Every finding on record at Shenandoah Valley Health and Rehab

Based on staff interview, facility document review, and clinical record review, the facility staff failed to follow professional standards of care regarding medication orders for one of eight residents in the survey sample (Resident #1). The findings include: Facility staff failed to clarify and enter updated admission orders for Resident #1, resulting in medications, that were recommended by the hospital to be discontinued, being ordered and administered to the resident. Resident #1 (R1) was admitted to the facility with diagnoses that included atrial fibrillation, retroperitoneal hematoma, renal hemorrhage, acute blood loss anemia, pleural effusion, hypertension, clostridium difficile (C-diff), acute kidney failure, sepsis, pneumonia, pyelonephritis with renal abscess, protein-calorie malnutrition, breast cancer and alcohol abuse. The minimum data set (MDS) dated [DATE] assessed R1 with moderately impaired cognitive skills. R1's clinical record documented a hospital discharge summary/order sheet dated 9/19/24 listing medication orders after R1's hospital stay from 9/16/24 to 9/19/24. This discharge summary/order sheet documented that R1 was to continue taking the medications apixaban (Eliquis) 5 mg (milligrams) twice per day, diltiazem 180 mg each day, lisinopril 10 mg each day, and enteric-coated aspirin 81 mg each day. R1 was admitted to the nursing facility on 11/7/24 following a hospital stay from 10/11/24 through 11/7/24. Medication orders entered upon R1's admission and signed by the physician on 11/12/24 included apixaban (Eliquis) 5 mg (milligrams) twice per day, diltiazem 180 mg each day, lisinopril 10 mg each day, enteric-coated aspirin 81 mg each day, which was also listed on the 9/19/24 hospital discharge summary. An additional order for Zosyn 4.5 grams intravenously (IV) every 8 hours for six days was entered at that time, which was not included on the 9/19/24 hospital discharge summary. R1's clinical record documented a nursing note dated 11/7/24 stating, .Resident arrived with discharge summary which did not list any IV medications. Called and spoke with discharging nurse who explained medication list for discharge had been updated. MD [hospitalist] with was [was with] nurse while speaking with this nurse on the phone. Faxed over a new list of medications and was told by MD [hospitalist] to use that med list for d/c [discharge] . R1's clinical record documented the updated hospital discharge summary/order sheet dated 11/7/24, referencing a hospital stay from 10/11/24 to 11/7/24. The 11/7/24 discharge/order sheet had a note written by licensed practical nurse (LPN) #1 stating, Updated list that was faxed for facility to use per MD for discharge and was signed by LPN #1 on 11/8/24. This discharge order summary documented that R1 was to stop taking apixaban, aspirin, diltiazem, and lisinopril, as well as including an order for the antibiotic Zosyn 4.5 grams intravenously every 8 hours for six days. R1's clinical record documented an Admission Checklist dated 11/7/24. LPN #1 had checked that all orders had been verified by a second nurse (unit manager). R1's admission orders entered on 11/7/24 were not clarified and/or reconciled based upon the discharge summary/order sheet dated 11/7/24 but were entered from an outdated discharge instruction sheet from the previous hospital stay ending on 9/19/24. The order for the Zosyn was entered on 11/7/24 as listed on the updated order sheet but the orders for the apixaban, aspirin, diltiazem, and lisinopril remained active and were not discontinued. R1's medication administration record (MAR) documented the apixaban aspirin, diltiazem, and lisinopril were administered from 11/8/24 through 11/19/24 per the entered orders. The diltiazem, lisinopril and apixaban were discontinued on 11/19/24. The Zosyn was administered from 11/8/24 through 11/14/24 as ordered. A new order was entered on 11/14/24 to continue the Zosyn with administration documented through 11/19/24. R1's clinical record documented daily skilled nursing notes, and assessment by the physician and/or nurse practitioner (NP) on 11/11/24, 11/12/24, 11/14/24, /11/18/24 and 11/19/24, noting that R1 was assessed with no signs of bleeding or shortness of breath. The NP assessed R1 on 11/18/24 for low blood pressure of 82/50. R1 was ordered and administered a dose of midodrine 5 mg for low blood pressure and parameters were ordered to hold the medications lisinopril and diltiazem, if systolic blood pressure was less than 100. The NP documented a conversation with R1 on 11/19/24 about her medications. A physician's order was entered on 11/19/24 to discontinue the apixaban, diltiazem, and lisinopril and to monitor the resident's blood pressure twice per day for two weeks. On 11/19/24, R1 was assessed with a non-functioning PICC line, with arm swelling, low blood pressure, and was sent to the emergency room via 911 for evaluation and treatment. On 1/21/25 at 2:00 p.m., the administrator and the director of nursing (RN #2) during R1's stay were interviewed about R1's conflicting admission orders and resulting medication errors. The administrator stated R1 arrived for admission on 11/7/24 with a discharge summary/order sheet dated 9/19/24. The administrator stated LPN #1 saw that R1 had a PICC (peripherally inserted central catheter) upon admission but no orders for intravenous (IV) medications. The administrator stated LPN #1 called the hospital and was provided an updated order summary and medicine list dated 11/7/24. The administrator stated the unit manager (LPN #1) entered the order for the IV medication and failed to reconcile the other orders to discontinue the apixaban, aspirin, diltiazem and lisinopril. RN #2 stated, [LPN #1] focused on the antibiotic order and did not pay attention to the discontinued meds [medicines]. The administrator stated the updated admission order list was not uploaded into the clinical record for view by providers. The administrator stated the nurse should have reviewed all the medicines on the updated list, compared it to what was entered, made corrections to what had already been entered, and provided this updated list to providers. The administrator stated that this error was not discovered until a family member questioned R1's medication orders on 11/18/24. RN #2 stated that the nurse admitting a resident was expected to enter admission orders into the electronic health record. RN #2 stated a unit manager or director of nursing was supposed to perform a review and check of all orders within 24 hours. RN #2 stated RN #1 entered the original orders for R1 on 11/7/24 and LPN #1 was supposed to review/verify the orders for accuracy. RN #2 stated LPN #1 failed to thoroughly review/correct the updated admission orders for R1. On 1/21/25 at 3:30 p.m., the admissions director (other staff #2) was interviewed about R1's admission orders. The admissions director stated the hospital usually uploaded a discharge summary and admission orders in the electronic health care portal prior to admission. The admissions director stated upon R1's admission, the hospital had uploaded an outdated admission order list dated 9/19/24. The admissions director stated she did not notice that the discharge summary did not match the current admitted . On 1/21/25 at 4:32 p.m., RN #1 that admitted R1 on 11/7/24 was interviewed. RN #1 stated the admissions director had provided the chart and discharge summary with admission orders for R1. RN #1 stated she did not recognize that the discharge orders were outdated and from a previous hospitalization . RN #1 stated she entered the medicine orders as listed on the original discharge summary (dated 9/19/24) and the unit manager (LPN #1) was supposed to review them. RN #1 stated LPN #1 called the hospital about an order for the IV antibiotic and entered the order for the IV Zosyn. RN #1 stated she had not been aware of the updated admission orders for the other medicines. On 1/22/25 at 8:20 a.m., the physician/medical director (other staff #5) was interviewed about R1's conflicting admission orders. The physician stated he was aware prior to admission that R1 had a history of gastrointestinal bleeding. The physician stated that when he reviewed and signed the admission orders on 11/12/24 which included orders for apixaban, aspirin, diltiazem, and lisinopril, he was not aware that the discharge summary/history uploaded in the health record was outdated. The physician stated he and the nurse practitioner would typically but not always follow recommended medicine orders from the hospitalist. The physician stated R1 had chronic atrial fibrillation and even with a hemorrhage history, there was a risk of stroke/blood clots if the apixaban was discontinued. The physician stated he approved the orders based upon the available discharge summary (dated 9/19/24). The physician stated he was not aware of an updated list of admission orders that had been obtained by LPN #1 that indicated discontinued use of these medicines. The physician stated if he had reviewed the discharge summary and orders dated 11/7/24, he would have most likely discontinued the medicines as recommended by the hospitalist. The physician stated R1 had labs, was routinely assessed/monitored, and had developed no signs of bleeding. The physician stated R1 had the IV antibiotic Zosyn extended for continued treatment of the kidney abscess, in addition to an antibiotic for additional treatment for C-diff. The physician stated when the discrepancy was identified on 11/19/24, the apixaban, diltiazem, and lisinopril were discontinued. The physician stated R1 was discharged to the emergency roiagnom on [DATE] due to a migrated, non-functioning PICC line. The physician stated facility staff should have noticed the 9/19/24 date on the admission orders. The physician stated the outdated admission orders were not caught by staff and the updated list was not implemented. The physician stated facility staff should have had the most recent orders and discharge information for R1 so that medication recommendations could have been followed. On 1/22/5 at 10:07 a.m., LPN #1 that was the unit manager at the time of R1's admission on 11/7/24 was interviewed. LPN #1 stated on 11/7/24, RN #1 had entered the admission orders based upon the orders that came with the resident and that were uploaded in the electronic health record. LPN #1 stated she nor RN #1 noted that the orders were not current (dated 9/19/24). LPN #1 stated when she assisted with R1's skin assessment, she noted the resident had a PICC in the right arm. LPN #1 stated the admission orders she had included no order for IV antibiotics, so she called the hospital for clarification. LPN #1 stated the hospital nurse verified with the hospitalist that the IV Zosyn was to continue, and the hospital nurse faxed a new list of admission orders dated 11/7/24. LPN #1 stated she focused only on the order for the Zosyn and did not reconcile/review the other medication orders listed. LPN #1 stated it was her error as she was the unit manager and was supposed to perform the second check/verification of the admission orders. LPN #1 stated the apixaban, aspirin, diltiazem and lisinopril should have been discontinued upon admission according to the 11/7/24 admission orders. LPN #1 stated she thought she put the updated order list in the communicate book for the providers. LPN #1 stated, This was a very sloppy admission. LPN #1 stated that R1 . came with the wrong orders from the hospital and staff did not pay attention to the dates on the orders. LPN #1 stated, I did the chart check. When I did the check, I did not catch the errors. Apparently, I did not check them all [orders]. LPN #1 stated the apixaban, aspirin, diltiazem and lisinopril should have not been ordered and that she should have reconciled all the orders on the updated list, not just the IV antibiotic. The nurse practitioner (other staff #1) that cared for R1 during her stay was not available for interview as she no longer worked at the facility. The facility's policy titled Medication Administration General Guidelines (dated 1/2023) documented, .Medications are administered as prescribed in accordance with manufacturers' specifications, good nursing principles .Medications are administered in accordance with written orders of the prescriber. If a dose seems excessive considering the resident's age and condition, or a medication order seems to be unrelated to the resident's current diagnosis or condition, the nurse calls the provider pharmacy for clarification prior to the administration of the medication. If necessary, the nurse contacts the prescriber for clarification. This interaction with the pharmacy and the resulting order clarification are documented in the nursing notes and elsewhere in the medical record as appropriate . The facility's Admission Checklist (undated) documented, .Place a check mark beside each task after completion. Leave the checklist in the Nurse notebook. All items MUST be complete . Checklist items for admission included, .Medication Orders entered in PCC [Point Click Care] per Hospital/another SNF Discharge Summary ONLY DO NOT USE PRINTED eMAR's .Orders are to be verified by a second Nurse . The Nursing 2022 Drug Handbook documents on page 1588 regarding unclear orders, A drug order with incomplete or unclear information can result in giving the wrong drug or wrong dose, by the wrong route, or at the wrong time .Clarify all incomplete or unclear orders with the prescriber . (1) On 1/22/25 at 2:40 p.m., the administrator stated the errors related to R1's outdated admission orders were reviewed by their quality assurance committee when identified on 11/19/24. The administrator presented a plan of correction to address failure to review/clarify admission orders that resulted in orders entered for medications (apixaban, aspirin, diltiazem and lisinopril) that should not have been entered. The plan documented that current residents and any new admissions had the potential to be affected by the deficient practice. Interventions implemented starting on 11/19/24 and included the following, with a correction date listed as 1/17/25. -DON notified nurse practitioner (NP) of discrepancies regarding discharge summaries. NP discontinued R1's apixaban, diltiazem and lisinopril. The DON documented a medication error report. - LPN #1 was re-educated on verifying orders, reconciliation with the discharge summary/admission orders and uploading documentation into electronic health record. - Admissions director was re-educated on ensuring that the discharge date on the discharge summary/admission orders corresponded to the admitted for all admission and readmissions. - Initiated practice for all orders for new admissions/readmissions to be reviewed in the morning meeting by the clinical team with the discharge summary reviewed in the electronic health record. Education provided to all unit managers and all department heads regarding admission order review protocol. -Audit completed by DON and/or designee of all admissions from 11/7/24 through 1/9/25 ensuring that the discharge date on the summary corresponded to the admitted and all medication orders were reviewed for accuracy with no identified discrepancies. -Weekly audits on all new admissions/readmission conducted starting on 12/31/24 for four weeks verifying correct admission orders, discharge summaries and medication orders with results reported to the quality assurance committee for review. -Date of correction listed as 1/17/25. Actions taken were reviewed. Education was documented as listed in the correction plan. Audits listed for all new admissions and readmissions were documented and revealed accurate admission orders from the hospital and no discrepancies in medication orders. Weekly audits of all new admissions/readmission were documented for week ending 1/4/25, 1/11/25, and 1/18/25, with no identified discrepancies. Interviews with staff that included the administrator, DON, unit managers, admissions director, and physician/medical director revealed knowledge of the admissions order review protocol and verification of admission orders. Seven of the most recent new admissions were reviewed. Admission orders were accurate with properly dated discharge summaries and no discrepancies identified. This included a new admission since the correction date of 1/17/25, with no discrepancies identified with discharge summary, admission orders, or medication orders. This plan was accepted with correction date of 1/17/25. This deficiency was cited as past non-compliance. R1's emergency room records for 11/19/24 were requested but not received prior to the end of the survey. These findings were reviewed with the administrator and regional consultant during a meeting on 1/22/25 at 3:45 p.m. with no further information presented prior to the end of the survey. (1) Woods, [NAME] Dabrow. Nursing 2022 Drug Handbook. Philadelphia: Wolters Kluwer, 2022.

Based on staff interview, facility document review and clinical record review, the facility staff failed to ensure one of eight residents in the survey sample was free from significant medication errors (Resident #1). The findings include: Resident #1 was ordered and administered the medications apixaban, aspirin, diltiazem and lisinopril for eleven days after admission when updated admission orders recommended these medicines be discontinued. Resident #1 (R1) was admitted to the facility with diagnoses that included atrial fibrillation, retroperitoneal hematoma, renal hemorrhage, acute blood loss anemia, pleural effusion, hypertension, clostridium difficile (C-diff), acute kidney failure, sepsis, pneumonia, pyelonephritis with renal abscess, protein-calorie malnutrition, breast cancer and alcohol abuse. The minimum data set (MDS) dated [DATE] assessed R1 with moderately impaired cognitive skills. R1's clinical record documented a hospital discharge summary/order sheet dated 9/19/24 listing medication orders after R1's hospital stay from 9/16/24 to 9/19/24. This discharge summary/order sheet documented that R1 was to continue taking the medications apixaban (Eliquis) 5 mg (milligrams) twice per day, diltiazem 180 mg each day, lisinopril 10 mg each day, and enteric-coated aspirin 81 mg each day. R1 was admitted to the nursing facility on 11/7/24 following a hospital stay from 10/11/24 through 11/7/24. Medication orders entered upon R1's admission and signed by the physician on 11/12/24 included apixaban (Eliquis) 5 mg (milligrams) twice per day, diltiazem 180 mg each day, lisinopril 10 mg each day, enteric-coated aspirin 81 mg each day, which was also listed on the 9/19/24 hospital discharge summary. An additional order for Zosyn 4.5 grams intravenously (IV) every 8 hours for six days was entered at that time, which was not included on the 9/19/24 hospital discharge summary. R1's clinical record documented a nursing note dated 11/7/24 stating, .Resident arrived with discharge summary which did not list any IV medications. Called and spoke with discharging nurse who explained medication list for discharge had been updated. MD [hospitalist] with was [was with] nurse while speaking with this nurse on the phone. Faxed over a new list of medications and was told by MD [hospitalist] to use that med list for d/c [discharge] . R1's clinical record documented the updated hospital discharge summary/order sheet dated 11/7/24, referencing a hospital stay from 10/11/24 to 11/7/24. The 11/7/24 discharge/order sheet had a note written by licensed practical nurse (LPN) #1 stating, Updated list that was faxed for facility to use per MD for discharge and was signed by LPN #1 on 11/8/24. This discharge order summary documented that R1 was to stop taking apixaban, aspirin, diltiazem, and lisinopril, as well as including an order for the antibiotic Zosyn 4.5 grams intravenously every 8 hours for six days. R1's clinical record documented an Admission Checklist dated 11/7/24. LPN #1 had checked that all orders had been verified by a second nurse (unit manager). R1's admission orders entered on 11/7/24 were not clarified and/or reconciled based upon the discharge summary/order sheet dated 11/7/24 but were entered from an outdated discharge instruction sheet from the previous hospital stay ending on 9/19/24. The order for the Zosyn was entered on 11/7/24 as listed on the updated order sheet but the orders for the apixaban, aspirin, diltiazem, and lisinopril remained active and were not discontinued. R1's medication administration record (MAR) documented the apixaban aspirin, diltiazem, and lisinopril were administered from 11/8/24 through 11/19/24 per the entered orders. The diltiazem, lisinopril and apixaban were discontinued on 11/19/24. The Zosyn was administered from 11/8/24 through 11/14/24 as ordered. A new order was entered on 11/14/24 to continue the Zosyn with administration documented through 11/19/24. R1's clinical record documented daily skilled nursing notes, and assessment by the physician and/or nurse practitioner (NP) on 11/11/24, 11/12/24, 11/14/24, /11/18/24 and 11/19/24, noting that R1 was assessed with no signs of bleeding or shortness of breath. The NP assessed R1 on 11/18/24 for low blood pressure of 82/50. R1 was ordered and administered a dose of midodrine 5 mg for low blood pressure and parameters were ordered to hold the medications lisinopril and diltiazem, if systolic blood pressure was less than 100. The NP documented a conversation with R1 on 11/19/24 about her medications. A physician's order was entered on 11/19/24 to discontinue the apixaban, diltiazem, and lisinopril and to monitor the resident's blood pressure twice per day for two weeks. On 11/19/24, R1 was assessed with a non-functioning PICC line, with arm swelling, low blood pressure, and was sent to the emergency room via 911 for evaluation and treatment. On 1/21/25 at 2:00 p.m., the administrator and the director of nursing (RN #2) during R1's stay were interviewed about R1's conflicting admission orders and resulting medication errors. The administrator stated R1 arrived for admission on 11/7/24 with a discharge summary/order sheet dated 9/19/24. The administrator stated LPN #1 saw that R1 had a PICC (peripherally inserted central catheter) upon admission but no orders for intravenous (IV) medications. The administrator stated LPN #1 called the hospital and was provided an updated order summary and medicine list dated 11/7/24. The administrator stated the unit manager (LPN #1) entered the order for the IV medication and failed to reconcile the other orders to discontinue the apixaban, aspirin, diltiazem and lisinopril. RN #2 stated, [LPN #1] focused on the antibiotic order and did not pay attention to the discontinued meds [medicines]. The administrator stated the updated admission order list was not uploaded into the clinical record for view by providers. The administrator stated the nurse should have reviewed all the medicines on the updated list, compared to what was entered, made corrections to what had already been entered and provided this updated list to providers. The administrator stated this was not discovered until a family member questioned R1's medication orders on 11/18/24. RN #2 stated the nurse admitting a resident was expected to enter admission orders into the electronic health record. RN #2 stated a unit manager or director of nursing was supposed to perform a review and check of all orders within 24 hours. RN #2 stated RN #1 entered the original orders for R1 on 11/7/24 and LPN #1 was supposed to review/verify the orders for accuracy. RN #2 stated LPN #1 failed to thoroughly review/correct the updated admission orders for R1. On 1/21/25 at 3:30 p.m., the admissions director (other staff #2) was interviewed about R1's admission orders. The admissions director stated the hospital usually uploaded a discharge summary and admission orders in the electronic health care portal prior to admission. The admissions director stated upon R1's admission, the hospital had uploaded an outdated admission order list dated 9/19/24. The admissions director stated she did not notice that the discharge summary did not match the current admitted . On 1/21/25 at 4:32 p.m., RN #1 that admitted R1 on 11/7/24 was interviewed. RN #1 stated the admissions director had provided the chart and discharge summary with admission orders. RN #1 stated she did not recognize that the discharge orders were outdated and from a previous hospitalization . RN #1 stated she entered the medicine orders as listed on the original discharge summary (dated 9/19/24) and the unit manager (LPN #1) was supposed to review them. RN #1 stated LPN #1 called the hospital about an order for the IV antibiotic and entered the order for the IV Zosyn. RN #1 stated she was not aware of the updated admission orders for the other medicines. On 1/22/25 at 8:20 a.m., the physician/medical director (other staff #5) was interviewed about R1's conflicting admission orders. The physician stated he was aware prior to admission that R1 had a history of gastrointestinal bleeding. The physician stated when he reviewed and signed the admission orders on 11/12/24 that included orders for apixaban, aspirin, diltiazem, and lisinopril, he was not aware that the discharge summary/history uploaded in the health record was outdated. The physician stated he and the nurse practitioner would typically but not always follow recommended medicine orders from the hospitalist. The physician stated R1 had chronic atrial fibrillation and even with a hemorrhage history, there was a risk of stroke/blood clots if the apixaban was discontinued. The physician stated he approved the orders based upon the available discharge summary (dated 9/19/24). The physician stated he was not aware of an updated list of admission orders that had been obtained by LPN #1 that indicated discontinued use of these medicines. The physician stated if he had reviewed the discharge summary and orders dated 11/7/24, he would have most likely discontinued the medicines as recommended by the hospitalist. The physician stated R1 had labs and was routinely assessed/monitored. The physician stated R1 developed no signs of bleeding, had the IV antibiotic Zosyn extended for continued treatment of the kidney abscess in addition to an antibiotic for additional treatment for C-diff. The physician stated when the discrepancy was identified on 11/19/24, the apixaban, diltiazem and lisinopril were discontinued. The physician stated R1 was discharged to the emergency roiagnom on [DATE] due to a migrated, non-functioning PICC line. The physician stated facility staff should have noticed the 9/19/24 date on the admission orders. The physician stated the outdated admission orders were not caught by staff and the updated list was not implemented. The physician stated facility staff should have had the most recent orders and discharge information for R1 so that medication recommendations could have been followed. On 1/22/5 at 10:07 a.m., LPN #1 that was the unit manager at the time of R1's admission on 11/7/24 was interviewed. LPN #1 stated on 11/7/24, RN #1 had entered the admission orders based upon the orders that came with the resident and that were uploaded in the electronic health record. LPN #1 stated she nor RN #1 noted that the orders were not current (dated 9/19/24). LPN #1 stated when she assisted with the resident's skin assessment, she noted the resident had a PICC in the right arm. LPN #1 stated the admission orders she had included no order for IV antibiotics, so she called the hospital for clarification. LPN #1 stated the hospital nurse verified with the hospitalist that the IV Zosyn was to continue, and the hospital nurse faxed a new list of admission orders dated 11/7/24. LPN #1 stated she focused only on the order for the Zosyn and did not reconcile/review the other medication orders listed. LPN #1 stated it was her error as she was the unit manager and was supposed to perform the second check/verification of the admission orders. LPN #1 stated the apixaban, aspirin, diltiazem and lisinopril should have been discontinued upon admission according to the 11/7/24 admission orders. LPN #1 stated she thought she put the updated order list in the communicate book for the providers. LPN #1 stated, This was a very sloppy admission. LPN #1 stated R1 came with the wrong orders from the hospital and staff did not pay attention to the dates on the orders. LPN #1 stated, I did the chart check. When I did the check, I did not catch the errors. Apparently, I did not check them all [orders]. LPN #1 stated the apixaban, aspirin, diltiazem and lisinopril should have not been ordered and that she should have reconciled all the orders on the updated list, not just the IV antibiotic. The nurse practitioner (other staff #1) that cared for R1 during her stay was not available for interview as she no longer worked at the facility. The facility's policy titled Medication Administration General Guidelines (dated 1/2023) documented, .Medications are administered as prescribed in accordance with manufacturers' specifications, good nursing principles .Medications are administered in accordance with written orders of the prescriber. If a dose seems excessive considering the resident's age and condition, or a medication order seems to be unrelated to the resident's current diagnosis or condition, the nurse calls the provider pharmacy for clarification prior to the administration of the medication. If necessary, the nurse contacts the prescriber for clarification. This interaction with the pharmacy and the resulting order clarification are documented in the nursing notes and elsewhere in the medical record as appropriate . The facility's Admission Checklist (undated) documented, .Place a check mark beside each task after completion. Leave the checklist in the Nurse notebook. All items MUST be complete . Checklist items for admission included, .Medication Orders entered in PCC [Point Click Care] per Hospital/another SNF Discharge Summary ONLY DO NOT USE PRINTED eMAR's .Orders are to be verified by a second Nurse . The Nursing 2022 Drug Handbook documents on page 1588 regarding unclear orders, A drug order with incomplete or unclear information can result in giving the wrong drug or wrong dose, by the wrong route, or at the wrong time .Clarify all incomplete or unclear orders with the prescriber . (1) On 1/22/25 at 2:40 p.m., the administrator stated the errors related to R1's outdated admission orders were reviewed by their quality assurance committee when identified on 11/19/24. The administrator presented a plan of correction to address failure to review/clarify admission orders that resulted in orders entered for medications (apixaban, aspirin, diltiazem and lisinopril) that should not have been entered. The plan documented that current residents and any new admissions had the potential to be affected by the deficient practice. Interventions implemented starting on 11/19/24 included the following with a correction date listed as 1/17/25. -DON notified nurse practitioner (NP) of discrepancies regarding discharge summaries. NP discontinued R1's apixaban, diltiazem and lisinopril. The DON documented a medication error report. - LPN #1 was re-educated on verifying orders, reconciliation with the discharge summary/admission orders and uploading documentation into electronic health record. - Admissions director was re-educated on ensuring that the discharge date on the discharge summary/admission orders corresponded to the admitted for all admission and readmissions. - Initiated practice for all orders for new admissions/readmissions to be reviewed in the morning meeting by the clinical team with the discharge summary reviewed in the electronic health record. Education provided to all unit managers and all department heads regarding admission order review protocol. -Audit completed by DON and/or designee of all admissions from 11/7/24 through 1/9/25 ensuring that the discharge date on the summary corresponded to the admitted and all medication orders were reviewed for accuracy with no identified discrepancies. -Weekly audits on all new admissions/readmission conducted starting on 12/31/24 for four weeks verifying correct admission orders, discharge summaries and medication orders with results reported to the quality assurance committee for review. -Date of correction listed as 1/17/25. Actions taken were reviewed. Education was documented a listed in the correction plan. Audits listed for all new admissions and readmissions were documented and revealed accurate admission orders from the hospital and no discrepancies in medication orders. Weekly audits of all new admissions/readmission were documented for week ending 1/4/25, 1/11/25 and 1/18/25 with no identified discrepancies. Interviews with staff that included the administrator, DON, unit managers, admissions director, and physician/medical director revealed knowledge of the admissions order review protocol and verification of admission orders. Seven of the most recent new admissions were reviewed. Admission orders were accurate with properly dated discharge summaries and no discrepancies identified. This included a new admission since the correction date of 1/17/25, with no discrepancies identified with discharge summary, admission orders, or medication orders. This plan was accepted with correction date of 1/17/25. This deficiency was cited as past non-compliance. R1's emergency room records for 11/19/24 were requested but not received prior to the end of the survey. These findings were reviewed with the administrator and regional consultant during a meeting on 1/22/25 at 3:45 p.m. with no further information presented prior to the end of the survey. (1) Woods, [NAME] Dabrow. Nursing 2022 Drug Handbook. Philadelphia: Wolters Kluwer, 2022.

Based on staff interviews, clinical record review, and facility documentation review, the facility staff failed to conduct timely revisions of the comprehensive care plan for two residents (Resident #1 and Resident #5) in a survey sample of 14 residents. For Resident #1 (R1) the failure to revise the care plan and implement interventions that ensured R1 received the required dialysis treatments as ordered, resulted in R1 missing 3 dialysis sessions and 3 partial treatments, which resulted in four hospitalization s. This constituted four occurrences of harm. The findings included: 1. For R1, the facility staff failed to address and implement interventions to ensure that the resident received dialysis services when the family was unable to accompany the resident, which resulted in 3 missed sessions and 3 partial treatments. This failure resulted in four hospitalization s for urgent treatment of fluid overload, a potentially life-threatening condition which occurs when fluid & toxins are not removed as scheduled with dialysis. According to the closed record review, R1 was ordered to receive dialysis on Monday, Wednesday, and Fridays. From August 1, 2023, until October 17, 2023, R1 had four hospitalization s, (8/2/23, 10/4/23, 10/13/23, and 10/17/23). According to R1's clinical record, a physician's order dated 8/1/23 noted that R1 required a companion during dialysis. According to the clinical record, the comprehensive care plan was not revised to address this need until 10/13/23. The associated goal read, I will not have any ill effects from my dialysis treatment and will receive my treatment timely through next care plan review. The intervention was noted as: family member is aware of dialysis days/times, however, will often no show up at the dialysis center therefore resident does not receive dialysis as scheduled. No interventions were found to ensure that R1 received treatments when facility staff were aware that the family would frequently not be able to attend the dialysis treatments. A review of the progress notes revealed a progress note entry dated 07/31/2023 at 10:27 a.m., that read, Resident returned from dialysis @ approximately 0800 via [transport company name redacted]. No s/s [signs or symptoms] distress. NNO [no new orders]. Fistula to RUA [right upper arm], thrill and bruit present. Pressure dressing in place, CDI [clean, dry, intact]. VSS [vital signs stable]. Received call from dialysis that the resident received very little dialysis d/t [due to] pulling needles out. Dialysis nurse also stated that to continue dialysis the resident will need someone to sit with her during treatment time. Management notified. Will continue to monitor. On 08/02/2023 at 2:10 p.m., a progress note was entered that read, Resident sent back from dialysis without receiving treatment. Daughter did not attend appointment due to childcare. NP spoke with daughter. [name redacted] informed NP that she would not be able to meet resident at dialysis, but she also did not want resident changed from full code. Daughter requested that resident be sent to ED [emergency department]. EMS [emergency medical services] called, resident left facility at 1108. Report called to ED and daughter aware. On 08/02/2023, the nurse practitioner (NP) entered a note that read in part, Date of Service: 08/02/2023, . Chief Complaint / Nature of Presenting Problem: No dialysis x 6 days, pt pulling lines out, dtr [daughter] cannot go to dialysis with pt due to children and no money for childcare. Dialysis will not do pt dialysis without family member present to keep her from pulling out line. [daughter's name redacted], pt dtr will not be able to go to dialysis with pt, she requests pt go to hospital . Plan: N18.6: ESRD (end stage renal disease) Pt unable to receive dialysis any longer through our facility, as she keeps pulling lines out, risk of bleeding to death. Dtr was asked to be present when she receives dialysis, dtr declined as she has no childcare and cannot afford it. Pt has not had sufficient dialysis in a week, in danger of fluid overload, etc. Sent to ER . R1's hospital records dated 8/2/23 read, ED Triage Notes Addendum: Pt arrived via EMS. From [facility name redacted]. dialysis pt last dialysis July 20, 2023. facility states family has to go with pt when she goes but that been unable to get in touch with family. Pt takes stuff off, so she has to have someone with her On 10/04/2023 at 8:21 p.m., a progress note read, Received call from [dialysis clinic name redacted] nurse stating that they are sending pt to ED due to family not present to sit with her during dialysis appt this AM and increased facial swelling. Pt sent to ED from Dialysis-no updates at this time. Will continue to monitor and awaiting updates from ED. Hospital records in R1's chart dated 10/4/23 read, visit information: arrival: 10/4/23 6:55 p.m., Chief complaint: shortness of breath . ED notes . missed dialysis, edema in eye/[NAME], chest x-ray shows fluid on lungs, on bipap, had temp 100.7 additional EMS patient and scene information: confused/does not cooperate. went to dialysis today. Issues with family can only get dialysis with a sitter, family did not show up so no dialysis. cxr [chest x-ray] fluid on lungs. de-satted [oxygen saturation levels dropped] to 67% so they placed her on BIPAP. fever 100.7 so they gave Tylenol. BP there ran 230/90s. they placed a nitro patch The hospital discharge summary noted, diagnosis to include acute respiratory failure with hypoxia, volume overload state . concern for uremic encephalopathy . Presented to hospital with respiratory distress after missing dialysis, noted to have lethargy, concerning for acute metabolic encephalopathy, hyperkalemia noted, underwent emergent HD [hemodialysis], hypertensive urgency, likely secondary to volume overload state and missing dialysis . concern for uremic encephalopathy . at baseline after HD On 10/08/2023 at 8:15 p.m., a progress note entry read, . Spoke with hospice nurse-family unable to sit with pt tomorrow for Dialysis and [dialysis clinic name redacted] will not give pt dialysis unless family present. Placed in primary care book. No distress noted-will notify primary care of worsening changes. On 10/13/23, the nurse practitioner entered another note that read, Date of Service: 10/13/23 . discharged to hospital r/t not being able to receive dialysis MWF . Discharge . Facility Course: Sent to hospital for further eval. Pt daughter is to go with her for dialysis, pt daughter did not, [dialysis clinic name redacted] will not do dialysis without the daughter present. Pt sent to ER for dialysis, as she cannot miss it, or edema builds up extremely quickly. On 10/17/2023, the NP wrote a note that read, .Chief Complaint / Nature of Presenting Problem: Edema of eyelids . Plan: ESRD missed dialysis, edema eyelids, sent to ED for dialysis A facility nurse also documented on 10/17/23, Resident up to w/c in dayroom. Facial swelling noted. Due to resident not receiving dialysis. New order noted to send resident to ED for further eval. Daughter [name redacted] notified. Resident left facility at 11:11. The care plan was not updated to address these missed dialysis treatments, the increased symptoms, or the resulting hospitalization s. On 1/16/24 and 1/17/24, interviews were conducted with multiple facility staff. They included, LPN C, LPN B/unit manager, Employee C/social worker, Employee D/admissions director, the facility administrator, and nurse practitioner. All of which indicated they were aware that Resident #1 required someone to be present for dialysis treatments for safety reasons. Each of them verbalized that the resident's family was supposed to accompany her. None of the staff identified that the facility had an obligation to implement interventions to ensure the resident received these life sustaining care and services. No one voiced an explanation as to why the care plan had not been updated to address the lack of consistent support R1 needed while at dialysis or the outcomes of the missed treatments. On 1/16/24, when asked why the facility didn't implement alternate measures or send someone with the resident she responded, the administrator stated that facility doesn't provide one on one care and didn't have the staffing to do this. On 1/17/24, when asked what the facility did in terms of other interventions to ensure R1 received the needed dialysis treatments, when they were aware that R1's family was not able to meet the resident and stay with them during dialysis consistently, the administrator didn't respond. On the afternoon of 1/30/23, an interview was conducted with Employee L and Employee M, the MDS (minimum data set - an assessment tool) nurses. Both Employee L and M confirmed that they develop and revise care plans. When asked about the purpose of the care plan, Employee L said, it is to provide an individualized picture of the care the resident needs based on diagnosis, medications, and ADL's (activities of daily living). It is anything we are going to provide while they are here. When asked about resident changes, both employees agreed that changes are reflected on the care plan. R1 was discussed and noted that on 8/1/23, an order was noted that the Resident needed a sitter while at dialysis. Employee M confirmed that it was not added to the care plan until 10/17/23. When asked why the delay and what interventions had been implemented when they were aware the family was not able to meet R1 consistently, Employees L and M said, We aren't involved in those discussions, while we are nurses those discussions are held between administration and the clinical team and we were not involved. The facility policy titled; Care Plan was reviewed. The facility in part read, . 22. There may be additional problem areas not triggered by the MDS, which will need to be addressed in the care plan. 23. The IDT is to review the 24-hour report during morning meeting for significant changes or changes in resident's ADL status. The IDT will add minor changes in resident's status to the existing care plans . No further information was provided. 2. The facility staff failed to revise the care plan for Resident #5 (R5) who had a MRSA infection and required transmission-based precautions be implemented. On 1/16/24 at approximately 11:30 a.m., during a facility tour, R5 was observed from the hallway to be lying in bed with an IV pole at the bedside and a medication bag hanging from the pole. Within the room there was a red 55-gallon trash barrel and a yellow 55-gallon trash barrel. There was no signage outside the room to indicate that any special isolation requirements were in place. On 1/16/24, a clinical record review was conducted. According to the clinical record, R5 was readmitted to the facility on [DATE], with diagnoses that included, but were not limited to, MRSA and ESBL [highly resistant bacterial infections] in the wound rt foot, per the hospital discharge records. On 12/27/23, an order for contact isolation was entered, which remained an active order at the time of survey. Review of the care plan revealed no mention of the MRSA or ESBL infections nor the transmission-based precautions. On 1/17/24 at approximately 10:30 a.m., observations were conducted of R5's room and signage was noted on the outside of the room to indicate the resident was on isolation. When asked about these findings, the director of nursing, who is the facility infection preventionist, stated that R1 remains on precautions and should be included in the care plan. No further information was provided.

Based on staff interviews, clinical record review, and facility documentation, the facility staff failed to ensure a Resident who required dialysis received scheduled dialysis treatments as ordered by the physician for 1 Resident (Resident #1) in a survey sample of 3 dialysis Residents reviewed. Resident #1 (R1) was hospitalized 4 times during a 3-month period due to missed dialysis treatments, requiring hospitalization for urgent dialysis due to being symptomatic of fluid overload, this constituted harm. The findings included: According to the clinical record R1, was initially admitted to the facility on [DATE]. Diagnoses for R1 included but were not limited to end stage renal disease and legal blindness. On [DATE] and [DATE], a closed record review was conducted of R1's chart. This review revealed that R1 was ordered to receive dialysis on Monday, Wednesday, and Fridays. From [DATE], until [DATE], R1 had four hospitalization s, ([DATE], [DATE], [DATE], and [DATE]) due to missing multiple dialysis treatments and being symptomatic with fluid overload because of not being dialyzed due to not having someone accompany the resident to the treatments. According to the clinical record, the following details were documented: 1. A progress note entry dated [DATE] at 10:27 a.m., read, Resident returned from dialysis @ approximately 0800 via [transport company name redacted]. No s/s [signs or symptoms] distress. NNO [no new orders]. Fistula to RUA [right upper arm], thrill and bruit present. Pressure dressing in place, CDI [clean, dry, intact]. VSS [vital signs stable]. Received call from dialysis that the resident received very little dialysis d/t [due to] pulling needles out. Dialysis nurse also stated that to continue dialysis the resident will need someone to sit with her during time. Management notified. Will continue to monitor. 2. Another progress note dated [DATE] at 10:41 a.m., read, Dialysis called and informed staff at this point resident is no longer allowed to come to dialysis unless someone is with her. This nurse and SSD [social services director] called [sic] and spoke to daughter [name redacted] about this. She stated she was going to call and talk with her sister and weigh options between going with resident or placing on hospice. 3. On [DATE] at 1:49 p.m., a note read, SSD spoke with daughter [name redacted] who advised they would have family accompany resident with dialysis and will meet resident at [dialysis name redacted] at chair time. SSD and [name redacted] called [dialysis name redacted] together to request change in chair time since family will have to accompany resident for each treatment. [dialysis name redacted] advised chair time can be changed to 9am. 4. On [DATE] at 06:06 a.m., a SBAR - Change of Condition note read, Situation: Puffy, swollen eyes. Background: CNA reported change in condition. CNA noted puffiness, swelling to both eyes around 515am. Assessment: Resident able to open eyes without difficulty. Some puffiness noted. No redness or drainage noted at present. No c/o pain. Response: CNA wash resident face with warm bath cloth. Nurse assess resident for redness, drainage, and pain to both eyes, none noted or voiced at present. 5. On [DATE] at 10:46 a.m., the nursing note read, This nurse noted resident to have very swollen eyes. Resident stated she could feel they were swollen but she was not having any pain associated with it. NP [nurse practitioner] made aware and assessed. She noted resident's eyes. Lungs sounded clear. NP stated she would reassess later to check for changes. 6. On [DATE] at 2:10 p.m., a note was entered that read, Resident sent back from dialysis without receiving treatment. Daughter did not attend appointment due to childcare. NP spoke with daughter. [name redacted] informed NP that she would not be able to meet resident at dialysis, but she also did not want resident changed from full code. Daughter requested that resident be sent to ED [emergency department]. EMS [emergency medical services] called, resident left facility at 1108. Report called to ED and daughter aware. 7. On [DATE], the nurse practitioner (NP) entered a note that read, Date of Service: [DATE], . Chief Complaint / Nature of Presenting Problem: No dialysis x 6 days, pt pulling lines out, dtr cannot go to dialysis with pt due to children and no money for childcare. Dialysis will not do pt dialysis without family member present to keep her from pulling out line. [daughter's name redacted], pt dtr will not be able to go to dialysis with pt, she requests pt go to hospital . Plan: N18.6: ESRD (end stage renal disease) Pt unable to receive dialysis any longer through our facility, as she keeps pulling lines out, risk of bleeding to death. Dtr was asked to be present when she receives dialysis, dtr declined as she has no childcare and cannot afford it. Pt has not had sufficient dialysis in a week, in danger of fluid overload, etc. Sent to ER . 8. The hospital records that were included in R1's facility chart dated [DATE] read, ED Triage Notes Addendum: Pt arrived via EMS. From [facility name redacted]. dialysis pt last dialysis [DATE]. facility states family has to go with pt when she goes but that been unable to get in touch with family. Pt takes stuff off, so she has to have someone with her . 9. On [DATE], the nurse practitioner wrote a note in the chart of R1. Excerpts from the note read, . chief Complaint/Nature of Presenting Problem: Eyes puffy, bilaterally. No distress . Plan: ESRD [end stage renal disease] recent av fistula clotted, continue current medication, Dialysis MWF, con't with nephrology, monitor for fvo [fluid volume overload], particularly lungs, DM II on insulin, continue current medication, con't to monitor closely . 10. On [DATE] at 8:21 p.m., a note read, Received call from [dialysis clinic name redacted] nurse stating that they are sending pt to ED due to family not present to sit with her during dialysis appt this AM and increased facial swelling. Pt sent to ED from Dialysis-no updates at this time. Will continue to monitor and awaiting updates from ED. 11. Hospital records in R1's chart dated [DATE] read, visit information: arrival: [DATE] 6:55 p.m., Chief complaint: shortness of breath . ED notes . missed dialysis, edema in eye/[NAME], chest x-ray shows fluid on lungs, on bipap, had temp 100.7 additional EMS patient and scene information: confused/does not cooperate. went to dialysis today. Issues with family can only get dialysis with a sitter, family did not show up so no dialysis. cxr [chest x-ray] fluid on lungs. de-satted [oxygen saturation levels dropped] to 67% so they placed her on BIPAP. fever 100.7 so they gave Tylenol. BP there ran ,d+[DATE]s. they placed a nitro patch . The discharge summary noted, diagnosis to include acute respiratory failure with hypoxia, volume overload state . concern for uremic encephalopathy . Presented to hospital with respiratory distress after missing dialysis, noted to have lethargy, concerning for acute metabolic encephalopathy, hyperkalemia noted, underwent emergent HD [hemodialysis], hypertensive urgency, likely secondary to volume overload state and missing dialysis . concern for uremic encephalopathy . at baseline after HD 12. On [DATE] at 8:15 p.m., a progress note entry read, S/P [status post] return from hospital-day 3-Pt alert/confused. Requires assist with all ADL's and transfers. Incontinent of bowel and bladder. Feeds self after tray set up. Requires Dialysis three times a week. Spoke with hospice nurse-family unable to sit with pt tomorrow for Dialysis and [dialysis clinic name redacted] will not give pt dialysis unless family present. Placed in primary care book. No distress noted-will notify primary care of worsening changes. 13. The nurse practitioner entered another note that read, Date of Service: [DATE], Transition of Care: No transition occurred . Discharge Summary . Chief Complaint / Nature of Presenting Problem: discharged to hospital r/t not being able to receive dialysis MWF . Discharge . Facility Course: Sent to hospital for further eval. Pt daughter is to go with her for dialysis, pt daughter did not, [dialysis clinic name redacted] will not do dialysis without the daughter present. Pt sent to ER for dialysis, as she cannot miss it, or edema builds up extremely quickly. 14. On [DATE], R1 was again sent to the hospital symptomatic for fluid overload. The NP wrote a note that read, .Chief Complaint / Nature of Presenting Problem: Edema of eyelids . Plan: ESRD [End Stage Renal Disease] missed dialysis, edema eyelids, sent to ED for dialysis. The NP wrote, Resident up to w/c in dayroom. Facial swelling noted. Due to resident not receiving dialysis. New order noted to send resident to ED for further eval. Daughter [name redacted] notified. Resident left facility at 11:11. 15. The hospital records dated [DATE] read, pt arrived to ED via EMS after dispatched as needs ride for dialysis pt complaining of increased swelling of face On [DATE] at approximately 2:15 p.m., an interview was conducted with LPN C. LPN C stated that R1 had been very pleasant and had started rubbing at their skin constantly. LPN C said that R1 did this at dialysis and at one point pulled the dialysis catheter out because she was rubbing at her skin so much. LPN C stated that dialysis told the facility if they couldn't get the resident calm, someone would have to sit with the resident through the dialysis sessions. LPN C said that the facility tried to pre-medicate R1 before dialysis, but it wasn't effective. LPN stated that at times R1 would have to be sent to the hospital for dialysis where they could sedate the resident. LPN C said that it went on for about a month and a half, when the family didn't meet the resident at dialysis, R1 would miss dialysis, and have to be sent to the hospital. LPN C said that it was her understanding that R1 was kept at the hospital and later expired. On [DATE] at 2:31 p.m., an interview was conducted with LPN B, who was the unit manager where R1 resided. LPN B explained that R1's rubbing caused him/her to not be able to do dialysis without someone being there, he/she was pulling out the dialysis line. LPN B stated that dialysis wouldn't let the resident in their building if the resident's daughter wasn't with them. LPN B said, The family wasn't always compliant. We would talk with them, and they would say they were on the way to meet the resident and then wouldn't show up. When asked why R1 didn't return to the facility, LPN B said, I don't know if it was a needs thing, I think the family put on Facebook they were going to put her on hospice. On [DATE] at 2:35 p.m., an interview was conducted with Employee C, the facility's social worker (SW). The SW stated R1 was a dialysis resident who had started to decline. The SW stated that the facility was having an issue with the family providing one on one to sit with the resident at dialysis and had gotten the ombudsman and adult protective services (APS) involved. Employee C said, The daughter locally was in agreement with meeting him/her at dialysis but wouldn't go, so dialysis would send her back. Because the daughters failed to meet the resident at the appointments it caused multiple hospitalization s. When asked why the resident had to have someone with them at dialysis, the SW said, They [dialysis] made that order because he/she was fidgety, restless and pulling at the line. The SW said that she had talked to APS about getting an order to make the daughters meet the resident, but that APS had said they were not able to do that. The SW went on to say that the family was getting the Resident's income and she felt they should have used that money to pay for a sitter so that the resident could get the needed treatment. On [DATE] at 2:55 p.m., an interview was conducted with Employee D, the admissions director. When asked about R1, Employee D said, Dialysis requested that he/she have a sitter due to restlessness. We would take [the resident's name redacted] back from the hospital and the family would agree they would meet them for dialysis, but they weren't consistent. [R1 name redacted] was sent out and due to them [the resident's family] not being able to provide what they said, they ended up just doing hospice at the hospital. On [DATE] at 3:10 p.m., an interview was conducted with the facility Administrator. The administrator said, We started having difficulty with dialysis. They put an order in that someone had to be with the resident [R1]. They [the family of R1] would quit going and dialysis would send the resident back. They said we couldn't send the resident unless the daughter would ride with her to the appointment. We would have to send the resident to the hospital, his/her eyes would swell shut from the fluid build-up, it put us at risk. On [DATE] at 8:43 a.m., the facility administrator requested to talk to the surveyor regarding R1. During the conversation the administrator said, . [R1's name redacted] would go 3 days maybe and we were having to send him/her back to the emergency room . The ER called and said we had to stop sending the resident. I explained the resident was a full code, and it was necessary because [R1] was short of breath and filling up with fluid When asked why they didn't send a staff member to accompany the resident so that R1 could get dialysis if the family didn't show up, the administrator said, We don't do one on one care here, we did it once, but we don't have the staffing here. The administrator further stated that the facility had tried to get the resident's family to change the dialysis to 2 days a week, but the family never followed through with that, but the doctor had said they didn't know if the resident could manage on two days. The administrator said, [R1 name redacted] couldn't manage missing one dialysis appointment and he/she would start filling up with fluid. On [DATE], an interview was conducted with the facility's nurse practitioner (NP). The NP was asked about R1 and the resident's discharge. The NP stated that it was her understanding that the resident's family decided to take the resident to another facility that could transport the resident to dialysis. The NP said that she was aware there were times that the family wouldn't meet R1 and the resident would have to be sent to the hospital for dialysis. When asked why the facility did not send someone to accompany the resident to dialysis so that R1 could have the dialysis treatment, the nurse practitioner said that she thought the facility had done that several times. On [DATE] and again on [DATE], when asked why the facility didn't implement steps or send someone with R1, the administrator responded, that the facility did not provide one on one care and don't have the staffing to do this. When asked when they were aware that R1's family was not able to meet the resident and stay with them during dialysis consistently, what did the facility do in terms of other interventions to ensure R1 received the needed dialysis treatments, the administrator didn't respond. On [DATE] at 2:32 p.m., a telephone call was placed to the daughter of R1. The family member stated that they were told they had to accompany R1 to dialysis and were told they didn't have the staff and it was our responsibility. R1's daughter went on to explain that R1 stayed in the hospital a month, before going to another facility where she passed away. On [DATE] at 3:14 p.m., an interview was conducted with Employee H, the activities director. Employee H stated that she had accompanied R1 to dialysis on one occasion and had her assistant accompany the resident at another time. When asked what had prompted her and her employee to accompany the resident on those 2 days, Employee H said, When we had trouble with the family. When asked why the facility didn't send someone with R1 on the other occasions when family was not able to accompany the resident, Employee H said, I wasn't asked to. On [DATE] at 3:40 p.m., an interview was conducted with Employee J, who coordinates transportation to outside appointments for residents. When asked about R1's transport to dialysis, Employee J said that transportation had not been a problem but the problem was the family meeting the resident at dialysis. When asked if the facility sends a staff member with residents to appointments, Employee J said, Usually not. When asked what happened in case a resident was confused and unable to communicate with the provider about what was going on, Employee J said, We would send someone in that case. I would not send someone who is not cognitively intact to an appointment alone, if the family can't go, then we have to send someone with them. Employee J went on to say that she is also a CNA and at times will accompany residents to appointments. When asked if she ever accompanied R1 to dialysis, Employee J said, No. On [DATE], during a review of the facility staffing, in the presence of the HRM (human resources manager)/Employee G, it was noted that on [DATE], the staff assignment sheet noted CNA E was assigned to provide one on one care. When asked about this provision of one on one care, Employee G stated that a resident had been having behaviors, so CNA E was called in to provide the one on one care. On [DATE], as CNA E was not working at the facility during the survey, a telephone call was placed to CNA E and an interview was conducted. CNA E identified that on [DATE], she was called by the HRM/Employee G and asked to come provide one-to-one care for Resident #12 (R12). CNA E went on to describe that R12 had been very anxious, wandering, and exit seeking. When asked what type of care was provided, CNA E stated that she had stayed with R12 and walked with them until they calmed down around 3 p.m. When asked if she had provided one-to-one care to any other residents, CNA E stated that she had provided one to one care for [name redacted - identified as Resident #11]. A closed clinical record review was conducted of Resident #11's chart. According to the clinical record documentation, Resident #11 (R11) received one on one care around the clock for at least a week in [DATE]. On the afternoon of [DATE], an interview was conducted with the Director of Nursing (DON) and administrator. When asked to explain how R11 and R12 having been provided one to one care, the DON stated that R12 could easily be mistaken for a visitor, ambulated without any assistive devices, and was exit seeking. The DON stated that despite having a wander guard on, with the increased visitors in the facility on the weekend, she had felt for the safety of R12 that one to one care was necessary. The DON and administrator explained that R11 had been having behaviors that required one to one supervision. When asked to explain how they identify when a person needs or is provided one to one supervision, the DON and administrator stated that when a resident has an altercation with another resident, the aggressor is usually put on 1:1. On [DATE] at 8:30 a.m., an interview was conducted with the administrator at the dialysis clinic R1 had attended for treatment. The dialysis administrator (DA) stated that the issue with R1 was that on two separate occasions R1 had pulled the dialysis lines out. DA stated that the governing body for the dialysis clinic met, ,which included the DA, medical director, clinical director, and others, because they didn't have a policy that covered such instances. DA stated that guidelines were developed and implemented to address this incident, which guided the doctor to order that R1 had to have someone at their side during treatment sessions at all times. The DA stated that they were very flexible in moving R1's treatment times to accommodate the family's ability to accompany R1, but on 3 occasions, the dialysis treatment was not provided due to no one being with R1. The DA stated that on numerous occasions R1 had shortened treatment sessions, which were not effective. The DA went on to say, transport was never the issue. When asked if the facility ever sent a staff member to accompany R1, the DA said reviewed the records and noted that there had been one occasion in October. The DA said they talked to the family on several occasions and encouraged them to talk to the facility for a care conference because the the family was having difficulty and had expressed concern about not being able to accompany R1 all the time. On [DATE], the DON provided the surveyor with an in-service sheet that had been provided to facility staff on [DATE]. The document read in part, . 1:1 for aggression or falls should be considered for ,d+[DATE] hours to allow the IDT [interdisciplinary team] to come up with a solid intervention. Then of course, based on your discretion. The DON was questioned about this, and she stated it was guidance she had gotten from their corporate office and was educating staff about it. The Surveyor pointed out that they have been saying they don't provide one to one with regards to R1 and that it was the family's responsibility to accompany the resident to dialysis, but it is clear they do, per the provided policy. The DON and Administrator did not respond. A review was conducted of the facility policy titled, Coordination of Hemodialysis. The policy read in part, Residents requiring an outside ESRD [end stage renal disease] facility will have services coordinated by the facility to include care planning, nursing, medications, nutritional, social services, activities, and physician services. There will be communication between the facility and the ESRD facility regarding the resident. The facility will establish a Dialysis Agreement/Arrangement if there are any residents requiring dialysis services. The agreement shall include how the residents care is to be managed. Two physicians wrote an article* for The American Journal of Kidney Diseases which included the following excerpts: Ultimately, missed dialysis treatments have a significant impact on mortality, morbidity, and resource use, in part due to increased emergency department visits and hospitalization s (including intensive care unit admissions) for urgent but often preventable hemodialysis treatments . Multilevel interventions targeting individual patients, patient-provider relationship/communication, and the process of care delivery should help improve overall dialysis treatment adherence, particularly missed hemodialysis treatments. On [DATE] and again on [DATE], during end of day meetings with the administrator and director of nursing, the above concerns were shared with them. When asked again why they didn't provide a staff member to accompany R1 to dialysis, they stated, We don't provide one on one and didn't have the staffing to do this. When it was reported that the facility had provided 1:1 to other residents, the director of nursing said, Yes, but that was short term, this was different. No further information was provided. *Menez, [NAME] and Jaar, [NAME] G. Missed Hemodialysis Treatments: A Modifiable But Unequal Burden in the World. American Journal of Kidney Disease 2018;72(5),d+[DATE].

Based on staff interview and facility documentation review, the facility staff failed to complete performance reviews of nurse aides and therefore failed to provide in-service education based on the outcome of the performance reviews, affecting all 40 nurse aides employed by the facility. The findings included: On 1/30/24 at 10 a.m., the survey team met with the human resources manager (HRM) and requested to review the employee files for three sampled CNAs (certified nursing assistants). The HRM asked what documents were requesting to be reviewed and the surveyor let her know that the performance reviews needed to be reviewed. The HRM said OK and stepped out of the room. A few moments later the HRM returned to the conference room and informed the surveyor that she had spoken with the DON (Director of Nursing) and said, we do not do performance evaluations. I don't know why, we do write-ups. The HRM was asked to have the DON and Administrator step in. On 1/30/24 at 10:20 a.m., the surveyor met with the HRM, administrator and DON. The Administrator said, I contacted corporate, and they said we are supposed to do them, but we don't. I haven't even had one. The DON was asked how she evaluates clinical staff's performance and educational needs if performance reviews are not conducted. The DON said, In October we did a competency fair, and they went around to each station, after that it is just as things come about or we have something new. The Adminnistrator and DON were made aware that regulations require that performance reviews be conducted at least every 12 months of nurse aides, and they provide regular in-service education based on the outcome of the reviews. A facility policy with regards to performance review and in-service education was requested. On the afternoon of 1/30/24, the DON reported that they do not have a policy as it relates to in-service education. The facility policy for performance reviews was received. The policy read in part, The performance evaluation provides a formal vehicle for the supervisor and employee to discuss the employee's overall work performance and developmental areas as it relates to the employee's job description. The policy mentioned that they are conducted within 30 days of the employee's original service date ., can be given at any time there is a significant change in job expectations or performance at management discretion. There was no mention in the policy about the evaluations being conducted on an annual basis nor that they would be used to identify in-service education opportunities for that employee. On 1/30/24, during an end of day meeting, the facility administrator was made aware of the above findings. No further information was provided.

Based on facility documentation and staff interviews, the facility staff failed to conduct and document a facility-wide assessment to include the care required by the resident population, staff competencies necessary for the care needed for the resident population, ethnic/cultural/religious factors that may affect care provided by the facility, services provided, and health information technology resources, which have the potential to affect all 75 residents residing at the facility. The findings included: On 1/29/24, the facility administrator was asked to provide the survey team with the facility assessment. On 1/29/24, a 5-page document was provided to the survey team. It listed a facility acuity/ADL (activities of daily living) calculation which was represented by numbers with no explanation. It noted 0=9 residents, 1=0 residents, 2=0 residents, 3=1 residents, 4=6 residents . It noted BIMS (brief interview for mental status score) noting a BIMS score of 0-15, and how many residents had scored each number. The second page noted religions and noted 11 religious categories and noted how many total residents and then how many residents were male versus female for each denomination. The third page was titled, Facility Resources and gave a summary of the facility in paragraph form of the facility's geographic location, physical structures, roadways, and nearby businesses. There was a sentence that read, Please see attached manager listing of department managers and please see attached listing of employees staffed in facility. The bottom of page 3 and page 4 contained a listing of equipment, which included but was not limited to, beds, scales, bedside tables, and kitchen equipment. The fourth page also included statements that included full maintenance office with tools . The facility also has in place an emergency preparedness program that includes evacuation to another facility, . severe weather conditions, . other misc. issues . The last page indicated that the facility holds a monthly QAPI (quality assurance and performance improvement) meeting. It discussed that the facility is located on a hill, which could be a risk to a resident who would walk outside. The assessment mentions that the road is heavily traveled and could be a risk for cognitively impaired residents. It mentioned the facility is at minor risk for flooding, low risk for tornados and winter weather with snow and ice is a high risk for the facility. On the afternoon of 1/29/24, the surveyor asked the facility if the document presented was the entire facility assessment. The administrator stated that it was. The administrator was made aware that the document presented was woefully deficient in what was required to be included in a facility assessment. On 1/29/24 at approximately 4 p.m., the administrator provided the surveyor with 2 pages and stated these were to replace the previously submitted first two pages. The information contained was of the same nature but with different numbers for the ADLs (activities of daily living) and BIMS. The second page noted facility resources and now included: Services provided: Therapy, 24/7 Nursing, Pharmacy, Lab, Mobile Imagining, Psych [NAME], Counselor, Personnel: Management 16 staff members, 23 nurses (including PRN [as needed]), 42 C.N.A's [certified nursing assistants] (including PRN), 8 therapy staff members, 4 housekeeping staff, 4 dietary staff, 7 professionals, 2 volunteers, and 1 activities assistant. Contracts/Agreements: which listed hospice companies, transport, staffing agencies, sprinkler company, home health and Technology Resources. On 1/30/24, the facility administrator provided a listing of facility staff names and titles for managers and nursing. On 1/30/24, the surveyor discussed with the facility administrator and director of nursing that the facility assessment did not include the care required by the resident population, staff competencies necessary for the care needed for the resident population, ethnic/cultural/religious factors that may affect care provided by the facility, services provided, and health information technology resources. The administrator acknowledged that she had reviewed the regulatory requirement and noted that additional information was needed. On 1/31/24 at 8:30 a.m., the facility administrator provided a revised facility assessment and facility policy. The revised facility assessment included an acuity calculation that again listed numbers 0-16 and had how many residents had scored each of the number values. There was no indication what the numbers represented. There was a listing of BIMS scores, again with no explanation. Also attached was a QM (quality measures): Facility Summary. This gave information as to the number of residents with various conditions such as, how many residents had fallen, had pressure ulcers, were taking antianxiety medications, had received flu and pneumonia immunizations, etc. There was also information with regards to rehospitalization rates, a resident roster and a diagnosis report which listed all the diagnosis their current population had. The administrator also provided a facility policy titled, Facility Assessment with a date of 1/1/18. The policy in part read, To comply with F838 and conduct and document a facility wide assessment to determine what resources are necessary to care for its residents competently during both day-to-day operations and emergencies. The policy listed items that would be included in the assessment which were stated as: the facility resident population, number of residents and facility capacity, the care required by the population, cultural or ethnic and religious factors, all buildings or other physical structures and vehicles, equipment, services provided, contracts, agreements and technology resources. The policy did not mention the inclusion of the staff training and competencies required to care for the resident population served by the facility. No further information was provided.

Based on observation, staff interview, clinical record review, and facility documentation review, the facility staff failed to implement infection control procedures and the Centers for Disease Control and Prevention recommendations to prevent the spread of infections within the facility which had the potential to affect residents and staff on 2 of 3 nursing units. The findings included: 1. For Resident #5 (R5), who had orders for contact isolation, there was no signage to indicate and alert staff and/or visitors of the isolation. On 1/16/24 at approximately 11:30 a.m., during a facility tour, R5 was observed from the hallway lying in bed with an IV pole at the bedside and a medication bag hanging from the pole. Within the room there was a red 55-gallon trash barrel and a yellow 55-gallon trash barrel. There was no signage outside the room to indicate that any special isolation requirements were in place. On 1/16/24 at approximately 11:50 a.m., an interview was conducted with LPN C. LPN C confirmed she was the nurse assigned to R5. LPN C reported that R5 was on two different antibiotics, had MRSA (Methicillin-resistant Staphylococcus aureus), and osteomyelitis. LPN C said, The precautions have ended. We are waiting for housekeeping to take the stuff out of the room. LPN C went on to say that this had happened this morning. LPN C stated that while she (LPN C) was calling the pharmacy to discuss dosing of one of the antibiotics, the unit manager had told her (LPN C) that R5 was no longer on precautions. On 1/16/24, a clinical record review was conducted. According to the clinical record, R5 was readmitted to this facility on 12/22/23, with diagnosis that included, but were not limited to, MRSA and ESBL in the wound rt foot, per the hospital discharge records. R5 did not have an order for contact isolation- +MRSA every shift until 12/27/23, which remained an active order at the time of survey. The nursing notes do not mention R5 being on isolation until 12/28/23. On 1/17/24, at 9:07 a.m., an interview was conducted with the facility's nurse practitioner (NP). The NP stated, I think [R5] is supposed to be on precautions from a scientific point of view. When asked how she determines when a person can come off precautions, the NP stated when the antibiotics are complete or she would consult with infectious disease, who is usually involved with such patients. On 1/17/24 at approximately 10:30 a.m., observations were conducted of R5's room and signage was noted on the outside of the room to indicate the resident was on isolation. When the director of nursing, who is the infection preventionist was asked about this, she stated that R5 remained on precautions. 2. The facility staff failed to follow The Centers for Disease Control and Prevention (CDC) guidance with regards to COVID-19 testing during an outbreak. On 1/17/24, a review of the facility's infection control program was conducted with the facility's director of nursing (DON), who is also the infection preventionist (IP). During the review it was noted that the facility experienced a COVID-19 outbreak on 1/8/24, due to a staff member testing positive for COVID-19. The facility had additional staff test positive on 1/9/24, 1/10/24, and 1/12/24. The DON stated the facility did contact tracing but had no evidence of such to present to the survey team. The IP stated that following a known exposure, in accordance with their policy and CDC guidance, they conduct testing on days 1, 3 and 5 for employees and exposed residents are tested on ce a week. The DON stated that residents on the 200 halls were tested following the exposure and would be tested again at the end of the week that the survey was being conducted. Review of a sample of clinical records confirmed that testing had not been conducted of the exposed residents on days 1, 3 and 5, with only one occurrence of testing conducted 1/17/24. The facility policy titled, Facility COVID-19 Testing with an effective date of 10/2022, was reviewed. Excerpts from the policy read as follows: . Higher-Risk Exposure or Close Contact Testing. Resident: 1. Asymptomatic residents with close contact with someone with SARS-CoV-2 infection should: A. Have a series of three viral tests for SARS-CoV-2 infection. i. Testing is recommended immediately (but not earlier than 24 hours after the exposure) ii. The testing will include an initial test and, if that test is negative, a 2nd test will be completed 48 hours after the first test. If the 2nd test is also negative, a 3rd test will be completed 48 hours after the 2nd test The CDC (Centers for Disease Prevention and Control) gives guidance to nursing facilities in their document titled, Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, which was updated May 8, 2023. This document read, . Responding to a newly identified SARS-CoV-2-infected HCP or resident . Perform testing for all residents and HCP identified as close contacts or on the affected unit(s) if using a broad-based approach, regardless of vaccination status. Testing is recommended immediately (but not earlier than 24 hours after the exposure) and, if negative, again 48 hours after the first negative test and, if negative, again 48 hours after the second negative test. This will typically be at day 1 (where day of exposure is day 0), day 3, and day 5 During a end of day meetings and a pre-exit meeting with the facility, the administrator and director of nursing were made aware of the above findings. No additional information was provided.

Based on staff interview, staff record reviews, and facility documentation review, the facility staff failed to develop a training plan based on the facility assessment, which had the potential to affect all staff employed by the facility and all residents in their care. The findings included: On 1/29/24, the facility administrator was asked to provide the survey team with the facility assessment. On 1/29/24, a 5-page document was provided to the survey team. The facility assessment did not identify the resident needs of the population they service and did not address the competencies or training necessary for the facility staff to provide for the residents in their care. On 1/30/24, at approximately 10:30 a.m., a meeting was held with the director of nursing and facility administrator. When asked how they identify what training staff need, they stated they did a skills fair in October and staff went to each station and they do monthly staff meetings and as things come up, she will provide education. On 1/30/24 at approximately 10:40 a.m., the surveyor discussed with the facility administrator and director of nursing that the facility assessment did not include the staff competencies and education needs of staff that were necessary for the care for the resident population. The administrator agreed that it did not. On 1/31/24, the facility Administrator stated that they do not have a training plan, the only thing they had was an orientation policy. When asked about the staff training provided throughout the year and if there is a schedule of this, she stated, no we just tell them they have to go into Relias (a computer-based training system) and do their training. No further information was provided.

Based on staff interviews and employee record reviews, the facility staff failed to provide QAPI (Quality Assurance and Performance Improvement) training to 9 of 9 sampled employees reviewed for educational requirements. The findings included: On 1/29/24, a sample of nine employees was selected from a listing of current staff. The sample included management staff, CNAs (certified nursing assistants), LPNs (Licensed practical nurses) and RNs (registered nurses). The facility identified the Director of Nursing (DON) as overseeing staff education. The DON was given the names of the nine sampled staff and was asked to provide all education and in-service training for those employees. On 1/29/24, the facility provided a transcript for an electronic training system for the sampled employees and in-service sign in sheets. These documents were reviewed and revealed that none of the 9 sampled employees had received any training with regards to the elements and goals of the facility's QAPI program. During an end of day meeting held at 4:35 p.m., on 1/29/24, the facility Administrator and DON were made aware that they had no evidence that any of the sampled staff had received training on the elements and goals of the QAPI program. On 1/30/24, the facility administrator provided an in-service sign-in sheet dated 1/30/24 and stated that she had conducted training that morning and 6 of the 9 sampled staff had attended. The administrator also stated she had reveiwed their electronic training program and QAPI was not part of the training. The administrator also stated that she was aware that they still had staff that had not attended the training. On 1/30/24 and 1/31/24, The Administrator and DON stated that the facility did not have a policy as it relates to staff in-service training or QAPI training. No further information was provided.

Based on staff interview, clinical record review, and facility documentation review, the facility staff failed to permit a resident to return to the facility after hospitalization , affecting 1 resident (Resident #1- R1) in a survey sample of 14 residents. The findings included: On [DATE], a closed clinical record review was conducted of R1's chart. According to the clinical record, staff documented on [DATE] at 11:20 AM, Resident up to w/c [wheelchair] in dayroom. Facial swelling noted. Due to resident not receiving dialysis. New order noted to send resident to ED [emergency department] for further eval. [evaluation] Daughter [name redacted] notified. Resident left facility at 11:11 [am]. The clinical record had no information about R1 returning from the hospital. On [DATE] at approximately 2:15 p.m., an interview was conducted with LPN C. LPN C stated that R1 was a very pleasant lady and had started rubbing at her skin constantly. LPN C said that the Resident did this at dialysis and at one point pulled her dialysis catheter out and dialysis told the facility if they couldn't get her calm someone would have to sit with her through her dialysis sessions. LPN C said that the facility tried to pre-medicate the resident before dialysis, but it wasn't effective and at times R1 would have to be sent to the hospital for dialysis where they could sedate her. LPN C said that it went on for about a month and a half of the family not meeting her at dialysis and so the resident would miss treatment sessions and have to be sent to the hospital. LPN C said that it was her understanding that the resident was kept at the hospital and later expired. On [DATE] at 2:31 p.m., an interview was conducted with LPN B, who was the unit manager. LPN B explained that R1's rubbing caused her to not be able to do dialysis, [R1] was pulling out the dialysis line. They wouldn't see [R1] anymore and said they wouldn't let [R1] in their building if the daughter wasn't with the Resident. The family wasn't complaint. We would talk with them, and they would say they were on the way to meet the resident and then wouldn't show up. When asked why R1 didn't return to the facility, LPN B said, I don't know if it was a needs thing, I think the family put on Facebook they were going to put [R1] on hospice. On [DATE] at 2:35 p.m., an interview was conducted with Employee C, the facility's social worker (SW). The SW said, R1 was a dialysis resident here and had a decline. She went on to state that the facility was having an issue with the family providing one on one to sit with her at dialysis and they had gotten the ombudsman and adult protective services (APS) involved. Employee C said, the daughter locally was in agreement with meeting her at dialysis but wouldn't go, so dialysis would send her back. because the daughters failed to meet her at the appointments it caused multiple hospitalization s. When asked why the resident had to have someone with her at dialysis the social worker said, they [dialysis] made that order, [R1] was fidgety, restless and pulling at her line. The social worker said she had talked to APS about getting an order to make the daughters meet the resident, but they said they were not able to do that. The SW went on to say that the family was getting R1's income and she [the social worker] felt they should have used that money to pay for a sitter. On [DATE] at 2:55 p.m., an interview was conducted with Employee D, the admissions director. Employee D was asked about R1, and she said, dialysis requested that she have a sitter due to her restlessness, we would take her back from the hospital and the family would agree they would meet her for dialysis, but they weren't consistent. She was sent out and due to them not being able to provide what they said, they ended up just doing hospice at the hospital. When asked if the facility declined to or refused to take the resident back, Employee D said, no but if she didn't get her dialysis, we would have to send her to the hospital and the family just wouldn't meet her consistently. During the above interview with the admissions director, she was asked to access the referral information and communication with the hospital with regards to R1. She accessed the system and printed the notes for the surveyor. Those noted indicated that on [DATE], the hospital notified the facility that the resident would like to return. On [DATE] at 10:18 a.m., a communication was sent that the facility would accept the resident. Then on [DATE] at 8:35 a.m., there was a communication entered by the facility administrator that stated, Status changed to decline. Does not meet admission criteria. The hospital case manager asked, She was a LTC [long-term care] patient with you receiving hospice care. Why would she not be able to return?. Then on [DATE] at 1:12 p.m., a note was entered that read, Administrator spoke to hospital/CM [case manager] on details as to why the patient could not return. thanks. On [DATE] at 3:10 p.m., an interview was conducted with the facility Administrator. The administrator said, we started having difficulty with dialysis, they put an order in that someone had to be with her [R1]. They [the family of R1] would quit going and dialysis would send her back. They said we couldn't send her unless the daughter would ride with her to the appointment. We would have to send her to the hospital, her eyes would swell shut from the fluid build-up, it put us at risk. We couldn't meet her needs. I told the Ombudsman we couldn't take her back and APS [adult protective services] got involved. I told the Ombudsman he would have to do what he had to do because we couldn't meet her needs. When asked if they had issued a 30-day discharge notice to notify the resident and family they were not able to meet her needs, the administrator stated they had not. On [DATE] at 8:43 a.m., the facility administrator stated to the surveyor, I wanted to talk with you about my reason behind not taking her back. We don't disregard regulations, but [R1] would go 3 days maybe and we were having to send her back to the emergency room and the ER called and said we had to stop sending her. I explained [R1] was a full code, and it was necessary because she was short of breath and filling up with fluid. I was looking out for the safety and well-being of the resident. When asked why a staff member was not sent to accompany R1 to ensure that dialysis was provided, even if the family didn't show up, the Administrator said, We don't do one on one care here. We did it once, but we don't have the staffing here. They had tried to get her family to change her dialysis to 2 days a week, but her family never followed through with that, and the doctor said they didn't know if she could manage on two days. She couldn't manage missing one dialysis appointment and she would start filling up with fluid. On [DATE], an interview was conducted with the facility's nurse practitioner (NP). When asked about R1's discharge, stated that it was her understanding that the resident's family decided to take her to another facility that could transport her to dialysis. When asked if she was aware that the facility had refused to take R1 back, the NP said that she was not. When questioned further, the NP said that she was aware there were times that the family didn't meet the resident at dialysis and that the dialysis would not be performed, which would require R1 to be sent to the hospital for treatment. On [DATE] and [DATE], staff interviews and facility documentation/staffing records indicated that the facility had provided one to one (1:1) supervision/companion services. As recently as [DATE], evidence revealed that Resident #12 (R12) was provided 1:1 care for a full shift. According to the clinical record, Resident #11 received 1:1 supervision serivces for a week, around the clock, due to behaviors in [DATE]. R12 was all of which the Director of Nursing confirmed. On [DATE], an interview with the DON and Administrator was conducted regarding the provision of 1:1 supervision/care services. When questioned why the needed 1:1 was not provided to ensure that R1 received dialysis, both the DON and Administrator stated that the facility did not provide 1:1 care. When presented with the findings that R11 and R12 had been provided 1:1 care, both responded that those situations were limited, again repeating that the facility doesn't provide 1:1 care. The surveyor explained that R11 had been provided 1:1 care, around the clock for a week, which totalled 168 hours. When it was pointed out that R1 only needed 1:1 companion services for 9 hours a week, (3 hours, 3 days per week), the Administrator stated, We didn't look at it that way. The facility administrator confirmed having had a conversation with the ombudsman about the facility not allowing R1 to return without first issuing a discharge notice. The Administrator stated that she had again spoken with her superiors, who would not accept R1 back. A review was conducted of the facility's policy titled, Discharge and Transfers. The policy read in part, Reasons for Discharge and Required Documentation. The medical record must show documentation of the basis for transfer or discharge. This documentation must be made before, or as close as possible to the actual time of transfer or discharge. 1. The resident's needs cannot be met in the facility. Must be necessary for the resident's welfare . 2. the resident's health has improved sufficiently so the services provided by the facility are no longer needed . 3. The safety of individuals in the facility is endangered due to the clinical or behavioral status of the resident . 4. The health of individuals in the facility would otherwise be endangered . 5. Non-payment if the resident has failed to pay or failed to submit the necessary paperwork for third party payment . 6. Resident is a danger to themselves or others . 8. Residents sent to the ER must be permitted to return to the facility unless the resident meets any of the above criteria. A. Must not be based on the resident's condition when originally transferred to the hospital . On [DATE], [DATE], and again on [DATE], during end of day meeting and pre exit meetings, the facility administrator and director of nursing were presented with the findings that the facility had not allowed R1 to return and had not issued the proper discharge notice to R1 in advance. No further information was provided.

Based on staff interview, clinical record review and facility documentation review, the facility staff failed to provide pharmaceutical services to meet the needs of 3 residents (Resident #3- R3, Resident #8- R8 and Resident #9- R9), in a survey sample of 14 residents. The findings included: The facility staff failed to administer medications as ordered by the physician due to medications not being available for administration from the pharmacy. On 1/16/24 and 1/27/24, clinical record reviews were conducted. The reviews revealed the following: 1a. According to the medication administration record (MAR), R3 was not administered a lidocaine patch as ordered for pain on 1/4/24 and 1/5/24. The progress notes had entries that read medication on order. 1b. The MAR for R3 also noted that on 1/5/24, the doctor had ordered pregabalin oral capsule 100 mg to be given twice daily. There was no indication that the medication was administered on the evening of 1/5/24, and neither of the two doses were given on 1/6 or 1/7, for a total of 5 doses being missed. Prior to this, the Resident was ordered this same medication, Pregabalin 75 mg, to be given three times daily since August 2023. The Resident did not receive any of the doses scheduled on 1/1 or 1/2. The progress notes had entries to indicate they were waiting for the pharmacy to bring the medication. 2. According to the clinical record, R8 had a progress note dated 12/22/23 at 7:22 p.m , that read, New orders for Advair, Albuterol and Mucinex due to non-productive cough, expiratory wheezing-sats 96% on room air . The Resident did not receive the Advair on 12/26/23 in the morning and neither dose on 12/27, due to the medication not being available. The progress notes for those days indicated awaiting arrival from pharmacy. 3. R9 was a prior resident of this facility and was discharged on [DATE], to the hospital for respiratory failure. According to the clinical record R9 was then readmitted on [DATE]. Per the MAR, R9 missed many of his medications the morning of 1/17, due to them being unavailable. Those medications included: Toprol being given for hypertension, Tiotropium Bromide Monohydrate Inhalation Capsule 18 MCG for COPD (chronic obstructive pulmonary disease), Mupirocin External Ointment 2 % for MRSA, Fluticasone-Salmeterol Inhalation Aerosol Powder Breath Activated for COPD, Gabapentin for Neuropathy, Empagliflozin Oral Tablet 25 MG for diabetes, Ertapenem Sodium Injection Solution Reconstituted 1 GM which is an antibiotic, and Primidone. It was noted that since R9 had previously been a resident many of the medications the resident was scheduled, they were taking prior to being hospitalized . On 1/17/24, an interview was conducted with the director of nursing (DON). When asked why the previous supply of medications could not have been used so that R9 didn't miss doses. The DON said, We send the medications back to the pharmacy when they discharge, we don't have room to store them. On the morning of 1/17/24, an interview was conducted with the facility's nurse practitioner. When asked about orders that she gives, when she expects them to start new medication orders she said, as soon as possible. She went on to add, what I mean by that is, I know the pharmacy has to get it here but no later than the next morning. She said if medications are not administered as ordered she expects staff to call her so that she is not only aware but could give additional or substitution orders if needed. She stated she is not aways made aware when medications are not given. A review of the facility's medication administration policies was conducted. The policies just indicated that medications are administered as prescribed. It did not address how the lack of medications being available was to be handled. The contents of the STAT box, emergency supply of medications maintained on-site, was reviewed. None of the above medications were available at the correct dosage in the STAT box. On the afternoon of 1/17/24, the administrator and director of nursing were made aware that the surveyor had concerns with residents missing medications because they were not available from the pharmacy. The DON reported that the pharmacy delivers to the facility twice daily Monday through Fridays. Once on Saturdays and they did no delivers on Sunday. When asked if they had a back-up pharmacy that medications could be obtained from, she stated, not local. No additional information was provided.

Based on staff interview, clinical record review and facility documentation review, the facility staff failed to maintain a complete and accurate medical record for one resident (Resident #1- R1) in a survey sample of 10 Residents. The findings included: For R1, the facility staff failed to maintain an accurate and complete clinical record with regards to the communication with and between the dialysis clinic and failed to maintain documentation with regards to instances of dialysis not being able to be performed or shortened treatment sessions. On 1/16/24 and 1/17/24, a closed record review was conducted of R1's chart. According to the clinical record on 8/1/23, the dialysis clinic gave an order that R1 was to have a sitter with them at dialysis for safety reasons. The facility staff required that the family accompany R1 and when the family was not present the resident would not receive dialysis treatments or only received a partial treatments. As a result, R1 would become symptomatic with fluid overload and would be sent to the hospital for urgent treatment, which included dialysis treatment. The facility staff had no evidence of communication between the facility and the dialysis clinic. The facility administrator stated that when R1 went to dialysis in October 2023 the dialysis clinic kept the book and the facility had not gotten this information back. The facility did not have complete documentation within the clinical record to indicate the instances of when R1 was not able to receive dialysis due to the lack of being accompanied by another person. Review of the facility policy titled; Coordination of Hemodialysis was conducted. Excerpts from this policy read, 1. A communication format will be initiated by the facility for any resident going to an ESRD [end stage renal disease] facility for hemodialysis. 2. Nursing will collect information regarding the resident to send to the ESRD facility with the resident- information recommended but not limited to: . e. blank ESRD communication form . 5. Upon the resident's return to the facility, nursing will review the ESRD communication form and communicate with the resident's physician and other ancillary departments as needed . 7. The completed ESRD form must be maintained as part of the medical record. On 1/17/24, an interview was conducted with the facility administrator. During this interview the administrator stated that they were working to see if they could get the communication book back and confirmed the communication between them and dialysis is considered part of the resident's clinical record. The administrator also said they were trying to figure out when that R1 missed dialysis treatments because it wasn't documented in the chart. No further information was provided.

Based on staff interview, facility document review, and clinical record review, the facility staff failed to provide adequate supervision/support to ensure safety during a transfer, resulting in serious adverse outcome (harm) for one of six residents in the survey sample (Resident #1). The findings include: Assessed as requiring two-person assistance, Resident #1 fell forward, hitting head against the wall, while being provided one-person assistance with toileting/transferring. Resident #1 complained of head/neck pain directly after the incident, was emergently hospitalized , diagnosed with an intracranial bleed due to the head injury, and subsequently died . Resident #1 was admitted to the facility with diagnoses that included cerebral infarction with left-sided hemiparesis, atherosclerotic heart disease, hypertension, epilepsy, anxiety, osteoarthritis, atrial fibrillation, diabetes with neuropathy, depression, gastroesophageal reflux disease, adrenal gland neoplasm and obstructive uropathy. The minimum data set (MDS) dated [DATE] assessed Resident #1 as cognitively intact and as requiring the extensive assistance of two people for transfers and limited assistance of two people for toileting. Resident #1's clinical record documented a nursing note dated [DATE] at 7:15 p.m. stating, Resident states was in bathroom getting pants pulled up and CNA [certified nurses' aide] pulled up pants, legs became weak and he head head on wall and hand rail .Hx [history] of CVA [stroke], Hemiplegia and hemiparesis of Left side .Resident c/o [complained of] headache, neck pain, nauseated, very clammy and sweaty. BP [blood pressure] ,d+[DATE] P [pulse] 89. Top of head without redness but yells out in pain when touched. PERRLA [pupils equal, round, reactive to light and accommodation] .Became more confused as time went on. Refused to do hand grasps due to pain .Spoke with .NP [nurse practitioner] and made decision to send to ED [emergency department]. 911 called .left facility at approx [approximately] 1935 [7:35 p.m.] . (Sic) A nurse documented on [DATE] at 3:09 a.m. that the hospital called and reported that the resident had expired and that .DON [director of nursing] will be informed in the am [morning] . The local emergency room physician's report dated [DATE] documented, .presents to the ER with complaints of fall .Per patient he states while he was walking to the bathroom, with assistance he fell hitting the top of his head .He complains of HA [headache], nausea, neck pain and upper back pain .Pt is on Eliquis . The physician ordered a CT scan. Prior to the scan the resident became unresponsive and was intubated. The CT scan was then performed, and the resident diagnosed with an intracranial hemorrhage. Resident #1 was transferred to a larger medical center for hospitalization /treatment. The hospital record dated [DATE] documented, .presents to ED .for evaluation of intracranial hemorrhage .Per EMS patient fell in the bathroom at .nursing home and hit his head .Patient is anticoagulated by Eliquis .Despite best efforts at outside hospital, large ICH [intracranial hemorrhage] and low probability of neurological outcomes . The hospital record documented the family was consulted and chose comfort care for the resident due to his condition. The hospital record dated [DATE] documented the resident was pronounced dead at 2:48 a.m. and that the medical examiner's office was contacted. The facility's investigation of Resident #1's injury of [DATE] documented a written statement from CNA #11, who was with the resident at the time of the incident. CNA #11's statement dated [DATE] documented, On [DATE]th [Resident #1] rang his call bell to go [to] the bathroom. I went in to assist him he was sitting in the wheelchair .I pushed him in the wheelchair into the bathroom. I pushed chair close to toilet, resident was able to grab the hand bar and pull himself up. While resident was standing I removed the brief and assisted him to the toilet. I remained in the room outside the bathroom door to provide privacy. Resident rang the emergency bathroom light and I was still in the room. Resident grabbed hold of handrail and I assisted him into the standing position. I assisted with pulling brief up, while pulling the brief up resident stated 'I can not stand much longer'. Residents legs buckled and resident was still holding handrail and tapped his forehead against the wall. I was able to reach behind me to get wheelchair to position under resident. I then proceeded to pull him out of the bathroom and place him back in front of television. I asked resident if he needed anything else. resident said 'no, but my neck and head are hurting' Upon exiting the room I went to the kiosk across from the desk to document on resident because I did not see nurse at that time .Nurse exited resident's room and asked me 'did [Resident #1] fall'? I proceeded to notify the nurse of what occurred. (Sic) The investigation documented an undated written statement by the licensed practical nurse (LPN #1) caring for Resident #1 on the evening of [DATE]. LPN #1's written statement documented, On ,d+[DATE] @ approx [approximately] 1900 [7:00 p.m.] was told by CNA that [Resident #1] needed a 'pain pill' .no order for pain med [medicine] so I wrote a standing order for Tylenol. Approx 2 minutes [after] being told went into res [resident's] room [with] pain med and saw res. hunched over moaning in w/c [wheelchair]. Asked what was wrong, res stated could not move neck and head was severly [severely] hurting. Asked what happened res told me that aid went to pull up pants in bathroom and res legs became weak and when aid pulled up pants, res went forward hitting top of head in wall. Res. skin clammy and sweaty took BP [with] extremely high reading. Pupils responded to light. Would not squeeze hands due to hurting. Called physician on call .order given to send to ED .911 called . observed res becoming more confused, drowsey [drowsy] .asked aid .what happened was told res in bathroom @ bar, legs gave out and she assisted res towards toilet, resident bumped head against wall. (Sic) The facility's investigation documented CNA #11, who was with Resident #1 at the time of the injury, was suspended on [DATE] due to the incident. The administrator documented a verbal education with CNA #11 on [DATE] at 2:31 p.m. about checking the Kardex for transfer status on each resident and that if listed as requiring two-persons, to make sure two certified staff members were providing transfer assistance. The administrator and CNA #11 signed the education sheet on [DATE]. Resident #1's death certificate issued on [DATE] documented the resident's primary cause of death as subdural and subarachnoid hemorrhage from a ground level fall that occurred on [DATE] at the nursing home. A facility report sent to the state agency dated [DATE] documented, On [DATE] the C.N.A [CNA #11] was assisting .[Resident #1] toileting. Resident bumped his head on wall while transferring off the toiilet [toilet]. Resident sent to ER .Resident declared dead at 2:48 am. Cause of death established on [DATE]. Cause of death Subdermal [subdural] hemorrage [hemorrhage] and subarachnoid hemorrage [hemorrhage] .Employee terminated. Staff re-educated on transfers and Kardex usuage [usage] . The report documented notification to adult protection services, department of health professions, ombudsman, and the local police. The facility's investigation documented CNA #11 was terminated on [DATE] due to not following proper care protocol during Resident #1's transfer from the toilet. The facility documented that after completing the investigation and receiving the medical examiner's report with cause of death, it was determined that CNA #11 did not follow the Kardex documentation or verbal reports provided that indicated a requirement for two-person assistance during transfers with Resident #1. The investigation documented re-education with all direct-care staff starting on [DATE] regarding use/reference of the Kardex to determine proper transfer assistance requirements for each resident. Resident #1's Kardex, used by CNAs as a guide for individualized safety/care requirements, was reviewed. Resident #1's Kardex in use on [DATE] documented the resident required the extensive assistance of two + persons for transfers and personal hygiene and required limited assistance of two + persons for toileting. This Kardex documented the resident was not steady when moving from seated to standing, when walking, turning around, moving on/off toilet, and had limited function of upper and lower extremities. Resident #1's plan of care on [DATE] documented the resident was at risk of falls due to left sided hemiparesis, had a physical functioning/self-care deficit due to impaired mobility, limited range of motion and was at risk of bleeding due to use of anticoagulant medication. Interventions to prevent significant fall related injuries and complications from anticoagulant use included provision of needed assistance for toileting, transfers, personal hygiene, locomotion, task segmentation, and monitoring Resident #1 for signs of bleeding or changes in condition. On [DATE] at 1:15 p.m., the nurse practitioner (NP - other staff #1) that cared for Resident #1 was interviewed. The NP stated that she had assessed Resident #1 earlier in the day on [DATE] in follow up to recent treatment for nausea. The NP stated that Resident #1 was neurologically intact during that assessment and stated he felt great with no further nausea or gastrointestinal symptoms. The NP stated that Resident #1 had a history of strokes and was weak in the legs. The NP stated that she was notified on [DATE] around 7:00 p.m. by nursing that the resident bumped his head, when his pants were being pulled up after toileting, and that he had complaints of headache. The NP stated that she ordered Resident #1 immediately to the emergency room , due to the symptoms and Resident #1's use of an anticoagulant (Eliquis), which increases risk of bleeding. On [DATE] at 12:05 p.m., LPN #1 caring for Resident #1 at the time of the incident, was interviewed by telephone. LPN #1 stated she had cared for Resident #1 since 7:00 a.m. on [DATE] and Resident #1 'was fine that day. LPN #1 stated on [DATE] around 7:00 p.m., a CNA (not CNA #11) reported to her that Resident #1 said he was hurting and wanted something for pain. LPN #1 stated that she checked the orders and retrieved Tylenol. LPN #1 stated, As soon as I hit the door, I knew something was wrong. LPN #1 stated that Resident #1 reported he was not able to move his neck and that his head was pounding. LPN #1 stated that the resident said when the aide was pulling up his pants in the bathroom, he hit the top of his head against the wall as his legs gave way. LPN #1 stated that she checked Resident #1's vital signs and noted a high blood pressure. LPN #1 stated that the resident refused to squeeze her hands, as he said he was in too much pain. LPN #1 stated that she called the NP who ordered the resident immediately be sent to the emergency room . LPN #1 stated CNA #11 had not previously reported to her that Resident #1 hit his head during the toilet transfer. LPN #1 stated that she was not aware of the incident until she went to Resident #1's room to assess his report of pain. LPN #1 stated that Resident #1 required two-person assistance for transfers/toileting. LPN #1 stated that Resident #1 usually requested assistance to/from the bathroom and required more assistance later in the day. LPN #1 stated that Resident #1's Kardex, used by CNAs for care instructions, listed a requirement for two-person assistance. On [DATE] at 1:45 p.m., CNA #2 that routinely cared for Resident #1 was interviewed about level of assistance with transfers/toileting. CNA #2 stated that Resident #1 was a two-person assist. CNA #2 stated that Resident #1 was weak in the legs. When questioned further, CNA #2 stated that he referenced the Kardex book to know what type of assistance/care residents required. On [DATE] at 2:00 p.m., the administrator and DON were interviewed about Resident #1's injury during transfer on [DATE]. The DON stated that she was notified that Resident #1 was sent to the hospital on the evening of [DATE] and was notified early the next morning ([DATE]) of the resident's death. The DON stated CNA #11 was suspended on [DATE] but came in and provided a written statement and demonstration of how the incident happened. The DON stated CNA #11 reported that Resident #1's legs got weak, and he hit his head against the wall as she was pulling up his pants/brief after toileting. The DON stated she was not sure of the exact time of the incident but stated CNA #11 reported to work on [DATE] at 6:00 p.m. and the nurse assessed the resident for headache/neck pain around 7:00 p.m. The DON stated that Resident #1 was listed as requiring two-person assistance during transfers/toileting, due to his weakness. The DON stated that when Resident #1 said his legs were weak, CNA #11 should have returned the resident to the toilet and called for help. The DON stated that Resident #1 was known to require two-person assistance especially late in the day. The DON stated that CNAs were expected to reference and follow the Kardex instructions for resident care, including the requirement for two-person assistance with transfers for Resident #1. The DON stated that CNA #11 was re-educated on [DATE] regarding use of the Kardex for resident care instructions and ensuring two certified staff members provided assisted for anyone listed as two-person assist for transfers. The DON stated CNA #11 did not work on [DATE], [DATE] or [DATE]. The DON stated CNA #11 worked on [DATE], but was terminated on [DATE] after the cause of death was provided. The administrator stated that when the cause of death was verified as intracranial hemorrhage from the head injury of [DATE], CNA #11 was terminated for not following Resident #1's Kardex for provision of two-person assistance. The administrator stated that all Kardex sheets were reviewed for accuracy on [DATE] and all direct-care staff were educated on [DATE] regarding provision of transfer assistance per the Kardex instructions. On [DATE] at 7:36 p.m., CNA #6 that previously provided care for Resident #1 was interviewed. CNA #6 stated Resident #1 was a two-person assist for going to the bathroom and transferring to bed. CNA #6 stated that she cared for Resident #1 during her orientation and always provided transfer assistance to him along with another aide. CNA #6 stated that the Kardex provided her with instructions for each resident's care. On [DATE] at 8:00 p.m., CNA #8 that previously provided care for Resident #1 was interviewed. CNA #8 stated Resident #1 was able to call for assistance to go/come from the bathroom and used the safety bar when transferring from the toilet. CNA #8 stated that Resident #1 required two-person assistance, especially when he was tired, and sometimes he was tired in the evening. CNA #8 was familiar with the Kardex and stated that this was the reference aides used for resident care instructions. On [DATE] at 8:15 p.m., CNA #9 was interviewed about Resident #1. CNA #9 stated that she only cared for Resident #1 during her orientation and that transfers were provided then with two-person assistance. CNA #9 stated that if she encountered problems during a transfer, she would use the call bell to get assistance, assist the resident back down if possible, and would get additional help. CNA #9 stated that she was aware the Kardex listed the care required for each resident. On [DATE] at 9:55 a.m., the registered nurse unit manager (RN #3) that cared for Resident #1 was interviewed. RN #3 stated the Kardex was updated based upon data entered routinely by CNAs about assistance provided with activities of daily living. RN #3 stated that Resident #1 was in the MDS/Kardex system as requiring two-person assistance for transfers/toileting and that CNAs were expected to follow the Kardex for resident care. These findings were reviewed with the administrator and director of nursing on [DATE] at 8:40 a.m. During this meeting, the administrator presented a correction plan initiated on [DATE] regarding Resident #1's improper transfer on [DATE] that resulting in serious injury/death. The correction plan included the following. [DATE] - CNA #11 suspended; written statements obtained from CNA #11 and LPN #1; CNA #11 provided demonstration to administrator and DON of the incident events; drug test administered to CNA #11; CNA #11 re-educated on providing required transfer assistance and following Kardex instructions for resident care. [DATE] - Cause of death verified through official medical examiner's report; CNA #11 terminated due to failure to provide required assistance that led to injury; Educated all administrative and direct-care staff on providing adequate transfer assistance and following Kardex instructions for care; 100% audit of all resident Kardex instructions for accuracy with updates made as needed; Initiated requirement for unit managers to bring Kardex binders to each morning meeting for review and updates for any changes in condition, new falls/incidents or new admissions; Reported incident to state agency, ombudsman, adult protective services, department of health professions and local police. [DATE] - Meeting held with remaining staff with re-education about proper transfer assistance and use of Kardex for care instructions. Audits were ongoing to ensure compliance. The administrator advised a date of compliance as [DATE]. The facility's incident and accident log for the past 30 days was reviewed with no other incidents/injuries involving staff assisted transfers listed. Five additional residents with injuries/incidents occurring after [DATE] were included in the survey sample with no deficient practice identified regarding transfer safety, falls and/or injuries. Care plan interventions for fall/injury prevention were observed in use. Education was documented for staff as listed in the correction plan. Interviews were conducted during the survey with direct-care staff from each unit and shift that included RN #1, CNA #1, CNA #2, LPN #1, CNA #2, CNA #3, CNA #4, CNA #5, CNA #6, CNA #7, RN #2, CNA #8, CNA #9, and CNA #10. All staff interviewed were aware of the care instructions provided on the Kardex, the expectation to follow the care instructions and knew where to access the Kardex book or Kardex information from a kiosk. The unit managers (LPN #3 and RN #3) were interviewed on [DATE] at 9:50 a.m. and stated they were now bringing the Kardex binder to each morning meeting for review/updates. The plan of correction was accepted. This deficiency cited as past non-compliance. There was no further information presented to the survey team regarding Resident #1's injury/death prior to exit.

Based on staff interview and facility document review, the facility staff failed to ensure the proper timeframe was in place to rescind a binding arbitration agreement for residents in the facility. Findings were: During the entrance conference on 02/21/2023 at approximately 1:00 p.m., the administrator was asked if residents or his/her representatives were asked to enter into a binding arbitration agreement with the facility. She responded, Yes. A copy of the facility arbitration agreement was requested. On 02/23/2023 at approximately 9:45 a.m., the VOLUNTARY ARBITRATION AGREEMENT PROGRAM GUIDE was reviewed and contained the following process listed under ARBITRATION PROCEDURES: If you sign the Agreement and later change your mind, you will have ten (10) business days from the date of execution of the Agreement to completely cancel and void the Agreement. Further review of the VOLUNTARY ARBITRATION AGREEMENT included the following: Right to Change Your Mind: The resident will receive from the Facility a copy of this agreement upon it being fully executed. This Agreement may be canceled via a written notice sent to the Facility administrator by certified mail, return receipt requested, within ten (10) business days of the date is is executed by the Resident. On the last page of the Agreement was a signature page with four bullets to be checked off the by the resident. The fourth bullet was : The Resident is aware that he/she may rescind this Agreement at any time within ten (10) business days of the date of its execution. The administrator was interviewed on 02/23/2023 at approximately 10:00 a.m. regarding the timeframe listed on the Agreement for residents to rescind their decision to enter the agreement. She stated she would look into it. At approximately 11:00 a.m., the administrator stated, We will be making changes to the Arbitration Agreement about the timeframe for the residents to rescind their decision. No further information was obtained prior to the exit conference on 02/23/2023.

Based on resident interview, staff interview, clinical record review, and facility document review the facility staff failed to follow professional standards of practice during medication administration for one of 19 residents in the survey sample: Resident # 33. Findings include: Resident # 33 was admitted to the facility 2/20/20 with diagnoses to include, but were not limited to: end stage renal disease, heart disease, high blood pressure, and insomnia. The most recent MDS (minimum set) was quarterly assessment dated [DATE]. Resident # 33 was assessed as cognitively intact with a total summary score of 15/15. On 2/21/23 beginning at approximately 3:00 p.m. during review of the clinical record, a nurses note dated 2/15/23 at 3:48 p.m. documented Resident was given the medication of another resident by mistake. Medication was Bethanechol (helps with urination)10 mg, Xanax (anti-anxiety) 0.5 mg, Cipro (antibiotic) 500 mg, Iron 325 mg, Fluvoxamine (antidepressant) 50 mg, Gabapentin (anticonvulsant) 200 mg, Lisinopril (for high blood pressure), Metformin (lowers blood sugars) 500 mg, Probiotic, and Senna 8.6. NP was notified and neuro checks were ordered every 15 minutes for one hour and then every hour for 4 hours. Then vital signs every 4 hours x 3. Resident had no issues after this medication was given. His vital signs as well as neuro checks have all been within normal limits. Resident is aware of the situation. On 2/21/23 at approximately 3:30 p.m. the DON (director of nursing) was asked if there was an investigation for the medication error. She stated there was. She was asked to see it, and she stated she would get it to me. On 2/22/23 at approximately 9:30 a.m. Resident # 33, who had just returned from dialysis, was asked about the incident. Resident # 33 stated Yes; I was sitting in my doorway and the nurse came down the hall and handed me a cup of medicines. Then she came back and said she made a mistake and gave me the wrong medicines and then she gave me my medicines. I was alright though . On 2/22/23 at approximately 10:00 a.m. the facility's nurse practitioner (NP) was interviewed. She stated I was notified no more than 15 minutes after it happened. I was already in-house. I went to talk to the nurse; went to patient's room and saw him fact-to-face 30-45 minutes after he got the meds .any sooner would not have had time for any effect he was tired, fatigued, and drowsy, so they had started to take effect. The main concern was Xanax and Gabapentin; even though he isn't a diabetic Metformin does not have a big impact on blood sugars so we did not check his blood sugars. I then gave the orders you see for the neuro checks and vital signs. The resident did not have any adverse event from the incident. On 2/22/23 at approximately 10:50 a.m. the nurse who administered the medications was contacted by phone. RN (registered nurse) # 1 was interviewed about the medication error. RN # 1 stated I had gotten his medications ready, but he wasn't ready to take them so I put the cup in the medication cart drawer. I started working on another resident's medications, and in the middle of that (name of Resident # 33) came to the med cart for his meds. I got the cup of pills from the cart and set it on top of the cart. He had just gotten back from dialysis, and we always take his blood pressure and vitals when he gets back, so I took his vitals, picked up the cup of pills I thought was his,and gave them. I even had his initials on the cup but still picked up the wrong one. I immediately notified the unit manager, and we did a medication incident form . On 2/22/23 at approximately 11:15 a.m., the DON, administrator, unit manager, and regional nurse were interviewed about the incident, and asked for the facility policy for medication administration. The unit manager, LPN (licensed practical nurse) # 2 stated, I did do verbal education on medication administration after the incident for RN # 1 . On 2/22/23 at approximately 11:30, the medication incident form was reviewed as filled out by RN # 1. The form identified Resident # 33 and the date of the incident of 2/15/23. The form included the medications that had been administered in error to Resident # 33, and under Explanation RN # 1 had documented Resident came up to have his medicine given. There was another med cup sitting on top of the cart that had just been pulled. Wrong cup was picked up and given. The facility policy Medication Administration General Guidelines directed 1. Medications are administered in accordance with written orders of the presciber 4. Medications are to be administered at the time they are prepared. 9. Verify medication is correct three (3) times before administering medication (a) When pulling medication from med cart (b) When dose is prepared (c) Before dose is administered 16. Medications supplied for one resident are never administered to another resident . 17. During administration of medications, the medication cart is kept closed and locked .No medications are kept on top of cart. On 2/23/23 beginning at approximately 12:50 p.m., the administrator, DON, LPN # 2, and regional nurse were informed of the above findings. No further information was provided prior to the exit conference.

Based on a medication pass and pour observation, staff interview, clinical record review, and facility document review, the facility staff failed to ensure a medication error rate of less than 5 percent. The facility had two medication errors out of 28 medication opportunities, which resulted in a medication error rate of 7.14 percent. Findings include: On 02/22/23 at 8:29 AM, a medication pass and pour observation was completed with Licensed Practical Nurse (LPN) #1. LPN #1 prepared medications for Resident #35, which included Vitamin C 500 milligrams (mg) (one tablet), Ferrous Sulfate 325 /65 mg (one tablet), Losartan Potassium 100 mg (one tablet), Miralax 17 grams (mixed with water) and Pravastatin Sodium Tablet 40 MG (one tablet). The resident had a total of 4 tablets and the Miralax mixture. The LPN administered the medication to Resident #35. At approximately 9:45 AM, a medication reconciliation was completed for Resident #35. The resident's physician's orders revealed the resident had an order for Protonix 40 mg once daily. The Protonix 40 mg was ordered on 02/21/23 and was ordered to start on 02/22/23. LPN #1 did not administer Protonix 40 mg to Resident #35 during the medication pass and pour observation. The resident's physician orders did not show a current order for the medication Pravastatin Sodium Tablet 40 MG. Further review of the resident's physician's orders revealed that the Pravastatin Sodium Tablet 40 MG had been discontinued for Resident #35 on 02/09/23. On 02/22/23 at 10:42 AM, LPN #1 was asked to pull up the resident's MAR (medication administration records) and to pull medication cards from the med cart for Resident #35. The LPN pulled out the medication cards, including the medication card for the Pravastatin 40 mg. The LPN was made aware that she did not give the ordered Protonix 40 mg, the LPN stated this is it and pointed to the Pravastatin 40 mg card. The LPN then stated, I gave her the wrong thing. I made a med error. The medication Pravastatin 40 mg (the discontinued medication) was given instead of Protonix 40 mg (ordered medication). The LPN stated she didn't understand why that medication (the discontinued medication) was still in the medication cart. The LPN was then asked if the medication Protonix 40 mg was available for administration. The LPN looked again in the medication cart and found the card for the Protonix. The LPN was made aware that the medication observation had resulted in two medication errors, the wrong medication (discontinued medication) was administered and the medication that was ordered was not given and was omitted. On 02/22/23 at 11:13 AM, the nurse consultant, administrator and DON (director of nursing) were made aware of the above information in a meeting with the survey team. The facility staff were asked for a policy on medication administration. The facility's policy titled, Medication Administration General Guidelines documented, .Medications are administered as prescribed in accordance with manufacturer's specifications, good nursing principles and practices .prior to administration, review and confirm medication orders for each individual resident .compare the medication and dosage schedule on the resident's MAR with the medication label .medications are administered in accordance with written orders of the prescriber .Verify medication is correct three (3) times before administering the medication .When pulling medication package from med cart .when dose is prepared .before dose is administered . No further information and/or documentation was presented prior to the exit conference on 02/23/23 at 1:30 PM.

Based on resident interview, staff interview, clinical record review, and facility document review the facility staff failed to ensure one of 19 residents in the survey sample was free from a significant medication error: Resident # 33. Findings include: Resident # 33 was admitted to the facility 2/20/20 with diagnoses to include, but were not limited to: end stage renal disease, heart disease, high blood pressure, and insomnia. The most recent MDS (minimum set) was quarterly assessment dated [DATE]. Resident # 33 was assessed as cognitively intact with a total summary score of 15/15. On 2/21/23 beginning at approximately 3:00 p.m. during review of the clinical record, a nurses note dated 2/15/23 at 3:48 p.m. documented Resident was given the medication of another resident by mistake. Medication was Bethanechol (helps with urination)10 mg, Xanax (anti-anxiety) 0.5 mg, Cipro (antibiotic) 500 mg, Iron 325 mg, Fluvoxamine (antidepressant) 50 mg, Gabapentin (anticonvulsant) 200 mg, Lisinopril (for high blood pressure), Metformin (lowers blood sugars) 500 mg, Probiotic, and Senna 8.6. NP was notified and neuro checks were ordered every 15 minutes for one hour and then every hour for 4 hours. Then vital signs every 4 hours x 3. Resident had no issues after this medication was given. His vital signs as well as neuro checks have all been within normal limits. Resident is aware of the situation. On 2/21/23 at approximately 3:30 p.m. the DON (director of nursing) was asked if there was an investigation for the medication error. She stated there was. She was asked to see it, and she stated she would get it to me. The DON returned a few minutes later and stated there had been a medication incident form completed, and a check sheet. She was then asked for a copy of the documentation. On 2/22/23 at approximately 8:45 a.m. the DON presented the requested information, as well as a copy of the facility medication administration policy. On 2/22/23 at approximately 9:30 a.m. Resident # 33, who had just returned from dialysis, was asked about the incident. Resident # 33 stated Yes; I was sitting in my doorway and the nurse came down the hall and handed me a cup of medicines. Then she came back and said she made a mistake and gave me the wrong medicines and then she gave me my medicines. I was alright though . On 2/22/23 at approximately 10:00 a.m. the facility's nurse practitioner (NP) was interviewed. She stated I was notified no more than 15 minutes after it happened. I was already in-house. I went to talk to the nurse; went to patient's room and saw him fact-to-face 30-45 minutes after he got the meds .any sooner would not have had time for any effect he was tired, fatigued, and drowsy, so they had started to take effect. The main concern was Xanax and Gabapentin; even though he isn't a diabetic Metformin does not have a big impact on blood sugars so we did not check his blood sugars. I then gave the orders you see for the neuro checks and vital signs. The resident did not have any adverse event from the incident. On 2/22/23 at approximately 10:50 a.m. the nurse who administered the medications was contacted by phone. RN (registered nurse) # 1 was interviewed about the medication error. RN # 1 stated I had gotten his medications ready, but he wasn't ready to take them so I put the cup in the medication cart drawer. I started working on another resident's medications, and in the middle of that (name of Resident # 33) came to the med cart for his meds. I got the cup of pills from the cart and set it on top of the cart. He had just gotten back from dialysis, and we always take his blood pressure and vitals when he gets back, so I took his vitals, picked up the cup of pills I thought was his,and gave them. I even had his initials on the cup but still picked up the wrong one. I immediately notified the unit manager, and we did a medication incident form . RN # 1 was asked if she had received any education following the incident, and if she had continued to give medications the rest of the shift. RN # 1 stated Yes, that happened around 10 or so in the morning. I finished my shift, and then was off 2/16/23 and 2/17/23. I came back to work 2/18/23 and worked that day, and 2/19/23, and 2/20/23. The unit manager came to me with education on medication administration, and I signed off on the policy I'm not positive a med pass observation being done with me . On 2/22/23 at approximately 11:15 a.m. the DON, administrator, unit manager, and regional nurse were interviewed about the incident, and asked for the facility policy for medication administration. The unit manager, LPN (licensed practical nurse) # 2 stated I did do verbal education on medication administration after the incident for RN # 1 .I don't have anything written. LPN # 2 confirmed RN # 1 stayed on the med cart until 7 p.m. on 2/15/23, was off 2/16/23 and 2/17/23, came back to work and gave meds 2/18/23, 2/19/23, and the morning of 2/20/23. The medication administration policy, which RN # 1 and LPN # 2 identified as the formal education piece was dated and signed by RN # 1 on 2/20/23. When asked about any reporting of the incident and for the complete investigation, the DON stated there was no investigation on paper. The administrator stated There was no harm to the resident so no reporting was done. On 2/22/23 at approximately 11:30 the medication incident form was reviewed as filled out by RN # 1. The form identified Resident # 33 and the date of the incident of 2/15/23. The form included the medications that had been administered in error to Resident # 33, and under Explanation RN # 1 had documented Resident came up to have his medicine given. There was another med cup sitting on top of the cart that had just been pulled. Wrong cup was picked up and given. The facility policy Medication Administration General Guidelines directed 1. Medications are administered in accordance with written orders of the presciber 4. Medications are to be administered at the time they are prepared. 9. Verify medication is correct three (3) times before administering medication (a) When pulling medication from med cart (b) When dose is prepared (c) Before dose is administered 16. Medications supplied for one resident are never administered to another resident . 17. During administration of medications, the medication cart is kept closed and locked .No medications are kept on top of cart. On 2/23/23 beginning at approximately 11:30 a.m. the administrator, DON, LPN # 2, and regional nurse were informed of the above findings. No further information was provided prior to the exit conference.

Based on resident interview, staff interview, and clinical record review, the facility staff failed to maintain a complete and accurate clinical record for one of 19 residents in the survey sample: Resident # 33. Findings include: Resident # 33 was admitted to the facility 2/20/20 with diagnoses to include, but were not limited to, end stage renal disease, heart disease, high blood pressure, and insomnia. The most recent MDS (minimum set) was quarterly assessment dated [DATE]. Resident # 33 was assessed as cognitively intact with a total summary score of 15/15. On 2/21/23 beginning at approximately 3:00 p.m. during review of the clinical record, a nurses note dated 2/15/23 at 3:48 p.m. documented Resident was given the medication of another resident by mistake. Medication was Bethanechol (helps with urination)10 mg, Xanax (anti-anxiety) 0.5 mg, Cipro (antibiotic) 500 mg, Iron 325 mg, Fluvoxamine (antidepressant) 50 mg, Gabapentin (anticonvulsant) 200 mg, Lisinopril (for high blood pressure), Metformin (lowers blood sugars) 500 mg, Probiotic, and Senna 8.6. NP was notified and neuro checks were ordered every 15 minutes for one hour and then every hour for 4 hours. Then vital signs every 4 hours x 3. Resident had no issues after this medication was given. His vital signs as well as neuro checks have all been within normal limits. Resident is aware of the situation. On 2/22/23 at approximately 9:30 a.m. Resident # 33, who had just returned from dialysis, was asked about the incident. Resident # 33 stated, Yes, I was sitting in my doorway and the nurse came down the hall and handed me a cup of medicines. Then she came back and said she made a mistake and gave me the wrong medicines and then she gave me my medicines. They took my blood pressure a couple of times .I was alright though . On 2/22/23 at approximately 10:00 a.m. the facility's nurse practitioner (NP) was interviewed. She stated, I was notified no more than 15 minutes after it happened. I was already in-house. I went to talk to the nurse; went to patient's room and saw him fact-to-face 30-45 minutes after he got the meds .any sooner would not have had time for any effect he was tired, fatigued, and drowsy, so they had started to take effect. The main concern was Xanax and Gabapentin; even though he isn't a diabetic Metformin does not have a big impact on blood sugars so we did not check his blood sugars. I then gave the orders you see for the neuro checks and vital signs. The NP was asked if it was known where the documentation for the neuro checks and vital signs were, as the current MAR (medication administration record) and TAR (treatment administration record) included the orders, but there were no staff initials to document the checks and vitals were done. The NP reviewed the record and stated, I don't know what was done on here; there's no documentation. Looks like there were 2 sets of vital signs done; there should have been 4 .there's nothing for the neuro checks . On 2/22/23 at approximately 10:50 a.m., the nurse who administered the medications was contacted by phone. RN (registered nurse) # 1 was interviewed about the medication error. RN # 1 stated, I had gotten his medications ready, but he wasn't ready to take them so I put the cup in the medication cart drawer. I started working on another resident's medications, and in the middle of that (name of Resident # 33) came to the med cart for his meds. I got the cup of pills from the cart and set it on top of the cart. He had just gotten back from dialysis, and we always take his blood pressure and vitals when he gets back, so I took his vitals, picked up the cup of pills I thought was his,and gave them. I even had his initials on the cup but still picked up the wrong one. I immediately notified the unit manager, and we did a medication incident form . RN # 1 was asked where the documentation for the vital signs were, as well as the neuro checks. She stated We did the vital signs and neuro checks; it's on a form that I turned in to the unit manager On 2/22/23 at approximately 11:15 a.m., the DON, administrator, unit manager, and regional nurse were interviewed about the incident. The unit manager, LPN (licensed practical nurse) # 2 was asked about the documentation for the vital signs and neuro checks that was turned in to her. LPN #2 stated she did not receive the documentation. The DON (director of nursing) added, [name of RN # 1] says she did the neuro checks, but we don't have anything that substantiates they were done .that includes the vital signs. On 2/23/23 beginning at approximately 12:50 p.m., the administrator, DON, LPN # 2, and regional nurse were informed of the above findings. No further information was provided prior to the exit conference.

Based on a medication pass and pour observation, staff interview, and facility document review, the facility staff failed to ensure infection control practices during the administration of medications. Findings include: On 02/22/23 at 8:29 AM, a medication pass and pour observation was conducted with LPN (Licensed Practical Nurse) #1. The LPN did not wash or sanitize her hands prior to preparing medications for Resident #67. The LPN prepared and administered the medications to Resident #67, left the resident's room and immediately began to prepare Resident #35. The LPN did not wash and/or sanitize her hands before proceeding to the next resident. LPN #1 prepared Resident #35's medications and administered the medications to the resident. LPN #1 left the resident's room, did not wash and/or sanitizer her hands and immediately began to prepare medications for Resident #9. LPN #1 prepared and administered medications to Resident #9, exited the room and then retrieved the hand sanitizer on the medication cart to cleanse her hands. At this time (8:53 AM), LPN #1 was made aware that she did not sanitize her hands at all between the residents' observed for the medication pass and pour observation (as described above). LPN #1 stated, I just realized that. The LPN sanitized her hands at that time. On 02/22/23 at 11:13 AM, the nurse consultant, the DON (director of nursing) and the administrator were made aware of the above information in a meeting with the survey team. The facility staff were asked for a policy on handwashing practices. The policy presented titled, Medication Administration General Guidelines documented, .Hands are washed with soap and water again after administration and with any resident contact .anti-microbial sanitizer may be used in place of soap and water as allowed by state nursing regulations and facility policy . The policy presented titled, Policies and Procedures Handwashing Technique documented, All personnel will wash hands before beginning the treatment/care of a resident and upon completion of such tasks, to prevent the spread of nosocomial infections . No further information and/or documentation was presented prior to the exit conference on 02/23/23 at 1:30 PM.

Based on staff interview, facility document review and clinical record review, the facility staff failed to follow abuse prevention policies regarding reporting/investigating an injury of unknown origin for one of two residents in the survey sample, Resident #1. Policies were not implemented regarding reporting/investigating bruising to Resident #1's breast and side of unknown source. The findings include: Resident #1 was admitted to the facility on [DATE] and discharged to the hospital on 7/18/21. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The minimum data set (MDS) dated [DATE] assessed Resident #1 with moderately impaired cognitive skills. Resident #1's clinical record documented a nursing note dated 6/30/21 stating, CNA [certified nurses' aide] alerted undersigned of bruise to left breast. This nurse observed purple bruising to left breast which extended to her L [left] side and 15 cm [centimeters] down side. Resident denies pain and states she does not know what happened to cause bruising. M.D. notified via communication book and family to be notified later in a.m. Will continue to monitor . A Bruise Investigation form dated 6/30/21 documented location of bruise as, L Breast that extends to L side + 15 cm down L side .Size: 21 cm from breast to side and 15 cm down L side .Color: purple .Time reported: 0300 [3:00 a.m.] .Resident condition: Alert [with] confusion . This form documented the resident did not ambulate alone and listed the resident took the anticoagulant medication [MEDICATION(S)] 2.5 milligrams twice per day. The nurse documented on this form, Resident has been observed Restless + lying side-ways (across bed) Perhaps metal portion of bed was culprit? Form instructions stated to list the caregivers on previous shifts based on color of bruise and document their response on back of form. Purple colored bruises required a list of caregivers during the last 24 hours. There were no caregivers listed on the form and no interviews and/or statements from any other staff members. The previous director of nursing (DON) signed the supervisor section of the form on 7/13/21 stating in her professional opinion, no abuse, neglect or mistreatment occurred. There was no documented investigation, no identified caregivers and no interviews or statements from anyone. There was no documented rationale for the DON's conclusion that no abuse, neglect or mistreatment occurred. Resident #1's plan of care (initiated 4/1/21) documented the resident had behaviors that included crying, screaming, shouting, feeling anxious, restlessness/panic, sad/tearful, accusing others, cursing at others, making disruptive sounds, hoarding and feelings of isolation. Interventions to minimize behaviors included medications as ordered, avoiding situations or people that were upsetting to the resident, notifying the physician when behaviors interfered with daily life, pain management and speaking to resident calmly. The DON that signed Resident #1's bruise investigation form was not available for interview, as she no longer worked at the facility. On 11/16/21 at 4:20 p.m., the current DON was interviewed about an investigation or reporting of Resident #1's breast/side bruising of unknown source. The DON stated the nurse that found the bruising completed the initial report but no investigation was done. The DON stated the nurse wrote down the initial assessment but no caregivers were identified, no interviews or statements were obtained and there was no reporting to the state agency. The facility's policy titled Resident Abuse - Injuries of Unknown Origin (revised 4/2020) documented, Provide treatment and documentation as indicated for the injuries of unknown origin. Injuries of unknown origin are bruises, skin tears, fractures, abrasions, etc., which have no known cause. The procedure for injuries of unknown origin included, .The Administrator and Director of Nursing are to be notified immediately .The administrator, Director of Nursing, or their designee, must begin a documented investigation for the cause of the injury .The investigation will include interviews with the resident, all staff involved (directly or indirectly), and family, visitors, or volunteers which may have had contact with the resident and may help with the investigation. Obtain written statements as deemed necessary .All injuries of unknown origin must be reported to the appropriate agencies per state specific protocols .If there is no reasonable cause to believe or suspect that an injury has been inflicted upon a resident by a CNA or other individual used by the facility or that neglect occurred .The investigation must be thoroughly documented using the Investigative Report form to show there is no cause to believe that abuse or neglect by staff caused the injury . This finding was reviewed with the administrator and DON on 11/16/21 at 4:45 p.m. and on 11/17/21 at 8:45 a.m.

Based on observation, resident interview, staff interview, facility document review and clinical record review, the facility staff failed to promptly assess, implement interventions, and provide immediate care for the prevention and/or treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #50 developed two pressure ulcers on the inside of both knees initially identified at an unstageable status with thick, necrotic tissue over the wounds. There was no prior assessment of impaired skin in those areas, and after treatment, were assessed as stage 4 pressure ulcers. Staff failed to follow physician orders and infection control practices during dressing changes to Resident #50's pressure ulcers. Facility staff failed to promptly assess and initiate treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . The findings include: Resident #50 was admitted to the facility on [DATE] with a readmission on 9/28/18. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The minimum data set (MDS) dated [DATE] assessed Resident #50 with moderately impaired cognitive skills and as requiring extensive assistance of two people for bed mobility, total assistance of two people for transfers and limited functional range of motion in both upper and lower extremities. a) Resident #50 developed two pressure ulcers on the inside of both knees initially identified at an unstageable status with thick, necrotic tissue covering the wound beds. Weekly skin checks never listed the knee wounds and the clinical record made no mention of the acquisition sequence of the new pressure ulcers. After treatment by the wound consultant, Resident #50's unstageable wounds were assessed as stage 4 pressure ulcers. Resident #50's clinical record documented the resident was currently treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . The clinical record documented Resident #50 was evaluated by occupational therapy (OT) on 3/26/21 for positioning due to abnormal posture and contractures. The OT plan of care dated 3/26/21 documented as underlying impairments, .Wounds - pt [patient] has wound .medial aspect of B [both] knees . Resident #50's clinical record documented the initial assessment of the medial knee ulcers on 4/1/21 by the facility's licensed practical nurse responsible for wounds (LPN #6). These assessments documented the knee ulcers were unstageable upon the initial assessment on 4/1/21 and listed the following: 4/1/21 - Left medial knee - unstageable pressure ulcer measuring 4.0 cm x 1.8 cm (length by width), Pressure injury currently presenting with dry scab covering wound. No drainage .Periwound red without breakdown . 4/1/21 - Right medial knee - unstageable pressure ulcer measuring 2.0 cm x 2.5 cm, Pressure injury to right medial knee presenting with dry scab covering wound. Periwound red without breakdown . The clinical record documented weekly skin integrity checks performed by nursing. In the weeks prior to, and week of the assessed unstageable ulcers, the skin checks documented no new areas of skin impairment. Skin integrity check sheets dated 3/5/21, 3/12/21, 3/19/21, 3/26/21 and 4/2/21 documented, Wound/Skin condition Present/No new change of condition. Documentation already established on all existing Wound/Skin Conditions. The weekly skin integrity sheets including the 4/2/21 sheet did not mention or identify the newly acquired unstageable pressure ulcers on the resident's knees. Nursing notes included no documentation of who initially found the knee ulcers, when the ulcers were found or who reported the ulcers to the wound nurse and physician. The facility's wound nurse (LPN #6) documented the first notes about the knee pressure ulcers on 4/1/21. A nursing note by the wound nurse (LPN #6) dated 4/1/21 at 1:44 p.m. documented, .Left Medial Knee - Pressure: Length = 4.0, Width = 1.8, Depth = NM [not measurable], - Stage Unstageable Drainage? No .No tunnelling or undermining present. The wound nurse documented a note on 4/1/21 at 1:50 p.m. stating, -Other (specify): : -Pressure: Length = 2.0, Width = 1.5, Depth = NM, - Stage Unstageable Drainage? No .No tunnelling or undermining present. (Sic) Other than the OT note referencing bilateral knee wounds on 3/26/21, the clinical record made no mention of the pressure ulcers to the medial aspect of both knees until 4/1/21 when they were assessed by the wound nurse as unstageable. The facility's consultant wound physician (other staff #8) assessed the resident's knee ulcers on 4/1/21 and listed both wounds as unstageable with thick necrotic tissue covering 100% of the wound beds. The physician's wound evaluation dated 4/1/21 documented the following initial assessment of the medial knee pressure ulcers: Left medial knee - pressure ulcer; unstageable due to necrosis, wound size 1.5 cm x 2.5 cm x non-measurable depth; moderate serosanguineous drainage; Thick adherent devitalized necrotic tissue: 100%. Right medial knee - pressure ulcer unstageable due to necrosis; wound size 2 cm x 1.5 cm x non-measurable depth; moderate serosanguineous; Think adherent devitalized necrotic tissue: 100%. The wound physician surgically debrided the left knee ulcer on 4/1/21. The resident refused surgical debridement of the right knee ulcer. The wound physician's note on the 4/1/21 assessment documented, Debridement refused. Patient/surrogate made aware of risks of not removing necrosis including infection; sepsis; limb loss or death . The wound physician ordered treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Follow up evaluations/treatments by the wound physician were documented on 4/8/21, 4/15/21, 4/22/21, 4/29/21, 5/6/21 and 5/13/21. The most recent wound physician assessment dated [DATE] documented the following status of the medial knee pressure ulcers. Left medial knee - stage 4 pressure, 3.9 cm x 3.9 cm x 0.2 cm, 10% granulation tissue Right medial knee - stage 4 pressure, 1.6 cm x 1 cm x 0.2 cm, 10% thick adherent devitalized tissue, granulation 90%. The most recent nursing assessment dated [DATE] documented the following assessments of the knee ulcers. Left medial knee - stage 4 measuring 3.4 cm x 4.0 cm x 0.4 cm (length x width x depth in centimeters) Right medial knee - stage 4 measuring 1.7 cm x 1.4 cm x 0.6 cm On 5/26/21 at 1:30 p.m., with the resident's permission and accompanied by licensed practical nurse (LPN) #5 and LPN #1, dressing changes to Resident #50's pressure ulcers were observed. The resident had a circular pressure ulcer on the inside of the left knee approximately the size of a 50-cent piece. The wound had serosanguineous drainage on the existing dressing with the edges of the wound slightly raised with the skin around the wound red. The resident had a circular wound on the inside of the right knee slightly smaller than a dime with small amount of black tissue noted in the wound bed. The skin around the right knee wound was red/pink. On 5/26/21 at 2:05 p.m., LPN #5 was interviewed about interventions in place prior to the resident's acquisition of unstageable pressure ulcers on both knees. LPN #5 stated they were using a pillow at one time between his knees but switched to a wedge after development of the knee wounds. On 5/26/21 at 3:06 p.m., Resident #50 was interviewed about the pressure ulcers on his knees. The resident stated a bed pillow was used prior to the knee wounds and now he had a firm wedge between his legs to keep his knees from resting against each other. Resident #50 stated he did not remember the exact dates of when the pillow and wedge were started. Resident #50 stated he had feeling in his extremities but was unable to move his legs and lower body due to severe contractures related to [CONDITION(S)]. When asked about the pillow used prior to the unstageable knee wounds, Resident #50 stated the pillow must not have been working because now he had wounds inside both knees. On 5/26/21 at 3:30 p.m., LPN #1 that worked on Resident #50's living unit was interviewed about the resident's wounds and any preventive interventions. LPN #1 stated that they tried to keep bed pillows between his knees. LPN #1 stated, I'm not 100% sure about whether they [pillows] have been there as she stated she worked mostly on the opposite end of Resident #50's unit. On 5/26/21 at 3:33 p.m., LPN #5 was interviewed again about Resident #50's knee wounds and why they were found covered with necrotic tissue. LPN #5 stated she did not know why the wounds were found at unstageable. LPN #5 stated nurses were assigned to perform weekly skin assessments and any new wounds or areas of concern were supposed to be reported immediately to the wound nurse. On 5/26/21 at 3:45 p.m., the certified nurses' aide (CNA #1) caring for Resident #50 was interviewed about any preventive measures regarding the knee wounds. CNA #1 stated, I'm agency. This is my second day. CNA #1 stated she was not familiar with Resident #50's wounds and did not know what preventive treatments were used in the past. CNA #1 stated she thought they were using pillows to keep his legs from rubbing. On 5/26/21 at 4:51 p.m., the registered nurse unit manager (RN #1) was interviewed about development of Resident #50's knee ulcers. RN #1 stated she remembered talking about the knee ulcers in the weekly wound meeting but did not remember the exact date. On 5/27/21 at 7:30 a.m., the director of nursing (DON) was interviewed about Resident #50's knee ulcers. The DON stated the resident's knee wounds started on 4/1/21 and care was initiated and had been provided since then. The DON stated, I read nursing notes. They were doing pillows. The DON stated the resident refused care at times. The DON stated she looked through the care plan and all the interventions used were listed. The DON stated she did not know who originally found the wounds or who reported the ulcers to the wound nurse. The DON stated the wound nurse did not document who reported or found the wounds. The DON stated the facility met weekly to review wounds. The DON stated prior to 4/1/21 she did not recall the knee ulcers being discussed in the weekly meeting. When asked why the weekly skin assessment sheets never documented the acquisition of the new knee pressure ulcers, the DON had no response. The wound nurse (LPN #6) was out on leave and not available for interview. On 5/27/21 at 7:50 a.m., LPN #4 that routinely cared for Resident #50 was interviewed about the acquisition of the knee ulcers at an unstageable status. LPN #4 stated they were using a blue cushion between the resident's knees prior to 4/1/21. LPN #4 stated when the blue cushion was in laundry, bed pillows were used. LPN #4 stated they attempted to keep the resident more on his left side to keep pressure off the right buttock wound. LPN #4 stated she did not know if this put more pressure on his knees. LPN #4 stated she did not know why the unstageable wounds were not identified earlier. LPN #4 stated nurses were assigned weekly skin assessments and were to report any new wounds to the wound nurse. On 5/27/21 at 8:10 a.m., the certified nurses' aide (CNA #2) that routinely cared for Resident #50 was interviewed. CNA #2 stated she used the blue cushion between the resident's legs when in bed and used the wedge when the resident was up in the wheelchair. CNA #2 did not know when the knee ulcers started and stated if she found new open skin areas she was supposed to be reported them immediately to a nurse. On 5/27/21 at 8:20 a.m., the physical therapist (PT - other staff #3) was interviewed about Resident #50. The PT stated he was not aware the resident had pressure ulcers on both knees. The PT stated the resident was very challenging due to his contractures and the best prevention was frequent repositioning. The PT stated occupational therapy (OT) evaluated the resident in March 2021 for positioning. On 5/27/21 at 9:25 a.m., the OT (other staff #4) that treated Resident #50 was interviewed. The OT stated she evaluated and treated the resident regarding bed and wheelchair positioning. The OT stated Resident #50 required constant monitoring due to contractures that caused his knees to rest against each other. The OT stated prior to 4/1/21 an abduction (blue) pillow was used with the resident when up in the wheelchair and bed pillows and/or a wedge were used when the resident was in bed. The OT stated all those interventions (pillow, blue cushion and wedge) were initiated months prior to 4/1/21. The OT stated the resident was very tight at the knees and she was concerned because his positioning was very complex and his contractures were aggressive. The OT stated that even with devices in place, there could be pressure created because the muscle tone/contractures were so aggressive. On 5/27/21 at 9:40 a.m., the DON was interviewed again about any explanation of why wounds were not identified prior to being found with adhered 100% necrotic tissue. The DON stated, No. I don't have that information. The DON stated nothing was documented about the knees until 4/1/21. The DON stated she did not have proof of how the wounds occurred or who found them because nothing was documented. The DON stated the wound nurse assessed the ulcers on 4/1/21 and we moved forward from there. On 5/27/21 at 10:07 a.m., the unit manager (RN #1) was interviewed again about Resident #50's knee wounds. RN #1 stated she knew a small wedge was implemented at some point but she did not go back and observe to see if the wedge contributed to any issues. RN #1 stated she did not know who originally found and/or reported the knee ulcers to the wound nurse as nothing was documented in the clinical record. RN #1 stated pressure ulcers typically did not begin as unstageable wounds and she had no explanation of why the knee ulcers were found at an unstageable status. On 5/27/21 at 11:15 a.m., the OT was interviewed again about her documented evaluation on 3/26/21 listing the resident had bilateral knee wounds. The OT reviewed the documented note and stated the information was not her observation but most likely came from communication from nursing or information shared during the weekly wound meeting. On 5/27/21 at 1:50 p.m., the wound physician (other staff #8) was interviewed by telephone about Resident #50. The physician stated he first assessed the knee ulcers on 4/1/21 and described the wounds upon his initial assessment as clearly unstageable. The physician stated after surgical debridement both wounds were assessed as stage 4. The physician stated Resident #50 was severely deconditioned and at high risk of skin breakdown due to contractures. The physician stated he performed a head-to-toe assessment only on new patients. The physician stated he was already treating Resident #50 for wounds on his foot and buttocks. The physician stated that for established patients like Resident #50, he depended on the wound nurses to perform assessments and notify him of changes or new wounds requiring treatment. The physician stated he knew they were using pillows for positioning at one time but did not know all the preventive interventions implemented. Resident #50's plan of care (revised 5/6/21) documented the resident had impaired mobility, self-care impairment, limited range of motion, right side weakness and contractures due to [CONDITION(S)]. Interventions to maintain physical functioning included, .Inspect skin with care. Report reddened areas, rashes, bruising, or open areas to charge nurse . This care plan documented the resident was at risk of pressure and non-pressure related skin impairment due to assistance required for bed mobility, deconditioning, diabetes, immobility, history of diabetic/pressure ulcers and history of moisture related skin impairment. Interventions to prevent/heal pressure ulcers were initiated on 12/28/20 and included Braden risk assessment, weekly skin inspection, float heels, heel boots, monitor labs, nutrition support, pressure reduction mattress, treatments as ordered, turning and repositioning in bed and weekly wound assessments. The care plan was updated on 5/6/21 listing the resident had stage 4 pressure ulcers on the right medial knee, right buttock/thigh, right proximal foot, left medial knee and right lateral foot. Interventions listed to prevent complications from pressure ulcers were dated 5/6/21 and included Braden risk assessment, weekly skin inspections, diabetic foot monitoring, do not massage bony prominences, lotion to skin, monitor labs, monitor under braces, splints, casts, nutrition support, pressure reducing wheelchair cushion, pressure reduction mattress, skin care after incontinence, therapy referral, treatments as ordered and weekly wound assessments. The care plan documented the resident had contractures due to [CONDITION(S)] and limited range of motion of all extremities. The care plan made no mention of the blue cushion, pillows or wedge referenced during staff interviews. The clinical record documented a physician's order dated 3/20/18 for an air/fluidized mattress and an order 10/28/20 to ensure resident was positioned on left side as much as possible for off-loading to right leg wound. A physician's order was entered on 4/26/21 to, Ensure Prevalon Boots are in place at all times. The clinical record documented Braden pressure ulcer risk assessments as part of a quarterly data collection tool. Resident #50's pressure ulcer risk assessment dated [DATE] and 4/20/21 listed the resident as a moderate risk for pressure ulcers with a total score of 13. Nursing notes from 3/1/21 through 5/25/21 made one reference to use of a pillow and wedge for positioning. A nursing note dated 4/25/21 documented, Resident is currently on ATB [antibiotic] therapy for [CONDITION(S)]. Redness to back and legs almost resolved .Continue to provide pressure wound dsgs [dressings] per MD [physician] orders. Refused to get out of bed this weekend. Has been experiencing multiple loose stools both days. Positioning resident of left side with pillow in between knees, and under bil [bilateral] feet-wedges used to keep positioned properly . (Sic) A note dated 5/24/21 documented the resident refused the Prevalon boots. Nursing notes from 3/1/21 through 5/25/21 made no other mention of positioning devices or the resident's refusal of skin care interventions. The facility's policy titled Skin Assessment - Weekly (effective 1/2107) documented, A Licensed Nurse will complete a total body assessment on each resident weekly, paying particular attention to any skin tears, bruises, stasis ulcers, rashes, pressure ulcers, [CONDITION(S)], abrasions, reddened areas and skin turgor problems. The purpose of the Skin Assessment is to evaluate the condition of the resident's skin on a regular basis. As the nursing assistants are the residents' primary care giver, Licensed Nurses do not routinely observe the resident's skin. This process not only provides a system for Licensed Nurses to regularly assess each resident's skin condition, but also provides a means of evaluating the nursing assistant's reporting of and response to residents with skin problems . b) Staff failed to follow infection control practices during dressing changes to Resident #50's pressure ulcers, failed to have a physician ordered dressing in place on the right buttock/thigh pressure ulcer and failed to have Prevalon boots in use for pressure ulcer prevention as ordered by the physician. On 5/26/21 at 1:30 p.m., with the resident's permission and accompanied by licensed practical nurse (LPN) #5 and LPN #1, dressing changes to Resident #50's pressure ulcers were observed. The resident was observed in bed without Prevalon boots in place. Without prior hand hygiene, LPN #5 sanitized the bed table with a wipe, placed a clean barrier and positioned gauze and other supplies onto the clean field. LPN #5 washed her hands, applied clean gloves, removed and then discarded the dirty dressing from two wounds on the resident's right foot. LPN #5 removed her gloves and donned a new pair of gloves but performed no hand hygiene between the glove changes. LPN #5 then cleansed the larger right foot ulcer with a Dakin's solution and then cleansed the smaller right foot ulcer with a Dakin's soaked gauze. LPN #5 then patted the wounds dry, applied a Dakin's soaked gauze to the larger foot ulcer and covered it with a non-stick gauze and [MEDICATION(S)] adhesive dressing. LPN #5 removed her gloves and without performing hand hygiene put on clean gloves then applied the Dakin's soaked gauze dressing to the smaller foot ulcer. LPN #5 removed her gloves after the dressing application and without prior hand hygiene, donned a new pair of gloves. The resident was then positioned for a dressing change to the right buttock/thigh pressure ulcer. The right buttock/upper thigh pressure ulcer had no existing dressing in place at the time of the dressing change. A new open area was observed on the right buttock adjacent to the existing wound. This new area was approximately postage stamp size with a red wound bed. LPN #5 stated she did not know why the right buttock ulcer had no dressing and she had not been made aware of the new open area. LPN #5 proceeded to cleanse the right buttock ulcer then the smaller new open area with Dakin's solution, packed the existing ulcer wound with Dakin's soaked gauze, applied a non-stick gauze then covered the wound with [MEDICATION(S)]. LPN #5 removed her gloves, donned new gloves without prior hand hygiene and placed a non-stick gauze with [MEDICATION(S)] over the new open area. LPN #5 changed gloves again without hand hygiene between the glove changes. LPN #5 removed the dirty dressing for the right knee ulcer and then cleansed this ulcer with Dakin's solution. LPN #5 removed her gloves, without hand hygiene put on clean gloves and then applied Dakin's soaked gauze, non-stick gauze and [MEDICATION(S)] dressing to the right knee ulcer. LPN #5 took off gloves then left the room to get more gauze. Upon return to the room, LPN #5 washed her hands. LPN #5 put on clean gloves and then removed the drainage soaked dressing for the ulcer on the inside of the left knee. LPN #5 changed gloves again without hand hygiene between the glove changes. LPN #5 failed to cleanse the left knee ulcer prior to application of the Dakin's soaked gauze, non-stick gauze and [MEDICATION(S)] dressing. LPN #5 removed gloves, put on new gloves without prior hand hygiene and then moved the trash can to the other side of the bed. LPN #5 then changed gloves without hand hygiene between glove changes, removed the soiled dressing on the left hip ulcer and discarded it. LPN #5 took off gloves and without prior hand hygiene, donned clean gloves then applied the Dakin's soaked gauze, non-stick gauze and [MEDICATION(S)] dressing to the left hip wound. LPN #5 then changed gloves, assisted LPN #1 with a brief change for the resident, discarded gloves and supplies then went to the treatment cart and applied hand sanitizer. The resident's clinical record documented current physician orders as of 5/26/21 for wet to dry dressing changes twice per day as follows for all the resident's pressure ulcers: Cleanse with Dakin's solution, apply Dakin's soaked gauze and cover with dry dressing. The record documented a physician's order dated 4/26/21 for Prevalon boots in place at all times. On 5/26/21 at 2:05 p.m., LPN #5 was interviewed about the lack of hand hygiene between glove changes, no dressing in place on the right buttock wound and not cleansing the left knee ulcer prior to application of the dressings. LPN #5 stated, I was very nervous. LPN #5 stated she should have taken hand sanitizer in with the dressing change supplies. LPN #5 stated she was not familiar with the resident's wound as the wound nurse usually performed treatments. LPN #5 stated the wound nurse was out on leave so floor nurses were now doing wound care. LPN #5 stated she did not know why there was no dressing in place on the existing right buttock ulcer. LPN #5 stated if a dressing came off during care the aides were supposed to inform the nurse so the dressing could be replaced. LPN #5 stated she did not know why the boots were not in use and again stated she had not been made aware of the new open area on the right buttock. On 5/26/21 at 3:00 p.m., the director of nursing (DON) was interviewed about assessments and treatments for wounds. The DON stated the wound nurse had been out since 5/19/21. The DON stated it was [NAME] podge on who was performing care with the wound nurse out. The DON stated a nurse was assigned daily from the schedule to perform dressing changes in the facility. On 5/26/21 at 3:45 p.m., the DON was interviewed again about a dressing change policy. The DON stated she did not have a policy about dressing changes. The DON stated they reviewed competencies for all the nurses that included wound care, prevention, treatments, weekly skin assessments and infection control. When asked about LPN #5 not performing hand hygiene between the glove changes during the dressing changes to multiple wounds, the DON stated it was nursing 101 to perform hand hygiene between glove changes and between wounds. The DON stated that new open areas were supposed to be reported immediately to nursing for assessment and treatment. 5/26/21 at 4:51 p.m., the registered nurse (RN #1) responsible for the infection control program was interviewed about the dressing change observation. RN #1 stated the nurse should have washed hands prior to the start of the dressing change and then performed hand hygiene after each glove change. RN #1 stated the sequence for dressing changes should be hand hygiene, gloves on, remove dirty dressing, remove gloves, perform hand hygiene, put on clean gloves, cleanse wound, remove gloves, perform hand hygiene, apply new gloves, apply treatments/clean dressings, discard supplies, remove gloves and perform hand hygiene. RN #1 stated she did not have a specific policy about dressing changes but presented dressing change information included with the policy about documenting wounds. RN #1 stated any new open areas or displaced dressings were supposed to be reported immediately to the nurse caring for the resident. On 5/27/21 at 7:45 a.m., LPN #2 that was assigned to Resident #50 on 5/26/21 was interviewed about the dressing not in place on the right buttock ulcer and the new open area observed on the right buttock. LPN #2 stated, I had him [Resident #50] yesterday [5/26/21] and nobody reported a new wound, open area or that the dressing had come off. The dressing change policy provided was titled Non-Sterile Dressing Change and was undated. This policy documented the following steps for a dressing change, Non-sterile dressings protect open wounds from contamination and absorb drainage .Wash hands, apply gloves .Remove soiled dressing, place it in trash bag .Remove gloves, wash hands, apply new gloves .Cleanse wound with normal saline or prescribed cleanser .Pat the tissue surrounding the wound dry with a 4 x 4 .Assess wound characteristics .Remove gloves, wash hands, apply new gloves .Apply prescribed topical agent to wound .Apply wound dressing .Discard gloves and all used supplies in trash bag .Wash hands .Document the dressing change in medical record . Resident #50's care plan (revised 5/6/21) listed the resident had stage 4 pressure ulcers on the right medial knee, right buttock/thigh, right proximal foot, left medial knee and right lateral foot. Interventions listed to prevent complications from pressure ulcers were dated 5/6/21 and included Braden risk assessment, weekly skin inspections, diabetic foot monitoring, do not massage bony prominences, lotion to skin, monitor labs, monitor under braces, splints, casts, nutrition support, pressure reducing wheelchair cushion, pressure reduction mattress, skin care after incontinence, therapy referral, treatments as ordered and weekly wound assessments. The Lippincott Manual of Nursing Practice 11th edition documents on page 843 concerning hand hygiene, Hand hygiene is the single most recommended measure to reduce the risks of transmitting microorganisms .Hand hygiene should be performed between patient contacts; after contact with blood, body fluids, secretions, excretions, and contaminated equipment or articles; before donning and after removing gloves is vital for infection control. It may be necessary to clean hands between tasks on the same patient to prevent cross-contamination of different body sites . Page 847 of this reference documents, .Gloves are worn to provide a protective barrier and prevent gross contamination of the hands of health care workers; if used properly, they reduce the transmission of microorganisms and help prevent cross-contamination within a patient. Wearing gloves does not replace the need for hand hygiene because gloves may have small defects or may be torn during use, and during the removal of gloves, hands may become contaminated .Perform hand hygiene before putting on gloves .Change gloves after contact with infective material, such as feces and wound drainage .Remove gloves before leaving the patient's environment and perform appropriate hand hygiene immediately . (2) c) Facility staff failed to promptly assess, notify the provider and seek treatment orders for the newly found pressure ulcer on Resident #50's right buttock. On 5/26/21 at 1:30 p.m., with the resident's permission and accompanied by licensed practical nurse (LPN) #5 and LPN #1, dressing changes to Resident #50's pressure ulcers were observed. Observed during the dressing change was a new open wound to the resident's right buttock adjacent to an existing right buttock/thigh ulcer. The open wound was approximately postage stamp size with a red wound bed. LPN #5 cleansed the wound, applied a non-stick gauze and covered the wound with a [MEDICATION(S)] dressing. LPN #5 stated at the time of the dressing changes that she had not previously been made aware of this new wound. On 5/26/21 at 2:05 p.m., LPN #5 was interviewed about the new open area on the resident's right buttock. LPN #5 stated she had not been made aware of the any new wounds and the aides and other nurses had reported no newly impaired skin integrity. LPN #5 stated she covered the wound and would contact the nurse practitioner for treatment orders. On 5/26/21 at 3:33 p.m., LPN #5 stated nurses were required to perform weekly skin assessments and if a new area was found, report it immediately to the wound nurse who would assess and obtain treatment orders. LPN #5 states aides were also to report any new skin impairments seen during care with the residents. On 5/26/21 at 5:00 p.m., the new open area found on the resident's right buttock during the dressing changes was reviewed with the administrator, director of nursing (DON) and registered nurse unit manager (RN #1) during a meeting with the survey team. On 5/27/21 at 7:45 a.m., LPN #2 that cared for Resident #50 was interviewed about the new open wound found on the right buttock. LPN #2 stated she was assigned to Resident #50 yesterday (5/26/21) and nobody reported a new wound or open area to her during the shift. LPN #2 stated she was performing wound care today (5/27/21) but had not been made aware of any new open area on Resident #50's buttock. On 5/27/21 at 9:15 a.m., Resident #50's clinical record was reviewed. The clinical record including nursing notes made no mention of the open area on the resident's right buttock found on 5/26/21. There was no nursing note, no assessment of the wound, no notification to a provider and no physician's order obtained regarding treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] On 5/27/21 at 9:40 a.m., [TRUNCATED]

Based on observation, staff interview, facility document review and clinical record review, facility staff failed to provide supervision and interventions for the prevention of accidents and injuries for four of 15 residents in the survey sample, Residents #15, #11, #5 and #6. 1.a. Resident #15 did not have interventions in place to prevent a fall with injury and resulting harm on 06/22/2016. 1.b. Resident #15 did not have interventions in place to prevent a fall with injury and resulting harm on 07/20/2016. 2. Resident #11 did not have interventions in place to prevent a fall with injury and resulting harm on 10/01/2016. 3. Resident #5 suffered a burn on 09/19/2016 when she spilled hot coffee on her lap during lunch. 4. Resident #6 did not have wheelchair anti-tippers in use as required in her plan of care for fall prevention. Findings included: Resident #15 was originally admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The most recent MDS (minimum data set) was a significant change assessment with an ARD (assessment reference date) of 07/05/2016. Resident #15 was assessed as severely impaired in her cognitive status with a total cognitive score of three out of 15. 1.a. Resident #15 did not have interventions in place to prevent a fall with injury and resulting harm on 06/22/2016. Resident #15's closed clinical record was reviewed 11/02/2016 at approximately 11:25 a.m. Review of Nursing Progress Notes revealed Resident #15 fell a total of five times from January 2016 through August 2016. Three of those falls resulted in injury, two of the three resulted in harm. Resident #15 fell on [DATE]. Gripper socks and a bed alarm were added to the care plan at that time. The second fall occurred 05/05/2016 at the nurse ' s station and was witnessed. This fall resulted in a fractured hip. Resident #15 was admitted to the hospital from 05/05/2016 through 05/09/2016 and had her hip fracture repaired. Resident #15 was readmitted to the facility on [DATE]. The only fall precaution initiated upon Resident #15 ' s readmission was to place anti-tippers on her wheelchair. In addition, Resident #15 did receive physical therapy after her readmission. However, as her mobility progressed, no other fall precautions were ever initiated. Resident #15 fell on [DATE] in her bathroom that resulted in a fractured nose. Educate staff to toilet resident before and after meals and before bedtime was added to the care plan. On 07/20/2016 Resident #15 fell again and required five staples to the back of her head. Will place resident in a low bed was added to the care plan. Resident #15 again fell on [DATE]. Right side of bed to wall and landing strips placed on the floor was added at that time. Alarms were never restarted after Resident #15 ' s readmission to the facility on [DATE]. Interventions were added reactively after each fall, not proactively. The actual Nursing Progress Notes included the following documentation: 01/25/2016 04:21 (4:21 a.m.) Change of Condition: Situation: Resident yelling 'help' from room. Resident was found by this nurse sitting on floor in residents room facing doorway. Residents walker was at bedside .Assessment: .Gripper socks applied and reminded resident to use walker for ambulation .Raised bruise/contusion was found on left inner buttocks .Multiple times of resident getting up unassisted and not using call bell. Bed alarm was put in place to alert staff of ambulation . 5/5/2016 20:11 (8:11 p.m.) .Change of Condition: Situation: Resident fell on the floor by the nurses desk .Assessment: Resident had witnessed fall by the nurses desk. Resident had got up out of w/c (wheelchair) without assistance and fell to left side. Resident hit head on floor although no injury to head noted. Complains of increased pain in left hip/pelvic area . Resident incurred a left femur fracture. Resident #15 was readmitted to the facility on [DATE] after surgical repair of her left hip fracture. According to documentation in the clinical record no specific fall interventions were implemented upon readmission to the facility except .Will place anti-rollbacks to w/c to prevent chair from rolling if resident attempts to stand unassisted , per Resident #15's care plan. 6/22/2016 15:50 (3:50 p.m.) .Change of Condition: Situation: Resident fell .Assessment: Nurse heard yelling out. Nurse walked into room and found resident in bathroom on knees with face near toilet. Large amount of bright red blood present. Resident has 2 areas to nose which were bleeding-steri-strips applied. Noted to have abrasive area to left knee, right knee is red . Per the care plan, .6/23/16-Will educate staff to offer toileting upon rising, AC (before meals), PC (after meals), and HS (bed time . As previously mention, no other fall interventions added at that time according to documentation in the clinical record. 6/27/2016 10:34 General Note: .MD (physician) in to visit, new order noted to schedule x-ray of face-nose to r/o (rule out) fx (fracture) . 6/28/2016 12:35 General Note: .Xray noted that nose is broken . 1.b. Resident #15 did not have interventions in place to prevent a fall with injury and resulting harm on 07/20/2016. 7/20/2016 18:21 (6:21 p.m.) .Change of Condition: Situation: Resident found sitting in floor by her bed .Assessment: Dining staff notified nurse that resident lying on floor. This nurse entered room and resident sitting up in floor and yelling 'My head hurts, I'm dyeing (sic) .Resident with raised are (sic) to mid lower back of head with moderate bleeding . 7/20/26 22:06 (10:06 p.m.) General Note: .T/C (telephone call) from (Name) nurse at (hospital initials) stating xrays did not show any abnormal findings. Res (resident) had 5 staples put in head . Care plan documentation included, .7/21/16-Will place resident in low bed . 8/3/2016 00:31 (12:31 a.m.) .Change of Condition: Situation: Resident found laying on back on floor at the end of residents bed . Care plan documentation included, .8/3/16-Will place Right side of bed against the wall so HOB (head of bed) is facing toward hallway, and will place landing strip to Left side of bed . Review of facility fall investigation reports for May through August 2016 correlated with documentation in the clinical record regarding Resident #15. Fall investigation dated 06/22/2016 stated, .After assessing resident, resident was brought into the dayroom so resident could be closely monitored .Resident has a history of falls. She has dementia and requires frequent cueing and redirection. Resident has poor vision and unsteady gait .Resident is not safe to ambulate unassisted but at times will get up out of bed and ambulate unassisted. Resident is located in semi-private room closest to nurses's station. Fall interventions reviewed and are appropriate at this time. Will educate staff to offer to toilet resident upon rising, ac, pc, and hs . Fall investigation dated 07/20 2016 stated, Upon investigation, resident was observed lying on the floor by dining staff who notified nursing .Resident examined and received staples to back of head and returned to the facility .Resident has a history of falls with appropriate interventions in place. Will place resident in a low bed . Fall investigation dated 08/02/2016 stated, Upon investigation, resident found laying on back on floor at the end of residents bed .Resident wearing gripper socks at time of fall. Resident has dementia and will not ring for assistance. Will place Right side of bed against the wall so HOB facing toward hallway, and will place landing strip to Left side of bed . The Administrator and DON (director of nursing) were informed of surveyor concerns regarding Resident #15's fall status during a meeting with the survey team on 11/02/2016 at approximately 3:45 p.m. Administrative staff was requested to present any information available concerning this resident's falls. On 11/03/2016 at approximately 8:00 a.m. the ADON (assistant director of nursing) entered the conference room to speak with this surveyor. The ADON stated, We feel we did all we could for (Resident #15). We kept her in the day room a lot of the time and moved her room closer to the nurses station so we could check on her often. When asked why alarms were not restarted on her readmission or thereafter the ADON stated, When she first came back she wasn't very mobile so we didn't feel she needed alarms. We did something after each of her falls. You can see that here on the care plan. The Administrator and DON were informed of the above during a meeting with the survey team on 11/03/2016 at approximately 9:30 a.m. No further information was received prior to the exit conference 11/03/2016. 2. Resident #11 did not have interventions in place to prevent a fall with injury and resulting harm on 10/01/2016. Findings were: Resident #11 was most recently admitted to the facility on [DATE] with the following diagnoses, but not limited to: Muscle weakness, congestive heart failure, dizziness and giddiness, and pancytopenia (deficiency of blood cells-red cells, white cells and platelets). Resident #11 was assessed on his admission MDS (minimum data set), ARD (assessment reference date) 09/28/2016 and a significant change MDS, ARD 10/16/2016 as having a cognitive summary score of 08, indicating moderate impairment with his cognitive status. Section G-Functional Status on the admission MDS included the following information: G0110. Activities of Daily Living (ADL) Assistance Transfer: Self Performance - Limited assistance (Resident highly involved in activity, staff provide guided maneuvering of limbs or other non-weight bearing assistance) Support: One person physical assist Walk in Room: Self Performance - Limited assistance Support: One person physical assist Walk in Corridor: Self Performance - Limited assistance Support: One person physical assist Toilet use: Self Performance - Limited assistance Support: Two + persons physical assist G0300 Balance During Transitions and Walking Moving from seated to standing position: Not steady, only able to stabilize with staff assistance Walking (with assistive device if used): Not steady, only able to stabilize with staff assistance Turning around and facing the opposite direction while walking: Not steady, only able to stabilize with staff assistance Moving on and off toilet: Not steady, only able to stabilize with staff assistance Surface-to-surface transfer (transfer between bed and chair or wheelchair): Not steady, only able to stabilize with staff assistance Initial tour of the facility was conducted on 11/01/2016 at approximately 11:30 a.m. Resident #11 was observed sitting in a wheelchair at the nurse's station. He wore a blue helmet on his head and had blue bruising bilaterally around his eyes. The clinical record was reviewed on 11/02/2016. The following information was observed in the progress note section: 9/21/2016 Res (resident) admitted to facility .Ambulatory but unsteady. Alert with some confusion at times .Requires assistance of one for ADL's (activities of daily living), transfers and toileting .Res encouraged to use call light for assistance . 9/22/2015 Res a/o (alert/oriented) with confusion at time (sic) .Transfers self without staff assistance and very unsteady. Staff encourages rs (resident) to use call light . 9/22/2016 Resident is alert with confusion .Requires assistance with ADLS. Can ambulate with supervision . 9/23/2016 SBAR-Change of Condition Situation: Resident fell in room reaching in drawer for razor Background: History of Falls Assessment: No injury Response: Razor removed reminded to use call light and walker. Shoes placed on 9/23/2016 Rs a/o with confusion at time .Transfers self without staff assist and very unsteady. Staff encourages rs to use call light .up in hallway walking with walker high risk for falls post fall precautions at this time. 9/24/2016 Resident A&O with confusion at time .Transfers self without staff assist and very unsteady. Staff encourages resident to use call light .Receiving therapy services for strengthening, ambulation, transferring, and personal hygiene . 9/25/2016 Resident A&O with confusion at time .Transfers self without staff assist and very unsteady. Staff encourages resident to use call light . 9/26/2016 Alert with confusion at times. receives skilled services for strengthening, ambulation, transferring and personal hygiene .Self transfers, unsteady. Ambulatory with rolling walker. Res. encouraged to use call light for assist . 09/27/2016 Alert with confusion .Receives skilled services for PT/OT (physical therapy/occupational therapy). Requires assist of one with ADL's, supine to sit, sitting to stand position. Ambulatory with assist of rolling walker, Res. forgets to use walker at times and encouraged to use walker at all times. Res. unsteady at times . 9/27/2016 Physician Note Note Text: CC (Chief Complaint): HX (History) FALLS/HEAD INJURY . Resident seen 09/27/2016 for follow-up evaluation s/p (status [REDACTED].HX FALLS hx frequent falls at risk for falls due to poor safety awareness continue to provide verbal and visual reminders to call for help . 09/28/2016 Resident A&O with confusion at time .Transfers self without staff assist and very unsteady. Staff encourages resident to use call light . 09/29/2016 Resident A&O with confusion at time .Transfers self without staff assist and very unsteady. Staff encourages resident to use call light . 09/29/2016 Physician Note HX FALLS hx frequent falls at risk for falls due to poor safety awareness continue to provide verbal and visual reminders to call for help . 09/30/2016 Weekly Care Management Meeting Current Functional Status in Therapy : CGA (contact guard assistance) Remaining Barriers (Performance with therapy): Cognitive/Safety Awareness Bed Mobility Transfers Walking Self Cares Toileting Bathing . 9/30/2016 . Transfers self without staff assist and very unsteady. Staff encourages resident to use call light . 10/02/2016 SBAR -Change of Condition Situation: Resident heard yelling help from room. Resident discovered on his back on the floor of his room just outside his bathroom by staff at 2200 (10:00 p.m.) Resident stated he got up to turn off his light. Background: MUSCLE WEAKNESS (GENERALIZED) 9/21/16 Primary Admission . Assessment: Resident laying on his back on the floor outside his bathroom. Large pool of blood noted underneath his head. Unable to assess laceration to the back of residents head related to concerns of head and neck trauma. Resident was alert and oriented. Able to answer questions appropriately. C/O (complained of) pain to right hip and head. Wheel chair found on left side of resident flipped over on front side. Walker at foot of the bed. Resident was barefoot . Response: Wife notified, 911 called and ER (emergency room ) nurse (name) notified at 2205. Resident transported out of facility to the hospital via ambulance at 2218. emergency room called for and update, Resident flown to Roanoke for further evaluation. 10/4/2016 Late Entry Physician Note: Note Text: CC: HX FALLS/HEAD INJURY . Resident seen 10/04/2016 for reevaluation following return from hospital following fall in facility resulting in head injury. Resident was airlifted from (names of facilities) and had repair of arterial laceration and scalp closure A/P (assessment and planning): HX FALLS/HEAD INJURY hx frequent falls at risk for falls due to poor safety awareness nursing to cleanse and monitor scalp wound daily . The care plan was reviewed. A focus area, At risk for falls related to: Use of medications that may cause dizziness, new environment, weakness, unsteadiness, hx (history) of falls, poor safety awareness at times, incontinence . was observed with the goal No fall related injuries The focus area and the goal were initiated on 09/21/2016 at the time of Resident #11's admission. The following interventions for falls were implemented on 09/21/2016: Call light or personal items available and in easy reach or provide reacher; Keep environment well lit and free of clutter; Observe for side effects of Medications; Orientation to new room and roommate; Therapy referral. On 09/26/2016 the following intervention was added: Will place sign in room to remind resident to ring for assistance. Also observed on the care plan was a focus area, I have a physical functioning deficit related to: Self care impairment, Mobility impairment . Interventions listed included but were not limited to: Transfer assistance of one, implemented 9/21/2016. On 11/02/2016 at approximately 3:00 p.m. the OT (occupational therapist) who had worked with Resident #11 was interviewed. She was asked what Resident #11's functional status was at the time of admission to the facility on [DATE]. She stated, He needed assistance whenever he was up .we tried putting signs up in his room and did repeated cueing to remind him not to get up unassisted .he acted like he comprehended but he was like a toddler, he couldn't remember what you told him .He needed contact guard assistance whenever he was up. She was asked to review the PT notes. She stated, PT evaluated him on 9/22/2016 he was moderate assistance for transfers, sit to stand, meaning he needed 50% assistance to transfer, he was minimal assistance, 25 % for transfers, stand to pivot and walking on level surfaces. The OT was asked what that meant. She stated, He shouldn't be up alone he is a fall risk. She continued, On 09/30 he was able to walk with someone beside him and he could do functional transfers with ques for safety. She was asked if he was safe for walking or transferring independently as of 09/30/2016. She stated, No. The DON (director of nursing) was interviewed on 11/02/2016 at approximately 3:15 p.m., regarding Resident #11. Daily documentation regarding Resident #11 self transferring without staff assistance and being Very unsteady from the time of admission on 09/21/2016 until the time of fall with injury on 10/01/2016, was discussed. The DON was asked what interventions had been implemented to ensure Resident #11's safety prior to the fall with injury on 10/01/2016. She stated, The company is moving away from alarms .he has one now but we are really trying not to use them. The DON was asked if any interventions other than the use of alarms were implemented prior to the fall with injury. She stated she would look. The DON presented a facility document FALLS Events By Resident on 11/02/2016. According to the document the only intervention implemented by the facility staff to ensure Resident #11's safety was to place a sign in room to call for assist on 09/23/2016. The DON was asked if any other interventions were implemented to address Resident #11's continued transfers without staff assistance. She shook her head from side to side, indicating No. A meeting was held with the DON and the administrator on 11/02/2016 at approximately 3:50 p.m. Concerns were voiced regarding Resident #11's fall on 10/01/2016 with resulting harm. The DON was asked for any additional information indicating precautions and interventions in place for Resident #11 to prevent falls prior to the fall with injury on 10/01/2016. On 11/03/2016 at approximately 8:30 a.m., the unit manager, RN (registered nurse) #4 came to the conference room to speak with this surveyor. No additional information was provided regarding new interventions that were put in place in response to Resident #11 transferring without assistance prior to his fall with injury on 10/01/2016. No further information was received prior to the exit conference on 11/03/2016. 3. Resident #5 suffered a burn on 09/19/2016 when she spilled hot coffee on her lap during lunch. Findings were: Resident #5 was most recently readmitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. The most recent MDS (minimum data set) was a quarterly assessment with an ARD (assessment reference date) of 09/07/2016. Resident #5 was assessed as having a cognitive summary score of 06, indicating severe impairment with her cognitive status. The clinical record was reviewed on 11/01/2016. The following notations were observed in the progress note section: 09/19/2016 Resident spilled coffee on pants during lunch. Resident left inner thigh pink and right inner thigh slightly pink. No blisters noted at this time. Will monitor area next few days. 09/21/2016 .no redness noted to bilateral inner thighs (from 9/119 (sic) - coffee spill) . The physician order [REDACTED]. The order was written on 07/01/2016. The DON (director of nursing) was asked on 11/02/2016 if there was an investigation regarding the burn that Resident #5 sustained on 09/19/2016. She stated she would see what she could find. The DON and the Dietary manager came to the conference room at approximately 9:30 a.m. on 11/02/2016. The DON stated, She has an order for [REDACTED]. The DON and the dietary manager were asked if the lid had been in place at the time Resident #5 spilled her coffee and was burned. The DON stated, I don't know .She has an order for [REDACTED]. The dietary manager stated, It's possible. The DON informed this surveyor that no investigation had been done regarding the burn. The DON was asked if the lid had been in place on the cup when the burn occurred and who was in the dining room with the resident at the time it happened. She stated, I don't know .I know that there are staff in the dining room during meal times but I don't know what the circumstances were when she spilled the coffee. The DON was asked why Resident #5 had orders for a lidded cup. She stated, It may be that she had spilled something in the past. No further information was obtained prior to the exit conference on 11/03/2016. 4. Resident #6 did not have wheelchair anti-tippers in use as required in her plan of care for fall prevention. Resident #6 was admitted to the facility on [DATE] with a re-admission on 11/11/15. [DIAGNOSES REDACTED]. The minimum data set ((MDS) dated [DATE] assessed Resident #6 with moderately impaired cognitive skills. Resident #6 was observed on 11/1/16 at 1:30 p.m. seated in her wheelchair in her room. The resident's wheelchair was missing an anti-tipper rod on the right side of her wheelchair. The left anti-tipper rod was not extended. This left anti-tipper did not extend beyond the circumference of the rear wheel and was approximately 4 to 5 inches from the floor. Resident #6 was observed again on 11/1/16 at 2:35 p.m. seated in her wheelchair with the missing right anti-tipper and short left anti-tipper rod. Resident #6's plan of care (revised 8/30/16) listed the resident was at risk for falls due to medications, dementia, poor safety awareness and history of falls. The care plan listed the resident had falls on 1/25/16, 2/3/16, 6/27/16, 8/13/16 and 8/29/16. Care plan interventions to prevent falls included the use of anti tippers on the wheelchair to prevent the wheelchair from overturning. On 11/1/16 at 2:40 p.m. accompanied by the licensed practical nurse (LPN #1), Resident #6 was observed in her wheelchair with the missing anti-tipper rod. LPN #1 was interviewed at this time about the missing right rod and the short left rod. LPN #1 stated, She (Resident #6) is supposed to have both anti-tippers. LPN #1 stated she did not know why the right anti-tipper was missing. LPN #1 stated she would check with the maintenance director about the missing rod. LPN #1 stated the anti-tipper rods were designed to prevent the wheelchair from overturning if the resident attempted to get out of the chair. On 11/1/16 at 4:15 p.m. was interviewed about the short anti-tipper rod mounted on the left side of the wheelchair. LPN #1 stated the left anti-tipper was too short and won't do much good. These findings were reviewed with the administrator and director of nursing during a meeting on 11/2/16 at 10:00 a.m.

Based on staff interview, family interview, clinical record review, and facility document review, the facility staff failed to ensure one of 16 residents was transferred safely, Resident # 4. The facility staff failed to transfer Resident # 4 using two staff members, as a result Resident # 4 fell and fractured his femur. This resulted in harm to Resident #4. Findings include: Resident # 4 was admitted to the facility on [DATE], with the most current readmission on 09/05/14. [DIAGNOSES REDACTED]. accident/stroke) with right side [DIAGNOSES REDACTED], history of polio[DIAGNOSES REDACTED] with amputation of toes (right side), and neurogenic bladder with supra-pubic catheter. The most current MDS (minimum data set) with CAAS (care area assessment summary) was a significant change assessment dated [DATE]. Resident # 4 was assessed as having a cognitive score of "9", indicating the resident was moderately impaired in daily decision making skills. The resident was also assessed as requiring extensive assistance with at least two persons physical assist for most all ADL's (activities of daily living), including transfers. The resident triggered for falls in the CAAS section. The resident was additionally assessed as "Not steady, only able to stabilize with staff assistance" on Section G0300. A. Moving from seated to standing position, D. Moving on and off toilet, and E. Surface-to-surface transfer (transfer between bed and chair or wheelchair) and as having impairment on the upper and lower extremity on one side of the body. A quarterly MDS, dated [DATE] was reviewed for comparison. This MDS assessed the resident with a cognitive score of "14", indicating the resident was cognitively intact. This MDS also assessed the resident as requiring extensive assistance with at least two persons physical assist for most all ADL's (activities of living), including transfers. The resident was also assessed as "Not steady, only able to stabilize with staff assistance" on Section G0300. A. Moving from seated to standing position, D. Moving on and off toilet, and E. Surface-to-surface transfer (transfer between bed and chair or wheelchair) and as having impairment on the upper and lower extremity on one side of the body. During clinical record review on 10/15/14, a H&P (history and physical) from a local hospital was reviewed and documented that Resident # 4 had a fall while transferring at the facility on 03/05/14 that resulted in an impacted fracture of the resident's right femoral neck (the resident's affected side). Nursing notes were then reviewed for the the month of March 2014. No nursing notes revealed information regarding or addressing Resident # 4's fall with injury. Nursing notes were found with limited information (during the month of March 2014) and identified that the resident had been sent out for evaluation, no further information or documentation was located within the nursing notes regarding Resident # 4's fall with injury. Resident # 4's CCP (comprehensive care plan) was reviewed and documented the following: "...At risk for falls related to generalized weakness, use of hypnotics, medications for blood pressure, pain, blood sugar, incontinence of bowel, supra pubic catheter, cognition impairment at times-forgetful, needs cues, prompting at times, incontinence, unsteady balance due to amputation of right fourth toe (osteo[DIAGNOSES REDACTED]). Had amputation of right fifth toe in August 2012, History of CVA with right hemiparesis...(date initiated 09/03/12)...keep environment well lit and free of clutter...Impaired cognition/neurological status related to CVA with [DIAGNOSES REDACTED]/hemiparesis (right side)...cognition and communication impairment-forgetful at times...(date initiated 09/03/12)...Assist in ADL's and mobility as needed...Physical functioning deficit related to self care and mobility impairment...right toes amputation...Bed mobility/transfers assistance of two...dressing assistance of two...locomotion assistance of one after transfer to w/c...toileting and personal hygiene assistance of two...(03/07/12)..." At approximately 11:15 a.m., the DON (Director of Nursing) was made aware that no information could be located in the nursing notes regarding Resident # 4's fall with injury; an investigation and/or any information/documentation regarding Resident # 4's fall with injury was requested at this time. At approximately 11:30 a.m., the investigation was presented and reviewed by the ADON (Assistant Director of Nursing). The investigation documented: "...date/time of occurrence: 03/05/14 14:25 (2:25 p.m.)...CNA (certified nursing assistant) # 2 transfer (sic) resident from recliner to w/c (wheelchair). CNA reported that resident's feet got twisted causing his balance to be off and resident assisted to floor...Resident c/o (complained of) hip pain...right hip noted to be sunken in...unable to bear weight...sent out to ER (emergency room ) for evaluation...CASUAL/CONTRIBUTING FACTORS AND OBSERVATIONS -SPECIFY RECOMMENDATIONS/INTERVENTIONS TAKEN: Feet got twisted up during transfer...Upon investigation resident was being transferred from lift recliner to w/c, when resident went to pivot, feet became tangled up and resident was lowered to the floor by CNA onto right side. Resident c/o hip pain, resident transferred to ER for further evaluation..." At approximately 1:00 p.m., Resident # 4's restorative records were reviewed and revealed that the resident had not participated in restorative nursing (active ROM-range of motion and walking) since November 15th, 2013. The resident's physical functioning was documented as declining from that point on. The ADON was interviewed at approximately 1:15 p.m. regarding the investigation and was asked if one person transferred the resident when the accident occurred. The ADON stated that, one CNA did transfer the resident. The ADON was then shown the resident's CCP and the resident was assessed as being a two person transfer. The ADON stated that she thought that was for bed mobility, but would look further into it. At approximately 1:30 p.m., CNA # 1 was interviewed regarding Resident # 4. CNA # 1 stated that she had been here working here for "a long time" and elaborated to "over 3 or 4 years." CNA # 1 was asked if she had was familiar with Resident # 4 and if she had worked with the resident on a regular basis, CNA # 1 stated, "Yes." CNA # 1 interviewed regarding the resident's fall with injury in March. CNA # 1 stated that she knew when that happened. The CNA further stated that prior to the fall the resident was "...always a two person assist with a gait belt..." The CNA was asked if that was from the bed to chair or bed/chair to w/c. CNA # 1 stated, "either or any of those..." The CNA was asked if she knew that Resident # 4 was transferred that day with one CNA. CNA # 1 stated, "No, I did not know that." At approximately 1:45 p.m., ADL sheets for Resident # 4 (from January 2014 through March 2014) were requested from the ADON (Assistant Director of Nursing) and an interview was requested from CNA # 2. ADL sheets for Resident #4 were presented and reviewed. The ADL sheets revealed that Resident # 4 had consistently been transferred with extensive assistance using two + persons physical assist for transfers. It was documented that, from February 16th through March 5th (including all three shifts) that Resident # 4 was transferred using only one person on three occasions. At approximately 2:00 p.m., CNA # 2 was interviewed regarding Resident # 4. CNA # 2 stated that she "considered" the resident to be 1 to 2 person assist at that time. The CNA further stated that her partner left their unit to retrieve a lift for another patient and she (CNA # 2) was left alone. CNA # 2 stated that the resident can be "impatient" and was wanting to go to the bathroom. CNA # 2 stated, "I asked (name of Resident # 4) if he was sure he could help me and he said, "yes, I'm sure we can do it." The CNA stated that she raised the resident's (electric recliner) and he stood for a brief second and then started going down. The CNA stated that she couldn't hold him and at that point lowered the resident to the floor. The CNA stated that it "depends on a particular day (of what the resident can do) and it was based on "my judgement." The CNA stated, "I realize in hind sight I should have waited on my partner." At 3:15 p.m., the resident's RP (responsible party) was interviewed via telephone. The RP stated that her father had a stroke [AGE] years ago and was paralyzed on the right side and had progressively declined physically. The RP further stated that the facility notified her of the fall that occurred on March 5th, 2014 and stated at one time "you" (caregivers) could do him with one person and most recently some were still caring for him with only one. The RP was asked if she knew that the resident was assessed to be a two person assist, the RP stated that she did not and stated that staff some would use two and some would/could handle him with one. The RP stated that her father could be impatient/demanding at times and can rush them (staff) and she didn't know if that may have contributed to him falling. The RP stated that she understands that accidents happen and was pleased with the care her father had been receiving. At approximately 3:45 p.m., the administrator, DON, ADON and RN (Registered Nurse) # 3 were informed of the above information and the concerns regarding the transfer of Resident # 4 with only one CNA that resulted in serious injury to the resident, in a meeting with the survey team. The facility staff were asked at that time for any additional information or documentation to evidence the resident was safe transferring with one person at that time. The DON stated that CNA # 2 was very upset and I told her to make sure there were always two. The DON stated that in "hind sight-should have had assist of two..." No further information or documentation was provided prior to the exit conference on 10/15/14 at 4:45 p.m.