Every finding on record at Rocky Mountain Care - Riverton

Based on observation and interview, the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety. Specifically, the dish machine was not running properly to sanitize the dishes after meals. Findings included: On 9/23/24 at 8:51 AM, an initial walk-through of the kitchen was conducted. On 9/23/24 at 9:17 AM, an observation was made of the dish machine. The Dietary Manager (DM) was running dishes through the dish machine, three racks had gone through the machine, and were on the belt. A fourth rack was inside the dish machine. The wash cycle was running at a temperature of 160 degrees Fahrenheit. After the wash cycle finished, no water entered the dish machine for a rinse cycle. A container of dish machine detergent was noted to be connected to the dish machine. When questioned what it was, the DM stated that it was empty and did not replace it. On 9/23/24 at 9:18 AM, an observation was made of the dish machine temperature log. The temperatures listed the wash temperature, the rinse temperature, and a sanitizer solution Parts per Million (PPM). The temperatures on the log were as follows: (B=Breakfast; L=Lunch; D=Dinner). It should be noted that all temperatures were in degrees Fahrenheit. a. On 9/1/24, B: wash 160/ rinse 120 PPM 400, L: 165/130 400, D: 165/170 400 b. On 9/2/24, B: 165/110 400, L: 160/110 400, D: 160/110 400 c. On 9/3/24, B: 160/120 400, L: 165/130 400, D: 1/65/120 400 d. On 9/4/24, B: 165/110 400, L: 170/120 400, D: 160/110 400 e. On 9/5/24, B: 170/140 400, L: 165/120 400, D: 105/120 400 f. On 9/6/24, B: 160/100 400, L: 170/130 400, D: 170/120 400 g. On 9/7/24, B: 160/100 400, L: 170/130 400, D: 170/120 400 h. On 9/8/24, B: 160/100 400, L: 160/130 400, D: 165/120 400 i. On 9/9/24, B: 150/100 400, L: 165/120 400, D: 170/110 400 j. On 9/10/24, B: 160/120 400, L: 170/110 400, D: 170/130 400 k. On 9/11/24, B: 175/110 400, L: 160/170 400, D: 160/110 400 l. On 9/12/24, B: 160/120 400, L: 165/130 400, D: 165/120 400 m. On 9/13/24, B: 170/130 400, L: 165/120 400, D: 165/120 400 n. On 9/14/24, B: 170/130 400, L: 170/120 400, D: 165/110 400 o. On 9/15/24, B: 160/120 400, L: 165/120 400, D: 165/120 400 p. On 9/16/24, B: 165/120 400, L: 170/130 400, D: 160/110 400 q. On 9/17/24, B: 165/120 400, L: 175/110 400, D: 175/130 400 r. On 9/18/24, B: 165/120 400, L: 175/110 400, D: 175/130 400 s. On 9/19/24, B: 165/120 400, L: 175/110 400, D: 175/130 400 t. On 9/20/24, B: 167/110 400, L: 180/110 400, D: 170/120 400 u. On 9/21/24, B: 160/110 400, L: 180/110 400, D: 165/120 400 v. On 9/22/24, B: 155/105 400, L: 160/110 400, D: 165/120 400 It should be noted that a high temperature dish machine uses hot water temperatures to sanitize dishware. According to the specification sheet for this model, the wash temperature should be 160 degrees Fahrenheit, and the rinse temperature should be 180 degrees Fahrenheit. On 9/23/24 at 9:19 AM, an observation of the Dietary Aide (DA) was made putting away the plate covers that had gone through the dish machine. The cereal bowls were removed from the rack and stacked on a tray in preparation for another meal. At 9:31 AM, an observation was made of the silverware being put away into the silverware caddy. On 9/23/24 at 9:33 AM, an observation was made that the rinse cycle on the dish machine was not working. An interview was conducted with the DM. When asked if the dish machine was not working properly were the dishes being sanitized, the DM shrugged her shoulders. The DM stated the service company came a while ago and when she told him the rinse cycle was not working he told her it was okay. The DM stated she did not know how long the dish machine had not been working properly and could not remember the date when the service company came last. When asked if she had a service receipt, the DM stated that someone else took care of that. On 9/24/24 at 12:34 PM, an observation was made of the dish machine doing the lunch dishes. The rinse cycle was not working. The dish detergent had been replaced with a new container. The dish machine temperature log was reviewed and no temperatures were documented on 9/23/24 and the morning of 9/24/24. On 9/24/24 at 12:35 PM, an interview was attempted with the DA, but the DA stated she did not understand much English. On 9/24/24 at 12:35 PM, an interview was conducted with the DM who stated they were using a high temperature dish machine. The DM stated the temperature was what sanitized the dishware. The DM stated the temperatures should be 160 for the wash cycle and 180 for the rinse cycle. The DM stated if the dish machine was not meeting the temperature requirements she would contact the Medical Records (MR) staff member who used to be the DM, and the MR staff member would contact the service company. The DM also stated until the machine was fixed, the dishes would be washed with the three sink method. The DM stated she would know the dish machine was not functioning properly if the water temperatures were not high enough. The DM stated she would then call the service company. The DM stated a dish detergent was used in the dish machine with the wash cycle. When asked why the dish temperature log had 400 (indicating parts per million chemical concentration) written on it, the DM stated she did not know. The DM stated the service company came earlier in the morning, checked the machine temperatures, and replaced one of the thermometers. The DM stated again that the dish machine was high temperature and did not need a sanitizer. The DM stated the detergent attached to the machine was for washing. On 9/24/24 at 12:42 PM, an interview was conducted with the MR who stated she helped in the kitchen occasionally as she used to be the DM. The MR stated the service company representative came to the facility on the morning of 9/24/24, and replaced one of the temperature gauges. The MR stated the representative was going to send a statement by email detailing the work that was done, but she had not received it yet. On 9/24/24 at 1:37 PM, an observation was made of the dish machine being used by the DM. The DM stated she had not heard anything from MR about a service sheet from the service company representative. On 9/24/24 at 1:39 PM, an interview was conducted with the MR who stated she had not yet heard from the service company representative. The MR stated she had placed a call to him and was waiting for a return call. The MR stated she did not know if the service company representative ran a few dish cycles while in the kitchen. After being told the rinse cycle was not running at all, the MR told the DM to wash all the lunch dishes with the three sink process. On 9/25/24 at 8:50 AM, an observation was conducted of the DM washing the breakfast dishes in the three-compartment sink. Each compartment was set up correctly with a wash, rinse, and sanitizing sequence. The sanitizing test strip was used to determine the PPM of the sanitizing compartment and registered 400 PPM which was the required amount. An interview was conducted with the DM. The DM stated she was not using the dishwasher today because the rinse temperature was not getting to 180 degrees. The dishwasher was set up as a high temperature machine since it did not have a sanitizer injection. An observation of the dishwasher determined that rinse water was not entering the machine or just at a trickle. The dish machine did have detergent injecting into the wash cycle.

Based on interview, the facility did not employ a clinically qualified full-time dietitian or another clinically qualified nutrition professional to serve as the director of nutrition services. Specifically, the facility did not employ a full time Registered Dietitian (RD) and the Dietary Manager (DM) did not meet the requirements to serve as the director of nutrition services. Findings included: On 9/23/24 at 8:51 AM, an initial walk-through of the kitchen was completed. An interview was conducted with the DM who stated she had not completed the training required to serve as the DM. The DM stated she was ServeSafe certified and had taken the RD consulting company's menu training. The DM stated the RD came to the facility every Wednesday, and was available by phone if she had questions or concerns. The DM stated the RD conducted a kitchen audit every week when she was in the facility, but she did not receive the information from those audits. 33215 On 9/25/24 at 10:11 AM, an interview was conducted with the RD. The RD stated that she had worked for the facility for two years and was full time with the RD consulting company. The RD stated that the DM started at the facility as a cook and in November 2023 the DM was hired as the DM. The RD stated that the DM had not started the Certified Dietary Manager (CDM) course as of yet. The RD stated that the Medical Records staff member was the past DM but she did had not completed the CDM course either. The RD stated that the Medical Records staff member was the DM for a year and switched to Medical Records because she did not want to put in the time to complete the CDM course. The RD stated that the DM had completed the videos and training's that the RD consulting company had on how to run the kitchen and the forms to use. On 9/26/24 at 11:28 AM, an interview was conducted with the Administrator. The Administrator stated that he was waiting see if the DM was going to stick before they signed her up for the CDM course. The Administrator stated he was going to sign the DM up for a Spanish speaking class. The Administrator stated that he thought the facility had a year for the DM to complete the CDM course.

Based on observation, interview, and record review, the facility did not establish an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Specifically, for 3 out of 22 sampled residents, staff were not using the appropriate personal protective equipment (PPE) for residents on Enhanced Barrier Precautions (EBP). In addition, a resident with a physician's order for EBP did not have signage posted on their door and PPE was not readily available. Resident identifiers: 21, 84, and 85. Findings included: 1. Resident 21 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, pyogenic arthritis, cellulitis of right lower limb, cellulitis of left lower limb, pressure ulcer of sacral region stage 3, localized edema, infection and inflammatory reaction due to internal right knee prosthesis, chronic kidney disease, protein-calorie malnutrition, essential hypertension, type 2 diabetes mellitus, congestive heart failure, sepsis, and chronic atrial fibrillation. On 9/26/24 at 9:30 AM, an observation was made of resident 21's room. The PPE storage holder on the back side of the door was empty other than a roll of garbage bags. No gowns or masks were observed in resident 21's room. Resident 21's medical record was reviewed on 9/26/24. A physician's order dated 8/9/24, documented Enhanced Barrier Precautions r/t [related to] PICC [peripherally inserted central catheter] line Every Shift. The physician's order was open ended. A physician's order dated 8/9/24, documented Enhanced Barrier Precautions r/t Wound Every Shift. The physician's order was open ended. On 9/26/24 at 9:44 AM, an observation of resident 21's wound care was conducted with the Unit Manager (UM). The PPE storage holder on the back side of resident 21's door contained garbage bags and no other PPE. The UM was observed to donn surgical gloves and cleaned resident 21's coccyx wound with wound cleaner. The UM was observed to doff the soiled surgical gloves and applied alcohol based hand rub (abhr) to her hands prior to donning a new pair of surgical gloves. The UM was observed to pack the coccyx wound with a collagen patch and allginate silver dressing. The UM was observed to doff the soiled surgical gloves and applied abhr to her hands. The UM was observed to cover the coccyx wound with a dressing. An immediate interview was conducted. The UM stated that she would use EBP if the resident had a urinary catheter. The UM stated she would put on a surgical gown if resident 21's wound was bigger. The UM stated that resident 21's coccyx wound had been irrigated before and the Wound Nurse would put on a surgical gown and a mask. The UM stated that resident 21's coccyx wound had gotten smaller. The UM stated that every Wednesday the Wound Nurse Practitioner would come to the facility. The UM stated the Wound Nurse would do all the resident skin assessments. The UM stated that the Certified Nursing Assistants (CNA) would wear PPE for the EBP residents any time the CNAs were doing catheter cares and or cleaning a bowel movement. Resident 21's room was observed to have an ENHANCED BARRIER PRECAUTIONS stop sign on the outside of the door. The sign documented EVERYONE MUST: Clean their hands, including before entering and when leaving the room. PROVIDERS AND STAFF MUST ALSO: Wear gloves and a gown for the following High-Contact Resident Care Activities. Dressing, Bathing/Showering, Transferring, Changing Linens, Providing Hygiene, Changing briefs or assisting with toileting, Device care or use: central line, urinary catheter, feeding tube, tracheostomy, Wound Care: any skin opening requiring a dressing. Do not wear the same gown or gloves for the care of more than one person. The sign was endorsed by the United States Department of Health and Human Services Centers for Disease Control and Prevention (CDC). In addition, resident 21's room was observed to have a Multridrug-resistant organisms (MDRO) are a threat to our residents sign on the outside of the door. The sign documented Enhanced Barrier Precautions (EBP) Steps Perform Hand Hygiene Wear Gown Wear Gloves Dispose of Gown & Gloves in Room Use EBP during high-contact care activities for resident with: 1. Indwelling Medical Devices (e.g. central line, urinary catheter, feeding tube, tracheostomy/ventilator) 2. Wounds 3. Colonization or Infection with a MDRO Protect residents and stop the spread of germs. The sign was endorsed by the CDC. On 9/26/24 at 10:05 AM, an interview was conducted with CNA 2. CNA 2 stated that she was just told about the EBP. CNA 2 stated that she was told to make sure to have the surgical gown on for resident 21's wounds. CNA 2 stated that she was told to use a surgical gown for anything regarding resident 21's wound or anytime she went into resident 21's room. CNA 2 stated that she did not wear a surgical gown just now while she was providing cares to resident 21 because there were no surgical gowns in resident 21's room. CNA 2 stated that she was Agency and had worked with resident 21 before and did not know about the EBP. 2. Resident 84 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, aftercare following joint replacement surgery, repeated falls, urinary tract infection, fracture of unspecified part of neck of right femur, essential hypertension, and depression. Resident 84's medical record was reviewed on 9/24/24. A physician's order dated 9/23/24, documented Enhanced Barrier Precautions- wounds Every Shift DAY, NIGHT. The physician's order was open ended. On 9/24/24 at 9:50 AM, an observation was conducted of resident 84's room. There was no EBP signage posted on the door and PPE was not available. 3. Resident 85 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, encounter for other orthopedic aftercare left hip open reduction and internal fixation, thrombophilia, disorders of bladder, bladder distention, gross hematuria, metabolic encephalopathy, presence of prosthetic heart valve, elevation of levels of liver transaminase levels, gram-negative sepsis, essential hypertension, epilepsy, acute kidney failure, urinary tract infection, severe sepsis with septic shock, and fracture of left femur. On 9/23/24 at 1:50 PM, an observation was conducted or resident 85's room. Resident 85 was observed to have EBP signage on the outside of the room posted on the door. There was no PPE observed inside or outside of resident 85's room. Resident 85's medical record was reviewed on 9/24/24. A physician's order dated 9/23/24, documented Enhanced Barrier Precautions- catheter Every Shift DAY, NIGHT. The physician's order was open ended. On 9/26/24 at 9:31 AM, an observation was conducted of resident 85's room. A PPE storage holder was observed hanging on the back side of the door. The PPE storage holder contained one disposable surgical gown and clear garbage bags. On 9/23/24 at 10:06 AM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated they only needed to wear PPE when there was a sign on the door and if they change a dressing. On 9/26/24 at 9:20 AM, an interview was conducted with the UM. The UM stated that EBP were implemented when a resident had a urinary catheter, intravenous picc line, open wounds, or Coronavirus disease (COVID-19) . The UM stated if a resident had COVID-19 the facility had PPE bins that would be placed in front of the resident's room with signage. The State Survey Agency (SSA) Lead Surveyor observed the storage room with the UM where the PPE bins were stored. The UM stated that she thought resident 84's wounds were healed. The UM stated the wound nurse came to the facility everyday to assess resident wounds and new admissions. The SSA Lead Surveyor observed the PPE storage holder with the UM on the back side of resident room [ROOM NUMBER]. The PPE storage holder was observed to contain garbage bags and no other PPE. The UM stated the PPE storage holder for room [ROOM NUMBER] should contain surgical gowns. On 9/26/24 at 10:43 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that EBP should be implemented for any patient that had an open wound, MDRO, picc line, Foley catheter, or any unnatural opening that should not be there on the body. The DON stated that staff should be gowned and gloved with any direct patient care. The DON stated the night shift CNAs were to stock the PPE storage holders every night. The DON stated that with the regular staff there was constant training and with Agency staff it was harder. The DON stated that staff were trained to keep their brains up to date and the staff should be passing those things along in report. The DON stated that resident 84 had scarring on the coccyx and the EBP was implemented for the surgical wound to resident 84's hip. 44640

Based on interview and record review, the facility did not ensure that each resident's drug regimen was free from unnecessary drugs. An unnecessary drug was any drug when used in excessive dose; or for excessive duration; or without adequate monitoring; or without adequate indication for its use; or in the presence of adverse consequences which indicated that the dose should be reduced or discontinued. Specifically, for 1 out of 22 sampled residents, a resident's blood pressure (BP) support medication was administered outside of the physician's ordered parameters. Resident identifier: 21. Findings included: Resident 21 was admitted to the facility on [DATE] with diagnoses which included cellulitis of right lower limb, cellulitis of left lower limb, pressure ulcer of sacral region, localized edema, muscle weakness, infection and inflammatory reaction due to internal right knee prosthesis, chronic kidney disease, protein-calorie malnutrition, essential hypertension, acute on chronic combined systolic (congestive) and diastolic (congestive) heart failure, type 2 diabetes mellitus with unspecified complications, sepsis, organism-right shoulder, iron deficiency anemia secondary to blood loss, and chronic atrial fibrillation. Resident 21's medical record was reviewed on 9/23/24 through 9/26/24. A physician's order dated 8/11/24, documented, Midodrine tablet 5 mg [milligrams]; oral. Special instructions: Hypotension - Hold for systolic > [greater than] 100 with meals 08:00 [8:00 AM], 12:00 [PM], 17:30 [5:30 PM]. The August 2024 Medication Administration Record (MAR) was reviewed and revealed Midodrine was administered outside of parameters on the following dates: a. On 8/13/24 at 5:50 PM, BP 134/46 b. On 8/19/24 at 8:00 AM, BP 132/60 c. On 8/19/24 at 12:00 PM, BP 132/60 d. On 8/20/24 at 8:00 AM, BP 125/57 e. On 8/20/24 at 12:30 PM, BP 129/41 f. On 8/23/24 at 5:30 PM, BP 117/52 g. On 8/24/24 at 8:00 AM, BP 148/57 h. On 8/24/24 at 12:30 PM, BP 148/57 i. On 8/25/24 at 5:30 PM, BP 119/53 j. On 8/27/24 at 5:30 PM, BP 135/52 k. On 8/28/24 at 8:00 AM, BP 160/57 l. On 8/30/24 at 8:00 AM, BP 121/57 m. On 8/30/24 at 12:00 PM, BP 121/57 n. On 8/30/24 at 5:30 PM, BP 121/57 The September 2024 MAR was reviewed and revealed Midodrine was administered outside of parameters on the following dates: a. On 9/1/24 at 8:00 AM, BP 124/62 b. On 9/1/24 at 12:00 PM, BP 116/81 c. On 9/1/24 at 5:30 PM, BP 116/81 d. On 9/3/24 at 8:00 AM, BP 133/62 e. On 9/3/24 at 5:30 PM, BP 128/53 f. On 9/6/24 at 8:00 AM, BP 119/55 g. On 9/6/24 at 12:00 PM, BP 119/55 h. On 9/6/24 at 5:30 PM, BP 119/55 i. On 9/10/24 at 8:00 AM, BP 137/87 j. On 9/10/24 at 12:00 PM, BP 137/87 k. On 9/10/24 at 5:30 PM, BP 137/87 l. On 9/16/24 at 8:00 AM, BP 159/69 m. On 9/16/24 at 12:00 PM, BP 159/69 n. On 9/19/24 at 5:30 PM, BP 162/75 o. On 9/23/24 at 8:00 AM, BP 112/70 The September 2024 MAR was reviewed and revealed Midodrine was held on 9/22/24 at 8:00 AM, BP 96/74. The Midodrine should have been administered. On 9/23/24 at 10:45 AM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated some orders had parameters and each nurse should follow those parameters. RN 1 stated blood pressure medications sometimes had parameters and should only be given if they fall within the ordered parameters. RN 1 stated if a medication was held, they were supposed to call the provider to let them know. On 9/26/24 at 10:39 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that with medications which had parameters the nurses were expected to follow those parameters. The DON stated the nurses were supposed to have given the medication within an hour, notify the provider if it was held, and enter a progress note in the medical record. The DON stated the nurses should have looked at the order and held the medication when the systolic blood pressure was more than 100 and should have given the medication when the systolic was less than 100.

Based on observation, interview, and record review, the facility did not ensure that a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible. Specifically, for 1 out of 22 sampled residents, a resident had a urinary catheter without a physician's order. Resident identifier: 180. Findings included: Resident 180 was admitted to the facility on [DATE] with diagnoses which included encounter for other orthopedic aftercare, diffuse large B-cell lymphoma, lymph nodes of head, face, and neck, other acute postprocedural pain, cellulitis of right lower limb, muscle weakness, obstructive sleep apnea, fracture of shaft of right fibula, subsequent encounter for closed fracture with routine healing, fracture of shaft of right tibia, subsequent encounter for closed fracture with routine healing, heart failure, venous insufficiency, hypothyroidism, hyperlipidemia, dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, bipolar disorder. On 9/23/24 at 10:39 AM, at interview was conducted with resident 180. Resident 180 stated she was unsure how long she has had the catheter. Resident 180 was observed to point in the direction of a whiteboard on the wall and stated that there was a note on the whiteboard from her daughter, who was a Nurse Practitioner. The whiteboard was observed and the writing in the right upper corner of the whiteboard read, Take out catheter before she gets an infection. Resident 180 stated she had no pain, burning or itching from the catheter. The catheter was observed to be hanging on the bed lower than the resident, tubing and bag observed to be clean, no sediment observed in the urine. Resident 180's medical record was reviewed on 9/23/24 through 9/26/24. A physician's order for a urinary catheter was not located in the medical record. No care plan entries for a urinary catheter or catheter care were located in the medical record. The hospital discharge notes dated 9/11/24, were reviewed and revealed that resident 180 was discharged with an Indwelling Urinary Catheter 9/10/24 Latex 16 Fr [French]. The Nurse to Nurse Report Sheet dated 9/11/24, documented resident 180 was admitted with a Foley catheter due to NWB [non-weight bearing] status that was last changed on 9/9/24. Point of care history dated 9/11/24, documented resident 180 had a urinary catheter and was incontinent of urine. A Daily Skilled Charting note dated 9/12/24, documented that resident 180 did not have any genitourinary appliances. On 9/25/24 at 9:33 AM, an interview was conducted with Certified Nursing Assistant (CNA) 1. CNA 1 stated that resident 180 did really great and that she was a minimal assist. CNA 1 stated resident 180 had an unwillingness to do therapy and to get out of bed. CNA 1 stated resident 180 had a bladder infection right now and that she had a catheter. CNA 1 stated the CNAs did catheter care every shift, chart the amount of fluid we get out, and the peri area that we had done. CNA 1 stated whenever there was a new admit the nurse would get report if they had catheter. CNA 1 stated she was unsure if the nurses checked the catheter. CNA 1 stated she did not notice the note on resident 180's white board. CNA 1 stated resident 180 had not complained to her of any urinary discomfort. On 9/25/24 at 9:42 AM, an interview was conducted with Registered Nurse (RN) 2. RN 2 stated if a resident had a catheter they would have orders in the chart, it should be checked every shift by the nurse, the down drain bag should be changed weekly, and the catheter should be changed every month. Observation was made as RN 2 looked in resident 180's medical record and stated, There are no orders for a catheter or catheter care, so the nurses would not even know to look for it. RN 2 stated the admit nurse was supposed to verify the orders that central admitting put into the medical record and correct any that were not right, but it was agency so that was why it got missed. RN 2 stated resident 180 complained of burning on Monday and her urine was tested and showed an infection so she was started on antibiotics. RN 2 stated she did notice the note on the white board and that they were going to talk to the provider to see what she wanted them to do with the catheter. RN 2 stated they were not checking resident 180's catheter because it was not in the orders and they did not know it was there. On 9/26/24 at 10:44 AM, interview conducted with the Director of Nursing (DON). The DON stated central admitting put all the orders in for new admits and the floor nurse was expected to verify those orders were correct. The DON stated the Assistant Director of Nursing was the third check of the orders and the DON was the final check of the new patient orders, so she was unsure how resident 180's catheter order was missed. The DON stated there should have been an order for a catheter, catheter care, enhanced barrier precautions, and a care plan put into place. The DON stated resident 180 was missed, the CNAs were doing the catheter care but the order was missed. The DON stated it was the expectation the CNAs would do the cares and inform the nurses when the cares were completed. The DON stated the nurses did not do the cares. The DON stated she was unaware the family wanted the catheter removed and that they were not really sure how her catheter had gotten missed with all of the medical record checks.

Based on observation, interview, and record review, it was determined, the facility did not ensure that each resident receives necessary respiratory care and services that are in accordance with professional standards of practice. Specifically, for 2 out of 21 sampled residents, oxygen therapy was provided to residents without a physician's order and there was no documentation regarding the oxygen concentrator tubing maintenance. Resident identifiers: 4 and 17. Findings included: 1. Resident 4 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included, but were not limited to, intraspinal abscess and granuloma, sepsis, vertebrogenic low back pain, infection and inflammatory reaction due to internal left knee prosthesis, dysphagia, muscle weakness, need for assistance with personal care, repeated falls, cognitive communication deficit, acute respiratory failure with hypoxia, methicillin susceptible staphylococcus aureus infection, Parkinson's disease, essential (primary) hypertension, depression, and obstructive sleep apnea. On 2/27/23 at 11:46 AM, an observation was conducted of resident 4's room. An oxygen concentrator was observed in Resident 4's bathroom. The tubing for the oxygen concentrator and the humidifier were not labeled with the date the tubing was last changed. An interview was conducted with Resident 4. Resident 4 stated that staff did regularly change the oxygen tubing but resident 4 was unsure when the oxygen tubing was last changed. On 3/1/23, Resident 4's medical record was reviewed. There were no physician's orders for oxygen therapy located in the medical record. There was no documentation of oxygen concentrator tubing changes or cleanings. On 3/1/23 at 9:19 AM, an interview with the Assistant Director of Nursing (ADON) was conducted. The ADON stated that Resident 4 used a continuous positive airway pressure (CPAP) machine, but did not use oxygen. On 3/1/23 at 9:32 AM, an observation was conducted of Resident 4's room. A CPAP machine was observed on the counter in resident 4's bedroom. An oxygen concentrator was observed in resident 4's bathroom connected to tubing that led to a nasal cannula for oxygen to be administered to resident 4. The nasal cannula was observed on resident's bed. On 3/1/23 at 9:37 AM, an additional interview was conducted with the ADON. The ADON stated that if a resident was using oxygen, there would be an order in the medical record. The ADON verified that Resident 4 did not have a physician's order for supplemental oxygen therapy or for oxygen therapy tubing changes and cleanings. On 3/1/23 at 10:23 AM, an interview was conducted with Certified Nursing Assistant (CNA) 1. CNA 1 stated there was not a set schedule for oxygen therapy tubing changes and the oxygen tubing was changed on an as needed basis. CNA 1 stated that the oxygen tubing was cleaned at least once daily. On 3/1/23 at 10:36 AM, an interview was conducted with Resident 4. Resident 4 stated that he did not know why he was on oxygen therapy and that he had not used oxygen at home prior to being admitted to the facility. 43212 2. Resident 17 was admitted on [DATE] with diagnoses that included left hip fracture, hypertension, gastroesophageal reflux disease, malnutrition, history of falls, and urinary retention. On 2/27/23 at 12:55 PM, an interview was conducted with resident 17. Resident 17 stated she wore oxygen at night and did not need it during the day. Resident 17 was observed to have an oxygen concentrator in her room beside the bed with oxygen tubing that was not labeled. Resident 17 stated she did not know when the last time the oxygen tubing was changed or who was responsible to do that. Resident 17's medical record was reviewed on 2/28/23. A review of resident 17's admission Minimum Data Set assessment dated [DATE], revealed that resident 17 had oxygen therapy prior to her admission and while she was at the facility. A review of resident 17's progress notes revealed that on 2/21/23 at 3:19 PM, Registered Nurse (RN) 3 received a report from the CNA on duty that resident 17's oxygen level was at 85%. The progress note revealed, placed patient on 2L [liters] of O2 [oxygen] sats [saturation] remained stable above 92%. The physician's orders were reviewed and there was not an order for oxygen, nor was there an order or schedule for changing the oxygen tubing on the concentrator. A review of resident 17's point of care documentation did not reveal any tasks related to changing oxygen tubing. On 2/28/23 at 10:13 AM, an interview was conducted with CNA 3. CNA 3 stated that resident 17 was on 3 liters of oxygen at night. CNA 3 stated that resident 17 only wore the oxygen at night. CNA 3 stated that the oxygen tubing was changed every week and the task was completed by either the CNA's or the nurses. CNA 3 stated staff were not documenting when the oxygen tubing was changed. CNA 3 stated that maybe the nurse writes it down. On 2/28/23 at 10:33 AM, an interview was conducted with RN 1. RN 1 stated that resident 17 used more oxygen when she had anxiety. RN 1 stated resident 17 only used oxygen once in a while, and sometimes during the night. RN 1 stated oxygen tubing should be changed every Monday. RN 1 stated the nurses changed the oxygen tubing and the task came up on the resident's treatment information in the treatment administration record. RN 1 stated if a resident was admitted on oxygen, there would be standing orders to change the oxygen tubing and the humidifier. RN 1 stated if a resident was not admitted on oxygen, the physician would initiate the order. On 2/28/23 at 1:36 PM, an interview was conducted with the ADON. The ADON stated that oxygen tubing was changed weekly if not more often. The ADON stated if a resident was admitted with oxygen, there would be standing orders. The ADON stated if a resident was put on oxygen while at the facility, the orders would be added to the resident's chart. The ADON stated he was the staff member who would put the orders in. On 3/1/23 at 11:59 AM, a second interview was conducted with the ADON. The ADON stated that either the nurse or the CNA could change the oxygen tubing. The ADON looked in resident 17's medical record and could not find a physician order for oxygen or an order for weekly oxygen tubing changes.

Based on interview and record review, it was determined, the facility did not consult with a resident's physician when there was a change in the resident's status. Specifically, for 1 out of 21 sampled residents, a resident had a blood glucose reading below 60 and the physician was not notified per the physician's order. Resident identifier: 137. Findings included: Resident 137 was admitted on [DATE] with diagnoses that included atrial fibrillation, esophageal obstruction, tinea pedis, history of falling, pain, heart failure, chronic kidney disease, type 2 diabetes, muscle weakness, and hypertension. On 2/27/23 at 12:13 PM, an interview was conducted with resident 137. Resident 137 stated that on 2/26/23, her blood sugar was checked in the morning and was 125. Resident 137 stated she was given her scheduled insulin. Resident 137 stated she started to feel unwell and when her glucose was checked it was 56. Resident 137 stated she was provided a glucagon shot and was given some orange juice through her feeding tube. Resident 137 stated the nurse told her she would document the low blood sugar in her medical record. Resident 137 stated she did not know if the physician was notified. On 2/28/23, resident 137's medical record was reviewed. A progress note dated 2/26/23 at 12:41 PM revealed, CNA [Certified Nursing Assistant] went into pt [patient] room to obtain a blood sugar for afternoon insulin. Aide [CNA] reported a BS [blood sugar] of 56. Pt complaining of feeling unwell and appeared diaphoretic and flushed. Glucagon shot was given @1225 [12:25 PM] along with orange juice given through NG [naso-gasstric] tube. Blood sugar was obtained 15 min [minutes] later and results were 96. Pt. reported feeling a little bit better, RN [Registered Nurse] asked pt. her full name and DOB [date of birth], pt responded appropriately. Will continue to monitor and recheck BS once more to confirm an upward trend. [Note: documentation did not include physician notification] A review of the physician's orders included: a. Glucagon Hydrochloride reconstituted solution 1 milligram per milliliter; Injection special instructions: Hypoglycemia protocol: Give per manufacturer instructions; dated 2/3/23 open ended. b. Human R Regular U-100 insulin (insulin regular human) solution; 100 unit/mL (units per milliliters); amount: 10 units; injection special instructions: TUBE FEED GLUCOSE MANAGEMENT-HOLD DOSES IF TUBE FEEDS NOT RUNNING. Every 6 hours at 7:00 AM, 1:00 PM, 7:00 PM, and 1:00 AM; dated 2/13/23 open ended. c. Lantus U-100 insulin (insulin glargine) solution; 100 unit/mL; amount 30 units; subcutaneous; Special instructions: DIABETES. Start with 30 units daily (may titrate to prior home dose of up to 40 units a day.) Once a day between 8:00 AM and 10:00 AM; dated 2/4/23 open ended. d. Fingerstick blood glucose: Every 6 hours at 7:00 AM, 1:00 PM, 7:00 PM, and 1:00 AM. Dated 2/3/23 open ended. A review of resident 137's February 2023 Medication Administration Record revealed: a. On 2/26/23 at 7:00 AM, RN 2 documented a blood glucose of 125. Resident 137 received 30 units of Lantus insulin and 10 units of Human Regular insulin. b. On 2/26/23 at 1:00 PM, RN 2 documented a blood glucose of 287. Human Regular insulin was not administered due to condition. A review of the physician's Protocols/Standing Orders revealed: a. Hold Lantus if blood glucose is < [less than] 70 and notify MD [Medical Director]. b. Perform finger stick glucose check at the following intervals: every 6 hours if no oral intake (NPO) or on continuous tube feeding, Check as needed if signs and symptoms of hypo and hyperglycemia are present. c. For conscious residents with blood sugar <60: give 4 ounces (oz) of orange juice or med pass with a protein snack (cheese, peanut butter, cottage cheese, milk, etc.); Re-check blood sugar in 30 minutes. If no improvement give 1/2 to 1 tube of glucose gel; Re-check blood sugar in 15 minutes. If no improvement call provider. On 3/1/23 at 10:31 AM, an interview was conducted with RN 1. RN 1 stated if a resident's blood sugar dropped below 60 the nurse should notify the physician. RN 1 stated if the resident was not NPO, they would be given orange juice if the blood sugar was low. RN 1 stated when glucagon was administered, the blood sugar should be checked again in 30 minutes. RN 1 stated if she had a resident with a low blood sugar she kept in close contact with the physician. RN 1 confirmed that resident 137 was receiving her Lantus in the morning as ordered, her humalog every 6 hours as ordered and her blood sugars were being checked every 6 hours. On 3/1/23 at 11:38 AM, an interview was conducted with the Assistant Director of Nursing (ADON). The ADON stated if a resident had a blood sugar below 60, the nurses had a standing order to notify the physician. The ADON stated there was also a standing order to provide 4 oz. of orange juice or med pass and re-check the blood sugars 30 minutes later. The ADON stated he was unsure if the physician was notified when resident 137 had the low blood sugar on 2/26/23. The ADON stated he would reach out to the physician to see if he received notification and provide the information. No additional information was provided.

Based on observation, interview, and record review, it was determined, the facility did not develop and implement a comprehensive person-centered care plan for each resident to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment. Specifically, for 2 out of 21 sampled residents, residents that were receiving oxygen therapy did not have the oxygen therapy included in their comprehensive care plan. Resident identifiers: 4 and 17. Findings included: 1. Resident 4 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included, but were not limited to, intraspinal abscess and granuloma, sepsis, vertebrogenic low back pain, infection and inflammatory reaction due to internal left knee prosthesis, dysphagia, muscle weakness, need for assistance with personal care, repeated falls, cognitive communication deficit, acute respiratory failure with hypoxia, methicillin susceptible staphylococcus aureus infection, Parkinson's disease, essential (primary) hypertension, depression, and obstructive sleep apnea. On 2/27/23 at 11:46 AM, an observation was conducted of resident 4's room. An oxygen concentrator was observed in Resident 4's bathroom. The tubing for the oxygen concentrator and the humidifier were not labeled with the date the tubing was last changed. An interview was conducted with Resident 4. Resident 4 stated that staff did regularly change the oxygen tubing but resident 4 was unsure when the oxygen tubing was last changed. On 3/1/23, Resident 4's medical record was reviewed. Resident 4's admission Minimum Data Set (MDS) assessment dated [DATE], indicated that Resident 4 had received oxygen therapy prior to admission and while residing at the facility. A review of resident 4's comprehensive care plan did not include a Problem area regarding oxygen therapy. There were no physician's orders for oxygen therapy located in the medical record. There was no documentation of oxygen concentrator tubing changes or cleanings. On 3/1/23 at 9:19 AM, an interview with the Assistant Director of Nursing (ADON) was conducted. The ADON stated that Resident 4 used a continuous positive airway pressure (CPAP) machine, but did not use oxygen. On 3/1/23 at 9:32 AM, an observation was conducted of Resident 4's room. A CPAP machine was observed on the counter in resident 4's bedroom. An oxygen concentrator was observed in resident 4's bathroom connected to tubing that led to a nasal cannula for oxygen to be administered to resident 4. The nasal cannula was observed on resident's bed. On 3/1/23 at 9:37 AM, an additional interview was conducted with the ADON. The ADON stated that if a resident was using oxygen, there would be an order in the medical record. The ADON verified that Resident 4 did not have a physician's order for supplemental oxygen therapy or for oxygen therapy tubing changes and cleanings. On 3/1/23 at 10:36 AM, an interview was conducted with Resident 4. Resident 4 stated that he did not know why he was on oxygen therapy and that he had not used oxygen at home prior to being admitted to the facility. 2. Resident 17 was admitted on [DATE] with diagnoses that included left hip fracture, hypertension, gastoesopageal reflux disease, malnutrition, history of falls, and urinary retention. On 2/27/23 at 12:55 PM, an interview was conducted with resident 17. Resident 17 stated that she used oxygen only at night and that she did fine without oxygen during the day. Resident 17's medical record was reviewed. An admission MDS assessment dated [DATE], revealed that resident 17 had used oxygen prior to her admission to the facility and was using oxygen while at the facility. A review of the physician's orders found no orders for oxygen therapy. A review of resident 17's treatment administration record for the month of February 2023 revealed no orders for or provisions of oxygen therapy. A review of resident 17's comprehensive care plan, last revised on 2/27/23, revealed no mention of oxygen use. A review of the physician's protocols and standing orders documented for respiratory concerns provide 0-5 liters oxygen as needed via nasal cannula for shortness of breath or comfort to keep oxygen saturation greater than 89%. A review of resident 17's progress notes dated 2/21/23 at 3:19 PM revealed that resident 17 had an oxygen saturation of 85%. Registered Nurse (RN) 3 documented that resident 17 was placed on 2 liters of oxygen and the oxygen level rose and remained stable at 92%. On 3/1/23 at 11:48 PM, an interview was conducted with the Director of Nursing (DON). The DON stated for completion of the comprehensive care plan, each discipline was responsible to assess the resident and populate the information in the resident's care plan. The DON stated if things came up after the resident was admitted , the care plan would be updated as needed. On 3/1/23 at 12:17 PM, an interview was conducted with the Social Services Director (SSD). The SSD stated that the baseline care plan was completed when a resident was admitted and within 48 hours. The SSD stated each discipline had their own assessments that needed to be completed and the comprehensive care plan was completed about 14 days after admission and within 7 days of the MDS assessment being completed. The SSD stated the comprehensive care plan was a fluid document that was updated throughout the resident's stay in conjunction with changes that occurred.

Based on interview and record review, it was determined , the facility did not provide the necessary services to maintain good nutrition, grooming, and personal and oral hygiene to residents who were unable to carry out activities of daily living. Specifically, for 1 out of 21 sampled residents, a resident did not receive showers or bathing assistance in a timely manner and according to the facility schedule for showers. Resident identifier: 7. Findings included: Resident 7 was admitted on [DATE] with diagnoses that in included myotonic muscular distrophy, major depressive disorder, mild intellectual disabilities, hypomagnesemia, acute upper respiratory infection, and long QT (measurement of the hearts electrical activity) syndrome. On 2/27/23 at 11:29 AM, an interview was conducted with resident 7. Resident 7 stated that sometimes the staff forgot to shower her. Resident 7 stated she did not remember when her last shower was. On 2/27/23, resident 7's medical record was reviewed. Resident 7's annual Minimum Data Set assessment dated [DATE], revealed that it was very important to resident 7 to choose between a tub bath, shower, bed bath, or sponge bath. The MDS also revealed that resident 7 required one person physical assistance for bathing as resident 7 was totally dependent for that service. The point of care (POC) documentation in the medical record, revealed resident 7's bathing was only documented on 2/18/23. The Certified Nursing Assistant (CNA) shower binder was reviewed. Resident 7 was scheduled to receive showers on Monday, Wednesday, and Friday mornings. According to the shower sheets for the month of February 2023, resident 7 received bed baths on 2/1/23, 2/5/23, 2/10/23, 2/15/23, 2/17/23, and 2/19/23. No refusal forms were found for 2/3/23, 2/6/23, 2/8/23, 2/13/23, 2/20/23, 2/22/23, 2/24/23, and 2/27/23. [Note: Resident 7 received 4 of the 12 scheduled showers and 3 showers on days other than her scheduled shower days.] On 2/27/23 at 3:12 PM, an interview was conducted with CNA 2. CNA 2 stated the resident shower days were posted on the wall behind the nurse's station. CNA 2 stated when he provided showers, he also checked for any skin issues. CNA 2 stated if a resident refused a shower they were required to sign the form. CNA 2 stated the floor nurse was required to sign off on the shower sheet if the resident refused a shower. On 2/28/23 at 1:31 PM, an interview was conducted with the Assistant Director of Nursing (ADON). The ADON stated the expectation for residents to receive bathing assistance was that the resident received the assistance on their scheduled shower day. The ADON stated that if a resident refused the refusal was documented by the CNA. The ADON stated if the resident was not available on their scheduled shower day, the resident should be offered the shower on a different day. The ADON stated if the CNA's were unable to get the shower done on the scheduled day and time, they would delegate that task to the next shift for follow-up. The DON stated the CNA's documented if showers were completed on the sheet that vital signs were documented. The ADON stated if the CNA needed to delegate the service to the next shift it would be documented on the vital signs sheet and the shower sheet should be ready for the next shift. The ADON stated if a resident refused a shower, the staff would try to encourage or educate the resident of the importance of good hygiene. The ADON stated the CNA's should also ask the resident if they would prefer to have the shower at another time. The ADON stated residents were required to sign the shower sheets and then the nurse would sign them before they were filed. The ADON stated the POC area in the residents medical record was for CNA's to document services provided to the resident. The ADON stated CNA's always document what they do in there. The ADON stated if the CNA's were not documenting in the POC, there was a report he could run to audit documentation and he would follow up with the staff. On 3/1/23 at 12:09 PM, an interview was conducted with the Director of Nursing (DON). The DON stated resident 7 required a longer time for assistance with bathing. The DON stated resident 7 refused showers occasionally and staff had to educate resident 7 about the need for bathing. The DON stated she had instructed staff to ask resident 7 every day if she wanted a shower and if resident 7 was willing, the staff were instructed to shower her.

Based on interview and observation, the facility did not provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. Specifically, shower chairs and boxes of trash can liners were stored in the common living spaces of the residents, and debris was observed to be left in common areas throughout the day. Findings included: On 6/28/22 at 11:30 AM, observations were made of the facility. Additional observations that revealed the following issues were still applicable at 3:00 PM, and included: a. Open, loose oxygen tubing was draped on the piano in the lobby. b. Empty containers were observed on the table that contained a chess board in a common area. Two cups that contained thickened water, one applesauce cup, and one potato chip container were observed, along with a black arm sling and two water mugs. c. In suite A, a towel was observed behind the toilet in the restroom. d. In the center of the 200 hall, behind a hand bike, a bottle of Master Blaster was observed along with two boxes of gloves in the book case. The last filled date on the bottle was 8/20/21. e. Boxes of garbage can liners were observed in the residents' common areas. f. Two shower chairs were observed in the common areas. g. A green plastic weight chair was observed on the west side of the main hallway. h. Bedding was observed on the floor of room [ROOM NUMBER]. No staff were observed in the resident's room. Additional debris on the floor was observed. On 6/28/22 at 12:28 PM, an interview was conducted with housekeeper (HK) 1. HK 1 stated that she was responsible for cleaning the residents' rooms, along with general cleaning in the facility. HK 1 stated that she was disinfecting a room after a resident left the facility. HK 1 stated that her supervisor and some of the Certified Nursing Assistants (CNAs) assisted with cleaning since the other housekeeper left one week previous. HK 1 stated she was currently the only housekeeper at the facility. On 6/28/22 at 3:06 PM, the Maintenance Director (MD) was interviewed. The MD stated that housekeeping cleaned full time, and the MD assisted the housekeeper when needed. The MD stated that the CNAs usually did not clean the facility but a few of the CNAs had assisted in the role of housekeeper. The MD stated that the CNAs were responsible to clean the shower chairs and put the shower chairs away in a storage room. The MD demonstrated that the storage room was full of bedside commodes. There was one shower chair observed in the storage room, hanging from hooks in the ceiling. The floor space was filled, and did not include room for storing the two shower chairs in the hallway. The MD stated that the green scale chair did not have a storage area, and therefore was stored in the hallway. The MD stated that garbage can liners were supposed to be stored in the housekeeping closet or in the storage closets. The MD stated that the disinfecting solution was filled weekly, so the date on the bottle was incorrect. On 6/28/22 at 6:40 PM, the Administrator (ADM) was interviewed. The ADM stated that he had seen the oxygen tubing on the piano and had thrown it away.

Based on interview and record review, it was determined that the facility did not inform resident families and representatives of a confirmed COVID-19 infection in a timely manner. Specifically, the facility did not send a notification to resident families and representatives by 5:00 p.m. the next calendar day following the occurrence of a confirmed COVID-19 infection. Findings included: On 6/28/22 at 1:57 PM, and interview was conducted with the Assistant Director of Nursing (ADON). The ADON stated that notification of a confirmed COVID-19 case would be sent to the primary email provided by the resident or family upon admission. The ADON stated a resident within the facility tested positive for COVID-19 during the evening of 6/26/22. The ADON stated that the resident had experienced a sore throat and shortness of breath and was therefore tested for COVID-19. The ADON stated that on 6/27/22 staff members worked on an email to be sent to resident families but was unsure if the email had been sent. On 6/28/22 at 2:53 PM, an interview was conducted with the Administrator (ADM). The ADM stated he had written a letter that stated there was a resident in the facility that tested positive for COVID-19 and outlined the protocols the facility had used to protect the residents. The ADM stated he had started writing the letter on 6/27/22 but was held up most of the day and was unable to finish the letter. The ADM stated he should have designated someone else to finish writing the letter for him. The ADM stated he sent out emails with the letter attached to all resident families in the early afternoon on 6/28/22. The ADM stated the letter that was written could serve as a template for the notification of resident families of a confirmed COVID-19 infection in the future. On 6/28/22, a review of resident medical records was conducted. No documentation could be found in the electronic health record (EHR) that showed resident families had been notified of confirmed COVID-19 infection(s) within the facility. The resident who tested positive for COVID-19 on 6/26/22 did not have a diagnosis in her EHR of COVID-19.

Based on interview and record review it was determined, for 2 of 22 sample residents, that the facility did not ensure each resident was free of significant medication errors. Specifically, a resident with a known allergy was administered a medication she was allergic to and required [MEDICATION(S)]. This finding resulted in a harm level deficiency. In addition, another resident that required medication with food was not administered medication with food. Resident identifiers: 28 and 195. Findings include: HARM 1. Resident 195 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 8/16/21 at 12:00 PM, an interview was conducted with resident 195. Resident 195 stated that facility staff over medicated and dehydrated her. Resident 195 stated that she was given pain medication that she was allergic to and had to go to the emergency room (ER) at the local hospital. Resident 195's medical record was reviewed on 8/18/21. Resident 195's discharge order from a local hospital dated 8/14/21 revealed an allergy to [MEDICATION(S)], Latex and [MEDICATION(S)]. The discharge medication orders revealed a new order for Oxycodone-acetaminophen 5mg (milligrams)-325 mg oral ([MEDICATION(S)]). There was no documentation on how often to administer the medication. According to resident 195's electronic medical record at the facility resident 195 was allergic to Latex, [MEDICATION(S)] and [MEDICATION(S)] [MEDICATION(S)]. Resident 195's August 2021 Medication Administrator Record (MAR) revealed [MEDICATION(S)]-acetaminophen 5mg-325 mg ([MEDICATION(S)]) was administered on 8/15/21 at 10:12 AM. Resident 195 was administered [MEDICATION(S)] on 8/14/21 at 10:52 PM, 8/15/21 at 10:01 AM, and 8/15/21 between 10:00 AM and 2:00 PM. According to Mayo Clinic, [MEDICATION(S)] and Acetaminophen, Oral route. https://www.mayoclinic.org/drugs-supplements/[MEDICATION(S)]-and-acetaminophen-oral-route/description/drg- 089. United States Brand Name was [MEDICATION(S)]. The product was available in the following dosage form of [MEDICATION(S)]. On 8/15/21 at 6:58 PM, a nurses note revealed that [MEDICATION(S)] was administered and after patient became dizzy when ambulating.Patients blood pressure became hypotensive. CNA (Certified Nursing Assistant) reported low blood pressure during afternoon vital check. Nurse took manual blood pressure and it was 70/40. Nurse reported to ON call. Nurse received order to give 1 L (liter) NS (normal saline). Nurse started 1L NS. Patient was very lethargic and having a hard time staying awake and responding. After 650ML nurse retook patients vitals. BP was undetectable. Nurse was unable to get manual or automatic. Nurse let on call know status and received orders to call paramedics. EMS (Emergency Medical Services) was unable to get patients blood pressure. EMS took patient via stretcher. Nurse called and gave report to ER. An ER note dated 8/15/21 revealed that resident 195 was diagnosed with dehydration, polypharmacy, [CONDITION(S)], and [CONDITION(S)]. The physician ordered to .decrease your dose of [MEDICATION(S)] for time being and HOLD your blood pressure medications until your blood pressure is consistently elevated about 140. On 8/16/21 at 1:06 AM a nursing note revealed, Resident returned from [local hospital] ED (emergency department) Physician noted 'Please decrease your dose of [MEDICATION(S)] for the time being, and HOLD your blood pressure medications until you blood pressure is consistently elevated above 140'. In phone report, .RN (Registered Nurse) stated the physician's desire that we hold [MEDICATION(S)] unless pain is uncontrolled by other medications. 1 Liter of fluids was also given while in the ED. On 8/18/21 at 12:33 PM, an interview was conducted with RN 3. RN 3 stated she was an agency nurse. RN 3 stated that she worked about three times per week for the last two weeks at the facility. RN 3 stated that she had not been involved in an admission process. RN 3 stated that usually other nurses helped her with questions about admissions. RN 3 stated that orders were sent to the the facility to enter into the electronic medical record. RN 3 sated she did not know if there was a process to double check new admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . RN 3 stated that the electronic medical record did not flag or create a warning that the resident was allergic to a medication. RN 3 stated that an order was entered incorrectly for resident 195. RN 3 stated she did not know that resident 195 had a allergy or that there was a problem until talking with the Nurse Practitioner (NP) on 8/15/21. RN 3 stated that she administered [MEDICATION(S)] before the [MEDICATION(S)]. RN 3 stated she told the NP that the resident was not doing very good. RN 3 stated that resident 195 was walking with someone and became dizzy and was unstable on her feet. RN 3 stated that resident 195 was taken to bed. RN 3 stated At that point I noticed something. RN 3 stated that resident 195 was very lethargic, slurring her speech, saying silly things, and asking if this was what a drug addict felt like. RN 3 stated she told the NP that she administered [MEDICATION(S)] to resident 195 which was ordered in the electronic medical record. RN 3 stated she provided a liter of Normal Saline through an IV and administered [MEDICATION(S)]. RN 3 stated that resident 195's BP did not go up and her BP was not reading manually or on the electronic machine. RN 3 stated resident 195 was awake and able to answer questions but was trying to fall asleep. RN 3 stated that she talked to resident 195 and told her to stay awake. RN 3 stated that resident was a full code and EMS was called. RN 3 stated that she thought the [MEDICATION(S)] and [MEDICATION(S)] caused resident 195's blood pressure to drop. [Note: Resident 195 was administered [MEDICATION(S)] on 8/14/21 and did not have a documented low blood pressure reaction.] On 8/18/21 at 2:03 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that a central intake department entered the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON stated the resident's nurse then reviewed the orders and ensured they were put in properly. The DON stated that central intake entered allergies into the electronic medical record. The DON stated that central intake fixed any questions. The DON stated that sometimes central intake entered in an allergy and clarified what happened as result of an allergy. The DON stated that RN 3, an agency nurse, administered a [MEDICATION(S)] to resident 195. The DON stated that RN 3 had not realized resident 195 had an allergy. The DON stated that RN 3 had [MEDICATION(S)] as an allergy. The DON stated that RN 3 notified the physician and administered 1 liter of fluid and [MEDICATION(S)]. The DON stated that resident 195's blood pressure was still low after the 1 bag of fluid. The DON stated that RN 3 called the physician again and resident 195 was sent to the ED via EMS. The DON stated that the resident 195 was administered another liter of fluid and given orders to hold blood pressure medications. The DON stated that after the nurse administered the [MEDICATION(S)], she planned on providing education to nursing staff to slow down and ensure the were giving proper medications. The DON stated an inservice would be provided the following week to double check medications entered, and that night shift would review the medications as well. POTENTIAL FOR HARM 2. Resident 28 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 8/16/21 at approximately 12:00 PM, an interview was conducted with resident 28. Resident 28 stated that she had a medication that needed to be administered when she was eating. Resident 28 stated that the medication was to help her digest food so taking it before or after the meal was not effective. Resident 28 stated that her medication was frequently 2 hours late. Resident 28's medical record was reviewed on 8/18/21. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the August 2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] a. 8/1/21 the 8:00 AM dose was refused at 10:33 AM. b. 8/7/21 the 8:00 AM dose was administered at 9:57 AM. c. 8/10/21 the 8:00 AM dose was administered at 9:49 AM. d. 8/10/21 the 12:00 PM dose was administered at 4:32 PM. The reason documented was flex. e. 8/11/21 the 12:00 PM dose was administered at 1:06 PM. f. 8/13/21 the 8:00 AM dose was administered at 9:30 AM. g. 8/13/21 the 12:00 PM dose was administered at 1:17 PM. h. 8/14/21 the 8:00 AM dose was administered at 11:27 AM. i. 8/14/21 the 12:00 PM dose was administered at 1:01 PM. j. 8/15/21 the 5:30 PM dose was administered at 9:56 PM. k. 8/17/21 the 12:00 PM dose was refused at 2:21 PM. A dietary progress note dated 7/30/21 at 7:32 PM revealed, Nutrition assessment summary and recommendations: .Pt receiving renal MVI (multivitamin) for repletion and Sevelamer as phosphorus binder. Rec (Recommend) providing phosphorus binder within 5 min of meals to be most effective. Will cont (continue) to monitor and f/u (follow up) prn (as needed). On 8/19/21 at 9:07 AM, an interview was conducted with RN 1. RN 1 stated resident 28 had 2 tablets of [MEDICATION(S)] binder that was to be taken with breakfast and lunch and 1 tablet with dinner. RN 1 stated that the [MEDICATION(S)] binders were not given because resident 28 was out of the facility at appointments. RN 1 stated that resident 28 had an order to send medications with her when the resident was out of facility for appointments so the medication was taken when she ate.

Based on observation and interview, it was determined that the facility did not store, prepare, distribute and serve food in accordance with professional standards of food service safety. Specifically, the kitchen floor was dirty, cracked and taped in several areas, the floor under the 3 sink wash station was buckling, the wall behind the stove had white splatter on it. Findings include: 1. On 8/16/21 at 7:50 AM, an initial tour of the kitchen was conducted. The following observations were made: a. A drain was broken near the steam table. b. The linoleum on the floor was cracked around another drain by the steam table. c. The linoleum under the 3 sink dishwashing station was buckled and cracked. d. Tape was observed to be covering cracks in the linoleum throughout the kitchen. e. The floor was dirty behind the oven/stove. 2. On 8/18/21 at 9:41 AM, a second observation was made of the kitchen. The following observations were made: a. The floor was observed to be dirty behind the stove. b. There was white splatter observed behind the stove on the wall. c. The floors were observed to be cracked and patched with tape throughout the kitchen. d. The floor was buckling under the 3 sink dishwashing station. e. The drain near the steam table was observed to be cracked. On 8/18/21 at 9:56 AM, an interview was conducted with the DM. The DM stated she provided in-services to the kitchen staff regarding labeling and dating food and completing each item on the cleaning schedule. The DM stated she had discussed with the facility administrator several areas in the kitchen that needed to be repair. The DM stated she had not been given an exact date when the items would be fixed.

Based on observation, interview and record the review, for 3 of 22 sample residents, it was determined that the facility did not establish an effective infection control program to help prevent the development and transmission of communicable diseases and infections. Specifically, staff members were not wearing personal protective equipment (PPE) in resident rooms that required isolation precautions and there was no aerosolizing generating policy and procedures for a resident that used a Continuous Positive Airway Pressure ([CONDITION(S)]) machine. In addition, food was transported through the hall uncovered. Resident identifiers: 5, 199 and 204. Findings include: 1. Resident 199 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 8/16/21 at 7:00 AM, an observation was made of resident 199's room. There was signage on the door and a cart containing PPE outside resident 199's room indicating droplet precautions. On 8/16/21 at 7:10 AM, an interview was conducted with Licensed Practical Nurse (LPN) 2. LPN 2 stated that resident 199 was admitted to the facility two days ago and required 14 days of quarantine for COVID-19 precautions. LPN 2 stated that resident 199 was not vaccinated for COVID-19. On 8/16/21 at 7:18 AM, it was observed that the Certified Nursing Assistant (CNA) 6 delivered resident 199's meal tray into the residents's room. CNA 6 did not don PPE prior to entering the room. On 8/17/21 at 1:13 PM, it was observed that the CNA 6 delivered resident 199's meal into the resident's room. CNA 6 did not don PPE prior to entering the room. Resident 199's medical record was reviewed on 8/16/21. According to physicians orders, resident 199 was on 14 days of droplet precautions due to resident 199's COVID-19 vaccination status. 2. Resident 204 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 8/17/21 at 1:31 PM, an observation was made of resident 204's room. Resident 204's room was observed to have signage regarding droplet precautions and a PPE cart was outside the door of resident 204's room. On 8/17/21 at 1:31 PM, an observation was made of resident 204's room. CNA 6 was observed to deliver resident 204's meal tray. CNA 6 was observed to enter resident 204's room with the meal tray without PPE. CNA 6 was observed to exit the room without PPE and continue delivering trays to other residents. Resident 204's medical record was reviewed on 8/17/21. According to physician orders, resident 204 was on 14 days of droplet precautions due to resident 204's lack of COVID vaccination status. On 8/16/21 at 9:28 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that staff who entered a designated isolation resident room needed to wear PPE according to the reason the resident was requiring isolation. The DON stated that there were signs and carts with PPE outside the door for residents that required isolation. On 8/19/21 at 11:36 AM, a follow-up interview was conducted with the DON. The DON stated that upon admission an unvaccinated resident was required to quarantine for 14 days. The DON stated that staff were to use eye protection, an N95 mask, a gown and gloves when entering the resident's room that required quarantine. The DON stated standard PPE was used for vaccinate patients. The DON stated that standard PPE used was eye protection and a surgical mask. On 8/19/21 at 12:00 PM, an interview was conducted with the Assistant Director of Nursing (ADON). The ADON stated that staff were to wear a gown, an N95 mask, eye protection and gloves for all new residents that required COVID-19 quarantine after admission. 3. On 8/16/21 at 2:10 PM, an observation was made of CNA 3 donning a gown and entering resident room [ROOM NUMBER] where resident 5 used a [CONDITION(S)] machine. Upon her exit, CNA 3 was interviewed. CNA 3 stated she had not been told to wear any particular PPE when going into room [ROOM NUMBER] until today when LPN 1 told her to don a gown and put on an N95 mask. CNA 3 stated she did not know if wearing PPE in the same room while providing care for the second resident in room [ROOM NUMBER] was appropriate. There was no signage outside room [ROOM NUMBER]. On 8/18/21 at 7:47 AM, an observation was made of CNA 2 entering room [ROOM NUMBER] with only a surgical mask and eye protection. Upon her exit, an interview was conducted. CNA 2 stated that resident 5 wore a [CONDITION(S)] 24/7. CNA 2 stated resident 5 used to have something in her urine that the staff had to use gowns when providing care about 3 weeks ago. CNA 2 stated that resident 5 had an infection of some kind. CNA 2 stated no PPE was necessary now and that she had asked the CNA coordinator that morning. CNA 2 stated the CNA's have 2 books for communication between staff. CNA 2 stated they call it the brain. CNA 2 stated the brain was used for letting other staff know about special needs of the residents. On 8/18/21 at 12:28 PM, an observation was made of CNA 2 obtaining a gown from a PPE cart down the hall and walking over to room [ROOM NUMBER] to deliver the lunch meal to the residents in that room. CNA 2 was observed donning the gown outside of room [ROOM NUMBER]. CNA 2 asked CNA 1 to bring her a meal tray for one of the residents in room [ROOM NUMBER]. CNA 1 brought CNA 2 a tray and CNA 2 brought the tray into the room. CNA 2 was observed to come back to the doorway and ask CNA 1 to bring her the tray for the second resident in room [ROOM NUMBER]. CNA 2 stated she would help feed the second resident. CNA 2 then went back into the room. CNA 1 removed another tray from the meal cart. CNA 1 was observed to enter room [ROOM NUMBER] without a gown, gloves or N95 mask. CNA 1 was observed to exit the room and did not sanitizer her hands. On 8/19/21 at 11:36 AM, an interview was conducted with the DON. The DON stated that she thought the [CONDITION(S)] machine was a closed system. The DON stated with vaccinated residents that required a [CONDITION(S)] machines were to have a 6 foot distance from a roommate with a curtain between them as long as there were no signs or symptoms of COVID-19. On 8/19/21 at 11:45 AM, an interview was conducted with Clinical Resource Nurse (CRN) 1. CRN 1 stated that resident 5 was in a private room but had been moved to a room with a roommate. CRN 1 stated that resident 5 was vaccinated and completed at least a 30 day quarantine period with no COVID-19 signs or symptoms prior to moving in with a roommate. CRN 1 stated there was no policy and procedure for aerosolizing generating procedures. 4. On 8/16/21 at 12:00 PM, an observation was made of the lunch meal trays. The meal trays were observed to be transported through the hall with the dessert uncovered. On 8/18/21 at 7:50 AM, an observation was made of the breakfast cart delivered to the halls. CNAs were observed to remove meal trays from the cart across from the back nurses station. Staff were observed to deliver trays to Suite A with the fruit was uncovered. Staff were observed to transport trays from the back nurses station to rooms 204, 231, 230, and 232 with fruit uncovered. On 8/18/21 at 8:29 AM, an observation was made of CNA 1 passing breakfast trays. CNA 1 brought a tray into room [ROOM NUMBER]. When CNA 1 exited room [ROOM NUMBER] she did not sanitize her hands before bringing a tray to room [ROOM NUMBER]. CNA 1 exited room [ROOM NUMBER] without sanitizing her hands and went to the meal cart to pour coffee for the resident in room [ROOM NUMBER]. CNA 1 then transported the coffee uncovered to the resident in room [ROOM NUMBER]. On 8/18/21 at 8:49 AM, an observation was made of CNA 4 carrying an uncovered plate of food to room [ROOM NUMBER]. An interview was conducted. CNA 4 stated she had not been educated by kitchen staff about passing trays or handling food from the kitchen. On 8/18/21 at 12:22 PM, an observation was made of the lunch cart delivered to the back hall. CNA 7 was observed to transport cake uncovered from the nursing station in the back hallway to rooms 221, 223 and 226. At 12:24 PM, CNA 4 was interviewed and stated that all food was to be covered when it was transported through the hallways. At 12:28 PM, an observation was made of CNA 4 transporting an uncovered piece of cake on a meal tray from the back nurses station to room [ROOM NUMBER]. An observation was made of staff transporting cottage cheese and fruit uncovered from the nurses station to room [ROOM NUMBER]. On 8/19/21 at approximately 1:00 PM, an interview was conducted with the Dietary Manager (DM). The DM stated she was aware that some food on the trays were not covered. The DM stated she was having a hard time getting the kitchen staff to remember to do everything they were supposed to, like cover all of the foods on the tray.

Based on observation and interview it was determined, for 5 of 22 sample residents, that the facility did not provide each resident with food and drink that was palatable, attractive, and at a safe and appetizing temperatures. Specifically, residents complained that the food was not palatable and the test tray was not attractive and palatable. Resident identifiers: 5, 17, 25, 28 and 191. Findings include: 1. On 8/16/21 at 1:44 PM, an interview was conducted with resident 5. Resident 5 stated the cook cannot cook vegetables. Resident 5 stated the food was awful and the pasta was overcooked. Resident 5 stated the meatballs were frozen and the spaghetti sauce looked like brown gravy. On 8/19/21 at 1:30 PM, a follow up interview was conducted with resident 5. Resident 5 stated that the sweet potatoes were hard and she could not chew them. Resident 5 stated she did not know what the sauce was on the meat because it had a strange flavor. 2. On 8/16/21 at 1:19 PM, an interview was conducted with resident 28. Resident 28 stated that all the veggies had been mushy and over cooked. Resident 28 stated that the spaghetti was the worst she had ever tasted. Resident 28 stated that the noodles were overcooked and mushy. Resident 28 stated that after tasting the veggies she was not sure what the veggies were. Resident 28 stated that bread was put under the dome and it was mushy and wet. 3. On 8/17/21 at 8:45 AM, an interview was conducted with resident 17. Resident 17 stated that the food was either really good or really bad. 4. On 8/18/21 at 9:09 AM, an interview was conducted with resident 191. Resident 191 stated that the food was crap. Resident 191 stated that she was supposed to be on a low sodium, heart healthy diet. Resident 191 stated that she got the same food as everybody else. Resident 191 stated that even though she was supposed to be on a low sodium diet, the kitchen always provided extra salt on her tray. Resident 191 stated that the food was over salted. Resident 191 stated that the vegetables were over cooked, and that the fruits were canned and mushy, nothing was ever fresh. 5. On 8/17/21 at 9:32 AM, an interview was conducted with resident 25. Resident 25 stated that the food was horrible. Resident 25 stated that he was on a mechanical soft diet, and the food was dry and difficult to swallow. On 8/19/21 a test tray was requested. At 12:21 PM the last meal cart was observed to be taken out of the kitchen to the back hallway. At 12:35 PM, the test tray was obtained from the meal cart after all residents had been served. The following was observed: [Note: All temperatures were in degrees Fahrenheit.] a. There was chicken with peaches with a temperature of 86.4. The chicken was dry and cold to the taste. The peaches on top of the chicken were mushy and did not taste like peaches. b. There was broccoli with a temperature of 119. The broccoli was slightly crunchy with a dull brownish-green color. The broccoli was bland to the taste. There was no salt and pepper provided on the tray. c. There was rice pilaf with a temperature of 84.3. The rice was flavorful and warm to the taste. The rice was observed to have colored peppers and onions. d. The cheesecake was cool to the taste with a graham cracker crust.

Based on interview and record review it was determined, for 1 of 22 sample residents, that the facility did not coordinate assessment with the pre-admission screening and resident review (PASARR) program under Medicaid in subpart C of that part. Coordination included referring all level II residents and all residents with newly evident or possible serious mental disorder for level II resident review upon significant change in status assessment. Specifically, a resident did not have all diagnoses check on the PASARR for a level II referral. Resident identifiers: 21. Findings include: Resident 21 was admitted to the facility on [DATE] with diagnoses which included [CONDITION(S)], [CONDITION(S)], pneumonia, major depressive disorder, and Post-traumatic stress disorder ([CONDITION(S)]). Resident 21's medical record was reviewed on 8/18/2021. A form titled Pre-Admission Screening Application/Resident Review Identification Screening dated 6/7/21 revealed no diagnoses of major depressive disorder or [CONDITION(S)]. A section titled Serious Mental Illness (SMI) Criteria revealed [CONDITION(S)] and major depression were not check which indicated that a level II PASRR evaluation was needed. At the bottom of the form the box was check that a .Level II evaluation SMI is NOT needed. Resident 21's history and physical from the local hospital dated 7/24/2021 revealed a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] On 8/19/21 at 10:16 AM, an interview was conducted with the Social Service Worker (SSW). The SSW stated that PASARR's were fill out by the hospital prior to admission or filled out after admission. The SSW stated that she tried to compare the diagnoses from the hospital to the ones on the PASARR form. The SSW stated that resident 21's PASARR did not have the [CONDITION(S)] or major depressive disorder marked on the form. The SSW stated that resident 21 should have been referred for a level II. The SSW stated that she did not catch them (diagnoses) every time.

Based on observation and interview it was determined, for 1 of 22 sample residents, that the facility did not treat each resident with respect, dignity and care in a manner and in an environment that promoted maintenance or enhancement of his quality of life. Specifically, a resident was sleeping on a mattress with no sheets. Resident identifier: 21. Findings include: Resident 21 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 8/17/21 at 9:46 AM, an observation was made of resident 21. Resident 21 was laying in bed with his feet hanging off the bed. Resident 21 did not have sheets or blankets on his bed. Resident 21 was observed without a shirt and visible from the hallway. On 8/17/21 at 10:04 AM, an observation was made of Registered Nurse (RN) 2 and Certified Nursing Assistant (CNA) 6. RN 2 and CNA 6 were observed to enter resident 21's room. RN 2 was immediately interviewed. RN 2 stated that she was started her shift at 9:45 AM. RN 2 stated that Licensed Practical Nurse (LPN) 2 had cared for resident 21 from 6:00 AM until 9:45 AM. CNA 6 stated that she did not know resident 21 had returned from the hospital. On 8/17/21 at 10:30 AM, an interview was conducted with LPN 2. LPN 2 stated she was resident 21's nurse from 6:00 AM until RN 2 took over. LPN 2 stated that she had not been into resident 21's room during her shift. LPN 2 stated that CNAs had not obtained vital signs for resident 21. LPN 2 stated vital signs were usually obtained at 5:30 AM. LPN 2 stated she did not know why resident 21's vital signs had not been completed. On 8/17/21 at 10:41 AM, an observation was made of CNA 6. CNA 6 was observed in the hallway with linens including sheets. CNA 6 stated that resident 21 should have sheets on his bed. CNA 6 stated she found out resident 21 returned last night. CNA 6 stated since he returned last night, that might be why he did not have sheets on his bed. CNA 6 stated that sheets fit resident 21's bed and mattress. CNA 6 stated she had not been in resident 21's room that morning.

Based on observation, interview and record review it was determined, for 1 of 22 sample residents, that the facility did not provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administration of all drugs and biological's) to meet the needs of each resident. Specifically, a resident did not have diabetic medication for 2 days. Resident identifier: 3. Findings include: 1. Resident 3 was admitted to the facility on [DATE] with diagnoses which included [CONDITION(S)], muscle weakness, type 2 diabetes mellitus, and history of COVID-19. Resident 3's medical record was reviewed on 8/18/21. A physician's order dated 5/9/21 revealed [MEDICATION(S)] tablet extended release 24 hr (hours); 750 mg (milligrams); 1 tab (tablet) orally once a day. According to the July 2021 Medication Administration Record (MAR) resident 3 was not administered [MEDICATION(S)] on 7/15/21 and 7/16/21. Facility staff documented Drug/Item Unavailable in the reason's section. On 8/17/21 at 9:15 AM during medication pass, Licensed Practical Nurse (LPN) 2 was observed to be following the medication orders from the physician for 750 MG of [MEDICATION(S)] for resident 3. LPN 2 was observed to remove resident 3's blister pack of [MEDICATION(S)] and there were no pills available. LPN 2 stated that she would notified the pharmacy, and that there was an onsite medication administration system that had the [MEDICATION(S)]. LPN 2 was observed to retrieve the [MEDICATION(S)] from the system and administer the 750 mg dose to resident 3. On 8/18/21 at 9:35 AM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated that nurses obtained refills by completing a refill order forms. RN 1 stated medications had labels that were removed and placed on the form, then the form was faxed to the pharmacy. RN 1 stated the medications arrived from the pharmacy at about 6:00 PM the same day or the next day. On 8/18/21 at 10:04 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that a sticker was removed from the medication, placed on a form and faxed to the pharmacy. The DON stated the medication was sent within the same day or the next day. The DON stated she was not sure why the [MEDICATION(S)] was not available. On 8/18/21 at 11:28 AM, a follow-up interview was conducted with DON. The DON stated that there were 2 doses of the [MEDICATION(S)] not administered on 8/15/21 and 8/16/21.

Based on interview and record review it was determined, for 2 of 22 sample resident, that medical records were not complete, accurately documented, readily accessible and systematically organized. Specifically, a resident that passed away did not have nursing progress note related to the event and another resident did not have [CONDITION(S)] communication forms in the medical record. Resident identifiers: 28 and 40. Findings include: 1. Resident 40 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 40's medical record was reviewed on 8/18/21. Resident 40's progress notes dated 7/26/21 revealed resident was having loose stools, nausea, vomiting but was feeling okay earlier in the day. The plan from the doctor was to check laboratory values and provide intravenous fluids. There was a form titled Record of Death in resident 40's medical record dated 7/27/21. The form revealed the spouse and children were present at time of his passing. There was other no discharge documentation. On 8/18/21 at 2:20 PM, an interview was conducted with the Director of Nursing (DON) and Assistant Director of Nursing (ADON). The DON stated that resident 40 was having loose stools, nausea and vomiting on 7/26/21. The DON stated that resident 40's family arrived and resident 40 had a quick change in condition and passed away quickly on 7/27/21. The DON stated that there should have been documentation regarding resident 40's passing. The DON stated that an agency nurse was working when it happened and must have not documented the event. The ADON stated there was a form for the mortuary release. The ADON stated that an event note and nursing progress note should have been entered into the medical record. 2. Resident 28 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 28's medical record was reviewed on 8/18/21. Resident 28 did not have [CONDITION(S)] communication forms in the medical record. On 8/20/21, the facility provided additional information. The facility provided forms titled Referral to Physicians and Clinics. There were forms dated 7/27/21, 7/29/21, 7/31/21, 8/3/21, 8/5/21, 8/7/21, 8/10/21, 8/12/21, 8/14/21, 8/17/21 and 8/19/21 regarding resident 28's [CONDITION(S)]. The forms were not in the medical record accessible for staff. On 8/20/21, a phone interview was conducted with the Administrator. The Administrator stated that she did not know why the forms were not in resident 28's medical record.

Based on interview and record review, it was determined the facility did not ensure that the pharmacist must report any irregularities to the attending physician and the facility's medical director and director of nursing, and these reports must be acted upon. Specifically, pharmacist recommendations related to laboratory values and insulin dosage were not acted upon for 2 of 22 sample residents. Resident identifier: 4 and 13 Findings include: 1. Resident 4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of resident 4's medical record was completed on 5/9/19. A Drug Regimen Review, dated 4/22/19, documented the following recommendation from the pharmacist related to resident 4's medication regimen: Medication Regimen Review Findings . To beetter (sic) control glucose consider increasing [MEDICATION NAME] to 23 units daily. A physician's orders [REDACTED]. insulin [MEDICATION NAME] ([MEDICATION NAME]) . 20 unit(s), Subcutaneous, Daily . (Note: This order remained unchanged 17 days following the pharmacist's recommendation on 4/22/19.) Resident 4's blood glucose measurements were reviewed from 3/23/19 through 4/17/19. 134 out of 147 blood sugar measurements were higher than the indicated reference range of 74-106 milligrams per deciliter (mg/dL). On 5/8/19 at 11:47 AM, an interview was conducted with RN (Registered Nurse) 4. RN 4 stated the monthly pharmacist reviews were received and followed up on by the Director of Nursing (DON) and Assistant Director of Nursing (ADON). On 5/9/19 at 9:16 AM, an interview was conducted with the DON. The DON stated comments from the physician in response to the pharmacist's recommendations should have been on file. The DON further stated she typically obtained the pharmacist's recommendations and discussed them with the physician. No physician communication could be located within the medical record related to the pharmacist's recommendation for resident 4's medication regimen on 4/22/19. 2. Resident 13 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of resident 13's medical record was completed on 5/9/19. Monthly Drug Regimen Review documented the following recommendations from the pharmacist related to resident 13's medication regimen: a. 1/22/19; Medication Regimen Review Findings . Lab (laboratory) orders needed. b. 2/24/19; Medication Regimen Review Findings . No labs on file . c. 3/26/19; Medication Regimen Review Findings . No labs on file . No laboratory results were documented within resident 13's medical record following the pharmacist's initial recommendation on 1/22/19. On 5/9/19 at 9:16 AM, an interview was conducted with the DON. The DON stated she was unsure whether or not the physician had responded to the insulin-related recommendation. On 5/9/19 at 9:59 AM, an interview was conducted with the Consultant Pharmacist (CP). The CP stated the facility's previous laboratory services company automatically scanned laboratory results into the medical record, and the new laboratory services company does not automatically scan laboratory results into the medical record. The CP stated that laboratory results were frequently not scanned into the medical record because the facility staff was not used to doing it. In addition the CP stated he obtained authorization to view laboratory results from any location three weeks prior, and there were no laboratory results on file for resident 13. The CP further stated he initially requested laboratory orders, specifically a comprehensive metabolic panel (CMP), because resident 13 was prescribed a diuretic medication and more than the average dose of potassium supplementation. No physician communication could be located within the medical record related to the pharmacist's recommendations for resident 13's medication regimen on 1/22/19, 2/24/19, or 3/26/19.

Based on observation, interview and record review, it was determined the facility did not ensure that residents with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 4 of 24 sample residents. The deficient practice identified for resident 186 was found to have occurred at a harm level. Resident identifiers: 6, 23, 186, and 232. Findings include: HARM 1. Resident 186 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 2/5/18 at 7:30 AM, a list of current residents with [DIAGNOSES REDACTED]. The list obtained documented the following for resident 186, .Open Left Heal (sic), Float while in bed. Podus boots all times unless ambulatoin (sic). On 2/5/18 at 10:45 AM, resident 186 was interviewed. Resident 186 was sitting in her wheelchair. Resident 186 had a bandage that had been placed on the left foot and ankle. Resident 186's left foot was planted on the floor. Resident 186 was not wearing shoes or a pressure relieving device. Resident 186 stated that she had developed a sore on her left heel approximately 2-3 weeks ago. Resident 186 stated that the sore developed because the left heel was rubbing on the sheets while she was laying in bed. Resident 186 stated that she tried to elevate her left heel on two pillows at night but that her heel still rubbed on the sheets. Resident 186 stated that she was supposed to wear a boot, but that the staff had not brought one in for her to wear. On 2/6/18 at 12:26 PM, resident 186 was observed in the therapy gym. Resident 186 had a dressing over the left foot and heel. Resident 186's left heel was again planted on the floor without a pressure relieving device. On 2/6/18 at 12:29 PM, resident 186 was pushed in her wheelchair back to her room by a facility therapist. Resident 186's left foot was planted on the wheelchair pedal of the wheelchair without a pressure relieving device in place. On 2/6/18 at 1:18 PM, resident 186 propelled herself in her wheelchair out of her room towards the nurse's station. Resident 186 was observed to step on her heel and place pressure on it to propel herself forwad. On 2/12/18 at 8:00 AM, resident 186 was observed to be sitting up at the side of the bed. An Occupational Therapist (OT) was present in resident 186's room. The OT stated that resident 186's podus boot had been delivered. The OT stated that resident 186 was to wear the podus boot on her left foot at all times except when ambulating. Also observed was a purple egg crate bootie which was to be placed on resident 186's right foot. Resident 186's medical record was reviewed on 2/7/18. On 1/2/18, a complete metabolic profile (CMP) was obtained for resident 186. Resident 186's total protein was low at 6.2 grams per deciliter (G/DL) with an [MEDICATION NAME] low at 2.6 G/DL. (Note: The laboratory company documented a normal reference range of 6.3 - 8.2 for total protein and 3.5 - 5.0 for the [MEDICATION NAME].) The Minimum Data Set (MDS) assessments completed for resident 186 were reviewed. A 5 day or admission MDS assessment was not available for review. On 1/7/18, a LTC (Long-term Care) Nutritional care plan was developed for resident 186. The documented goals were RSD (resident) will have ALB ([MEDICATION NAME]) WNR (within normal range) BY TNR (through next review); RSD WILL HAVE SIGNIFICANT WT (weight) CHANGE BY TNR; RSD WILL HAVE MOIST MUCOUS MEMBRANE AND NO TENTING OF SKIN BY TNR; RSD SKIN WILL REMAIN INTACT BY TNR; Nutritional Intake Meets Needs, (and) Average Meal Consumption Per Day. The interventions developed to achieve the goals included, WCTM (will continue to monitor) LABS, WKLY (weekly) WTS, SKIN REPORTS, AND PO (by mouth) INTAKES. MEDS (medications), DIET, AND SUPPLIMENTS (sic) AS ORDERED, and Evaluate Eating Limitations: Dentures, Oral Pain. (Note: Resident 186's nutritional care plan was not updated since it was developed on 1/7/18. ) On 1/8/18, a CMP was obtained for resident 186. Resident 186's total protein was down to 5.3 with an [MEDICATION NAME] of 2.4 (Note: Both of these lab values were lower than the previous laboratory values drawn on 1/2/18.) Review of the Admission Dietary Note revealed that the facility Dietary Technician (DT) completed the assessment on 1/7/18. The DT documented the following: RSD CBW (current body weight) 304, 230% IWR (ideal weight range), BMI (body mass index) 52.2, PO INTAKES 82% OF A CCHO REG (regular) THIN DIET. SKIN IS INTACT. LABS 1/2 (January 2) HGB (hemoglobin) 9.1, HCT (hematocrit) 27.2, ALB ([MEDICATION NAME]) 2.6, NA (sodium) 129, GLUC (glucose) 238, APPEARS TO INDICATE [MEDICAL CONDITION] OF CHRONIC DISEASE. RSD IS ALERT/ORIENTED AND ABLE TO MAKE NEEDS KNOWN. EEN (estimated energy needs)/EPN (estimated protein needs) NOT MET. REC (recommend) INC (increased) PROTEIN C (with) MEALS, AND PROTGOLD (Protein Gold) 30 ML (milliliters) Q/DAY (every day). WCTM LABS, WKLY (weekly) WTS (weights), SKIN REPORTS, AND PO INTAKES. FOR FURTHER REC'S (recommendations) PR[NAME]EED TO NAR (nutrition at risk). (Note: The DT estimated resident 186's protein needs at a 1.5 factor.) On 1/7/18, a telephone order was written by the DT to Inc (increase) protein (with) meals (and to administer) ProtGold (Protein Gold) 30 ml (milliliters) Q/day (daily). The order was not received by a registered nurse, but was signed by the physician on 1/18/18. On 1/10/18, the Registered Dietitian (RDN) added an addendum to the admission dietary note. The RDN documented, RDN reviewed above info (information) (and) aware RSD CBW 304# which is 230% IWR and BMI 52.2 resulting in RSD being obese. Currently 82% of a CCHO reg (regular) diet consumed. Labs 1/2 HGB 9.1, HCT 27.2, Alb 2.6, NA 129, GLUC 238. Appears to indicate [MEDICAL CONDITION] of chronic disease. EEN/EPN not met. Agree w (with) DT rec (recommend) to inc protein c (with) meals and add 30 ml Q/day of ProtGold. Rec to encourage RSD to drink H20 (water)/healthy fluids. Educate about health food choices, encouraging not to select sugary - high fat foods. WCTM. (Note: The RDN did not address the laboratory values drawn on 1/8/18.) Review of the (MONTH) (YEAR) Medication Administration Records (MARs) revealed that resident 186 refused the ProtGold on 1/13/18, 1/15/18, and 1/17/18 through 1/19/18. On 1/15/18, a CMP was obtained for resident 186. Resident 186's total protein was 6.1 with an [MEDICATION NAME] of 3.0. There was no documented evidence that resident 186's abnormal labs obtained on 1/15/18 were reviewed by the DT or the RDN. On 1/19/18, a telephone order was written to DC (discontinue) Protein Gold (per) pt. (patient) request. On 1/22/18, a CMP was obtained for resident 186. Resident 186's total protein was 6.0 with an [MEDICATION NAME] of 3.0. On 1/25/18, a CMP was obtained for resident 186. Resident 186's total protein was 5.1 with an [MEDICATION NAME] of 2.5. On 1/25/18 at 8:24 PM, a licensed nurse documented in a progress note, .Pt (patient) has weeping on her left heel. On 1/26/18 at 1:07 PM, a licensed nurse documented in a progress note, Noted open area on left heal (sic). skin is necrotic with cracked open area that are (sic) draining a clear fluid. Hydro dsg (dressing) applied after cleaning. wrapped with loose coban. heals are floating. MD (Medical Doctor) Notified. WCTM. On 1/27/18 at 5:26 PM, a licensed nurse documented in a progress note, .Dressing changed via family request. Wound has serosanguineous fluid coming out from wound. Under the skin is a necrotic round area abt (about) 3 x (by) 3 inches round. Skin around this area is cracked and dry. Wound area was cleaned, skin prep applied, sponge patch placed, kerlix around and then loose coban. Nurse was able to place two fingers under coban, patient was instructed to notify staff if dressing becomes too tight. Heals (sic) where then floated on pillow, so heals (sic) did not touch . Nurse checked dsg throught (sic) the night, but by morning, dressing was coming off. Patient was rubbing heals (sic) on bed. Nurse cleaned wound and applied new dressing. heals (sic) where (sic) again placed floating on pillow, advised patient to try and keep heals (sic) floating and notify staff if dressing becomes too tight or uncomfortable in any way. Patient understood and claimed she wount (sic) comply, patient is alert and oriented x4 (person, place, time and situation). Wound nurse will come in today and assess the wound and call (name of physician redacted) our wound Doctor. On 1/28/18 at 1:46 PM, a licensed nurse documented in a progress note, Family approached RN (Registered Nurse) this afternoon. Family had numerous questions that this RN has knowledge of. Family requests to know about patients plan of care regarding wound ulcers and therapy. I educated both the family and patient what measures they could implement themselves, the first to compliance (sic) with therapy and wound care instructions. More so, the family should really take their concerns to the case manager and or Administrator/DON (Director of Nursing). Family voiced understanding and appreciated my input. Nothing further. On 1/28/18, the DT documented an added an addendum to the admission dietary note. The DT documented, RES HAD ERROR IN INITIAL EVAL (evaluation) DUE TO MISCOMMUNICATION. WOUND VAC (vacuum) SHOULD BE CLARIFIED TO ULCER ON HEEL. CURRENT RECS (recommendations) ARE MEETING NTL (nutritional) NEEDS. WCTM FOR FURTHER CHANGES AS NEEDED. (Note: The admission dietary note, dated 1/7/18, and the Registered Dietitian note, dated 1/10/18, did not indicate that resident 186 had a wound vac in place. Additionally, the admission physician orders did not indicate that resident 186 had a wound vac in place.) There was no evidence that the DT addressed resident 186's abnormal labs that were obtained on 1/25/18. On 1/29/18, a CMP was obtained for resident 186. Resident 186's total protein was 5.9 with an [MEDICATION NAME] of 3.0. On 1/30/18 at 3:24 PM, a licensed nurse documented in a progress note, pt left heel bandage was changed, [MEDICATION NAME] (sic) with some extra padding was placed with a 2 layer wrap to help hold in place per DON. On 2/1/18 at 2:21 PM, a licensed nurse documented in a progress note, NEW ORDER: L-heel: Paint w/iodine dark eschar area only. Strips of xeroform or [MEDICATION NAME] around edge (do not get eschar wet). 2 Small ABD pad over damaged area, folded in 3rds. Small ABD place just above ankle crease, and 1 folded, tripled, on bottom of foot, covering heel pad. Secure w/Kerlix & then Coban. Paint eschar daily, can use folded ABD's again. Keep dry. D/C (discontinue) previous order. These are per (name of the wound care physician). On 2/3/18 at 3:40 PM, a licensed nurse documented in a progress note, Wound on heel continues to improve, . On 2/5/18, a CMP was obtained for resident 186. Resident 186's total protein was 6.3 with an [MEDICATION NAME] of 3.2. Resident 186's noon meal was observed on 2/6/18 at approximately 1:45 PM. Resident 186 stated that she was nauseated and was not interested in eating her lunch. On 2/5/18, the physician with a local wound clinic documented in a physician's progress note, .complete pressure relief - heel float . Resident 186's breakfast meal was observed on 2/7/18 at approximately 9:00 AM. Resident 186 was served scrambled eggs and toast. No additional proteins were added. Resident 186 stated that she was nauseated. Resident 186 had not eaten her breakfast. On 2/7/18 at 10:56 AM, an observation was made of Wound Technician (WT) 1, a non-registered, non-certified employee of a local wound clinic, while changing the dressing to resident 186's left heel. WT 1 stated that she was Wound Care Certified. WT 1 removed the old dressing on resident 186's left heel. The old dressing was observed to have yellowish drainage on the bandage. The WT was asked if the dressing had yellowish drainage, she stated, No. The WT measured the left heel wound to be 7 cm (centimeters) by 6 cm with an an eschar that measured 6 cm X 5 cm. The WT stated that resident 186's unstageable pressure ulcer was worse than what it was on Monday (2/5/18). The WT stated that the pressure ulcer developed from her heels rubbing on the sheets when she was in bed. The WT stated that the unstageable pressure ulcer was avoidable. The following assessments and documentation were obtained after resident 186's nutritional status was brought to the attention of the facility staff: On 2/7/18 at 10:50 AM, an the DT was interviewed. The DT stated that residents with healing pressure ulcers were reviewed in the Nutrition At Risk (NAR) meetings monthly. The DT stated that he was not aware that resident 186's ProtGold had been discontinued on 1/19/18. On 2/7/18 at 2:49 PM, an interview was conducted with the Director of Nursing (DON) related to resident 186's podus boots. The DON stated that the podus boots had been ordered, but were back ordered. The DON stated that the podus boots were ordered approximately one week ago. The DON stated that resident 186's heels were to be floated when in bed and that resident 186 was asked to keep her heels off of the foot rest. On 2/7/18, the DT documented in a dietary progress note, RS (Resident) 109 (unknown) ADDED FOR WOUND ON HEELS. PO INTAKES HAVE SHOWN SLIGHT AVERAGE IMPROVEMENT FROM 70% TO 74% AS OF 2/5. NEW LABS ON 2/6 INDICATE [MEDICAL CONDITION] OF CHRONIC DISEASE AND ALB IMPROVEMENT FROM 2.6 TO CURRENTLY 3.2 DIETARY WAS NOT INFORMED RSD HAD PROT (Protein) GOLD 30 ML Q/DAY DC'D (discontinued) ON 1/19 PER RSD REQUEST. RESD (Resident) EXPRESSED EXTREME DISLIKE OF SUPPLEMENTS AND IS SELF DIRECTED WITH MOST FOOD CHOICES. REC ADD NSA (No Sugar Added) MED PASS 120 ML Q/DAY FOR ADDED NUTRITION. WCTM FOR FURTHER CHANGES AS NEEDED AND RSD FEEDBACK OF NEW SUPPLEMENT. (Note: The DT estimated resident 186's protein needs as 94 grams (gms) using a 1.2 factor which was decreased from the 1.5 factor used on 1/7/18.) On 2/7/18, the DT documented in a nutritional evaluation, DON (Director of Nursing) AND DIETARY MANAGER CONCUR WITH 103 (unknown) ADDENDUM FOR SKIN ISSUE (WOUND ON HEEL). RECS AT THIS TIME ARE MEETING NTL NEEDS. On 2/7/17, a telephone order was written by the Dietary Tech (DT) to start resident 186 on NSA (No Sugar Added) med pass 120 ml (milliliters) Q/day (daily) , Vit (Vitamin) C 500 mg (milligrams) PO (by mouth) QD (daily) X 14 days, (and) Zinc 220 mg PO QD X 14 (days). The telephone order was signed by a registered nurse as the nurse receiving the order. On 2/7/18 at 8:55 PM, the local wound clinic physician documented in a progress note: Delayed Entry Wound Care Note-DOS (Date of Service) 2/5/18 S (Subjective); .She has been on cephtriaxone then [MEDICATION NAME]. She developed a L (left) heel pressure ulcer during this period of immobility. She has a history of chronic leg swelling, no compression at home. .O (Objective): Bilateral LE: L heel- Heel cap, 4cm in diameter, is enveloped with firm black, dry eschar, without fluctuance or periwound [DIAGNOSES REDACTED]. There is a 2mm margin of sl (slight) moist granular tissue circumferentially. A (Assessment): .L Unstageable heel PU (Pressure Ulcer), P (Plan): .Maintain dry heel, daily iodine painting or q2-3 days iodine painting under dry gauze heel dressing and 2-layer compression wrap. On 2/7/18, resident 186 was assessed by a local wound clinic physician. The wound care physician documented the following: .Chief Complaint: .She developed a L (left) heel pressure ulcer . L heel- Heel cap with firm black, dry eschar, without fluctuance or periwound [DIAGNOSES REDACTED]. There is a 2mm (millimeter) margin of sl (slight) moist granular tissue. Visit is for: wound assessmnt (assessment)/care .Wound Location: L heel back .Comments: L heel BLISTER and mild swelling in Lower leg//Blister was noticed on Jan (January) 26 and on [DATE] there was an eschar center surrounded by a small open area of healthy pink tissue. .Amount of Drainage: Scant Type of Drainage: Serosang (serosanguineous) .Measurements Are: original measurement of global wound: 10cm (centimeters) L (length) X (by) 7cm W(wide) ///Eschar was 5cm X 4cm and is solid in palpation // 0.2cm open area around eschar, completely circular. //NEW addition to bruising on lateral side fo heel. there is increased open area on the posterior side of the heel .Stage: Unstageable .Periwound Condition: healthy looking skin surrounding heel/ankle/lower leg-calf area .Wound dressed with: Eschar was painted with Iodine and stipped (sic) xeroform placed around edges, gauze placed on heel w/ABD placed over gauze. 2sm (2 small) tri-folded ABD/s placed above heel on back side and 1 trifoided ABD under neath the heel, Secured with Kerlix from toes to above the ankle. Coban was placed over and secured at ankle. .Additional Comments: Request to Podus Boot w/brace was requested for patient. On 2/8/18 at 10:25 AM, a telephone inderview was conducted with the facility RDN. The RDN stated that the DT had been completing nutritional assessments for residents for several years. The RDN stated that the DT was trained by a previous RDN on what guidelines to use on determining the nutritional needs of residents with abnormal laboratory values and pressure ulcers. The RDN stated that she was not informed that resident 186's protein gold had been discontinued on 1/19/18. The RDN further stated that resident 186's protein needs should have been calculated using a 1.4 factor ionstead of a 1.2. The RDN stated that resident 186 should have been reviewed in a weekly NAR meeting. On 2/81/8 at 11:10 AM, an interview was conducted with Unit Manager (UM) 1. UM 1 stated that an admission MDS assessment was not completed for resident 186 until 2/7/18. UM 1 further stated that resident 186's care plans were not updated to include the pressure ulcer until 2/7/18. On 2/9/18, the DT documented in a nutrition evaluation, NAR WEEKLY REVIEW: DON, RDN, DIET TECH, DIETARY MANAGER PRESENT AND CONCUR WITH RECS. RDN CLARIFIED PROTEIN NEEDS BACK TO 1.5 DUE TO SKIN ISSUE. NO FURTHER CHANGES AT THIS TIME. On 2/11/18 at 2:07 PM, the RDN documented in a dietary progress note, RD talked to RSD on Thurs (Thursday) evening 2/8/18 and she expressed that the supp (supplement) was better than the other (liquid protein) and would continue it as a trail (sic). RDN was in the facility Friday and she said she would continue with the supp and foods with added protein. Talked with RSD Sat. (Saturday) at lunch and she agreed to try supp BID (twice a day). Talked with RSD at 1PM Sun (Sunday) and she was not sure she could drink the supp BID but will drink what she can at the time. Heel is improving. WCTM by talking with nursing & RSD. On 2/11/18 at 11:59 PM, The RDN documented in a dietary progress note, .DO (Diet order): CCHO/REG Thin Liquids with increased protein at meals. RSD stated would eat oatmeal, cream of wheat, pudding, gravies with protein added. Also cottage cheese with fruit, string cheese, yogurt, etc, Recorded Ave (average). PO Intake for past 24 hrs (hours) 81.3% (percent), last 7 days 84.2%, last 30 days 72.9%. Sat lunch was 90% with consuming all juice. RSD makes food choices, will eat sugar free cookies, etc. Discussed with RSD importance of protein, vit (vitamins), min (minerals) etc in healing process.RSD has refused liquid protein, did agree to take 120 ml of 1.75 NSA Supp Q/day for three days and then discuss further plan. Checked with her on Thurs & Fri (Friday) how this was going & stated tasted better than other supp. Sat talked with RSD & she agreed to try 120 ml of 1.75 NSA Supp X BID, this would increase prot (protein) 20 gm. Sun (Sunday) when visited with RSD she was not sure if she could drink all the supp at two different times. Discussed the importance of protein & nutrients and to see how much she can drink. She is 'self-directed' and will continue to encourage her to consume supp, increased protein foods and make healthy food choices. WCTM. On 2/8/18 at 1:00 PM, the DON was interviewed. The DON stated that on 1/26/18, the facility identified that the weekly NAR meetings had not occurred. The DON stated that she had not attended the NAR meetings. The DON stated that it was the DT responsibility to communicate resident changes (such as the development of pressure ulcers and abnormal laboratory values) to the RDN. (Cross refer to 692) POTENTIAL FOR HARM 2. Resident 6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 2/6/18 at 3:10 PM, an observation was made of a wound on resident 6's left ischium as Licensed Practical Nurse (LPN) 1 measured resident 6's wound. LPN 1 measured the wound as being 4.5 cm in length. The wound appeared to be shaped like a slit with a narrow opening measuring 0.5 cm. The opening was narrow enough that LPN 1 had to spread the skin along the length of the wound to measure the depth. The depth on the left side of the wound was 2 cm, and the depth closer to the right side of the wound was 1 cm. The nurse measured tunnelling from the left side of the wound under the wound entrance at 2 cm. There was no drainage or odors observed. The area around the wound was darkened but blanchable, circular in shape measuring 9 cm by 7 cm. LPN 1 described the skin in this area as 'tight'. Below the wound were 2 small circular skin tears with blood that the nurse stated were caused from the dressing. LPN 1 stated I can't tell if it's (the wound) to the bone because I have to go in on an angle. It tunnels sideways. Resident 6's medical record was reviewed on 2/6/18. On 11/10/17 a complete metabolic panel (CMP) was obtained for resident 6. Resident 6's [MEDICATION NAME] was 3.5. (Note: The laboratory company documented a normal reference range of 3.5-5.0 for [MEDICATION NAME].) A telephone order was written by the Dietary Technician (DT) on 11/15/17 which stated 1) Increase protein (with) meals 2) ProtGold (Protein Gold) 30 mL (milliliters) Q (every) day. A telephone order was written 11/16/17 which stated: left ischial tuberosity abrasion-cleanse (with) wound cleanser, sure prep to edges of wound bed, apply [MEDICATION NAME] dressing (change) q (every) week and PRN (as needed) saturation. A nursing note from 11/16/17 stated: Pt requested dressing to left ischial tuberosity be changed. Removed old dressing ([MEDICATION NAME] dressing) and noted superficial abrasion 2.5 x 2.5 cm with sanguineous drainage which had saturated dressing. Cleansed and new dressing applied and order written per (name of physician) for [MEDICATION NAME] dressing to this abrasion site. Pt aware. On 11/18/17 a wound care note stated: wounds continue to improve on buttocks and great toe. Red area noted on the left heel. MD (medical doctor), DON notified. On 11/19/17 a telephone order for the following was placed: DC (discontinue) Liquid Gold, pt request add Boost chocolate 1 box QD (every day). On 2/6/18, resident 6's current medications were reviewed. One box of chocolate Boost was noted to be included in the active orders. On 11/25/17 a wound care note stated: Wound on Right ischem (sic) is closed, left ischemia has declined MD notified of change in condition. New order placed to have wound packed with gauze and covered with boarder (sic) gauze, changed daily. A telephone order was written on 11/26/17 which stated: (Change) ProtGold to 30 mL BID (twice daily). On 12/3/17, a telephone order was placed which stated: D/C Protein Gold Pt request. A wound care note dated 12/9/17 stated: Wounds continue to improve. no s/s (signs and symptoms) of infection. pt would like it changed 2x (times) a day due to the drainage on the wounds. A nurses note from 12/12/17 stated: [MEDICATION NAME] lab draw ordered by (name of physician's assistant) R/T (related to) wound healing. The result was received on 12/13/17. The lab results were as follows: [MEDICATION NAME] result 18.8 WNL Ref (reference) range 17.6-36. A nursing note from 12/12/17 stated: LT ISCHIAL PRESSURE ULCER IMPROVING BUT STILL RED WITH 1 CM TUNNELING, 1 CM IN DIAMETER, RT (right) HAS HEALED AND IS DOING WELL, LG (large) TOE HAS ALSO HEALED. On 12/16/17 a nursing note stated: Dressing changed to left ischial tuberosity ulcer-cleansed and new dressing applied as per MD orders. Wound now measure 2 cm deep-packed with packing gauze as per orders. Peri wound skin slightly improving. Will continue to monitor. On 12/19/17 a nursing note stated: SKIN CHECK: PRESSURE ULCER ON LT BUTT[NAME]K NEAR SACRUM IS HEALING WELL, DRESSING CHANGED EACH DAY, 0.5 CENTIMETER TUNNELING, IT HAS IMPROVED FROM LAST WEEK, RT HIP HAS HEALED, LG TOE HAS HEALED. A wound care note was documented 12/23/17 which stated: pt wound is improving, he still has depth at 6 o'clock no s/s of infection. A wound care note from 12/30/17 stated: Pt wound is stable, No s/s of infection. Added collegen (sic) to wound every other day. Educated pt and LN (?) on new dressing. On 12/31/17 a Nutrition Evaluation was performed by the DT for resident 6. In a section titled Assessment-Per Registered Dietitians Clinical Charting Handbook, there was a space for calculating estimated protein needs for the resident. It was noted that the resident's protein needs were calculated with a 1.2 factor which would have provided 89-113 grams. It then assessed if protein needs were met with current intake and No was marked. A progress note associated with the assessment was completed by the DT which stated: RSD (resident) 109 (form number) IMPLEMENTED FOR ISCHEMIA ON C[NAME]CYX. RSD CBW (current body weight) IS UNAVAILABLE DO (sic) TO RSD REFUSING. PO INTAKES HAVE SLIGHTLY IMPROVED AND REMAIN ABOVE 80%. RSD NUTL (nutritional) NEEDS SHOULD BE EXCEEDED AT THIS TIME. NURSING HAS STATED WOUND IS HEALING. AT THIS TIME NURSING HAS NO CONCERNS PERTINENT TO DIETARY. WCTM (will continue to monitor) FOR FURTHER CHANGES AS NEEDED. NO FURTHER RECS (recommendations) AT THIS TIME. An addendum to the above note was added by the Registered Dietitian (RD) on 12/31/17 which stated: RDN reviewed above info (information) and aware RDS ischemia on coccyx, CBW unavailable RDS refusing. PO (by mouth) intake slightly improved remaining above 80%. Nutl needs should be exceeded att (at this time). Nursing states wound healing (and) no concern pertinent to dietary. WCTM, no new recs att (at this time). (Note: The Clinical Charting Handbook the DT used to calculate protein needs was reviewed. For a 94 kg male, reasons stated for a 1.2 mg/kg protein factor were: High Risk of Developing a Pressure Ulcer, Stage I and II Pressure Ulcers Multiple Stage I Pressure Ulcers, Open and Weeping Stasis Ulcer, Open Wound The justification for using a 1.3 gm/kg protein factor was: Stage III Pressure Ulcer, Multiple Stage II Pressure Ulcers. The justification for using a 1.5 gm/kg protein factor was: Stage IV Pressure Ulcer, Multiple Stage III Pressure Ulcers Deep Tissue Injury.) On 1/7/18 a wound care note documented: Pt wound has improved no s/s of infection. cont (continue) with current wound treatment. A nursing note from 1/16/18 stated: LT BOTTOM PRESSURE ULCER IS HEALING WELL LESS THAN 0.5 CM TUNNELING, REDNESS HAS IMPROVED. HE IS AT AN APPOINTMENT TO ASSESS WOUND, NO OTHER SKIN PROBLEMS NOTED. A wound care note from 1/20/18 stated: Wound continues to improve, no s/s of infection, no complaints of pain or discomfort at this time. A nursing note from 1/25/18 stated: Left ischium wound cleansed and new dressing applied. Noted that along anal fold which leads to left ischium wound there is tunnel which measures 4 cm (centimeters) deep. Called and left message with (name of physician) regarding tunneling of left ischium wound. Talked with (name of physician's) assistant and without (sic) call back. Will continue to dress wound and monitor. Pt (patient) to see (name of physician) next week at appointment. Pt aware. A nursing note from 1/26/18 stated: WOUND DR NOTIFIED OF 4CM TUNNELING IN ISCHIUM. HE STATED THAT SINCE PT HAS APPT (appointment) WITH CLINIC ON TUESDAY TO CONTINUE WHAT WE ARE DOING BUT TO PREPARE THE PT THAT IF THE TUNNELING TOUCHES BONE THAT HE WILL NEED MORE SURGERY. PT NOTIFIED. A nursing note from 1/27/18 stated: Facility wound nurse recommended a culture of drainage from left ischium due to tunneling and lack of healing. On 1/27/18 a wound care documented: Wound is deteriorating with increase drainage. Wound measurement 2 x 0.2 x 1.5 tunneling 9:00 5 cm 10:00 6 cm. MD notified of change in wound status recommended culture be obtain pt has a hx [MEDICAL CONDITION] ([MEDICAL CONDITION]-resistant Staphylococcus aureus) in previous sites. A nursing note from 1/30/18 stated: APPOINTMENT NOTES: LT ISCHIAL PRESSURE WOUND TO BONE, CONTINUE PACKING WOUND. SURGICAL PR[NAME]EDURE TO CLOSE WOUND WED (Wednesday) FEB (February) 7, . On 1/30/18 a nursing note stated: SKIN CHECK: (Resident 6) HAS A PU (pressure ulcer) ON HIS LT BUTT[NAME]KS, CONTINUES TO HAVE SMALL AMOUNT OF TUNNELING, IT IS IMPROVING, HE IS AT WOUND DR TODAY TO HAVE THE WOUND EVALUATED. NO OTHER SKIN PROBLEMS ALL HAS HEALED. Later the same day (1/30/18) a nursing note stated: APPOINTMENT NOTES: LT ISCHIAL PRESSURE WOUND TO BONE, CONTINUE PACKING WOUND. SURGICAL PR[NAME]EDURE TO CLOSE WOUND WED (Wednesday) FEB (February) 7, . On 1/31/18 a nursing note stated: PT IN A VERY PLEASANT MOOD THIS EVENING. OPTIMISTIC AND RELIEVED ABOUT UPCOMING SURGERY A wound care note on 2/3/18 stated: Wound continues to decline resident will be go for surgery on Wednesday this week. On 2/6/18 a nursing note stated: LT ISCHIUM PU TUNNELING CONTINUES, TO HAVE SURGERY ON WED (Wednesday) TO CLOSE. PT HAS NO OTHER SKIN PROBLEMS On 2/7/18 at 9:55 AM resident 6 was interviewed. He stated he never had Boost during his stay at the facility. He stated the protein gold was nasty and he refused it. He denied ever meeting with the dietitian. He stated he had education on increasing protein years ago, but nothing recently. Resident 6 was observed to be transferred out of the facility on 2/7/18 at approximately 10:00 AM, for surgical repair of left ischial pressure wound. On 2/8/18 at 2:05 PM, RN 2 was interviewed. RN 2 stated that when Boost was ordered, it was put in the medication list and charted on in the Medication Administration Record [REDACTED]. RN 2 stated that she assumed the Boost would be delivered with the meal trays. On 2/8/18 at 2:15 PM, an interview was conducted with the dietary manager (DM). The DM stated that if a supplement was ordered for a resident, it could be sent on the resident's meal tray. The DM stated she was unable to recall any resident receiving Boost on their tray. The DM was asked to provide resident 6's tray ticket. The tray ticket for resident 6 was reviewed, and the Boost was not listed. On 2/8/18 at 10:02 AM, the Registered Dietitian (RD) was interviewed. The RD stated she relied on the DT to inform her of new wounds. The RD stated when she was informed of a pressure ulcer stage 2 and above, she would write a weekly note on those residents. The RD stated for a stage 4 pressure ulcer she would likely use 1.3-1.4 fact (TRUNCATED)

Based on observation, interview and record review, it was determined for 4 of 24 sample residents, that the facility did not ensure that residents maintained acceptable parameters of nutritional status, such as protein levels, unless the resident's clinical condition demonstrated that this was not possible. Specifically, the facility staff were not identifiying nor implementing interventions for residents who were admitted with pressure ulcers or developed pressure ulcers. The deficient practice identified for residents 6 and 186 were found to have occurred at a harm level. Resident identifiers: 1, 6, 17 and 186. Findings include: HARM 1. Resident 186 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 2/5/18 at 10:45 AM, resident 186 was interviewed. Resident 186 was sitting in her wheelchair. Resident 186 had a bandage that had been placed on the left foot and ankle. Resident 186 stated that she had developed a sore on her left heel approximately 2 to 3 weeks ago. Resident 186's medical record was reviewed on 2/7/18. Review of the physician's orders revealed an order, dated 1/2/18, that resident 186 was to be on a regular texture CCHO (Consistent Carbohydrate) diet, with thin liquids. On 1/2/18, a complete metabolic profile (CMP) was obtained for resident 186. Resident 186's total protein was low at 6.2 grams per deciliter (G/DL) with an [MEDICATION NAME] low at 2.6 G/DL. (Note: The laboratory company documented a normal reference range of 6.3 - 8.2 for total protein and 3.5 - 5.0 for the [MEDICATION NAME].) On 1/7/18, a LTC (Long-term Care) Nutritional care plan was developed for resident 186. The documented goals were RSD (resident) will have ALB ([MEDICATION NAME]) WNR (within normal range) BY TNR (through next review); RSD WILL HAVE SIGNIFICANT WT (weight) CHANGE BY TNR; RSD WILL HAVE MOIST MUCOUS MEMBRANE AND NO TENTING OF SKIN BY TNR; RSD SKIN WILL REMAIN INTACT BY TNR; Nutritional Intake Meets Needs, (and) Average Meal Consumption Per Day. The interventions developed to achieve the goals included, WCTM (will continue to monitor) LABS, WKLY (weekly) WTS, SKIN REPORTS, AND PO (by mouth) INTAKES. MEDS (medications), DIET, AND SUPPLIMENTS (sic) AS ORDERED, and Evaluate Eating Limitations: Dentures, Oral Pain. (Note: Resident 186's nutritional care plan was not updated since it was developed on 1/7/18. ) On 1/8/18, a CMP was obtained for resident 186. Resident 186's total protein was down to 5.3 with an [MEDICATION NAME] of 2.4 (Note: Both of these lab values were lower than the previous laboratory values drawn on 1/2/18.) Review of the Admission Dietary Note revealed that the facility Dietary Technician (DT) completed the assessment on 1/7/18. The DT documented the following: RSD CBW (current body weight) 304, 230% IWR (ideal weight range), BMI (body mass index) 52.2, PO INTAKES 82% OF A CCHO REG (regular) THIN DIET. SKIN IS INTACT. LABS 1/2 (January 2) HGB (hemoglobin) 9.1, HCT (hematocrit) 27.2, ALB ([MEDICATION NAME]) 2.6, NA (sodium) 129, GLUC (glucose) 238, APPEARS TO INDICATE [MEDICAL CONDITION] OF CHRONIC DISEASE. RSD IS ALERT/ORIENTED AND ABLE TO MAKE NEEDS KNOWN. EEN (estimated energy needs)/EPN (estimated protein needs) NOT MET. REC (recommend) INC (increased) PROTEIN C (with) MEALS, AND PROTGOLD (Protein Gold) 30 ML (milliliters) Q/DAY (every day). WCTM LABS, WKLY (weekly) WTS (weights), SKIN REPORTS, AND PO INTAKES. FOR FURTHER REC'S (recommendations) PR[NAME]EED TO NAR (nutrition at risk). (Note: The DT estimated resident 186's protein needs at a 1.5 factor.) On 1/7/18, a telephone order was written by the DT to Inc (increase) protein (with) meals (and to administer) ProtGold (Protein Gold) 30 ml (milliliters) Q/day (daily). The order was not received by a registered nurse, but was signed by the physician on 1/18/18. On 1/10/18, the Registered Dietitian (RDN) added an addendum to the admission dietary note. The RDN documented, RDN reviewed above info (information) (and) aware RSD CBW 304# which is 230% IWR and BMI 52.2 resulting in RSD being obese. Currently 82% of a CCHO reg (regular) diet consumed. Labs 1/2 HGB 9.1, HCT 27.2, Alb 2.6, NA 129, GLUC 238. Appears to indicate [MEDICAL CONDITION] of chronic disease. EEN/EPN not met. Agree w (with) DT rec (recommend) to inc protein c (with) meals and add 30 ml Q/day of ProtGold. Rec to encourage RSD to drink H20 (water)/healthy fluids. Educate about health food choices, encouraging not to select sugary - high fat foods. WCTM. (Note: The RDN did not address the laboratory values drawn on 1/8/18.) Review of the (MONTH) (YEAR) Medication Administration Records (MARs) revealed that resident 186 refused the ProtGold on 1/13/18, 1/15/18, and 1/17/18 through 1/19/18. On 1/15/18, a CMP was obtained for resident 186. Resident 186's total protein was 6.1 with an [MEDICATION NAME] of 3.0. There was no documented evidence that resident 186's abnormal labs obtained on 1/15/18 were reviewed by the DT or the RDN. On 1/19/18, a telephone order was written to DC (discontinue) Protein Gold (per) pt. (patient) request. On 1/22/18, a CMP was obtained for resident 186. Resident 186's total protein was 6.0 with an [MEDICATION NAME] of 3.0. On 1/25/18, a CMP was obtained for resident 186. Resident 186's total protein was 5.1 with an [MEDICATION NAME] of 2.5. On 1/25/18 at 8:24 PM, a licensed nurse documented in a progress note, .Pt (patient) has weeping on her left heel. On 1/26/18 at 1:07 PM, a licensed nurse documented in a progress note, Noted open area on left heal (sic). skin is necrotic with cracked open area that are (sic) draining a clear fluid. Hydro dsg (dressing) applied after cleaning. wrapped with loose coban. heals are floating. MD (Medical Doctor) Notified. WCTM. On 1/27/18 at 5:26 PM, a licensed nurse documented in a progress note, .Dressing changed via family request. Wound has serosanguineous fluid coming out from wound. Under the skin is a necrotic round area abt (about) 3 x (by) 3 inches round. Skin around this area is cracked and dry. Wound area was cleaned, skin prep applied, sponge patch placed, kerlix around and then loose coban. Nurse was able to place two fingers under coban, patient was instructed to notify staff if dressing becomes too tight. Heals (sic) where then floated on pillow, so heals (sic) did not touch . Nurse checked dsg throught (sic) the night, but by morning, dressing was coming off. Patient was rubbing heals (sic) on bed. Nurse cleaned wound and applied new dressing. heals (sic) where (sic) again placed floating on pillow, advised patient to try and keep heals (sic) floating and notify staff if dressing becomes too tight or uncomfortable in any way. Patient understood and claimed she wount (sic) comply, patient is alert and oriented x4 (person, place, time and situation). Wound nurse will come in today and assess the wound and call (name of physician redacted) our wound Doctor. On 1/28/18 at 1:46 PM, a licensed nurse documented in a progress note, Family approached RN (Registered Nurse) this afternoon. Family had numerous questions that this RN has knowledge of. Family requests to know about patients plan of care regarding wound ulcers and therapy. I educated both the family and patient what measures they could implement themselves, the first to compliance (sic) with therapy and wound care instructions. More so, the family should really take their concerns to the case manager and or Administrator/DON (Director of Nursing). Family voiced understanding and appreciated my input. Nothing further. On 1/28/18, the DT documented an added an addendum to the admission dietary note. The DT documented, RES HAD ERROR IN INITIAL EVAL (evaluation) DUE TO MISCOMMUNICATION. WOUND VAC (vacuum) SHOULD BE CLARIFIED TO ULCER ON HEEL. CURRENT RECS (recommendations) ARE MEETING NTL (nutritional) NEEDS. WCTM FOR FURTHER CHANGES AS NEEDED. (Note: The admission dietary note, dated 1/7/18, and the Registered Dietitian note, dated 1/10/18, did not indicate that resident 186 had a wound vac in place. Additionally, the admission physician orders did not indicate that resident 186 had a wound vac in place.) There was no evidence that the DT addressed resident 186's abnormal labs that were obtained on 1/25/18. On 1/29/18, a CMP was obtained for resident 186. Resident 186's total protein was 5.9 with an [MEDICATION NAME] of 3.0. On 2/5/18, a CMP was obtained for resident 186. Resident 186's total protein was 6.3 with an [MEDICATION NAME] of 3.2. On 2/7/18 at 10:56 AM, an observation was made of Wound Technician (WT) 1, a non-registered, non-certified employee of a local wound clinic, while changing the dressing to resident 186's left heel. WT 1 stated that she was Wound Care Certified. WT 1 removed the old dressing on resident 186's left heel. The old dressing was observed to have yellowish drainage on the bandage. The WT was asked if the dressing had yellowish drainage, she stated, No. The WT measured the left heel wound to be 7 cm (centimeters) by 6 cm with an an eschar that measured 6 cm X 5 cm. The WT stated that resident 186's unstageable pressure ulcer was worse than what it was on Monday (2/5/18). The WT stated that the pressure ulcer developed from her heels rubbing on the sheets when she was in bed. The WT stated that the unstageable pressure ulcer was avoidable. The following assessments and documentation were obtained after resident 186's nutritional status was brought to the attention of the facility staff: On 2/7/18 at 10:50 AM, an the Dietary Tech (DT) was interviewed. The DT stated that residents with healing pressure ulcers were reviewed in the Nutrition At Risk (NAR) meetings monthly. The DT stated that he was not aware that resident 186's ProtGold had been discontinued on 1/19/18. On 2/7/18, the DT documented in a dietary progress note, RS (Resident) 109 (unknown) ADDED FOR WOUND ON HEELS. PO INTAKES HAVE SHOWN SLIGHT AVERAGE IMPROVEMENT FROM 70% TO 74% AS OF 2/5. NEW LABS ON 2/6 INDICATE [MEDICAL CONDITION] OF CHRONIC DISEASE AND ALB IMPROVEMENT FROM 2.6 TO CURRENTLY 3.2 DIETARY WAS NOT INFORMED RSD HAD PROT (Protein) GOLD 30 ML Q/DAY DC'D (discontinued) ON 1/19 PER RSD REQUEST. RESD (Resident) EXPRESSED EXTREME DISLIKE OF SUPPLEMENTS AND IS SELF DIRECTED WITH MOST FOOD CHOICES. REC ADD NSA (No Sugar Added) MED PASS 120 ML Q/DAY FOR ADDED NUTRITION. WCTM FOR FURTHER CHANGES AS NEEDED AND RSD FEEDBACK OF NEW SUPPLEMENT. (Note: The DT estimated resident 186's protein needs as 94 grams (gms) using a 1.2 factor which was decreased from the 1.5 factor used on 1/7/18.) On 2/7/18, the DT documented in a nutritional evaluation, DON (Director of Nursing) AND DIETARY MANAGER CONCUR WITH 103 (unknown) ADDENDUM FOR SKIN ISSUE (WOUND ON HEEL). RECS AT THIS TIME ARE MEETING NTL NEEDS. On 2/7/17, a telephone order was written by the Dietary Tech (DT) to start resident 186 on NSA (No Sugar Added) med pass 120 ml (milliliters) Q/day (daily) , Vit (Vitamin) C 500 mg (milligrams) PO (by mouth) QD (daily) X 14 days, (and) Zinc 220 mg PO QD X 14 (days). The telephone order was signed by a registered nurse as the nurse receiving the order. On 2/7/18, resident 186 was assessed by a local wound clinic physician. The wound care physician documented the following: .Chief Complaint: .She developed a L (left) heel pressure ulcer . L heel- Heel cap with firm black, dry eschar, without fluctuance or periwound [DIAGNOSES REDACTED]. There is a 2mm (millimeter) margin of sl (slight) moist granular tissue. Visit is for: wound assessmnt (assessment)/care .Wound Location: L heel back .Comments: L heel BLISTER and mild swelling in Lower leg//Blister was noticed on Jan (January) 26 and on [DATE] there was an eschar center surrounded by a small open area of healthy pink tissue. .Amount of Drainage: Scant Type of Drainage: Serosang (serosanguineous) .Measurements Are: original measurement of global wound: 10cm (centimeters) L (length) X (by) 7cm W(wide) ///Eschar was 5cm X 4cm and is solid in palpation // 0.2cm open area around eschar, completely circular. //NEW addition to bruising on lateral side fo heel. there is increased open area on the posterior side of the heel .Stage: Unstageable .Periwound Condition: healthy looking skin surrounding heel/ankle/lower leg-calf area .Wound dressed with: Eschar was painted with Iodine and stipped (sic) xeroform placed around edges, gauze placed on heel w/ABD placed over gauze. 2sm (2 small) tri-folded ABD/s placed above heel on back side and 1 trifoided ABD under neath the heel, Secured with Kerlix from toes to above the ankle. Coban was placed over and secured at ankle. .Additional Comments: Request to Podus Boot w/brace was requested for patient. On 2/8/18 at 10:25 AM, a telephone inderview was conducted with the facility RDN. The RDN stated that the DT had been completing nutritional assessments for residents for several years. The RDN stated that the DT was trained by a previous RDN on what guidelines to use on determining the nutritional needs of residents with abnormal laboratory values and pressure ulcers. The RDN stated that she was not informed that resident 186's protein gold had been discontinued on 1/19/18. The RDN further stated that resident 186's protein needs should have been calculated using a 1.4 factor ionstead of a 1.2. The RDN stated that resident 186 should have been reviewed in a weekly NAR meeting. On 2/9/18, the DT documented in a nutrition evaluation, NAR WEEKLY REVIEW: DON, RDN, DIET TECH, DIETARY MANAGER PRESENT AND CONCUR WITH RECS. RDN CLARIFIED PROTEIN NEEDS BACK TO 1.5 DUE TO SKIN ISSUE. NO FURTHER CHANGES AT THIS TIME. On 2/11/18 at 2:07 PM, the RDN documented in a dietary progress note, RD talked to RSD on Thurs (Thursday) evening 2/8/18 and she expressed that the supp (supplement) was better than the other (liquid protein) and would continue it as a trail (sic). RDN was in the facility Friday and she said she would continue with the supp and foods with added protein. Talked with RSD Sat. (Saturday) at lunch and she agreed to try supp BID (twice a day). Talked with RSD at 1PM Sun (Sunday) and she was not sure she could drink the supp BID but will drink what she can at the time. Heel is improving. WCTM by talking with nursing & RSD. On 2/11/18 at 11:59 PM, The RDN documented in a dietary progress note, .DO (Diet order): CCHO/REG Thin Liquids with increased protein at meals. RSD stated would eat oatmeal, cream of wheat, pudding, gravies with protein added. Also cottage cheese with fruit, string cheese, yogurt, etc, Recorded Ave (average). PO Intake for past 24 hrs (hours) 81.3% (percent), last 7 days 84.2%, last 30 days 72.9%. Sat lunch was 90% with consuming all juice. RSD makes food choices, will eat sugar free cookies, etc. Discussed with RSD importance of protein, vit (vitamins), min (minerals) etc in healing process.RSD has refused liquid protein, did agree to take 120 ml of 1.75 NSA Supp Q/day for three days and then discuss further plan. Checked with her on Thurs & Fri (Friday) how this was going & stated tasted better than other supp. Sat talked with RSD & she agreed to try 120 ml of 1.75 NSA Supp X BID, this would increase prot (protein) 20 gm. Sun (Sunday) when visited with RSD she was not sure if she could drink all the supp at two different times. Discussed the importance of protein & nutrients and to see how much she can drink. She is 'self-directed' and will continue to encourage her to consume supp, increased protein foods and make healthy food choices. WCTM. On 2/8/18 at 1:00 PM, the Director of Nursing (DON) was interviewed. The DON stated that on 1/26/18, the facility identified that the weekly NAR meetings had not occurred. The DON stated that she had not attended the NAR meetings. The DON stated that it was the DT responsibility to communicate resident changes (such as the development of pressure ulcers and abnormal laboratory values) to the RDN. (Cross refer to F636, F686 and F840) 2. Resident 6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 2/6/18 at 3:10 PM, an observation was made of a wound on resident 6's left ischium as Licensed Practical Nurse (LPN) 1 measured resident 6's wound. LPN 1 measured the wound as being 4.5 cm in length. The wound appeared to be shaped like a slit with a narrow opening measuring 0.5 cm. The opening was narrow enough that LPN 1 had to spread the skin along the length of the wound to measure the depth. The depth on the left side of the wound was 2 cm, and the depth closer to the right side of the wound was 1 cm. The nurse measured tunnelling from the left side of the wound under the wound entrance at 2 cm. There was no drainage or odors observed. The area around the wound was darkened but blanchable, circular in shape measuring 9 cm by 7 cm. LPN 1 described the skin in this area as 'tight'. Below the wound were 2 small circular skin tears with blood that the nurse stated were caused from the dressing. LPN 1 stated I can't tell if it's (the wound) to the bone because I have to go in on an angle. It tunnels sideways. Resident 6's medical record was reviewed on 2/6/18. On 11/10/17 a complete metabolic panel (CMP) was obtained for resident 6. Resident 6's [MEDICATION NAME] was 3.5. (Note: The laboratory company documented a normal reference range of 3.5-5.0 for [MEDICATION NAME].) A telephone order was written by the Dietary Technician (DT) on 11/15/17 which stated 1) Increase protein (with) meals 2) ProtGold (Protein Gold) 30 mL (milliliters) Q (every) day. On 11/18/17 a wound care note stated: wounds continue to improve on buttocks and great toe. Red area noted on the left heel. MD (medical doctor), DON notified. On 11/19/17 a telephone order for the following was placed: DC (discontinue) Liquid Gold, pt request add Boost chocolate 1 box QD (every day). On 2/6/18, resident 6's current medications were reviewed. One box of chocolate Boost was noted to be included in the active orders. On 11/25/17 a wound care note stated: Wound on Right ischem (sic) is closed, left ischemia has declined MD notified of change in condition. New order placed to have wound packed with gauze and covered with boarder (sic) gauze, changed daily. A telephone order was written on 11/26/17 which stated: (Change) ProtGold to 30 mL BID (twice daily). On 12/3/17, a telephone order was placed which stated: D/C Protein Gold Pt request. A wound care note dated 12/9/17 stated: Wounds continue to improve. no s/s (signs and symptoms) of infection. pt would like it changed 2x (times) a day due to the drainage on the wounds. A nurses note from 12/12/17 stated: [MEDICATION NAME] lab draw ordered by (name of physician's assistant) R/T (related to) wound healing. The result was received on 12/13/17. The lab results were as follows: [MEDICATION NAME] result 18.8 WNL Ref (reference) range 17.6-36. A nursing note from 12/12/17 stated: LT ISCHIAL PRESSURE ULCER IMPROVING BUT STILL RED WITH 1 CM TUNNELING, 1 CM IN DIAMETER, RT (right) HAS HEALED AND IS DOING WELL, LG (large) TOE HAS ALSO HEALED. On 12/16/17 a nursing note stated: Dressing changed to left ischial tuberosity ulcer-cleansed and new dressing applied as per MD orders. Wound now measure 2 cm deep-packed with packing gauze as per orders. Peri wound skin slightly improving. Will continue to monitor. On 12/19/17 a nursing note stated: SKIN CHECK: PRESSURE ULCER ON LT BUTT[NAME]K NEAR SACRUM IS HEALING WELL, DRESSING CHANGED EACH DAY, 0.5 CENTIMETER TUNNELING, IT HAS IMPROVED FROM LAST WEEK, RT HIP HAS HEALED, LG TOE HAS HEALED. On 12/31/17 a Nutrition Evaluation was performed by the DT for resident 6. In a section titled Assessment-Per Registered Dietitians Clinical Charting Handbook, there was a space for calculating estimated protein needs for the resident. It was noted that the resident's protein needs were calculated with a 1.2 factor which would have provided 89-113 grams. It then assessed if protein needs were met with current intake and No was marked. A progress note associated with the assessment was completed by the DT which stated: RSD (resident) 109 (form number) IMPLEMENTED FOR ISCHEMIA ON C[NAME]CYX. RSD CBW (current body weight) IS UNAVAILABLE DO (sic) TO RSD REFUSING. PO INTAKES HAVE SLIGHTLY IMPROVED AND REMAIN ABOVE 80%. RSD NUTL (nutritional) NEEDS SHOULD BE EXCEEDED AT THIS TIME. NURSING HAS STATED WOUND IS HEALING. AT THIS TIME NURSING HAS NO CONCERNS PERTINENT TO DIETARY. WCTM (will continue to monitor) FOR FURTHER CHANGES AS NEEDED. NO FURTHER RECS (recommendations) AT THIS TIME. An addendum to the above note was added by the Registered Dietitian (RD) on 12/31/17 which stated: RDN reviewed above info (information) and aware RDS ischemia on coccyx, CBW unavailable RDS refusing. PO (by mouth) intake slightly improved remaining above 80%. Nutl needs should be exceeded att (at this time). Nursing states wound healing (and) no concern pertinent to dietary. WCTM, no new recs att (at this time). (Note: The Clinical Charting Handbook the DT used to calculate protein needs was reviewed. For a 94 kg male, reasons stated for a 1.2 mg/kg protein factor were: High Risk of Developing a Pressure Ulcer, Stage I and II Pressure Ulcers Multiple Stage I Pressure Ulcers, Open and Weeping Stasis Ulcer, Open Wound The justification for using a 1.3 gm/kg protein factor was: Stage III Pressure Ulcer, Multiple Stage II Pressure Ulcers. The justification for using a 1.5 gm/kg protein factor was: Stage IV Pressure Ulcer, Multiple Stage III Pressure Ulcers Deep Tissue Injury.) A nursing note from 1/25/18 stated: Left ischium wound cleansed and new dressing applied. Noted that along anal fold which leads to left ischium wound there is tunnel which measures 4 cm (centimeters) deep. Called and left message with (name of physician) regarding tunneling of left ischium wound. Talked with (name of physician's) assistant and without (sic) call back. Will continue to dress wound and monitor. Pt (patient) to see (name of physician) next week at appointment. Pt aware. A nursing note from 1/26/18 stated: WOUND DR NOTIFIED OF 4CM TUNNELING IN ISCHIUM. HE STATED THAT SINCE PT HAS APPT (appointment) WITH CLINIC ON TUESDAY TO CONTINUE WHAT WE ARE DOING BUT TO PREPARE THE PT THAT IF THE TUNNELING TOUCHES BONE THAT HE WILL NEED MORE SURGERY. PT NOTIFIED. A nursing note from 1/27/18 stated: Facility wound nurse recommended a culture of drainage from left ischium due to tunneling and lack of healing. On 1/27/18 a wound care documented: Wound is deteriorating with increase drainage. Wound measurement 2 x 0.2 x 1.5 tunneling 9:00 5 cm 10:00 6 cm. MD notified of change in wound status recommended culture be obtain pt has a hx [MEDICAL CONDITION] ([MEDICAL CONDITION]-resistant Staphylococcus aureus) in previous sites. A nursing note from 1/30/18 stated: APPOINTMENT NOTES: LT ISCHIAL PRESSURE WOUND TO BONE, CONTINUE PACKING WOUND. SURGICAL PR[NAME]EDURE TO CLOSE WOUND WED (Wednesday) FEB (February) 7, . On 1/30/18 a nursing note stated: SKIN CHECK: (Resident 6) HAS A PU (pressure ulcer) ON HIS LT BUTT[NAME]KS, CONTINUES TO HAVE SMALL AMOUNT OF TUNNELING, IT IS IMPROVING, HE IS AT WOUND DR TODAY TO HAVE THE WOUND EVALUATED. NO OTHER SKIN PROBLEMS ALL HAS HEALED. Later the same day (1/30/18) a nursing note stated: APPOINTMENT NOTES: LT ISCHIAL PRESSURE WOUND TO BONE, CONTINUE PACKING WOUND. SURGICAL PR[NAME]EDURE TO CLOSE WOUND WED (Wednesday) FEB (February) 7, . On 2/7/18 at 9:55 AM resident 6 was interviewed. He stated he never had Boost during his stay at the facility. He stated the protein gold was nasty and he refused it. He denied ever meeting with the dietitian. He stated he had education on increasing protein years ago, but nothing recently. Resident 6 was observed to be transferred out of the facility on 2/7/18 at approximately 10:00 AM, for surgical repair of left ischial pressure wound. On 2/8/18 at 2:05 PM, RN 2 was interviewed. RN 2 stated that when Boost was ordered, it was put in the medication list and charted on in the Medication Administration Record [REDACTED]. RN 2 stated that she assumed the Boost would be delivered with the meal trays. On 2/8/18 at 2:15 PM, an interview was conducted with the dietary manager (DM). The DM stated that if a supplement was ordered for a resident, it could be sent on the resident's meal tray. The DM stated she was unable to recall any resident receiving Boost on their tray. The DM was asked to provide resident 6's tray ticket. The tray ticket for resident 6 was reviewed, and the Boost was not listed. On 2/8/18 at 10:02 AM, the Registered Dietitian (RD) was interviewed. The RD stated she relied on the DT to inform her of new wounds. The RD stated when she was informed of a pressure ulcer stage 2 and above, she would write a weekly note on those residents. The RD stated for a stage 4 pressure ulcer she would likely use 1.3-1.4 factor for protein, not a 1.2 as the DT had used in his assessment. The RD stated if Boost was ordered, it could be delivered by the kitchen on meal trays or it could be delivered by the nurses between meals. The RD stated she did recommend labs at times and would recommend them if a resident had wounds. If a pressure ulcer was worsening, the RD stated she would expect [MEDICATION NAME] and [MEDICATION NAME] to be monitored. (Note: There was a nutrition assessment completed 12/31/17. There was not a new assessment after the identification of the new pressure ulcer 1/25/17. The factor used to calculate the resident's protein needs was 1.2. The resident had his [MEDICATION NAME] measured on 11/10/17 and his [MEDICATION NAME] measured on 12/13/17. It should be noted that [MEDICATION NAME] has a half life of approximately 21 days and [MEDICATION NAME] has a half life of approximately 2 days.) On 2/8/18 at 2:00 PM, the director of nursing (DON) was interviewed. The DON stated that nurses would be expected to administer Boost when ordered. The DON stated that a resident would be expected to have a nutrition reassessment after a new pressure ulcer was identified. The DON stated that wounds should be reviewed weekly at Nutrition at Risk (NAR) meetings. The DON stated that the facility was transitioning from one NAR policy to another. She stated the change was occurring because it was noticed that not everyone who needed a review was being captured in the old NAR policy. (Note: A copy of the old NAR policy was reviewed. It stated that pressure injuries should be reviewed weekly. A copy of the new NAR policy was reviewed. It stated that residents with a wound should be weighed and reviewed weekly. ) POTENTIAL FOR HARM 3. Resident 17 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 17's medical was reviewed on 2/5/18. A Hospice note from 12/30/17 stated: Patient has a baseline weight reported of 160# (pounds) 12 months ago and a current weight of 140# which is a 20# or 12.5% loss in a year. The vitals section of the resident's record revealed that on 1/7/18 the resident weighed 57.1 kilograms or 125.6 pounds. The resident was not weighed again until 1/28/18. On 1/28/18, the resident weighed 53.8 kilograms or 118.3 pounds. (Note: This was a decline of 7.26 pounds or 5.8% over 3 weeks.) Resident 17 had an initial nutrition note completed on 1/10/18 by the dietary technician (DT). The note stated HT (height) is unavailable. PO (by mouth) intakes 69% of reg (regular) thin diet. Skin is intact . EEN/EPN (estimated energy needs/estimated protein needs) not met. Rec (recommend) inc (increase) protein (with) meals, and MV/MIN (multivitamin/mineral). WCTM (will continue to monitor) labs, wkly (weekly) wts (weights), skin reports and PO intakes for further recs (recommendations) proceed to NAR (nutrition at risk). An addendum was added by the RD on 1/14/18 which stated RDN reviewed above info (and) aware HT is unavailable. Consumes 69% PO intake of reg diet. Labs 1/5 GLUC 124, all other nutl labs wnr (within normal range). EEN/EPN not met. Agree (with) DT rec inc prot (with) meals and add MV/MIN. WCTM and watch for HT. On 1/19/18 A nurses note stated Pt went to see (name of physician) today and returned with order to change die (sic) to puree with thick liquids. The daughter (name of daughter) attended the appointment and stated the pt. throat is getting 'tight' and this is what the doctor recommended be tried. I called Rocky Mountain Hospice and notified the case manager of the change to the plan of care. Diet slip sent to dietary. On 2/8/18 at 10:02 AM, an interview was conducted with the Registered Dietitian (RD). The RD stated she came in to the facility weekly. The RD stated the DT would report concerns or if there was a new resident admitted to the facility. The RD stated she would assess a resident who had a weight shift of 2.5% in 1 week, 5% in 3 months or 10% in 6 months. The RD stated she would assess a resident if they lost 3 to 4% body weight in one month. The RD stated if someone dropped 5 to 6% x 1 month, she would expect to be notified. The RD stated the DT had been monitoring residents who had weekly and monthly weight changes. The RD stated if a resident lost 5 to 6% in one month she would add a supplement such as Med Pass, Boost, Glucerna or another calorie and protein boosting supplement. When asked specifically about resident 17, the RD confirmed that there should have been an assessment done between 1/28/18 and 2/8/18. On 2/10/18 at 4:55 PM, a note from the dietary tech stated: Dietary aware of RDS (resident) possible significant monthly wt change. RSD is to be re-weighed due to possible wt errors present in system. Rec add Med Pass 120 mL BID (twice daily) to address lower PO intakes and possible wt loss no further recs at this time. This was not signed off by the dietitian. 4. Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 1's medical record was reviewed on 2/5/18. Laboratory results were reviewed. Labs completed on 1/18/18 revealed that resident 1's total protein was 5.6 (Low) and his [MEDICATION NAME] was 2.9 (Low). On 1/20/18 there was an order change for resident 1. The new order was for resident 1 to receive a regular diet with thin liquids plus increased protein with meals. On 1/21/18 the facility RDN added an addendum on the Nutrition Evaluation completed by the facility Dietary Technician (DT). The RDN agreed with the DT to increase protein with meals, to better meet resident 1's estimated energy needs (EEN) and estimated protein needs (EPN). Laboratory results were reviewed. Labs completed on 1/23/18 revealed that resident 1's total protein was 5.7 (Low) and his [MEDICATION NAME] was 3.0 (Low). On 2/6/18 at approximately 1:15 PM, resident 1 was asked if he was getting any additional protein either directly from the nurse or added into his food. Resident 1 stated that he did not believe there was anything he was getting except for a thinned regular plate of food. On 2/12/18 at 10:10 AM, an interview was conducted with the facility Dietary Manager (DM). The DM stated tha (TRUNCATED)

Based on interview and record review, it was determined the facility did not ensure that residents were free from verbal and mental abuse. Specifically, a facility Occupational Therapist (OT) told a resident who refused prescribed treatment that the resident would be responsible for paying $300.00 per day if she refused therapy and that if she didn't participate in therapy, she should leave so that another resident could be admitted to the facility who wanted to participate in therapies. Resident identifier: 85. Findings include: Resident 85 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. 1. On 4/14/11 at approximately 9:30 AM, resident 85 was observed sitting in a semi-fowlers position bed reading a book. Resident 85 was asked how she was doing today. Resident 85 became teary eyed and stated that Occupational Therapist (OT) 1 had entered her room yesterday (4/13/11) for her OT exercises. She stated that she was in a lot of pain and was concerned that her left hip incision was infected. She stated that she refused her OT exercises due to pain. Resident 85 stated that OT 1 then entered into a "tirade" and told her that she "had" to participate in therapy in order for the facility to get reimbursement for her stay at the facility. She stated that OT 1 told her that it cost $300.00 per day and that if she didn't participate in therapy, she would have to pay that dollar amount every time she refused therapy. She further stated that OT 1 told her that if she didn't want to participate in therapies, that she should go home and someone else would be admitted to the facility who did want to participate in therapies. Resident 85 stated that OT 1's comments "intimidated" her and she felt "threatened" by his comments. Resident 85 stated that she reported the above incident to Licensed Practical Nurse (LPN) 1 yesterday afternoon. She stated that LPN 1 told her that OT 1's behavior was "inappropriate" and would report the incident to the facility Director of Nursing (DON). On 4/14/11, at 9:35 AM, resident 85's nurses notes were reviewed. No documentation was found in resident 85's medical record related to the incident above. 2. On 4/14/11 at 9:40 AM, OT 1 was interviewed. OT 1 was asked about the allegation reported by resident 85 on 4/13/11. OT 1 stated that he did tell resident 85 if she refused services, the facility could not bill Medicare for her services and that she would be responsible for paying the bill. OT 1 stated he didn't remember giving her a dollar amount for a daily charge to reside at the facility but stated that it did cost approximately $300.00 to live at the facility. OT 1 was asked if he thought his comments to resident 85 were intimidating or threatening in any way and he responded "No". 3. On 4/14/11 at approximately 10:00 AM, the facility DON, Assistant Director of Nursing (ADON), Social Worker (SW) and the Corporate Regional Nurse were verbally informed of the above incident. On 4/14/11 at 10:15 AM, the facility "Abuse - Prevention, Investigating and Reporting" policies and procedures were reviewed. The Policy revealed "(The Facility) seeks to promote the well being of its residents by providing a safe and supportive environment. Every resident has the right to be free from verbal, sexual, physical and mental abuse, corporal punishment and involuntary seclusion." The definition of verbal abuse was listed as "...the use of oral, written, or gestured language that willfully includes degrading or derogatory terms to residents or their families, or within their hearing distance, regardless of their age, ability to comprehend, or their disability." Examples that were given included "Threats of harm, saying things to frighten a resident, making fun of a resident, and saying something that would make the resident uncomfortable, or others uncomfortable." The definition of mental abuse was "Includes but is not limited to humiliation, harassment, and threats of punishment or deprivation." The facility abuse policy included: "4. Identification - Any employee, consultant, or any other person affiliated with the operation of this facility that has reason to believe that a resident has been subject to abuse, neglect, or exploitation, shall immediately notify the facility Administration, Director of Nursing, or their designee, so that appropriate action may be taken." Additionally, the policy indicated "Complete an Incident Report immediately which shall include a complete description of the circumstances and details of the incident relating to the abuse, neglect or exploitation. The descriptions should include names of all persons involved, time, place, and all other pertinent information and evidence related to the occurrence in question". The abuse policy further revealed "6. Protection: If the complaint alleges abuse by a staff member, that staff member will be suspended or removed from direct patient care (which ever is appropriate to protect the resident) until an investigation has been completed". 4. On 4/14/11 at 10:50 AM, OT 1 was observed in the therapy room providing services to residents. On 4/14/11 at 11:05 AM, resident 85 was interviewed. Resident 85 stated she refused her OT exercises again that morning related to pain. She stated that OT 1 started to tell her again that she would be responsible for paying privately for her bill. On 4/14/11 at 12:35 PM, a meeting was conducted with the facility Administrator, DON, and ADON. The DON reported that she verbally spoke with LPN 1 on the telephone. The DON stated that LPN 1 confirmed the above incident and stated that he was going to "discuss" the incident with the DON but that he "got busy" and forgot to report the incident. The Administrator further stated that OT 1 continued to provide Occupational Therapy services to other residents at the facility. On 4/14/11 at 1:15 PM, the facility Administrator informed the survey team that OT 1 had been suspended and that the abuse allegation was ongoing. On 4/14/11 at 1:30 PM, LPN 1 documented a late entry in the facility nurse's notes. LPN 1 documented "I went into pt's (patient's) room to change dressing to hip. Pt. was crying and looked upset. I asked pt. if she was in pain. Pt. stated "No". I asked her what was wrong, she stated she didn't know how she was going to pay her bill here, because the therapist told her she was going to have to back pay the cost of her care." LPN 1 further documented "I asked (resident 85) to explain what exactly was said. She stated that (OT 1) told her that she was not doing enough therapy and if she didn't start doing therapy every day the cost of her stay here, she would have to pay out of pocket from admission to discharge." On 4/14/11 at approximately 3:00 PM, the SW provided a written statement from OT 1. This written statement revealed "...Pt. (patient) again said that Dr (doctor) said she didn't have to do therapy for 1 week. I again reminded her about the note and it's (sic) content. She replied that she was not doing therapy today. I reminded her of the effects of the Diathermy in relieving her shoulder pn (pain). She stated I don't care. I'm not going. I asked her what her goals were. She stated "I want to get better and go home". I asked her how did she expect to get better (without) treatment. she replied I don't care. I told her that this is a rehab care facility and that was the expectation of patients who come here. I tried to explain that if she didn't do rehab that it concern (sic) Medicare that if she is in a rehab facility, why isn't she doing therapy and that they may refuse to cover her. She asked how much should would have to pay. I explain (sic) that I wasn't sure but it could be as high as $300.00 per day. I explained that it wasn't my intent to bully her into doing therapy, but if she wasn't willing to comply (with) the facility expectation then the facility could ask her to leave (with) the intent of having another patient who would be compliant." On 4/14/11 at approximately 3:30 PM, the facility SW stated that she had interviewed resident 85 and had recommended that OT 1 be suspended until the abuse investigation was completed. On 4/18/11 at 8:07 AM, the facility Administrator and SW were interviewed. The SW stated that an in-service was provided on Friday 4/15/11 for all therapists working at the facility. The Administrator and SW stated that OT 1 continued to be suspended. 5. Nursing notes for resident 85 were again reviewed. On 4/15/11 at 3:30 PM, a facility licensed nurse documented in the nurse's notes "Assessed L (left) hip incision with pt's nurse. Pt. describes increased pain to touch, increased redness. Red area marked and dated. Drainage noted on wound 2 inches from top of incision. Nurse will call surgeon". On 4/15/11 at 5:30 PM, a facility licensed nurse documented in the nurse's notes "(Doctor) returned page to nurse. MD (Medical Doctor) given assessment of incision. MD stated with patient's hx (history) of staff (sic) he would like her sent out to (Hospital)". On 4/16/11 at 10:47 AM, a facility licensed nurse documented "Pt's left hip surgical wound was bright red, warm, draining serosanguinous, and pain was increased for the pt. Pt. started on antibiotics on the 12 of April and the wound has not improved". On 4/16/11 at 6:11 PM, a facility licensed nurse documented "I called and spoke with the nurse at (hospital) concerning the condition of the patient. The nurse stated that the pt. will be going in for a surgical debridement in the morning on 4/17/11".