Every finding on record at Richfield Health Center - Salem

Based on interviews, clinical record review, and facility document review, the facility staff failed to prevent significant medication errors for one (1) of five (5) sampled residents (Resident #1). The findings included: The facility staff failed to administer Resident #1's diabetic medication according to the medical provider's orders. This resulted in the need to administer an injectable medication to increase Resident #1's blood sugar on the morning of 5/16/24, with a subsequent transfer to a local emergency department. Resident #1's Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 5/8/24, was signed as completed on 5/15/24. Resident #1 was assessed as being able to be understood, and as able to understand others. Resident #1's Brief Interview for Mental Status (BIMS) summary score was documented as a 13 out of 15; this indicated intact or borderline cognition. Resident #1's diagnoses included Type 2 Diabetes Mellitus, and Congestive Heart Failure. Resident #1's clinical record included an order, for the dates 5/7/24 - 5/16/24, for Tresiba 30 units to be administered at bedtime, with instructions to hold this medication if the resident's finger stick blood sugar (FSBS) is less than 200. (Tresiba is a long-acting insulin used to manage blood sugar levels.) The Director of Nursing confirmed that Tresiba 30 units were administered on 5/12/24, 5/14/24, and 5/15/24 when it should have been held due to the resident's FSBS being less than 200. Resident #1's clinical record included the following information: - The 5/12/24 bedtime dose of Tresiba was documented as being administered at 9:12 p.m.; Resident #1's blood sugar was documented as 141 on 5/12/24 at 9:12 p.m. - The 5/14/24 bedtime dose of Tresiba was documented as being administered at 11:35 p.m.; Resident #1's blood sugar was documented as 129 on 5/14/24 at 11:34 p.m. - The 5/15/24 bedtime dose of Tresiba was documented as being administered at 9:00 p.m.; Resident #1's blood sugar was documented as 111 on 5/15/24 at 9:06 p.m. (The Director of Nursing confirmed the 9:06 p.m. FSBS results would have been used to guide administration of the 9:00 p.m. administration of Tresiba.) A nurse's note, dated 5/16/24 at 8:25 a.m., indicated Resident #1 was discovered in bed unresponsive with minimal amounts of blood coming out of (the resident's) mouth. Resident #1 was assessed as having a finger stick blood sugar of 39. This note indicated that injectable Glucagon was administered. Resident #1 was sent to a local emergency department. (Glucagon is an injectable medication used to treat low blood sugar levels.) Resident #1's clinical record included an Emergency Provider Report dated 5/16/24. This document indicated Resident #1 was sent to the emergency department on the morning of 5/16/24 due to a low blood sugar level. Upon Resident #1's arrival at the emergency department, the resident was alert and oriented with a blood sugar level of 71 gm/dL. Resident #1 was discharged from the emergency department with orders to decrease the medication (Tresiba) from 30 units at bedtime to 15 units at bedtime. Resident #1's clinical record included an order, for the dates 5/16/24 - 6/4/24, for Tresiba 15 units to be administered at bedtime with instructions to hold this medication if the resident's finger stick blood sugar (FSBS) is less than 200. The Director of Nursing confirmed the Tresiba 15 units was administered on 5/31/24 when it should have been held due to the resident's FSBS being less than 200. Resident #1's clinical record included the following information: - The 5/31/24 bedtime dose of Tresiba was documented as being administered at 8:03 p.m.; Resident #1's blood sugar was documented as 121 on 5/31/24 at 8:01 p.m. This medication was administered when it should have been held. The following information was found in a facility policy titled Medication and Treatment Administration (dated 11/2015): - PURPOSE: To ensure all medications and treatments are administered to each resident according to the correct dose, route and times as ordered by the provider. - All medications and treatments are prepared and administered by a Registered Nurse or Licensed Practical Nurse per their practice acts. - The licensed nurse is responsible for preparing, administering and recording all medications and treatments. The licensed nurse must assume total responsibility for preparing, administering, and documenting the medications/treatments which he/she gives. On 12/5/24 at 11:46 a.m., the surveyor met with the facility's Administrator and Director of Nursing (DON). During this meeting, the surveyor discussed the facility staff members incorrectly administering Resident #1's Tresiba (on 5/12/24, 5/14/24, 5/15/24, and 5/31/24) when it should have been held due to the resident's blood sugar level at the time of administration.

Based on interviews, clinical record review, and facility document review, the facility staff failed to follow professional standards of practice related to assessing a resident's change in condition for one (1) of five (5) sampled residents (Resident #1). The findings include: The facility staff failed to ensure Resident #1 had assessments, including reassessments, completed and/or documented according to professional standards of practice. Resident #1's Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 5/8/24, was signed as completed on 5/15/24. Resident #1 was assessed as able to make self understood and as able to understand others. Resident #1's Brief Interview for Mental Status (BIMS) summary score was documented as a 13 out of 15; this indicated intact or borderline cognition. Resident #1 had a change in condition which resulted in the need to obtain medical provider orders for oxygen via a nasal cannula for oxygen saturation levels less than 90% on 6/12/24 at 7:48 p.m. Resident #1's condition also resulted in the nurse obtaining an order for a chest x-ray on 6/12/24 at 10:15 p.m. (The chest x-ray order included the following wording: . x-ray (related to) increased (shortness of breath) and increased fluid .) The nurse failed to complete and/or document an assessment to address the resident's condition resulting in the need for these orders. The nurse failed to document contacting the medical provider to obtain the orders. On 12/4/24 at 11:25, the Director of Nursing (DON) reported the nurse should have documented a progress note when receiving medical provider orders. Resident #1's clinical record included a note documented by Respiratory Therapist (RT) #1, dated 6/13/24 at 12:04 p.m., which stated the resident's oxygen saturation level dropped to 80's [sic] during therapy. Assessed (the resident) while at rest, SPO2 81%. Placed on 3 lpm (three liter per minute) O2 (oxygen) and alerted nursing. No documentation was found to detail the resident's vital signs and/or lung sounds. No documentation was found to identify which nursing staff member had been notified. No documentation was found of a reassessment of the resident's condition after the application of the oxygen. On 12/3/24 at 4:16 p.m., the surveyor interviewed RT #1 about Resident #1's care on 6/13/24. RT #1 reported they were unable to remember Resident #1. RT #1 stated they did not recall which nursing staff member was notified in the aforementioned note; RT #1 reported they had not been told to document the name of the individual to whom they provide information about resident changes. RT #1 reported respiratory assessment includes: oxygen saturation level, heart rate, use of accessory muscles, lung sounds, and work of breathing. The following information was found in a facility policy titled NURSING DOCUMENTATION (dated 3/2016): - All observations, medications administered, services performed, etc., must be documented in the resident's clinical records. - Documentation should include the status of the identified problems until they are resolved. - WHAT TO CHART: . All injuries, illnesses and unusual health situations until they are resolved . - WHAT TO CHART: . Response to a medication or treatment . - WHAT TO CHART: . New symptoms or change in condition . The following information was found in a facility policy titled Change in Resident Condition or Status (dated 8/2008): All changes in the resident's medical condition must be properly recorded in the resident's medical record . On 12/5/24 at 11:46 a.m., the surveyor met with the facility's Administrator and Director of Nursing (DON). During this meeting, the surveyor discussed the failure of facility staff to follow professional standards of practice related to assessing and reassessing Resident #1's respiratory status.

Based on interviews, clinical record review, and facility document review, the facility staff failed to obtain medical provider ordered laboratory tests for one (1) of five (5) sampled residents (Resident #1). The findings include: The facility staff failed to obtain Resident #1's medical provider ordered laboratory blood test. Resident #1's Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 5/8/24, was signed as completed on 5/15/24. Resident #1 was assessed as able to make self understood and as able to understand others. Resident #1's Brief Interview for Mental Status (BIMS) summary score was documented as a 13 out of 15; this indicated intact or borderline cognition. The following information was found in a facility policy titled Telephone Orders (dated 11/2020): Verbal telephone orders must be documented by the nurse receiving the order. The documentation occurs in two locations in the order entry field and in the resident's medical record under progress notes. Resident #1's clinical documentation included the following information, in a nursing progress note dated 5/13/24 at 5:53 p.m.: N.O. (new order) one-time dose of Bumex 2 mg now (5:00 p.m.). Bumex 2 mg daily (due to) (bilateral) edema in legs and arms. Obtain cbc and cmp [sic] on 5/24/24. Lymphatic drainage massage suggested COTA (certified occupational therapist assistant) made aware. Compression socks on during the day and off at night. (A complete blood count (CBC) and comprehensive metabolic panel (CMP) are laboratory blood tests.) The results of the 5/24/24 CBC and CMP test results were not found in Resident #1's clinical record. On 12/4/24 at 9:02 a.m., the Director of Nursing (DON) confirmed results for Resident #1's medical provider ordered CBC and CMP, for 5/24/24, was not found. On 12/5/24 at 11:46 a.m., the surveyor met with the facility's Administrator and Director of Nursing (DON). During this meeting, the failure of the facility staff to obtain Resident #1's laboratory blood tests ordered for 5/24/24 was discussed for a final time.

Based on interviews, clinical record review, and facility document review, the facility staff failed to ensure prompt implementation of a medical provider order for rehabilitative services for one (1) of five (5) sampled residents (Resident #1). The findings include: The facility staff failed to promptly implement a medical provider order for Resident #1 to be assessed for and/or receive lymphatic drainage massage. Resident #1's Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 5/8/24, was signed as completed on 5/15/24. Resident #1 was assessed as able to make self understood and as able to understand others. Resident #1's Brief Interview for Mental Status (BIMS) summary score was documented as a 13 out of 15; this indicated intact or borderline cognition. The following information was found in a facility policy titled Telephone Orders (dated 11/2020): Verbal telephone orders must be documented by the nurse receiving the order. The documentation occurs in two locations in the order entry field and in the resident's medical record under progress notes. Resident #1's clinical documentation included the following information, in a nursing progress note dated 5/13/24 at 5:53 p.m.: N.O. (new order) one-time dose of bumex 2 mg now (5:00 p.m.). Bumex 2 mg daily (due to) (bilateral) edema in legs and arms. Obtain cbc and cmp [sic] on 5/24/24. Lymphatic drainage massage suggested COTA (certified occupational therapist assistant) made aware. Compression socks on during the day and off at night. On 12/4/24 at 10:16 a.m., the Director of Therapy reported they could not find where therapy staff was notified of Resident #1's medical provider order related to lymphatic drainage massage. The Director of Therapy reported therapy staff became aware of the lymphatic drainage massage order during a care plan meeting on 5/23/24. On 12/4/24, the Director of Therapy provided the surveyor with: (a) documentation to show Resident #1 was assessed for lymphatic drainage massage on 5/24/24 and (b) documentation to show the first lymphatic drainage massage occurred on 5/29/24. On 12/5/24 at 11:46 a.m., the surveyor met with the facility's Administrator and Director of Nursing (DON). During this meeting, the delay in implementing Resident #1's medical provider ordered lymphatic drainage massage was discussed.

Based on resident interview, staff interview, facility document review, facility staff failed to ensure the resident was treated with dignity related to toileting for 1 of 23 current residents in the survey sample (Resident #89). Resident #89 was admitted to the facility with diagnoses which included aftercare joint replacement, anemia, hypertension, anticoagulants, abnormal gait, and a history of pulmonary embolism. On the most recent Minimum Data Set assessment, the resident scored 15/15 on the brief interview for mental status and was assessed as without signs of delirium, psychosis, or behavior affecting care. During initial tour on 5/13/2024, Resident #89 complained that she was left on the toilet for 2 1/2 hours on 5/12/24. On 5/14/24, the surveyor received the call Alarm History for the resident's room from 5/12/24 at 12:00 AM through 5/13/24 at 12 AM. The log documented a call from the bed active from 10:21:01 through 12:21:41 (duration 120 minutes). The log documented 7 calls from the bathroom starting at 12:41:27 and ending 14:44:48 (duration in minutes 7.55, 9.33, 2.78, 18.52, 38.28, 39.07, and 6.68) indicating the resident had been in the bathroom for 122 minutes. The surveyor discussed the Alarm History with the director of nursing (DON), stating that it appeared the resident had been left in the bathroom for a significant amount of time. Nursing staff working on 5/13 reported that neither of the nurses or aids working that day had worked on 5/12. The surveyor reported the concern to the director of nursing (DON) and asked to contact the nurse responsible for the resident's care on 5/12/24. On 5/14, the DON supplied the nurse's contact information, however, the nurse was unable to make contact with the nurse for an interview. Activity of daily living notes documented the resident used the toilet 1 time during the day shift on 5/12/24. The administrator and DON were notified of the ongoing concern during a summary meeting on 5/14/2024.

Based on staff interview, clinical record review, and facility document review, the facility staff failed to notify and consult with the medical provider following a significant weight loss for 1 of 23 current sampled residents, Resident #69. The findings included: For Resident #69, the facility staff failed to notify and consult with the medical provider following a significant weight loss identified on 3/11/24. Resident #69's diagnosis list indicated diagnoses, which included, but not limited to Alzheimer's Disease, Convulsions, Parkinson's Disease, Lymphedema, Essential Hypertension, and Second-Degree Atrioventricular Block. The most recent minimum data set (MDS) with an assessment reference date (ARD) of 3/11/24 coded the resident as being severely impaired in cognitive skills for daily decision making with short-term and long-term memory problems. Resident #69 was coded as having had a significant weight loss without a physician-prescribed weight loss regimen. A review of Resident #69's weights revealed a weight of 160.6 on 3/01/24 and a weight of 148.6 on 3/11/24 revealing a 12-pound/7.47% loss in 10 days. The resident's most recent weight of 137.8 was obtained on 5/13/24. Surveyor reviewed Resident #69's clinical record and was unable to locate evidence of medical provider notification of the significant and sustained weight loss. Surveyor spoke with the Director of Nursing (DON) on 5/15/24 at 11:10 AM regarding Resident #69's significant weight loss. The DON was unable to provide evidence of medical provider notification of the weight loss. Surveyor requested and received the facility policy titled Weight Assessment and Intervention dated 10/2023 which read in part .3. Any significant weight changes since last weight assessment will be retaken for confirmation. If the weight is verified, nursing will notify the dietician and the physician/practitioner . On 5/15/24 at 3:15 PM, the survey team met with the Administrator and DON and discussed the concern of staff failing to notify the medical provider of Resident #69's significant weight loss. No further information regarding this concern was presented to the survey team prior to the exit conference on 5/15/24.

Based on staff interview, clinical record review, and facility document review, the facility staff failed to provide a Skilled Nursing Facility (SNF) Advanced Beneficiary Notice of Non-coverage (ABN) notification for 1 of 3 residents selected for SNF Beneficiary Notification Review (BNR), Resident #69. The findings included: For Resident #69, the facility staff failed to provide a SNF ABN notification when the resident was discharged from Medicare Part A services with skilled benefit days remaining while continuing to reside in the facility. Resident #69's diagnosis list indicated diagnoses, which included, but not limited to Alzheimer's Disease, Convulsions, Parkinson's Disease, Lymphedema, Essential Hypertension, and Second-Degree Atrioventricular Block. The most recent minimum data set (MDS) with an assessment reference date (ARD) of 3/11/24 coded the resident as being severely impaired in cognitive skills for daily decision making with short-term and long-term memory problems. Resident #69's clinical record included a social services progress note dated 3/18/24 10:36 AM which read in part, SW [social worker] spoke with [name omitted]/POA [power of attorney] via phone. Explained Notice of Non-coverage and appeal rights. Made aware of effective date of 3-20-24 as date of skilled services ending and date financial liability to begin on 3-21-24. Informed that a request for an immediate appeal should be made as soon as possible, but no later than noon on the day before the effective date. Provided QIO [Quality Improvement Organization] Contact # [number omitted]. Confirmed that the representative understood all information explained. Last skilled day will be 3-20-24 and will be discharged on [DATE]. A copy of the NOMNC [Notice of Medicare Non-Coverage] was mailed to [name omitted]. Surveyor requested to view notices that were provided to the resident's POA when discharged from Medicare Part A services. On 5/14/24 at 2:54 PM, the Administrator provided a copy of a NOMNC dated 3/18/24 and stated they could not locate an ABN notice for Resident #69. On 5/15/24 at 3:15 PM, the survey team met with the Administrator and Director of Nursing and discussed the concern of staff failing to issue Resident #69 a SNF ABN. No further information regarding this concern was presented to the survey team prior to the exit conference on 5/15/24.

Based on resident interview, staff interview, and clinical record review, the facility staff failed to accurately complete a minimum data set (MDS) assessment for 2 of 23 residents, Resident #65 and #102. The findings included: 1. The facility staff failed to accurately complete a quarterly MDS assessment. The facility staff failed to mark the resident self-catheterization (intermittent catheterization). Resident #65's diagnoses included, obstructive and reflux uropathy, chronic kidney disease, and diabetes. Section C (cognitive patterns) of Resident #65's quarterly MDS assessment with an assessment reference date (ARD) of 04/10/24 included a brief interview for mental status (BIMS) score of 15 out of a possible 15 points. Section H (bladder and bowel) was coded always continent of urine. The box beside of intermittent catheterization was left blank (unchecked). On 05/13/24 during initial tour Resident #65 stated they did their own catheterization and had been doing so for a while. Resident #65's clinical record included a provider order dated 05/25/23 that read Resident to self cath 4 times a day. On 05/14/24 at 8:45 a.m., during an interview with MDS Coordinator/Registered Nurse #1 this staff reviewed the MDS and confirmed catheterization was not marked on the MDS. On 05/14/24 at 4:00 p.m., during an end of the day meeting with the Administrator and Director of Nursing (DON) the inaccurate MDS was reviewed. No further information regarding this issue was provided to the survey team prior to the exit conference. 42353 2. For Resident #102, the facility staff coded the resident as being discharged to a hospital when in fact the resident had been discharged home. Resident #102's diagnosis list indicated diagnoses, which included, but not limited to Wedge Compression Fracture of T11-T12 Vertebra, Syndrome of Inappropriate Secretion of Antidiuretic Hormone, Protein-Calorie Malnutrition, Cirrhosis of Liver, and Type 2 Diabetes Mellitus. The discharge minimum data set (MDS) with an assessment reference date (ARD) of 2/29/24 coded the resident as being discharged to a short-term general hospital. However, a 2/29/24 12:25 PM nursing progress note read in part Patient discharged home . Resident #102's clinical record also included a medical provider order dated 2/29/24 stating D/C [discontinue] all meds [medications] and tx [treatment] pt [patient] discharged home. On 5/15/24 at 10:19 AM, surveyor spoke with the MDS Nurse and requested they review the MDS coding related to the resident's discharge location. The MDS Nurse returned at 1:34 PM and provided documentation indicating the 2/29/24 discharge MDS had been corrected to indicate Resident #102 was discharged home. On 5/15/24 at 3:15 PM, the survey team met with the Administrator and Director of Nursing and discussed the concern of the inaccurate MDS coding for Resident #102. No further information regarding this concern was presented to the survey team prior to the exit conference on 5/15/24.

Based on resident interview, staff interview, clinical record review, and facility document review, the facility staff failed to implement a comprehensive person-centered activity care plan to provide one-to-one activity programming for two (2) of 23 sampled residents (Resident #34 and Resident #26). The findings include: 1. For Resident #34 (R34) the facility staff failed to implement a comprehensive person-centered activity care plan to provide one-to-one activities in her room two times per week. R34's diagnosis list indicated diagnoses that included, but were not limited to, Dementia, Abnormal Posture, Hemiplegia and Hemiparesis, Aphasia following Cerebral Infarction (stroke), Cognitive Communication Deficit, Depression and Epilepsy. The most recent minimum data set (MDS) with an assessment reference date (ARD) of 02/17/24, coded the resident as having modified independence in cognitive skills for daily decision making with short and long-term memory problems. On 05/14/24 at 10:42 AM, surveyor interviewed R34 about activities and she conveyed activity staff do not do anything in her room with her. A review of the most recent comprehensive activity care plan dated 2/15/24, revealed, .enjoys independent activities in her room and does not prefer to get out of bed very often .will be encouraged to accept social and active one on one visits at least twice a week .Ensure frequent 1:1 visits to encourage participation in independent activities .Offer social one on one visits such .to help build rapport . The care plan revealed an initiated date of, 11/25/2015 and a revision date of, 9/5/2023 and no changes were identified for this Focus, Goal, or Interventions during these revisions. On 5/14/24 at 11:05 AM, surveyor interviewed Activity Director (AD) and asked what types of activities are provided for R34. AD stated R34 used to come to bingo, and he has been told she hasn't been feeling well and has not been attending bingo. AD stated she turns down supplies and he holds music twice a month, but she doesn't want to come to bingo now. Surveyor requested to see activity participation records for R34, and AD stated he has no documentation for any activities that he does, and he does not do activity participation records. AD was unable to provide evidence of one-on-one visits with R34. Surveyor requested and received a facility policy for care planning with no title, that revealed, The facility will develop a comprehensive care plan .which will include measurable objectives and timetables to meet the resident's .mental, and psychosocial needs .PROCEDURE: 1. The comprehensive plan of care .will be designed to: A. Address the needs, risks, strengths, and preferences of the resident . Surveyor also requested and received a facility policy titled, .Activities Program, that revealed, 4 .Activities are offered in several settings to include: (a) one-to-one programming .for residents who will not or cannot plan their own activity pursuits or residents needing specialized programming to enhance their overall quality of life .6 .staff must be assigned to assist with activity programming . This concern was discussed with the Administrator and DON (director of nursing) at the end of day meeting on 5/14/24 and at pre-exit meeting on 5/15/24. No further information was provided to the survey team prior to exit. 2. For resident #26 (R26) facility staff failed to implement a comprehensive person-centered activity care plan to ensure frequent one-to-one staff visits to encourage socialization. R26's diagnosis list indicated diagnoses that included, but were not limited to, Alzheimer's Disease, Vascular Dementia, Depression, Chronic Pain Syndrome, History of Falling, and Insomnia. The most recent minimum data set (MDS) with an assessment reference date (ARD) of 04/14/24, coded the resident as being severely cognitively impaired for making decisions with short and long-term memory problems. A review of the most recent comprehensive activity care plan dated 4/12/24, revealed, .At risk for activity participation related to: cognitive deficit .Will attend/participate in 1 activity a week .Ensure frequent 1:1 staff visits to encourage socialization . The care plan revealed an initiated date of, 8/16/2022 and a revision date of, 7/14/2023 and no changes were identified for this Focus, Goal, or Interventions during these revisions. On 5/14/24 at 11:05 AM, surveyor interviewed the Activity Director (AD) and asked what types of activities he provides for R26. AD stated due to her condition he usually tries to involve her in food-related programs. Surveyor asked what he does for one-to-one programming and lower-functioning programming/sensory programming and AD stated he does the best he can. Surveyor requested to see activity participation records for R26, and AD stated he has no documentation for any activities that he does, and he does not do activity participation records. AD was unable to provide evidence of one-on-one staff visits with R26. Surveyor requested and received a facility policy for care planning with no title, that revealed, The facility will develop a comprehensive care plan .which will include measurable objectives and timetables to meet the resident's .mental, and psychosocial needs .PROCEDURE: 1. The comprehensive plan of care .will be designed to: A. Address the needs, risks, strengths, and preferences of the resident . Surveyor also requested and received a facility policy titled, .Activities Program, that revealed, 4 .Activities are offered in several settings to include: (a) one-to-one programming .for residents who will not or cannot plan their own activity pursuits or residents needing specialized programming to enhance their overall quality of life .6 .staff must be assigned to assist with activity programming . This concern was discussed with the Administrator and DON at the end of day meeting on 5/14/24 and at the pre-exit meeting on 5/15/24. No further information was provided to the survey team prior to exit.

Based on resident interview, staff interview, and clinical record review, the facility staff failed to review and revise the residents comprehensive care plan (CCP) for 1 of 23 current residents, Resident #65. The findings included: The facility staff failed to review and revise the residents CCP to include their prophylactic antibiotic and their self-catheterization. Resident #65's diagnoses included, obstructive and reflux uropathy, chronic kidney disease, and diabetes. Section C (cognitive patterns) of Resident #65's quarterly minimum data set (MDS) assessment with an assessment reference date (ARD) of 04/10/24 included a brief interview for mental status (BIMS) score of 15 out of a possible 15 points. Section H (bladder and bowel) was coded to indicate this resident was always continent of urine. The box beside of intermittent catheterization was left blank (unchecked). On 05/13/24 during initial tour Resident #65 stated they did their own catheterization and had been doing so for a while. Resident #65's clinical record included provider orders to self-cath 4 times a day (05/25/23) and for the prophylactic antibiotic Macrobid 100 mg 1 capsule one time a day every Monday, Wednesday, and Friday (06/23/23). During the clinical record review, the surveyor was unable to locate a care plan that included either of these areas. On 05/14/24 at 8:45 a.m., during an interview with MDS Coordinator/Registered Nurse #1 this staff reviewed the clinical record and confirmed there was not a care plan in place for these areas. During and end of the day meeting with the Administrator and Director of Nursing (DON) on 05/14/24 at 4:00 p.m. the issue with Resident #65's CCP was reviewed. On 05/15/24 at 9:00 a.m., the Administrator and DON provided the surveyor with a copy of a revised care plan that included the focus areas alteration in bladder elimination has an order that they may self-cath up to 4 times a day. Receives a prophylactic antibiotic for urinary tract infections. 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 the administration of medications for 2 of 23 residents, Resident #93 and Resident #312. The findings included: 1. For Resident #93 the facility staff failed to administer the medications tramadol and gabapentin per the physician's order. Resident #93's face sheet listed diagnoses which included but not limited to pain in left hip and unspecified dementia. Resident #93's most recent minimum data set with an assessment reference date of 02/17/24 coded the resident as having both long- and short-term memory loss with severely impaired cognitive skills for daily decision making. Resident #93's comprehensive care plan was reviewed and contained care plans for . is at risk for altered levels of pain r/t (related to) a dx (diagnosis) of left hip and vertebrae fx (fracture). She has scheduled and prn (as needed) ordered. Resident #93's clinical record was reviewed and contained a physician's order summary which read in part, tramadol HCl Oral Tablet 50 mg (Tramadol HCl). Give 1 tablet by mouth four times a day for pain and Gabapentin capsule 100 mg. Give 1 capsule by mouth every 8 hours for neuropathy. Resident's clinical record also contained a physician's order which read in part, tramadol HCl 50 mg. Give 0.5 tablet by mouth two times a day for pain. Resident #93's electronic medication administration record (eMAR) for the months of March, April, and May 2024 were reviewed and contained entries as above. On 03/18/24, the entry for tramadol was coded 9 at 2 pm and blank at 8 pm. On 03/19/24, the tramadol was coded [NAME] at 8 pm. On 04/05/24 the gabapentin was coded 5 at 2 pm. On 04/15/24 and 04/30/24 the tramadol was coded [NAME] at 8 pm. On 05/04/24 the gabapentin was coded [NAME] at 10 pm. On 05/05/24 the gabapentin was coded [NAME] at 6 am and 9 at 10 pm. Chart coded 5 is equivalent to Hold/See Progress Note. Chart code 9 is equivalent to Other/See Nurses Notes Effective. Surveyor spoke with the director of nursing (DON) on 05/15/24 at 9:15 am, and asked DON what [NAME] on the eMAR meant. DON stated, Medication unavailable. Resident #93's nurse's progress notes were reviewed and contained notes which read in part, 3/19/2024 21:32 tramadol HCl Oral Tablet 50 mg. Give 0.5 tablet by mouth two times a day for pain med on order, 4/5/2024 13:23 Gabapentin capsule 100 mg. Give 1 capsule by mouth every 8 hours for Neuropathy. On hold until arrival from pharmacy. MD notified, 4/15/2024 22:30 tramadol HCl Oral Tablet 50 mg. Give 1 tablet by mouth three times a day for pain no tramadol in narc box per nurse that report was taken from she reordered no pain noted at this time and MD was made aware, and 5/52024 21:50 Gabapentin capsule 100 mg. give 1 capsule by mouth every 8 hours for Neuropathy. Medication unavailable at this time. There was no note for 05/04/24. Surveyor spoke with registered nurse (RN) #3 on 05/14/24 at 11:30 am regarding unavailability of medications. RN #3 stated that if a medication is unavailable, they check the medication cart, then check to see if the medication is available in the facility Cubex (emergency medication supply). If not available in the Cubex, notify the pharmacy and call the physician. Surveyor requested a list of medications available in the facility Cubex. The medications tramadol 50 mg and gabapentin 100 mg were both listed as available. Surveyor requested and was provided with a facility policy entitled Ordering and Procuring Extra Doses (XD) of Medication which read in part, Policy: A nurse may be required to request an extra dose (XD) of medication for the following reasons: b. Missing dose. Procedure: 1. If a medication is not available in the 24 hour unit dose supply, the nurse will check the next day's bag (same resident and time pass) and remove the unit dose medication from the bag to administer. Document on the outside of the bag that medication was removed and by whom. Also document on the bag that an XD was ordered. 2. The nurse will fax the pharmacy indicating that an extra dose (XD) is required using the 'Extra Dose Request Order Form.' The concern of not following physician's orders for Resident #93 was discussed with the DON and administrator on 05/15/24 at 3:15 pm No further information was provided prior to exit. 2. For Resident #312 the facility staff failed to administer the medications diazepam and oxycodone per the physician's orders. Resident #312's face sheet listed diagnoses which included but not limited to anxiety disorder, long-term (current) use of opiate analgesic and chronic pain syndrome. Resident #312's most recent minimum data set with an assessment refer date of 05/07/24 assigned the resident a brief interview for mental status score of 8 out of 15 in section C, cognitive patterns. This indicates that the resident is moderately cognitively impaired. Resident #312 is a new admission; therefore, the comprehensive care plan has not been completed. Resident #312's clinical record was reviewed and contained a physician's order summary which read in part, diazepam Oral Tablet 5 mg (Diazepam). Give 2.5 mg every morning and at bedtime for anxiety and oxycodone HCl Oral Tablet 5 mg (Oxycodone HCl). Give 1 tablet by mouth every morning and at bedtime for pain management. Resident #312's electronic medication administration record (eMAR) for the month of May 2024 was reviewed and contained entries as above. The entry for diazepam was coded [NAME] on 05/10/24 at 9 am and the entry for oxycodone was coded 9 on 05/11/24. Chart code 9 is the equivalent of Hold/See Nurses Note Effective. Surveyor spoke with the director of nursing (DON) on 05/15/24 at 9:15 am, and asked DON what [NAME] on the eMAR meant. DON stated, Medication unavailable. Resident #312's nurse's progress notes were reviewed and contained notes which read in part, 5/10/2014 11:36 diazepam Oral Tablet 5 mg. Give 2.5 mg every morning and at bedtime for anxiety. Medication unavailable in stat box. This nurse does not have access to the Omnicell (emergency medication supply). New prescriptions requested by this nurse to be sent in by . (name omitted) NP (nurse practitioner) and 5/11/2024 12:27 oxycodone HCl Oral Tablet 5mg. Give 2.5 mg every morning and at bedtime for pain management. Medication is not available, MD is aware. Surveyor spoke with registered nurse (RN) #3 on 05/14/24 at 11:30 am regarding unavailability of medications. RN #3 stated that if a medication is unavailable, they check the medication cart, then check to see if the medication is available in the facility Cubex (emergency medication supply). If not available in the Cubex, notify the pharmacy and call the physician. Surveyor requested a list of medications available in the facility Cubex. The medications diazepam 5 mg and oxycodone mg were both listed as available. Surveyor requested and was provided with a facility policy entitled Ordering and Procuring Extra Doses (XD) of Medication which read in part, Policy: A nurse may be required to request an extra dose (XD) of medication for the following reasons: b. Missing dose. Procedure: 1. If a medication is not available in the 24-hour unit dose supply, the nurse will check the next day's bag (same resident and time pass) and remove the unit dose medication from the bag to administer. Document on the outside of the bag that medication was removed and by whom. Also document on the bag that an XD was ordered. 2. The nurse will fax the pharmacy indicating that an extra dose (XD) is required using the 'Extra Dose Request Order Form.' The concern of not following physician's orders for Resident #312 was discussed with the DON and administrator on 05/15/24 at 3:15 pm No further information was provided prior to exit.

Based on staff interview and clinical record review, the facility staff failed to follow up on pharmacy recommendations for 2 of 5 residents chosen for the unnecessary medication task, Residents #7 and #26. The findings included: 1. For Resident #7, the facility staff did not follow up on a pharmacy recommendation dated 03/20/24 until 05/02/24. Resident #7's diagnoses included, but were not limited to, insomnia and major depressive disorder. Section C (cognitive patterns) of Resident #7's quarterly minimum data set (MDS) assessment with an assessment reference date (ARD) of 03/15/24 included a brief interview for mental status summary score of 13 out of a possible 15 points. On 03/20/24 the pharmacist documented Monthly medication regimen and chart review. Please see pharmacist report for recommendation. The surveyor was unable to find this recommendation in the clinical record. On 05/14/24 at 4:00 p.m., during an end of the day meeting with the Administrator and Director of Nursing (DON) the missing pharmacy recommendation was reviewed. On 05/15/24, the DON provided the surveyor with a copy of a pharmacy recommendation dated 03/20/24 requesting the provider to consider a gradual dose reduction (GDR) of the medications Ramelteon and Buspar. This recommendation was unsigned and the boxes that read agree, disagree, or other were all unchecked. The clinical record included the following provider orders Ramelteon 8 mg 1 tablet by mouth at bedtime for insomnia date of order 08/17/23 and Buspirone (Buspar) 15 mg 1 tablet by mouth three times a day for depression date of order 07/16/23. The clinical record also included a progress note documented by the Nurse Practitioner on 05/02/24 that read GDR for ramelteon and buspar not recommended at this time. Current regimen is necessary to maintain the residents function. Indicating the recommendation was not followed up on from 03/20/24 until 05/02/24. The medication Ramelteon was discontinued by the provider on 05/15/24. No further information regarding this issue was provided to the survey team prior to the exit conference. 49622 2. For Resident #26, the facility staff failed to provide evidence of the 1/25/24 and 3/19/24 drug regimen reviews being reported to and acted upon by the medical provider. Resident #26's diagnosis list indicated diagnoses, which included, but not limited to Alzheimer's Disease, Vascular Dementia, CHF (congestive heart failure), Depression, History of Falling and CKD (chronic kidney disease) Stage 2 (two) Mild. Section C (cognitive patterns) of Resident #26's most recent minimum data set (MDS) with an assessment reference date (ARD) of 4/14/24, coded the resident as being rarely/never understood with short/long-term memory problems and indicated the resident was severely cognitively impaired and never/rarely making decisions. A review of the Resident #26's clinical record revealed progress notes which indicated drug regimen reviews were completed on 1/25/24 and 3/19/24, each with recommendations. Surveyor was unable to locate the recommendation reports in the resident's clinical record. On 5/15/24, surveyor requested and received the drug regimen review recommendation reports completed by the pharmacist on 1/25/24 and 3/19/24 from the Director of Nursing (DON). The 1/25/24 Note to Attending Physician/Prescriber read in part .Resident has an order for Abilify 2 (two) mg (milligrams) BID (two times per day). This medication is intended to be dosed QD (once a day). Please evaluate for possible QD dosing . The 1/25/24 Note to Attending Physician/Prescriber report had not been signed by the medical provider indicating review and the boxes that read .agree, disagree, or other . were all unchecked. A review of the physician's orders included the following order dated 1/16/24, Abilify Oral Tablet 2 mg (Aripiprazole) Give 1 (one) tablet by mouth two times a day for mood disorder . A new physician's order dated 5/2/24, revealed, Abilify Oral Tablet 2 mg (Aripiprazole) Give 2 tablet by mouth one time a day for mood disorder . The pharmacy recommendation dated 03/19/24 requesting the provider to consider a gradual dose reduction (GDR) of the medications Sertraline and Mirtazapine, had not been signed by the medical provider indicating review and the boxes that read .agree, disagree, or other . were all unchecked. On 5/15/24 at 10:58 AM, the survey team met with the Administrator and DON, and discussed the concern of staff failing to address Resident #26's January and March drug regimen reviews. Surveyor requested but did not receive the facility policy for Medication Drug Regimen Review, as the DON stated she was not sure if there was a policy, and if there was, she was unable to locate it. No further information regarding this concern was presented to the survey team prior to the exit conference on 5/15/24.

Based on staff interview, clinical record review and facility document review the facility staff failed to ensure a complete and accurate clinical record for 1 of 23 residents, Resident #93. The findings included: 1. For Resident #93 the facility staff failed to ensure the electronic medication administration record (eMAR) and electronic treatment administration record (eTAR) were complete. Resident #93's face sheet listed diagnoses which included but not limited to pain in left hip and unspecified dementia. Resident #93's most recent minimum data set with an assessment reference date of 02/17/24 coded the resident as having both long- and short-term memory loss with severely impaired cognitive skills for daily decision making. Resident #93's comprehensive care plan was reviewed and contained care plans for . is at risk for altered levels of pain r/t (related to) a dx (diagnosis) of left hip and vertebrae fx (fracture). She has scheduled and prn (as needed) ordered, . has the potential for/impaired skin integrity r/t recent hip fx with limited mobility, dementia and overall weakness. Stage 3- POA- wound vac in place- see MAR/TAR, and . is at risk for nutritional decline 2' (secondary to) hx (history) dysphagia, needs modified diet. She has increased nutrient needs 2' wounds/wound healing. Hx hip fx, dementia, CKD (chronic kidney disease). She has had significant wt (weight) loss and wt gain. Resident #93's clinical record was reviewed and contained a physician's order summary which read in part, Geri sleeves as tolerated to BUE (bilateral upper extremities), heel protectors on while in bed, group 2 mattress check for function, wound vac to sacrum continuously @ 125mmhg every shift for wound care, House Supplement 2 ounces three times a day for supplement, Pro-Stat Oral Liquid (Amino Acids-Protein Hydrolysate). Give 30 ml by mouth two times a day for wound healing, and Tylenol Oral Tablet 325 mg (Acetaminophen). Give 2 tablet by mouth four times a day for pain. Resident #93's eMAR for the month of March 2024 was reviewed and contained entries for House Supplement, Pro-Stat, and Tylenol. These entries were blank on 03/03/24 at 5 pm. Resident #93's eTAR for the month of May 2024 was reviewed and contained entries for geri sleeves, check mattress, heel protectors, and wound vac. These entries were blank on 05/05/24 on evening shift. Surveyor requested and was provided with a facility policy entitled Nursing Documentation which read in part, Purpose: 1. To substantiate daily care, communicate the resident's needs and care received. Procedure: 1. All observations, medications administered, services performed, etc., must be documented in the resident's clinical records. The concern of leaving blanks on the resident's eMAR/eTAR was discussed with the administrator and director of nursing on 05/15/24 at 3:15 pm. No further information was provided prior to exit.

Based on staff interview, clinical record review, and facility document review, the facility staff failed to offer a pneumococcal vaccine in accordance with nationally recognized standards for 1 of 5 sampled residents reviewed for immunizations, Resident #99. The findings included: For Resident #99, the facility staff failed to offer the resident a pneumococcal conjugate vaccine 15 (PCV15) or a pneumococcal conjugate vaccine 20 (PCV20) following admission to the facility. A review of the Centers for Disease Control and Prevention (CDC) guideline titled, Pneumococcal Vaccination: Summary of Who and When to Vaccinate last reviewed 9/22/23 read in part that adults [AGE] years or older that have never received any pneumococcal vaccine should receive one dose of PCV15 or PCV20. Resident #99's diagnosis list indicated diagnoses, which included, but not limited to Metabolic Encephalopathy, Traumatic Subdural Hemorrhage, Dementia, Acute Kidney Failure, and Atrial Fibrillation. The most recent minimum data set (MDS) with an assessment reference date (ARD) of 4/14/24 assigned the resident a brief interview for mental status (BIMS) summary score of 6 out of 15 indicating the resident was severely cognitively impaired. Resident #99 was over the age of [AGE] years when admitted to the facility. Resident #99's clinical record included their Virginia Immunization Information System (VIIS) Record dated 4/20/24. According to this record, Resident #99 had not received a pneumococcal vaccine prior to admission to the facility. Surveyor reviewed the resident's clinical record and was unable to locate evidence of Resident #99 being offered a PCV15 or a PCV20 following admission to the facility. On 5/15/24 at 1:00 PM, surveyor spoke with the Director of Nursing/Infection Preventionist (DON) regarding Resident #99's pneumococcal vaccine history. DON was unable to provide evidence of the resident being offered a pneumococcal vaccine following admission to the facility. Surveyor requested and received the facility policy titled, Influenza/Pneumococcal/COVID-19 Immunization and Education which read in part, Purpose: To provide a means for the facility to track .pneumococcal immunization administration and education ensuring all eligible residents receive immunization as recommended by the Center for Disease Control .1. Upon admission the resident or their responsible party will be provided the option for the resident to receive the .pneumococcal .immunization .10. Persons sixty-five (65) years of age and older who have not received the pneumococcal vaccine is [sic] the past five (5) years should receive another dose of vaccine . On 5/15/24 at 3:15 PM, the survey team met with the Administrator and DON and discussed the concern of the facility staff failing to offer Resident #99 a pneumococcal vaccine following admission. No further information regarding this concern was presented to the survey team prior to the exit conference on 5/15/24.

Based on staff interview, employee record review, and facility document review, the facility staff failed to follow their policy and procedure in regard to screening of new hires for 9 of 25 new hires. The findings included: The facility staff failed to obtain reference checks on new hire #1, #2, #3, #6, #7, #9, #10, #16, and #17 and failed to obtain background checks on new hire #3 and #9 until 02/07/23. 02/07/23, the survey team requested employee files from the facility. 02/08/23, the surveyor reviewed 25 new hire records (employee records). New hire #1, #2, #3, #6, #7, #9, #10, #16, and #17 employee records did not include reference checks. For new hires #3 and #9 background checks were not completed until 02/07/23. New hire #3's date of employment was documented as 11/14/22 and #9's was documented as 08/15/22. A review of the results obtained on 02/07/23 indicated there was no issue with either employees background check. On 02/08/23, the facility staff provided the surveyor with a copy of a document titled, Hiring Process. This document read in part, .All candidates for employment and any new positions should proceed through the hiring process according to these guidelines .Human Resources .Perform Background checks and Reference check .Unsatisfactory results of the background check, references .should be discussed with the Administrator . 02/08/23 11:05 a.m., Human Resource employee (HR) #1 stated reference checks were not completed on all new hires. 02/08/23 11:20 a.m., HR #1 stated the employees that would have completed the employee files were no longer employed at the facility and they had obtained new hire's #3 and #9's criminal background checks on 02/07/23. 02/08/23 12:25 p.m., the Administrator and Director of Nursing (DON) were made aware of the issues regarding the employee files. No further information regarding this issue was provided to the survey team prior to the exit conference.

Based on observation, resident interview, staff interview, clinical record review, and facility policy review, the facility staff failed to provide activity of daily living (ADL) care for 4 of 23 current Residents, Residents #3, #4, #8, and #60. The findings included: 1. For Resident #3, the facility staff failed to provide nail care. Resident #3's fingernails were observed to be long. Resident #3's diagnoses included, but were not limited to, cerebral palsy, diabetes, and apraxia. Section C (cognitive patterns) of Resident #3's annual minimum data set (MDS) assessment with an assessment reference date (ARD) of 11/04/22 included a brief interview for mental status (BIMS) summary score of 15. Section G (functional status) was coded 3/2 for personal hygiene to indicate they required extensive assistance of one person for this task. Resident #3's comprehensive care plan included the focus area has self-care deficits in ADL performance due to decreased mobility, unsteady balance, and communication. Interventions included, but were not limited to, check nail length and trim and clean on bath day and as necessary. 02/07/23, during initial tour of the facility Resident #3 was observed to be up in their wheelchair. Their fingernails were observed to be long. 02/07/23 09:20 a.m., Resident #3's nails were observed to be long. When asked if they liked their nails this length Resident #3 shook their head, no. 02/07/23 10:44 a.m., the Director of Nursing (DON) was made aware of the issues regarding Resident #3's nails. The facility staff provided the survey team with a copy of their policy titled, Fingernails/Toenails, Care of effective date January 2021. This policy read in part, .The purposes of this procedure are to clean the nail bed, to keep nails trimmed, and to prevent infections .Nail care includes a cleaning and regular trimming as needed or desired by resident . 02/07/23 4:00 p.m., during and end of the day meeting with the Administrator and DON the issue regarding Resident #3's fingernails was reviewed. No further information regarding this issue was provided to the survey team prior to the exit conference. 2. For Resident #4, the facility staff failed to provide nail care. Resident #4's nails were observed to be long, jagged with debris present. Resident #4's diagnoses included, but were not limited to, cognitive communication deficit, aphasia, and muscle weakness. Section C (cognitive patterns) of Resident #4's admission minimum data set (MDS) with an assessment reference date (ARD) 01/08/23 included a brief interview for mental status (BIMS) summary score of 13 out of a possible 15 points. Resident #4's comprehensive care plan included the focus area has potential for decline in activity of daily living (ADL) capabilities. 02/06/23 2:30 p.m., Resident #4's fingernails were observed to be long, jagged, with debris present. Resident #4 stated they needed to be cut. 02/07/23 9:25 a.m., certified nursing assistant (CNA) #1 in room. Resident #4's bilateral fingernails were observed to be long, jagged, with debris present. CNA #1 stated they were going to cut Resident #4's nails. 02/07/23 10:44 a.m., the Director of Nursing (DON) was made aware of the issues regarding Resident #4's nails. The facility staff provided the survey team with a copy of their policy titled, Fingernails/Toenails, Care of effective date January 2021. This policy read in part, .The purposes of this procedure are to clean the nail bed, to keep nails trimmed, and to prevent infections .Nail care includes a cleaning and regular trimming as needed or desired by resident . 02/07/23 4:00 p.m., during and end of the day meeting with the Administrator and DON the issue regarding Resident #4's fingernails was reviewed. No further information regarding this issue was provided to the survey team prior to the exit conference. 47299 3. For Resident #8, the facility staff failed to provide nail care. Resident #8's listed diagnoses included, but were not limited to, dementia, dysphagia, heart failure, hypertension and chronic obstructive pulmonary disease. Resident #8's most recent Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/16/23 indicates under Section C., Cognitive Patterns, that resident is rarely to never understood, that they have impaired long and short-term memory, and decision making is severely impaired. In Section G., Functional Status, the resident is coded as needing extensive physical assistance of one person for personal hygiene. Under Section E. Behavior, there were no instances of care refusals coded. On 2/6/23 at 2:30 P.M. During the initial tour, surveyor met observed resident #8 and noted that their fingernails were long and jagged with debris underneath. Resident was nonverbal and unable to answer surveyor questions regarding nail care. On 2/7/23 at 9:10 A.M. Surveyor again noted that resident #8's nails were long, jagged and had yellow and brown debris caked under them. Surveyor interviewed C.N.A. #3 at this time. When asked about how often nail care is provided to resident's they stated, We do manicures once a week but some residents refuse. When asked about resident #8, C.N.A. #3 stated that resident is one who refuses. Surveyor asked where this would be documented and they replied, In the care plan. On 2/7/23 at 9:15 A.M. surveyor interviewed Certified Nursing Assistant (C.N.A.) #2 who was in resident #8's room and stated they were just finishing her morning care. When asked if resident refuses care such as nail care, they stated, No, not really and then stated resident is usually Just stiff. 2/7/23 at 2:30 P.M. Observed resident #8 sitting in the day room eating popcorn, nails remained long, jagged and with debris underneath. 2/7/23 2:56 P.M. surveyor met with the Director of Nursing (DON) and asked them to look at resident #8's fingernails. DON stated that resident can be resistive to care at times. Surveyor asked if that would be included in the resident's care plan and DON stated it would be. Surveyor requested the policy regarding nail care, face sheet, care plan and MDS. Surveyor reviewed resident #8's care plan at 3:00 P.M. on 2/7/23 and was unable to locate a focus, goal or intervention addressing care refusals. End of day meeting 2/7/23 4:05 P.M. Surveyor reviewed concerns regarding nail care with DON and Administrator. 2/8/23 8:18 A.M. Resident observed by surveyor sitting in the day room. Nails were clean and trimmed. 2/8/23 at 9:45 A.M. DON brought surveyor documents that included the residents care plan. Surveyor noted that there was an activity care plan with a goal statement that read, ________ needs a lot of encouragement during nail care most of the time they will refuse due to agitation. The care plan included a revision date of 2/7/23. Documents also included a nurse's progress note date 2/7/23 10:00 A.M. that read, C.N.A. #3 attempted to trim resident nails at this time, resident started pulling hand back and stating no no. Nail care was stopped at this time due to resident not wanting nail care at this time. A second progress note dated 2/7/23 at 5:33 P.M. read in part, . the resident gets anxious when nails are trimmed. The household coordinator was keeping resident occupied by talking and this nurse cut nails. This nurse was able to cut all nails with minimal distress. 2/8/23 at 12:00 P.M. Surveyor asked DON to clarify if the care plan had been revised for nail care refusals on 2/7/23 and she stated that it had been. 2/8/23 at 3:05 P.M. during end of day meeting surveyor again reviewed concerns regarding nail care with DON and Administrator. no further information was received prior to exit. 34307 4. For Resident #60 the facility staff failed to provide nail care. Resident #60's face sheet listed diagnoses which included but not limited dementia, peripheral vascular disease, type 2 diabetes, and hypertension. The most recent minimum data set with an assessment reference date of 12/27/22 assigned the resident a brief interview for mental status score of 0 out of 15 in section C, cognitive patterns. This indicates that the resident is severely cognitively impaired. Section G, functional status, coded the resident as needing extensive assistance of two-person physical assist in personal hygiene. Resident #60's comprehensive care plan was reviewed and contained a care plan for Potential for decline in ADL (activities of daily living) capabilities Surveyor observed Resident #60 on 02/07/23 at 8:25 am. Resident was sitting up in bed, eating breakfast. Surveyor observed that resident's fingernails were long and jagged, with brownish discoloration. Surveyor was provided with a facility policy entitled Fingernails/Toenails, Care of, which read in part 1. Nail care includes cleaning and regular trimming as needed or desired by resident Surveyor spoke with director of nursing (DON) on 02/08/23 at 9:15 am, and informed them of Resident #60's nails being long, and DON stated that a 100% audit of resident nails had been completed. The concern of Resident #60's nails being long and jagged was discussed with the administrator and DON on 02/08/23 at 3:05 pm. No further information was provided prior to exit.

Based on staff interview, and clinical record review the facility staff failed to ensure 1 of 23 residents was free of unnecessary medications (Resident #26). The findings included: Resident #26 was admitted to the facility with diagnoses that included paranoid schizophrenia, metabolic encephalopathy, dementia, congestive heart failure, pain, osteoarthritis, hypertension, depression, and a history of falls. On the minimum data set assessment with assessment reference date 1/10/2023, the resident scored 1/15 on the brief interview for mental status and was assessed as psychosis or behaviors affecting care. The resident weighed 79 pounds. Resident #26 was chosen for medication regimen review. During clinical record review on 2/08/2023, the surveyor found monthly pharmacy reviews were conducted from admission. The recommendation dated 8/17/2022 contained several suggestions including: 5) remains on iron 325 mg every 48 hours for supplement. Non coated iron is very likely to cause GI disturbance /constipation/GI pain. Consider using Slow-FE as this is more gentle on the GI system. The family nurse practitioner (FNP) wrote change to Slow-FE of comparable dose on 8/18/2022. The October 2022 medication administration record (MAR) showed staff started administering Slow-FE Extended Release 142 (45 Fe) MG Ferrous Sulfate ER) Give 1 tablet by mouth every 48 hours for Supplement every other day on 8/19/22. Staff continued administering Ferrous Sulfate Tablet 325 (65 Fe) MG Give 1 tablet by mouth every 48 hours for Supplement. The resident then received iron supplements daily instead of every 48 hours from October 19/2022 through 2/8/23. A pharmacy recommendation dated 12/23/2022 stated Mid November [resident #26] started on alternating orders-Slow-Fe alternating days with regular iron 325 mg. As this is fairly atypical/ patients usually take one or the other just for simplicity and the Slow-Fe is kinder on the GI tract, consider using only one of these or note that it is appropriate as is. The FNP (not the one who wrote the 8/18/22 recommendation) accepted the recommendation on 12/29/22 and wrote an order to change to current dose of Slow-Fe daily and discontinue regular iron. The resident received Slow-Fe daily from 12/29 through the survey date of 2/8/2022. During a summary meeting on 2/8/2022 which included the administrator and director of nursing, the surveyor notified staff of the concern that the pharmacy recommendation was to replace the iron order with Slow FE rather than add another dose and that the physician and nurse practitioner had not intended to continue the order for regular iron when the order for Slow-Fe was written and that the physician and nurse practitioner had not intended to double the dose of iron the resident received.

Based on staff interview, clinical record review, and facility document review, the facility staff failed to provide laboratory services to meet the needs of the resident for 1 of 23 residents in the survey sample, Resident #83. The findings included: For Resident #83, the facility staff failed to obtain a urinalysis with reflex and a complete blood count (CBC) lab test as ordered by the physician on 2/04/23. Resident #83's diagnosis list indicated diagnoses, which included, but not limited to fracture of T9-T10 Vertebra, Paroxysmal Atrial Fibrillation, Neuromuscular Dysfunction of Bladder, Hypertensive Heart Disease, Chronic Kidney Disease, and Pneumonia. The most recent admission minimum data set (MDS) with an assessment reference date (ARD) of 1/10/23 assigned the resident a brief interview for mental status (BIMS) summary score of 0 out of 15 indicating Resident #83 was severely cognitively impaired. A review of Resident #83's clinical record revealed physician's orders dated 2/04/23 for a urinalysis with reflex and a CBC lab test; surveyor was unable to locate results for lab tests. On 2/07/23 at 2:04 pm, surveyor spoke with the director of nursing (DON) regarding the lab tests. The DON stated the labs were missed over the weekend and it was an oversight. The DON further stated staff have discussed the missed labs with the physician and family and both agreed that the labs were no longer needed as the resident went on hospice care yesterday. Resident #83's clinical record included a nursing progress note dated 2/07/23 at 1:31 pm stating in part Dr. [name omitted] made aware of missed labs over weekend. Patient is now hospice and family does not wish to have these labs repeated. Surveyor requested and received the facility policy entitled Lab and Diagnostic Test Results - Clinical Protocol which read in part Purpose 1. The physician/practitioner will identify and order diagnostic and lab testing based on the resident's diagnostic and monitoring needs. 2. The staff will process test requisitions and arrange for tests . On 2/08/23 at 3:04 pm, surveyor met with the administrator and DON and discussed the concern of staff failing to obtain the physician ordered urinalysis and CBC for Resident #83. No further information regarding this concern was presented to the survey team prior to the exit conference on 2/08/23.

Based on observation, staff interview, clinical record review the facility staff failed to review and revise the comprehensive care plan for 2 of 26 residents, Resident #38 and Resident #83. The findings included: 1. For Resident #38 the facility staff failed to revise the care plan for COVID status. Resident #38's face sheet listed diagnoses which included but not limited to aphasia, type 2 diabetes mellitus, hypertension, depression and dementia. Resident #38's most recent minimum data set with an assessment reference date of 01/05/23 assigned the resident a brief interview for mental status score of 13 out of 15 in section C, cognitive patterns. This indicates the resident is cognitively intact. Resident #38's comprehensive care plan was reviewed and contained a care plan for . (Resident #38) is positive for COVID-19 This care plan was initiated on 12/29/2022. Goals for this care plan included . care and symptoms will be managed per CDC (Centers for Disease Control) guidelines and facility protocol This goal has a revision date of 01/31/2023. Resident #38's clinical record was reviewed and contained a physician's order summary which read in part Remain on droplet isolation every shift for monitoring for 5 days-start date 12/29/2022, end date-01/03/2023 and Remain droplet isolation every shift for monitoring until 01/09/2023-start date 01/02/2023, end date-01/09/2023 Surveyor observed Resident #38 on 02/06/23 at 2:20 pm. Resident was resting on bed with eyes closed. There was no signage indicating resident was on any type of contact precautions. Surveyor observed Resident #38 on 02/07/23 at 8:30 am. Resident was resting on bed. Surveyor asked resident is they had COVID-19, and resident replied that they did not, but had had it in the past. Surveyor spoke with the director of nursing (DON) on 02/08/23 at 8:50 am. Surveyor asked DON how often care plans were updated and DON stated that anytime there was a change in resident's status the care plan should be updated to reflect the change. Surveyor pointed out that Resident #38 was care planned for being COVID positive, and DON stated that should have been resolved and that they would take care of it immediately. DON provided surveyor with an updated care plan on 02/08/23 at 9:15 am. The concern on not revising Resident #38's care plan to reflect current status was discussed with the administrator and DON on 02/28/23 at 3:05 pm. No further information was provided prior to exit. 42353 2. For Resident #83, the facility staff failed to revise the comprehensive person-centered plan of care following discovery of a deep tissue injury (DTI) to the right heel. Resident #83's diagnosis list indicated diagnoses, which included, but not limited to fracture of T9-T10 Vertebra, Paroxysmal Atrial Fibrillation, Neuromuscular Dysfunction of Bladder, Hypertensive Heart Disease, Chronic Kidney Disease, and Pneumonia. The most recent admission minimum data set (MDS) with an assessment reference date (ARD) of 1/10/23 assigned the resident a brief interview for mental status (BIMS) summary score of 0 out of 15 indicating Resident #83 was severely cognitively impaired. A review of Resident #83's clinical record revealed a physician's order dated 2/03/23 to apply Betadine every day and evening shift to the left and right heels. Surveyor reviewed the resident's current comprehensive person-centered plan of care and was unable to locate documentation of any treatment needs to the right heel. On 2/07/23 at approximately 2:05 pm, surveyor spoke with the director of nursing (DON) regarding Resident #83's right heel. The DON stated the area to the right heel was acquired and discovered on the day of the treatment order, 2/03/23. Resident #83's clinical record included a late entry nursing progress note dated 2/07/23 for 2/03/23 stating in part Nurse came to writer stated that she noted a skin area to patients lateral right heel, after assessing area writer noted 1 x 1 DTI [deep tissue injury] area to lateral right heel. NP [nurse practitioner] and RP [responsible party] made aware and new order placed for betadine and applied'. On 2/08/23 at 1:28 pm, surveyor spoke with the MDS Coordinator who stated the area to Resident #83's right heel was new and should have been care planned on 2/03/23 and they are providing education to the nurses to update the plan of care when initiating treatment. Surveyor requested and received the facility policy entitled, Care Plans, Comprehensive Person-Centered which read in part .14. The interdisciplinary team must review and update the care plan: a. when there has been a significant change in the resident's condition . On 2/08/23 at 3:04 pm, surveyor met with the administrator and DON and discussed the concern of staff failing to revise Resident #83's comprehensive care plan to include a DTI to the right heel. No further information regarding this concern was presented to the survey team prior to the exit conference on 2/08/23.

Based on observation, family interview, staff interview and facility policy review the facility failed to ensure a clean, comfortable, and homelike environment as for 3 of 23 Residents (Resident #26, #8, and #50). The findings included: 1. For Resident #26, facility staff failed to clean the wheelchair the resident used when it was visibly soiled. Resident #26 was admitted to the facility with diagnoses that included paranoid schizophrenia, metabolic encephalopathy, dementia, congestive heart failure, pain, osteoarthritis, hypertension, depression, and a history of falls. On the minimum data set assessment with assessment reference date 1/10/2023, the resident scored 1/15 on the brief interview for mental status and was assessed as psychosis or behaviors affecting care. On 2/6/2023 at 2:30 PM, the surveyor interviewed the resident's family member concerning life in the facility. The family member stated that floors and the wheelchair were often dirty. The family member speculated staff appear to clean once per week. The surveyor observed the wheelchair had dried drips on arm and footrests and what looked like splashes on the frame and food in treads. There was also a powder on seat and behind back rest. The floors had some visible dirt and debris. On 2/7/2023 from 10 AM to 1 PM, the surveyor observed the resident in the wheelchair in the common area of the nursing unit. The resident was dressed in clean clothing and appeared well-groomed. The wheelchair had the same stains observed on 2/6/2023. The floors in the room appeared to have the same dirt and debris the surveyor saw the previous day. On 2/7/2023, the surveyor reported the concern with the cleanliness of the room and wheelchair during a summary meeting that included surveyors and the administrator and director of nursing. The facility policy titled Cleaning and Disinfection of Wheelchairs/Power chairs dated January 2021 under Policy /Procedure states: 1. Staff are to monitor the cleanliness of resident's wheelchairs/powerchairs. Staff are to ensure they clean wheelchairs twice a year and as needed if a wheelchair/power chair becomes dirty. On 2/8/2023, the resident's floor was clean. Physical therapy staff had assessed the resident's positioning in the chair and replaced the chair with one that better fit the resident's needs. 47299 2. For resident #8 the facility failed to maintain a clean and sanitary wheelchair. Resident #8's diagnosis list includes but is not limited to, dementia, dysphagia, heart failure, hypertension and chronic obstructive pulmonary disease. Resident #8's most recent Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/16/23 indicates under Section C., Cognitive Patterns, that resident is rarely to never understood, that they have impaired long and short-term memory, and decision making is severely impaired. In Section G., Functional Status, the resident is coded as needing extensive physical assistance of one person for personal hygiene. On 2/6/23 at 3:11 P.M. Surveyor observed resident lying in her bed with wheelchair at bedside. Wheelchair was dirty, heavily soiled with food particles and other debris on the footrests, frame, support bars, seat cushion, and back support had dried brown matter smeared on it. 2/7/23 at 9:10 A.M. Surveyor observed resident still in bed. Wheelchair was dirty with food particles caked on frame and foot pedals as well as brown material on the back rest of the chair. 2/7/23 2:56 P.M. Surveyor asked the Director of Nursing (DON) to look at resident #8's chair. Resident was up in the chair seated in the day room. Chair remained heavily soiled with debris. Surveyor requested the policy for wheelchair cleaning. DON stated that chairs are cleaned on an as needed basis. 2/7/23 4:05 P.M. during the end of day meeting with the Administrator and DON, surveyor reviewed concerns with wheelchairs. Surveyor asked for a policy for cleaning wheelchairs and DON stated that the wheelchairs are already clean, I let them know how nasty they were, and they are already clean. Chair observed to be clean 2/8/23 at 8:05 A.M. 2/8/23 at 8:08 A.M. surveyor interviewed C.N.A.#3 about the process for cleaning chairs, they replied, Let me check and get back to you. 2/8/23 8:16:23 Surveyor Interviewed Licensed Practical Nurse (L.P.N.) #2, about the policy for cleaning wheelchairs. They stated, usually, I'm not 100% sure, but it's done on night shift because residents don't need their chairs at night. I'm not sure of the schedule or anything. 2/8/23 9:45 A.M. Surveyor received a copy of the policy entitled, Cleaning and Disinfecting of Wheelchairs/Power Chairs with an effective date of 1/21/23, which read in part, Staff are to monitor the cleanliness of resident's wheelchairs/power chairs. Staff are to ensure they clean wheelchairs twice a year and as needed if a wheelchair/power chair becomes dirty. 2/8/23 at 3:05 P.M. during end of day meeting surveyor again reviewed concerns regarding resident's wheelchair with DON and Administrator. No further information was received prior to exit. 3. For resident #50 the facility failed to maintain a clean and sanitary power chair. Resident #50's diagnosis list includes but is not limited to, Cerebral Vascular Accident (CVA) with right sided hemiplegia, anxiety, depression, hypertension, and anemia. Resident #50's annual MDS with an ARD of 11/3022 is coded under Section C., Cognitive Patterns a BIMS score of 15 indicating resident is cognitively intact. In Section G., Functional Status resident is coded as 8/8 for walking meaning this activity did not occur, and under locomotion on and off the unit, resident is coded as independent. On 2/6/23 at 2:45 P.M. and during initial tour, surveyor observed resident #50 sitting in power chair that was soiled with dust, and food debris that was caked on bilateral foot pedals. Surveyor asked resident if they knew how often chair was cleaned and they stated, twice a year. Surveyor asked if it had been a while since the last time and they stated that it had, and I can't even remember when the last time was. 2/7/23 2:56 P.M. Surveyor asked the Director of Nursing (DON) to look at resident #50's chair. Resident was up in the chair seated in the day room. Chair remained soiled with debris. Surveyor requested the policy for wheelchair cleaning. DON stated that chairs are cleaned on an as needed basis. 2/7/23 4:05 P.M. during the end of day meeting with the Administrator and DON, surveyor reviewed concerns with resident #50's power chair. Surveyor asked for a policy for cleaning wheelchairs and DON stated that the wheelchairs are already clean, I let them know how nasty they were, and they are already clean. Chair observed to be clean 2/8/23 at 8:05 A.M. 2/8/23 at 8:08 A.M. surveyor interviewed C.N.A.#3 about the process for cleaning chairs, they replied, Let me check and get back to you. 2/8/23 8:16:23 Surveyor Interviewed Licensed Practical Nurse (L.P.N.) #2, about the policy for cleaning wheelchairs/power chairs. They stated, usually, I'm not 100% sure, but it's done on night shift because residents don't need their chairs at night. I'm not sure of the schedule or anything. 2/8/23 9:45 A.M. Surveyor received a copy of the policy entitled, Cleaning and Disinfecting of Wheelchairs/Power Chairs with an effective date of 1/21/23, which read in part, Staff are to monitor the cleanliness of resident's wheelchairs/power chairs. Staff are to ensure they clean wheelchairs twice a year and as needed if a wheelchair/power chair becomes dirty. 2/8/23 at 3:05 P.M. during end of day meeting surveyor again reviewed concerns regarding resident's wheelchair with DON and Administrator. No further information was received prior to exit.

Based on staff interview, facility document review, clinical record review, and in the course of a complaint investigation, the facility staff failed to follow professional standards of nursing practice for 1 of 19 residents (Resident #118) when the central line was removed improperly and the resident became unresponsive and was sent to the emergency room and the facility staff failed to follow the facility policy for the care and treatment of [REDACTED]. The findings include: For Resident #118, the facility staff failed to ensure the facility staff followed professional standards of nursing practice for the removal of a central line that had been placed in the resident's jugular vein into the [MEDICATION NAME] vein. Registered Nurse #3 removed the central line without central line removal guidance and removed the central line based on the facility policy on PICC line removal and the facility staff provided no evidence of competency in the removal of the central line. The facility staff failed to follow the facility policy on flushing central lines. Resident #118's central line was not flushed during her long term care admission [DATE] through [DATE]. Information about central venous catheters and PICC (peripherally inserted central catheters) was found in Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 10th edition, 2004, pages ,[DATE]. The [MEDICATION NAME] vein is the most common vessel used, because the [MEDICATION NAME] area provides a stable insertion site to which the catheter can be anchored, allows the patient freedom of movement, and provides easy access to the dressing. The jugular or femoral vein also may be used. Non tunneled central catheters are available in single, double, and triple lumens. To ensure accessibility, triple lumen [MEDICATION NAME] catheters should be used, because it offers three (3) ports for various uses. Tunneled central catheters are for long term use and may remain in place for many years. These catheters are cuffed and can have single or double lumens. These catheters are surgically inserted. They are threaded under the skin to the [MEDICATION NAME] vein, and the distal end of the catheter is advanced into the superior vena cava 2 to 3 cm above the junction of the right atrium. Peripherally inserted central catheters (PICC) are used for intermediate term (3 to 12 months) IV therapy in the hospital, long term care, or home setting. These catheters may be inserted at the bedside or in the outpatient setting by a specially trained nurse. The basilic or cephalic vein is accessed through the antecubital space, and the catheter is threaded to a designated location, depending on the type of solution to be infused. Registered Nurse #3 removed the central line on [DATE] at 10:30 p.m. and the resident was found unresponsive 3 hours and 45 minutes later ([DATE] at 2:15 a.m.) to verbal and tactile stimuli, skin moist, pupils pinpoint, oxygen saturation on room air was 95%, right knee was mottled and feet were cold and slightly cyanotic, pulse ,[DATE], accucheck (blood sugar) was 185, [DEVICE] patent/intact with placement verified by auscultation, head of bed elevated, attempted to notify responsible party of decline in status. Message left to call facility. [DATE] 2:20 a.m. Order noted from MD to send to emergency room (name omitted) to eval (evaluate) and tx (treat). [DATE] 2:22 a.m. 911 called for transport." Resident was sent to the emergency room with [MEDICATION NAME] 1.2 administered enroute to the emergency room by EMS (emergency medical services). Resident expired [DATE] after neurology examined Resident #118 on [DATE] and determined that she had a neurological examination compatible with widespread [MEDICAL CONDITION]. Post [MEDICAL CONDITIONS] and air emboli are etiologies of this date. Prognosis for meaningful recovery due to either of these entities is not good, worse with both together. "Impression: 1. [MEDICAL CONDITIONS] 2. Air emboli. Plans/Suggestions: I have endorsed the family's decision to withdraw full support." Resident #118 had her breathing tube removed [DATE]. Resident #118's clinical record was reviewed [DATE] and [DATE]. Resident #118 was admitted to the facility [DATE] with [DIAGNOSES REDACTED]. Resident #118's 5 day admission minimum data set (MDS) assessment with an assessment reference date (ARD) of [DATE] revealed Resident #118 had a cognitive summary score of 13 out of 15 in Section C Cognitive Patterns. Section I Active [DIAGNOSES REDACTED]. Section O. Special Treatments, Procedures, and Programs did not have IV medications checked. The clinical record also revealed the referring hospital discharge summary dated [DATE]. The summary revealed CT brain showed no evidence of acute intracranial process. Old right temporal and right lentiform (lens shaped) nuclear artifacts were noted. CT angiogram of the neck showed no hemodynamically significant stenosis (blockage). CTA head-no aneurysm noted. She was intubated (breathing tube in throat) and required mechanical ventilation on [DATE]and was extubated (breathing tube removed) on [DATE]. She required re-intubation on [DATE] for hypercarbic [MEDICAL CONDITION]. She was extubated on [DATE] but remained tachypneic (abnormally rapid respirations). CT scan of the chest showed bilateral pleural effusions with a large left effusion. Resident #118 underwent chest tube drainage (a catheter inserted through the thorax into the chest cavity for removing air or fluid, used after chest or heart surgery or pneumothorax). Swallow evaluation suggested oropharnygeal dysphagia with signs of aspiration. A PEG (percutaneous endoscopic gastrostomy-a tube placed in the stomach for feeding) was placed on [DATE]. Chest x-ray done [DATE] had the following impression and read "Stable chest exam. Small bilateral pleural effusions persist. Left chest tube is unchanged in position as is the NG (nasogastric tube) and right IJ (internal jugular) central venous catheter. The chest tube was removed [DATE]. The chest x-ray did document "Central venous catheter is in place. The left sided chest tube has been removed." The facility admission history and physical dated [DATE] did not reveal orders for the care and treatment of [REDACTED].#118 had a central line. The nurse's admission note dated [DATE] at 10:30 p.m. read in part: "Resident is alert and able to verbalize needs, some confusion is noted regarding place and time. Resident is noted to have triple lumen in right jugular." The admission physician orders [REDACTED]. Telephone orders dated [DATE], [DATE], [DATE] and [DATE] did not reveal physician orders [REDACTED]. an order written [REDACTED]." Resident #118 was seen by the registered dietician administrative staff #6 on [DATE]. No documentation of the central line. The interim care plan dated [DATE] had no section marked for placement of the central line or the care of the central line. The nurse's note on [DATE] and [DATE] did not reveal care of the central line. The nurse's note of [DATE] at 11:30 a.m. did read in part "Central line remains to right [MEDICATION NAME]." The [DATE] medication administration records (MARs) and the [DATE] treatment administration record (TAR) did not reveal documentation of the care of the central line. The [DATE] 9:30 p.m. nurse's note read in part "Visiting with family most of the day and evening." The [DATE] 10:30 p.m. nurse's note read " PICC (peripherally inserted central catheter) line in R (R in a circle and indicated right) [MEDICATION NAME] neck area removed under aseptic technique no problem removing PICC line which was about 32 cm (centimeters) long. Removed with blue tip intact. No bleeding noted. Pressure drg (dressing) applied. No c/o (complaints of) pain or discomfort. No s/s (signs/symptoms) of any distress noted." Signed by registered nurse #3. The [DATE] 2:15 a.m. nurse's note read "resident unresponsive to verbal and tactile stimuli, skin moist, pupils pinpoint, oxygen saturation on room air was 95%, right knee was mottled and feet were cold and slightly cyanotic, pulse ,[DATE], accucheck (blood sugar) was 185, [DEVICE] patent/intact with placement verified by auscultation, head of bed elevated, attempted to notify responsible party of decline in status. Message left to call facility. [DATE] 2:20 a.m. Order noted from MD to send to emergency room (name omitted) to eval (evaluate) and tx (treat). [DATE] 2:22 a.m. 911 called for transport." The surveyor reviewed the hospital notes on [DATE]. The emergency department physician note dated [DATE] at 7:23 a.m. read "Had central line (IJ) removed yesterday morning at 11:00 a.m. Pt was found unresponsive yesterday afternoon at about 1:30 p.m. by nursing home staff, and has remained unresponsive to noxious stimuli since then. Oxygen saturation was ,[DATE]% on arrival of EMS to scene. EKG obtained by EMS showed ST elevations. Physical exam as follows: Head: Normocephalic and atraumatic Eyes: Conjunctivae are normal. Right eye exhibits no discharge. Left eye exhibits no discharge. No sclera icterus. Gaze deviated to right bilaterally Pupils 2 mm (millimeters), not reactive Neck: No JVD present. No tracheal deviation present Cardiovascular: Normal rate, regular rhythm, normal heart sounds and intact distal pulses. Exam reveals no gallop or rub. No murmur heard. Pulmonary/Chest: Effort normal and breath sounds normal. No accessory muscle usage. No respiratory distress. She has no decreased breath sounds. She has no wheezes. She has no rales. She exhibits no tenderness. Abdominal: Soft. Normal appearance and bowel sounds are normal. She exhibits no distension. There is no tenderness. There is no rebound, no guarding, no tender mass at McBurney's point and negative Murphy's sign. Musculoskeletal: She exhibits no [MEDICAL CONDITION] and no tenderness. Lymphadenopathy: She has no cervical adenopathy Neurological: She has normal sensation, normal strength, and intact cranial nerves. Pt (patient) obtunded GCS 3 (Glasgow coma scale) EKG reading and Cardiac Monitor: Interpreted at [DATE] at 0311. Rate is 127 bpm (beats per minute). [MEDICAL CONDITION]. ST elevation in anterior leads. No reciprocal changes. Treatments and ED Course: [DATE] 3:19 a.m. Patent arrived as heart alert. Cardiology is at bedside. Will intubate after CT obtained. 3:40 a.m. Head CT results listed below 3:50 a.m. 20 mg Etomidate administered. 3:50 a.m. [MEDICATION NAME] administered. 3:52 a.m. Intubated the patient 4:40 a.m. Spoke with patient's family at bedside. Daughter claims that she saw patient last night at which time patient seemed to be in normal condition. Confirms patient is full code. 5:00 a.m. Paged hospitalist for admission 5:56 a.m. Will be admitted CT Head Impression: There is evidence of old encephalom alacia in the right frontoparietal and parietal temporal lobes. There are multiple areas of decreased attenuation seen throughout the cerebrum most likely representing small lobules of fat. However, evaluation of Hounsfield units is limited given their small size. Other etiologies could include foci of pneumocephalus. However, this is less likely given the appearance. MRI Brain: Innumerable foci of sulcal, cisternal, and intraparenchymal low-density noted bilaterally on concurrent head CT correlate to foci of susceptibility artifact on brain MRI confirming that these are indeed pockets of gas (as opposed to lobules of fat seen in the context of recently ruptured dermoid, often mistaken as pneumocephalus on CT imaging). After gadolinium administration, there is diffuse abnormal leptomeningeal and pachymeningeal enhancement as well as abnormal enhancement within the perivascular Virchow-robin spaces throughout both cerebral hemispheres, right greater than left. Right cerebellar foliar enhancement is also seen although less conspicuous. Labs: Troponin 1, Istat 9.68 BNP .0 CK-MB 40.2 Procedures: The patient was [MEDICATION NAME] and under direct visualization, a 7.5 mm cuffed endotracheal tube was placed through the vocal chords into the trachea Critical Care Time: The reason for providing this level of medical care for this critically ill patient was due to a critical illness that impaired one or more vital organ systems such that there was a high probability of imminent or life threatening deterioration in the patient's condition. This care involved high complexity decision making to assess, manipulate, and support vital system functions, to treat vital organ system failure and to prevent further life threatening deterioration of the patient's condition. Final Impression: 1. Unresponsiveness 2. STEMI (ST elevation [MEDICAL CONDITION] infarction) 3. Acute [MEDICAL CONDITION] 4. Acute [MEDICAL CONDITION] 5. Air embolism, major 6. [MEDICAL CONDITION] 7. Cardiogenic shock 8. Chronic systolic heart failure 9. Diabetes mellitus 10. [MEDICAL CONDITION] 11. [MEDICAL CONDITION] 12. Leukocytosis 13. Tachycardia 14. Unresponsive episode The hospital admitted d [DATE] 2:21 p.m. gave a brief history of present illness described as "Female who presents to the ED after being found unresponsive at nursing facility. Patient recently discharged to SNF after a 6 week hospital stay, where she was treated for [REDACTED]. She had right IJ pulled around 11pm. The family states that she was doing better and on the mend and then was found unresponsive later. In the ED, she was totally unresponsive. She was intubated for airway protection. Her EKG showed ST elevation indeed. An initial troponin was near 10. Her blood pressures have been low. Her propofol sedation was stopped. Versed was started. A head CT done in the ED showed what appears to be multiple areas of air consistent maybe with air emboli. The question mark was whether this was related to the right IJ that was pulled earlier. Additionally, the ?? Is whether this was also possibly a precipitant of her STEMI? Currently she remains tenuous at best. Neurology was contacted for a quick read on this head CT. Other #9 (hospital neurologist) confirms that this does look like air. The neurology consult dated [DATE] read in part "This woman has a neurological examination compatible with widespread [MEDICAL CONDITION]. Post [MEDICAL CONDITIONS] and air emboli are etiologies of this date. Prognosis for meaningful recovery due to either of these entities is not good, worse with both together. Impression: 1. [MEDICAL CONDITIONS] 2. Air emboli. Plans/Suggestions: I have endorsed the family's decision to withdraw full support." Patient admitted to the ICU ventilated and requiring pressors for BP maintenance. Discussed prognosis with relatives, including patient's husband and daughter. After a brief conversation, they have requested withdrawal of care due to insignificant possibility of any quality of life in the event of recovery. We have discussed a proposed plan to stop all monitoring and drugs and give [MEDICATION NAME] and [MEDICATION NAME] if needed for comfort and anxiety. The surveyor interviewed registered nurse #3 on [DATE] at 6:00 p.m. about the incident of [DATE]. Upon the surveyor's introduction to R.N. #3, the first comment made by R.N. #3 was "Do I have to admit to my stupidity? She had a line in her right neck (R.N. #3 pointed to the base of the surveyor's neck) and I thought it was a PICC (peripherally inserted central catheter). I checked the order. The order said D/C PICC Line." When the surveyor informed R.N. #3 that the order was to remove a central line, she look stunned and stated "I thought the order was to D/C (discontinue) a PICC line." She then stated she pulled out the policy and procedure manual and reviewed the policy and procedure for a PICC line. She stated "I then explained the procedure to the resident. I always tell them what I am doing." She stated Resident #118 was positioned at a 45 degree angle in bed. I had my dressings ready. I gently pulled it out. I applied a pressure dressing. I always have to have my vaseline gauze. I try to backtrack and make sure I document length. She was fine with the removal and fine after the PICC line was removed. The incident happened on 11- 7 shift. I had already left to go home before knowing of issue. L.P.N. #5 worked that night. If I don't know how to do a procedure, I look it up. I did look up central line removal. I should have turned her head to the side and tell her to hold her breath while I removed the line. I do know the difference between a PICC line and a central line." She stated after the incident, she was interviewed by a lawyer but was unable to recall who the lawyer represented or what day the interview occurred. The surveyor interviewed licensed practical nurse #5 on [DATE] at 5:18 a.m. She stated she had little recollection of the events of [DATE]. "I am all over the building as a supervisor." She was asked what nurses in the facility remove central lines and PICC lines. She stated "Usually an RN removes PICC lines. L.P.N.s don't remove central lines. We rarely have to remove central lines." She also was asked what the facility protocol for flushing central lines. She stated "Usually flushed every shift and with each medication administration." The surveyor interviewed the current staff educator registered nurse #4 on [DATE] at 9:28 a.m. Administrative staff #4 was also present during the interview. The surveyor asked the R.N. educator for the training she provided to new nursing hires. She stated this was her first group of new nurses and she had no packets together yet. "I review medications, admissions, discharges, incident reporting, facility policies, incontinence program, and falls."During the interview, R.N. #4 was asked for a policy on the removal of central lines. She stated "We don't have a policy for removal. We only have a policy on care including dressing changes. RNs don't remove central lines here. We (RNs) don't even remove central lines in the hospital. It's considered a medical procedure. RNs have removed PICC lines. Usually send resident out to have PICC lines removed. The process for removal of central lines in the hospital has changed. The resident has to lay flat, hold their breath, remove the central line, apply pressure for ,[DATE] minutes, and now to lay flat 30 minutes to 1 hour after the central line has been removed." The surveyor asked for competencies for RNs who have been deemed competent to remove central lines. She stated "I don't have any competencies. I am new to my position and I don't have access to the previous educator's training." The surveyor requested a copy of the orientation checklist on [DATE]. The checklist was never provided prior to the exit on [DATE]. The surveyor informed the administrator, the director of nursing, and the medical director of the above concern where R.N. #3 removed the central line from Resident #118 and was subsequently found unresponsive and sent to the emergency room for evalaution and treatment on [DATE] at 1:40 p.m. The administrator stated she was not aware of any documentation of the incident of [DATE] and [DATE]. The director of nursing also stated she had no knowledge of the incident of [DATE] and [DATE] until the article in the newspaper. The medical director stated he attended a deposition (no date given) and spoke with the family. The deposition, he stated, included conversation that central line removals would not be done in nursing homes. He stated he informed them that he would look into maintaining central lines here. He stated the HR (human resources) director was also in the meeting. The medical director stated that by [DATE], he hoped things would settle down with nursing policies. He stated he spoke with the director of nursing (no date provided), decided to send any resident out if they are admitted with a central line and replace with a PICC line. The surveyor requested the facility policy on the care of a central line from 2013 on [DATE]. The policy tilted Medication Administration Central IV Line, revised ,[DATE] read in part under "CV Catheters (Hickman): General Information: 1. Central venous catheters should be [MEDICATION NAME] following each infusion, after blood withdrawals or before an interruption in the infusion. 2. The catheter will be flushed at least daily, if not infusing solutions. 3. Flushing protocols will be performed per a physician's orders [REDACTED]. -type of catheter -catheter/extension set volumes -use of positive pressure flushing to prevent reflux of blood into the catheter -should not alter resident's clotting factors 4. Physician may order a ,[DATE] cc Normal saline flush pre and post infusion. 5. The minimum dose of [MEDICATION NAME] saline is 2.0 cc to 3.0 cc of 100 units/cc for adults. The policy did not reveal instructions for the removal of a central line; the policy did reveal instructions for the removal of a PICC line and read "PICC lines will be removed only by staff trained in this procedure." During the meeting with the administrator, the director of nursing and the medical director on [DATE] at 1:40 p.m., the surveyor asked the medical director what would be possible complications from the removal of a central line or a PICC line. He replied "thrombus or air emboli; wouldn't anticipate a pneumothorax from removal, only from insertion of central line." The surveyor also asked the medical director if central lines were removed by registered nurses in the nursing home. He stated he wasn't sure about long term care but in the hospital, it was a medical procedure. He stated the resident needed to be in the Trendelenburg position and the line [MEDICATION NAME]. The medical director also stated that the facility will not accept residents with a central line. "As of [DATE], we don't accept residents with a central line. We don't remove central lines or PICC lines here." The former quality assurance registered nurse #7 came into the meeting on [DATE] at 2:00 p.m. She stated as the former QA nurse ([DATE] through February 2014 and interim director of nursing [DATE]- [DATE]/[DATE]), she was not told anything when the central line was removed by registered nurse #3 and the resident was sent to the hospital. She stated the issue was never discussed in quality assurance meetings. The surveyor reviewed the personnel file of registered nurse #3 on [DATE] at 10:00 a.m. provided by the human resources generalist. The employee file revealed her hire date, her license verification, pay rate, and facility write-ups. There were no write ups for [DATE]. The surveyor interviewed the human resources director and the human resources generalist on [DATE] at 3:48 p.m. The human resources director stated on [DATE], she received a complaint from the administrator of Resident #118's estate. The complaint, she stated, involved the care of Resident #118 and the cause of her death. She stated she was not at liberty to tell the surveyor the contents of the complaint. "I can't say anything due to the non-disclosure clause." She stated she contacted the facility insurance company and filed the insurance the same day she received the complaint. She stated the insurance company assigned an attorney. "The attorney contacted me and the administrator (current), lawyer, and I met on [DATE]. He wanted to look at the file and speak with the employee. He talked to R.N. #3 but I have no idea what they discussed. We sent him a copy of the file. R.N. #3 continued to work and is still working at the facility. Discussed the incident with the new medical director hired [DATE] (no date of the discussion provided) and he went to the mediation. By changing the policy we felt we had fixed the problem. We had a mock survey in [DATE] or February 2014 and no issues were found. We got nothing from the hospital. There was no admission from the facility about the facility being at fault. Interrogatories were done by the lawyer." On [DATE], she stated the judge approved the settlement. "The settlement and mediation had to be approved by a judge. The facility never admitted liability. I can't say anything because of the non disclosure agreement." The facility did provide a copy of the policy and procedure from ,[DATE] for Medication Administration Central IV Line. The changes made were the "Removal of the PICC line" from the ,[DATE] policy. The facility staff provided the policy and procedure for Medication Administration Central IV Line, revised [DATE] on [DATE] at 3:50 p.m. The last line in the policy read "AT No Time Will Any Central or PICC Line Be Removed At This Facility. ALL Patients are to be sent out to RMH or LGH at [MEDICATION NAME] radiology for their removal. Please call DON or Medical Director to have this facilitated." No further information was provided prior to the exit conference on [DATE]. This is a complaint deficiency.

Based on observation, staff interview, resident interview, facility document review, and clinical record review, the facility staff failed to identify, assess and treat the development of an unstageable pressure ulcer for 1 of 41 residents (Resident #18). The facility staff also failed to provide treatment to prevent a pressure ulcer for 1 of 41 residents (Resident # 2). The findings include: The facility staff failed to prevent the development of an unstageable pressure ulcer on the resident's right heel. Resident #18 was admitted to the facility on [DATE]. Resident #18's [DIAGNOSES REDACTED].. A review of Resident #18's clinical record revealed on the most recent minimum data set (MDS) with an assessment reference date of 11/1/13, the facility staff assessed the resident to understand and be understood and as having no problems with short and long term memory. He was assessed as needing assistance of two persons in activities of daily living and he was coded to have a stage 2 pressure ulcer on his left heel. The right heel was not coded. Resident #18 had a tube feeding of [MEDICATION NAME] 1.5 at 60 cc per hour. But also takes a mechanical soft diet. Resident #18 ' s care plan was reviewed on 2/5/14 to reveal under Problem/Need identified: pressure ulcer #16 the following updates read: " Consult wound care nurse as needed. 9/6/13, L heel wound cleansed N.S., and allevyn border applied QOD (every other day) PRN (as needed). 10/2/13 Area to buttocks- TX (treatment) as indicated. 12/30/13 Area to (L) heel - TX as indicated. " There was no other wound care documentation located in the care plan. On 2/5/14 at 8:35am during ADL (activities of daily living) care, the surveyor observed the resident ' s skin. During the observation the surveyor noted that Resident #18 did not have a pressure ulcer on the buttocks. A wound dressing was noted on the left heel. CNA #7 lifted Resident #18 ' s right leg and washed the leg and heel without looking at the right heel. The surveyor asked the CNA to hold the leg up so she could look at the heel. Looking at the heel the surveyor noted a black area with one edge peeling that was unstageable. CNA #7 asked the CNA working with her to go and get the nurse to look at the heel. When LPN #30 entered the room she placed on gloves and began to assess Resident #18 ' s right heel. The surveyor asked if the heel wound was documented. She told the surveyor that the heel wound was boggy and said, " This is not documented that I know of. " At 9:20 am, the surveyor informed the director of nurses of the right heel wound and she would like her to see the heel before the resident went out for a physician ' s visit. The surveyor met the director of nurses, the unit supervisor and LPN #30 at Resident #18 rooms. During the assessment of the wound, the surveyor asked the nurses what was the stage of the wound. The director of nurses said, " It is unstageable. " Resident #18 was asked if the right heel hurt. He replied, " It has a sharp pain at times. " Further review of Resident #18 ' s clinical record revealed his summary of physician's order [REDACTED]. The following order was noted on the POS; 10/20/13 right heel: apply skin prep 2 times a day. A review of the resident ' s treatment record evidenced the following: the physician's order [REDACTED]. However, on 2/4/14 for the 7/3 shift, there was no documentation of the administration of the skin prep. There was no proof of the heel having been assessed or treated on the record. A Braden scale assessment was done on Resident #18 on 2/2/14. His score was 13. A score of 13 placed the resident at a moderate risk for developing a pressure ulcer. Review of Resident #18 ' s nurse ' s notes did not contain any documentation related to the right heel. LPN #4 the wound care nurse was asked for any notes she had on the resident ' s right heel. The wound care nurse gave the surveyor weekly documentation on the left heel. The surveyor told LPN #4 again that she needed any skin assessment documentation for the right heel because of the unstageable wound. She said, " I looked a week ago; it was not there. I didn ' t document the assessment because it wasn ' t there. " On 2/5/14 at approximately 1:30 pm, during a meeting with the director of nurses and the administrator, the wound found on Resident #18 ' s heel was discussed. A copy of the wound care policy and procedure was requested. On 2/6/14 the surveyor was provided with a copy of the facility policy and procedure titled " Skin Integrity/Wound Management. " Under procedure section c.: Licensed Nurse must perform skin assessment as part of full system assessment weekly. On 2/6/14 at 12:40pm, Resident #18 ' s right heel wound was discussed with the director of nurses and the administrator. The director of nurses was asked if she would have expected the wound care nurse to do a weekly skin assessment and document her findings. She said, " I can ' t answer; I am new and am putting new processes in place. I do not know what the staff has been doing here. The administrator said, ' We are developing guidelines. ' " The director of nurses was then asked if she would call the wound avoidable or unavoidable. She said, " Hard to say because he is compromised and my assessment system isn ' t in place. " Prior to exit on 2/6/14 at 7:00pm, no further information was given to the surveyor related to Resident #18 ' s right heel wound. 2. Facility staff failed to follow Resident #2's physician's orders [REDACTED]. Resident #2's clinical record was reviewed on 2/4/14 at 10:00 AM. The resident was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. The latest annual MDS (minimum data set) assessment, dated 6/21/13, coded the resident with slight cognitive impairment, but unimpaired communication skills. The resident needed assistance with most of the ADLs, but a set-up only to eat. She triggered at risk for pressure ulcers and was coded with one stage II pressure ulcer during the look-back period. The latest CCP (comprehensive care plan) updated 11/21/13 did not address the resident's risk for pressure ulcers. The CCP directed staff to assist the resident with her ADLs as needed. The interventions included, "Podiatry consultation and tx as needed." Resident #2's latest physician's orders [REDACTED]." The clinical record contained "Podiatrist Progress Notes." The consult sheet was signed by the attending physician but not dated, under the statement "Podiatrist to see as a consultation for the following...." There were no podiatry notes on this record to indicate the resident had ever been seen. On 2/4/14 at 11:15 AM LPN IV removed the resident's shoes and socks so her feet could be observed. The resident did not have a corn pad between the two toes as ordered by the physician. The sock was inspected, but the corn pad was not found in it either. The 2cd toe of the resident's left foot was observed to twist over top of the great toe and was applying pressure against it. Resident #2's toenails were observed to be extremely long and curling over her toes. The toenails were chipped and split. LPN IV was asked for an assessment and stated, "She needs to see a podiatrist." LPN IV was not sure what had happened to the corn pad that was supposed to be between the two toes, but said another one would be applied immediately. The DON was informed of these findings on 2/6/14 at 3:00 PM. No additional information was provided prior to the survey team exit.

Based on observation, staff interview and clinical record review it was determined the facility staff failed to implement pressure ulcer interventions for 2 of 19 residents (#104 and #119): ~ #104 - Failed to provide physician ordered pressure ulcer treatments. ~ #119 - Failed to assess and treat a pressure area. Findings: 1. Facility staff failed to follow Resident #104's physician ordered pressure ulcer treatments. Resident #104's clinical record was reviewed on 4/1/14 at 3:30 PM. Resident #104 was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. The latest MDS (minimum data set) assessment dated [DATE] coded the resident with severe cognitive impairment. The resident required the assistance of at least one staff member to accomplish all the ADLS (activities of daily living.) Resident #104's MDS documented the resident had one stage II pressure ulcer and that she was at risk for developing new areas.. The latest CCP (comprehensive care plan) updated on 2/22/14 documented Resident #104 was "at risk for pressure ulcer D/T decreased mobility, incontinent of bowel and bladder, total care for all ADLs." The direction to nursing staff was, "Protective/preventive creams/lotions per MD order. Tx (treatment) and TX changes as ordered." The CNA pocket care plan included documentation about the resident's pressure ulcer treatment. The direction to nursing staff were to elevate heels at all times as tolerated. Resident #104's latest physician's orders [REDACTED]. Right lateral ankle, [MEDICATION NAME] daily - cover with dry protective dressing for prevention and prn" and "2. Bilat heels: Apply skin prep once a day and as needed for prevention. The ankle dressing was documented on the April 2014 treatment sheet on the 7 AM to 3 PM shift. The skin prep to the heels was documented as perfoemed on the 11 PM to 7 AM shift. On 4/2/14 at 3:00 PM Resident #104's right ankle dressing was observed to cover the entire foot from the toes to above her ankle. The gauze dressing, dated 4/1/14, was completely covering the heel, so that skin prep could not be applied as documented on 4/2/14 between 11PM and 7 AM. On 4/2/14 at 3:30 PM LPN I was observed to change the dressing on Resident #104's right foor and ankle. LPN I wrapped the foot, ankle and heel completely covering the heel with a gauze wrapping. No skin was left exposed on the bottom or side of the heel. The LPN initialed (DR) and dated (4/2/14) the tape securing the gauze. On 4/3/14 at 9:35 AM two survey team members observed the dressing on Resident #104's right foot. The heel was completely covered by gauze dressing at that time. The initials and date were the same as the day previous. At 10:30 AM the administrator and DON were informed that third shift had been signing off on a heel prep for both Resident #104's heels. The surveyor questioned how a heel prep was done on a resident whose entire heel was completely covered daily by a gauze bandage that remained on the resident from its application on first shift. The DON said she would check on it. She said maybe the third shift nurse was removing the dressing done on first shift and then rewrapping it after applying the heel prep. At 11:10 AM the DON approached the two survey team members and reported that she had observed the dressing and that the heel was exposed so third shift only needed to apply the skin prep to the area. The DON stated, "The heel is exposed. We just now looked at it. You have to lift the foot up and look under it. It still has the tape on it." The two surveyors returned to look at the foot again. The dressing had clearly been removed and reconfigured to expose the resident's entire heel. This was apparent without even lifting the resident's foot. Furthermore, the tape securing the gauze bandage had been stretched and was curling. It had been pulled off and replaced -- covering a different section of the resident's dressing. No additional evidence was provided prior to the survey team exit. 2. For Resident #119, the facility staff failed to assess, treat, and document an area on the top of the left little toe. The clinical record of Resident #119 was reviewed 4/3/14. Resident #119 was admitted to the facility 8/12/13 with [DIAGNOSES REDACTED]. Resident #119's quarterly minimum data set (MDS) assessment with an assessment reference date (ARD) of 2/14/14 assessed that the resident usually understood others and usually was understood. Her brief interview for mental status was scored as 06 out of 15. Section M Skin Conditions was reviewed. Resident #119 was assessed to be at risk but had no current unhealed pressure ulcers as of 2/14/14. Skin and ulcer treatments included pressure relieving device for chair and bed and application of ointments/medications other than to feet were checked on the quarterly MDS. The current comprehensive care plan reviewed 2/27/14 identifed the problem/need that Resident #119 was at risk for pressure ulcers. Interventions documented were bathing as tolerated, skin assessment as per facility protocol, encourage/assist with repositioning frequently, incontinent care as per protocol, observe for seating and positioning problems, diet as ordered, encourage/assist with rest periods, R.D. (registered dietician) consult as needed, medications and treatments as ordered-see MAR, TAR for specifics, partial SR (side rails) per MD order, consult wound nurse as needed, transfer per resident handling program, and pressure reduction mattress/seat cushion. The surveyor observed Resident #119 on 4/3/14 at 7:52 a.m. She was in a low bed, alert, and was covered with a sheet/blanket. She was turned to her left side and was facing the entrance of the door. No foot cradle was observed at the foot of the bed. The surveyor observed a bed bath given by the hospice certified nursing assistant (other # 2) on 4/3/14 at 8:35 a.m. The surveyor observed an undated [MEDICATION NAME] dressing positioned over the sacral area. Other #2 stated she had been instructed by hospice nurses not to remember the bandages. The surveyor and other #2 observed an area on the top of Resident #119's left little toe. The area appeared about the size of a six pence (a little smaller than the diameter of a dime), brown in color, no odor detected. Other #2 stated the area had been there for awhile. "I told the hospice nurse months ago, either other #7 or other #8. I can't remember which one or exactly when I told them." She was asked would she document this information down somewhere. She stated on the hospice aide notes. The surveyor requested the assistance of the wound care nurse licensed practical nurse #2 to assess the area on the top of the left little toe. Administrative staff other #4 accompanied the wound care nurse. She stated "Resident #119 is not being followed by me." At the request of the surveyor, she assessed the top of the left little toe and stated to the surveyor, the area looked like a scabbed area. "I'll clean it up and see what's underneath the area." She donned her gloves, placed tap water on gauze 4 x 4, and cleaned the area. Under the scabbed area was an area which was decribed by the wound care nurse as a wound bed red in color and shiny. No depth was observed. The area was approximately ? inch in diameter. No odor and no drainage noted during the observation. The wound care nurse licensed practical nurse #2 stated "The area is blancheable, has new skin formation, red wound bed, and is dry. It looks like an abraded area to me. Resident #119 gets restless and kicks off her heel protectors sometimes." Taber's Cyclopedic Medical Dictionary, 20th edition, 2001, page 1945 was used to define "scabs." Scab is a crust of a cutaneous sore, wound, ulcer, or pustule formed by the drying of the discharge. The Clinical Practice Guideline Number 15 treatment of [REDACTED].S Department of Health and Human Services Public Health Service Agency for Health Care Policy and Research in conjunction with the National Pressure Ulcer Advisory Panel (www.npuap.org <http://www.npuap.org>) defined a pressure ulcer as any lesion caused by unrelieved pressure resulting in damage of underlying tissue and a stage II (2) pressure area as partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open /ruptured serum-filled or sero-sanguinous filled blister, shallow crater, or abrasion. Presents as a shiny or dry shallow ulcer without slough or bruising. This category should not be used to describe skin tears, tape burns, incontinence associated [MEDICAL CONDITION], maceration or excoriation. Mosby's Textbook for Nursing Assistants, Sheila A. Sorrentino, 5th edition, 2000, pages 596-597 and Table 25-1was reviewed. A pressure ulcer is any injury caused by unrelieved pressure. It usually occurs over a bony prominence. Prominence means to stick out. Therefore a bony prominence is an area where the bone sticks out or projects out from the flat surface of the body. The shoulder blades, elbows, hip bones, sacrum, knees, ankle bones, heels, and toes are bony prominences. Table 25-1 also identified the following areas as pressure points: back of head, ear, side of head, genitalia (men), breast (women), acromial process, greater trochanter, ischial tuberosity, shoulder, foot, and cheek. The surveyor reviewed the hospice notes from 1/1/14 through 4/3/14. Resident #119 was seen by other #8 on 1/8/14, 1/15/14, 1/21/14, 1/29/14, and 2/5/14. The 1/29/14 nurses note by other #8 read in part "Skin protectant cream to buttocks. Heel protectors along with app mattress and bed cradle in use to protect skin." No documentation of alteration in skin integrity. Resident #119 was seen by other #7 on 2/19/14, 3/4/14, 3/10/14, and 3/18/14. The 3/10/14 visit note by other #7 read in part "Alteration in skin integrity noted. Bil (bilateral) lower legs discoloration noted. Sacral area with blancheable pink area noted. Upper thigh lower buttocks with moist reddened area noted. Skin intervention in place by facility skin nurse." The 3/18/14 visit note by other #7 read "Skin Intact" under Integumentary Assessment. The surveyor reviewed the bi-weekly skin assessments and the "Shower/Tub Bath/Bed Bath Sheets" from 3/23/14 through 4/3/14. The information under the "Shower/Tub Bath/Bed Bath Sheets" read "All Abnormal Skin Conditions Are To Be Reported To The Charge Nurse Immediately. Document any identified issues on the diagram below. Rash, Bruises, Redness, and Skin Intact." None of the shower/tub bath/ bed bath sheets indicated an alteration in skin intact. The baths were given by the facility certified nursing assistant #3 on 3/26/14 (bed bath), 3/29/14 (tub bath), and 4/2/14 (tub bath); the boxes checked were "no rashes, no bruises, no redness, and skin intact." The nurse's bi-weekly skin checks were as follows: ? 3/24/14 Sacral area bony-- treatment in place, discolored area, bil (bilateral) legs ? 3/28/14 Sacral area-tx (treatment) in place discolored areas both arms and legs ? 3/31/14 Sacral area bony-- see tx (treatment)Chronic discolored BLE (bilateral lower extremities)/arms The surveyor reviewed the nurses notes 1/1/14 through 4/3/14 and found no documentation of the area on the top of the left little toe. The clinical record did not reveal any physician orders [REDACTED]. The surveyor informed the administrator and the director of nursing of the above finding on 4/3/14 at approximately 2:00 p.m. and again with the administrator on 4/3/14 at 6:45 p.m. No further information was provided prior to the exit survey on 4/3/14.

Based on observation, resident, family and staff interview it was determined the facility staff failed to obtain podiatry services for residents in need of foot care for 3 of 41 residents (Residents # 2, 1, and 22.) Findings: 1. Facility staff failed to provide podiatry services as needed for Resident #2. Resident #2's clinical record was reviewed on 2/4/14 at 10:00 AM. The resident was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. The latest MDS (minimum data set) assessment dated , 11/8/13 coded the resident with slight cognitive impairment, but unimpaired communication skills. The resident needed assistance with most of the ADLs, but a set-up only to eat. The latest CCP (comprehensive care plan) updated 11/21/13 directed staff to assist the resident with her ADLs as needed. The interventions included, "Podiatry consultation and tx as needed." The clinical record contained "Podiatrist Progress Notes." The consult sheet was signed by the attending physician but not dated, under the statement "Podiatrist to see as a consultation for the following...." There were no podiatry notes on this record to indicate the resident had ever been seen. On 2/4/14 at 11:15 AM LPN IV removed the resident's shoes and socks so her feet could be observed. Resident #2's toenails were observed to be extremely long and curling over her toes. The toenails were chipped and split. LPN IV was asked for an assessment of her nails and stated, "She needs to see a podiatrist." At 11:25 AM LPN V was asked if the resident had a podiatry appointment scheduled. She said that she didn't know because the secretary handled those details. "I'll put her on the list the secretary keeps that." LPNs IV and V were unsure how often the podiatrist came to the facility. The DON was informed of these findings on 2/6/14 at 3:00 PM. She was asked how often the podiatrist came to the facility and how the scheduling for the podiatrist was managed. At 3:40 PM the DON reported back to the survey team that the podiatrist came to the building every third Wednesday of the month. She said she wasn't sure why the residents (#2, 22 and 1) had not been seen, but thought they might have been "bumped" off the list--depending on the nature of the other resident's needs at that time. 2. Facility staff failed to provide podiatry services as needed for Resident #22. Resident #22's clinical record was reviewed on 2/5/14 at 2:30 PM. Resident #22 was admitted to the facility on [DATE]. His clinical record included the following Diagnoses: [REDACTED]. The latest MDS (minimum data set) assessment, dated 12/13/13 coded the resident with significant cognitive deficit, primarily due to the progression of his [MEDICAL CONDITION]. The resident was coded with needing assistance with all ADLs (activities of daily living) with a set-up only to eat. The resident's CCP (comprehensive care plan) noted the resident was at risk of a decline in his ADL status and that he required assistance from staff with hygiene and incontinence care. The interventions included "Podiatry consult as needed." The clinical record contained "Podiatrist Progress Notes." The last consult recorded by the podiatrist was on 6/12/13. On 2/5/14 at 3:10 PM, Resident #22's FM (family member) was interviewed regarding his care at the facility. The FM said she thought the biggest problem at the facility was they did not have enough staff to care for the residents there. She said Resident #22 often had to wait for long periods after she rang the bell for him to get assistance to toilet (as long as one-and-a-half hours.) FM also told the surveyor that she came every day and helped to feed Resident #22. The FM also said she had been trying to get them to arrange an appointment with a podiatrist for several months, "His toenails are very long and need trimming. The nurses here won't do it." On 2/6/14 at 9:35 AM CNA I came into the room and removed Resident #22's TED hose so they could look at his feet and toenails. The toenails were long and extended way past the ends of his toes. CNA I agreed, "They could use a trim." On 2/6/14 at 10:00 AM RN II was asked if the resident had a podiatrist consult since 6/12/13. She said she could not find one in the record, but would put the resident on the list to be checked. The DON was informed of these findings on 2/6/14 at 3:00 PM. 3. Facility staff failed to provide podiatry services as needed for Resident #1. Resident #1's clinical record was reviewed on 2/4/14 at 8:50 AM. Resident #1 was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. The latest MDS (minimum data set) assessment dated [DATE] coded the resident with significant cognitive impairment. Her communication skills were limited to making concrete requests for her self. The resident was dependent on the nursing staff to accomplish all the ADLs (activities of daily living) and needed someone to feed her. Resident #1's CCP, updated on 1/9/14 did not addressed the resident's need for assistance with her ADLs due to her general decline. The clinical record contained "Podiatrist Progress Notes." The last consult recorded by the podiatrist was on 7/10/13. On 2/6/14 at 1:55 PM the surveyor was with CNA III and CNA IV when they were repositioning the resident for lunch. The surveyor inspected Resident #1's feet and toes and that time. The toenails were observed to be long, ragged and needed trimming. The DON was informed of these findings on 2/6/14 at 3:00 PM. No additional info was provided.

Based on staff interview, facility document review, clinical record review, and in the course of a complaint investigation, the facility staff failed to ensure 1 of 19 residents (Resident #118) received proper treatment and care for a central line. The findings include: For Resident #118, the facility staff failed to ensure the resident received proper treatment and care for a central line. Resident #118's central line was not flushed during her long term care admission [DATE] through [DATE] and registered nurse #3 removed the central line without central line removal guidance and removed the central line based on the facility policy on PICC line removal and the facility staff provided no evidence of competency in the removal of the central line. Information about central venous catheters and PICC (peripherally inserted central catheters) was found in Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 10th edition, 2004, pages ,[DATE]. Non tunneled central catheters are used for short term (less than) 30 days) IV therapy in the acute care, long term care, and home setting. The physician inserts these catheters. The [MEDICATION NAME] vein is the most common vessel used, because the [MEDICATION NAME] area provides a stable insertion site to which the catheter can be anchored, allows the patient freedom of movement, and provides easy access to the dressing. The jugular or femoral vein also may be used. Non tunneled central catheters are available in single, double, and triple lumens. To ensure accessibility, triple lumen [MEDICATION NAME] catheters should be used, because it offers three (3) ports for various uses. Tunneled central catheters are for long term use and may remain in place for many years. These catheters are cuffed and can have single or double lumens. These catheters are surgically inserted. They are threaded under the skin to the [MEDICATION NAME] vein, and the distal end of the catheter is advanced into the superior vena cava 2 to 3 cm above the junction of the right atrium. Peripherally inserted central catheters (PICC) are used for intermediate term (3 to 12 months) IV therapy in the hospital, long term care, or home setting. These catheters may be inserted at the bedside or in the outpatient setting by a specially trained nurse. The basilic or cephalic vein is accessed through the antecubital space, and the catheter is threaded to a designated location, depending on the type of solution to be infused. Registered Nurse #3 removed the central line on [DATE] at 10:30 p.m. and the resident was found unresponsive 3 hours and 45 minutes later ([DATE] at 2:15 a.m.) to verbal and tactile stimuli, skin moist, pupils pinpoint, oxygen saturation on room air was 95%, right knee was mottled and feet were cold and slightly cyanotic, pulse ,[DATE], accucheck (blood sugar) was 185, [DEVICE] patent/intact with placement verified by auscultation, head of bed elevated, attempted to notify responsible party of decline in status. Message left to call facility. [DATE] 2:20 a.m. Order noted from MD to send to emergency room (name omitted) to eval (evaluate) and tx (treat). [DATE] 2:22 a.m. 911 called for transport." Resident was sent to the emergency room with [MEDICATION NAME] 1.2 administered enroute to the emergency room by EMS (emergency medical services). Resident expired [DATE] after neurology examined Resident #118 on [DATE] and determined that she had a neurological examination compatible with widespread [MEDICAL CONDITION]. Post [MEDICAL CONDITIONS] and air emboli are etiologies of this date. Prognosis for meaningful recovery due to either of these entities is not good, worse with both together. "Impression: 1. [MEDICAL CONDITIONS] 2. Air emboli. Plans/Suggestions: I have endorsed the family's decision to withdraw full support." Resident #118 had her breasthing tube removed [DATE]. Resident #118's clinical record was reviewed [DATE] and [DATE]. Resident #118 was admitted to the facility [DATE] with [DIAGNOSES REDACTED]. Resident #118's 5 day admission minimum data set (MDS) assessment with an assessment reference date (ARD) of [DATE] revealed Resident #118 had a cognitive summary score of 13 out of 15 in Section C Cognitive Patterns. Section I Active [DIAGNOSES REDACTED]. Section O. Special Treatments, Procedures, and Programs did not have IV medications checked. The clinical record also revealed the referring hospital discharge summary dated [DATE]. The summary revealed CT brain showed no evidence of acute intracranial process. Old right temporal and right lentiform (lens shaped) nuclear artifacts were noted. CT angiogram of the neck showed no hemodynamically significant stenosis (blockage). CTA head-no aneurysm noted. She was intubated (breathing tube in throat) and required mechanical ventilation on [DATE]and was extubated (breathing tube removed) on [DATE]. She required re-intubation on [DATE] for hypercarbic [MEDICAL CONDITION]. She was extubated on [DATE] but remained tachypneic (abnormally rapid respirations). CT scan of the chest showed bilateral pleural effusions with a large left effusion. Resident #118 underwent chest tube drainage (a catheter inserted through the thorax into the chest cavity for removing air or fluid, used after chest or heart surgery or pneumothorax). Swallow evaluation suggested oropharnygeal dysphagia with signs of aspiration. A PEG (percutaneous endoscopic gastrostomy-a tube placed in the stomach for feeding) was placed on [DATE]. Chest x-ray done [DATE] had the following impression and read "Stable chest exam. Small bilateral pleural effusions persist. Left chest tube is unchanged in position as is the NG (nasogastric tube) and right IJ (internal jugular) central venous catheter. The chest tube was removed [DATE]. The chest x-ray did document "Central venous catheter is in place. The left sided chest tube has been removed." The facility admission history and physical dated [DATE] did not reveal orders for the care and treatment of [REDACTED].#118 had a central line. The nurse's admission note dated [DATE] at 10:30 p.m. read in part: "Resident is alert and able to verbalize needs, some confusion is noted regarding place and time. Resident is noted to have triple lumen in right jugular." The admission physician orders [REDACTED]. Telephone orders dated [DATE], [DATE], [DATE] and [DATE] did not reveal physician orders [REDACTED]. an order written [REDACTED]." Resident #118 was seen by the registered dietician administrative staff #6 on [DATE]. No documentation of the central line. The interim care plan dated [DATE] had no section marked for placement of the central line or the care of the central line. The nurse's note on [DATE] and [DATE] did not reveal care of the central line. The nurse's note of [DATE] at 11:30 a.m. did read in part "Central line remains to right [MEDICATION NAME]." The [DATE] medication administration records (MARs) and the [DATE] treatment administration record (TAR) did not reveal documentation of the care of the central line. The [DATE] 9:30 p.m. nurse's note read in part "Visiting with family most of the day and evening." The [DATE] 10:30 p.m. nurse's note read " PICC (peripherally inserted central catheter) line in R (R in a circle and indicated right) [MEDICATION NAME] neck area removed under aseptic technique no problem removing PICC line which was about 32 cm (centimeters) long. Removed with blue tip intact. No bleeding noted. Pressure drg (dressing) applied. No c/o (complaints of) pain or discomfort. No s/s (signs/symptoms) of any distress noted." Signed by registered nurse #3. The [DATE] 2:15 a.m. nurse's note read "resident unresponsive to verbal and tactile stimuli, skin moist, pupils pinpoint, oxygen saturation on room air was 95%, right knee was mottled and feet were cold and slightly cyanotic, pulse ,[DATE], accucheck (blood sugar) was 185, [DEVICE] patent/intact with placement verified by auscultation, head of bed elevated, attempted to notify responsible party of decline in status. Message left to call facility. [DATE] 2:20 a.m. Order noted from MD to send to emergency room (name omitted) to eval (evaluate) and tx (treat). [DATE] 2:22 a.m. 911 called for transport." The surveyor reviewed the hospital notes on [DATE]. The emergency department physician note dated [DATE] at 7:23 a.m read "Had central line (IJ) removed yesterday morning at 11:00 a.m. Pt was found unresponsive yesterday afternoon at about 1:30 p.m. by nursing home staff, and has remained unresponsive to noxious stimuli since then. Oxygen saturation was ,[DATE]% on arrival of EMS to scene. EKG obtained by EMS showed ST elevations. Physical exam as follows: Head: Normocephalic and atraumatic Eyes: Conjunctivae are normal. Right eye exhibits no discharge. Left eye exhibits no discharge. No sclera icterus. Gaze deviated to right bilaterally Pupils 2 mm (millimeters), not reactive Neck: No JVD present. No tracheal deviation present Cardiovascular: Normal rate, regular rhythm, normal heart sounds and intact distal pulses. Exam reveals no gallop or rub. No murmur heard. Pulmonary/Chest: Effort normal and breath sounds normal. No accessory muscle usage. No respiratory distress. She has no decreased breath sounds. She has no wheezes. She has no rales. She exhibits no tenderness. Abdominal: Soft. Normal appearance and bowel sounds are normal. She exhibits no distension. There is no tenderness. There is no rebound, no guarding, no tender mass at McBurney's point and negative Murphy's sign. Musculoskeletal: She exhibits no [MEDICAL CONDITION] and no tenderness. Lymphadenopathy: She has no cervical adenopathy Neurological: She has normal sensation, normal strength, and intact cranial nerves. Pt (patient) obtunded GCS 3 (Glasgow coma scale) EKG reading and Cardiac Monitor: Interpreted at [DATE] at 0311. Rate is 127 bpm (beats per minute). [MEDICAL CONDITION]. ST elevation in anterior leads. No reciprocal changes. Treatments and ED Course: [DATE] 3:19 a.m. Patent arrived as heart alert. Cardiology is at bedside. Will intubate after CT obtained. 3:40 a.m. Head CT results listed below 3:50 a.m. 20 mg Etomidate administered. 3:50 a.m. [MEDICATION NAME] administered. 3:52 a.m. Intubated the patient 4:40 a.m. Spoke with patient's family at bedside. Daughter claims that she saw patient last night at which time patient seemed to be in normal condition. Confirms patient is full code. 5:00 a.m. Paged hospitalist for admission 5:56 a.m. Will be admitted CT Head Impression: There is evidence of old encephalom alacia in the right frontoparietal and parietal temporal lobes. There are multiple areas of decreased attenuation seen throughout the cerebrum most likely representing small lobules of fat. However, evaluation of Hounsfield units is limited given their small size. Other etiologies could include foci of pneumocephalus. However, this is less likely given the appearance. MRI Brain: Innumerable foci of sulcal, cisternal, and intraparenchymal low-density noted bilaterally on concurrent head CT correlate to foci of susceptibility artifact on brain MRI confirming that these are indeed pockets of gas (as opposed to lobules of fat seen in the context of recently ruptured dermoid, often mistaken as pneumocephalus on CT imaging). After gadolinium administration, there is diffuse abnormal leptomeningeal and pachymeningeal enhancement as well as abnormal enhancement within the perivascular Virchow-robin spaces throughout both cerebral hemispheres, right greater than left. Right cerebellar foliar enhancement is also seen although less conspicuous. Labs: Troponin 1, Istat 9.68 BNP .0 CK-MB 40.2 Procedures: The patient was [MEDICATION NAME] and under direct visualization, a 7.5 mm cuffed endotracheal tube was placed through the vocal chords into the trachea Critical Care Time: The reason for providing this level of medical care for this critically ill patient was due to a critical illness that impaired one or more vital organ systems such that there was a high probability of imminent or life threatening deterioration in the patient's condition. This care involved high complexity decision making to assess, manipulate, and support vital system functions, to treat vital organ system failure and to prevent further life threatening deterioration of the patient's condition. Final Impression: 1. Unresponsiveness 2. STEMI (ST elevation [MEDICAL CONDITION] infarction) 3. Acute [MEDICAL CONDITION] 4. Acute [MEDICAL CONDITION] 5. Air embolism, major 6. [MEDICAL CONDITION] 7. Cardiogenic shock 8. Chronic systolic heart failure 9. Diabetes mellitus 10. [MEDICAL CONDITION] 11. [MEDICAL CONDITION] 12. Leukocytosis 13. Tachycardia 14. Unresponsive episode The hospital admitted d [DATE] 2:21 p.m. gave a brief history of present illness described as "Female who presents to the ED after being found unresponsive at nursing facility. Patient recently discharged to SNF after a 6 week hospital stay, where she was treated for [REDACTED]. She had right IJ pulled around 11pm. The family states that she was doing better and on the mend and then was found unresponsive later. In the ED, she was totally unresponsive. She was intubated for airway protection. Her EKG showed ST elevation indeed. An initial troponin was near 10. Her blood pressures have been low. Her propofol sedation was stopped. Versed was started. A head CT done in the ED showed what appears to be multiple areas of air consistent maybe with air emboli. The question mark was whether this was related to the right IJ that was pulled earlier. Additionally, the ?? Is whether this was also possibly a precipitant of her STEMI? Currently she remains tenuous at best. Neurology was contacted for a quick read on this head CT. Other #9 (hospital neurologist) confirms that this does look like air. The neurology consult dated [DATE] read in part "This woman has a neurological examination compatible with widespread [MEDICAL CONDITION]. Post [MEDICAL CONDITIONS] and air emboli are etiologies of this date. Prognosis for meaningful recovery due to either of these entities is not good, worse with both together. Impression: 1. [MEDICAL CONDITIONS] 2. Air emboli. Plans/Suggestions: I have endorsed the family's decision to withdraw full support." Patient admitted to the ICU ventilated and requiring pressors for BP maintenance. Discussed prognosis with relatives, including patient's husband and daughter. After a brief conversation, they have requested withdrawal of care due to insignificant possibility of any quality of life in the event of recovery. We have discussed a proposed plan to stop all monitoring and drugs and give [MEDICATION NAME] and [MEDICATION NAME] if needed for comfort and anxiety. The surveyor interviewed registered nurse #3 on [DATE] at 6:00 p.m. about the incident of [DATE]. Upon the surveyor's introduction to R.N. #3, the first comment made by R.N. #3 was "Do I have to admit to my stupidity? She had a line in her right neck (R.N. #3 pointed to the base of the surveyor's neck) and I thought it was a PICC (peripherally inserted central catheter). I checked the order. The order said D/C PICC Line." When the surveyor informed R.N. #3 that the order was to remove a central line, she look stunned and stated "I thought the order was to D/C (discontinue) a PICC line." She then stated she pulled out the policy and procedure manual and reviewed the policy and procedure for a PICC line. She stated "I then explained the procedure to the resident. I always tell them what I am doing." She stated Resident #118 was positioned at a 45 degree angle in bed. I had my dressings ready. I gently pulled it out. I applied a pressure dressing. I always have to have my vaseline gauze. I try to backtrack and make sure I document length. She was fine with the removal and fine after the PICC line was removed. The incident happened on 11- 7 shift. I had already left to go home before knowing of issue. L.P.N. #5 worked that night. If I don't know how to do a procedure, I look it up. I did look up central line removal. I should have turned her head to the side and tell her to hold her breath while I removed the line. I do know the difference between a PICC line and a central line." She stated after the incident, she was interviewed by a lawyer but was unable to recall who the lawyer represented or what day the interview occurred. The surveyor interviewed licensed practical nurse #5 on [DATE] at 5:18 a.m. She stated she had little recollection of the events of [DATE]. "I am all over the building as a supervisor." She was asked what nurses in the facility remove central lines and PICC lines. She stated "Usually an RN removes PICC lines. L.P.N.s don't remove central lines. We rarely have to remove central lines." She also was asked what the facility protocol for flushing central lines. She stated "Usually flushed every shift and with each medication administration." The surveyor interviewed the current staff educator registered nurse #4 on [DATE] at 9:28 a.m. Administrative staff #4 was also present during the interview. The surveyor asked the R.N. educator for the training she provided to new nursing hires. She stated this was her first group of new nurses and she had no packets together yet. "I review medications, admissions, discharges, incident reporting, facility policies, incontinence program, and falls."During the interview, R.N. #4 was asked for a policy on the removal of central lines. She stated "We don't have a policy for removal. We only have a policy on care including dressing changes. RNs don't remove central lines here. We (RNs) don't even remove central lines in the hospital. It's considered a medical procedure. RNs have removed PICC lines. Usually send resident out to have PICC lines removed. The process for removal of central lines in the hospital has changed. The resident has to lay flat, hold their breath, remove the central line, apply pressure for ,[DATE] minutes, and now to lay flat 30 minutes to 1 hour after the central line has been removed." The surveyor asked for competencies for RNs who have been deemed competent to remove central lines. She stated "I don't have any competencies. I am new to my position and I don't have access to the previous educator's training." The surveyor requested a copy of the orientation checklist on [DATE]. The checklist was never provided prior to the exit on [DATE]. The surveyor informed the administrator, the director of nursing, and the medical director of the above concern where R.N. #3 removed the central line from Resident #118 and was subsequently found unresponsive and sent to the emrgency room for evalaution and treatment on [DATE] at 1:40 p.m. The administrator stated she was not aware of any documentation of the incident of [DATE] and [DATE]. The director of nursing also stated she had no knowledge of the incident of [DATE] and [DATE] until the article in the newspaper. The medical director stated he attended a deposition (no date given) and spoke with the family. The deposition, he stated, included conversation that central line removals would not be done in nursing homes. He stated he informed them that he would look into maintaining central lines here. He stated the HR (human resources) director was also in the meeting. The medical director stated that by [DATE], he hoped things would settle down with nursing policies. He stated he spoke with the director of nursing (no date provided), decided to send any resident out if they are admitted with a central line and replace with a PICC line. The surveyor requested the facility policy on the care of a central line from 2013 on [DATE]. The policy tilted Medication Administration Central IV Line, revised ,[DATE] read in part under "CV Catheters (Hickman): General Information: 1. Central venous catheters should be [MEDICATION NAME] following each infusion, after blood withdrawals or before an interruption in the infusion. 2. The catheter will be flushed at least daily, if not infusing solutions. 3. Flushing protocols will be performed per a physician's orders [REDACTED]. -type of catheter -catheter/extension set volumes -use of positive pressure flushing to prevent reflux of blood into the catheter -should not alter resident's clotting factors 4. Physician may order a ,[DATE] cc Normal saline flush pre and post infusion. 5. The minimum dose of [MEDICATION NAME] saline is 2.0 cc to 3.0 cc of 100 units/cc for adults. The policy did not reveal instructions for the removal of a central line; the policy did reveal instructions for the removal of a PICC line and read "PICC lines will be removed only by staff trained in this procedure." During the meeting with the administrator, the director of nursing and the medical director on [DATE] at 1:40 p.m., the surveyor asked the medical director what would be possible complications from the removal of a central line or a PICC line. He replied "thrombus or air emboli; wouldn't anticipate a pneumothorax from removal, only from insertion of central line." The surveyor also asked the medical director if central lines were removed by registered nurses in the nursing home. He stated he wasn't sure about long term care but in the hospital, it was a medical procedure. He stated the resident needed to be in the Trendelenburg position and the line [MEDICATION NAME]. The medical director also stated that the facility will not accept residents with a central line. "As of [DATE], we don't accept residents with a central line. We don't remove central lines or PICC lines here." The former quality assurance registered nurse #7 came into the meeting on [DATE] at 2:00 p.m. She stated as the former QA nurse ([DATE] through February 2014 and interim director of nursing [DATE]- [DATE]/[DATE]), she was not told anything when the central line was removed by registered nurse #3 and the resident was sent to the hospital. She stated the issue was never discussed in quality assurance meetings. The surveyor reviewed the personnel file of registered nurse #3 on [DATE] at 10:00 a.m. provided by the human resources generalist. The employee file revealed her hire date, her license verification, pay rate, and facility write-ups. There were no write ups for [DATE]. The surveyor interviewed the human resources director and the human resources generalist on [DATE] at 3:48 p.m. The human resources director stated on [DATE], she received a complaint from the administrator of Resident #118's estate. The complaint, she stated, involved the care of Resident #118 and the cause of her death. She stated she was not at liberty to tell the surveyor the contents of the complaint. "I can't say anything due to the non-disclosure clause." She stated she contacted the facility insurance company and filed the insurance the same day she received the complaint. She stated the insurance company assigned an attorney. "The attorney contacted me and the administrator (current), lawyer, and I met on [DATE]. He wanted to look at the file and speak with the employee. He talked to R.N. #3 but I have no idea what they discussed. We sent him a copy of the file. R.N. #3 continued to work and is still working at the facility. Discussed the incident with the new medical director hired [DATE] (no date of the discussion provided) and he went to the mediation. By changing the policy we felt we had fixed the problem. We had a mock survey in [DATE] or February 2014 and no issues were found. We got nothing from the hospital. There was no admission from the facility about the facility being at fault. Interrogatories were done by the lawyer." On [DATE], she stated the judge approved the settlement. "The settlement and mediation had to be approved by a judge. The facility never admitted liability. I can't say anything because of the non disclosure agreement." The facility did provide a copy of the policy and procedure from ,[DATE] for Medication Administration Central IV Line. The changes made were the "Removal of the PICC line" from the ,[DATE] policy. The facility staff provided the policy and procedure for Medication Administration Central IV Line, revised [DATE] on [DATE] at 3:50 p.m. The last line in the policy read "AT No Time Will Any Central or PICC Line Be Removed At This Facility. ALL Patients are to be sent out to RMH or LGH at [MEDICATION NAME] radiology for their removal. Please call DON or Medical Director to have this facilitated." No further information was provided prior to the exit conference on [DATE]. This is a complaint deficiency.