Every finding on record at River View on the Appomattox Health & Rehab Center

Based on interview, clinical record review and facility documentation the facility staff failed to ensure Residents were free from unecessary medications for 1 Resident (#2), in a survey sample of 5 Residents. The findings included: For Resident #2 the facility staff failed to follow physicians orders resulting in Resident #2 receiving meclizine after the Nurse Practitioner had ordered it discontinued. On 5/15/24 a review of the clinical record revealed the following excerpt from the NP (Nurse Practitioner) progress note. Date of Service: 02/27/2024 12:00 AM - The nursing staff will arrange an appointment for the resident to be evaluated by pulmonologist. The order has been placed. The nursing staff will monitor her for chest congestion, wheezing, and hypoxia. Vertigo-the resident has requested her meclizine be discontinued. It will be discontinued at this time. A review of the MAR (Medication Administration Record) revealed that although the physician put in her orders that the medication would be discontinued it was not stopped. Resident #2 continued to get the medication until 3/10/24. On 5/15/24 an interview with LPN B was conducted and she stated that when a physician orders a medication to be discontinued, they put it in the system so that it is no longer given to the patient and so that pharmacy can know not to send the medication. When asked if doctors put in the orders to discontinue, she stated that sometimes they do. On 5/15/24 a during the end of day meeting the Administrator was made aware of the concerns with medication administration and no further information was provided.

Based on interview, clinical record review, and facility documentation, the facility staff failed to review and revise the care plan after each assessment or change in Resident condition for 1 Resident (#2) in a survey sample of 5 Residents. The findings included: For Resident #2 the facility staff failed to review/revise the care plan to add additional interventions after the Resident fell while left unattended in the bathroom. A review of the clinical record revealed that Resident #2 did have a fall in her bathroom on 3/8/24 at 3:00 PM. A review of the progress notes revealed the following: 3/8/24 3:00 PM -Note Text: Resident is alert and verbal this writer heard resident calling out into the hall. When entering room resident was noted to be sitting on the floor on her buttocks in her bathroom. Resident stated she was using the bathroom and stood up but when she stood up [sic], she felt dizzy and fell forward onto her knees. Right Knee is red in color and warm ROM [range of motion] WNL [within normal limits]. Resident was hoyered into her wheelchair MD in facility made aware and gave new order to obtain x-ray of r knee r/t pain. Resident is own RP [responsible party] and made aware. On 5/15/24 the facility submitted a copy of the fall investigation excerpts are as follows: Location of fall - Bathroom (resident room) Conditions -Check ALL conditions that may have impacted THIS fall. Dizziness [box checked] History of falls in past 6 mos. [box not checked in spite of history of 2 falls at hospital prior to admission], Psychoactive medication - [box not checked in spite of Resident having orders for amitriptyline at bedtime, as well as Buspar twice per day and PRN alprazolam for anxiety], Recent medication change [box unchecked in spite of having Buspar and Alprazolam newly prescribed on 3/6/24], ambulating without needed help [box unchecked in spite of diagnosis of muscle weakness, difficulty walking, fibromyalgia, lack of coordination]. Impact of fall - Check ALL outcomes that resulted from this fall. No boxes checked, however Resident #2's right knee was described as red, and the Resident complained of Right knee pain at time of fall. Resident Interview 3. Did you experience any of the following symptoms just prior to fall? Lightheadedness, slurred speech, Irregular heart rate, shortness of breath, Numbness, Dizziness Strange smell, Flashing lights, or other unusual symptoms? Yes Dizziness 6. How did you fall what were you trying to do? Go to bathroom Care Plan / Individualized Service Plan (ISP) Review: Educated to call for assistance r/t [related to] dizziness w/toileting. [Signed by nurse on 3/8/24 signed by Quality Review on 3/11/24] A review of the Fall Prevention Program page 2 Paragraph #7 read: When any patient experiences a fall, the Center will: a. Assess the patient. b. Complete a post fall assessment. c. Complete an incident report. d. Notify the physician / physician extender and legal representative / family. e. Review the patient's care plan and update as indicated. f. Document all assessments and actions g. Obtain witness statements in the case of injury. On 5/15/24 a review of the care plan revealed the following with regard to falls: FOCUS: (Resident #2 name redacted) is at risk for falls Date initiated: 2/11/24 GOAL: Will not sustain an avoidable fall or injury through the next review period Date initiated 2/11/24 INTERVENTIONS: Assess fall risk per facility protocol and implement appropriate measures. Reassess per protocol and as needed. Date initiated 2/11/24. Orient patient and family to room, call bell, lighting, and bathroom encourage to call for assistance. Date initiated 2/11/24. A review of the care plan policy revealed the following excerpt: Comprehensive Care Planning Process - CP 102 Page 1 Paragraph #3 Additionally, the care plan is a fluid document and shall be reviewed and updated at any time the resident, family or representative or member of the ID team determines a need for additional interventions or care areas to be addressed. On the afternoon of 5/15/24 an interview with LPN C was conducted and she stated, When there is a fall, we first assess for injuries get vitals, assist them back to bed, then we do the post fall assessment and notify the family and the physician and document everything in the notes. When asked if the care plans should be updated after a fall, she stated that the care plan should be reviewed, the actual fall should be added along with new interventions. On 5/15/24 during the end of day meeting the Administrator was made aware of the findings and no further information was provided.

Based on interview, clinical record review, and facility documentation, the facility staff failed to provide timely diagnostic services to meet the needs of 1 Resident, (#2) in a survey sample of 5 Residents. The findings included: For Resident #2 the facility staff failed to obtain a diagnostic sleep study as ordered by the discharging hospital prior to admission and again ordered by the Nurse Practitioner on 3/6/24 after a hypoxic episode at the facility. Resident #2 was admitted to the facility on [DATE] with diagnoses that included but were not limited to chronic obstructive pulmonary disease, with acute exacerbation, long term use of insulin, fibromyalgia, hyperlipidemia, asthma with acute exacerbation, hypertensive heart disease with heart failure, morbid obesity, OSA (Obstructive Sleep Apnea), type 2 diabetes, acute on chronic combined systolic (congestive) and diastolic (congestive) heart failure. On 5/14/24 a review of the clinical record revealed that Resident #2 had written discharge orders with the following excerpts: Follow up with [name of pulmonologist redacted] on 2/22/24 at 11:15 AM. Obtain outpatient sleep study. A review of the progress notes for 2/22/24 did not mention the Resident leaving the facility for a doctor appointment nor did it mention the appointment being canceled. On the afternoon of 5/14/24 an interview was conducted with the scheduler (employee D) and the Administrator. Employee D was asked the process for making appointments and transportation arrangements to outside appointments. Employee D stated that upon admission the nurses get the discharge summary and make the appointments then they fill out a Transportation slip and give it to employee D for her to arrange the transportation. When asked the process if the Resident already has the appointment scheduled she stated that the nurse confirms the appointment and puts in Transportation Slip so that she can schedule transportation. When asked if this process took place for Resident #2's appointment on 2/22/24, she stated that she could not find it in her book. She stated that she thought maybe the family might have taken Resident #2 or the appointment might have been canceled. The Administrator then asked, Wouldn't we have some kind of documentation that it was canceled? Employee D responded that the nurses were supposed to document any changes to the appointment. On 5/15/24 at approximately 10 AM the Administrator provided documentation that the Resident was unwell, and the appointment had been canceled due to gastrointestinal issues. A review of the clinical record revealed a progress note from the Nurse Practitioner on 3/5/24 excerpts read: [Resident #2 name redacted] is being seen in follow-up today for shortness of breath with hypoxia, chest pain, and for vertigo. The resident reports that she is having more shortness of breath and dyspnea on exertion with task that would normally cause no shortness of breath. She reports that her oxygen saturations have been dropping when she sleeps. The resident reports that she was tested for obstructive sleep apnea several years ago, however she tested negative. Per her medical record however, she was diagnosed with obstructive sleep apnea. She reports no use of CPAP. The resident reports she has been on steroids for the last 3 months and has gained over 50 pounds. Plan: . Will have stat labs drawn to assess for abnormalities. The resident will also have a stat EKG [Electrocardiogram] performed to rule out ischemia. I have ordered a home sleep study to assess for degree of sleep apnea. Resident will be monitored for chest pain, palpitations, hypotensive/hypertensive episodes, dizziness, headache, or blurred vision. I have ordered a head CT to be performed to rule out insidious cause of the residents dizziness and nausea. The resident will be evaluated by neurologist. The nursing staff will arrange an appointment for pulmonary as well. The resident will start supplemental oxygen ATC [Around the Clock] at 2 L/min via nasal cannula. The nursing staff will monitor her for ongoing hypoxia, increased shortness of breath, PND [Paroxysmal Nocturnal Dyspnea], orthopnea, chest congestion, and wheezing. When asked if the pulmonologist appointment was rescheduled and if the sleep study was scheduled employee D stated that she could not find any evidence that the appointments were scheduled. On 5/15/24 during the end of day meeting the Administrator was made aware and no further information was provided.

Based on interview, clinical record review, and facility documentation, the facility staff failed to provide care that meets professional standards of quality for 1 Resident (#2) in a survey sample of 5 Residents. The findings included: For Resident #2 the facility staff failed to obtain vital signs every 4 hours as ordered on 3/5/24. On 5/15/24 a review of the clinical record revealed a progress note from the Nurse Practitioner on 3/5/24 excerpts read: [Resident #2 name redacted] is being seen in follow-up today for shortness of breath with hypoxia, chest pain, and for vertigo. The resident reports that she is having more shortness of breath and dyspnea on exertion with task that would normally cause no shortness of breath. She reports that her oxygen saturations have been dropping when she sleeps. PLAN: The resident will start supplemental oxygen ATC [Around the Clock] at 2 L/min via nasal cannula. The nursing staff will monitor her for ongoing hypoxia, increased shortness of breath, PND [Paroxysmal Nocturnal Dyspnea], orthopnea, chest congestion, and wheezing. A review of the clinical record revealed that on 3/5/24 the the orders for vital signs monitoring was increased to every 4 hours. On 5/15/24 a review of the MAR (Medication Administration Record) revealed the vital signs were recorded identically on several occasions excerpts are as follows: On 3/6/24 at 2 a.m., 6 a.m., 10 a.m. and 2 p.m. the vital signs were recorded as: Blood pressure 144/82, Temp. 97.4, Pulse 90, Respiration 22, Oxygen Saturation 90% On 3/6/24 at 6 p.m., and 10 p.m., the vital signs were recorded as : Blood pressure 136/74, Temp. 97.1, Pulse 82, Respiration 18, Oxygen Saturation 96%. On 3/7/24 at 6 a.m., 10 a.m., 2 p.m., 6 pm and 10 p.,m. the vital signs were recorded as: Blood pressure 118/84, Temp. 97.3, Pulse 88, Respiration 20, Oxygen Saturation 90%. On 3/8/24 at 6 a.m., 2 a.m., and 6 a.m. the vital signs were recorded as: Blood pressure 134/86, Temp. 97.1, Pulse 95, Respiration -20, Oxygen Saturation 94% On 3/9/24 at 2 a.m. and 6 a.m. the vital signs were recorded as : Blood pressure - 129/85, Temp. 96.8, Pulse - 84, Respiration -18, Oxygen Saturation 93% On 3/9/24 at 10 p.m. and 3/10/24 at 2 a.m. and 6 a.m. vitals were recorded as: Blood pressure 129/87, Temp. 97.4, Pulse 76, Respiration 20, Oxygen Saturation 95% **Note : Vital signs fluctuate normally during the day and night factors that affect the vital signs are positioning, stress, sleep, pain, anxiety, infection, medications and the normal homeostasis of the body reacting to ambient temperature. It would be extremely rare to find the all of the vital signs exactly the same twice in a row.** According to the National Institutes of Health / National Library of Medicine website: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6333367/ Vital signs, i.e. respiratory rate, oxygen saturation, pulse, blood pressure and temperature, are regarded as an essential part of monitoring hospitalized patients. Changes in vital signs prior to clinical deterioration are well documented and early detection of preventable outcomes is key to timely intervention. On 51524 during the end of day meeting the Administrator was made aware of the concerns and no further information was provided.

Based on observations, staff interviews, record review, and facility policy review, the facility failed to conduct timely assessment and identification of pressure wounds for four of four residents (Resident (R) 75, R39, R16, R15) reviewed for pressure sores until the wounds had progressed to advanced stages (stage III - full thickness skin loss involving damage or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia; stage IV - a deep wound reaching the muscles, ligaments, or bones which often causes extreme pain, infection, invasive surgeries, or even death). Immediate Jeopardy was called on 03/01/23 at 5:08 PM. The Immediate Jeopardy began on 11/11/22, when R15 was noted with an open area on the sacrum that was assessed on 11/28/22 with 100% necrotic tissue that required surgical debridement. The Immediate Jeopardy was removed on 03/09/23 at 12:02 PM. Deficiencies remain at a level 2 isolated including for Resident #16, the facility staff failed to provide care and position changes for an extended period (9 hours) which resulted in the development of a Deep Tissue Injury. Findings include: 1. R75 developed multiple avoidable pressure ulcers. Review of R75's undated Profile, located in the Profile tab of the electronic medical record (EMR), revealed she was admitted to the facility on [DATE] with diagnoses including encephalopathy, protein-calorie malnutrition, respiratory failure, anxiety, and muscle weakness and atrophy. Review of R75's significant change in status Minimum Data Set (MDS) assessment, with an assessment reference date (ARD) of 02/17/23, revealed she scored 6 of 15 on the Brief Interview for Mental Status (BIMS), indicating severely impaired cognition. She did not exhibit any behavioral symptoms, including rejection of care. R75 required extensive assistance by two staff with bed mobility and was totally dependent on staff for personal hygiene, and bathing. R75 was at risk of developing pressure ulcers and had one stage II, one stage III, one stage IV, and one deep tissue injury. R75 was receiving hospice services. Review of R75's 01/02/23 Care Plan, found in the Care Plan tab of the EMR, revealed R75 was at risk for skin breakdown and currently had open areas to her right buttocks, sacrum, and right lateral heel and deep tissue injuries on her right ankle. The interventions included: Air mattress to bed . Assess skin thoroughly and implement precautions and/or treatment as indicated . Consult wound MD [physician] as needed . Encourage frequent position changes for pressure relief . Encourage patient to allow heels to be floated while in bed . Observe for moisture and incontinence issues that affect skin. Report for further assessment if noted . Off-laoding [sic] boots while in bed . Provide pressure reduction surfaces as ordered/indicated . [and] Provide treatments as ordered. Report unusual change or decline in skin integrity. Review of R75's 01/17/23 Unavoidable Skin Breakdown worksheet, provided in a soft file for R75 on paper by Employee F, revealed Resident hospice [with] expected decline and was completed by Licensed Practical Nurse (LPN) E. The form documented, In reviewing this resident, I believe the pressure sore(s) meet the criteria to be unavoidable and was signed by a physician. There was no evidence or rationale documented on the form to indicate why the resident's skin breakdown was unavoidable, other than she was receiving hospice care. Review of R75's physician Progress Notes, located in the Documents tab of the EMR, revealed no indication the physician assessed the resident and determined her skin breakdown was unavoidable. NOTE: a soft file is a group of documents that are not part of the official clinical record. Review of R75's 02/24/23 Body Audit, located in the Assessments tab of the EMR, revealed she had a pressure ulcer to her right buttock, a pressure ulcer to her sacrum, and unidentified skin issues to her right heel and ankle. Review of R75's 02/28/23 physician's Orders, found in the Orders tab of the EMR, revealed she was receiving daily wound treatments to her right buttock, sacrum, right heel and was receiving application of skin prep (a liquid film-forming dressing that forms a protective film to help reduce friction during removal of tapes and bandages) to her bilateral outer ankles and bilateral heels. Observation in R75's room on 02/28/23 at 11:46 AM revealed the resident was lying in bed. Though her eyes were open, she was unable to respond to questions or acknowledge the surveyor. She appeared thin and frail. There was a pressure-reducing air mattress on the bed and she had pressure-reducing boots on both feet. A. Right Buttock Review of a 12/06/22 Health Status Note, found in the Progress Notes tab of the EMR, revealed, CNA [Certified Nurse Aide] reported to charge nurse . resident has new area on buttocks. This nurse into assess and noted shearing to right buttock. Cleaned area and applied zinc, charge nurse to update NP [Nurse Practitioner] and treatment nurse. Review of a 12/07/22 Skin Note, located in the Progress Notes tab of the EMR, revealed, This writer went in to assess area and an OA [open area] area [sic] was noted to the right buttocks that presents with characteristics of friction from resident sliding down in bed. Area was cleansed with WC [wound cleanser], Medihoney [an ointment containing active leptospermum (Manuka) Honey (ALH) that helps to promote a moist wound environment and aids autolytic debridement] applied, and covered with a foam dressing; pillow placed behind back and buttocks for offloading. Hospice aide in room and made aware, this writer also asked hospice nurse to [sic] for an air mattress. NP/RP [Responsible Party] updated. Review of a 12/08/22 Wound & Skin Evaluation, found in the Assessments tab of the EMR and completed by the facility's wound nurse (LPN E) revealed a pressure ulcer, stage II, on the right buttock that was in-house acquired on 12/06/22. The wound measured 2.9 centimeters (cm) long, 1.9 cm wide, and 0.1 cm deep. LPN E recommended cleansing the wound with wound cleanser, using Medihoney, and covering with a foam dressing. Review of R75's 12/12/22 Initial Wound Evaluation & Management Summary from the contract wound physician, located in the Documents tab of the EMR, revealed R75 had a pressure ulcer to her right buttock, full thickness, that was unstageable due to necrosis. The summary documented the physician performed surgical debridement of the wound: The wound was cleansed with normal saline and anesthesia was achieved using topical benzocaine. Then with clean surgical technique, 15 blade was used to surgically excise devitalized tissue and necrotic subcutaneous level tissues were removed at a depth of 0.2 cm and healthy bleeding tissue was observed. As a result of this procedure, the nonviable tissue in the wound bed decreased from 100 percent to 75 percent. Review of R75's 02/22/23 Skin & Wound Assessment, located in the Assessments tab of the EMR revealed a picture of the right buttock wound, which appeared as small, circular bright red area of denuded skin. Review of R75's EMR revealed no evidence the right buttock wound was assessed for appropriate treatment and healing measures by a Registered Nurse, physician, or physician extender from 12/06/22 when the wound was first identified until 12/12/22, when the wound was assessed by the physician as unstageable due to necrosis and requiring surgical debridement. B. Sacrum Review of a 01/02/23 Skin Note, located in the Progress Notes tab of the EMR, revealed, Resident seen during wound rounds [by consultant wound physician] and new area was noted to the sacrum. Area presents with characteristics of a pressure injury stage 3. Area was cleansed with WC, Medihoney applied, alginate (alginic acid salts in hydrogel form to aid in wound healing) applied and covered with a foam dressing. NP/hospice and RP updated. Review of a 01/02/23 Wound & Skin Evaluation, found in the Assessments tab of the EMR and completed by LPN E revealed a new pressure ulcer, stage III, on the sacrum that was in-house acquired. The wound measured 1.1 cm long by 0.5 cm wide by 0.2 cm deep. Review of R75's 01/02/23 Wound Evaluation & Management Summary from the contract wound physician, located in the Documents tab of the EMR, revealed R75 had a stage IV, full thickness, pressure ulcer to the sacrum which measure 1.1 cm long by 0.5 cm wide by 0.8 cm deep. The summary documented the physician performed surgical debridement of the wound: The wound was cleansed with normal saline and anesthesia was achieved using topical benzocaine. Then with clean surgical technique, 15 blade, pick-ups were used to surgically excise devitalized tissue and necrotic muscle level tissues were removed at a depth of 0.9 cm and healthy bleeding tissue was observed. As a result of this procedure, the nonviable tissue in the wound bed decreased from 100 percent to 35 percent. Review of R75's 03/01/23 Skin & Wound Assessment, located in the Assessments tab of the EMR revealed a picture of the sacral wound, which appeared as a very large and very deep crater exposing the fascia, bones, and tendon. The entire surrounding sacral and coccyx were dark red. Review of R75's EMR revealed there was no information addressing the disparities between LPN E's Wound & Skin Evaluation, which documented a stage III wound with a depth of 0.2 cm and the physician's Wound Evaluation & Management Summary, which documented a stage IV wound with a depth of 0.8 cm. C. Right Ankle Review of a 01/09/23 Health Status Note, located in the Progress Notes tab of the EMR, revealed, Hospice [nurse] stated that resident has 3 new wounds. She stated one on the heel and 1 each on lateral ankles. Review of a 01/10/23 Skin Note, located in the Progress Notes tab of the EMR, revealed, This writer went in to assess new areas noted. The right . ankle present with characteristics of a DTI [deep tissue injury] . Treatment orders have been implemented. NP/RP updated. Review of a 01/11/23 Wound & Skin Evaluation, found in the Assessments tab of the EMR and completed by LPN E revealed a new right ankle pressure ulcer, presenting as a deep tissue injury, that was facility-acquired on 01/09/23 that measured 0.7 cm long by 0.4 cm wide. Review of R75's 01/16/23 Wound Evaluation & Management Summary from the contract wound physician, located in the Documents tab of the EMR, revealed R75 had an unstageable deep tissue injury on the right ankle. Though the wound physician had provided treatment to R75's sacral and buttock wounds on 01/09/23, there was no evidence the physician had been alerted to the right ankle wound for assessment and treatment on 01/09/23. Review of R75's 03/01/23 Skin & Wound Assessment, located in the Assessments tab of the EMR revealed a picture of the right ankle wound, which appeared as a small, circular, scabbed area that was dark purple/black and yellow. A large area of the surrounding skin appeared red. D. Left Ankle Review of a 01/09/23 Health Status Note, located in the Progress Notes tab of the EMR, revealed, Hospice [nurse] stated that resident has 3 new wounds. She stated one on the heel and 1 each on lateral ankles. Review of a 01/10/23 Skin Note, located in the Progress Notes tab of the EMR, revealed, This writer went in to assess new areas noted. The . left ankle present with characteristics of a DTI [deep tissue injury] . Treatment orders have been implemented. NP/RP updated. Review of a 01/11/23 Wound & Skin Evaluation, found in the Assessments tab of the EMR and completed by LPN E revealed a new left ankle pressure ulcer, presenting as a deep tissue injury, that was facility-acquired on 01/09/23 that measured 1.7 cm long by 0.8 cm wide. Review of R75's 01/16/23 Wound Evaluation & Management Summary from the contract wound physician, located in the Documents tab of the EMR, revealed R75 had an unstageable left ankle pressure ulcer that presented as a deep tissue injury. Though the wound physician had provided treatment to R75's sacral and buttock wounds on 01/09/23, there was no evidence the physician had been alerted to the left ankle wound for assessment and treatment on 01/09/23. E. Right Heel Review of a 01/09/23 Health Status Note, located in the Progress Notes tab of the EMR, revealed, Hospice [nurse] stated that resident has 3 new wounds. She stated one on the heel and 1 each on lateral ankles. Review of a 01/10/23 Skin Note, located in the Progress Notes tab of the EMR, revealed, This writer went in to assess new areas noted . The right lateral heel presents with characteristics of a pressure injury. Treatment orders have been implemented. NP/RP updated. Review of a 01/11/23 Wound & Skin Evaluation, found in the Assessments tab of the EMR and completed by LPN E revealed a new right heel pressure ulcer, presenting as a stage IV, that was facility-acquired on 01/09/23 and measured 0.7 cm long by 0.6 cm wide by 0.2 cm deep. LPN E documented a treatment of wound cleanser, Medihoney, calcium alginate, and a foam dressing. Review of R75's 01/16/23 Wound Evaluation & Management Summary from the contract wound physician, located in the Documents tab of the EMR, revealed R75 had a stage IV, full thickness, pressure ulcer on her right heel that required surgical debridement: The wound was cleansed with normal saline and anesthesia was achieved using topical benzocaine. Then with clean surgical technique, 15 blade was used to surgically excise devitalized tissue and necrotic muscle level tissues were removed at a depth of 0.3 cm and healthy bleeding tissue was observed. As a result of this procedure, the nonviable tissue in the wound bed decreased from 100 percent to 45 percent. Review of R75's 03/01/23 Skin & Wound Assessment, located in the Assessments tab of the EMR revealed a picture of the right heel wound, which appeared as a large, black circular area that covered the entire back side of the heel. It appeared deep and covered with necrotic tissue. The edges of the wound appeared as whitish/yellow scabbed tissue. Though the wound physician had provided treatment to R75's sacral and buttock wounds on 01/09/23, there was no evidence the physician had been alerted to the right heel wound for assessment and treatment on 01/09/23, until it had progressed to a stage IV and required surgical debridement. In an interview on 03/01/23 at 11:41 AM, R75's hospice nurse stated the resident had declined rapidly in the past two weeks. The nurse stated, Before, she could tell who she is or where she is; now, she can't do that anymore. In an interview on 03/01/23 at 5:27 PM, LPN D, who served as the unit manager, stated R75 had been experiencing more of a decline in the last two weeks. LPN D added R75 had poor food intake recently. LPN D stated the facility had recently implemented shower sheets, where the CNAs could document new skin issues to communicate to the nurse. She stated, before the shower sheets were implemented at the end of January 2023, CNAs communicated new skin issues to the nursing staff verbally for follow up. LPN D stated she would expect the staff to report any new skin issue, from reddened or non-blanching areas to wounds. LPN D stated she would expect the staff to note a new skin issue before it becomes a stage 4 or unstageable necrotic wound. LPN D added, I was told a wound can change within two hours, it can decline fast. LPN D added the shower sheets were implemented to help the staff identify skin issues earlier, rather than after decline to a stage 4 or unstageable necrotic wound. On 03/02/23, the facility provided a paper Body Audit form for R75, which was undated and unsigned, that had been completed the evening of 03/01/23 or early morning of 03/02/23. It revealed a new pressure sore to the resident's left ear, a new pressure sore to the left heel, and a pressure sore to the right heel. The right buttock pressure ulcer, right sacrum pressure ulcer, and right and left ankle pressure ulcers were not included. On 03/02/23 at 10:23 AM, employee E confirmed the Body Audit was inaccurate and would be re-done. F. Left Heel Review of R75's 03/01/23 Skin & Wound Assessment, located in the Assessments tab of the EMR, revealed a picture of both her heels. Though the picture focused on the right heel wound, a clear visual of a large, purplish-black scabbed area on R75's left heel with several smaller areas that appeared as suspected deep tissue injury. Review of R75's EMR revealed there was no assessment or treatment order for the wound on her left heel. During an observation in R75's room on 03/02/23 at 3:52 PM, LPN G uncovered R75's legs to reveal she had pressure-reducing boots on both feet and was lying with her ankles crossed. LPN G gently un-crossed R75's legs, causing her to moan and grimace. LPN G reported R75 only expressed pain with movement. LPN G removed the resident's boots to reveal a bandaged area on her right heel. Her left heel had no bandage or covering. There was a large purplish-black circular area on the left heel that looked as if scabbed, and two smaller circular areas that appeared as deep tissue injuries. LPN G stated she did not see an assessment of the left heel wounds in the EMR or treatments, other than skin prep. In an interview on 03/02/23 at 4:00 PM, LPN D, who served as the Unit Manager, stated the picture of R75's left heel on 03/01/23 showed wounds on the heel. She stated she did not see any treatment orders for the left heel wounds or an assessment of the wounds. She stated she would expect the wound to be assessed and the physician notified for treatment orders of any newly identified wound. In an interview on 03/02/23 at 4:31 PM, LPN E, who served as the facility's wound/treatment nurse, stated she had taken the picture of R75's heels on 03/01/23 but did not notice the wounds on the left heel at that time. LPN E was unable to explain why she did not see the left heel wound on 03/01/23, stating there was no reason for it. LPN E stated she first noticed the left heel wound on 03/02/23 when she was providing wound care for R75's right heel. LPN E stated the certified nurse aides (CNAs) and floor nurses were observing residents frequently, and if a staff member noticed a new area, they were to put in a skin alert on the EMR so the wound could be assessed, notifications could be made, and treatment could be started. LPN E stated she would expect nursing staff to identify areas when they were red, non-blanching areas or partial thickness loss, rather than at a full thickness tissue loss with or without necrosis. The LPN stated, I kind of take it personally [when wounds are not reported until they reach full thickness] because this is what I do all day every day. It's heartbreaking sometimes when you see one that progressed that bad. If you saw some red areas or something, nobody reported. LPN E continued she would expect new wounds to be identified immediately, adding, When it first starts, if you see redness, whether it blanches or not, it's important to know for progression of the wound to get ahead of it. LPN E explained risks of wounds included infections (osteomyelitis , sepsis), pain, surgical debridement, and potential amputation. LPN E stated she performed all wound treatments during the week, and the LPNs on the floor would do the treatments on the weekend. She stated she completed the Wound & Skin Evaluations for all wounds and attended wound rounds weekly with the consultant wound physician. LPN E stated she performed the measurements and assessment of the type of tissue, wound bed, and other wound characteristics. She stated there was no Registered Nurse who participated in wound assessments. 2. R39 developed multiple avoidable pressure ulcers. Review of R39's undated Profile, located in the Profile tab of the EMR revealed he was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including obstructive hydrocephalus, epilepsy, chronic respiratory failure, tracheostomy, and contracture. Review of R39's annual MDS assessment with an ARD of 01/03/23, located in his EMR under the MDS tab, revealed the Brief Interview for Mental Status (BIMS) could not be conducted, and staff assessed R39 with severely impaired cognition. R39 was rarely/never able to make himself understood or understand others. He exhibited behavioral symptoms not directed toward others, but the behaviors did not impact the resident's care. R39 was totally dependent on staff for bed mobility and all activities of daily living. He was at risk for developing pressure sores but did not have any current pressure sores. Review of R39's 01/16/23 Care Plan, located in the Care Plan tab of the EMR, revealed, [R39] has skin integrity problem r/t [related to] h/o [history of] skin breakdown and irritation r/t reduced mobility, incontinence of bowel and bladder, use of feeding tube, and trach. Pressure ulcer to right buttock resolved, scar and self-inflicted scratches noted to right inner thigh-resolved, and abrasion noted to right flank area-resolved, redness to sacrum. The goal was, Wound will not demonstrate signs of deterioration, new complication, or new or increasing infection through the next review. The facility's interventions included: Administer treatment per physician order. Report unusual change or decline in skin integrity or failure to improve within 2 weeks to MD [physician] for change in tx [treatment] if indicated . Air Mattress check placement and function Q [every] shift . Barrier cream as needed . Heel lift boots as tolerated . Larger briefs issued . MD addressed unavoidable risks . Observe for sporadic head movements and position resident to avoid injury to skin . [and] RD [registered dietician] available for dietary update/review PRN [as needed]. A. Coccyx/Sacrum and Right Buttock Wounds Review of R39's 12/21/22 Body Audit, located in the Assessments tab of the EMR, revealed R39 did not have any red or open areas on his sacrum/coccyx or buttocks. Review of R39's 12/28/22 Body Audit, located in the Assessments tab of the EMR, revealed he had redness to the sacrum. The area to identify any new areas was left blank, as was the area to document notification of the physician and responsible party. Review of 01/04/23, 01/11/23, 01/18/23, 01/25/23, 02/01/23, Body Audit, located in the Assessments tab of the EMR, revealed redness was noted to R39's coccyx. The area to identify any new areas was left blank, as were the areas to document notification of the physician and responsible party. Review of R39's 02/03/23 Health Status Note revealed, Resident's father called and stated he would like for him to remain in the bed for the weekend, due to area on his buttocks. Review of R39's 02/08/23 Body Audit, located in the Assessments tab of the EMR, revealed the resident had a pressure ulcer to the right hip (ischium) and a pressure ulcer to the right buttock. The physician and responsible party were notified of these new pressure sores on 02/06/23. Review of the 02/08/23 Wound Evaluation & Management Summary, completed by the contract wound physician, documented an Unstageable (due to necrosis), full thickness pressure ulcer of the right ischium measuring 4.1 cm long, 4.8 cm wide, and 0.2 cm deep. The summary indicated the wound required surgical debridement: The wound was cleansed with normal saline and anesthesia was achieved using topical benzocaine. Then with clean surgical technique, 15 blade was used to surgically excise 2.95 cm2 of devitalized tissue and necrotic subcutaneous level tissues were removed at a depth of 0.3 cm and health bleeding tissue was observed. As a result of this procedure, the nonviable tissue in the wound bed decreased from 35 percent to 20 percent. The evaluation also documented MASD, full thickness, to the right buttock measuring 2.3 cm long, 2.7 cm wide, and 0.2 cm deep. The physician determined the wound required surgical debridement: The wound was cleansed with normal saline and anesthesia was achieved using topical benzocaine. Then with clean surgical technique, 15 blade was used to surgically excise 1.55 cm2 of devitalized tissue including slough, biofilm and non-viable muscle-level tissues were removed at a depth of 0.3 cm and healthy bleeding tissue was observed. As a result of this procedure, the nonviable tissue in the wound bed decreased from 100 percent to 75 percent. Review of R39's 02/28/23 physician's Orders under Orders tab located in the EMR revealed an order for zinc paste to right buttock every shift to treat MASD, which originated on 02/08/23, and an order to clean the right ischium with saline, apply Medihoney, and cover with calcium alginate a foam dressing every day to treat a pressure ulcer, which originated on 02/09/23. Review of R39's EMR revealed there was no indication the redness to the resident's sacrum/coccyx that had been identified weekly since 12/28/22 on the Body Audits and on the right buttock identified by the resident's responsible party on 02/03/23 had been reported to the physician, assessed by the wound nurse, and treated to prevent deterioration and promote healing prior to 02/08/23, when the wounds were assessed and identified as full thickness wounds by the contract wound physician which required surgical debridement. In an interview on 03/02/23 at 4:31 PM, LPN E, who served as the facility's wound/treatment nurse, stated CNAs and floor nurses observed residents frequently, and if a staff member noticed a new area, even just new redness, they were to put in a skin alert on the EMR so the wound could be assessed, notifications could be made, and treatment could be started. LPN E stated she would expect nursing staff to identify areas when they were red, non-blanching areas or partial thickness loss, rather than at a full thickness tissue loss with or without necrosis. Review of the facility's 05/27/22 Body Audit policy revealed, A full body, or head to toe, body audit will be conducted by a licensed or registered nurse upon admission/readmission and weekly thereafter. The body audit may also be performed after a change of condition or after any newly identified pressure injury . Documentation of the body audit in the EHR [electronic health record] includes but it not limited to: Include date and time of the assessment, your name, and position title. Document observations (e.g. skin conditions, how the patient tolerated the procedure, etc.). Document type of wound. Describe wound (measurements, color, type of tissue in wound bed, drainage, odor, pain). Document if patient refused assessment and why. Document other information as indicated or appropriate. Review of the facility's 05/27/22 Skin - Wound Mobile Application Documentation policy revealed, The Center will document wound evaluation using skin and wound mobile application through [the EMR]. Wound evaluation includes Pressure and vascular wounds, and other non-pressure wounds as indicated . Photograph measurements obtained by the skin-wound mobile application will be considered a part of the medical record . The frequency of wound documentation will be at least weekly or as determined by the DON or designated wound nurse . For capturing new wounds or re-evaluation of weekly wound measurements through the skin wound mobile application, techniques to ensure consistency will be utilized. Review of the facility's 05/27/22 Pressure Injury Prevention Guidelines policy revealed, The effectiveness of interventions will be monitored through ongoing assessment of the patient and/or wound. Considerations for needed modifications include: Development of a new pressure injury. Lack of progression towards healing or changes in wound characteristics. Changes in the patient's goals and preferences, such as at end-of-life or in accordance with his/her rights. Surveillance will be utilized as a method to prevent and to promote the early identification of pressure injuries, to the extent possible. RNs and LPNs participate in surveillance through the evaluation of patients and reporting changes in condition to the patient's physician/physician extender and other nursing management employees of new or worsened pressure injuries . Pressure injuries will be tracked, and a focused review completed on pressure injuries that develop or worsen in the Center. 41449 3. For Resident #16, the resident developed an avoidable stage 3 pressure ulcer and the facility staff failed carry out wound physician orders. On the afternoon of 2/28/23, Resident #16 was visited in the day room, where he was sitting in a Geri-chair. Resident #16 did not respond when spoken to. Observations revealed Resident #16 had a contracture of his left arm at the elbow. Review of the clinical record of Resident #16 revealed the following: Resident #16 had diagnoses of, but not limited to: Dementia and Hemiplegia and hemiparesis following cerebrovascular disease affecting right non-dominant side. Resident #16's care plan indicated the Resident was incontinent of bowel and bladder. The care plan also identified that Resident #16 was at risk for skin breakdown. Resident #16 was also noted as being totally dependent upon facility staff for all care needs. Resident #16 had a body audit completed 12/12/22, that noted, left antecubital [of or relating to the inner or front surface of the forearm] skin tear. On 12/14/22, a nurse entered a progress note that read, CNA reported that resident has open area to his left arm. Resident has open area noted to his left AC [antecubital]. Wound bed is red with scant amount of serosanguinous drainage noted. Area is approximately 2 cm by 2 cm. Area cleaned with normal saline and Medi honey applied with dry dressing. RP [responsible party] and NP [nurse practitioner] aware. NP in to assess and new order to clean with normal saline (at dry and apply Medi honey to area daily until healed [sic]. On 12/14/22, the nurse practitioner note indicated that Resident #16 was seen for .Generalized weakness with constipation and dysphagia . There was no mention of the Resident's skin being impaired. On 12/16/22, a Skin & Wound Evaluation was completed by the facility staff that identified the wound on Resident #16's Left antecubital space as a Stage III pressure wound, which measured 1.0 cm x 1.2 cm x 0.3 cm. On 12/18/22, Resident #16 was seen by the wound care physician/specialist that indicated, .a thorough wound care assessment and evaluation was performed today. He has a stage 3 pressure wound of the left arm . there is moderate serous exudate . A surgical excisional debridement procedure was performed to remove necrotic tissue and establish the margins of viable tissue . 15 blade was used to surgically excise devitalized tissue and necrotic subcutaneous level tissues were removed at a depth of 0.4 cm . The wound care physician then ordered, Dressing and treatment plan: Leptospermum honey apply once daily for 30 days; Alginate calcium apply once daily for 30 days. Secondary dressing: Gauze Island with border apply once daily for 30 days. Review of the December 2022 and January 2023, treatment administration record (TAR) revealed the order by the wound care physician was entered as Cleanse left antecubital space skin tear with NS/WC [normal saline/wound cleanser], apply Medi honey, alginate and cover with a dry dressing. every day shift every other day for Skin Tear . This treatment was performed every other day from 12/14/22-12/30/22, and on 1/1/23, for a total of 10 occurrences versus the daily treatment. On 1/2/23, the wound care physician saw Resident #16 and noted the following orders, .Dressing treatment plan: Primar [TRUNCATED]

Based on observations, staff interviews, record review, and facility policy review, the facility failed 1) to ensure a multi-use glucometer was disinfected per manufacturer's instructions between use on each resident to prevent potential spread of bloodborne pathogens during finger-stick blood glucose checks for three of three residents (R104, R100, and R105) observed for blood sugar monitoring. R105 was diagnosed with bloodborne pathogens potentially transmissible to other residents using the glucometer. This failure had the potential to transmit infection to all 15 residents who received finger-stick blood glucose monitoring. On 03/03/23 at 2:55 PM, Immediate Jeopardy was called. The Immediate Jeopardy began on 03/03/23 at 10:29 AM, and was removed on 03/06/23 4:30 PM. Deficiencies remain at a level 2 isolated including 2) The facility staff failed to wear proper personal protective equipment (PPE) prior to entering the room of Resident # 101 in a survey sample of 71 residents. Findings include: 1. Review of R104's undated Profile, located in the Profile tab of the electronic medical record (EMR), revealed she was admitted to the facility on [DATE] with multiple diagnoses including type II diabetes mellitus. Review of R104's 03/03/23 physician's Orders, located in the Orders tab of the EMR, revealed an 11/09/22 order for Humalog insulin per sliding scale (amount given based on the current blood sugar reading) to be given at 6:00 AM, 11:00 AM, 4:00 PM, and 8:00 PM. There was no specific order for finger-stick blood glucose monitoring. 2. Review of R100's undated Profile, found in the Profile tab of the EMR, revealed she was admitted to the facility on [DATE] with multiple diagnoses including type II diabetes mellitus. Review of R100's 03/03/23 physician's Orders, located in the Orders tab of the EMR, revealed a 06/16/22 order for Humalog insulin per sliding scale to be given at 6:00 AM, 11:00 AM, 4:00 PM, and 8:00 PM. There was no specific order for finger-stick blood glucose monitoring. 3. Review of R105's undated Profile in the Profile tab of the EMR revealed she had diagnoses including osteomyelitis (bone infection that can spread via the bloodstream), methicillin-resistant staphylococcus aureus (MRSA) infection (a staph infection that is difficult to treat because of resistance to antibiotics, that can be spread via the blood. https://www.cdc.gov/mrsa), klebsiella pneumoniae (a bacterium associated with pneumonia spread by person-to-person contact and can be spread through the blood. https://www.cdc.gov/hai/organisms/klebsiella/klebsiella.html), and type II diabetes mellitus. Review of R105's 03/03/23 physician's Orders, located in the Orders tab of the EMR, revealed a 02/09/23 order for blood sugar monitoring at 6:00 AM, 11:00 AM, 4:00 PM, and 8:00 PM. On 03/03/23 at 10:29 AM, Licensed Practical Nurse (LPN) B was observed as she prepared to perform finger-stick blood glucose checks for R104, R100, and R105. LPN B placed three pairs of gloves, three lancets, one glucometer, and three alcohol prep pads on a piece of paper and brought them with her into R104's room. LPN B donned gloves, opened the alcohol prep pad, and wiped R104's finger. LPN B then used a lancet to pierce R104's skin, inserted the test strip in the glucometer, touched the test strip to the finger to obtain the blood sample, and obtained a blood sugar reading of 75. LPN B then discarded her gloves and exited the room without first washing or sanitizing her hands. LPN B then walked to R100's room and entered the room. LPN B donned gloves without first washing or sanitizing her hands. LPN B then inserted the test strip into the glucometer without first cleaning or sanitizing the glucometer. LPN B then used the lancet to perform the finger stick and touched the test strip to R100'S finger to obtain the blood sample with a blood sugar reading of 254. LPN B then doffed her gloves and exited the room. LPN B proceeded toward R105's room when Surveyor I intervened. LPN B stated she only had one glucometer and used the same glucometer for every resident she cared for. LPN B stated she would wipe it off with an alcohol prep pad when she went back to her cart after obtaining all three residents' blood sugar values. LPN B stated she was trained to sanitize the glucometer between each use, but she was just trying to hurry up and get it done. LPN B stated she used an alcohol prep pad [70% isopropyl alcohol] to clean the glucometer after use. Surveyor I then requested LPN B sanitize the glucometer before proceeding with R105's blood sugar check. LPN B was observed to use one alcohol prep pad to wipe the front of the glucometer, and another pad to wipe the back of the glucometer, then placed it on a tissue on top of the cart to dry. In an interview on 03/03/23 at 10:38 AM, LPN D, who served as the Unit Manager, stated glucometers should be cleaned and sanitized between use on each resident, and the staff were to use the grey-top wipes to sanitize the machine. She stated, We try to have two [glucometers] on each so they can rotate and use one while the other dries. LPN D stated failure to sanitize the glucometer between each resident could lead to transmission of infection and contamination to other residents. Observation of the grey-top wipes revealed they were Sani-Cloth Germicidal Disposable Wipes with Environmental Protection Agency (EPA) registration #9480-9. In an interview with the Administrator and Employee F on 03/03/23 at 2:55 PM, Employee F stated the staff should be using the appropriate Super Sani-cloth for glucometer disinfection between use on each resident. Review of the April 2021Assure Prism glucometer User Instruction Manual under the section Cleaning and Disinfection revealed, The cleaning procedure is needed to clean dirt as well as blood and other body fluids on the exterior of the meter and lancing device before performing the disinfection procedure. The disinfection procedure is needed to prevent transmission of blood-borne pathogens . The meter should be cleaned and disinfected after use on each patient. This Blood Glucose Monitoring System may only be used for testing multiple patients when Standard Precautions and the manufacturer's disinfection procedures are followed. We have validated Clorox Healthcare Bleach Germicidal Wipes [0.55% Sodium Hypochlorite, EPA#67619-12], Dispatch Hospital Cleaner Disinfectant Towels with Bleach [0.65% Sodium Hypochlorite, EPA#56392-8], CaviWipes1 [0.76% Didecyldimethylammonium chloride, 7.5% Ethanol, 15% isopropanol; EPA#46781-13], and PDI Super Sani-Cloth Germicidal Disposable Wipe [n-Alkly (68% C12, 32% C14) dimethyl ethylbenzyl ammonium chlorides, 0.25% n-Alkyl (60% C14, 30% C16, 5% C12, 5% C18) dimethyl benzyl ammonium chlorides, 0.25%, 55% isopropyl alcohol; EPA#9480-4] for disinfecting the Assure Prism multi meter. These disinfectants are available commercially in towelette form . Only wipes with EPA registration numbers listed in the previous tables have been validated for use in cleaning and disinfecting the meter. Any disinfectant product containing the EPA registration numbers may be used on this device. Review of the facility's 05/27/22 Blood Glucose Monitoring policy revealed, It is the policy of this Center to perform blood glucose monitoring per physician/physician extender's orders . The nurse will abide by the infection prevention and control practices of cleaning and disinfection of the glucometer per manufacturer's instructions . The nurse is responsible for cleaning and disinfection of the glucometer between patients following the manufacturer's instructions. On 03/03/23 at 2:55 PM, the Administrator and the Regional Clinical Registered Nurse (employee F) were notified the failure to ensure a multi-use glucometer was disinfected between use on each resident to prevent the potential spread of bloodborne pathogens constituted Immediate Jeopardy to the health and safety of the residents who used the multi-use glucometers. The Immediate Jeopardy began on 03/03/23 at 10:29 AM, when observations of the failure to disinfect the glucometer between use on each resident were first made. The facility presented the following removal plan. 1) All residents have the potential for risk if employee fails to disinfect of glucometer. Facility obtained proper [EPA registered] disinfectant wipes to clean the glucometers. Resident #100 was assessed and is being monitored for any adverse signs or symptoms. MD/RP made aware of incident. All Glucometers disinfected on 3/3/23. 2) Before being permitted to work all licensed nurses (LPNs and RNs) will be educated on and preform [sic] a return demonstration on the process of disinfecting a glucometer after each use. 3) Date of completion 3/3/23 at 6:15pm. The survey team verified the facility's removal plan by doing the following: Resident #100's clinical chart was reviewed, and it was confirmed that a nursing progress note was entered into the record that the nurse practitioner was made aware of the incident and gave no new orders. The Resident's Responsible party was also made aware of the incident. Surveyor C made observations on both nursing stations to verify that the correct purple top Super Sani cloths (EPA registered) were present and available for staff use. Surveyor C conducted staff interviews with all of the nurses (LPN/RN) currently working (10 LPNs and 1 RN) and all were able to verbalize the correct way to disinfect a glucometer, able to verbalize that they would do this prior to use and after each use (between each Resident). They would wipe all surfaces of the glucometer with a purple-top sani wipe and then take a clean super sani-wipe and wrap the glucometer and let it sit for 2 minutes, then remove the super sani-wipe and let the glucometer sit on a clean towel to air dry before using. 2 Nurses performed return demonstration. Facility staff were observed correctly sanitizing glucometers in-between residents. Immediate Jeopardy was removed on 3/6/23 at 4:30 PM 41449 2. The facility staff failed to wear proper personal protective equipment (PPE) prior to entering the room of a Resident with a known condition that was highly transmissible. This deficient practice was not related to the Immediate Jeopardy. On 2/28/23 at approximately 9:00 AM, Resident #105 was observed to have a sign on her room door that read, Contact Precautions, Prior to Entering Room: Clean hands using alcohol-based hand rub, gown, gloves. There was a station set-up in the hallway, outside of the room that contained isolation gowns, gloves, etc. On 2/28/23 at approximately 9:03 AM, an interview was conducted with CNA B. CNA B confirmed with the nurse on duty and then responded to the Surveyor that Resident #105 was on isolation for MRSA (Methicillin-resistant Staphylococcus aureus is a cause of staph infection that is difficult to treat because of resistance to some antibiotics). On 2/28/23 at 9:20 AM, Surveyor C observed Employee D enter the room of Resident #105 without putting on an isolation gown or gloves. Upon Employee D's exit from the room she was asked about the signage on the door, which indicated isolation. Employee D said, it was with the roommate she had, I overlooked the sign. On 2/28/23 at 10:12 AM, Employee E, who was a housekeeper was observed in Resident #105's room cleaning without wearing an isolation gown or gloves. When asked about the signage and PPE bin outside of the room, she said it will say hot room if it is COVID, but we haven't had COVID in a while. If it's something that can be transmitted, I wear it, otherwise I don't. When asked how she wound know if it is something that can or cannot be transmitted and she said she didn't know. On 2/28/23 at 10:20 AM, an interview was conducted with LPN D, the unit manager. LPN D said, Everyone should be wearing PPE, including housekeeping. Review of the facility policy titled; Contact Precautions was conducted. This policy read, .3. Use of personal protective equipment (PPE) and hand hygiene: a. Perform hand hygiene by using an alcohol-based hand rub prior to donning PPE and room entry. Wash hands with soap and water or use alcohol-based hand rub, in accordance with hand hygiene practices. b. Don gown and gloves upon room entry, doff and discard PPE in appropriate container, perform hand hygiene prior to room exit. During providing care for residents, gloves and gown will be changed after having contact with infective material that may contain high concentrations of microorganisms or if becomes visibly soiled (fecal material or wound drainage) . On 3/3/23, during an end of day meeting, the facility Administrator and Corporate Clinical Consultant were made aware of the above findings. No additional information was provided, prior to the conclusion of the survey.

Based on observations, resident and staff interviews, and record review, the facility failed to ensure 1) staff knocked and waited for permission to enter the rooms of one of two residents (Resident (R)56) reviewed for privacy and 2) six of six residents (R76, R104, R59, R67, R98, and R72) interviewed in the resident group meeting; and 3) that electronic medical records (EMRs) were only accessible by staff members based on their need to know for all 103 facility residents. Findings include: 1. Review of R76's quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 12/23/22 revealed she scored 15 out of 15 on the Brief Interview for Mental Status (BIMS), indicating no cognitive impairment. Review of R104's significant change in status MDS with an ARD of 01/03/23 revealed she scored a 15 out of 15 on the BIMS, indicating no cognitive impairment. Review of R59's quarterly MDS with an ARD of 01/27/23 revealed she scored 15 out of 15 on the BIMS, indicating no cognitive impairment. Review of R67's admission MDS with an ARD of 12/06/22 revealed he scored 15 out of 15 on the BIMS, indicating no cognitive impairment. Review of R98's annual MDS with an ARD of 12/31/22 revealed he scored 15 out of 15 on the BIMS, indicating no cognitive impairment. Review of R72's quarterly MDS with an ARD of 12/05/22 revealed she scored 15 out of 15 on the BIMS, indicating no cognitive impairment. During a resident group interview on 03/02/23 from 11:00 AM to 12:30 PM with the above six Resident Council representatives in attendance, all six residents stated the staff frequently failed to knock and wait for permission to enter their rooms. The residents stated they felt they had little privacy in the facility. 2. During an observation on 02/28/23 at 11:02 AM in R56's room, the resident was lying in bed and unable to respond appropriately to questioning due to advanced dementia. Certified Nurse Aide (CNA) D entered the room to provide care to R56 without knocking or announcing her presence. Review of R56's undated Profile, found in the Profile tab of the EMR, revealed she was admitted to the facility on [DATE] with diagnoses including dementia, glaucoma, legal blindness, insomnia, and muscle weakness. Review of R56's significant change in status MDS assessment with an ARD of 02/18/23, located in the MDS tab of the EMR, revealed she scored two out of 15 on the BIMS indicating severely impaired cognition. R56 had severely impaired vision and was sometimes able to understand others. She did not exhibit any behavioral symptoms. Review of R56's comprehensive Care Plan, located in the Care Plan tab of the EMR and dated 11/06/22, revealed, Res. [resident] wears eyeglasses, but her vision is severely impaired . and is legally blind and, Res. requires assist with her ADLs [activities of daily living] d/t [due to] imp. [impaired] mobility, imp. cognition, generalized muscle weakness, anemia, dementia, glaucoma, legally blind, [and] osteoarthritis. Review of email from the Regional Clinical Registered Nurse, Employee F, on 03/03/23 at 5:20 PM, revealed the facility did not have a policy addressing resident privacy. During a concurrent interview with the Administrator and Employee F on 03/03/23 at 7:30 PM, Employee F stated she expected the staff to knock and introduce themselves before entering residents' rooms. 41449 3. The facility staff failed to uphold the confidentiality of the electronic health record of all 103 Residents residing in the facility in a manner to limit staff access to only the Resident information needed to perform their job duties. On 3/5/23 at 6:11 PM, an interview was conducted with CNA F. CNA F was questioned about some documentation he had made into the clinical record of a Resident. CNA F explained that he had not cared for the Resident in question. When told he had completed the documentation, CNA F said, I didn't do that, let me show you, we can document under anyone's name. CNA F then took Surveyor C to the computer at the nursing station and demonstrated how he was able to log into the clinical record using numerous staff member's access information that had been saved on the computer. CNA F then proceeded to say that staff just choose anyone's name to complete documentation and chart on Residents. CNA F further demonstrated that he could log-in under the access of an LPN and had access to the entire clinical record of every Resident. On 3/6/23 at approximately 9:30 AM, Surveyor B and Surveyor C went to the nursing station. The surveyors were able to access the electronic health record of all Residents using various staff members credentials that were saved in the computer system. The CNA's had limited access to the clinical record but if log-in was made under a nurses name the entire clinical record could be seen/accessed. The facility staff provided a document titled, State of Resident Rights. This policy was reviewed, and the following was noted, .Right to privacy. Each resident has a right to: Privacy regarding their personal, financial, and medical affairs . On 3/7/23 at 2:40 PM, during an end of day meeting held with the facility Administrator, Director of Nursing and Corporate Staff, the above findings were discussed and all parties in attendance confirmed this should not be happening. On 3/8/23 at approximately 9 AM, the facility Administrator confirmed they had validated that facility staff's log-in credentials were saved on several computers and staff were able to access the electronic health record of all Residents without any restrictions. The Administrator further stated that their IT [information technology] staff had corrected the issue. No further information was provided.

Based on observation and staff interview, the facility staff failed to 1) label eye drops with an open date for one resident (Resident #515) in a survey sample of 71 residents and 2) failed to secure medications delivered from the pharmacy. The findings include: 1. For Resident #515, the facility failed to label the resident's Dorzolamide eye drops with an open date. On 03/02/2023 at approximately 11:15 AM, a medication cart on north unit was inspected. The inspection found Dorzolamide eye drops (for Resident #515) were not labeled with an open date. On 03/02/2023 at approximately 11:28 AM, an interview was conducted with LPN G. LPN G stated that the eye drops should be labeled and needed to be discarded 30 days after opening. 41449 2. The facility staff failed to secure medications delivered from the pharmacy as evidenced by leaving medications at the nursing station without staff oversight. On 3/3/23 at 8:30 AM, upon the survey team's arrival to the facility it was noted that the pharmacy was delivering medications to the facility. The survey team held the door open for the pharmacy employee and noted that he had two large gray bags with paperwork attached that identified the contracted pharmacy name. On 3/3/23 at 9:36 AM, Surveyor C noted on one nursing unit that the bag of medications was sitting on the nursing station. There was a staff member down the hallway, several doors down who was passing medications. Another employee was seen towards the end of the hallway walking away from the nursing station. Upon further inspection it was noted that there was a white bag stapled to the larger gray bag. The packing slip indicated that Gabapentin Capsules with a quantity of 7 were contained within the bag. Review of the packing slip revealed there was an abundance of medications that were contained within the bag. The packing slip listed IV medications and cycle fills. Surveyor C then went to the unit manager's office/LPN D and made her aware of the unsecured medications. LPN D stated, they should have taken the items that need to be refrigerated and put in the fridge and then secured the rest in the medication room, I will have to call the pharmacy to see who signed for them. LPN D then retrieved the medications and put them in the medication room where they were secure. On 3/3/23 at 11:16 AM, an interview was conducted with LPN H, another unit manager. LPN H was asked to explain the process when the pharmacy delivers medications. LPN H said that the pharmacy delivers daily in the morning. When they bring medications, it is for the next day, they give them to the nurse because they have to be signed for. The nurse then puts then in the medication room until they have time to put them away. When asked why it is important to secure the medications, LPN H said, so patients won't get in them, and you don't know who is going to get a hold of them, we have a lot of patients that are incoherent, or someone could steal them. LPN H went on to say that You definitely know where there is a narcotic because that is in a separate white bag. Review of the facility policy titled; General Guidelines for Medication Storage was conducted. This policy read, . 2. Only licensed nurses, the Consultant Pharmacist and those authorized to administer medications (e.g., medication aides) are allowed access to medications. Medication rooms, carts, and medication supplies are locked or attended by persons with authorized access . 7. Schedule II medications and other drugs subject to abuse are stored in a separate, permanently affixed area and are under double lock. Schedule III-V medications may be stored along with non-controlled drugs but may be under more strict storage controls at the Facility's discretion or as required by state regulations . On 3/3/23, during an end of day meeting, the facility Administrator and Director of Nursing were made aware of the above findings. No further information was provided.

Based on resident and staff interviews, record review, and facility policy review, the facility failed to ensure grievances voiced in Resident Council and by six of six residents (R76, R104, R59, R67, R98, and R72) interviewed in the resident group meeting were acted upon in a timely manner and the Grievance Official responded to the resident group's concerns. Findings include: 1. Review of the facility's September 2022 to February 2023 Resident Council Meeting minutes, provided on paper by the Administrator, revealed several concerns were voiced several times over the last six months without evidence of follow-up and/or resolution presented to the Resident Council. These concerns included call bell response time, rooms not being cleaned consistently, and disrespectful treatment by staff. A. The 09/21/22 minutes documented the Administrator and five additional staff attended the meeting along with the resident council president and 12 additional residents. The minutes documented, Reviewed last month's minutes. There was no evidence a review of the prior grievances and their corrective actions was presented. The minutes documented, Residents had concerns of call bell response time. B. The 10/26/22 minutes documented the Administrator and eight additional staff attended the meeting along with the resident council president and 15 additional residents. The minutes documented, Reviewed last month's business with no further explanation of the information reviewed or who presented the information. Under Housekeeping was documented, Rooms need more frequent cleaning. C. The 11/30/22 minutes documented the Administrator and eight additional staff attended the meeting along with the resident council president and eight additional residents. The minutes documented, Reviewed last month's business. All concerns were followed up on: Staff were in-serviced on residents being bathed in a timely manner. Housekeeping has been in-serviced on room cleaning schedule. Under Housekeeping was documented, Rooms need more frequent cleaning, confirming the in-service training of housekeeping staff was ineffective at addressing the residents' grievance. D. The 12/28/22 minutes documented the Administrator, Activity Director, Social Service Director, Director of Nursing, and Housekeeping Supervisor attended the meeting in addition to the resident council president and nine additional residents. Under Nursing was documented, Residents had concerns of staff being on cell phones. Over hearing staff talking about their personal concerns and under Housekeeping was documented, Rooms not always being cleaned on a consistent basis. [Housekeeping Supervisor] made residents aware that she hired 3 more staff, and they were to start on 12/29/2022. There was no follow-up documented regarding concerns from the previous meeting, including rooms not being cleaned consistently. E. The 01/25/23 minutes documented the Regional Clinical Registered Nurse (employee F), the Activity Director, the resident council president, and 14 additional residents attended the meeting. Under nursing concerns was documented, Residents' [sic] states call bells are not answered in a timely manner. Nursing staff on cell phones while giving care. Evening and night staff talking loudly in hallways. Under Housekeeping was documented, Rooms are not being cleaned daily. There was no follow-up documented regarding concerns from the previous meeting, including disrespectful treatment by staff and rooms not being cleaned consistently. F. The 02/21/23 minutes documented the Administrator was in attendance along with the resident council president, six additional residents, and two social services staff. Under nursing concerns was documented, 3-11 [evening shift] staff not always being respectful. Though the Administrator presented information regarding filing grievances, contacting the Ombudsman, and the corporate compliance line, there was no follow-up documented regarding concerns from the previous meeting, including call light response time, disrespectful treatment by staff, and rooms not being cleaned consistently. 2. A resident group interview was held on 03/02/23 from 11:00 AM to 12:30 PM with six alert and oriented Resident Council representatives in attendance, including the resident council president. A. Review of R76's quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 12/23/22, located in the MDS tab of the electronic medical record, revealed she scored 15 out of 15 on the Brief Interview for Mental Status (BIMS), indicating no cognitive impairment. B. Review of R104's significant change in status MDS with an ARD of 01/03/23 revealed she scored a 15 out of 15 on the BIMS, indicating no cognitive impairment. C. Review of R59's quarterly MDS with an ARD of 01/27/23 revealed she scored 15 out of 15 on the BIMS, indicating no cognitive impairment. D. Review of R67's admission MDS with an ARD of 12/06/22 revealed he scored 15 out of 15 on the BIMS, indicating no cognitive impairment. E. Review of R98's annual MDS with an ARD of 12/31/22 revealed he scored 15 out of 15 on the BIMS, indicating no cognitive impairment. F. Review of R72's quarterly MDS with an ARD of 12/05/22 revealed she scored 15 out of 15 on the BIMS, indicating no cognitive impairment. During the resident group interview, all six residents (R76, R104, R59, R67, R98, and R72) reported they felt the concerns they voiced in Resident Council meetings were not always addressed and resolved by staff. R76 stated, We don't feel like anything has been done to address our concerns and the other five residents agreed. R104 stated the Administrator was good at talking in circles . but does not address our concerns or give us any report on any follow-up. She will say they are working on it but nothing ever happens. The additional five residents agreed, and R67 stated, There is no real response in Resident Council. During the resident group interview, when reviewing concerns related to disrespectful treatment by staff, R59 stated she had a recent experience where a certified nurse aide (CNA) got upset with her when she had an incontinent episode, and she felt the staff attitudes had not improved. R104 stated the staff would fuss at her for using a bedside commode rather than the toilet, but this was because she was physically unable to use the toilet. R104 felt the staff attitudes had not improved. R76 stated there were still problems with staff being on their phones while providing care. R76 explained that often, the staff would enter her room while talking into their cell phone via an earpiece, and she would mistakenly believe they were talking to her. R76 stated the staff attitudes had not improved. All six residents agreed they often heard staff complaining of being short-staffed and overworked or other personal issues. All six residents reiterated they felt the staff continued to treat residents disrespectfully and they were not aware of any follow-up done to their repeated resident council grievances. During the resident group interview, when reviewing concerns related to call light response time, all six residents agreed response to call lights had not improved. All six residents agreed the staff would complain they were short-staffed or had staff that did not show up. R104 stated, It can take up to 30 or 40 minutes to answer call lights at times. Sometimes they turn off and say they will be back, but then don't come for a long time. The five other residents agreed. R76 added, I'll have to sit on the toilet for up to 40 minutes because they take so long to answer the light and R104 stated, I've waited 10 minutes after calling for help to get out of the shower and get dried off. It's cold to wait so long so I've gotten to where I keep the water running until they come in. During the resident group interview, when reviewing concerns related to inconsistent cleaning of resident rooms, all six residents agreed the rooms were not cleaned well, and this has been an ongoing problem. All six residents stated this had come up repeatedly in Resident Council, but was still an issue. 3. In an interview with the Administrator on 03/02/23 at 6:00 PM, any follow-up to the Resident Council's repeated grievances was requested. On 03/03/23, the Administrator provided paper records of staff trainings, which included: A. Call bell response for nursing staff on 02/07/23 B. Patient [and] Employee Experience - customer service module 2 for department heads on 02/03/23 C. Customer Service for nursing staff on 01/25/23 D. Service excellence for all staff on 01/19/23 E. Cleaning and floor care in December 2022 for environmental services staff The Administrator did not provide any additional follow-up, written resolution to Resident Council grievances, or monitoring to ensure the training was effective. In a concurrent interview on 03/03/23 at 7:30 PM with employee F and the Administrator, the Administrator stated the facility had implemented changes to improve call light response time, including managers assigned to answer lights during lunch and dinner when most staff were busy with the meal. The Administrator stated there was no documentation of this resolution and may not have been presented to the Resident Council because there were several meetings where she was not invited to attend. The Administrator stated the facility had implemented a program with the department heads to talk about positive attitudes, and the department heads were to present this information to their staff. In addition, there was training on service excellence. The Administrator stated there was no documentation of this resolution and may not have been presented to the Resident Council because there were several meetings where she was not invited to attend. The Administrator added that the housekeeping department had implemented a new cleaning schedule, implemented training, and hired new employees to address the residents' concerns of lack of consistent room cleaning. The Administrator stated this resolution may not have been presented to the Resident Council because there were several meetings where she was not invited to attend. Review of the facility's policy for Resident Council revealed the facility provided the Centers for Medicare and Medicaid Services (CMS) December 2017 Resident Council Interview pathway. The pathway documented, Does the facility consider the views of the resident or family groups and act promptly upon grievances and recommendations? and Does the Grievance Official respond to the resident or family group's concerns? Review of the facility's 03/17/22 Grievance Policy revealed, The Administrator is the designated grievance official . If a grievance is received by a staff member, the staff member receiving the grievance will record the nature and specifics of the grievance on the designated grievance form . The Grievance Official, or designee, will take appropriate steps to resolve the grievance promptly but no more than 30 days from the time the grievance is reported to the Center . All information about the grievance and any resulting actions will be recorded on the Grievance/Concern Form . The Grievance Official, or designee, will keep the patient appropriately apprised of progress towards resolution of the grievance . the Grievance Official, or designee, will issue a written decision on the grievance to the patient or representative at the conclusion of the investigation if requested.

Based on staff interview, clinical record review, the facility staff failed to ensure medications were available as ordered for one resident (Resident # 91) in a survey sample of 71 residents. This happened on multiple occasions. Findings included: For Resident # 91, the facility staff failed to ensure medications were available as ordered by the physician, Resident # 91's diagnoses included, but were not limited to: Epilepsy, Cerebrovascular Accident, Diabetes and Hypertension Review of the open electronic clinical record was conducted on 3/2/2023-3/9/2023. Review of the clinical record revealed documentation of medications being unavailable on scheduled times of administration. Examples of times medications were unavailable included but were not limited to: 2/3/2023 11:34 eMar - Medication Administration Note (electronic medication administration record) Note Text: Phenobarbital Solution 20 MG/5 ML (20 milligrams/ 5 milliliters) Give 15 ml via PEG (percutaneous Endoscopic Gastrostomy)-Tube every 12 hours for Epilepsy awaiting pharmacy to deliver 2/2/2023 20:28 eMar - Medication Administration Note Note Text: Phenobarbital Solution 20 MG/5 ML Give 15 ml via PEG-Tube every 12 hours for Epilepsy on order from pharmacy 1/26/2023 23:27 eMar -Medication Administration Note Note Text: Phenobarbital Solution 20 MG/5 ML Give 15 ml via PEG-Tube every 12 hours for Epilepsy awaiting med from pharm (pharmacy) 1/18/2023 18:09 eMar -Medication Administration Note Note Text: Labetalol HCL Tablet 200 MG Give 1 tablet via PEG-Tube two times a day for HTN (Hypertension) not available 12/17/2022 10:47 eMar -Medication Administration Note Note Text: Phenobarbital Solution 20 MG/5 ML Give 15 ml by mouth every 12 hours for epilepsy Pharmacy was called and said they would send the med stat (immediately) 12/16/2022 21:15 eMar -Medication Administration Note Note Text: Phenobarbital Solution 20 MG/5 ML Give 15 ml by mouth every 12 hours for epilepsy Awaiting delivery from pharmacy The medications that were unavailable included the medication, Phenobarbital prescribed for Epilepsy and Labetalol prescribed for Hypertension. During an interview on 3/2/2023 at approximately 1:51 p.m., LPN (Licensed Practical Nurse) D stated medications should be provided by the pharmacy. LPN D stated the staff should check the inventory to determine if the missing medications were available in the facility and notify the physician if medications were unavailable for administration. LPN D also stated the family representative should be notified. On 3/3/2023 during the end of day debriefing, the Corporate Nurse Consultant stated the expectation was for the pharmacy to make sure medications were available for administration by the facility staff as ordered by the physician. The Corporate Nurse Consultant stated the facility staff was expected to contact the Pharmacy whenever medications were not available at the time of administration, check the stat box, notify the physician and follow any new orders. She stated the Pharmacy used by the facility was local and should be able to provide medications quickly. Review of the stat box inventory revealed no documentation of the two medications Phenobarbital and Labetalol being available in the list of contents. During the end of day debriefings on 3/3/2023 and 3/6/2023, the Administrator and Corporate Nurse Consultant (in the role of interim Director of Nursing) were informed of the findings of medications being unavailable. No further information was provided.

Based on observation, staff interview, and facility documentation review, the facility staff failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety which have the potential to affect multiple Residents on 2 of 2 nursing units. The findings included: 1. The facility staff failed to label food with the date the item was opened/prepared and/or a use by date. On 2/28/23 at 7:30 AM, a brief initial tour/inspection of the kitchen was conducted with Employee S, a dietary aide. During this tour, the following was noted: In the walk-in refrigerator there was turkey sandwich meat that had been wrapped in cellophane, there was no labeling to indicate when it was opened or to be used by. In the stand-alone refrigerator, there was a bowl of lettuce and another container of tomatoes that were covered but not labeled with a date of when they were prepared or to be used by. In the dry food storage there were two bags of dry pasta that had been opened and were not dated. On 2/28/23 at approximately 7:42 AM, an interview was conducted with Employee S, a dietary aide. When asked about dating of items, stated, items are dated when we open them. When asked why dating is important, Employee S said, so that you know how long it is good for. On 2/28/23 at approximately 7:50 AM, following the walk-through, Employee S confirmed all the above observations. On 03/01/23 at 11:30 AM, another more detailed walk-through was conducted of the kitchen with the dietary manager, Employee Q. Employee Q stated all items are to be labeled when opened or prepared so that staff know when to use them by. She was made aware of the findings from 2/28/23. On 3/5/23 at approximately 5:30 PM, the stand-alone refrigerator was checked. Inside there were 3 plates of tossed salads that were wrapped in cellophane that were not labeled or dated as to when they were prepared or to be used by. There was also a container of a brown substance that appeared to be chocolate pudding that had no label to indicate the contents, when it was prepared/opened or to be used by. On 3/7/23 at 10:30 AM, the Dietary manager was made aware of the items in the stand-alone walk-in cooler that were not labeled, that were observed on 3/5/23. A review of the facility policy titled, Safe Food and Supply Storage was conducted. This policy read, . 4. All opened packages of lunch meat must be securely wrapped and dated with a use by date of 5 days from date opened. Lunch meat, including ham, should be placed on a drip tray, and stored under or away from produce . 6. Cut tomatoes, lettuce, and melon should be used within 3 days . Dry Goods . 4. If no manufacturer use by date is listed, dry goods will be labeled with a use by date of 1 year from the date received if unopened. Dry goods may be kept for 3 months from date opened . On 3/2/23 at 4:29 PM and again on 3/7/23, the facility Administrator was made aware of the above findings. No further information was provided. 2. The facility staff failed to obtain food temperatures for 42 of 66 meals served from 2/6/23-2/27/23. On 02/28/23 at 07:42 AM, a brief tour of the kitchen was conducted. The dietary staff were preparing to start the tray line/meal service for breakfast. The cook, Employee P was observed taking temperatures of foods. When asked why temperatures are taken, the cook stated, to make sure it is cooked properly. Employee P then provided the surveyor with the book of where meal temperatures are recorded. Review of the meal temperature logs revealed that from 2/6/23-2/27/23, 42 of the 66 meals had no temperatures recorded. Copies of the food temperature logs were provided to Surveyor C by facility staff. On 3/1/23 at approximately 11:15 AM, Employee R, a cook was asked about meal temperatures. Employee R said, it is important to take temps to make sure food is up to temp, if not, we can't serve it and we are not supposed to serve cold food. On 03/01/23 at 11:30 AM, Employee Q the dietary manager was asked to obtain the meal temperatures for the past few weeks. Employee Q obtained the meal temperature logs and Surveyor C showed the copy of the temperature logs provided to the surveyor on 2/28/23. Employee Q was asked to explain how all the dates with missing documentation on 2/28/23, now had temperatures filled in, Employee Q was not able to explain. The facility policy titled; Monitoring Food Temperatures was reviewed. This policy read, 1. The cook is responsible for checking meat temperatures when items are removed from the oven to ensure proper internal temperature. 2. The staff member serving from a steam table is responsible for checking food temperatures within 15 minutes of start of service. If an item is not at least 135 degrees F, it will be removed from the line, reheated to a minimum of 165 degrees F, and returned to the steam table. Cold food items which are time and temperature sensitive and are above 41 degrees will be chilled in an ice bath to 41 degrees or less. Temperatures are recorded on a Food Temperature Log. 3. Measure and record the temperatures for each food product, milk, and coffee at all meals. Record temperature on a Food Temperature Log. 4. When holding hot foods for service, food temperature should be measured when placing it on the steam table line. 5. No food will be served that does not meet the food code standard temperatures . On 3/2/23 at 4:29 PM, during an end of day meeting, the facility Administrator was made aware of the above findings. No further information was provided. 3. The facility staff failed to dry dishes in a manner to avoid wet nesting to prevent the development of microorganism growth. On 3/5/23 at approximately 6:30 PM, an observation was made of the cleaning of the evening meals dishes. Three employees were working in the dish room. Employee T, a dietary aide was observed removing the racks of dishes from the dishwasher and immediately stacked the wet dishes which included the plate warmer pellets, plates, and bowls. Employee T also removed the meal trays from the dishwasher and immediately stacked them on a cart, while they were still wet. When asked about drying of dishes, Employee T said she put the pellets and plates into the warmer. When asked about allowing them to air dry, Employee T stated, what was being observed is how she does it. On 3/7/23 at 10:30 AM, an interview was conducted with the dietary manager, Employee Q. When asked about how dishes are to be dried, she said they are to remain on the rack to air dry because it is important so that bacteria don't grow. Employee Q and Surveyor C then walked over to dish room and they observed bowls stacked, eating surface facing up, with water being visible inside the bowls. The dietary manager confirmed the observation of dishes wet nesting. The dietary manager was also made aware of the observations that occurred on 3/5/23. The facility policy regarding the drying of dishes was requested. The facility stated they did not have a policy or procedure regarding this. According to the 2017 Food Code published by the U.S. Public Health Service, FDA U.S. Food & Drug Administration chapter 4, section 4-901.11, titled Equipment and Utensils, Air-Drying Required pages 151-152 stated: After cleaning and sanitizing, equipment and utensils: (A) Shall be air-dried or used after adequate draining as specified in the first paragraph of 40 CFR 180.940 Tolerance exemptions for active and inert ingredients for use in antimicrobial formulations (food-contact surface sanitizing solutions), before contact with food; and (B) May not be cloth dried except that utensils that have been air-dried may be polished with cloths that are maintained clean and dry. On 3/7/23, during an end of day meeting, the facility Administrator was made aware of the above findings. No further information was provided. 4. The facility staff failed to remove a dented can so that it was not available for use, to ensure the integrity of the product. On 2/28/23 at approximately 1:20 PM during observation of the dry storage area of the kitchen revealed on the rack of canned goods, a dented can of marinara sauce that was available for use. Employee S was asked about the facility process with regards to dented cans. Employee S said, we sit it on the side. When asked, why? Employee S said, we aren't supposed to use them when dented up. Employee S was shown and confirmed that the can of marinara sauce was dented and should have been put in the designated area so that it wouldn't be available for use. On 03/01/23 at 11:30 AM, Employee Q the dietary manager was interviewed. The dietary manager stated that dented cans are placed in a separate area, designated for dented cans so that they are not used. When asked what the risk of using dented cans is, she said that the quality of the product can be compromised, and the food has the potential to be contaminated from the dent. The dietary manager was made aware of the above findings noted on 2/28/23. Review of the facility policy titled Safe Food and Supply Storage stated, . 7. Dented cans should be stored in a designated area for return to the distributor or discarded. On 3/2/23 at 4:29 PM, during an end of day meeting the facility administrator was made aware of the above findings. No further information was provided. 5. The facility staff failed to have hand soap available in the kitchen, for staff to wash hands prior to the preparation of food. On 2/28/23 at 07:42 AM, Surveyor C entered the kitchen to conduct a brief tour. Upon entry to the kitchen, Surveyor C proceeded to the hand sink to wash her hands and identified there was no soap, the dispenser was empty. Surveyor C inquired if there was another sink available and the dietary staff stated that was the only hand sink available. Employee P, a dietary aide stated she would go get some. On 2/28/23 at approximately 7:50 AM, Employee P, the dietary aide returned and informed Surveyor C that housekeeping didn't have any extra soap on their cart and would have to wait for a supervisor to arrive to unlock the supply area. The dietary staff then proceeded to prepare the tray line by taking food temperatures and plate set-up. When asked about hand hygiene, the dietary employees stated, There was soap when I went to wash my hands. On 3/2/23, during an end of day meeting, the facility was asked to provide any facility policies with regards to hand washing. The facility stated they didn't have a hand washing policy with regards to dietary staff. Review of the Infection Prevention and Control policy was conducted. It read, 4. Hand Hygiene Protocol: a. Employees will wash hands when coming on duty, between patient contacts, after handling contaminated objects, after PPE removal, before/after eating, before/after toileting, and before going off duty. b. Employees will wash their hands before and after patient care procedures. c. Hands will be washed in accordance with standards of practice . On 3/2/23, during an end of day meeting, the facility Administrator was made aware of the above findings. During the end of day meeting, the facility Administrator told the survey team that there are additional soap dispensers in the kitchen available for handwashing. On 3/3/23 at 9:22 AM, Surveyor C went to kitchen and interviewed the dietary manager. It was noted that the only additional soap available to staff other than the dispenser by the hand sink was the dish soap dispenser at the three-compartment sink. The Dietary manager confirmed this. On 3/3/23, the facility administrator provided the survey team with a copy of an in-service training that was conducted with regards to staff being provided a tour of the facility to access points where supplies are maintained. No further information was provided.

Based on staff interview and facility documentation review, the facility staff failed to obtain licensure verification after a professional license expired to ensure the license was current for 1 Registered Nurse, (Employee #15) in the survey sample of 25 employees. The findings included: During the survey, reviews of 25 employee records were conducted. The reviews revealed that Employee #15 (an RN) did not have a licensure verification check completed through the Virginia Department of Healthcare Professionals (DHP) Licensure Exchange upon expiration of her professional nursing license on [DATE]. The facility failed to obtain a renewal certificate of licensure without encumbrances. An interview was conducted with the Human Resource Manager on [DATE] at approximately 4:00 p.m. The Human Resource Manager stated that the documents could not be found, and that the facility had nothing further to provide. The facility administration was informed of the findings during an end of day briefing on [DATE] at approximately 6:30 p.m. The facility did not present any further information about the findings.

Based on observation, record review, staff interview, and facility policy review, the facility failed to maintain an effective housekeeping program to keep the floors free from debris and pests for one of 37 residents (Resident (R) 56) rooms observed in Initial Pool and six of six residents (R76, R104, R59, R67, R98, and R72) interviewed in the resident group meeting. Findings include: 1. Review of R56's undated Profile, found in the Profile tab of the electronic medical record (EMR), revealed she was admitted to the facility on [DATE] with diagnoses including dementia, glaucoma, legal blindness, insomnia, and muscle weakness. Review of R56's significant change in status Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 02/18/23, located in the MDS tab of the EMR, revealed she scored two out of 15 on the Brief Interview for Mental Status (BIMS), indicating severely impaired cognition. R56 had severely impaired vision and was sometimes able to understand others. She did not exhibit any behavioral symptoms. Review of R56's comprehensive Care Plan, located in the Care Plan tab of the EMR and dated 11/06/22, revealed, Res. [resident] wears eyeglasses, but her vision is severely impaired . and is legally blind and, Res. requires assist with her ADLs [activities of daily living] d/t [due to] imp. [impaired] mobility, imp. cognition, generalized muscle weakness, anemia, dementia, glaucoma, legally blind, [and] osteoarthritis. During an observation on 02/28/23 at 1:55 PM, R56 was observed lying in bed in her room. On the floor behind the head of the bed was a piece of candy with many small black ants swarming on it and crawling in a line on the floor along the baseboard behind R56's bed. R56 was unable to answer questions regarding the cleanliness of her room, responding help me to any questioning. During observations in R56's room on 03/01/23 at 9:00 AM, 10:11 AM, and 12:33 PM; on 03/02/23 at 10:32 AM and 3:50 PM; and on 03/03/23 at 9:21 AM, the candy was still present on the floor behind the head of R56's bed, with a swarm of ants on the candy and crawling along the wall in a line to and from the candy. In an interview and concurrent observation in R56's room on 03/03/23 at 11:03 AM, the housekeeper assigned to R56's room, employee J, stated there was candy on the floor with ants on and around it. Employee J picked up the piece of candy and threw it away. Employee J stated the candy must have been dropped today, as he cleaned behind the beds every day. Employee J stated, I get upset when things are on the floor like that . they need to keep it clean . The floors need to be kept very clean otherwise you get bugs. In an interview with the Employee K, Housekeeping Supervisor, on 03/03/23 at 12:18 PM, she stated the floors in every room were to be cleaned daily and there was a deep cleaning schedule as well where furniture would be moved, and the entire floor cleaned. Employee K stated she did walk-throughs on each unit at the end of the day to verify daily cleaning was done. She was not aware of the candy with ants on the floor of R56's room from 02/28/23 to 03/03/23. 2. Review of R76's quarterly MDS, with an ARD of 12/23/22, revealed she scored 15 out of 15 on the BIMS, indicating no cognitive impairment. Review of R104's significant change in status MDS, with an ARD of 01/03/23, revealed she scored a 15 out of 15 on the BIMS, indicating no cognitive impairment. Review of R59's quarterly MDS, with an ARD of 01/27/23, revealed she scored 15 out of 15 on the BIMS, indicating no cognitive impairment. Review of R67's admission MDS, with an ARD of 12/06/22, revealed he scored 15 out of 15 on the BIMS, indicating no cognitive impairment. Review of R98's annual MDS, with an ARD of 12/31/22, revealed he scored 15 out of 15 on the BIMS, indicating no cognitive impairment. Review of R72's quarterly MDS, with an ARD of 12/05/22, revealed she scored 15 out of 15 on the BIMS, indicating no cognitive impairment. During a resident group interview on 03/02/23 from 11:00 AM to 12:30 PM with the above six Resident Council representatives in attendance, all six residents stated their rooms were not cleaned well and often their floors remained dirty, and this a problem brought up by the resident council on several occasions but has not been corrected by the facility staff. Review of the facility's undated 5-Step Daily Room Cleaning policy revealed, The entire floor must be dust mopped - especially behind dressers and beds . move all furniture to dust mop . all corners and along all baseboards must be dust mopped to prevent build up . The most important area of a patient's room to disinfect is the floor. This is where most air-borne bacteria will settle and so it needs to be sanitized daily . move all furniture necessary and run the mop along the edges first.

Based on observation, interview, clinical record review, the facility staff failed ensure freedom from neglect for 1 Resident (#16) in a survey sample of 71 Residents. The findings include: For Resident #16 the facility staff neglected to provide care which resulted in the Resident being left to sit in a Geri chair (medical style recliner) for a prolonged time, which exceeded 9 hours. As a result, Resident #16 developed a deep tissue injury. On 2/28/23 at approximately 9:00 AM, Resident #16 was observed to reside in room [number redacted] and was on droplet precautions as identified by signage on the door. Staff interviews confirmed that Resident #16 was under quarantine for COVID-19. On 2/28/23 at 10:12 AM, Resident #16 was noted to no longer be in room [number redacted] and the signage had been removed from the door alerting to droplet precautions. An interview was conducted with the unit manager/LPN D. The unit manager stated that Resident #16 was being moved back to the room he was in previously, due to his quarantine period had ended at mid-night. On 2/28/23 at approximately 1:00 PM, Resident #16 was observed in a Geri chair in the day room. The assigned room that Resident #16 was moving to was observed and it was noted there was not a bed in the room for Resident #16. Resident #16 was not able to be interviewed and didn't respond when spoken to. On 2/28/23 at approximately 3:30 PM, Resident #16 was observed to still be sitting in a Geri chair in the day room and again did not respond to questions. The observation revealed the assigned room did not have a bed in the room. LPN C was questioned about Resident #16 being in the Geri chair in the day room and no bed being in the room. LPN C responded that she would call to get them to bring the bed from the other unit. Review of the clinical record of Resident #16 revealed the following: Resident #16 had diagnoses of, but not limited to: Dementia and Hemiplegia and hemiparesis following cerebrovascular disease affecting right non-dominant side. Resident #16's care plan indicated the Resident was incontinent of bowel and bladder. The care plan also identified that Resident #16 was at risk for skin breakdown. Review of the interventions to prevent skin breakdown included but were not limited to: Encourage frequent position changes for pressure relief, observe for moisture and incontinence issues that affect skin. Report for further assessment if noted and provide pressure reduction surfaces as ordered/indicated. On 3/1/23 at approximately 10:00 AM, an interview was conducted with Resident #26, who was now Resident #16's roommate. Resident #26 presented to be alert and oriented. When asked what time Resident #16 got moved into the room, Resident #26 said, It was real late. When asked several questions to elicit a time, Resident #26 said, he had eaten his supper, it was dark outside and then said it was around 9-10 PM. On 3/1/23 during the late morning, an interview was conducted with LPN C, who was the nurse assigned to Resident #16 following the room change on 2/28/23. LPN C was asked about the room change process and said that the nursing staff move the Resident and their belongings. LPN C confirmed that she worked over on 2/28/23, and at the time she left around 5 PM, Resident #16's bed still had not been moved. Review of the timecard revealed LPN C left at 5:06 PM on 2/28/23. On 3/1/23 at 10:31 AM, an interview was conducted with Employee M/Maintenance Associate. Employee M stated he had been asked by nursing staff to move a bed into a room for Resident #16 on 2/28/23. He indicated that it was not brought to his attention until about 6 PM that evening. He then moved a bed into the room and advised nursing that it was available and needed to have sheets put on it. On 3/5/23 at approximately 4 PM, an interview was conducted with CNA F. CNA F confirmed that he was not the assigned CNA for Resident #16 on 2/28/23, that the assigned CNA had to leave mid-shift. CNA F said that when he went on break at 8 PM, Resident #16 was still sitting in the day room and had not been put to bed. On 3/6/23 an interview was conducted with the Wound Care Physician (WCP). The WCP confirmed that Resident #16 had developed a deep tissue injury to the back of his calf. On 3/7/23, an interview was conducted with the Corporate Nurse/Employee F. The corporate nurse consultant confirmed that Resident #16 had developed a deep tissue injury that was consistent with him being left sitting in a Geri-chair for an extended period. A review of the facility policy titled; Abuse Prevention was conducted. This policy defined neglect as, Neglect: the failure of the Center, its employees or any service provider to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. On 3/3/23 and again on 3/7/23, during an end of day meeting, the facility Administrator and Corporate Nurse consultant were made aware of the above findings and reported this was unacceptable. No further information was provided.

Based on interview, clinical record review, and facility documentation the facility staff failed to ensure the Residents right to participate in care planning for 2 Residents (#26 & # 82) in a survey sample of 71 Residents. The findings included: 1. For Resident # 26 the facility staff did not inform of and offer opportunity for RR (Resident Representative) to attend the care plan meetings since February 2022. On 2/28/22 at approximately 9:00 AM, an interview was conducted with Resident #26 who stated that he did not participate in care plan meetings. When asked why he did not participate, he stated he did not know when they were. A review of the clinical record revealed that Resident #26 was not his own RR due to his diagnoses. On 3/2/23 at 2:15 PM an interview was conducted with Employee G who stated that Resident #26 has not attended a care plan meeting in a while. When asked about his Representative attending the care plan meetings, she stated that the facility has been a little lax on getting invitations to care plan meetings out to Resident Representatives. Resident #26's last care plan meeting invite was sent to his Representative in February of 2022. On 3/3/23 during the end of day meeting the Administrator was made aware of the concerns and no further information was provided. 41450 2. For Resident #82, the facility staff failed to provide the opportunity for her to participate in her own care planning. On 2/28/23 at approximately 9:00 AM, Surveyor C conducted an interview with Resident #82 and asked if she participated in planning her care at the facility, to which Resident #82 replied, I have never been asked or invited to attend any meetings about my care here, I would like to be involved. On 3/1/23, a review of Resident #82's clinical record was performed and revealed the most recent MDS (Minimum Data Set), a quarterly review with an ARD (Assessment Reference Date) of 2/1/23, coded Resident #82 with a BIMS (Brief Interview of Mental Status) score of 15 out of 15, indicating no cognitive impairment. Resident #82 was documented as her own Responsible Party. Review of the clinical record also revealed care plan reviews conducted on 4/22/22, 7/29/22, 10/26/22, and 2/1/23, however there was no documentation indicating that Resident #82 was invited to participate with care plan meetings. On 3/1/23, an interview was conducted with the Social Services Director (SSD), which included a review of Resident #82's clinical record. The SSD verified the care plan reviews were conducted without Resident #82 in attendance and verified there was no evidence that Resident #82 had been invited to participate in her care planning since her admission on 4/22/22. The SSD stated, We have had some turnover in our department and in the facility and we are trying to get back on track with things. On 3/2/23, the Facility Administrator was made aware of the findings. No further information was provided.

Based on observation, staff interview, clinical record review, and facility documentation review, the facility staff failed to ensure the Resident's right to a dignified existence for 1 Resident (Resident #47) in a survey sample of 71 Residents. The findings included: For Resident #47, the facility staff failed to maintain dignity and assist Resident #47 with a meal on 3-1-23 resulting in Resident #47 sitting at a table with 2 other Residents observing them eat breakfast as she was unable to feed herself. On 3-1-23 at 8:00 A.M., Surveyor B observed Resident #47 sitting in a communal area on the nursing unit at a table with 3 other residents who were able to feed themselves. The residents were being served breakfast and eating while Resident #47 watched them eat with no meal in front of her. This dining observation was conducted from 8:30 A.M., until 9:35 A.M., when all of the food had been eaten by the other three residents, and Resident #47 had not been served nor assisted with a meal. No staff stayed in the room until 9:34 A.M. On 3-2-23, Resident #47's clinical record was reviewed. Resident #47's most recent quarterly Minimum Data Set with an Assessment Reference Date of 1-28-23 coded the Resident's functional status for eating as extensive assistance on 1 staff member for eating. The Brief Interview for Mental Status was coded as severe cognitive impairment. The Resident's care plan was reviewed. There was a focus, goals, and interventions on the care plan associated with The Resident's nutritional status, however, the interventions listed that the Resident would be encouraged to eat in the dining room for lunch. No mention of communal eating was included in the care plan for breakfast or dinner. On 3-3-23 at approximately 5:00 P.M., the Administrator and Regional Registered Nurse Consultant were notified of findings. When asked about the expectation for meal service to table mates, and they both agreed that the Resident should not have been left there for an hour to watch others eat.

Based on observation, resident interview, staff interview, and clinical record review, the facility staff failed to develop a comprehensive dental care plan for one Resident (Resident #48) in a survey sample of 71 residents. The findings included; For Resident #48, the facility staff failed to include the problems, interventions and goals to address the Resident's ongoing dental care. Resident # 48's most resent MDS (Minimum Data Set) with an Assessment Reference Date of 2-2-23 was coded as a Quarterly assessment. The Brief Interview for Mental Status was coded as 12 out of possible 15 indicating very mild cognitive impairment. On 3-1-23 the Resident was interviewed by Surveyor B. The Resident complained of dental problems and stated he had seen the dentist, and was eating soft food, but wanted to start having regular dental care appointments. The Residents weight history was reviewed and in 6 months the Resident had experienced weight loss, however, not significant, and was stable for 5 months. Dental consult exam notes were reviewed and revealed a Dental doctors orders for; brushing of teeth and tongue twice daily morning and evening due to plaque and calculus build up, with follow up dentist cleaning every 4 months, and exam every 6 months. The dentist also recommended fluoride varnish due to high risk for caries. On 3-2-23 the clinical record for Resident #48 was reviewed and no dental care plan could be found. The nursing progress notes, physician progress notes, as well as dental progress notes documented that the Resident had been seen by a dentist in January 2023, and needed to be scheduled to return on regular appointments, however, there was no dental care plan in the clinical record to guide daily dental care, nor to plan for continuity of care. On 3-2-23 at 3:10 p.m., Surveyor B conducted an interview with LPN (Licensed Practical Nurse) H who stated the facility staff should follow the care plans and that care plans should be individualized for each resident and updated as needed. On 3-3-23, during the end of day debriefing at 5:50 P.M., the Administrator and Corporate Registered Nurse Consultant were informed of the findings. No further information was provided.

Based on observation, interview, clinical record review, and facility documentation the facility staff failed to review and revise care plans to include changes in resident care for 2 Residents (#65 and #15) in a survey sample of 71 Residents. The findings included: 1. For Resident #65 the facility staff failed to revise the care plan after a verbal abuse allegation, to include LPN C not being assigned to Resident #65. On 3/2/23 at 12:15 PM Resident #65 was again observed in bed with her privacy curtain closed, an interview was conducted with Resident #65 who stated that on LPN C was rude to her. The Resident explained the incident and stated that the facility had stated that she would not have LPN C as her nurse anymore, however she continued to pull her medications and give them to another nurse to administer, causing Resident #65 to be concerned about her messing with her medications. Resident #65 also stated that when she got a roommate, LPN C was assigned to the roommate. On 3/3/23 a review of the facility investigation revealed the following excerpts: Based on an investigation including resident and staff statements, we were unable to substantiate that abuse occurred. Our center values service excellence, so in an abundance of caution the center provided customer service education to the staff member prior to her returning to the center. In addition [LPN C name redacted] will not provide care to [Resident 65 name redacted]. Her care plan has been updated and revised. On 3/3/23 a review of the Resident care plan did not reveal any revision related to this matter. On 3/3/23 during the end of day meeting the Administrator was made aware of the concerns and no further information was provided. 2. For Resident #15 the facility staff failed to revise care plan to include interventions for pressure ulcer prevention and treatment. On 2/28/23 a review of the clinical record revealed that Resident # 15 had a pressure area to her sacrum that was facility acquired. According to facility documentation entitled Skin and Wound Assessment V5.0 dated 3/1/23 at 6:13 AM, Resident #15 had a stage IV pressure area to the sacrum that was in house acquired, first identified on 11/9/22. On 3/1/23 at approximately 10 AM an observation was made of the stage IV pressure area to the sacrum The wound doctor was consulted on 11/28/22 and measured the wound as 2.9 cm x 1.9 cm x 0.4 cm and described it as 100% necrotic devitalized tissue and performed surgical debridement at that time. On 3/1/23 a review of the care plan revealed no mention of a wound or wound care or interventions to prevent pressure areas from developing. On 3/1/23 at 9:00 AM, an interview was conducted with LPN F who stated that Care plans should reflect anything that is required to care for the Resident. When asked if a newly discovered wound should be added to the care plan, she stated that it should. She stated that the care plans should be updated with any changes in care or condition of the Resident. A review of the facility policy # CL.2105, entitled Pressure Injury and Prevention Guidelines revealed the following excerpts: 1. Individualized interventions will address specific factors identified in the patient's risk assessment, skin assessment, and any pressure injury assessment (e.g., moisture management, impaired mobility, nutritional deficit, staging, wound characteristics). 2. The goal and preferences of the patient and/or legal representative will be included in the plan of care. 3. Interventions will be implemented in accordance with physician/physician extender orders, including the type of prevention devices to be used and, for tasks, the frequency for performing them. On 3/3/23, during the end of day meeting, the acting DON was asked if the care plan should reflect the presence of a wound and associated wound care and interventions, she stated that it should. When asked why this information was not in Resident #15's care plan she stated that it was. She then showed the surveyor a care plan that read as follows: Focus Is at risk for skin breakdown pressure injury to sacrum and right heel Date Initiated: 12/19/2022 Created on: 12/19/2022. On this copy of the care plan, there were interventions entered for the same date. When the acting DON was questioned about why the copy of the care plan the survey team obtained did not mention the wound or interventions, she stated that it had been marked as Resolved in Jan and she (the DON) had just Reactivated it in the system. However, the care plan focus and interventions were dated 12/19/22 and the wound was identified on 11/9/23 indicating that the care plan was not updated, until over a month later, and was discontinued too soon before the wound healed as evidence by the observation of the wound on 3/1/23 at 10 am. On 3/3/23 during the end of day meeting the Administrator was made aware of the concerns and no further information was provided.

Based on staff interview, clinical record review and facility documentation review, the facility staff failed to follow standards of nursing practice with regards to following physician orders for one Resident (Resident #16) in a survey sample of 71 Residents. The findings included: For Resident #16 the facility staff failed to provide daily treatment to a pressure wound as ordered by the physician for a period of 11 weeks. Review of the clinical record revealed that on 12/18/22, Resident #16 was seen by the wound care physician. This physician noted that Resident #16 had . a stage 3 pressure wound of the left arm for at least 1 day duration .Dressing Treatment Plan: Primary Dressing(s) Leptospermum honey apply once daily for 30 days; Alginate calcium apply once daily for 30 days Secondary Dressing(s) Gauze Island w/ bdr [with border] apply once daily for 30 days . However, review of the Treatment Administration Record revealed the order by the wound care physician was entered as Cleanse left antecubital space skin tear with NS/WC [normal saline/wound cleanser], apply Medi honey, alginate and cover with a dry dressing. every day shift every other day for Skin Tear . This treatment was performed every other day from 12/14/22-12/30/22, and on 1/1/23, for a total of 10 occurrences versus the daily treatment that the wound specialist ordered. On 1/2/23, the wound care physician saw Resident #16 and noted the following orders, .Dressing treatment plan: Primary Dressing(s) Alginate calcium w/[with] silver apply once daily for 30 days Secondary Dressing(s) Gauze Island w/ bdr [with border] apply once daily for 15 days . However, review of the Treatment Administration Record (TAR) for January revealed the above order from 1/2/23, was transcribed to the TAR as, Cleanse left antecubital space skin tear with NS/WC. apply silver alginate and cover with a dry dressing every day shift every other day for Skin Tear. This treatment was administered every other day from 1/3/23-1/31/23, for a total of 15 treatments. In February 2023, the treatment continued every other day for a total of 15 Administrations/treatments. This wound continued to deteriorate as evidenced by the wound care physician noting in a progress note dated 2/27/23, that the Resident had . a stage 4 pressure wound of the left arm for at least 66 days duration. There is moderate serous exudate . On 3/6/23, during the afternoon, an interview was conducted with the wound care physician. During the interview, when asked about his expectation regarding treatments ordered for wound care, the physician stated he expects them to be carried out as ordered with regards to frequency. When Resident #16 was discussed, the physician stated he was not aware that the facility staff had not been providing the treatments daily as ordered. The Corporate Nurse Consultant cited Lippincott as their nursing professional guidance used by the facility. Fundamentals of Nursing, by Lippincott, stated The physician is responsible for directing medical treatment. Nurses follow physicians' orders unless they believe the orders are in error or harm clients. During an end of day meeting held, the facility Administration was made aware of the above findings. They responded that the notation of the wound being a skin tear was in error. No further information was provided.

Based on staff interview and clinical record review, the facility failed to develop discharge plans for one Resident (Resident # 113) in a survey sample of 71 Residents. Findings included: Review of the clinical record was conducted on 3/2/2023. Review of the Progress Notes and care plans revealed no documentation of discharge plans for Resident # 113. Review of the Progress Notes revealed that Resident # 113 did not return to the facility after an outing with his wife. Review of the care plan revealed no documentation of discharge plans for Resident # 113. On 3/3/2023 at 12:24 p.m., an interview was conducted with the Social Services Director who stated # 113 did not return to the facility after going on leave with family. The Social Services Director stated that discharge plans should be developed for residents. During the end of day debriefing on 3/3/2023, the facility Administrator and Corporate Nurse Consultant were informed of there findings. No further information was provided.

Based on staff interview, facility documentation review, and clinical record review, the facility staff failed to provide infection control surveillance, monitoring, and tracking of staff for COVID-19 in accordance with the Center for Medicare and Medicaid Services (CMS) and The Centers for Disease Control and Prevention (CDC) recommendations, to prevent the spread of COVID-19, for 5 Residents (Resident #1, #10, #11, #12 and #13) in a survey sample of 13 Residents and for 8 facility staff (Employees K & L, LPN D, LPN H, LPN I, CNA B, CNA F, CNA I) . 1. The facility staff permitted employees who had tested positive for COVID-19 to continue to work, which exposed Residents #1, #10, #11, #12, and #13. Per the CDC Return to Work Criteria for HCP (health care personnel) with [DIAGNOSES REDACTED]-CoV-2 Infection. Symptom-based strategy for determining when HCP can return to work. HCP with mild to moderate illness who are not severely immunocompromised: At least 10 days have passed since symptoms first appeared and At least 24 hours have passed since last fever without the use of fever-reducing medications and Symptoms (e.g., cough, shortness of breath) have improved Immediate Jeopardy was identified on 01/7/2021 at 1:00 PM. After verification, Immediate Jeopardy was abated on 1/14/2021 at 3:45 PM, and the scope and severity was lowered to a Level 2 pattern. 2. The facility staff failed to maintain a complete and accurate infection control surveillance, monitoring and tracking system for staff for COVID-19 infections, involving Employees K & L, LPN D, LPN H, LPN I, CNA B, CNA F, CNA I. The findings included: 1. The facility staff permitted employees who had tested positive for COVID-19 to continue to work, which exposed Residents #1, #10, #11, #12, and #13 1a. On 1/5/21 at approximately 11:45 AM, an interview was conducted by Surveyor B with the facility Administrator in regards to facility staffing. When asked if the facility had implemented emergency staffing strategies during the COVID-19 pandemic, the Administrator stated no. When asked if they had experienced any staffing problems, the Administrator stated, no. The Administrator was then asked if Resident care had been impacted by any staffing concerns regarding COVID-19, he said no, we are having no problems, we are using agency staff, but have had no problems. On 1/7/21, a review of the facility's revised COVID-19 testing log submitted that morning to the survey team, revealed that on 1/4/21, LPN D had COVID-19 symptoms and tested positive for COVID-19. The log indicated that symptom onset was 1/4/2021. Despite having symptoms and being positive for COVID-19, this employee worked 1/5/21 and 1/6/21 on the unit which contained COVID negative Residents. This was confirmed by review of Resident clinical records, Resident #1, #10, #11, #12, and #13, all which showed clinical charting by this employee within Resident records on 1/5/21 and 1/6/21. On the testing log, LPN D was highlighted in yellow. When the facility staff was asked what this mean, Employee A, the facility Administrator confirmed that it indicated they had tested positive for COVID-19. 1b. On 1/7/21, a review was conducted of the revised employee testing log for COVID-19, received on 1/7/21. This log revealed that on 12/31/2020, CNA B tested positive for COVID-19. Review of the as-worked schedule for 1/7/21, revealed that CNA B was working. On 1/7/21 (Thursday), an interview was conducted with CNA B. CNA B indicated she had tested positive for COVID-19 last Thursday (12/31/2020). She stated, I got to feeling bad and left work early. My company made me stay out (referring to her employer, the nurse staffing agency) until they talked to management of the facility who said I could work. When asked when she returned to work, CNA B stated, on Tuesday. Surveyor A confirmed that she had seen CNA B on 1/5/21 and 1/6/21 working on the COVID positive unit when conducting facility observations. On 1/7/2021 at 1:00 PM, the Survey Team called Immediate Jeopardy (IJ), due to the facility allowing COVID-19 positive staff to work, which exposed Residents's to the COVID-19 virus. This created the likelihood that serious harm or death could occur if the Resident's contracted COVID-19. The facility staff, which included the Administrator and Employee C, the Assistant Director of Nursing (ADON) who is also the Infection Preventionist (IP), were made aware of IJ. On 1/7/21, at approximately 4:15 PM, the facility Administrator also provided Surveyor A with the COVID-19 Employee Screening Log which indicated on 1/4 and 1/5/21, LPN D had attested to not having symptoms of COVID-19. The Administrator stated, on the tracker log it says he was symptomatic but per the sign-in log he was not symptomatic. On 1/8/21 at 3:25 PM, the facility Administrator stated during an interview, we were under the assumption that positive people without symptoms could work on the positive unit, but that assumption was wrong. On 1/12/21, the Facility Administrator submitted an IJ removal plan, which the survey team accepted. The removal plan stated: 1. All staff and residents have potential for risk if employees work while COVID-19 positive, with or without symptoms of COVID-19. Any staff testing positive for COVID-19 within last 10 days have been removed from the schedule and not permitted to work until they have met the Return to Work Criteria. All staff will be retested on [DATE] or the next scheduled workday per the Center's testing plan. Any staff testing positive will be sent home immediately and the Center's Return to Work Criteria will be followed. All Residents identified as being exposed to COVID-19 positive staff not meeting the Return to Work Criteria were tested , assessed, and placed on transmission-based precautions. The Center's Infection Control Preventionist or designee will oversee the Center's Infection control tracking, screening, testing and surveillance. 2. All staff will be re-educated on the facility's screening process and Return to Work Criteria related to COVID-19, 97 staff member's education was completed by 1/12/21. The remaining staff education is ongoing and will be completed prior to the start of their next assigned shift until all staff re-education requirement is met. 3. To prevent reoccurrence any positive employee test result or symptomatic employee will be immediately reported to DON, ICP or designee to ensure employee or vendor is sent home immediately. 4. Date of completion 1-12-21 On 1/14/21, during review of the employee screening forms, the survey team identified that Employee J had reported symptoms of COVID-19 upon her arrival to work on 1/14/21. On 1/14/21 at 11:33 AM, an interview was conducted with Employee J, who was working. Employee J reported she had been tested for COVID-19 that day, which was negative. Employee J confirmed that she had reported and was still experiencing a sore throat and sinus drainage. I have issues throughout the year with my sinus. On 1/14/21 at 12:14 PM, the survey team met with the facility management team, which included, the Administrator, DON, ADON, and a Corporate Nurse. The survey team advised the facility staff that Employee J had reported symptoms of COVID-19 upon arrival to work but is still working. The Facility Administrator and DON confirmed that they are using the Center for Disease Control document titled Considerations for Interpreting [MEDICATION NAME] Test Results In Nursing Homes to guide their testing. This document had been submitted to the survey team by the facility Administrator on 1/13/21, as part of the education they were training staff on. Per this algorithm, Employee J was symptomatic which would have required a POC (point of care) [MEDICATION NAME] Test, if that test was negative, then perform confirmatory RT-PCR test immediately. Isolate/exclude from work until RT-PCR results. When the facility Administrator and DON were asked why this was not done, the facility Administrator stated he had been notified by the screener that Employee J was symptomatic. we did a POC test that returned negative. This is chronic and per the CDC because it is chronic it said do the POC test, because allergies can mimic COVID, she told me it is chronic so we didn't do a PCR. When asked what the purpose of doing PCR testing following a POC test was, the facility Administrator stated, to ensure it was correct. When asked if the facility Medical Director or any other physician had been involved, the Administrator stated, no. On 1/14/21 at approximately 2:25 PM, the facility Administrator advised Surveyor A that Employee J had a PCR test conducted and had been sent home. On 1/14/21 at approximately 2:30 PM, the facility Administrator provided Surveyor A with a document he indicated they had used to make the determination about Employee J. This document had a heading that read, People with seasonal Allergies and had been printed from the CDC website: https://www.cdc.gov/coronavirus/2019-ncov/faq.html#People-with-seasonal-Allergies. This document read, because some of the symptoms of COVID-19 and seasonal allergies are similar, it may be difficult to tell the difference between them, and you may need to get a test to confirm your diagnosis. Review of the facility policy titled, Testing Plan Updated 11/19/20 stated, Testing for Staff with COVID-19 Signs or Symptoms: Staff with signs or symptoms of COVID-19 will be tested and restricted from the Center pending the results of COVID-19 testing. If COVID-19 test is positive, the Center will require staff to follow the most current CDC Criteria for Return to Work for Healthcare Personnel with [DIAGNOSES REDACTED]-CoV2 Infection. If the COVID-19 test is negative, the most current CDC symptom-based strategy will be used for determining when staff may return to work, in accordance with applicable Center employee health guidelines. Table 3 of this same policy indicated if staff are symptomatic to confirm negative [MEDICATION NAME] result with a PCR test immediately, while results are pending HCP (health care personnel) should be excluded from work. Per the CDC Return to Work Criteria for HCP (health care personnel) with [DIAGNOSES REDACTED]-CoV-2 Infection. Symptom-based strategy for determining when HCP can return to work. HCP with mild to moderate illness who are not severely immunocompromised: At least 10 days have passed since symptoms first appeared and At least 24 hours have passed since last fever without the use of fever-reducing medications and Symptoms (e.g., cough, shortness of breath) have improved Accessed online 1/7/2021: https://www.cdc.gov/coronavirus/2019-ncov/hcp/return-to-work.html AND The facility staff's failure to provide infection control surveillance, monitoring and tracking has put Residents in direct contact with staff who are symptomatic and have a known positive COVID status. On 1/13/21 and 1/14/21, the survey team was onsite to verify the IJ removal plan had been implemented and Immediate Jeopardy had been removed. The survey team conducted the following to verify this: 1. The survey team verified that all staff that had tested positive for COVID-19 within the last 10 days had been removed from the schedule and were not working on 1/14. 2. The survey team verified that staff testing was conducted on 1/8/21, and anyone testing positive had been removed from the schedule. The as worked schedule for 1/13/21 and 1/14/21, were reviewed to confirm this. 3. The survey team verified that all staff working 1/13/21 and 1/14/21, had been tested on [DATE], or their first working shift following that date and received negative test results. 4. Staff education of the Return to Work (RTW) criteria and the COVID-19 screening process was reviewed. The survey team verified that all staff working 1/13/21 and 1/14/21, received training prior to being permitted to work. 5. Staff interviews were conducted to verify that they had received training and were able to verbalize the criteria and process if they develop symptoms or test positive. They were also interviewed regarding the screening process, reporting of symptoms, and importance of screening. 6. Resident's clinical records were reviewed, to ensure they were tested for COVID-19, assessed for COVID-19 signs and symptoms and had been placed on Transmission Based Precautions (TBP). 7. An interview was conducted with the Director of Nursing (DON) and Infection Preventionist (IP) to ensure they were made aware of any staff testing positive or COVID-19 and anyone displaying symptoms. 8. An interview was conducted with the IP to verify that she was going to oversee the Infection Control program to include, tracking, screening, testing and surveillance. 9. The screening forms were reviewed to ensure that all staff working 1/13/21 and 1/14/21, had been screened in and had not reported any symptoms of COVID-19. Staff working 1/14/21 at 3:45 PM, had been screened in and reported no symptoms of COVID-19. IJ was then abated at 3:45 PM on 1/14/21, all staff currently working had tested negative for COVID-19 within the last 7 days. All staff currently working had attested to not having any COVID-19 symptoms and been screened in and were afebrile at the start of their shift. 2. The facility staff failed to maintain a complete and accurate infection control surveillance, monitoring and tracking system, for staff for COVID-19 infections, involving Employees K & L, LPN D, LPN H, LPN I, CNA B, CNA F, CNA I. On 1/6/21 and 1/7/21, a review of the COVID-19 Employee Tracking Log was conducted. The facility Administrator and Infection Preventionist indicated this is the document used to track staff who have had positive COVID-19 test results. Review of this document revealed the following: 1. A total of 37 employees were noted on this log from 12/1/20-1/5/21, all of which, were listed as testing positive for COVID-19. The reason code was listed as 3 for each of these employees, the table which was part of the same document, listed reason code 3 as Associate is experiencing symptoms of COVID-19 and seeking [DIAGNOSES REDACTED]. 2. Of the 37 total employees listed on this log all had a date out recorded as the date they were taken out of work. Only 7 of these 37 had a recorded date return listed as to when they returned to work. 3. Three of the 7 employees, (CNA F & G, LPN I) recorded with return to work dates, returned to work prior to performing a 10 day quarantine as per the recommendations from the CDC. In comparison to the revised Employee Testing Log, received on 1/7/21, five employees (CNA I, Employee K, Employee L, CNA B, LPN D) were identified as testing positive for COVID-19 per the testing log but were not being tracked and monitored for surveillance. They were not included on the COVID-19 Employee Tracking Log. On 1/14/21 at 2:00 PM, the facility Administrator provided Surveyor A with an additional staff tracking logs that had not been presented during the survey prior to 1/14/21. The Administrator indicated, this is a log that (human resources name redacted) was keeping, she was tracking the agency staff. Employee K, CNA B and LPN D were all listed on this log. The staff tracking log received on 1/14/21, revealed LPN H as testing positive via PCR test. Her date out was noted as 1/4/21 and her date of return was noted as 1/4/21. When this was questioned, the facility Administrator stated, today was her first day back, this is a typo error. She may have worked the 7th, so we sent her home. On 1/14/21 during an end of day meeting, the survey team shared with the facility staff, the concern about inaccurate and incomplete records as well as various staff maintaining various parts of tracking. No further information was received. Complaint related deficiency.

Based on staff interview and clinical record review, the facility staff failed to accurately assess one of 4 residents (Resident #4) in the survey sample for a change in condition, resulting in harm (admission to the intensive care unit). And the facility failed to obtain blood work as ordered by the MD (medical doctor) to accurately and timely assess worsening symptoms of dehydration. The findings included: Resident #4 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Resident #4's Minimum Data Set (an assessment protocol) with an Assessment Reference Date of 4/10/13 coded Resident #4 with a BIMS (brief interview of mental status) of "3" out of a possible 15, or severe cognitive impairment. The MDS also coded the resident as exhibiting behaviors of verbal abuse and vocalizations 1-3 days a week. Resident #4 required extensive to total dependence, on staff, for Activities of Daily Living care and was incontinent of bowel and bladder. Review of Resident #4's clinical record revealed that on the day of admission, Resident #4 refused food and liquids. On 4/4/13, Resident #4 was "loud and disruptive" and a room change was requested, in which the RP (responsible party) was agreeable. On 4/6/13, psychiatry was consulted and a [DIAGNOSES REDACTED]. On 4/9/13, labs were ordered with the following results: Sodium: 137 (normal 133-143) Potassium: 5.4 (normal 3.5- 5.1) BUN (blood urea nitrogen): 82 (normal 7-25) Creatinine: 2.60 (normal 0.6- 1.2) On 4/10/13, the physician discontinued the potassium, since the potassium level was high according to the Lab test. Resident #4 was on [MEDICATION NAME] and [MEDICATION NAME] for high blood pressure, as well as potassium supplement due to [MEDICATION NAME] (diuretic causing loss of potassium). On 4/24/13, Resident #4 was moved to a private room due to increasing behavior. Also, a MBS (modified [MEDICATION NAME] swallow) was ordered. On 4/25/13, her diet was downgraded to puree due to coughing and "decreased alertness". On 4/25/13, Resident #4 refused her medications due to mouth soreness. An assessment was conducted which showed a sore on each side of her tongue. The physician was notified, and [MEDICATION NAME] was ordered for her mouth. The physician was in, and ordered labs in the AM, which included a CBC (complete blood count), BMP (basic metabolic profile which included sodium, potassium, chloride, Creatinine and BUN), a TSH ([MEDICAL CONDITION] stimulating hormone), and neurology and psychiatry consults. The physician contacted the daughter by phone. His assessment was "confusion and disorientation". In addition, the RD (registered dietician) had noted a 5.3% weight loss in 30 days of 11.6 pounds from her admission weight of 218 pounds. The RD's notes included the following: "BMI (body mass index) remains indicative of obesity and although weight loss is unplanned does appear desirable. The amount of weight she has lost however is a concern. Will continue therapeutic diet as ordered and follow further weight changes closely." On 4/26/13 at 7:53 AM, a nurse's note contained the following: "Resident did allow two attempts while wiggling, pulling/tugging at linen, pillow, causing needle to dislodge from site. The resident became very beligerent (sic) and jerking arm away, refusing to allow another attempt to obtain lab specimen. Day shift nursing staff made aware and urged to attempt to draw specimen once resident is more complacent/agreeable." There were no further notes regarding other attempts to redraw the labs, nor were there any notes that the physician was made aware the labs were not drawn. Continued nurse's notes on 4/26/13 revealed during the 7-3 shift that the resident refused morning medications and "both day time meals." On the 3-11 shift, the resident was moved to a private room, "very combative, hard to redirect." On the 11-7 shift, the resident "was restless this shift." On 4/27/13 at 1:54 PM, the nurse's notes contained the following: "I observed the resident as restless and lethargic and did not follow commands very well. I did ask her to open her mouth and she did open it but not very wide, and nodded back to a sleep like state. I did not see any open areas, her tongue was clean and was not coated and skin was dry and warm, VSS (vital signs stable): 127/80 (blood pressure), 86 (pulse), 20 (respirations), 94% on rm (room) air (oxygen saturation). I explained to the family that we can start an IV (intravenous line) and give fluids, but the sister who is the POA (power of attorney) was insistent that she go to the hospital, charge nurse did call the MD and was made aware, and Ok' d transfer to (name of hospital) to be evaluated for AMS (altered mental status)". The nurse's notes also contained this entry at 1:55 PM: "Family very concerned about resident po (by mouth) intake, resident refused breakfast and lunch as well as meds this shift, resident noted to be yelling throughout the shift and while being assessed by writer. Responds to questions appropriately at times, denied pain when asked. Resident moving all extremities restlessly. VS: 127/80, 86, 20, 97.8, mucous membranes noted dry. MD (Medical Doctor) updated on writer's assessment and with family concerns and their urgency to send to ER. (emergency room ) for eval (evaluation). The last nurse's note was made 4/27/13 at 2:41 PM, in which the nurse had attempted to notify the RP (responsible party) and talked with RP's husband, and that "we are sending her out to the ER." There was no note regarding the time or condition of the resident at discharge to the ER. The ER triage notes dated the time of arrival at 2:25 PM. ER notes revealed the following labs results compared with 4-9-13 labs: 4-27-13 labs (ER) 4-9-13 labs on facility admission: Sodium: 145 (normal 133-143) Sodium: 137 Potassium: 7.4 (normal 3.5-5.1) Potassium: 5.4 Chloride: 113 (normal 98-108) Chloride: 102 BUN: 199 (normal 7-25) BUN: 82 Creatinine: 8.20 (normal 0.6- 1.2) Creatinine: 2.60 The following information was obtained at the web site: http://www.mayoclinic.com/health/blood-urea-nitrogen/MY "A blood urea nitrogen test measures the amount of urea nitrogen that's in your blood. Your liver produces ammonia - which contains nitrogen - after it breaks down proteins used by your body's cells. The nitrogen combines with other elements, such as carbon, hydrogen and oxygen, to form urea, which is a chemical waste product. The urea travels from your liver to your kidneys through your bloodstream. Healthy kidneys filter urea and other waste products from your blood. The filtered waste products leave your body in urine. If a blood urea nitrogen test reveals that your urea nitrogen levels are higher than normal, it probably indicates that your kidneys aren't working properly. Or it could point to high protein intake, inadequate fluid intake or poor circulation..." And at the following web site: http://www.mayoclinic.com/health/creatinine/MY "Creatinine is a chemical waste product that's produced by your muscle metabolism and to a smaller extent by eating meat. Healthy kidneys filter Creatinine and other waste products from your blood. The filtered waste products leave your body in your urine. If your kidneys aren't functioning properly, an increased level of Creatinine may accumulate in your blood. A serum Creatinine test measures the level of Creatinine in your blood and gives you an estimate of how well your kidneys filter (glomerular filtration rate). A Creatinine urine test can measure Creatinine in your urine." According to Clinical Chemistry, Techniques, Principles, Correlations, Sixth edition, page 679, "Elderly people have a decreased capacity to conserve water through the kidneys and a significantly lower sensation of thirst. This, of course, could lead to dehydration, a common and under-appreciated problem in the elderly. Not only is dehydration a common finding in the elderly, it can be serious, leading to increased mortality rates. Clinical laboratory tests indicative of dehydration include [MEDICAL CONDITION] (high sodium levels), which can be caused by decreased water intake, increased BUN/Creatinine ratio, increased serum osmolality, and increased urine specific gravity. Severe [MEDICAL CONDITION] (high potassium) can ultimately cause a lack of muscle excitability, which may lead to paralysis or a fatal cardiac arrhythmia." Resident #4's history and physical (H&P), written on admit to the ER by the resident's attending physician at the facility documented the following: "Increased BUN and Creatinine secondary to intravascular volume depletion and [MEDICAL CONDITION] (high potassium), as well as acute dehydration." The H&P went on to state, "mild metabolic acidosis secondary to [MEDICAL CONDITION]." The resident also was admitted with left lower lobe pneumonia, and exhibited wheezing in all lung fields. The resident was admitted to the ICU (intensive care unit). The Merck Manual,. February 2012 defined dehydration as "Dehydration occurs when the body loses more water than it takes in. Vomiting, diarrhea, the use of diuretics (drugs that increase urine excretion), profuse sweating (for example, during heat waves, particularly with prolonged exertion), and decreased water intake can lead to dehydration. Dehydration is particularly common among older people because their thirst center may not function as well as that in younger people. Therefore, some older people may not recognize that they are becoming dehydrated. Certain disorders such as diabetes mellitus can increase the excretion of urine and thereby lead to dehydration." "At first, dehydration stimulates the thirst center of the brain, causing people to drink more fluids. If water intake cannot keep up with water loss, dehydration becomes more severe. Sweating decreases, and less urine is excreted. Water moves from inside the cells to the bloodstream to maintain the needed amount of blood (blood volume) and blood pressure. If dehydration continues, tissues of the body begin to dry out, and cells begin to shrivel and malfunction. Symptoms of mild to moderate dehydration include thirst, reduced sweating, reduced skin elasticity, reduced urine production, and dry mouth. With severe dehydration, blood pressure can fall, causing light-headedness or [MEDICAL CONDITION], particularly upon standing (a condition called orthostatic [MEDICAL CONDITION]). If dehydration continues, shock and severe damage to internal organs, such as the kidneys, liver, and brain occur. Brain cells are particularly susceptible to more severe levels of dehydration. Consequently, confusion is one of the best indicators that dehydration has become severe. Very severe dehydration can lead to coma. Dehydration can often be diagnosed because of the symptoms and the results of an examination. But sometimes doctors do blood tests for people who appear seriously ill or who take certain drugs or have certain disorders. Dehydration normally causes the sodium level in the bloodstream to increase." On 5/14/13 at 8:45 AM, an interview was conducted with the COTA (certified occupational therapy assistant). She stated she had worked with the resident on 4/26/13 (Friday). She reported the resident was less alert, and would not open her mouth, so she performed passive ROM (range of motion) for the resident. On 5/14/13 at 11:05 AM, the DON (director of nursing) was notified of above. After researching, the DON stated, "I talked to the nurse who was there that day and she stated she was unable to obtain labs and did not notify the physician." The Administrator and DON were notified of harm level findings. Complaint Deficiency