Every finding on record at Saint Joseph of the Pines Health Center

Based on observation, record review, Nurse Practitioners and staff interviews, the facility failed to change the dressing to Resident #76's Peripherally Inserted Central Catheter (PICC) line. This occurred for 1 of 1 resident (Resident #76) reviewed for intravenous (IV) antibiotic therapy. The findings included: Resident #76 was admitted to the facility on [DATE] with diagnoses that included osteomyelitis (infection of the bone) and methicillin-resistant Staphylococcus aureus (MRSA). The 5-day Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #76 was cognitively intact and was coded with IV access and antibiotics. Review of the active nurse practitioner orders dated 7/8/25 revealed orders to change the PICC dressing every seven days and as needed using sterile technique. On 7/28/25 at 2:35 PM an observation of Resident #76's PICC line, in the left upper arm, revealed a transparent dressing with rolled edges covering the insertion site dated 7/2/25. There was no redness, drainage, or signs of infection at the entry site. The resident denied itching or discomfort. Review of the treatment administration record (TAR) revealed an incomplete order entry on 7/8/25 under the heading PICC dressing change every seven days. The TAR did not have staff initials, or a scheduled timeframe available, for staff to document a dressing change had been completed. The Clinical Coordinator was interviewed on 7/29/25 at 11:29 AM and stated the dressing should be changed every seven days for any resident with a PICC line, and that the floor nurse assigned to the resident was responsible for completing the change. She further stated the date on the PICC line dressing was correct for the last dressing change. The Clinical Coordinator then assessed the PICC line and confirmed it was dated 7/2/25. She stated Resident #76 was getting ready to leave for an appointment with the Infectious Disease clinic, but she would change his dressing upon return to the facility since she was serving as the unit's nurse that day. On 7/29/25 at 12:27 PM the Director of Nursing (DON) was interviewed. She stated Resident #76 had an order to change his PICC line dressing every seven days, but it was not entered in the computer correctly. She stated due to the order not being entered correctly it did not show up on the TAR for the resident, so the nursing staff did not see an order to change the PICC line dressing. She confirmed the date on the PICC line dressing, 7/2/25, was correct for the last time the dressing was changed. On 7/30/25 at 4:26 PM the Infectious Disease clinic Nurse Practitioner (NP #2) was interviewed by phone. She stated she saw Resident #76 in the clinic on 7/29/25 and noted his PICC line dressing had not been changed since 7/2/25. She stated she assessed the site, and it did not appear to be infected, no redness, drainage, or pain at the site. She stated she had the clinic nurse change the PICC line dressing, called the facility, and requested they educate the staff on PICC line care. She further stated the clinic's PICC line dressing protocol for weekly dressing changes was sent with the resident at discharge from the hospital. A follow-up interview with the DON on 7/30/25 at 9:03 AM was completed. She stated she had received a phone call from the Infectious Disease clinic on 7/29/25 and was informed Resident #76's PICC line dressing was changed during his appointment. She stated the clinic asked the facility to educate the staff regarding PICC line care. She further stated she had entered the order for the PICC line dressing changes in Resident #76's chart, and it was now showing on the TAR. The DON stated she and the Clinical Coordinator had reviewed the order entry completed by the Clinical Coordinator, and they were uncertain how the computer system had allowed the order to advance without being completed correctly. Nurse Practitioner #1 was interviewed on 7/29/25 at 12:56 PM who stated Resident #76's PICC line dressing should be changed every seven days and as needed to prevent infection. She stated she had been regularly reviewing the resident's labs, and he had not shown any complications or signs of a new infection. She stated she had not been informed Resident #76's PICC line dressing had not been changed since 7/2/25.

Based on record review and staff interviews, the facility failed to transmit a discharge Minimum Data Set (MDS) assessment within the required time frame for 1 of 5 residents selected to be reviewed for submission of Resident Assessments within the required time frame (Resident #59). The findings included: Resident #59 was admitted to the facility on [DATE]. A review of Resident #59's most recent completed MDS was dated 5/7/25 and was coded as a discharge to home. The record indicated the assessment had been completed but not transmitted or accepted. During an interview with MDS Nurse #1 on 7/30/25 at 3:20 PM, she indicated the discharge assessment was completed on 5/7/25 but had not been submitted. She felt it was an oversight. On 7/31/25 at 8:21 AM, an interview occurred with the Director of Nursing who stated that she would expect all MDS assessments to be completed and submitted within the required timeframe.

Based on record review and staff interviews, the facility failed to report allegations of abuse to Adult Protective Services (APS). This deficient practice was for 4 of 4 residents reviewed for abuse. (Resident # 41, Resident #324, Resident #72 and Resident #223). Finding included: 1. A review of the Initial Allegation Report for an allegation of misappropriation of property submitted on 6/18/24 at 3:47 PM indicated the facility became aware of the alleged incident on 6/18/24 at 1:00 PM for Resident #41. The allegation details revealed Resident #41 alleged that someone stole $100 from her pocketbook. The initial report indicated local law enforcement was notified on 6/18/24 at 2:30 PM. The initial report did not indicate APS was notified. The Investigation Report completed on 6/24/24 for the 6/18/24 incident concerning Resident #41 indicated APS was not notified of the allegation of misappropriation of resident property. During an interview with the Director of Clinical Services 7/11/24 9:52 AM he indicated that he did not contact APS and that he was not aware APS needed to be notified an allegation of misappropriation of resident property During an interview with the Administrator on 7/11/24 at 10:08 AM he indicated that he did not know APS needed to be notified of an allegation of misappropriation of resident property. 2. A review of the Initial Allegation Report for an allegation of misappropriation of property submitted on 6/18/24 at 3:47 PM indicated the facility became aware of the alleged incident on 6/18/24 at 1:00 PM for Resident #72. The allegation details revealed Resident #41 alleged that someone stole $20 from her pocketbook. The initial report indicated local law enforcement was notified on 6/18/24 at 2:30 PM. The initial report did not indicate APS was notified. The Investigation Report completed on 6/24/24 for the 6/18/24 incident concerning Resident #72 indicated APS was not notified of the allegation of misappropriation of resident property. During an interview with the Director of Clinical Services 7/11/24 9:52 AM he indicated that he did not contact APS and that he was not aware APS needed to be notified of the allegation of misappropriation of resident property During an interview with the Administrator on 7/11/24 at 10:08 AM he indicated that he did not know APS needed to be notified of the allegation of misappropriation of resident property. 3. A review of the Initial Allegation Report for an allegation of resident abuse submitted on 7/2/24 at 3:57 PM indicated the facility became aware of the alleged incident on 7/2/24 at 12:00 AM for Resident #324. The allegation details revealed Resident # 324 alleged the accused pushed resident #324 into the shower, shut the door to the shower and did not come back when Resident #324 yelled for help. Resident #324 also alledged the accused told Resident #324 to shut up, and to go to bed. The initial report indicated no injuries occurred and local law enforcement was notified on 7/2/24 at 2:06 AM. The initial report did not indicate whether APS was notified. The Investigation Report completed on 7/9/24 for the 7/2/24 incident concerning Resident #324 indicated the allegation was not substantiated and APS was not notified of the allegation of resident abuse. During an interview with the Director of Clinical Services 7/11/24 9:52 AM he indicated that he did not contact APS and that he was not aware APS needed to be notified of the allegation of resident abuse. During an interview with the Administrator on 7/11/24 at 10:08 AM he indicated that he did not know APS needed to be notified of the allegation of resident abuse. 40197 4) A review of the Initial Allegation Report for an allegation of abuse with no serious bodily injury was submitted on 6/7/24. The report indicated the facility became aware of the incident on 6/7/24 at 10:00 AM for Resident #223. The allegation details read Resident #223 alleged that another resident hit her in the hip. The initial report indicated law enforcement was notified on 6/7/24 at 11:06 AM. The initial report did not indicate that APS was notified. The Investigation Report completed on 6/14/24 for the 6/7/24 incident concerning Resident #223 revealed that APS was not notified for an allegation of abuse. On 7/11/24 at 9:43 AM, an interview occurred with the Administrator and the Director of Clinical Services. They stated they were not aware that APS had to be notified regarding an allegation of abuse.

Based on staff interviews and record review, the facility failed to issue a Centers for Medicare and Medicaid Services (CMS), CMS-10055 Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) to 1 of 3 residents reviewed for SNF Beneficiary Protection Notification Review (Resident # 50). Findings included: Resident #50 was admitted to the facility under part A Medicare services on 5/22/24. A review of the medical record revealed a CMS-10123 Notice of Medicare Non-Coverage letter (NOMNC) was discussed by telephone with Resident #50's responsible party on 6/17/24. The notice indicated that Medicare coverage for skilled services was to end 6/19/24 and the resident would remain in the facility. A review of the medical record revealed a CMS-10055 SNF ABN (ABN) was not provided to the resident or responsible party. An interview was conducted with the Social Worker on 7/10/24 at 12:26 PM and he revealed that Residents # 50 planned to remain in the facility and the social worker made the resident and family aware that there would be a private pay cost. The social worker further revealed the SNF ABN form was not issued because the family had appealed the Notice of Medicare Non-Coverage (NOMNC) and he thought he had to wait to issue the SNF ABN notice until after the NOMNC appeal decision had been received. An interview was conducted with the Administrator on 7/11/24 at 9:56 AM revealed the social worker had not yet issued the SNF ABN to Resident #50 because he did not want to confuse the family member by issuing the SNF ABN notice before the NOMNC appeal decision had been finalized.

Based on record reviews, observations, and staff interviews, the facility failed to ensure the daily nurse staffing sheets were completed and posted for 1 of 30 days reviewed (07/08/24) for staffing. Findings included: On 07/08/24 at 09:51 AM the daily nurse staff sheets observed in the lobby of the facility was dated 06/28/24 through 07/01/24. An interview was conducted on 07/08/24 at 09:52 AM with the Administrator. He stated that he had been at the facility about six weeks, and they had a change in the staffing position. He stated the Director of Nursing (DON) had been posting the daily nurse staff postings however she was on vacation and the postings had not been updated since 07/01/24. He then stated he would get it updated right now. An interview was conducted on 07/09/24 at 3:30 PM with the Staff Coordinator. She stated she had been in her current position since 07/07/24 and she was still learning her duties. She indicated she did not post nurse staffing in the lobby for 07/08/24. She explained that the Director of Nursing (DON) had been handling some things but was currently on vacation. An interview was conducted on 07/11/24 at 10:03 AM with the Administrator. He stated his expectation was for the daily nurse staff sheets to be completed and posted 7 days a week.

Based on observation, record review, and staff interviews the facility failed to treat a resident with dignity and respect by not removing food debris from a resident's clothing and bed after meal trays were removed for 1 of 4 residents reviewed for dignity (Resident #28). The reasonable person concept was applied to this deficiency as individuals have the expectation of being treated with dignity while in their home environment. The findings included: Resident #28 was admitted to the facility on [DATE] with multiple diagnoses which included Parkinson's Disease and Alzheimer's Disease. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #28 had a severe cognitive impairment and required supervision with eating with 1 staff member. Resident #28 was observed on 04/03/23 at 9:40 AM to be lying asleep in her bed. She had large pieces of brown food debris on her face, clothing, and clothing protector, an article worn around a resident's neck and drapes over the resident's torose to prevent food from soiling the resident's clothing. There was no meal tray located in the room. Resident #28 was observed on 04/04/23 at 11:00 AM to be lying awake in her bed. She was wearing a clothing protector around her chest with large pieces of brown food debris on her right side of her chest and a large brown piece of food debris on her bed sheet. There was no meal tray located in the room. Resident #28 was observed on 04/04/23 at 11:26 AM to be lying asleep in her bed with a clothing protector around her chest with what appeared to be the same large brown pieces of food debris on her face and in her bed. There was no meal tray located in her room. Resident #28 was observed on 04/05/23 at 1:05 PM. She was lying awake in her bed. She was wearing a clothing protector with large brown pieces of food debris on it. There was no meal tray located in her room. An observation and interview with Nurse Aide #3 occurred on 04/05/23 at 1:12 PM. She stated she was familiar with Resident #28's care needs and was assigned to work with Resident #28 on this day and stated she had not worked with Resident #28 the other two days. She stated Resident #28 required assistance with feeding but was able to feed herself. She stated Resident #28 often dropped food on her clothing. She stated she did not remove the clothing protector or the food from Resident #28's clothing when she removed her lunch tray because she was busy assisting other residents A joint interview with the Director of Nursing and Administrator on 04/05/23 at 2:49 PM revealed it was their expectation for the staff to come back after removing trays and clean residents after meals to promote dignity.

Based on record review, observations and staff interviews, the facility failed to trim and clean a dependent resident's nails (Resident #35) for 1 of 3 residents reviewed for Activities of Daily Living (ADLs). The findings included: Resident #35 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's dementia, lack of coordination and muscle weakness. Resident #35's active care plan, with an effective date of 12/30/22, included a problem area for self-care deficit associated with the need for assistance with ADLs related to weakness, decreased mobility and range of motion secondary to a fall with fracture to the left femur (hip). One of the interventions included to provide assistance to complete ADL tasks. An admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #35 had severely impaired cognition and displayed no behaviors or rejection of care. She required extensive assistance for personal hygiene and was dependent on staff for bathing tasks. A review of Resident #35's nursing progress notes from 12/30/22 through 4/4/23 revealed no refusals of nail care documented. On 4/3/23 at 9:50 AM, an observation of Resident #35 occurred while she was lying in bed with her hands resting on top of the covers. Her left thumb and fourth finger had a dark substance under them, and the third fingernail was broken and jagged. Her right first finger had a dark substance under it and the fifth fingernail was broken and jagged. Resident #35 was observed on 4/4/23 at 2:24 PM while sitting in her recliner. Her fingernails were unchanged from the prior observation. An interview occurred with Nurse Aide (NA) #1 on 4/5/23 at 9:57 AM and explained that nail care should occur during showers and personal care tasks. She was not assigned to Resident #35. Resident #35 was observed on 4/5/23 at 10:03 AM while sitting up in her recliner. Her hands rested in her lap and revealed her nails remained the same from prior observations. An interview occurred with NA #2 on 4/5/23 at 10:41 AM. She was the NA assigned to care for Resident #35. She stated nail care was completed when there was a need during a shower or personal care. An observation occurred with NA #2 of Resident #35's nails. NA #2 confirmed there was a dark substance under the left thumb and fourth finger and the right first finger as well as broken and jagged nails to the left third and right fifth fingernails. NA #2 stated she had not observed Resident #35's nails during personal care that morning and care would be rendered to them. The Director of Nursing was interviewed on 4/5/23 at 2:45 PM and stated she was not aware of any refusals of nail care from Resident #35 or that nail care was needed. She added that she would expect fingernails to be observed on shower days and during personal care daily with nail care rendered as needed.

Based on observations, staff interviews and record review, the facility failed to complete a thorough fall investigation to determine the root cause, failed to timely address falls with effective interventions. The facility also failed to implement interventions as care planned to prevent further falls. This was for 2 (Resident #25 and Resident #18) of 5 sampled residents reviewed for accidents. The findings included: 1. Resident #25 was admitted on [DATE] with cumulative diagnoses of dementia, [CONDITION(S)] and [CONDITION(S)] (CVA) with left side [CONDITION(S)]. Resident #25's quarterly Minimum Data Set (MDS) dated [DATE] indicated severe cognitive impairment and he exhibited no behaviors. He was coded for total assistance with transfers, extensive assistance with bed mobility. He was coded for 2 falls without any injuries and 2 falls with minor injuries. Resident #25's care plan created 5/24/21 and last revised on 6/18/21 read he had experienced multiple falls since his admission secondary to poor balance, poor trunk control, left-sided weakness and impulsiveness related to his dementia. Interventions included a defined parameter mattress (DPM), low bed and bilateral mats on the floor to the sides of the bed. Review of an incident report dated 3/22/21 at 7:15 PM read Resident #25 was heard yelling. He was found on the fall mat beside his bed and sustained an abrasion. The intervention implemented by the floor staff on 3/22/21 was to take him to the common area in a recliner for close observation. The incident report read there needed to be an action plan. There was no other documentation regarding an action plan. The incident report was signed off by the DON on 3/26/21 (4 days later). Review of a nursing note dated 3/28/21 at 3:30 PM read a nursing note read Resident #25 was found on the floor mat beside his bed. The DON stated on 7/13/21 at 3:47 PM, there was no incident report for this fall and she was not aware of this fall until the survey. Review of an incident report dated 4/12/21 at 7:30 PM read Resident #25 was found on the fall mat beside his bed. The floor staff moved him to the common area for closer observation. The incident report read there needed to be an action plan. There was no other documentation regarding an action plan. The incident report was signed off by the DON on 4/19/21 (7 days later). Review of an incident report dated 4/13/21 at 3:00 PM read Resident #25 was found lying on the floor mat beside his bed. The report indicated he had just been moved from the 800 hall to the 600 hall where he was currently residing. There were no interventions documented but the report read to allow him to be on the floor as he wishes. The incident report for this fall was incomplete with the following sections not answered: post fall analysis was not completed which included: medical Factors, cognitive factors, functional factors, sensory factors, environmental factors and the post fall huddle. The incident report read there needed to be an action plan. There was no other documentation regarding an action plan. The incident report was signed off by the DON on 4/19/21 (7 days later). On 5/19/21 at 3:30 PM, a nursing note read Resident #25 was found with the lower half of his body on the floor. The DON stated on 7/13/21 at 3:47 PM, there was no incident report for this fall because it wasn't considered a fall. Review of an incident report dated 6/15/21 at 7:20 PM read Resident #25 was found on the mat beside the bed. He sustained a hematoma to the right side of the back of his head. The intervention implemented by the floor staff on 6/15/21 was to take him to the common area in a recliner for close observation and neurological checks. The incident report read there needed to be an action plan. There was no other documentation regarding an action plan. The incident report was signed off by the DON on 6/18/21 (3 days later). Review of a Nurse Practitioner (NP) note dated 6/17/21 referenced that fall on 6/15/21. The note read his hematoma was not discovered until 6/17/21 when an aide was providing is morning care. He was sent to the emergency room for imaging due to the use of an anticoagulant. Review of Resident #25's hospital records dated 6/17/21 read he was sent to the emergency room for an evaluation related to a fall on 6/15/21 because Resident #25 was prescribed an anticoagulant (blood thinner). His CT Scan at the hospital was negative for injury and he returned to the facility on the same day with no new orders. Review of an incident report dated 7/3/21 at 6:30 PM read Resident #25 was found on the floor mat. The intervention implemented by the floor staff on 7/3/21 was incontinence care and he was remined to use his call bell. The incident report was unsigned by the DON. The follow up actions section was blank. The DON stated on 7/13/21 at 3:47 PM, she was not sure why this fall had not yet been reviewed to date (7/13/21). Resident #25 was observed in his bed on 7/12/21 at 10:30 AM. He was lying on a defined perimeter mattress (DPM) and his bed was at normal height. There was no mat on the right side of his bed and the left side of his bed was pushed up flush against the wall. Resident #25 was observed in his bed on 7/13/21 at 2:00 PM. He was lying on a DPM, his bed was at normal height and there was observed a floor mat on the right side of his bed. The left side of his bed was pushed against the wall. The Rehabilitation Manager (RM) was interviewed on 7/13/21 at 2:58 PM. He stated that he attended the daily clinical care meeting. He stated the incident reports including falls were reviewed, investigated and interventions identified during those meetings. The RM stated the following staff attended the daily clinical are meetings: MDS Nurse, himself, the DON and the Clinical Care Coordinators (CCC). The Clinical Care Coordinator (CCC) #1 was interviewed on 7/13/21 at 3:45 PM. She stated that she was assigned as CCC on the unit Resident #25 was residing. She indicated that falls were reviewed in the daily clinical care meeting and the floor staff's immediate interventions were reviewed and new or ineffective interventions were discussed at that time. She stated the MDS Nurse updated the care plan during the meetings. The Director of Nursing (DON) was interviewed on 7/13/21 at 3:47 PM. She stated that falls were reviewed in the daily clinical care meetings and possible new interventions were discussed during the meetings. The DON stated Resident #25 had a long standing history of falls and fortunately, he hadn't experienced any serious injuries. The DON stated she had not recognized that all of Resident #25's falls from his bed occurred on 2nds shift. She stated she was late in reviewing the fall incidents because she and the CCC were working on the floor on occasion. The DON stated all falls should be reviewed daily in the clinical care meeting. The DON stated in their computer system, the areas post fall analysis of medical Factors, cognitive factors, functional factors, sensory factors, environmental factors and the post fall huddle were all optional for documentation in the computer system. She stated the optional areas on the incident report should be required to complete to get an accurate assessment of Resident #25's root cause analysis (RCA) for his falls. A third observation was completed on 7/13/21 at 4:35 PM. Resident #25 was lying on a DPM, his bed was at normal height and a floor mat on the right side of his bed. The left side of his bed was pushed against the wall. Resident #25 was observed in his bed on 7/14/21 at 8:20 AM. His bed made been moved away from the wall, the bed was in the low position and floor mats were observed on both sides of the bed. NA #2 was interviewed on 7/14/21 at 8:23 AM. She stated she was assigned Resident #25. She stated his cognition had declined and he could not understand to use his call bell for assistance. She stated she rounds on Resident #35 frequently on her shift which ends at 3:00 PM. Nurse #1 was interviewed on 7/14/21 at 8:30 AM. She was assigned to Resident #25. She stated he had a long history of falls due to his impaired cognation and his left sided weakness. She stated the first shift aides were very good about frequent monitoring of Resident #25 but the second shift aides were obviously no implementing his fall interventions and closely monitoring Resident #25. Nurse #1 stated Resident #25's behaviors increased in the late afternoon and evenings. The DON was interviewed on 7/14/21 at 2:58 PM. The DON stated that she expected Resident #25's fall investigations to be thoroughly completed, addressed timely and effective interventions to be implemented. 2. Resident # 18 was admitted to the facility on [DATE] with multiple diagnoses including dementia. Review of the facility's incident/accident log revealed that Resident #18 had falls on 1/27/21, 1/28/21 and 2/6/21. The incident report revealed that the fall on 1/28/21, Resident #18 slid out of the recliner. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated that Resident #18 had moderate cognitive impairment and was dependent on the staff for transfers. The assessment further indicated that Resident #18 did not have a fall since admission, reentry, or prior assessment. Resident #18's care plan reviewed on 5/21/21 included a problem at risk for falls and potential for injury associated with falls due to impaired mobility and vision, dementia and forget to call for assist and get up without assist. The interventions included seat cushion with dycem to recliner to prevent cushion from sliding out (added 2/5/21). Resident #18 was observed up in a recliner on 7/14/21 at 11:20 AM. There was no seat cushion with dycem noted on the recliner. Nurse #1, assigned to Resident #18, was interviewed on 7/14/21 at 11:21 AM. She stated that she had not seen a seat cushion with dycem on Resident #18's recliner. Nurse #1 reviewed Resident #18's care plan and she verified that the resident was supposed to have a seat cushion with dycem on his recliner when he was up. Nurse #1 went into the resident's room and verified that the resident did not have a cushion with dycem on his recliner. NA #1, assigned to Resident #18, was interviewed on 7/14/21 at 11:22 AM. NA #1 reported that she had not seen a seat cushion with dycem on the resident's recliner. She reviewed the resident's care plan on the kiosk (a machine where NAs obtained and entered resident's information) and stated that the resident's care guide did not include to provide cushion with dycem on the resident's recliner. The DON was interviewed on 7/14/21 at 2:58 PM. The DON stated that she expected the staff to implement the care plan interventions to prevent further falls.

Based on observation, record review, and staff interview, the facility failed to apply a splint as ordered to a resident with a contracture for 1 of 2 residents (Resident #8) reviewed for range of motion. The findings included: Resident #8 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An Occupational Therapy (OT) progress and discharge summary for Resident #8 dated 7/24/20 indicated she received OT from 5/25/20 through 7/24/20 for a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The form indicated that Resident #8 was tolerating her splint well, but she had not met her long term goal of wearing the soft splint for 8 hours per day due to an early discharge from therapy related to a hospice referral. She was noted to require total assistance with donning the splint. The discharge instructions stated that caregiver education was initiated with nursing staff focusing on the application and wear schedule of splint. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #8's cognition was severely impaired. She had no behaviors and no rejection of care. Resident #8 was dependent on staff for assistance with Activities of Daily Living (ADLs) and she had impairment on 1 side of her upper extremities. Resident #8's active care plan (last reviewed on 3/29/21) as of 7/12/21 included the problem area of the risk for skin breakdown or injury related to impaired bed mobility, incontinence, poor nutritional intake, decreased activity due to staying in bed frequently, and wearing a splint on left hand for contracture. The interventions included, in part, a soft splint to left hand/finger contracture, apply in the morning and remove after 4 hours as will allow for contracture management, and check skin under splint when removed for cleaning and passive range of motion. An observation was conducting of Resident #8 on 7/12/21 at 10:40 AM. Her left hand was contracted and she had no splint in place. During an interview with the Rehabilitation Manager on 7/13/21 at 3:00 PM he stated that if a resident was supposed to have a splint in place there would be a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #8's active orders on of 7/13/21 indicated the 7/24/20 order for soft splint application to the left hand for 4 to 6 hours daily remained in place. An observation was conducted of Resident #8 on 7/14/21 at 9:00 AM. Her left hand was contracted and she had no splint in place. An interview was conducted with Nurse #1 on 7/14/21 at 9:05 AM. She was asked if Resident #8 wore a splint. She stated that she had not believed Resident #8 had a splint, but that it would have been in the care plan if she required this intervention. Resident #8's care plan was reviewed with Nurse #1 and she verified that Resident #8 was supposed to have a soft splint to her left hand 4 hours daily as indicated in the care plan. She revealed she had not known this was on the care plan. Nurse #1 stated that this left hand splint had not appeared on the MAR for the nurse to check off daily so she had not realized Resident #8 required this intervention. An interview was conducted with Nursing Assistant (NA) #2 on 7/14/21 at 9:07 AM. She stated that Resident #8 used to have a splint when she was on 800 hall, but she had no splint in place since been on the 600 hall. NA #2 was not sure of the exact date Resident #8 moved to the 600 hall, but indicated it had been several months. A review of the room history for Resident #8 was conducted on 7/14/21 at 9:15 AM. Resident #8 resided on the 600 hall beginning on 2/4/21 through 3/8/21, she resided on the 400 hall from 3/9/21 through 3/21/21, and then moved back to the 600 hall from 3/22/21 through present. An interview was conducted with MDS Nurse #1 on 7/14/21 at 11:10 AM. She verified that Resident #8 had an active physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated that she revised this order this morning (7/14/21) so it would appear on the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . She explained that the previous order was entered as a continuous order and these types of orders had not appeared on the MAR. She reported that this was an error that occurred when the order was entered in July 2020 and was not an issue until Resident #8 moved to a new unit with staff who had not worked with her regularly and had not known that she was supposed to have the soft splint applied daily. During an interview with the Administrator and Director of Nursing on 7/14/21 at 2:56 PM they both stated that they expected splints to be applied as ordered.

Based on record review, observation, and interview with the Wound Nurse Practitioner and staff, the facility failed to obtain order for treatment to the pressure ulcers on admission and failed to treat the pressure ulcer for 1 of 1 sampled resident reviewed for pressure ulcers (Resident # 99). Findings included: Resident #99 was admitted to the facility on [DATE] with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The modification to the admission Minimum Data Set (MDS) assessment dated [DATE] indicated that Resident #99 had 2 pressure ulcers. Review of the admission doctor's orders (5/28/21) for Resident #99 revealed that there was no order for treatment to the left and right calcaneous (heel) pressure ulcers. Review of the facility's wound assessment dated [DATE] revealed that Resident #99 had pressure ulcers to the left calcaneous measuring 3 x (times) 4 x 0.2 centimeter (cm) and to the right calcaneous measuring 2 x 3 x 0.2 cm. Resident #99's care plan problems initiated on 6/11/21 included pressure ulcers to left heel (unstageable) and to right heel (stage IV). The goal was for the ulcer to show evidence of healing by decrease in size, length, width, depth, and no sign/symptoms of infection. The approaches included notify physician of any impaired skin integrity issues and obtain orders as needed, implement, and modify care plan as needed. Review of Resident #99's Treatment Administration Records (TARs) for May 2021 revealed that there was no treatment provided to the left and right calcaneous pressure ulcers from 5/29/21 through 5/31/21. Resident #99 was seen by the wound clinic on 6/4/21. The note indicated that Resident #99 was seen for follow up evaluation of multiple bilateral feet wounds. The left calcaneous pressure ulcer was larger than during the hospitalization and was covered with dry eschar. The left calcaneous was unstageable measuring 2.3 x 2 x 0.1 cm with large amount of necrotic tissue within the wound bed including eschar and adherent slough. The right calcaneous was stage IV measuring 2 x 2 x 0.4 cm with large amount of necrotic tissue within the wound bed including adherent slough. The note indicated to continue the treatment with the [MEDICATION(S)]. The note did not indicate the frequency of the treatment. Review of Resident #99's TARs for June 2021 revealed that there was no treatment provided to the left and right calcaneous pressure ulcers from 6/1/21 through 6/10/21. Resident #99 was observed during the dressing change on 7/13/21 at 9:45 AM. The resident was observed to have pressure ulcers to the left and right calcaneous. The ulcers were dry with no signs of infection noted. Nurse #2 was observed to clean the left calcaneous pressure ulcer with Normal Saline, [MEDICATION(S)] was applied, covered with dry gauze and secured with roll gauze. The pressure ulcer to the right calcaneous was cleaned with Normal Saline, covered with wet to dry [MEDICATION(S)] gauze and secured with roll gauze. Clinical Care Coordinator (CCC) #1 was interviewed on 7/14/21 at 1:15 PM. The CCC reviewed the May 2021 and June 2021 doctor's orders and TARs and verified that there was no treatment order on admission for the pressure ulcers and there was no treatment provided from 5/29/21 through 6/10/21. She stated that Resident #99 was being followed by the wound clinic weekly and was first seen on 6/4/21. The Wound Nurse Practitioner (NP) was called on 7/14/21 at 1:45 PM and she called back at 3:45 PM. She reported that Resident #99 was being followed by the wound clinic prior to admission to the hospital and to the nursing facility. He had pressure ulcers to his bilateral heels and other venous stasis ulcers to the lower extremities. Her first visit at the facility was on 6/9/21. Resident #99's pressure ulcer on the right calcaneous was a stage IV, with eschar and adherent slough but no exudate/odor. The left calcaneous pressure ulcer was unstageable with large necrosis but with no exudate/odor. She added that she had recommended to treat the ulcers with [MEDICATION(S)] 3 times a week. The Wound NP stated that she didn't know what type of treatment the resident was provided at the hospital, but she expected the facility to obtain a treatment order and to treat the ulcers at least 3 times a week. She also indicated that Resident #99 was seen by the wound clinic on 6/4/21 and had recommended to continue [MEDICATION(S)] 3 times a week to the ulcers. The Director of Nursing (DON) was interviewed on 7/14/21 at 2:53 PM. The DON stated that the admitting nurse was responsible for notifying the doctor and for obtaining treatment order if a resident was admitted with pressure ulcer. The DON reported that the admitting nurse for Resident #99 was no longer employed at the facility. She stated that the admitting nurse missed to call the doctor for the treatment order and nobody was responsible for monitoring pressure ulcers since the facility did not have a treatment nurse.

Based on record review and staff interviews, the facility failed to transcribe the correct medication administration route for 1 of 1 resident reviewed for gastric feeding tube (Resident #6). The findings included: Resident #6 was originally admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #6 was cognitively intact. He required total assistance with eating and received all nutrition and fluids via a feeding tube. Review of the active care plan, last reviewed on 7/9/21, revealed Resident #6 required tube feeding for all nutrition and fluids. The active July 2021 physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] - An order dated 10/10/19 for [MEDICATION(S)] 800 micrograms (mcg) 1 tablet by mouth once a day for supplement. - An order dated 11/2/20 for Aspirin 81 milligrams (mg) 1 tab by mouth once a day for prophylaxis. - An order dated 12/4/20 for [MEDICATION(S)] 220 mg 1 capsule by mouth once a day for supplement. - An order dated 1/8/21 for [MEDICATION(S)]-DM 10mg-100mg/5 milliliters (ml). Give 15 ml by mouth as needed every 6 hours for cough/congestion. - An order dated 3/16/21 for [MEDICATION(S)] 5mg 1 tablet by mouth once a day. All other medications were written to be provided through the gastric feeding tube. The physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 7/13/21 at 3:15 PM, an interview occurred with Nurse #3 who was working the medication cart for Resident #6's hall and had administered his medications earlier. The nurse confirmed Resident #6 did not receive any medications by mouth and he had not provided the morning doses of [MEDICATION(S)], Aspirin, [MEDICATION(S)] or [MEDICATION(S)] by mouth. Nurse #3 acknowledged the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . An interview was conducted with the facility Nurse Practitioner (NP) on 7/14/21 at 9:15 AM, who stated she had ordered the [MEDICATION(S)] 5mg on 3/16/21. The NP explained she entered the medication, dose, and frequency into the Electronic Medical System as a draft. When the nurse completed the order the medication route should have been changed to gastrostomy tube (G-tube) instead of leaving at the default route of oral. On 7/14/21 at 9:55 AM, an interview was completed with Nurse #4 who was working on the medication cart for Resident #6's hall. She stated she was familiar with Resident #6 and had administered his medications many times and confirmed he did not receive any medications by mouth. Nurse #4 acknowledged the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The Director of Nursing (DON) was interviewed on 7/14/21 at 11:23 AM. She reviewed Resident #6's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . She further explained when entering the medication into the electronic medical system the default route was oral and she felt it was an oversight that when the nurses entered the medications, they failed to change the route to G-tube. The DON stated it was her expectation for all medication administration routes to be entered correctly when the order was received and/or reviewed.

Based on record review and staff interview, the facility failed to code the Minimum Data Set (MDS) assessments accurately in the areas of accident (Resident #13) and medications (Resident #22) for 2 of 15 sampled residents reviewed. Findings included: 1. Resident # 13 was admitted to the facility on [DATE] with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] #13 had severe cognitive impairment and with a fall with injury since admission, reentry or prior assessment. Review of the facility's incident/accident log was conducted. Resident #13 had 1 incident report dated 3/20/21. The report indicated that the resident had a skin tear to her left forearm during the transfer. The Clinical Care Coordinator (CCC) #1 was interviewed on 7/13/21 at 2:10 PM. The CCC reported that Resident #13 was noted to have a skin tear during transfer on 3/20/21 incident report, but she did not have a fall. The MDS Nurse #1 was interviewed on 7/14/21 at 1:25 PM. The MDS Nurse stated that after reviewing the incident report, she verified that Resident #13 did not have a fall on 3/20/21. She indicated that she would complete a modification assessment to reflect that resident did not have a fall since admission, reentry, or prior assessment. The Director of Nursing (DON) was interviewed on 7/14/21 at 2:53 PM. She stated that she expected the MDS assessments to be coded accurately. 2. Resident #22 was most recently admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #22's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #22's cognition was intact. She was coded with hypnotic medication on 6 of 7 days during the MDS review period. The medications section of this MDS was coded by MDS Nurse #2 An interview was conducted with MDS Nurse #2 on 7/14/21 at 11:15 AM. The medications section of Resident #22's 6/23/21 MDS that indicated the resident received hypnotic medication on 6 of 7 days was reviewed with MDS Nurse #2. The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . She revealed that she coded [MEDICATION(S)] as a hypnotic medication because it was prescribed for [CONDITION(S)]. MDS Nurse #2 indicated that [MEDICATION(S)] was classified as an antidepressant and should not have been coded as hypnotic on the MDS. She stated that a modification assessment would be completed to correct the error. During an interview with the Administrator and Director of Nursing (DON) on 7/14/21 at 2:56 PM they both indicated they expected the MDS to be coded accurately.

Based on observations, staff interviews and record review, the facility failed to ensure residents were free of physical restraints by pushing the bed against the wall to prevent residents from exiting the bed. This was for 2 (Resident #25 and Resident #18) of 2 sampled residents reviewed for physical restraints. The findings included: 1. Resident #25 was admitted on [DATE] with cumulative diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the facility's incidents/accidents log revealed that Resident #25 had falls on 3/22/21, 3/28/21, 4/12/21, 4/13/21, 5/19/21, 6/15/21 and 7/3/21. All falls were from his bed and related to transferring from his bed without assistance. Resident #25's quarterly Minimum Data Set, dated dated dated [DATE] indicated severe cognitive impairment and he exhibited no behaviors. He was coded for total assistance with transfers, extensive assistance with bed mobility. He was coded for 2 falls without any injuries and 2 falls with minor injuries. Resident #25 was not coded for the use of a restraint. Resident #25's care plan created 5/24/21 and last revised on 6/18/21, read he had experienced multiple falls since his admission secondary to poor balance, poor trunk control, left-sided weakness and impulsiveness related to his dementia. Interventions included a defined parameter mattress (DPM), low bed and bilateral mats on the floor to the sides of the bed. Resident #25 was observed in his bed on 7/12/21 at 10:30 AM. He was lying on a DPM and his bed was at normal height. There was no mat on the right side of his bed and the left side of his bed was against the wall. Resident #25 was observed in his bed on 7/13/21 at 2:00 PM. He was lying on a DPM, his bed was at normal height and there was observed a floor mat on the right side of his bed. The left side of his bed was pushed flush against the wall. The Rehabilitation Manager (RM) was interviewed on 7/13/21 at 2:58 PM. He stated that he attended the daily clinical care meeting and incident reports including falls were reviewed. The RM indicated that he would never recommend to place resident's bed against the wall, this would keep resident from being able to get out of bed. The Clinical Care Coordinator (CCC) #1 was interviewed on 7/13/21 at 3:45 PM. She stated that she was assigned as CCC on the unit Resident #25 was residing. She reported that she was not aware that the resident's bed was against the wall. She also indicated that falls were reviewed on the daily clinical care meeting and placing the bed against the wall was never mentioned as intervention for falls. The Director of Nursing (DON) was interviewed on 7/13/21 at 3:47 PM. The DON stated that the facility was restraint free. She stated that she was not aware that Resident #25's bed was against the wall; this would restrict resident from getting in and out of bed and would be considered a restraint. She stated that falls were reviewed on the daily clinical care meeting and placing the bed against the wall was not discussed as an intervention to prevent falls. She commented that it might have been the nursing assistants (NAs) who were moving these beds against the wall. A third observation was completed on 7/13/21 at 4:35 PM. Resident #25 was lying on a DPM, his bed was at normal height and a floor mat on the right side of his bed. The left side of his bed was pushed flush against the wall. Resident #25 was observed in his bed on 7/14/21 at 8:20 AM. His bed made been moved away from the wall, the bed was in the low position and floor mats were observed on both sides of the bed. NA #2 was interviewed on 7/14/21 at 8:23 AM. She stated she was assigned Resident #25. She stated his bed was against the wall because she was told it was to keep him from falling out of bed. NA #2 was unable to remember who and when the bed was moved against the wall. Nurse #1 was interviewed on 7/14/21 at 8:30 AM. She was assigned to Resident #25. She stated that she did not notice that the resident's bed was against the wall until yesterday (7/13/21) afternoon when the NAs were moving his bed away from the wall. Nurse #1 stated his bed against the wall would be considered a restraint. NA # 1 was interviewed on 7/14/21 at 11:22 AM. She stated she started working the 600 hall about 3 months ago and Resident #25's bed was already positioned against the wall at that time. NA #1 indicated that yesterday afternoon, the NAs were informed by the Nurse #1 to move his bed away from the wall. The DON was interviewed on 7/14/21 at 2:58 PM. The DON stated that she expected residents to be free from restraints and for the staff not to move beds against the walls as this would be considered as restraints. 2. Resident # 18 was admitted to the facility on [DATE] with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the incident/accident log revealed that Resident #18 had falls on 1/27/21, 1/28/21 and 2/6/21. The falls on 1/27/21 and 2/6/21 were related to transfer from/to bed or chair without assistance. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated that Resident #18 had moderate cognitive impairment and was dependent on the staff for transfers. The assessment further indicated that Resident #18 did not use restraints. Resident #18's care plan reviewed on 5/21/21 included a problem at risk for falls and potential for injury associated with falls due to impaired mobility and vision, dementia and forget to call for assist and get up without assist. The interventions included assistance x (times) 1 when transferring and toileting using a rolling walker (RW) and physical therapy (PT)/Occupational therapy (OT) were being provided. Resident #18 was observed in bed on 7/13/21 at 9:10 AM. His bed was against the wall (left side) and there was a floor mat on the right side of the bed. The Rehabilitation (Rehab) Manager was interviewed on 7/13/21 at 2:58 PM. He stated that he attended the daily clinical care meeting and incident reports including falls were reviewed. The Rehab Manager indicated that he would never recommend to place resident's bed against the wall, this would keep resident from being able to get out of bed. The Clinical Care Coordinator (CCC) #1 was interviewed on 7/13/21 at 3:45 PM. She stated that she was assigned as CCC on the unit Resident #18 was residing. She reported that she was not aware that the resident's bed was against the wall. She also indicated that falls were reviewed on the daily clinical care meeting and placing the bed against the wall was never mentioned as intervention for falls. The Director of Nursing (DON) was interviewed on 7/13/21 at 3:47 PM. The DON stated that the facility was restraint free. She stated that she was not aware that Resident #18's bed was against the wall; this would restrict resident from getting in and out of bed and would be considered a restraint. She stated that falls were reviewed on the daily clinical care meeting and placing the bed against the wall was not discussed as an intervention to prevent falls. She commented that it might have been the nursing assistants (NAs) who were moving these beds against the wall.

Based on record review, staff interview, and family interview, the facility failed to honor a resident's right for compassionate care visitation in accordance with guidance from the Centers for Medicare and Medicaid Services (QSO-20-39-NH) and the facility's COVID-19 Policy for 1 of 1 residents reviewed for compassionate care visitation (Resident #8). The findings included: A Centers for Medicare and Medicaid Services (CMS) memo (QSO-20-39-NH) dated 9/17/20 titled Nursing Home Visitation - COVID-19 included, in part, the following information under the heading of Compassionate Care Visits: While end-of-life situations have been used as examples of compassionate care situations, the term compassionate care situations does not exclusively refer to end-of-life situations. Examples of other types of compassionate care situations include, but are not limited to: - A resident, who was living with their family before recently being admitted to a nursing home, is struggling with the change in environment and lack of physical family support. - A resident who is grieving after a friend or family member recently passed away. - A resident who needs cueing and encouragement with eating or drinking, previously provided by family and/or caregiver(s), is experiencing weight loss or dehydration. - A resident, who used to talk and interact with others, is experiencing emotional distress, seldom speaking, or crying more frequently (when the resident had rarely cried in the past). Allowing a visit in these situations would be consistent with the intent of, 'compassionate care situations' . Furthermore, the above list is not an exhaustive list as there may be other compassionate care situations not included. A review of the facility's policy titled Infection Prevention and Control Manual Coronavirus (COVID-19) undated, included, in part, that in person visitation would be suspended when there was a new case of COVID-19 among residents or staff. Compassionate care visits were noted to be excluded from this suspension. Resident #8 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #8's care plan, effective 7/30/20, included the problem area of Resident #8 having a terminal diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The interventions included, in part: support my family's efforts to remain at my bedside and respect my family's specific requests and support their needs. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #8's cognition was severely impaired, she had a life expectancy of 6 months or less, and she was on hospice services. The medical record indicated Resident #8 was confirmed positive for COVID-19 on 12/1/20. She resided on the COVID-19 unit from 12/1/20 through 12/14/20. A nursing note dated 12/15/20 indicated Resident #8 had a decreased appetite and drank little amounts intermittently with staff's assistance. She was noted to take medication with staff's encouragement. A nursing note dated 12/18/20 indicated Resident #8 appeared weak, fragile, and fatigued. She often had her eyes closed and needed encouragement to engage. She required assistance with eating and consumed 50% of her meal and 720 cubic centimeters (cc) of fluids. Hospice nurse stated that family had concerns due to Resident #8's COVID-19 diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Nursing notes dated 12/21/20 indicated the nurse attempted to reach Resident #8's family member by phone to discuss present condition. Resident #8 was noted to be alert and oriented to self and appeared weak and very confused. A nursing note dated 1/2/21 at 3:17 AM indicated the Nursing Assistant (NA) reported Resident #8 had not urinated and a bladder scan was completed with 356 cc of urine in bladder. Hospice staff were spoken with and an order was received for a catheter to be put in. The catheter obtained 700 cc of dark amber urine. A nursing note dated 1/3/21 at 6:13 AM by Nurse #2 indicated the night shift nurse reported Resident #8 had not voided during the day or night shift. The night shift nurse called hospice staff and had received an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . A nursing note dated 1/3/21 at 6:35 AM (entered at 6:42 PM) by Nurse #2 indicated Resident #8 had 350 milliliters (ml) in catheter drainage bag and based on a decline in nutrition as evidenced by not eating or drinking and minimal output, hospice stated that Resident #8 was at the end of life. Nurse #2 wrote that the family was informed. An order was received to keep the urinary catheter in place for [CONDITION(S)]. A nursing note dated 1/4/21 at 12:00 AM (entered at 6:45 PM) by Nurse #2 indicated the physician saw Resident #8 via telehealth and stated that because she had 150 ml urine in bag, she was drinking some sips, and eating small amounts intermittently that she was not at the end of life. The family and hospice nurse were noted to be aware. A phone interview was conducted with Resident #8's Responsible Party (RP) on 7/12/21 at 3:43 PM. She stated that in December 2021 Resident #8 had COVID-19 and in the beginning of January 2021 she was informed by phone that Resident #8 had a decline in condition and was minimally eating and drinking. She reported that nursing staff, unable recall a name, indicated Resident #8 was at the end of life. She stated that she informed two of her family members of this information and they both drove over 13 hours that same night to have a face to face visit with the resident on 1/3/21, but when they arrived at the facility they were not allowed to enter. She explained that the staff told the family members that Resident #8 had stabilized from the prior day and she was no longer qualified for end of life visitation. The RP stated that Resident #8 had since bounced back from her decline in condition, but at the time the family came to the facility in January 2021 they were under the impression that it was possible she would not recover and they had wanted to spend time with the resident in case it was their last chance. An interview was conducted with the Administrator on 7/13/21 at 2:43 PM. She stated that she was not the Administrator at the facility in January 2021, but that throughout the COVID-19 pandemic the facility was following CMS guidance for compassionate care visitations. A phone interview was conducted on 7/14/21 at 9:54 AM with one of Resident #8's family members who went to the facility on [DATE] for a face to face visit. He confirmed the RP's statement that he was alerted by the RP that Resident #8 had a decline in condition and was not doing well so he and another family member drove through the night over 13 hours to see the resident in person. He indicated that when he arrived at the facility the security guard contacted the charge nurse or one of the managers (unable to recall a name) and they stated that based on the visitation protocol since Resident #8 had stabilized and was not believed to be at end of life that they could not enter the facility to see her. A phone interview was attempted with Nurse #2 on 7/14/21 at 11:50 AM. She was unable to be reached. During a follow up interview with the Administrator and Director of Nursing on 7/14/21 at 2:56 PM they both indicated that they expected CMS guidance for compassionate care visitation to be followed.

Based on observations, record review, resident interview and staff interviews, the facility failed to place a resident's call light (Resident #11) within reach to allow for the resident to request staff assistance if needed for 1 of 1 resident reviewed for accommodation of needs. The findings included: Resident #11 was admitted to the facility on [DATE] with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #11 was cognitively intact and displayed no behaviors or rejection of care. She required supervision of one person for transfers and toileting. Resident #11's care plan, last reviewed on 4/28/21, indicated she had a potential for injury associated with falls related to the need for assistance with bathing, toileting and some transferring relating to a history of TIA's, CHF and diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The interventions included to keep the call light within reach and the bed in the lowest position. On 7/12/21 at 10:45 AM, an observation occurred of Resident #11 who was observed sitting up in bed watching TV. The call light cord was draped over the drawer of the nightstand, with the call bell on the floor. The nightstand was to the right and behind of Resident #11, out of her reach. An observation and interview was conducted with Resident #11 on 7/13/21 at 8:55 AM. Resident #11 was sitting upright in the bed watching TV. The call light cord was draped over the nightstand drawer touching the floor and out of her reach. Resident #11 was alert and interviewable and stated she would push the call bell for assistance but had been unable to reach it for the past few days and had resorted to yelling out for staff or motioning for them when they walked by her room. Resident #11 added she only transferred with staff assistance due to weakness in her legs and occasional pain. An interview occurred with Nurse Aide (NA) #3 on 7/13/21 at 3:40 PM. She indicated she was familiar with Resident #11, who was able to use the call light to request staff assistance. NA #3 was unable to explain why the call bell had been out of reach of the resident and stated the resident had been calling out for staff or motioning for them as they walked by her room. At 3:44 PM on 7/13/21, Resident #11 was observed sitting up in the wheelchair at her bedside. The call bell cord was draped in the nightstand drawer and touching the floor, which was located behind Resident #11. She was unable to reach the cord if assistance was needed. An interview was completed with the Director of Nursing and Administrator on 7/14/21 at 3:00 PM regarding Resident #11's call light not being placed within her reach. Both parties indicated it was their expectation for staff to place resident call lights within their reach at all times.

Based on record review, staff and physician interviews from the facility and vascular surgeon's office, the facility failed to initiate physician orders [REDACTED]. This affected 1 of 3 residents reviewed for well-being (Resident #1). The findings included: Resident #1 was admitted to the facility on [DATE] and discharged to the hospital on [DATE]. His [DIAGNOSES REDACTED]. Review of the Hospital records dated 10/9/19 revealed Resident #1 was admitted to the hospital with [REDACTED]. Areas of black eschar (dead tissue found in a full thickness wound) was present to the right and left feet. The After-Visit Summary from the hospital, dated 10/28/19, included the following wound care orders: Normal Saline and Santyl to the right second and third toe ulcers daily and place a 2x2 gauze between the 2nd and 3rd toes. The Comprehensive Nursing Assessment completed by Nurse #1 and dated 10/29/19 indicated Resident #1 had bilateral bruising to both upper arms, an abrasion to the back of his left hand with dressing intact and pressure areas to both heels with dressing intact. A review of the (MONTH) 2019 Physician order [REDACTED]. Review of the (MONTH) 2019 Treatment Administration Record (TAR) revealed no treatment orders present for the care of diabetic ulcers to Resident #1's bilateral toes or heels. A review of the (MONTH) 2019 Physician order [REDACTED]. The Admission Minimum Data Set ((MDS) dated [DATE] indicated Resident #1 was cognitively intact. He required limited assistance for bed mobility and personal hygiene; extensive assistance with dressing and was dependent on staff for toileting, bathing and transfers. A [DIAGNOSES REDACTED]. Section M of the MDS assessment revealed Resident #1 was admitted with [MEDICAL CONDITION] and skin tear and had an application of dressing other than to feet. Resident #1's medical record included a lab report dated 11/4/19, with normal limits for the white blood cell count (an elevated count could signify infection). A review of the Care Area Assessment (CAA) Summary dated 11/8/19 indicated Resident #1 had no areas of pressure noted on admission or during the look back period. Per the hospital note he had diabetic ulcers to his feet and a skin tear to his hand. A review of the care plan dated 11/8/19 revealed the following areas of focus, in part: - At risk for pain related to diabetic ulcers. - At risk for skin breakdown related to end stage [MEDICAL CONDITION] and diabetic ulcers. Review of the (MONTH) 2019 TAR's indicated Resident #1 had skin assessments completed on 11/4/19 and 11/11/19 with no new skin problems identified. No further information was found regarding the skin assessments. A lab report dated 11/11/19 revealed Resident #1's white blood cell count was within normal limits. Resident #1's medical record included a Nursing Progress Note written by Nurse #6 and dated 11/17/19. The note revealed bandages to both feet were soiled and once they were removed multiple wounds were observed to bilateral feet to include the toes and heels. Feet were cool to the touch and lower legs were discolored. Unstageable wounds were noted to both the left and right foot as well as a Stage 3 (full thickness skin loss) ulcer to the right 4th toe. All areas were cleansed with Normal Saline, painted with [MEDICATION NAME] and wrapped in a clean dressing. Gauze was placed between toes and a foam cup was applied to bilateral heels for protection. The on-call practitioner was notified and provided an order to send Resident #1 to the emergency room for evaluation. The (MONTH) 2019 TAR indicated treatment orders for the diabetic ulcers to Resident #1's heels and toes starting on 11/17/19 written by Nurse #6, as follows: - Paint unstageable wound to left lateral big toe with [MEDICATION NAME] every day and as needed. - Paint unstageable wound to the left lateral 2nd toe with [MEDICATION NAME] every day and as needed. - Paint unstageable wound to the left lateral 3rd toe with [MEDICATION NAME] every day and as needed. - Paint Stage 3 wound to left lateral pinkie toe with [MEDICATION NAME] every day and as needed. - Paint left heel with [MEDICATION NAME] every day and as needed. - Paint unstageable wound to the right 2nd toe with [MEDICATION NAME] every day and as needed. - Paint unstageable wound to right lateral big toe with [MEDICATION NAME] every day and as needed. - Paint unstageable wound to bottom of right big toe with [MEDICATION NAME] every day and as needed. - Paint unstageable wound to right 3rd toe with [MEDICATION NAME] every day and as needed. - Paint unstageable wound to right pinkie toe with [MEDICATION NAME] every day and as needed. - Paint right heel with [MEDICATION NAME] every day and as needed. - After [MEDICATION NAME] has been applied and dried, separate each toe with dry gauze and wrap bilateral feet with Kerlix daily and as needed. - Apply heel protectors to bilateral feet. Change daily and as needed. - Assess bilateral feet for pedal pulses daily and notify physician if any changes or abnormalities are noted. - Assess wounds daily when providing wound care. Notify physician if any changes are noted or foul o odor/drainage is present. Review of the hospital records dated 11/17/19 to 11/18/19 revealed Resident #1 was brought to the emergency room with reports of discolored toes that were noted after having dressings changed at the facility. Areas of necrosis present to the right 2nd toe with ulcers in between toes. He had no evidence of fever or elevated white blood cell count. A computed tomography [MEDICATION NAME] (CTA) was performed and showed evidence of occlusion to the right peroneal artery (an artery running along the back part of the leg to the heel) and right tibial arteries (two arteries of the lower leg) appear to be patent to the level of the ankle. Vascular surgery was consulted and completed an assessment on 11/18/19. Recommendation was to proceed with an angiogram of the right lower extremity with possible right transmetatarsal amputation. Resident #1 was currently in the hospital at the time of the survey. On 11/20/19 at 2:37pm a phone interview occurred with the Medical Director who was familiar with Resident #1. He recalled assessing him on 2 different occasions due to his heart concerns and the use of a Life Vest (a personal defibrillator worn by someone who is at risk for sudden [MEDICAL CONDITION]). The physician indicated Resident #1 had no complaints of foot pain or of not having his dressings changed and he was not aware the treatments had not been completed. He further stated he would have expected the treatments to be completed as ordered. The Medical Director stated due to Resident #1's chronic [MEDICAL CONDITION], diabetes and the necrotic tissue present to his feet on admission, the damage was irreversible and progression towards a possible amputation was possible in the future. On 11/20/19 at 2:48pm a phone call was placed to Nurse #2 who completed the skin assessment on 11/11/19. A message was left for a return call. A phone interview was conducted with the Clinical Coordinator on 11/20/19 at 3:02pm. He stated the day Resident #1 was admitted to the facility, he handed the admission orders [REDACTED]. Normally he reviewed the discharge orders to ensure all orders were captured but did not recall doing so for Resident #1. The Clinical Coordinator went on to say he was not aware Resident #1 had [MEDICAL CONDITION] but would have expected the nurses who completed the skin assessments to identify, obtain treatment orders and report to him for wound care follow-up. The Clinical Coordinator oversaw the wound care for the rehab residents and could not recall receiving any information regarding [MEDICAL CONDITION] for Resident #1. Nurse Aide (NA) #1 was interviewed on 11/20/19 at 3:25pm and indicated she was familiar with Resident #1 and had provided him with bed baths during his stay. She could recall seeing dressings to his feet but nothing on his toes that were dark in color. She was unable to recall drainage or odor noted during personal care or Resident #1 with complaints of pain to his feet. A phone interview occurred with Nurse #4 on 11/20/19 at 4:50pm. She could not recall seeing any types of ulcers or discolorations to Resident #1's feet at the time of the skin assessment completed on 11/4/19. On 11/20/19 at 5:45pm a phone interview was conducted with Nurse #3. He recalled entering Resident #1's admission orders [REDACTED]. Stated normally he only entered the medications, diet and allergies and would not have entered the wound care orders. Nurse #3 went on to say when the nurse completing the admission assessment completed the skin assessment and found any issues, they would then look for any wound care orders on the discharge paperwork or initiate treatment orders per the facility standing orders. A telephone interview occurred with Nurse #5 on 11/21/19 at 9:29am. She worked 6pm to 6am and was familiar with the resident. Nurse #5 could not recall Resident #1 with any complaints of pain to his feet, seeing any dressings to his feet and was not assigned to participate with skin assessments, dressing changes or showers as they occurred on the 6am to 6pm shift. She further stated when doing an admission assessment and a wound was identified Licensed Practical Nurses (LPN's) were told to describe the wound in the narrative note but to leave a note for the Clinical Coordinator who would then do a wound assessment and initiate wound care orders, as LPN's were not allowed to stage wounds or enter into the facility wound tracker. A phone call was placed to Nurse #2 on 11/21/19 at 9:44am. A message was left for a return call that was not received during the survey time. On 11/21/19 at 9:48am a phone interview was held with Nurse #6. She was the weekend supervisor and familiar with Resident #1. She explained on 11/17/19 she was asked to evaluate wounds identified on Resident #1, that she was unaware he had. Kerlix wrap was present to bilateral feet with a date of 10/31/19 and no initials. When the Kerlix wrap was removed dried dressings were present to both heels and toes to both feet. Normal saline was used to soak the dressings off which revealed dark colored areas to bilateral heels and toes to both feet with minimal drainage and a foul odor. She further stated a review was made of the orders in the Electronic Medical Records which did not reveal any current orders for treatments, and she did not look at the hospital discharge orders. The resident had a normal temperature, but she felt due to the nature of the wounds an assessment at the emergency room was indicated. An order was obtained from the on-call practitioner and the resident and emergency contact were made aware of the transfer. On 11/21/19 at 10:03am an interview occurred with the interim Administrator and Director of Nursing (DON). The DON explained several staff members had been trained on inputting admitting orders into the Electronic Medical Records (EMR) and Nurse #3 was one of them. Nurses were expected to put in all discharge orders to include wound care and the clinical coordinator should have reviewed them to ensure all orders had been transcribed correctly and completely. He felt it was a lack of education for missing the wound care orders at the time of admission but was unable to state why the diabetic ulcers were not identified with scheduled skin assessments or until 11/17/19. The interim Administrator stated as of 11/21/19 a plan of correction had been initiated for the failure to assess wounds and provide treatments timely. The plan of correction will include, in part: skin audits, clinic record audits and staff education. He further indicated an Initial Allegation Report and 5 working day investigation would be completed and sent in. A phone interview was completed with Nurse #1 on 11/21/19 at 10:39am. She recalled completing the comprehensive nursing assessment when Resident #1 was admitted . She recalled Resident #1 having a foam dressing to his heels that she peeled back, looked at the heels and replaced. No odor was noted, and his toes were dark in color. She went on to say as an LPN she has been instructed to place a note for the Clinical Coordinator regarding wounds found on admission so he can assess and initiate treatment. Nurse #1 stated she left a note in the door of the Clinical Coordinator's office alerting him to the wounds that were present and the need for follow-up. She went on to explain that one nurse was responsible for putting the orders into the EMR and another completed the admission assessment to include assessing the skin. They have a high number of admissions daily and are still responsible for completing medication administration and treatments to other residents in a timely manner. She stated the nurse responsible for orders should have included labs, wound care, etc., but since she was not assigned to putting in the orders, she would not have looked at the discharge orders for wound care. On 11/21/19 at 11:41am a phone interview was held with the Vascular Surgeon assisting with the care of Resident #1 currently in the hospital. He felt the diabetic ulcer to the right foot was not reversible as the diabetes affected the small vessels of the toes with the result of dying digits. He stated it was a natural course of the disease and an amputation was possible in the future as the toes were already necrotic at the time of admission to the facility on [DATE]. He did not feel the lack of dressing changes increased the chance of amputation or necrosis but instead, would have made staff aware of the severity of changes as they occurred. He further stated the resident was not symptomatic of infection at the time of admission on 11/17/19 or currently. A right foot transmetatarsal amputation had been suggested but Resident #1 was undecided. An interview occurred with the Clinical Coordinator on 11/21/19 at 1:45pm. He oversaw the wound care for the rehab unit. If wounds were present at the time of admission, a note was left for him and he followed up the same or next day. He could not recall receiving any written information regarding Resident #1's diabetic ulcers. The Clinical Coordinator stated Nurse #3 had been trained on putting in discharge orders into the EMR, should have included the wound care orders and could not speculate as to why that did not occur. Normally he would have gone back over the orders to ensure they were transcribed correctly and completely but a family emergency occurred, and he did not do so. He further stated he felt staffing played a big part in the wound care orders being missed as the number of admits per day is high and the nurses are also trying to complete medication administration and treatments in a timely manner as well as the admission assessment and inputting the orders. Resident #1 came in late that afternoon between 4pm to 5pm and was 1 of 4 admissions to that hall. The Assistant Director of Nursing (ADON) was interviewed on 11/21/19 at 3:45pm and stated she typically reviewed the new admission and readmission orders [REDACTED]. She was unsure why Resident #1's orders were not verified or reviewed only to say she was off that day, there were 7 admissions to the facility, and it was an oversight. An interview occurred with the DON on 11/21/19 at 3:45pm. The DON was unable to state why the orders not being transcribed correctly, treatments did not occur, or the diabetic ulcers were not identified for 21 days. He could only state it was his expectation for admission orders [REDACTED].

Based on record review and family member, Physician and staff interviews, the facility failed to provide sufficient nursing staff to initiate physician's orders for treatment of [REDACTED].#1)of 3 sampled residents reviewed for well -being and failed to provide showers for 3 (Residents # 2, #3 & #6) of 3 sampled residents reviewed for activities of daily living (ADL). Findings included: This tag is cross-referred to: F684: Based on record review, staff and physician interviews from the facility and vascular surgeon's office, the facility failed to initiate physician orders on admission for the treatment of [REDACTED]. This affected 1 of 3 residents reviewed for well-being (Resident #1). F561 - Based on record review, resident and staff interview, the facility failed to provide showers as scheduled for 3 of 3 sampled residents reviewed for activities of daily living (ADL) (Resident # 2, 3 & 6). On 11/21/19 at 3:45 PM, the Director of Nursing (DON) was interviewed. The DON stated that the average staffing on the 100 hall was 2 nurses and 2 NAs but was budgeted for 3 NAs. He further stated that there would be a Job Fair on 11/21/19 with hopes of hiring more NAs for the 100 hall.

Based on record review, staff, Responsible Party (RP) and Physician interview, the facility failed to immediately inform the resident's RP when there were changes in resident's medications for 1 of 3 sampled residents reviewed for notification of changes (Resident #2). Findings included: Resident #2 was originally admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. Resident #2's hospital after visit summary (AVS) form dated 10/10/19 was reviewed. The form included a list of discharged medications which included Klonopin (an anti-anxiety medication) 0.5 milligrams (mgs) by mouth twice a day for 5 days. The Physician's progress note dated 10/14/19 was reviewed. Under assessment and plan, the note indicated that resident's anxiety was stable and to discontinue Klonopin after the resident completed the course of 5 days and to add [MEDICATION NAME] (an anti-anxiety medication) 5 mgs by mouth 3 times a day and [MEDICATION NAME] (used for dementia) 5 mgs by mouth daily. Resident #2 had doctor's orders dated 10/14/19 for [MEDICATION NAME] 5 mgs by mouth 3 times a day and [MEDICATION NAME] 5 mgs by mouth daily. This order was received by Nurse #7. Review of the Physician's progress notes and nurse's notes revealed no documentation that the resident's RP was informed of the changes in resident's medications. On 11/20/19 at 8:50 AM, Nurse # 7 was interviewed. She verified that she was the nurse who received the order for [MEDICATION NAME] and [MEDICATION NAME] on 10/14/19 for Resident #2. She also indicated that she did not inform the RP of the new orders. Nurse #7 further stated that a nursing staff was assigned to go with the physician during rounds. The nursing staff wrote the orders and transcribed the orders in the computer. The nursing staff who accompanied the physician during rounds, should be responsible for informing the RP of the new orders. Nurse #7 also indicated that when a physician made his round and wrote new orders, he should be responsible for calling the RP and for informing the RP of new changes in the resident's medications. On 11/20/19 at 1:08 PM, Resident #2's RP was interviewed. The RP stated that he/she was not informed when the resident's Klonopin was discontinued and when [MEDICATION NAME] and [MEDICATION NAME] were added. On 11/21/19 at 9:05 AM, Nurse # 5 was interviewed. Nurse #5 stated that she accompanied the physician during his rounds. She wrote orders for the physician and at times transcribed orders in the computer when she had time. When she had no time to transcribe the orders in the computer, she handed the orders to the nurse assigned to the resident. Nurse #5 indicated that she had not been informing the RP of new medication orders. She stated that she didn't know that she had to inform the RP of changes in medications or new medication orders. On 11/21/19 at 1:15 PM, the Physician of Resident #2 was interviewed. He stated that he normally called the resident's RP to discuss any major issues or acute episode and not for minor issues, but he was available anytime when families requested to talk to him. He expected the nurses to notify the RP for minor changes in resident's medications like new medication orders. On 11/21/19 at 4:45 PM, the Director of Nursing (DON) was interviewed. He stated that most of his nursing staff came from the acute care setting and were not aware of the regulations in nursing homes. He indicated that he would train all nursing staff on notification of RP when there was a change in resident's treatment/medication.

Based on record review, resident, family member and staff interview, the facility failed to provide showers as scheduled for 3 of 3 sampled residents reviewed for activities of daily living (ADL) (Residents # 2, 3 & 6). Findings included: 1. Resident #3 was originally admitted to the facility on [DATE] and was readmitted on [DATE] with multiple [DIAGNOSES REDACTED]. The admission Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #3's cognition was intact, he had no rejection of care and he was totally dependent with bathing. The assessment under preferences for customary routine/activities indicated that it was very important for him to choose between a tub bath, shower, bed bath or sponge bath. The shower schedule for the 100 hall (rehabilitation (rehab) hall) was reviewed. The shower schedule listed Resident #3 to have a shower every Tuesday and Friday on night shift. The Nursing Assistant (NA) ADL worksheet which included the documentation of type of bath received was reviewed from 10/29/19 - 11/21/19. Four of 4 scheduled showers were not provided to Resident #3. The worksheet did not indicate that Resident #3 was provided or had received a shower on 11/1/19, 11/5/19, 11/15/19 and 11/19/19. Resident #3 was at the hospital on [DATE] and 11/12/19. The worksheet indicated that Resident #3 was provided a bed bath on 11/1/19, 11/3/19, 11/16/19, 11/17/19 and 11/18/19. On 11/20/19 at 3:51 PM, Resident #3 was interviewed. A family member was in the room during the interview. Resident #3 stated that he was not offered any shower since he was admitted to the facility. Resident #3 stated that the facility was short of staff and he needed 2 persons assist in getting in and out of bed due to the lift. The family member added that she came to visit often and the facility was short of staff. The family member verified that the resident had not received a shower since he was admitted to the facility, but the NA provided him bed bath. The family member further stated that the resident would love to have a shower. On 11/20/19 at 4:10 PM, NA # 1 was interviewed. She stated that she started working at the facility in (MONTH) 2019. She indicated that the normal staffing on the 100 hall was 3 NAs on day shift. The 100 hall was a rehab hall and most of the residents needed assistance with their ADL due to weakness, so sick or had broken bones. NA #1 revealed that the staffing most of the time was only 2 NAs. She tried her best to provide the care for her residents, however if she needed help, she had to wait until the other NA or a Nurse was available to help. NA #1 added that most of the time, residents were not provided showers as scheduled due to short of staff. On 11/20/19 at 4:20 PM, NA #2 was interviewed. NA #2 stated that the normal staffing on the 100 hall was 3 NAs and most of the time there were only 2 NAs assigned. The NA indicated that he/she could do the work but if the resident was a 2 person assist, he had to wait until a NA or a Nurse was available. There was no time to provide showers to residents when only 2 NAs on the floor. On 11/21/19 at 2:53 PM, NA #3 was interviewed. She stated that Resident #3 was scheduled to have a shower on night shift. She stated that most of the residents refused to have a shower at night including Resident #3. The residents preferred to have shower during the day. NA #3 stated that she had informed the nurse that Resident #3 had refused to have a shower at night. On 11/21/19 at 3:14 PM, the Assistant Director of Nursing (ADON) was interviewed. She stated that she was responsible for updating the shower schedule. The ADON indicated that she was not aware that Resident #3 was refusing to have shower at night. On 11/21/19 at 4:45 PM, the Director of Nursing (DON) was interviewed. He stated he expected the NAs to provide the shower as scheduled and to notify the nurse and to document when the resident refused shower. The DON stated that Resident #3 was alert and oriented and had not refused care. The DON also added that the staffing budget for the 100 hall was to have 3 NAs on day shift however there were only 2 NAs assigned. 2. Resident #6 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. The admission Minimum Data Set (MDS) assessment dated [DATE] indicated that Resident #6 had cognitive impairment and needed assistance with bathing. The assessment indicated that Resident #6 had no rejection of care. The assessment under preferences for customary routine/activities indicated that it was very important for her to choose between a tub bath, shower, bed bath or sponge bath. The shower schedule for the 100 hall (rehabilitation (rehab) hall) was reviewed. The shower schedule listed Resident #6 to have a shower every Wednesday and Saturday on day shift. The Nursing Assistant (NA) ADL worksheet which included the documentation of type of bath received was reviewed from 11/11/19 - 11/21/19. Three of 3 scheduled showers were not provided to Resident #6. The worksheet did not indicate that Resident #6 was provided or had received a shower on 11/13/19, 11/16/19 and 11/20/19. The worksheet indicated that the resident was provided a sponge bath on 11/13/19. On 11/20/19 at 3:51 PM, Resident 6's family member was interviewed. The family member stated that Resident #6 was not offered any shower since she was admitted to the facility. The family member added that she came to visit every day and the facility was short of staff. The family member indicated that the resident preferred to have a shower. On 11/20/19 at 4:10 PM, NA # 1 was interviewed. She stated that she started working at the facility in (MONTH) 2019. She indicated that the normal staffing on the 100 hall was 3 NAs on day shift. The 100 hall was a rehab hall and most of the residents needed assistance with their ADL due to weakness, so sick or had broken bones. NA #1 revealed that the staffing most of the time was only 2 NAs. She tried her best to provide the care for her residents, however if she needed help, she had to wait until the other NA or a Nurse was available to help. NA #1 added that most of the time, residents were not provided showers as scheduled due to short of staff. On 11/20/19 at 4:20 PM, NA #2 was interviewed. NA #2 stated that the normal staffing on the 100 hall was 3 NAs and most of the time there were only 2 NAs assigned. The NA indicated that he could do the work but if the resident was a 2 person assist, he had to wait until a NA or a Nurse was available. There was no time to provide showers to residents when only 2 NAs on the floor. On 11/21/19 at 4:45 PM, the Director of Nursing (DON) was interviewed. He stated he expected the NAs to provide the shower as scheduled and to notify the nurse and to document when the resident refused shower. The DON also added that the staffing budget for the 100 hall was to have 3 NAs on day shift however there were only 2 NAs assigned. 3. Resident #2 was originally admitted to the facility on [DATE] and was readmitted on [DATE] with multiple [DIAGNOSES REDACTED]. The admission Minimum Data Set (MDS) assessment dated [DATE] indicated that Resident #2's cognition was intact, she had no rejection of care and she was dependent with bathing. The shower schedule for the 100 hall (rehabilitation (rehab) hall) was reviewed. The shower schedule listed Resident #2 to have a shower every Monday and Thursday on day shift. The Nursing Assistant (NA) ADL worksheet which included the documentation of type of bath received was reviewed from 10/10/19 - 11/7/19. Four of 4 scheduled showers were not provided to Resident #2. The worksheet did not indicate that Resident #2 was provided or had received a shower on 10/14/19, 10/17/19, 1021/19 and 10/24/19. The worksheet indicated that the resident was provided a sponge bath/bed bath on 10/10/19, 10/11/19, 10/12/19, 10/15/19, 10/16/19, 10/17/19, 10/19/19, 10/20/19, 10/21/19, 10/22/19 and 10/24/19. On 11/20/19 at 1:08 PM, Resident#2's family member was interviewed. The family member stated that the resident was alert and oriented and she had been telling the family that she had not had a shower since admitted to the facility. On 11/20/19 at 4:10 PM, NA # 1 was interviewed. She stated that she started working at the facility in (MONTH) 2019. She indicated that the normal staffing on the 100 hall was 3 NAs on day shift. The 100 hall was a rehab hall and most of the residents needed assistance with their ADL due to weakness, so sick or had broken bones. NA #1 revealed that the staffing most of the time was only 2 NAs. She tried her best to provide the care for her residents, however if she needed help, she had to wait until the other NA or a Nurse was available to help. NA #1 added that most of the time, residents were not provided showers as scheduled due to short of staff. On 11/20/19 at 4:20 PM, NA #2 was interviewed. NA #2 stated that the normal staffing on the 100 hall was 3 NAs and most of the time there were only 2 NAs assigned. The NA indicated that he could do the work but if the resident was a 2 person assist he had to wait until a NA or a Nurse was available. There was no time to provide showers to residents when only 2 NAs on the floor. On 11/21/19 at 4:45 PM, the Director of Nursing (DON) was interviewed. He stated he expected the NAs to provide the shower as scheduled and to notify the nurse and to document when the resident refused shower. The DON also added that the staffing budget for the 100 hall was to have 3 NAs on day shift however there were only 2 NAs assigned.

Based on record review, observation, and interviews with the physician, Psychiatric Nurse Practitioner (PNP), Pharmacy Consultant, and staff, the facility failed to have an adequate clinical indication for the use of antipsychotic medication (Residents #83 and #291), failed to complete an Abnormal Involuntary Movement Scale (AIMS) test (used to assess for extrapyramidal symptoms for residents receiving antipsychotic medication) prior to the administration of an antipsychotic medication (Resident #291), and failed to ensure as needed (PRN) [MEDICAL CONDITION] medications were time limited in duration (Residents #43 and #291). This was for 3 of 5 residents reviewed for unnecessary medications. The findings included: 1. Resident #83 was initially admitted to the facility on [DATE] and most recently readmitted on [DATE] with multiple [DIAGNOSES REDACTED]. A physician's order [REDACTED].#83. The plan of care for Resident #83, effective on 4/2/18, included, in part, the problem area of behaviors noted as yelling out, resisting care, throwing dentures accords the room, removing clothing, and being combative. The interventions included, in part, record behaviors on behavior tracking form and monitor pattern of behavior (time of day, precipitating factors, specific staff or situations). A pharmacy recommendation dated 4/9/18 indicated Resident #83 was admitted with an order for [REDACTED]. The pharmacy recommendation additionally requested that if antipsychotic therapy was to continue, that the physician provide detailed documentation of: 1. Specific diagnosis/indication requiring treatment 2. Symptom criteria/target behaviors 3. Facility interdisciplinary team should ensure ongoing monitoring of specific target behaviors and document a) whether danger to self or others, b) desired outcome(s), c) the efficacy of individualized, nonpharmacological approaches, and d) potential adverse consequences This recommendation was marked as accepted and was signed by Resident #83 ' s physician on 4/30/18 and a GDR of [MEDICATION NAME] was to be completed. There was no additional documentation on this pharmacy recommendation by Resident #83 ' s physician. A physician's order [REDACTED].#83 ' s [MEDICATION NAME] 12.5 mg at rising and a decrease in the 25 mg at bed to 12.5 mg at bed. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #83 ' s cognition was severely impaired. She had no mood issues, no potential indicators of [MEDICAL CONDITION], no behaviors, and no rejection of care. Resident #83 was administered antipsychotic medication on 7 of 7 days, she received antipsychotic medications on a routine basis only, and the date of her last GDR was 5/2/18. There was no physician documentation that a GDR was clinically contraindicated for Resident #83. A Psychiatric Nurse Practitioner (PNP) note dated 8/14/18 indicated Resident #83 was on a very low dose of [MEDICATION NAME] (12.5 mg at bed) for behaviors and the family ' s request to continue the medication. The PNP noted Resident #83 ' s presentation as energetic and smiling with no symptoms of anxiety and no interference with Activities of Daily Living (ADLs). She wrote that she would discontinue [MEDICATION NAME] at some point, with family support. Resident #83 was discharged to the hospital on [DATE] following a fall resulting in injury. She was readmitted on [DATE]. The hospital discharge summary dated 9/10/18 included a physician's order [REDACTED]. This was an increase in the [MEDICATION NAME] dosage she was on when she was admitted to the hospital on [DATE]. At that time, she was on [MEDICATION NAME] 12.5 mg at bed. A PNP note dated 9/11/18 indicated Resident #83 was on [MEDICATION NAME] with no chart [DIAGNOSES REDACTED]. The PNP wrote that she would GDR [MEDICATION NAME] for no supporting [DIAGNOSES REDACTED]. Medication orders by the PNP indicated to discontinue [MEDICATION NAME] 12.5 mg once daily. A physician's order [REDACTED].#83. She remained on 25 mg of [MEDICATION NAME] at night. A Social Worker (SW) note dated 9/13/18 indicated Resident was alert and oriented to self only. She was noted to be an exit seeker but was easily redirected. Resident #83 had a recent fall with injury to her leg and subsequent pain that caused her yell out and refuse ADL care when the leg was moved. The significant change MDS dated [DATE] indicated Resident #83 ' s cognition was severely impaired. She had no mood issues and no potential indicators of [MEDICAL CONDITION]. Resident #83 had verbal behaviors on 1 to 3 days and rejection of care on 1 to 3 days. She was on PRN (as needed) pain medications and was noted with vocal complaints of pain and/or facial expressions indicating possible pain on 3 to 4 days during the 5-day MDS look back period. Resident #83 was administered opioid medication and antipsychotic medication on 7 of 7 days. Antipsychotic medications were received on a routine basis only and there was no physician documentation that a GDR was clinically contraindicated for Resident #83. A PNP note dated 9/25/18 indicated Resident #83 was on [MEDICATION NAME] for behaviors with no supporting diagnosis. Resident #83 was witnessed with no symptoms of anxiety and staff had reported that she had both good and bad days. The PNP indicated she deferred a further GDR of [MEDICATION NAME] at this time. A review of the behavior monitoring flow record for (MONTH) (YEAR) indicated Resident #83 was monitored for the behaviors of yelling and resisting care. She was documented with one episode of yelling (9/29/18) and one episode of resisting care (9/13/18). A PNP note dated 10/16/18 indicated Resident #83 was on a low dose of [MEDICATION NAME] for behaviors. The PNP wrote that the low dose of [MEDICATION NAME] was a recently reinstated dose due to a GDR fail. (Based on the medical record, there was no evidence of GDR fail of [MEDICATION NAME]). This PNP note also indicated that Resident #83 had no witnessed anxiety and that staff reported no concerns. A nursing note dated 10/22/18 at 3:30 PM indicated Resident #83 was self-propelling her wheelchair around the unit and yelling at others who walked by. She entered another resident ' s room and became more agitated when staff attempted to approach her. A nursing note dated 10/22/18 at 6:33 PM indicated Resident #83 continued to yell out and when asked if she was in pain she replied yes. PRN pain medication was provided. A nursing note dated 10/29/18 indicated Resident #83 yelled out frequently and when asked if she was in pain she confirmed she was. A nursing note dated 10/30/18 indicated Resident #83 was frequently yelling at staff, leave me alone, can ' t you see I ' m hurting. Her PRN pain medication was administered. A review of the behavior monitoring flow record for (MONTH) (YEAR) indicated Resident #83 was monitored for the behaviors of yelling and resisting care. She was documented with two episodes of yelling (10/30/18 x2) and no episodes of resisting care. A pharmacy recommendation dated 11/5/18 indicated Resident #83 had noted pain per nursing documentation when she was exhibiting behaviors. She had no routine pain therapy in place. Resident #83 was noted with [MEDICATION NAME] and the pharmacy consultant wrote, Please note surveyors may consider inappropriate use of antipsychotic if resident ' s behaviors are related to pain. The recommendation was to re-evaluate to determine if routine pain medication could be started for Resident #83. The physician indicated on this form that Resident #83 was okay on [MEDICATION NAME] and no routine pain medications. The form was signed by Resident #83 ' s physician on 12/20/18. A nursing note dated 11/12/18 indicated Resident #83 began to sundown around 3:00 PM and was noted to yell out at staff and at other residents. Resident #83 ' s family had reported that she could be pain when she exhibited this behavior. She had PRN pain medication which was effective. A PNP note dated 11/13/18 indicated Resident #83 was on a low dose of [MEDICATION NAME] for behaviors. The PNP again wrote that the low dose of [MEDICATION NAME] was a recently reinstated dose due to a GDR fail. (Based on the medical record, there was no evidence of GDR fail of [MEDICATION NAME]). Staff reported Resident #83 had been without sleep for 24 hours. [MEDICATION NAME] (antidepressant) was to be initiated for sleep and [MEDICATION NAME] was to be changed from 25 mg at bed to 25 mg at morning. A physician's order [REDACTED].#83. A nursing note dated 11/19/18 indicated Resident #83 was self-propelling her wheelchair around the unit and was meowing like a cat. She continued to yell out frequently and ignore staff when she was spoken to. A nursing note dated 11/20/18 indicated Resident #83 continued to remove her clothing in the common area. She attempted to stand up unassisted and stated, I ' ll just fall and go to the hospital. A PNP note dated 11/27/18 indicated Resident #83 was on a low dose of [MEDICATION NAME] for behaviors. The PNP again wrote that the low dose of [MEDICATION NAME] was a recently reinstated dose due to a GDR fail. (Based on the medical record, there was no evidence of GDR fail of [MEDICATION NAME]). Resident #83 ' s presentation was described as calm and cooperative, mood was stable, and sleep and appetite were reported to be adequate. The staff reported no concerns. A review of the behavior monitoring flow record for (MONTH) (YEAR) indicated Resident #83 was monitored for the behaviors of yelling out and resisting care. She was documented with five episodes of yelling out (11/2/18 x 2 and 11/8/18 x 3) and 7 episodes of resisting care (11/19/18 x 3, 11/20/18 x 2, and 11/21/18 x 2). A nursing note dated 12/7/18 indicated Resident #83 was noted to be very combative and using profanity at staff. A SW note dated 12/17/18 indicated Resident #83 could become easily agitated and combative both verbally and physically. She had exit seeking behaviors and entered other resident ' s rooms looking for her mother or father. Staff reported she refused care at times and was combative with ADL care. A PNP note dated 12/28/18 indicated Resident #28 was on a low dose of [MEDICATION NAME] for behaviors and staff reported this was beneficial for delusions. A review of the behavior monitoring flow record for (MONTH) (YEAR) indicated Resident #83 was monitored for the behaviors of yelling out, resisting care, and sleeplessness. She was documented with two episodes of yelling out (12/10/18 x2) and no episodes of resisting care or sleeplessness. A nursing note dated 1/7/19 indicated Resident #83 began to sundown around 3:00 PM and was noted to yell out at staff and at other residents. Resident #83 ' s family had reported that she could be pain when she exhibited these behaviors. She had an order for [REDACTED].>A PNP note dated 1/29/19 indicated staff reported no recent behaviors or concerns for Resident #83. The PNP recommended to taper and discontinue [MEDICATION NAME] if Resident #83 remained stable. She advised staff to consider her behaviors as consistent with dementia. A review of the behavior monitoring flow record for (MONTH) 2019 indicated Resident #83 was monitored for the behaviors of loss of interest in eating, paranoia, and [MEDICAL CONDITION]. She was documented with no episodes of any of these behaviors. A nursing note dated 2/1/19 indicated Resident #83 was reportedly awake all night. She was cooperative with taking her medications but refused her laboratory draw. During breakfast Resident #83 was taking other residents ' plates and when redirected she threw them on the floor. A nursing note dated 2/13/19 indicated Resident #83 began to sundown around 3:00 PM and was noted to yell out at staff and at other residents. Resident #83 ' s family had reported that she could be pain when she exhibited these behaviors. She had an order for [REDACTED].>A nursing note dated 2/17/19 indicated Resident #83 was having outbursts of yelling at staff, using profanity, and taking items from other residents. A nursing note dated 2/19/19 indicated Resident #83 was picking up dining room chairs off the floor and carrying them around by way of her wheelchair. Redirection was attempted, and her PRN pain medication was offered, and she spit it on the floor. A PNP note dated 2/26/19 indicated Resident #83 was on low dose of [MEDICATION NAME] for behaviors. Staff reported a disturbed sleep pattern and intermittent irritability. A medication adjustment was made with Resident #83 ' s [MEDICATION NAME] prescribed for sleep. A review of the behavior monitoring flow record for (MONTH) 2019 indicated Resident #83 was monitored for the behaviors of loss of interest in eating and paranoia. She was documented with no episodes of loss of interest in eating and 9 episodes of paranoia (2/14/19 x 2, 2/19/19 x 2, 2/20/19 x 4, and 2/21/19 x 1). A nursing note dated 3/4/19 (entered as late entry note on 3/6/19) indicated Resident #83 refused to go to sleep and she talked continuously to anyone and everyone. Redirection was noted to be effective for a short period of time. A PNP note dated 3/12/19 indicated Resident #83 was on a low dose of [MEDICATION NAME] for behaviors. A recent dose increase in [MEDICATION NAME] for sleep had showed no obvious changes per staff report. Resident #83 was observed by the PNP to be calm, pleasantly confused, and in no distress. A review of the behavior monitoring flow record for (MONTH) 2019 indicated Resident #83 was monitored for the behaviors of loss of interest in eating and paranoia. She was documented with no episodes of these behaviors. A nursing note dated 4/9/19 indicated Resident #83 began to sundown around 3:00 PM and was noted to yell out at staff and at other residents. Resident #83 ' s family had reported that she could be pain when she exhibited these behaviors. She had an order for [REDACTED].>A PNP note dated 4/9/19 indicated Resident #83 was on a low dose of [MEDICATION NAME] prescribed by her primary care physician for behaviors. Resident #83 was noted to be calm with a witnessed stable mood. A review of the behavior monitoring flow record for (MONTH) 2019 indicated Resident #83 was monitored for the behaviors of loss of interest and paranoia. She was documented with no episodes of loss of interest and 4 episodes of paranoia (4/1/19 x 2 and 4/2/19 x 2). An observation was conducted of Resident #83 on 4/29/18 at 12:20 PM. Resident #83 was observed eating her lunch in the dining room of the secured memory care unit. At the completion of her meal she picked up her plate and began self-propelling her wheelchair out of the dining room as she carried her plate. Staff attempted to redirect Resident #83 and to take the plate from her. Resident #83 yelled no, no to the staff and she had not let go of the plate. Staff proceeded to let Resident #83 leave the dining room area and she had no further behaviors observed at this time. An interview was conducted with Nurse #2 on 5/1/19 at 10:35 AM. She reported that she was very familiar with Resident #83 and that she had worked with her since her admission to the facility. She indicated that Resident #83 had behaviors that included yelling out, refusing care, standing up without assistance, and exit seeking. She stated that the behaviors seemed to worsen in the afternoon with sundowning. Nurse #2 also indicated that she believed some of Resident #83 ' s behaviors were related to pain that the resident was unable to express. She reported that Resident #83 was on [MEDICATION NAME] since her admission to the facility and that the family reported she was on it in the past. She stated that she had witnessed no disturbing delusions or AVH for Resident #83. An interview was conducted with the Pharmacy Consultant on 5/2/19 at 8:25 AM. The pharmacy recommendation dated 11/5/18 that indicated Resident #83 had noted pain per nursing documentation when she was exhibiting behaviors was reviewed with the Pharmacy Consultant. She reported that based on her review of the nursing notes, Resident #83 ' s behaviors were related to pain. She stated that the only place she saw a mention of delusions was in the PNP notes. A phone interview was conducted with the PNP on 5/1/19 at 2:45 PM. The PNP was asked what the clinical indication for Resident #83 ' s [MEDICATION NAME] was. She reported that from her recollection, Resident #83 had no known history of a true psychiatric disorder requiring antipsychotic medication. She stated that Resident #83 was on [MEDICATION NAME] when she first began treating her and that she had not initiated the order. The PNP explained that she normally did not initiate an antipsychotic medication for a [DIAGNOSES REDACTED]. She further explained that an example of a disturbing delusion was seeing snakes in their food causing the resident not to eat. She reported that to her knowledge Resident #83 had some delusions, but they were not disturbing delusions and that her behaviors were typical for a resident with dementia. The PNP stated that Resident #83 ' s family and the facility were resistant to discontinuing the [MEDICATION NAME]. A phone interview was conducted with Resident #83 ' s physician on 5/2/19 at 10:05 AM. The physician was asked what the clinical indication for Resident #83 ' s [MEDICATION NAME] was. He reported that he believed this was for behavior modification. He indicated that Resident #83 was impulsive which put her at a safety risk and that she had a history of [REDACTED]. The pharmacy recommendation dated 11/5/18 that indicated Resident #83 had noted pain per nursing documentation when she was exhibiting behaviors was reviewed with the physician. He reported that he had no evidence that Resident #83 ' s pain correlated to her behaviors and that he thought it was completely unrelated. He stated that he talked to the nursing staff and depended on their interpretation of the behaviors. An interview was conducted with the Director of Nursing (DON) on 5/2/19 at 10:25 AM. He stated he expected all antipsychotics to have an adequate clinical indication for use. 2a. Resident #291 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A physician's order [REDACTED]. A review of Resident #291 ' s Medication Administration Record [REDACTED]. The admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #291 had short term memory problems, long term memory problems, and severely impaired decision-making skills. He was administered antipsychotic medication on 1 of 7 days during the MDS look back period. A review of the medical record revealed there was no AIMS (Abnormal Involuntary Movement Scale) test completed for Resident #291. An interview was conducted with the Director of Nursing (DON) on 4/30/19 at 3:10 PM. He verified that there was no AIMS completed for Resident #291. He stated that he expected an AIMS to be conducted prior to the initiation of an antipsychotic medication. 2b. Resident #291 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident #291 ' s admission documentation included a Psychiatric Nurse Practitioner (PNP) note dated 3/26/19 that indicated he was prescribed as needed (PRN) [MEDICATION NAME] (antipsychotic medication) for agitation. She indicated that there was no supporting [DIAGNOSES REDACTED].#291 ' s behaviors were typical for advanced dementia. The PNP noted that she was considering a discontinuation of Resident #291 ' s PRN [MEDICATION NAME]. A physician's order [REDACTED]. There was no stop date for this PRN [MEDICATION NAME] order. A physician ' s note dated 4/10/19 indicated Resident #291 was on PRN [MEDICATION NAME] and that he was going to follow up with psychiatric services to see if this [MEDICATION NAME] could be discontinued. A review of Resident #291 ' s Medication Administration Record [REDACTED]. A review of Resident #291 ' s active physician's order [REDACTED]. Resident #291 continued to have an active order for PRN [MEDICATION NAME] with no stop date. A phone interview was conducted with the PNP on 5/1/19 at 2:45 PM. The 3/26/19 PNP note for Resident #291 that indicated he was prescribed PRN [MEDICATION NAME] with no supporting [DIAGNOSES REDACTED]. She stated that she was not the original prescriber of this PRN [MEDICATION NAME] and she confirmed there was no supporting diagnosis. She additionally indicated that she was aware of the regulation for PRN antipsychotics to be limited to a 14-day duration. The PNP stated she would discontinue the PRN [MEDICATION NAME] at her next visit with Resident #291. An interview was conducted with Resident #291 ' s physician/the facility ' s Medical Director on 5/2/19 at 8:30 AM. The 4/9/19 physician's order [REDACTED]. He reported that the PRN [MEDICATION NAME] was in place for agitation and adjustment. He indicated he was aware of the regulation for PRN antipsychotics to be limited to a 14-day duration. He reported that the PRN [MEDICATION NAME] should be discontinued as per the regulations. An interview was conducted with the Director of Nursing (DON) on 5/2/19 at 10:25 AM. He stated he expected all antipsychotics to have an adequate clinical indication for use and for PRN antipsychotic medication orders to be limited to a 14-day duration. 3. Resident #43 was admitted on [DATE] with the [DIAGNOSES REDACTED]. Resident #43 ' s physician order [REDACTED]. A review of the pharmacist ' s Medication Review Forms for Resident #43 dated 11/14/18, 2/4/19 and 4/2/19, the pharmacist recommended to discontinue [MEDICAL CONDITION] medication [MEDICATION NAME] 0.5 mg every hour as needed, to provide stop date of 14 days or be evaluated every 14 days as required by State regulation. Physician #1 responded and declined the recommendation dated 4/15/19. A review of Resident #43 ' s care plan created 11/21/18 and updated on 2/21/19 revealed the resident had [MEDICAL CONDITION] with Hospice services. There was pain management for [MEDICAL CONDITION] and Hospice (and staff) to provide comfort medications as ordered. A review of the nurse practitioner notes for Resident #43 dated 1/10/19 and 3/14/19 revealed to continue [MEDICATION NAME] 0.5 mg as needed, the resident was stable. A review of Resident #43 ' s Medication Administration Record [REDACTED]. A review of Resident #43 ' s nurses' note dated 1/30/19 revealed the resident was alert to person only and able to make needs known. On 5/1/19 at 9:30 am and 2:10 pm an observation was done of the resident in her bed sleeping. The resident looked comfortable. She was clean and without odor. The resident was not interviewed. 5/1/19 at 11:50 am an interview was conducted with Nurse #2 who stated that the resident was calm and alert on her current medication. Nurse #2 commented that the resident had not required as needed [MEDICATION NAME]. The resident received Hospice services and had terminal/comfort care medications for pain and anxiety. On 5/2/19 at 9:30 am an interview was conducted with Physician #1 via telephone who was the attending for Resident #43. Physician #1 stated that [MEDICATION NAME] (for anxiety) 0.5 mg every 1 hour as needed was a terminal care medication and would not need a stop date. Physician #1 commented that he was aware of the pharmacist ' s medication reviews and recommendations. Physician #1 declined the recommendation, signed the form and did not provide a rationale. Physician #1 did not believe it was necessary to re-evaluate the [MEDICATION NAME] (anti-psychotic) for a terminal resident. Physician #1 was aware of the 14-day stop date or re-evaluation, justification for use and reorder periodically for [MEDICAL CONDITION] medication that was required to be documented. On 5/2/19 at 11:00 am an interview was conducted with the Administrator who stated he expected all medical staff to provide a stop date and reorder according to regulation for all [MEDICAL CONDITION] medications.

Based on medical record review, hospital record review, staff and physician interviews, the facility failed to identify signs of dehydration and intervene for one of one sampled residents (Resident #150) which resulted in hospitalization for dehydration. The findings included: Resident #150 was admitted to the facility on [DATE] and discharged to the hospital on [DATE]. Cumulative [DIAGNOSES REDACTED]. Physician admission orders [REDACTED] Regular diet renal panel and CBC (complete blood count) on 5/27/14 Aspirin 325 mg (milligrams) by mouth two times a day [MEDICATION NAME] (diuretic medication) 25 mg by mouth daily [MEDICATION NAME] (stool softener) 100 mg by mouth two times daily [MEDICATION NAME] (hypertensive medication) 20 mg by mouth daily [MEDICATION NAME] sulfate (iron medication) 325 mg by mouth two times daily insulin Determir 30 (thirty) units SQ (subcutaneous) at bedtime [MEDICATION NAME]-[MEDICATION NAME] (pain medication) 5-325 mg one tablet by mouth every four (4) hours as needed for pain. A Nutrition Risk assessment dated [DATE] indicated Resident #150 received a regular diet and fed herself with set-up help only. Her food and fluid intake was 76--100%. Estimated nutritional needs for adequate fluid intake were 2600 ml (milliliters) based on a weight of 195. Fluid intake sheets for May and June 2014 were reviewed and revealed the following 24 hour fluid intake totals: 5/24/14--1140 ml; 5/25/14--830 ml; 5/26/14--720 ml; 5.27.14--960 ml; 5/28/14--900 ml; 5/29/14--880 ml; 5/30/14--800 ml; 5/31/14--1120 ml; 6/1/14--480 ml; 6/2/14--1220 ml; 6/3/14--720 ml; 6/4/14--1080 ml; 6/5/14--1080 ml; 6/6/14--1260 ml; 6/7/14--1200 ml; 6/8/14--780 ml; 6/9/14--840 ml; 6/10/14--240 ml; 6/11/14--360 ml; 6/12/14--960 ml; 6/13/14--840 ml; 6/14/14--700 ml and 6/15/14 75 ml. Meal Intake sheets for June 2014 were reviewed and revealed Resident #150 consumed 50-100% of every meal from 6/1/14 through 6/7/14. Meal consumption for 6/8/14-breakfast (25%), lunch (25%), dinner (refused); 6/9/14-breakfast (100%), lunch (75%), dinner (refused); 6/10/14-breakfast (not recorded), lunch (not recorded), dinner (25%); 6/11/14-breakfast (75%), lunch (resident not available), dinner (not recorded); 6/12/14-breakfast (50%), lunch (25%), dinner (255); 6/13/14-breakfast (50%), lunch (25%), dinner (25%); 6/14/14-breakfast (50%), lunch (0%), dinner (25%); 6/15/14-breakfast (0%), lunch (0%). Laboratory results for a renal panel dated 5/27/14 revealed a sodium level of 129 (normal--136--147), BUN (blood urea nitrogen) 64 (normal--7--24) and creatinine 1.70 (normal--0.60--1.30). Laboratory results for a renal panel dated 5/30/14 revealed a sodium level of 122, BUN 82 and creatinine 1.80. Nursing notes dated 5/25/14 through 5/31/14 indicated Resident #150 was alert and oriented to self, place, time and reason for admission to the facility, able to feed herself, was incontinent of bladder and bowel. An Admission Minimum Data Set ((MDS) dated [DATE] indicated Resident #150 was cognitively intact. She required supervision with eating and extensive assistance with toilet use. Resident #150 was frequently incontinent of bladder and occasionally incontinent of bowel. A care plan dated 5/28/14 and last revised on 6/2/14 did not address the use of diuretic medication, the low sodium level, elevated BUN and creatinine. Laboratory results for a renal panel dated 6/4/14 revealed a sodium level of 131, potassium 3.6 (normal), BUN 50 and creatinine 1.00. Laboratory results for a urinalysis dated 6/10/14 indicate white blood cells TNTC (too numerous to count) and red blood cells 5--10 (normal is none) as well as heavy bacteria. The culture and sensitivity was received 6/12/14. A physician's progress note dated 6/12/14 stated Resident #150 was somewhat somnolent (drowsy) and it was felt that this may be due to her pain medication [MEDICATION NAME]. Her oral mucosa was somewhat dry. Lab work would be repeated (CBC and renal panel) and her [MEDICATION NAME] was discontinued and changed to [MEDICATION NAME]. A physician's orders [REDACTED]. A physician's orders [REDACTED]. A physical therapy progress note dated 6/12/14 stated Resident #150 did not want to get out of bed. Physical therapy discussed with nursing regarding Resident #150's decline in status Speech therapy was to start working with resident regarding improving po intake. A speech therapy consultation dated 6/12/14 indicated Resident #150 was referred to speech therapy due to the fact nursing staff and therapy staff indicated Resident #150 had difficulty swallowing, was unable to chew food and had poor po intake. A speech therapy note dated 6/12/14 stated Resident #150 was seen in her room. She had limited verbalizations and was fatigued. She tolerated a mechanical soft diet without signs/ symptoms of difficulty for less than 50% of presentations, spit out food, prolonged chewing. Meal intake was less than 25%. A speech therapy note dated 6/13/14 stated Resident #150 was seen in her room for the breakfast meal. She was very fatigued. She tolerated a mechanical soft diet without difficulty for 50% of presentations-soft cold cereal, eggs, soft bread. Resident #150 had prolonged chewing, oral residue (food in her mouth) and a slight cough. The speech therapist consulted with the hall nurse regarding poor po intake and fatigue. A social work note dated 6/13/14 stated an interdisciplinary care plan meeting was held with a family member present. Physical therapy and Occupational therapy had reported Resident #150 was making minimal progress. Resident #150 had a lack of motivation, had dizzy spells at times and therapy had noted she was sleeping more, staying in bed and did not engage in conversation. speech therapy had evaluated Resident #150 on 6/12/14 and indicated she had poor intake with a diet downgrade to mechanical soft diet. A nursing note dated 6/13/14 at 7:16PM stated Resident #150 was oriented with some confusion noted. She continued to feed herself and no concerns were noted with speech, swallowing foods/ liquids or medications. A nursing note dated 6/14/14 at 1:55AM stated Resident #150 had some difficulty swallowing which was noted during medication administration. Resident #150 remained groggy and disoriented that evening. A nursing note dated 6/15/14 at 1:20PM stated a family member had visited and stated Resident #150 did not look right or open her eyes to look at her or talk to her. The family member requested Resident #150 go to the hospital. The physician was notified and Resident #150 was transferred to (name) hospital. vital sings at that time were temperature 96.2, pulse--77, respirations 18, blood pressure 118/62. Vital signs were reviewed and revealed the following: 5/23/14 at 4:18PM 121/65; 5/24/14 at 2:25pm--108/51; 5/26/14 at 11:25am--101/56; 5/27/14 at 7:23pm--95/56; 5/28/14 at11:16am--96/48; 5/28/14 at 7:26pm--108/55; 5/29/14 at 11:11AM--99/60; 5/31/14 at 1:49AM--92/55; 6/9/14 at 1:01AM--98/50; 6/13/14 at 1:58AM--93/48; 6/13/14 at 2:20PM--96/52; 6/14/14 at 11:42AM--105/59. Pulse rate remained in the 70-80 ' s except the following days: 6/8/14 at 5:58PM--97, 6/9/14 at 1:52AM--93 and 6/9/14 at 1:46PM--97. emergency room records dated 6/15/14 revealed the following Diagnoses: [REDACTED]. The emergency room records revealed that resident #150 had a urinary tract infection withy 3+leukocytes and greater than 100 white blood cells and heavy bacteria. Her white blood cell count was significantly elevated at 47.5. [MEDICAL CONDITION] was noted with a hemoglobin of 10.4 and hematocrit 30.5. Acute [MEDICAL CONDITION] was noted with a BUN (blood urea nitrogen) of 204 and creatinine of 6.71. Impression: 1. altered mental status 2. urosepsis 3. acute [MEDICAL CONDITION] 4. [MEDICAL CONDITION] 5. [MEDICAL CONDITION]. The records revealed Resident #150 was admitted to the intensive care unit at the hospital. History and Physical from (name) hospital dated 6/15/14 stated Resident's vital signs on admission were as follows: blood pressure of 97/36, pulse of 77, respiratory rate of 12 and temperature of 96.4. Renal (kidney) function panel revealed, in part, a sodium of 126, potassium 6.1, chloride 92, [MEDICATION NAME] of 16, BUN (blood urea nitrogen) of 204 and creatinine of 6.71. Assessment and Plan: 1. acute/ subacute [MEDICAL CONDITION]/ altered mental status, multifactorial secondary to severe dehydration with acute kidney injury and urinary tract infection. 2. acute kidney injury, likely pre-renal with [MEDICAL CONDITION] with some metabolic acidosis. 3. [MEDICAL CONDITION]ly secondary to acute kidney injury and metabolic acidosis. 5. [MEDICAL CONDITION] probably due to decreased oral intake and dehydration. A consultation note dated 6/16/14 from (name) hospital stated the physician was concerned that Resident #150 might require [MEDICAL TREATMENT] if her renal function did not continue to improve. A catheter was placed for access and also for the possibility of [MEDICAL TREATMENT]. On 8/12/14 at 3:51PM, Nurse #5 stated resident #150 she would feed herself sometimes but needed encouragement and assistance to continue with a meal or complete a meal. She stated nursing staff encouraged resident to eat and drink. She stated she had not noticed a change in Resident #150 ' s medical condition. Nurse #5 stated Resident #150 ' s vital signs were " good ' but the family member with the resident insisted that Resident #150 go to the hospital. On 8/12/14 at 5:48PM, Nurse #6 stated Resident #150 was alert and oriented when she was admitted to the rehabilitation unit (150 hall) on 5/23/14. She stated Resident #150 fed herself but required assistance with turning, repositioning and transfers. Resident #150 was not participating in therapy and was transferred to the 200 hall because she required more assistance with activities of daily living. On 8/13/14 at 8:46AM, NA#1 stated she provided care for Resident #150 on 200 hall. She said Resident #150 would feed herself when she first arrived on 200 hall. Around 6/12/14, she noted that Resident #150 was not eating or drinking much and just left the food and fluids on her tray. She stated she offered and provided alternate food and fluids but Resident #150 refused them. NA#1 stated the last time she provided care for Resident #150 was on 6/12/14. At that time, Resident #150 just kept her eyes closed and would not say anything to her which was different because Resident #150 had talked with her when she first came to the 200 hall. On 8/13/14 at 9:22AM, NA#2 stated she had provided care for Resident #150 a few times. NA#1 said she noticed that Resident #150 was feeding herself when she first came to the 200 hall, then stopped feeding herself. She said they would encourage her to eat and drink and try and feed Resident #150 but she would not open her mouth or just turn her head away when food and fluids were offered. NA#1 said a family member was present on 7/13/14 and asked what was going on with the resident because she was not eating. NA #1 said she spoke with the nurse that day and told the nurse that Resident #150 was not eating and only drinking small sips of fluid. On 8/13/14 at 11:24AM, NA#3 stated Resident #150 fed herself meals and was not assisted with meals. She said, at first, Resident #150 consumed her food and fluids, then began refusing her meals and refused substitutes. She stated she thought it was a couple of days before Resident #150 went to the hospital, she informed the nurse on the hall that Resident #150 was eating and drinking only small amounts of food and fluids. On 8/14/14 at 12:30PM, Nurse #4 stated she provided care to Resident #150 on 6/12/14. She stated a family member was with the resident that day and informed her that Resident #150 had not eaten much the day before and was not feeling well. Nurse #4 did not recall if the nursing assistants had informed her that Resident #150 was not eating or drinking On 8/14/14 at 2:17PM, Resident #150's physician was interviewed. He stated he visited Resident #150 on admission and also on 6/12/14. The physician said he did not recall if he saw a change in her medical condition that day but did document that Resident #150 was somewhat somnolent and her oral mucosa was somewhat dry. He did not recall being notified that she was not eating and drinking much.