LPN #1. An excerpt read: [DATE] Rsd (resident) came to nurses station Saturday morning to say hello and then did a morning exercise where they would hold on to the bar and stand up then sit back own several times. Rsd then said that they were going outside, and I told (Resident 1) it was already hot outside, and they don't need to be out there. Rsd looked at this nurse and told me 'ma'am you ever been in prison before, I said nope, you know better that that. (Resident #1) said 'ma'am, I'd rather be dead than not be able to go outside every day.' I said don't stay out there long ., it's hot. The next time I saw (Resident #1), it was exactly 11:10 am, and I was checking rsd blood sugar and I told . (names omitted) to come inside. (name omitted) came in with me, . (Resident #1) said they were going to come inside and eat lunch. Several other rsds came in the building when we did, but . (Resident #1) did not. When lunch trays were passed, . (Resident #1) came in the building at around 1:15 pm. they ate lunch and sat his/her tray on his/her lap and brought the tray to the tray cart to be put on the cart. Later after second shift arrived, I was getting ready to start my 3:30 pm med pass and . (Resident #7) rolled into the hallway from outside and said hey help . (Resident #1) is unresponsive. This nurse ran outside, I instructed the resident to go the other nurses station and get that nurse and tell them that I needed help. I ran to rsds calling their name, the were sitting in wheel chair with head back, both arms laid to side and one foot on the pedal, the other on the ground kinda beside the wheel. I attempted to get rsd out of sun. This nurse ran to nurse station 4 the get the two nurses to come assist me with getting rsd in the building. Myself, Nurse 3 and Nurse 4 picked rsd up and carried them out of the sun. Rsd was hot to the touch, they were sweating, their face was slightly swollen by the cheeks, wrist and arm. I instructed nurse 3 to go call 911. Nurse 4 went with nurse 3. I called for CNA 1 to go get me some cold wash clothes and towel, and I placed those on his/her head, waiting for the other nurses to come back. Nurse 3 and Nurse 4 came back and stated rsd was a full code, which CPR was NOT an option because rsd was breathing independently respirations were 24 per min. (Resident #1's) blood pressure was 95/55 and their eyes were fixed with pupils dilated. Ambulance crew came and said it looks like rsd had had heat stroke and began to work on rsd give EKG (electrocardiogram), IV (intravenous) fluids, etc and took rsd. Nurse 3 and Nurse 4 contacted MD. This nurse notified DON . The DON provided this surveyor with a typed interview from Resident #7, which read in part Interview with . (Resident #7) [DATE] . who is a resident of our facility . has a BIMS (brief interview for mental status) of 14. Inquired as to what happed on [DATE] with resident . (Resident #1). (Resident #7) stated that they were in the courtyard. (Resident #7 and Resident #1) had come back from eating lunch and returned to the courtyard. (Resident #7) stated they encouraged . (Resident #1) to come out of the sun. (Resident #1) stated they would in a bit. (Resident #7) stated they think they were probably in the courtyard for maybe an hour or so. (Resident #7) stated they saw . (Resident #1) put their head down and thought they had gone to sleep. A few minutes later they saw (Resident #1) lean their head back. At that point, . (Resident #7) went over to (Resident #1) and touched them, and called his/her name and when (Resident #1) did not respond, (Resident #7) came inside and went to the nurse and told them that . (Resident #1) was unresponsive. They stated the nurse went immediately out to check on . (Resident #1). They stated the nurses then took . (Resident #1) inside to his/her room. The concern of not providing supervision or extra fluids during an official Heat Advisory from the National Weather Service, resulting in Resident #1 having a heat stroke, was discussed with the Administrator, DON, and Regional Director of Clinical Services on [DATE] at 3:00 pm. No further information was provided prior to exit.

Based on staff interview, resident interview, clinical record review, facility document review, and during a medication pass and pour observation, the facility staff failed to provide adequate pain management for 1 of 16 residents, Resident #12, resulting in harm. Resident #12's pain medications [MEDICATION(S)] 10 mg and [MEDICATION(S)] 300 mg were not available for administration. The findings included: Resident #12's face sheet listed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #12's most recent quarterly MDS (minimum data set) with an ARD (assessment reference date) of 12/31/21 assigned the resident a BIMS (brief interview for mental status) score of 15 out of 15 in section C, cognitive patterns, indicating the resident was cognitively intact. LPN (licensed practical nurse) #1 was observed during a medication pass and pour on 02/09/22 at 7:50 am. LPN #1 was preparing Resident #12's medications. While preparing the resident's medications, LPN #1 stated that they did not have the resident's [MEDICATION(S)] or [MEDICATION(S)] available to administer due to the resident having been in the hospital, and had only returned early this morning. LPN #1 stated they could not pull Resident #12's pain medications from the stat supply due to the pharmacy needing a new hard script prior to giving an authorization code to pull medications. Upon exiting Resident #12's room, LPN #1 asked another staff member when the resident had returned from the hospital, and this staff person stated . came back early Monday morning (02/07/22). Resident #12's medications were reconciled on 02/09/21. Resident #12's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Give 2 capsule by mouth three times a day for restless leg and [MEDICATION(S)] HCl Tablet 10 mg. Give 1 tablet by mouth two times a day for r/t (related to) pain. Resident #12's eMAR (electronic medication administration record) for the month of February was reviewed and documented, [MEDICATION(S)] Capsule 300 mg. Give 2 capsule by mouth three times a day for restless leg and [MEDICATION(S)] HCl Tablet 10 mg. Give 1 tablet by mouth two times a day for r/t (related to) pain. The start date for these medications was listed as 02/07/22. The entry for [MEDICATION(S)] was initialed as administered on 02/07/22 and 02/08/22 at 9:00 pm. On 02/08/22 at 9:00 am, the entry was coded 9. The entry for [MEDICATION(S)] was initialed as administered on 02/07/22 and 02/08/22 at 9:00 pm. On 02/08/22 at 9:00 am, the entry was coded 9. The chart code 9 was defined as, Other/See Nurse Notes. Resident #12's nurse's notes were reviewed and no documentation was located regarding Resident #12's medications. Resident #12's comprehensive care plan was reviewed and contained care plans for Alteration in comfort related to pain . has an alteration in musculoskeletal r/t (related to) severe scoliosis, MD ([CONDITION(S)]) with bilateral upper and lower contractures . is at risk for alteration in comfort r/t self care deficit [NAME] (sic) bedfast, contractures, Dx (diagnosis): of [CONDITION(S)], Chronic resp. failure with vent dependency . has intermittent pain due to MD with noted deformities to joints, especially back. Interventions for these care plans included medications per MD (medical doctor) orders, give analgesics as ordered by the physician, notify the physician if pain control is ineffective, and observe for nonverbal indications of pain. The DON (director of nursing) was interviewed on 02/09/22 at 10:55 am regarding Resident #12's medications. The DON stated they had faxed the hard script to the pharmacy and confirmed that they were received. The DON stated they had obtained an authorization code to pull the medications from the stat supply this morning. The DON was asked about the medications that were signed as administered on 02/07 and 02/08, and the DON stated, I believe it was a falsification of a record. I do not believe (Resident #12) received them at all. I destroyed the previous meds when (Resident #12) went in the hospital so there were none here to administer. The DON provided a copy of the hard scripts for the medications, dated 01/19/22. The DON also provided a copy of the resident's narcotics control record for each medication indicating that the medications had been destroyed on 02/07/22 by the DON and ADON (assistant director of nursing). Resident #12 was interviewed on 02/09/22 at 1:15 pm. Resident #12 was asked about their pain medications and Resident #12 stated, I just got back from the hospital and they had to get my pain meds straightened out. Resident #12 was asked if they were in pain without receiving their medications. Resident #12 stated, My legs and back hurt. The first night was bad in my legs and feet. Resident #12 was asked to rate their pain on a scale of 1-10 and the resident stated, I have nerve pain in my legs and feet and it was over a 10, probably 5-6 in my back, it comes and goes. I have scoliosis in my back. Resident #12 was asked if they had received anything else for pain and the resident stated, Only Tylenol, but it doesn't help much. Resident #12's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #12's eMAR included an entry for Tylenol 325 mg tablet, give 650 mg by mouth every 8 hours as needed for pain or fever. This entry listed a pain level of 7 on 02/08/22 at 8:20 am. This administration was documented as ineffective. The facility document Pain Assessment and Management included, Implementing Pain Management Strategies: 6. Implement the medication regimen as ordered, carefully documenting the results of the interventions. The concern of not providing adequate pain control for Resident #12 was discussed with the administrative team (administrator, DON, ADON, regional nurse consultant) on 02/11/22 at 11:55 am. No further information was provided prior to exit.

Based on staff interview, clinical record review, and during the course of a complaint investigation, the facility staff failed to ensure residents with pressure ulcers receive necessary treatment and services to promote healing and prevent infection for 1 of 30 residents in the survey sample, Resident #108. The findings included: For Resident #108, the facility staff failed to treat an unstageable pressure area to the sacrum and deep tissue injuries to the right malleolus, right heel, and left heel: 1) Greers [NAME] ordered but records do not consistently demonstrate that it was applied. 2) Treatment administration record records did not consistently demonstrate completed treatment 3) Although the physician stated resident was receiving treatment, receipt of treatment to the sacral pressure wound from discovery on readmission on 3/16/21 until 3/22/21 could not be demonstrated. This is harm. Resident #108's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The most recent significant change MDS (minimum data set) with an ARD (assessment reference date) of 4/06/21 assigned the resident a BIMS (brief interview for mental status) score of 9 out of 15 in section C, Cognitive Patterns. Resident #108 was coded as requiring extensive assistance with bed mobility, dressing, toilet use, personal hygiene, and being totally dependent on staff for bathing. In section M, Skin Conditions, the resident was coded for the presence of one unstageable pressure ulcer with slough and/or eschar present on admission or reentry and three unstageable pressure ulcers with deep tissue injury present on admission or reentry. A review of Resident #108's closed clinical record revealed the following documentation: Resident #108 was readmitted from (hospital name omitted) on 3/15/21. A nursing progress note dated 3/16/21 8:36 am states in part, Admit skin assessment complete: Stage 2 and MASD (moisture-associated skin damage) to sacrum: 11x5x0.1 .Treatments applied. Surveyor was unable to locate a treatment order for the Stage II pressure area. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the resident's March 2021 MAR (medication administration record) and March 2021 TAR (treatment administration record), Greers [NAME] was never initialed by a nurse as being applied. Resident #108 was assessed by the wound physician on 3/18/21 and the sacral wound had progressed from a Stage II to an unstageable area. The progress note states in part unstageable sacral pressure ulcer measuring 6 cm x 5.8 cm x 0.8 cm with small serosanguineous exudate, 60% slough, and 40% dermis. Treatment recommendations to the sacral pressure ulcer stated clean wound with wound cleaning spray daily and apply santyl to deeper slough area with foam cover every day and [MEDICATION(S)] to macerated periwound. A Weekly Pressure Wound Observation Tool dated 3/19/21 described the sacral would as a stage X with slough tissue present and moist with scant amount of serosanguineous drainage. Wound measurement documented as 6 mm x 58 mm x 08 mm with periwound tissue described as macerated/denuded. The current treatment plan stated clean with wound cleaner, apply santyl to wound bed, cover with foam. [MEDICATION(S)] to macerated/denuded areas. The first order for treatment to the sacral pressure ulcer was not until 3/19/21 with treatment to begin on 3/22/21. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #108's March 2021 TAR (treatment administration record) revealed the first documented treatment to the unstageable area to the sacrum was recorded on 3/22/21. The treatment due to be completed on 3/23/21 was not initialed by the nurse as being completed. The treatment was initialed as being completed on 3/24/21. On 8/04/21 at 1:45 pm, surveyor spoke with the wound nurse who stated Resident #108 was readmitted on [DATE] or 3/16/21 and the sacrum and buttocks were red to deep purple with a shallow open area, the treatment was [MEDICATION(S)] to the open area and Greer's [NAME] to the red area. The treatment nurse stated they wrote the treatment order down but failed to enter the order. The wound nurse further stated it was a disconnect on my part and they had just stepped into the position of wound nurse. The wound nurse stated they were the one addressing the sacral area and the treatment was done on 3/18/21 and 3/19/21 but did not do the treatment on 3/20/21 or 3/21/21. Resident #108 was again seen by the wound physician on 3/25/21, the progress note describes the sacral pressure ulcer as unstageable, measuring 6.5 cm x 8 cm x 0.8 cm with small serosanguineous exudate, 20% slough and 80% necrotic. The wound progress was documented as deteriorating. The treatment recommendation stated in part needs ER evaluation for sacral wound infection for IV antibiotics cover loosely with DSD. Will follow up with additional wound care after patient returns from the hospital. A skin/wound progress note by the wound nurse dated 3/25/21 12:15 pm states in part Wounds assessed and measured by (wound physician). Unstageable pressure ulcer to sacrum: 6.5x8x0.8 - Upon entering room odor noted coming from wound. (Wound physician) cleaned wound with wound cleaner and Dakin's to assess for need of debridement, when doctor wiping cleaning solution from wound black colored drainage noted. 80% necrotic, 20% slough, redness and [CONDITION(S)] note around wound. Infection suspected. (Wound physician) suggested for resident to be sent to ED for further evaluation and IV ABX (antibiotics). Resident #108 was also seen by the facility physician on 3/25/21, progress notes states in part, This (gentleman/lady) has sacral decubitus. Being followed by wound care nurse and wound care consultant, (name omitted). Wound care nurse asked me to evaluate the wound today. It has developed malodorous character. Also there has been rapid evolution of an eschar with some [CONDITION(S)] and induration. (He/she) has been afebrile. (He/she) has been having pain. Sacral decubitus ulcer rapidly worsening. Necrotic tissue. Eschar. Likely infected. The rapid evolution raises concerns about possible [CONDITION(S)]. [CONDITION(S)] involving tissues about the sacral decubitus. Rapidly evolving. Concern regarding possible [CONDITION(S)]. Plan: Emergency transport to the emergency room . (He/she) is going to need stat labs. Likely needs IV antibiotics. Discussed the situation with director of nursing. EMS contacted. A subsequent nursing progress noted dated 3/25/21 12:22 pm states in part, Resident is being sent out due to significant change in wound on sacrum. 911 was called. On 8/04/21 at 1:45 pm, the surveyor spoke with the Wound Nurse who stated they contacted the wound physician the day prior to their onsite visit concerning and wound appearance and the wound physician wanted to visualize the wound themselves. The Wound Nurse stated after assessing the sacral area on 3/25/21, the wound physician was concerned that the area was a Kennedy Ulcer or [CONDITION(S)]. On 8/05/21 at 11:53 am, surveyor met with the Resident #108's primary care physician while a resident at the facility and the wound physician concerning the resident's care. The wound physician stated the first time they saw Resident #108 the sacral wound had a little slough and when they saw the resident a week later the sacral wound was a little bigger with redness around the area and it looked like IV antibiotics were needed. Surveyor informed the physicians of Resident #108 not receiving treatment to the sacral pressure wound from discovery on readmission on 3/16/21 until 3/22/21. The primary care physician stated the care was being provided, this was a process issue as they enter their own orders but the wound physician does not. The wound physician stated that the missing treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . On 8/02/21, Surveyor requested hospital records from (hospital name omitted) for the dates of 3/25/21 through 3/30/21 for Resident #108, the complete requested records were received on 8/30/21. The Hospitalist History and Physical dated 3/25/21 states in part Upon presentation, found to be febrile with leukocytosis and suspected source of infection being sacral ulcer along with possibility of pneumonia based on CXR (chest x-ray). The Discharge Summary from (hospital name omitted) dated 3/30/21 10:57 am documents in part, Resident #108 was admitted on [DATE] and discharged on [DATE] with discharge diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Presented with fever, leukocytosis with [CONDITION(S)] predominance, very elevated CRP/ESR with suspected sources including sacral ulcer (pictures in media section), as well as recurrent pneumonia. A CT of the abdomen and pelvis showed bilateral peripheral infiltrates in the lower lungs and posterior sacral ulcer and subcutaneous [CONDITION(S)] without subcutaneous air. No bony erosion or [CONDITION(S)]. Surgery consulted for sacral ulcer; underwent debridement 3/26 surgical path and culture sent; no growth from culture; surgical path still pending with blood cultures x 2 NGTD (no growth to date). Discharge wound care included sacral wound: cleanse with saline moist saline gauze on top and a dry cover dressing. Resident #108 was readmitted to the facility from the hospital on 3/30/21. A skin/wound progress note dated 3/31/21 8:34 am by the Wound Nurse states in part Admission skin assessment complete: Unstageable to coccyx: 10x7x1.5, Right heel blister: 4x2x0, left heel stage I pressure: 4.2x2.8x0 . Right lateral leg pressure: 10x1.5x0 .Unstageable: Santyl, cover with bordered gauze, abrasions and stage 1 pressure, blisters: skin prep, cover with [MEDICATION(S)] for protection. The previous physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . This treatment order remained in effect until it was discontinued on 4/07/21. The treatment was not initialed by the nurse as being completed on 4/01/21. On 8/04/21 at 1:45 pm, surveyor met with the wound nurse who stated on 3/31/21 following Resident #108's readmission from the hospital the sacral pressure had been debrided and the treatment was kept as Dakin's wet to dry. Surveyor asked the wound nurse if they could locate that treatment on the March 2021 or April 2021 TAR and they stated I could not. Surveyor reviewed Resident #108's clinical record and was unable to locate treatment orders for the following areas noted on 3/31/21: right heel blister, left heel stage I, and right lateral leg pressure area. When speaking with the wound nurse on 8/04/21 at 1:45 pm, the wound nurse stated they skin prepped the areas to the left heel, right heel, and right malleolus because they were not open. The wound nurse stated they would check on the orders for these areas. The wound nurse returned to the surveyor at 2:25 pm and stated I didn't put orders in for the other areas. Resident #108 was seen by the NP (nurse practitioner) on 3/31/21, progress note states in part seen toady following readmission to facility due to [CONDITION(S)] secondary to sacral wound with weakness During hospital stay, pts (patient's) sacral wound was debrided and (he/she) was on IV abx (antibiotic) therapy, converted to antibiotic via peg until 4/04 for 10 day course/also tx (treated) for aspiration PNA (pneumonia). Resident #108 was assessed by the wound physician on 4/01/21. The sacral pressure ulcer was described as unstageable measuring 7.5 cm x 8.5 cm x 2.5 cm with undermining at 9-12 o'c: 1.5 cm. The wound bed was described as 60% granulation, 30% bone, and 10% subcutaneous with progress noted as improving. The right lateral malleolus DTI was documented as 2.3 cm x 1 cm x 0 cm, closed with ecchymosis and [CONDITION(S)] of the periwound. The right lateral heel DTI was documented as 0.9 cm x 0.9 cm x 0 cm, closed with ecchymosis and [CONDITION(S)] of the periwound. The left medial heel DTI was documented as 3.5 cm x 1.6 cm x 0, closed with ecchymosis and [CONDITION(S)] of the periwound. Treatment recommendations included: Sacral pressure ulcer - clean with wound cleaning spray, recommend NWPT (negative pressure wound therapy) 150mmHg, white foam on bone and undermined areas, black foam on rest, change Monday, Wednesday, and Friday; right lateral malleolus, right lateral heel, and left medial heel - cleanse, apply skin prep, honey hydrogel or [MEDICATION(S)] and heel boots daily. Surveyor reviewed Resident #108's clinical record and was unable to locate physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The treatment to the sacrum continued as previously ordered on 3/19/21 that stated unstageable to sacrum: clean with wound cleaner, apply santyl, cover with foam/[MEDICATION(S)] to macerated area on buttocks every day shift. This treatment order remained in effect until it was discontinued on 4/07/21. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Change M/W/F every day shift every Mon, Wed, Fri for wound care. According to the April 2021 TAR, this order was only initialed as being performed on 4/09/21. Surveyor was unable to locate treatment orders per the wound physician's recommendations for the areas to the right lateral malleolus, right lateral heel, or the left medial heel. While speaking with the wound nurse on 8/04/21 at 1:45 pm, they stated the wound vac was implemented on 4/01/21 and they changed the wound vac every Monday, Wednesday, and Friday. The wound nurse also stated honey hydrogel was being used on the right lateral malleolus, right lateral heel, and the left medial heel. Resident #108 was reassessed by the wound physician on 4/08/21. The progress note states in part, stage 4 sacral pressure ulcer 7.5 cm x 8.5 cm x 3 cm with undermining 12-11 o'c 3 cm, with light serosanguineous exudate, 60 % granulation and 40% soft tissue, moderate odor and [CONDITION(S)] of the periwound. Progress noted as no change. DTIs to the right lateral heel and right lateral malleolus were noted as improving. DTI to the left medial heel progress noted as no change. During the visit, negative pressure [NAME]-extrlCARE 3600 was applied to the sacral pressure ulcer. Treatment recommendations included: DTIs: cleanse, apply skin prep, [MEDICATION(S)] and heel boots daily; sacral pressure ulcer: cleanse with Dakin Solution 0.25% mmHg 150, black foam, white foam to undermined areas three times weekly Monday/Wednesday/Friday. A Weekly Wound Pressure Wound Observation dated 4/08/21 documents the current treatment plan to the sacral area as NWPT 150mmhg. Change m/w/f - white foam covering bone and undermined areas, black foam on rest of wound. Again, the order for NWPT was not written until 4/07/21 with a start date of 4/09/21. A skin/wound progress note dated 4/09/21 10:46 am states in part Unstageable: NWPT, abrasions and DTI: skin prep, cover with honey hydrogel for protection. Surveyor was unable to locate any treatment orders for the DTIs as documented in the progress note until 4/10/21. Treatment orders for the DTIs to the right malleolus, right heel, and left heel were not ordered until 4/10/21. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . These treatments were scheduled to begin on 4/12/21 however, Resident #108 was sent out to theER on [DATE]. Therefore the TAR does not include documentation that treatments were ever administered to these areas since first noted on 3/31/21. A NP progress note dated 4/12/21 states in part upon exam however pt is noted to be lethargic, diaphoretic, tachypnea present with respirations at 34. Pt is to be sent to ED for possible [CONDITION(S)]. A nursing progress note dated 4/12/21 12:12 pm states in part Resident was observed by NP (name omitted). (He/she) suggested to send (him/her) out due to very lethargic, diaphoresis, and thought maybe septic. Nurse took vitals BP 187/120, HR 87, 02 (oxygen) 70-80s, Res (respirations) 22 temp 100.5. Resident #108 did not return to the facility. On 8/02/21, surveyor requested the resident's clinical records from (hospital name omitted), the complete requested records were received on 8/30/21. The Emergency Department Note dated 4/12/21 states in part .numerous wounds found on skin check after initial assessment that all seem related to pressure wounds as they are located on the heels, elbows, cheek (noticeable indent with wound under nasal cannula), sacral. Patient also has had numerous bandages with underlying skin changes suggesting that they have been there for several days .Social work consulted for referral to APS (adult protective services) due to both provider and nursing concern that patient was not having adequate care (especially with inadequate turning to prevent pressure ulcers), social work reports that (adult child) is also concerned. Resident #108 ' s discharge diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Also included in the Discharge Summary was a clinical consult note dated 4/12/21 2140 (9:40 pm) which states in part Sacral decubitus ulcer with pressure necrosis along the edges, fibrinous tissue in the base, no tracking, no evidence of necrotizing soft tissue infection, no purulent drainage. Wound vac removed to evaluate. There is some maceration of skin from vac and odor consistent with vac that has been in place over non-viable issue [sp] for 2-3 days. Would avoid vac when there is non-viable tissue present in the wound base. Sacral wound is not a source of [CONDITION(S)], but could stand some debridement to aid with wound care. On 8/05/21 at 11:53 am, while meeting with Resident #108's primary care physician at the facility and the wound physician, surveyor also informed the physicians of Resident #108's DTIs noted on 3/31/21 with treatment not being ordered until 4/10/21, the primary care physician again stated this is not a care issue, it is a process issue. Surveyor informed the physicians that the order for the wound vac was not dated until 4/07/21 and was only initialed as being changed one time on 4/09/21. The wound physician stated the wound nurse did a great job changing the wound vac. Resident #108's comprehensive person-centered care plan included a focus area created on 3/22/21 and revised on 4/09/21 stating The resident has pressure ulcer to sacrum and has the potential for further pressure ulcer development r/t poor mobility, incontinence with an intervention to administer treatments as ordered and monitor for effectiveness, and the intervention of wound vac to area per MD orders was dated 4/09/21. Surveyor was unable to locate documentation on the resident's care plan related to the DTIs to the resident's right malleolus, right heel, or the left heel. Surveyor requested and received the facility policy entitled, Wound Treatment Management which states in part: 1. Wound treatments will be provided in accordance with physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 2. In the absence of treatment orders, the licensed nurse will notify physician to obtain treatment orders. This may be the treatment nurse, or the assigned licensed nurse in absence of the treatment nurse. 7. Treatments will be documented on the Treatment Administration Record. Surveyor requested and received the facility policy entitled, Pressure Injury Prevention and Management which states in part: 2. The facility shall establish and utilize a systemic approach for pressure injury prevention and management, including prompt assessment and treatment; intervening to stabilize, reduce or remove underlying risk factors; monitoring the impact of the interventions; and modifying the interventions as appropriate. 4. Interventions for Prevention and to Promote Healing a. After completing a thorough assessment/evaluation, the interdisciplinary team shall develop a relevant care plan that includes measurable goals for prevention and management of pressure injuries with appropriate interventions. d. Evidence-based treatments in accordance with current standards of practice will be provided for all residents who have a pressure injury present. f. Interventions will be documented in the care plan and communicated to all relevant staff. On 8/04/21 at 5:20 pm, surveyor met with the administrator, director of nursing, Regional Vice President of Clinical Services, and the Regional Director of Operations and discussed the concern of Resident #108 not receiving treatments as ordered to an unstageable pressure area to the sacrum and deep tissue injuries to the right malleolus, right heel, and left heel. The Regional Vice President of Clinical Services stated they would review the documentation. The following morning at 8:51 am, surveyor met with the Regional Vice President of Clinical Services and who stated they were unable to find any additional documentation. They further stated that the wound nurse had started the job a week prior and thought the doctor put the orders in. According to the CMS-671 form completed by the facility staff at the time of the survey, the facility reported six (6) current residents with pressure ulcers at a stage II or greater. During the course of the survey, the survey team investigated three current residents and one discharged resident with pressure ulcers. No additional concerns were identified with pressure ulcers. No further information regarding this issue was presented to the survey team prior to the exit conference on 8/05/21. This is a complaint deficiency.

Based on clinical record review, staff interview, family interview, facility document review, and over the course of a complaint investigation, the facility staff failed to prevent accident hazards for 1 of 25 Residents in the survey sample, Resident # 38. The findings included: The facility staff failed to assess and implement interventions following falls which led to Resident # 38 having a fractured right humerus and increased pain that could not be controlled, which caused Resident # 38's responsible party to remove him from hospice in order to have diagnostic exams in efforts to relieve Resident # 38's pain. The diagnostic exams revealed that Resident # 38 had 2 subacute compression fractures. Resident # 38 was a [AGE] year-old-male who was originally admitted to the facility on [DATE], with a readmission date of [DATE]. [DIAGNOSES REDACTED]. The clinical record for Resident # 38 was reviewed on 4/24/19 at 11:00 am. The most recent MDS (minimum data set) assessment was a significant change assessment with an ARD (assessment reference date) of 3/15/19. Section C of the MDS assesses cognitive patterns. In Section C1000, the facility staff documented that Resident # 38's cognitive status was severely impaired. On 5/15/18, prior to the survey team's arrival at the facility, the complainant notified the local ombudsman that Resident # 38 had fallen out of bed. On 4/24/19 at 10:35 am, the complainant came into the facility and spoke with the surveyor. The complainant stated that Resident # 38 had fallen out of bed multiple times and has broken 5 bones from falling out of the bed. The complainant stated that Resident # 38 was on hospice from 7/11/18 until 1/18/19. The complainant stated That Resident # 38 fell on [DATE] and 1/11/19. The complainant stated that hospice would not allow and x-ray and was attempting to manage Resident # 35's pain with pain medications. The complainant stated that Resident # 38's pain was not relieved, so she made the decision to take Resident # 38 off hospice in order to get an x-ray. The complainant stated that Resident # 38 was found to have 2 compression fractures. On 4/24/19 at 11:00 am, the surveyor reviewed the nurse's note for Resident # 38. The surveyor observed a nurse's note documented on 5/7/18 at 8:03 pm. The nurse's note was documented as Resident found on floor, feet at HOB (head of bed). Resident states pain, then no pain. Resident's right hip higher than left hip. New order given to send to ER (emergency room ) Resident sister made aware. Requesting resident sent to (Facility name withheld). The surveyor observed a nurse's note documented on 5/13/18 at 4:16 pm. The nurse's note was documented as, This writer observed Resident push himself off the mattress to the floor. But was unable to prevent him from making contact with the fall mat on the floor beside his bed. Bed in low position no noted [MEDICAL CONDITIONS], bruising. Does have some redness to right side of his face. Assisted back to bed with the Hoyer lift. RP (responsible party) notified and voiced understanding. The surveyor observed an X-ray report in Resident # 38's clinical record dated 5/14/18. The x-ray was taken of the right elbow anterior, posterior, and lateral. The conclusion of the report was documented as acute fracture distal humerus. The surveyor observed a nurse's note that was documented on 12/27/18 at 8:44 pm. The nurse's note was documented as, At 2044 (8:44 pm) this evening resident observed lying on the fall mat in between his bed and roommate's bed. Resident was yelling out very loudly. Resident was on his back with his feet still on the bed. Resident stated he hit his head but denied any pain. Called RP (responsible party) at both available numbers and left message to return call. The surveyor observed a nurse's note documented on 1/11/19 at 6:03 pm. The nurse's note was documented as, This nurse was called to resident's room by sister. Resident's upper part of body was lying on fall mat with legs still in the bed. HOB (head of bed) was elevated. Bed has air mattress, which sister says has a slick cover. Resident denied pain. ROM (range of motion) as prior to fall. Vital signs 99.3-76-18-126/75 Hoyer lift used and resident was returned to bed. Supervisor aware and assisted with transfer. MD (medical doctor) notified via communication form. The surveyor observed a nurse's note that was documented on 1/18/19 at 11:51 am. The nurse's note was documented as, Residents sister arrived. Sister has called and cancelled hospice services. She states he is having extreme back pain and has worked with hospice for a week to try to help the pain. Resident's medication has been increased with no result. Spoke with hospice and they confirmed hospice has been canceled. Sister demanded resident be sent to ER (emergency room ) for evaluation, resident yelling ow repeatedly when asked what is wrong, he states he is in pain in his back. EMT's (emergency medical technicians) arrived and transported resident to (Facility name withheld). The surveyor reviewed an emergency room report in Resident # 38's clinical record that was dated 1/18/19. The emergency room report contained documentation that included but was not limited to, .Discharge instructions You have been found to have 2 subacute compression fractures on today's imaging. These fractures do not generally require an operation, and so pain control is very important. Recommend aggressive management of pain and discomfort with medication dosing at least every 4 hours PRN (as needed). On 4/25/19 at 4:30 pm, the surveyor spoke with the DON (director of nursing) and asked her to provide documentation on the investigations that were completed for falls that occurred with Resident # 38 while he was a Resident in the facility. On 4/26/19 at 8:30 am, the DON provided the surveyor with investigation reports regarding falls for Resident # 38 that occurred on 5/7/18, 5/13/18, 5/17/18, 12/27/18, and 1/11/18. The surveyor asked the DON if she felt that the fractures that Resident # 38 had obtained were attributed to the falls. The DON stated, Yes. The surveyor reviewed the clinical record for Resident # 38 further and observed a facility Fall Risk Tool in Resident # 38's clinical record that was documented on 2/2/18 at 5:47 pm upon admission to the facility. The fall risk tool contained documentation that Resident # 38 had a fall assessment score of 13. Documentation on the fall risk assessment for Resident # 38 categorized him as High Risk for Falls. The surveyor reviewed a facility Fall Risk Tool in Resident # 38's clinical record that was documented on 1/16/19 at 1:55 pm. The fall risk tool contained documentation that Resident # 38 had a fall assessment score of 14. Documentation on the fall risk assessment for Resident # 38 categorized him as High Risk for Falls. The facility staff initiated a plan of care for Resident # 38 on 2/4/18. The facility staff documented a focus area for Resident # 38 as Resident # 38 is at risk for falls with Hx: (history) r/t (related to) deconditioning, [MEDICAL CONDITIONS], history of falls. The surveyor observed the following interventions listed, Anticipate and meet the resident's needs, which was initiated on 2/4/18. At risk plan for fall: low bed, fall mats, which was initiated on 5/13/18. Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance, which was initiated on 2/4/18. Educate the resident/family/caregivers about safety reminders and what to do if a fall occurs, which was initiated on 2/4/18. PT (physical therapy) evaluate and treat as ordered PRN (as needed), which was initiated on 2/4/18. The resident needs a safe environment with: even floors free from spills and/or clutter, adequate, glare-free light; a working and reachable call light, the bed in transfer position, personal items within reach, which was initiated on 2/4/18. The resident needs to be evaluated for, and supplied appropriate adaptive equipment or devices as needed. Re-evaluate PRN and as needed for continued appropriateness, which was initiated on 2/4/18. The surveyor did not observe care plan revisions on the plan of care following the falls that Resident # 38 had on 5/7/18, 5/17/18, 12/27/18, and 1/11/19. The facility policy on Managing Falls and Fall Risk contained documentation that included but was not limited to, .Prioritizing Approaches to Managing Falls and Fall Risk 4. If falling recurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant. 5. If underlying causes cannot be readily identified or corrected, staff will try various interventions based on assessment of the nature or category of falling is reduced or stopped, or until the reason for the continuation of the falling is identified as unavoidable. 6. In conjunction with the attending physician, staff will identify and implement relevant interventions (e.g., hip padding or treatment of [REDACTED]. Monitoring Subsequent Falls and Fall Risk 1. The staff will monitor and document each resident's response to interventions intended to reduce falling or the risks of falling. 3. If the resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change interventions. As needed, the attending physician will help the staff reconsider possible causes that may not previously have been identified. On 4/26/19 at 3:30 pm, the administrative team was made aware of the findings as stated above. On 4/26/19 at 3:45 pm, the surveyor was approached by the DON with questions of the deficient practice. The surveyor explained to the DON that while Resident # 38 did have a [DIAGNOSES REDACTED].# 38 was a high risk for falls upon admission. Resident # 38 has also had several falls since his admission on 2/2/18. After the initial plan of care was developed, there is no evidence to support that assessments and interventions were put in place to attempt to minimize falls other that low bed and fall mats that were put in place after Resident # 38 had fallen and sustained a fractured right humerus. Resident # 38 had falls on 5/17/18, 12/27/18, and 1/11/19. Again, there was no documentation of assessments or interventions put into place to minimize falls, which it was determined that Resident # 38 had 2 compression fractures following a fall that occurred on 1/11/19. The director of nursing stated that the fractured humerus and 2 compression fractures were attributed to Resident # 38's falls. In addition, while it was evident that Resident # 38 had previous conditions, Resident # 38 did not experience the level of pain that he did following the fall on 1/11/19, which led his sister to make the decision to remove him from hospice in order to attempt to get pain relief for Resident # 38. The director of nursing voiced understanding. No further information regarding this issue was provided to the survey team prior to the exit conference on 4/26/19. This is a complaint deficiency.