Every finding on record at Signature Healthcare of Clarksville

Based on policy review, fall investigation review, medical record review, observation, and interview, the facility failed to ensure a safe and secure environment for 5 of 7 (Resident #31, #50, #248, #498 and #501) sampled residents reviewed for falls and accidents. The facility failed to ensure processes were implemented to provide supervision and assistance to ensure the residents' environment was free of accident hazards. The facility failed to conduct thorough fall investigations to identify all contributing factors (root causes) and failed to implement appropriate interventions to ensure resident safety. Resident #498 was admitted on [DATE] and had 13 falls from [DATE] through [DATE]. On [DATE], Resident #498 sustained 3 falls, that resulted in a subdural hemorrhage, a C5 fracture (cervical neck fracture) and bilateral rib fractures. Resident #498 was sent to the emergency room (ER), was admitted to the hospital and discharged back to the facility on [DATE]. Resident #498 was a vulnerable Resident with memory impairment and abnormalities of gait and mobility. The facility's failure to provide supervision and ensure a safe environment free of accident hazards resulted in Immediate Jeopardy for Resident #498. Immediate Jeopardy (IJ) (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) was identified related to the facility's failure to use its resources effectively to attain and maintain the highest practicable well-being of vulnerable residents, to ensure systems and processes were implemented to provide supervision and assistance to ensure the resident environment was free of accident hazards. The Administrator was notified of the Immediate Jeopardy (IJ) for F-689 during the recertification/complaint investigation on [DATE] at 6:48 PM, in the Conference Room. The facility was cited at F-689, at a scope and severity of J which is Substandard Quality of Care. The Immediate Jeopardy existed from [DATE]-[DATE]. An acceptable Removal Plan, which removed the immediacy of the Jeopardy, was received on [DATE] at 2:42 PM, with an alleged removal date of [DATE]. The Removal Plan was verified and validated onsite by the surveyors on [DATE] through review of the in-service training records and audits, review of the facility's policy, observations, and staff interviews. The last day of the IJ was [DATE]. The IJ was removed on [DATE]. After the acceptable Removal Plan for F-689 was validated on [DATE], noncompliance remains for F-689 at a scope and severity of D. The facility is required to submit a Plan of Correction. The findings include: 1. Review of the facility's policy titled, Falls, with a revision date of [DATE], revealed .The intent of this policy is to ensure the facility provides an environment that is as free from accident hazards, as possible, over which the facility has control to prevent avoidable falls .All residents will have a fall risk assessment on admission/readmission, quarterly, annually, and with a significant change of condition to identify risk for falls .A Comprehensive Care Plan will be implemented based on the resident's risk for falls with an individual goal and interventions specific to each resident to attempt to reduce the risk of avoidable falls .Care Plan Accidents goals and interventions will be revised as applicable .The Interdisciplinary Team (IDT) which includes the Director of Nursing (DON) or their designee reviews during the At-Risk Meeting .Falls may be reviewed at the facility Quality Assurance/Performance Improvement (QAPI) Committee . Review of the facility's policy titled, Accidents and Incidents, with a revision date of [DATE], revealed .The intent is to ensure the facility provides an environment that is as free from accidents and incidents that are avoidable, the facility investigates these occurrences with applicable documentation, and appropriate reporting is completed as applicable .The Nurse, Nurse Supervisor/Charge Nurse and /or the Department Director of Supervisor shall initiate and document the accident or incident . Review of the facility's document titled, Neuro Check Guidelines, dated [DATE], revealed .Witnessed Fall- No Head injury / did not Hit Their Head .Complete fall event in MatrixCare .Neuro checks not needed- follow provider orders .Continue charting on resident for 72 hours .Unwitnessed Fall or Witnessed Fall With Head Injury / Hit Their Head .Complete fall event in MatrixCare .Neuro checks every 15 minutes x [times] 4 (total of 1 hour) .Neuro checks every 30 minutes x 2 (total of 1 hour) .Neuro checks every 1 hour x 4 (total of 4 hours) .Neuro every 4 hours x 4 (total of 16 hours) .Resume routine charting for the remainder of the 72 hours post fall . 2. Review of the medical record revealed Resident #498 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses including Traumatic Subarachnoid Hemorrhage, End Stage Renal Disease (ESRD), Osteoporosis, Epistaxis, Malignant Neoplasms of Lymphoid, Hematopoietic, and related Tissues [group of cancers that affect blood cells and the tissues of the lymphatic system], Chronic Obstructive Pulmonary Disease (COPD), Pulmonary Fibrosis, and Dementia. Review of the facility's Event Report dated [DATE], revealed Resident #498 had an unwitnessed fall at 10:35 AM. Resident #498's Fall Risk Score was 21 indicating the Resident was at a high fall risk. Staff documented following the Resident's fall that the Resident's pupils were 3 mm [millimeters] and Neuro Checks were completed as follows: Three (3) Neuro checks were performed every 15 minutes (not 4 every 15 minutes), Two (2) Neuro checks were performed every 30 minutes, One Neuro check was performed once for 1 hour (should have been every hour for 4 hours then every 4 hours times 4 for a total of 16 hours). Review of the Progress Note dated [DATE] at 6:25 PM, revealed Unwitnessed fall noted this shift. Resident confused and doesn't know why she was walking. No pain noted or reported . This was fall #1. Review of the Care Plan dated [DATE] revealed .Falls Resident at risk for falling R/T [related to] history of falls, impaired cognition, medications, ESRD, dementia, COPD, arthritis, pain, cancer, unsteady, poor safety awareness . Review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #498 had a Brief Interview for Mental Status (BIMS) score of 2, which indicated severe cognitive impairment. Resident #498 had 1 fall with no injury documented. Review of the progress note dated [DATE] at 2:30 PM, revealed Resident [#498] was seen crawling into the main hallway by CNA [Certified Nursing Assistant], resident refused to verbalize what occurred prior to CNA finding pt [patient] crawling on the floor, resident did not sustain any visible injuries and neuro [neurological] & cognitive sts [status] remain at baseline, no s/s [signs/symptoms] or c/o [complaint of] pain, resident was holding their chest and appeared to be SOB [short of breath], O2 [oxygen] sat [saturation] at time of incident was 84% [percentage symbol][normal oxygen sat is 95% - 100%], applied 1L [Liter] O2 and current sat. is 99% while on 1L O2 via [by way of] NC [nasal cannula], all other vitals at this time are WNL [within normal limits]. This was fall #2. Review of the progress note dated [DATE], revealed IDT [Interdisciplinary Team] Review: Resident [#498] sustained a fall without acute or latent injury on [DATE] Root Cause: [Named Resident #498] is at risk for falls related to impaired cognition and mobility per the comprehensive plan of care. Resident sustained fall on [DATE] without injury Intervention: Resident to be encouraged to remain in communal areas when possible. Discussed in AM clinical with no further recommendations offered at this time . Resident #498's BIMS score was 2, indicating severe cognitive impairment. The facility failed to complete neuro checks according to the neuro check guide after one hour following the unwitnessed fall on [DATE]. Vital signs were obtained at 2:30 PM and 2:45 PM. Neuro checks were completed every 15 minutes x 4 then stopped. Review of the facility's Event Report dated [DATE] at 10:40 PM, revealed Observed in the floor .[checked] Witnessed [fall] and did not hit her head . This was fall #3. The facility failed to identify this fall where Resident #498 was observed in the floor as an unwitnessed fall and no neuro checks were completed. The intervention implemented after this fall was a fall mat by the bed. Review of the progress note dated [DATE] revealed IDT Review: Resident sustained two falls without acute or latent injury on [DATE]. Resident #498 sustained two falls on [DATE] and the facility was unable to provide fall investigations for the 2 falls on the [DATE]. This was fall #4 and #5. Review of the Progress Note dated [DATE] at 1:44 PM, revealed Unwitnessed fall noted this shift. Resident confused and attempted to get out of bed. 5/10 pain reported . This was fall #6. Review of the care plan intervention for the Resident's falls dated [DATE], revealed, . fall mat to left side of bed . The facility failed to complete neuro checks according to the neuro check guide for this unwitnessed fall. Review of the facility's Event Report dated [DATE], revealed .unwitnessed fall .Fall Risk Assessment 17 High fall risk . Review of the progress note dated [DATE] at 12:39 AM, revealed Resident had an unwitnessed fall approximately 1900 [7:00 PM] in hallway 200. Vitals obtained were 96.9 [Temperature (T)], 134/78 [Blood Pressure (BP)], 82 [Pulse (P)], 98% [O2 sat] room air. Resident was on the fall [floor] with her head near the wall. Unsure if she hit her head. She was ambulating with the walker. Called DON [Director of Nursing] and reported the fall. Started neuro checks .Staff was able get resident to sit in the geri chair [a type of reclining chair] for just a little time before she climbed out and fell again about 19:45 [7:45 PM] .transferred resident [to the hospital] . This is fall #7. The facility failed to complete neuro checks according to the neuro check guide and failed to complete vital signs. Review of the progress note dated [DATE] at 5:42 PM, revealed While staff was attempting to assist resident, she quickly sat herself in the floor 'indian style' .Assisted with rising per one staff and much encouragement, res [Resident] quickly squatted in the floor . This is fall #8. Review of the Care plan intervention for the Resident's fall dated [DATE] revealed, .keep w/c [wheelchair] within reach at bedside .therapy eval [evaluation] for use of walker . Review of the progress note dated [DATE] at 2:06 PM, revealed resident [#498] continues on alert charting for monitoring falls resident had a fall on [DATE] no latent injury no neuro checks requested at this time no behaviors noted on this shift resident vitals remain WNL [within normal limits] . Interview revealed Resident #502 informed staff that Resident #498 was in the floor. Resident #502 no longer resided in the facility. See the Director of Nursing (DON) interview on [DATE] at 5:20 PM. This was an unwitnessed fall, and no neuro checks were completed. This was fall #9. Review of the facility's Event Report dated [DATE] at 11:53 AM, revealed resident [#498] was seated in dialysis chair in common area. Resident stood up and lost her balance and fell to floor, resident did not hit her head. Safely assisted resident back to chair, resident then attempted to get up again without assistance. Vitals taken BP 105/54, P 88, R 20, no injuries observed at this time .continue neuro checks .Witnessed . This was fall #10. Review of the Care plan intervention for the Resident's fall dated [DATE] revealed .sensory device to chair . The facility documented continue neuro checks but were unable to provide neuro check documentation. Review of the progress note dated [DATE], revealed Resident [#498] sent to hospital, resident had three unassisted falls that led to head injury, and other facial bruising with complaint of pain. Want to make sure resident has no underlying issues related to the falls . This was fall #11, #12, and #13. The facility failed to complete a fall investigation, vital signs, and neuro checks for the 3 falls on [DATE] for Resident #498. Review of the Emergency Documentation [Hospital #1], dated [DATE], revealed .Computed Tomography [CT scan] Head or Brain . Impression . subdural hemorrhage the anterior aspect of .4.1 mm [millimeters] .Discharge Diagnosis .Recurrent Falls; Subdural bleeding . Further review revealed Resident #498 was transferred from Hospital #1 to Hospital #2 on [DATE] to follow up with neurosurgery. Review of the [Named Hospital #2] History and Exam form dated [DATE], revealed .Patient diagnosed with SDH [Subarachnoid Hemorrhage], C [cervical]-5 fracture and bilateral rib fractures .Neurosurgery is following patient for SDH . Review of the [Named Hospital #2] Trauma Surgery Discharge Summary dated [DATE], revealed Additional Discharge Diagnoses . Subarachnoid Hematoma, Unspecified fracture of fourth lumbar vertebra, subsequent encounter for fracture with routine healing, Other nondisplaced fracture of fifth cervical vertebra, subsequent encounter for fracture with routine healing, and Multiple fractures of ribs, bilateral, subsequent encounter for fracture with routine healing. Review of the progress note dated [DATE] at 16:39, revealed Rtn [returned] to facility via EMS [Emergency Medical Services] on gurney; transferred to bed by EMS; tol [tolerated] well; resident alert and oriented to self; no s/s pain observed; c [cervical]-collar in place. No skin issues noted. LS [lung sounds] clear bilat [bilateral]; BS [bowel sugar] active X [times] 4 quads [quadrants]; no edema noted; will monitor. VSS [vital signs stable] . Review of the progress note dated [DATE] at 1:04 AM, revealed resident [#498] sustained unwitnessed fall and hit her head, no injuries noted but resident was bleeding from her nose. Vitals checked T-97.8, HR-74, R-16, BP-103/58, SP02-98% RA [room air] . EMS [Emergency Medical Services] arrived and safely transferred resident from bed to stretcher via assist x2. This was fall #14. Review of the Care Plan interventions for Resident 498's falls dated [DATE], revealed, .offer sensory sound device to assist in promoting restful sleep at hs [bedtime] . Review of the NP Progress Note dated [DATE], revealed Resident #498 was admitted to inpatient services at Hospital #1 from [DATE] - [DATE]. .seen today following readmission to the facility .She [Resident #498] presented to the hospital following and [an] unwitnessed fall with a nosebleed .She has a C5 c-spine fracture from another fall. She was admitted for acute blood loss anemia and anemia of chronic disease. She received one unit of PRBCs [packed red blood cells] . Review of the Care Plan dated [DATE], revealed .ADLs [Activities of daily living] Functional Status/Rehabilitation Potential .Resident has a self care deficit related to impaired physical functioning and medical conditions as evidenced by the need for staff assistance for adequate completion of ADL care, weakness, impaired cognition from dementia, ESRD with dialysis, COPD with shortness of breath, rib fractures .C-Collar as ordered . Review of the quarterly MDS dated [DATE], revealed Resident #498 had a BIMS score of 00, which indicated severe cognitive impairment. No falls were documented on the assessment. Review of the Care Plan edited on [DATE], revealed .Pain .Resident has at risk for complaints of acute/chronic pain R/T [related to] ESRD with dialysis, cancer .rib fractures .Encourage resident to request pain medication PRN [as needed]. Observations in the resident's room on [DATE] at 4:26 PM and on [DATE] at 10:52 AM revealed no fall mat in Resident #498's room and Resident #498 was in a Broda chair (a type of reclining chair) in the hallway. During an interview on [DATE] at 2:13 PM, the Administrator was asked when she presented the Roster Matrix to the surveyor to verify the facility did not have any falls with major injuries. The Administrator stated, No. The Administrator was asked to verify the facility did not have any resident falls with fractures. The Administrator stated, No, we did not. During an interview on [DATE] at 11:03 AM, CNA E was asked if she worked with Resident #498. CNA E Stated, .yes, She [Resident #498] likes to crawl out of bed and lay on the floor. In March her face had bruising, and they said she fell. She had a C collar on. She tries to remove the collar. She was out [at the hospital] when I came back [back to work from being off], and she [the Resident] returned a few days later [to the facility] .She [Resident #498] is hard to redirect and yells at you, she will swing at you at times. She needs a fall mat, I tell them [staff] all the time because she likes to lie in floor. Never seen a fall mat in her room . During an interview on [DATE] at 1:54 PM, the Regional Nurse Consultant handed the surveyor the discharge summary and history and physical and stated, I cannot find a fall investigation for [DATE]. Observation in the resident's room on [DATE] at 10:08 AM, revealed no fall mat by Resident #498's bed. During a telephone interview on [DATE] at 7:15 AM, Licensed Practical Nurse (LPN D) was asked about Resident 498's fall which occurred on [DATE]. LPN D stated, . [named CNA U] came and told me what occurred. CNA [U] was helping another resident on the hall while she found [named Resident #498] on the floor. She didn't witness the fall. LPN D was asked if she had been reprimanded for not conducting a fall investigation. LPN D stated, I did not get written up .Someone did give me a call the next day and asked me what I did .I was on the phone with the on-call NP [Nurse Practitioner] the EMS arrived. I worked as agency then, but I have not worked there since. She [DON] asked me to come in early one night and I don't recall writing a statement . During an interview on [DATE] at 10:04 AM, CNA V was asked if there was a fall mat in Resident #498's room. CNA V stated, No Ma'am, no fall mat. During an interview on [DATE] at 5:20 PM, the DON was asked when and how often should neuro checks be initiated. The DON stated, For unwitnessed falls, after doing a complete assessment, notify provider, family, and follow through with orders . The DON was asked what was considered a fall with major injury. The DON stated, A fracture, a SDH [subdural Hemorrhage] is a major injury. The DON was asked when should neuro checks be done. The DON stated, It's nursing 101 you know to call family and provider, look at standard of care and best practices is neuro checks. It should be at least 3 days after the fall noted in the progress notes . The DON was asked who should start the fall investigation. The DON stated, The nurse should open it, and we review it in IDT [Interdisciplinary Team] Should be opened and started at point of the fall . The DON was asked who does fall risk assessments. The DON stated, [The] Nurse on the floor and at a minimum quarterly . The DON was asked who is responsible for witness statements. The DON stated, The DON and ADON [Assistant Director of Nursing]. The DON was asked why Resident #498 and #501 were not listed on the facility's matrix as falls with major injury (FMI). The DON stated, It was on there. The surveyor showed the DON the facility's matrix that did not reflect Resident #498 and #501's fall with major injury. The DON stated, Well, that was a mistake. The DON was asked which resident observed Resident #498 on the floor on [DATE]. The DON stated, [Named Resident #502] . The DON confirmed Resident #502 no longer resided in the facility. The DON was asked why there was no fall investigation for the falls that occurred on [DATE]. The DON stated, We did one investigation for all 3 falls that day .The third fall she went out because she hit her head that time . The DON was asked should a fall mat have been in room by the bed last week. The DON stated, Yes, it was not discontinued . The DON was asked should vital signs be taken with fall investigations. The DON stated, Vital Signs are fundamental nursing 101 .They charted WNL, Stable . The Vital signs were documented as stable, but the actual vital signs were not documented. During an interview with the Assistant Director of Nursing (ADON) on [DATE] at 3:00 PM. The ADON confirmed the neurological assessments were not completed per protocol and stated there should have been more than just one for an unwitnessed fall. 2. Review of the medical record revealed Resident #31 was admitted to the facility on [DATE], with diagnoses including Diabetes, Cellulitis Bilateral Legs, Edema, and Venous Insufficiency. Review of the annual MDS dated [DATE], revealed a BIMS score of 8, which indicated Resident #31 had moderate cognitive impairment. Resident #31 required maximum assistance of staff to perform activities of daily living (ADLs). Review of the facility's Event Report dated [DATE], revealed Resident #31 sustained an unwitnessed fall in the Resident's room. Staff performed a neuro check at 9:03 PM and at 9:15 PM. The facility failed to perform neuro checks according to the neuro check guide on Resident #31 after 9:15 PM. During an interview on [DATE] at 5:20 PM, the DON confirmed that neuro checks should be performed every 15 minutes for 1 hour, every 30 minutes x 4, every hour x 4, and every 8 hours x 2. 3. Review of the medical record revealed Resident #50 was admitted to the facility on [DATE], with diagnoses including Dementia, Diabetes, Peripheral Vascular Disease, and Hypertension.? Review of the admission MDS assessment dated [DATE], revealed a BIMS score of 3, which indicated Resident #50 had severe cognitive impairment. Resident #50 required maximum staff assistance to perform toileting and bathing, and moderate staff assistance for transfers. Resident #50 had 1 fall since admission documented. Review of the facility's Event Report dated [DATE] at 5:46 PM, revealed Resident #50 sustained a witnessed fall in his room by the bedside table. .Staff CNA [Certified Nursing Assistant] witnessed fall .Notes XXX[DATE] 5:54 PM .Resident had a witnessed fall and hit his head while attempting to get snacks off of his table . The facility failed to perform neuro checks according to the neuro check guide and obtain a witness statement from staff. 4. Review of the closed medical record revealed Resident #248 was admitted to the facility on [DATE], with diagnosis including Alzheimer's Disease, Chronic Obstructive Pulmonary Disease, Dementia, Acute Kidney Failure, Psychotic and Mood Disturbance, and Anxiety. Resident #248 expired [DATE]. Review of Care Plan dated [DATE], revealed .Problem: Resident at risk for falling R/T [related to]: weakness, frequent falls, dementia, COPD [Chronic Obstructive Pulmonary Disease] with shortness of breath, tremor, bradycardia, medications .2 person assist with transfers .highlighted call light .encourage to be up in communal areas .non slip material to wheelchair .bilateral fall mats .bed in lowest position .Problem: Resident has impaired cognitive skills as evidenced by: Decision making problems, Short term memory problem, dementia, takes medications with potential for side effects . Review of the admission MDS assessment dated [DATE], revealed Resident #248 had a BIMS score of 3, which indicated severe cognitive impairment. Resident #248 required maximal staff assistance for ADLs. Review of the Event Report dated [DATE], revealed .14:37 [2:47 PM] .unwitnessed fall w/o [without injury] .resident room .[Named Resident #248] Fall Risk Score Total:21 .high fall risk .Seen resident lying on foam fall mat left side of bed .Reminded resident to press call lights for needs and assistance XXX[DATE] Root Cause: .at risk for falls related to impaired cognition and impaired mobility . The facility failed to complete neuro checks after an unwitnessed fall according to the facility neuro check guide. Resident #248 had severe cognitive impairment so a reminder to press the call light for assistance was an inappropriate intervention. 5. Review of the medical record revealed Resident #501 was admitted to the facility on [DATE], with diagnoses including Atrial Fibrillation, Fractured Rib, Diabetes, and Cerebral Infarction. Review of the admission MDS assessment dated [DATE], revealed Resident #501 had a BIMS score of 10, which indicated moderate cognitive impairment. Resident #501 had 1 fall with no injury documented. Review of the progress note dated [DATE], revealed Fall event occurred, neuro checks in place no new injuries or concerns, redirected and encouraged to use call light and to keep bed at safe level, informed DON .Oncall Np [Nurse Practitioner], and RP family member, son .to make them aware of incident but no serious injury noted. Left voice mails with all appropriate contacts and encouraged son to know his dad is ok [okay] . Review of the facility's Event Report dated [DATE] at 1:49 AM, revealed .Fall unwitnessed .Neuro checks 11:00 PM, 11:15 PM, 11:30 PM, 11:45 PM, 12:15 AM, 12:45 AM, 1:15 AM, 2:15 AM, 2:15 AM, 3:15 AM, 4:35 AM .Fall Risk Score 16 High Fall Risk .[Named resident is at risk for falls .related to impaired mobility . The facility failed to complete neuro checks according to the facility neuro check guide. Review of the Care Plan dated [DATE] revealed Resident has a right rib fracture r/t to fall . 6. An acceptable Removal Plan, which removed the immediacy of the Jeopardy, was received on [DATE] at 2:42 PM. The surveyors validated the Removal Plan through review of the in-service training records and audits, review of the facility's policy, observations, and staff interviews. 1. Corrective Actions for identified resident(s) affected by the deficient practice. The facility failed to have a system in place to ensure the resident's environment remained as free of accidents and hazards as was possible and to ensure that the resident received adequate supervision to prevent accidents for resident #498. a. Resident #498 expired at the campus on [DATE]. b. On [DATE] at 22:42 resident was sent to the hospital after falling at the campus and obtaining a suspected head injury. Resident had documentation from the nurse in a nurse's note that the resident had 3 unassisted falls that led to head injury, facial bruising, and complaint of pain. The Director of Nursing (DON), nurse practitioner (NP), and the resident's family member were notified, and order was obtained to send to ER for evaluation. c. [DATE]: Resident was assessed at Vanderbilt hospital and was noted to have a 4mm subdural hematoma with no neurological changes, both pupils equal and reactive, and Glascow Coma Scale (GCS) was 14. Resident was confused, which is her baseline, and obeys commands. CT of the head showed small subdural hemorrhage with no visible acute infarct, contusion, hydrocephalus, or midline shift. d. [DATE]: Vanderbilt Discharge Summary shows that neurological exams remained stable throughout stay and she discharged from hospital to return to the campus. e. Resident returned to the campus at her baseline and returned to participation in her routine per her norm. f. [DATE]: upon the interdisciplinary teams (IDT) (Director of Nursing (DON), Assistant Director of Nursing (ADON), Social Services Director (SSD), and minimum data set coordinator (MDSC), review of records it was determined that the fall event(s) were not opened in the medical record in correlation with the assessment note. The DON and ADON immediately initiated an investigation that included interviews and education of nurses on completion of documentation. Through the investigation it was determined that each time the resident had a fall there was an intervention placed; however, the interventions did not get added into the plan of care. g. [DATE]: the Resident and her family opted to pursue hospice due to diagnosis of multiple myeloma, unrelated to fall and associated injuries from [DATE]. Hospice was initiated at this time and the resident stopped dialysis per her preference and end of life planning. Resident expired on [DATE] under the care of Hospice. 2. Identification of other residents who may be affected by the deficient practice and corrective actions that will be put in place to ensure the deficient practice does not reoccur. The facility took immediate action to ensure all residents are free from accident hazards and to ensure the residents receive adequate supervision to prevent accidents. a. [DATE]: All residents were reviewed by regional nurses and campus nurse leadership for fall risk and all resident care plans were reviewed for appropriate fall interventions. b. [DATE]: All falls since [DATE] were reviewed by regional nurses and campus clinical leadership to ensure that processes and procedures were followed per the plan of care and neuro checks were completed for unwitnessed falls and/or falls that resulted in the resident hitting their head. c. [DATE]: Resident rooms were rounded on by facility clinical leadership and regional nurses to ensure that fall interventions are in place. No concerns noted. d. All resident's that fall will be reviewed in clinical morning meeting by the members of the IDT (DON, ADON, MDS Coordinator (MDSC), and Social Services Director (SSD) to ensure that appropriate interventions are in place and care plans are updated. e. All residents that fall will be followed weekly in the campus At-Risk meeting to ensure interventions implemented are in place and effective. The IDT, in conjunction with the medical provider, who are reviewing weekly may make changes to the plan of care and interventions that are reviewed. 3. Measures put into place and systemic changes you will make to ensure that the deficient practice does not reoccur. a. All nurses will be re-educated on the Fall policy and completion of neurological checks for residents that have a fall and hit their head, or the fall was unwitnessed beginning 5[TRUNCATED]

Based on policy, medical record review, observation, and interview, the facility failed to follow Physician's Orders for oxygen for 1 of 1 (Resident #14) sampled residents reviewed for respiratory care. The findings include: 1. Review of the facility policy titled, Oxygen Administration Policy, revised 1/31/2025, revealed .Oxygen therapy is administered as Ordered by a Physician .Determine appropriate oxygen source and equipment needed for Physician's Orders . Review of the facility policy titled, Physicians Orders, revised 1/31/2025, revealed .It is the standard of this facility that physicians [physician's] orders are followed, reviewed to ensure delivery of applicable care .Each resident will have physician's orders to guide the facility in caring for and treating each resident .Licensed Nurses .are expected to follow physician's orders . 2. Review of the medical record revealed Resident #14 was admitted to the facility on [DATE], with diagnoses including Anemia, Heart Failure, Dementia and Anxiety Disorder. Review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 11, which indicated Resident #14 was moderately cognitively impaired, and received oxygen therapy. Review of Physician's Orders dated 5/5/2025, revealed, Oxygen via [by way of] NC [nasal cannula] @ [at] _2_Liters per minute PRN [as needed]. Review of the Medication Administration Record (MAR) dated 5/2025, revealed Resident #14 was administered Oxygen therapy via NC at 2 Liters per minute daily from 5/5/2025 through 5/20/2025. Observations in the Resident's room on 5/19/2025 at 3:28 PM and 5/21/2025 at 7:52 AM, revealed Resident #14 was receiving oxygen via NC with the oxygen concentrator set at 3 liters per minute. During an observation and interview in the resident's room on 5/21/2025 at 1:33 PM, the Director of Nursing (DON) confirmed Resident #14's oxygen concentrator was set at 2.5 liters per minute. The DON confirmed Resident #14 had a Physician's Order for oxygen at 2 liters per minute and that staff should follow physician orders.

Based on facility policy review, medical record review, facility documentation review, and interview, the facility failed to report alleged violations involving abuse and injury of unknown source for 2 of 19 (Resident #28 and #82) sampled residents reviewed. The findings include: 1. Review of the facility policy titled, Abuse, Neglect and Misappropriation of Property, with a review date of 1/31/2025, revealed .It is the organization's intention to prevent the occurrence of abuse, neglect, exploitation, injuries of unknown origin, and misappropriation of resident property, and to assure that all alleged violations of federal or State laws which involve abuse, neglect, exploitation, injuries of unknow origin and misappropriation of resident property are investigated, and reported immediately to the Facility Administrator, the State Survey Agency, and other appropriate State and local agencies in accordance with Federal and State Law .Abuse .Is defined as the willful infliction of injury .intimidation, or punishment with resulting physical harm .or mental anguish .Physical abuse Includes, but is not limited to, hitting, slapping .controlling behavior through corporal punishment, or any similar touching of a resident that does not have an appropriate therapeutic purpose, and that is not reasonably related to the appropriate provision of ordered care and services .Injury of Unknown Source .This means an injury that meets both of the following conditions: (1) the source of the injury was not observed by any person, or the source of the injury could not be explained by the resident; and (2) the injury is suspicious because of the extent of the injury; or the location of the injury (for instance, the injury is located in an area not generally vulnerable to trauma) .Such occurrences will be investigated by the Administrator, Director of Nursing, or designee as outlined below in the investigation guidelines .Serious Bodily Injury .is defined as an injury involving extreme physical pain .involving the protracted loss or impairment of the function of a bodily member .or requiring intervention such as surgery, hospitalization . 2. Review of the medical record revealed Resident #28 admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including Displaced Bimalleolar Fracture (both of the bony knobs on the inside and outside of the ankle are broken) of Left Lower leg, Metabolic Encephalopathy, Abnormalities of Gait and Mobility, Dementia, and History of Falling. Review of the Progress Note dated 3/12/2025, revealed .Resident returned via stretcher by 2 EMS [Emergency Medical Services] personnel from [Hospital #1] .Resident was free form [from] skin tears .Resident is incontinent of bowel and bladder. Resident was placed on bed and left safe and comfortable with call light in reach . Review of the admission Observation dated 3/12/2025, revealed the Assistant Director of Nursing (ADON) noted on 3/16/2025 an observation of normal skin color. Continued review under history of the admission Observation, revealed the ADON noted on 4/2/2025, .bruise noted to left leg . This note was added after the resident had been discharged to the hospital on 3/25/2025 for the fractured ankle. Review of the Nursing Leader Wound assessment dated [DATE], revealed the Director of Nursing (DON) noted on 4/2/2025 .skin assessment .location of bruise left extremity .ankle yellow green This note was added after the resident had been discharged to the hospital on 3/25/2025 for the fractured ankle. Review of the Progress Note dated 3/13/2025, revealed .Blanchable redness to the gluteal fold to bilateral buttocks, approximately 18 cm x 30 cm no open areas noted . The admission progress note did not reflect a bruise on Resident #28's left ankle. Review of the Physical Therapy Treatment Encounter Note(s) dated 3/13/2025, revealed .Patient is able to perform bed mobility with [NAME] [Maximum Assistance] .with cues for safety and sequencing. Patient is able to perform functional transfer sit<> stand with TD [Touch-Down Weight Bearing] .from EOB [Edge of Bed] .She is able to sit EOB for about 5mins [minutes] with list to the left requiring Max A. Pt [patient] engages in supine range and endurance activities to BLE [Bilateral Lower Extremities] with tactile and verbal cues .Response to Session Interventions: actively participates with skilled interventions . Review of the Physical Therapy Treatment Encounter Note(s) dated 3/17/2025, revealed .Pt. sleeping during 2 attempts for treatment, with pt. non-responsive to name or light .remaining asleep. At following attempt for tx [treatment] during lunch, bed repositioned with HOB [Head of Bed] elevated and use music to facilitate increased alertness in order to eat. Pt becoming alert and able to engage in assisted dining with attending CAN [Certified Nursing Assistant]. Pt returning to room approx [approximately] 1.5 hours later, at which time, pt had returned back to sleep, unable to keep eyes open when name called . Review of the significant change MDS dated [DATE], revealed Resident #28 had a Staff Assessment for Mental Status which revealed the resident had poor short term and long-term memory. Resident #28 was dependent for toileting hygiene, lower body dressing, substantial/maximal assistance with personal hygiene, rolling left and right, and dependent for chair/bed-to-chair transfer. Review of Nurse Practitioner (NP) I note dated 3/24/2025, revealed .Daughter [of Resident #28] reports that patient has some bruising and swelling to left ankle that she first notice [noticed] while patient was in the hospital and was wondering if it could be gout .Area to left ankle has slight edema and slight erythema .Services Ordered .X-RAY EXAM OF LOWER LEG . Review of the Radiology Report for Resident #28 dated 3/25/2025, revealed .Results: Diffuse bone demineralization. There is a fracture present at the distal fibula above the ankle mortise with mild lateral displacement of indeterminate age. There is minimal soft tissue swelling. The ankle mortise is maintained. Conclusion: Distal fibular fracture of indeterminate age . Review of the History and Physical from Hospital #1 dated 3/25/2025, revealed, .[Resident #28] non ambulatory from [Named Facility #1] has xray of left ankle for swelling, facility state its fratured [fractured] without trauma of fall, pt [patient] is bed bound .hx [history] of gout .Patient is a [AGE] year-old female who presented to the ED [Emergency Department] from [Named Facility #1] nursing home with left ankle swelling which x-ray at the facility showed a fracture without known trauma, baseline bedbound for this reason patient was sent to the ED for further evaluation. On presentation, she was found to have oblique fracture [a bone break that occurs at an angle to the bone's long axis] of the distal fibula for which Dr [Doctor] .was consulted by the ED clinician, and patient's notes which I reviewed plan for left ankle fixation 3/27/25 [2025] .Oblique fracture of distal fibula, unknown etiology, per the nursing home had no known trauma . Review of an undated Witness Statement completed by Licensed Practical Nurse (LPN) H revealed, .On 3/16/25 [2025] residents [Resident #28's] daughter was talking to another staff member about her mother. I joined the conversation briefly and she was talking about her hospital visit/meds .She then mentioned her foot has a bruise and wasn't sure when or where it happened, she said she was going to come in tomorrow to talk with someone about it. I looked at her ankle/foot and saw a bruise with discoloration .around the edges . Review of an undated Witness Statement completed by Certified Nursing Assistant (CNA) K revealed, .I saw that [named Resident #28 room and bed number] had bruises on her left ankle when I came back to work on 3-14-25 [2025] . Review of an undated Witness Statement completed by LPN L revealed, .I do not recall a bruise. It may have been reported to me, but I don't recall seeing it . Review of an undated Witness Statement completed by Registered Nurse (RN) M revealed, .I am unaware of any bruising on [Named Resident #28] . Review of an undated Witness Statement completed by CNA N revealed, .I was here the day after the resident [Resident #28] came back from the hospital. I notified the nurse .She said she would make a note about the bruise on the left foot . During an interview on 5/20/25 at 8:50 AM, LPN B stated, .she [Resident #28] had went to the hospital before that x-ray .daughter wanted an x-ray done because she had a bruise on her ankle, we don't really know what happened to the ankle . During an interview on 5/20/2025 at 2:09 PM, Family Member O stated .we do not know how her ankle was broke .I was visiting [Resident #28] and the [Named CNA K] asked me if I had noticed her ankle .the ankle was black and blue swelled like a baseball .I ended up asking the PA [Physician Assistant] to get an x-ray then the DON [Director of Nursing] called me and said we going to send her to the hospital because something is going on with the ankle .I was at the hospital with [Resident #28] her ankle was not like that at the hospital . During an interview on 5/21/25 at 9:49 AM, the Regional Nurse stated, I have a soft file on an incident that the resident [Resident #28] had I will make you a copy of that report. The witness statements were noted in the investigation. During an interview on 5/23/2025 at 9:35 AM, Rehab Director Q was asked if she observed a bruise to Resident #28's left ankle. Rehab Director Q stated, .I don't recall a bruise on her ankle .if I had noticed one, I would have reported it . During an interview on 5/23/25 at 9:49 AM, Physical Therapist (PT) R stated, .if I had seen a bruise to her [Resident #28] left ankle .I would report it and note it and tell the nurse .I was never asked about her fracture to her ankle .I saw her on the 17th .I don't recall any injuries during that time . During an interview on 5/23/2025 at 10:05 AM, CNA K stated, .we was in the room together daughter was here .I was doing patient care and I noticed her [Resident #28] left ankle .around the ankle above the foot .swelled and the color purple faded color .I know it wasn't the 14th it was either the 15 or 16th .daughter did not know what happened .no one in the building knew where it came from .I did fill out a witness statement .I am sure I told the nurse on the hall .I wasn't around when the daughter spoke to the NP .DON just asked me to do the witness statement .just because no one knew where it came from . CNA K was asked to review her written statement. CNA K stated, .I know it wasn't 3/14/2025 because I didn't work that date .I don't think I put that date on the statement form . During an interview on 5/23/25 at 10:41AM, LPN S stated, .[Resident #28's] daughter wasn't sure how it [left ankle fracture] happened .the daughter never told me she had a bruise at the hospital .I never seen a bruise on her ankle . During an interview on 5/23/25 at 11:30 AM, the MDS RN stated, .I was aware of the fracture to her [Resident #28] ankle . The MDS RN was asked if the facility knew how it happened. The MDS RN stated, .not that I am aware of . During a telephone interview on 5/23/2025 at 8:36 AM, Family Member O was asked again if she observed a bruise on (Resident #28)'s ankle while at the hospital. Family Member O stated, .I did not notice it at all, the CNA brought it to my attention .I did not tell the NP it was present at the hospital .the CNA was giving her bath and she seen it .I asked if she had been gotten up .the hospital never called me about an incident at the hospital .I just couldn't believe how big the bruise was, black and blue, her whole ankle all the way around and the whole thing was swelled . During an interview on 5/23/2025 at 5:30 PM, the DON was asked to review the admission Observation dated 3/12/2025, for Resident #28. The DON confirmed the ADON documented the bruise on 4/2/2025. The DON was asked to review the Nursing Leader Wound assessment dated [DATE], for Resident #28. The DON confirmed she had documented the bruise on 4/2/2025. The DON was asked why she noted this after Resident #28 was discharged . The DON stated, .I don't know, I don't know what date she discharged . The DON was asked why the facility performed an investigation for Resident #28's fracture. The DON stated, .it was a fracture .at that point we didn't know .I reported it to the Administrator . The DON was asked if the injury was reported to the state agency. The DON stated, .I am not sure if it was reported . During an interview on 5/23/2025 at 6:00 PM, the Administrator was asked if she reported the injury of unknown origin to the state agency. The Administrator stated, .no, because we felt it happened at the hospital . The Administrator was asked if she had any report from the hospital which revealed Resident #28 was involved in an accident. The Administrator stated, .No . 3. Review of the medical record revealed Resident #82 was admitted on [DATE], with diagnoses which included Hemiplegia and Hemiparesis, Cerebral Infarction, Memory Deficit, Restlessness and Agitation, Aphasia, Personal History of Traumatic Brain Injury, and Generalized Anxiety Disorder. Review of the admission MDS dated [DATE], revealed Resident #82 had a BIMS score of 4 which indicated severe cognitive impairment. Review of the care plan for Resident #82 dated 5/10/2025, revealed .Problem: Resident demonstrates inappropriate behaviors with his visitors including cussing, saying inappropriate things to others, hitting .Approach: Observe for triggers of inappropriate behaviors with residents [resident's] visitors and alter environment as needed .Approach: Assist resident away from other residents and his visitors as needed . Review of the Summary of Investigation for Resident #82 dated 5/10/2025, revealed .On May 10th, 2025, the Social Worker .stated that she was outside with [Named Resident #82] along with his significant other and her family member .significant other informed him that he would not be able to come back home for some time .[Named Resident #82] became verbally aggressive towards his significant other .the family member swatted at [Resident #82] chest .[Named Social Worker] states that she separated the two and then told them that they couldn't hit each other .The significant other and her family member left the facility .[Named Social Worker] brought [Resident #82] back into the building care plan was updated to reflect his family relationship dynamics .[Named Administrator] explained to [Resident #82] that he and his girlfriend could not argue and hit each other .[Resident #82] will be followed by psych services for mood. The facility investigation determined that no abuse occurred . Review of the Behavioral Health PROGRESS NOTE dated 5/12/2025, revealed .Resident [#82] had impaired cognitive skills as evidenced by decision making challenges and challenges with his memory related to hx [history] of TBI [Traumatic Brain Injury] and CVA [Cerebrovascular Accident]. Resident is at an overall risk for decline in psychosocial well-being due to his health .During session resident presented as cooperative and engaged .Per staff, Resident had challenges with interpersonal dynamics over the weekend. Resident stated that he was hungry and had a disagreement with his partner due to wanting her to bring him food .Resident denied any safety issues/concerns .Overall, resident's cognitive performance fell in the moderate range of impairment. Their [Resident #82] memory performance was impaired, as evidenced by a Delayed Recall Score [measures how much information is remembered after a delay] of 0/3 . During an interview on 05/21/2025 at 10:55 AM, the Social Worker stated, .Family member hit him while he was outside, I witnessed it, I immediately intervened, open hand hit, chest area .I don't know her name, I got between both of them and brought him back inside, I told the visitor she was not allowed to put her hands on him .the visitor said she hit because he made some inappropriate remarks to her .He said he was fine and psych [the Licensed Clinical Social Worker] seen him on the following Monday, it happened on a Saturday, 5/10/2025, I did not consider that physical abuse .I told her she is not allowed to put her hands on the resident, I reported it to the Administrator and the Director of Nursing (DON). The Social Worker was asked why she did not consider that physical abuse. The Social Worker stated, .it was an open hand tap . The Social Worker was asked if any changes were made to limit his visitation with his family after the incident. The Social Worker stated, .I have not seen them since the incident, I am not sure about the visitation access for these visitors . During an interview on 5/21/25 at 11:12 AM, the DON was asked if Resident #82 had any issues with a visitor and was she aware a visitor hit the resident. The DON stated, .no issues that I know of .I don't know anything about a visitor hitting him, no one ever reported to me concerns about a visitor . The DON was asked if Resident #82 was alert and oriented and able to make sound decisions. The DON stated, .at times I think he is cognitively accurate . During an interview on 5/23/2025 at 12:08 PM, the MDS RN was asked who added the care plan for resident demonstrates inappropriate behaviors for Resident #82. The MDS RN stated, .SSD [Social Services Director] added it to the care plan, I don't know why it was added . The MDS RN reviewed SSD notes and stated, .I don't see anything about why it was added . During an interview on 5/23/25 at 3:35 PM, the Licensed Clinical Social Worker stated, .on 5/12/2025 SSD [the Social Worker] had asked me to see him because he had a disagreement with his girlfriend .he told me it was a verbal disagreement .it was not reported to me that he was hit .he has moderate cognitive impairment . During an interview on 5/23/2025 at 5:30 PM, the Administrator was asked if she reported the incident of Resident #82 being hit by his visitor to the state agency. The Administrator stated, No, because I talked to him, and he said he didn't feel abused. The Administrator was asked if a resident with a BIMS score of 4 could make an accurate recall if he experienced abuse. The Administrator stated, .he talks to me all the time, I thought he could make that decision .

Based on review of resident trust accounts, policy review, medical record review, and interview, the facility failed to notify the family and/or resident when the amount in the residents' account exceeded the eligibility limit for 2 of 20 (Resident #2 and #31) residents personal fund account statements reviewed. The findings include: 1. Review of the facility policy titled Resident Trust Fund, dated 3/26/2024, revealed .facilities are entrusted with holding, handling, and tracking certain monetary funds belonging to its residents, per their written requests .facility has an established Resident Trust Fund (RTF) .desires to ensure that at all time; all funds deposited into a facility's RTF are appropriately earmarked and tracked for each resident .safeguarded as per Federal and State Regulations and Facility Policy and Procedure .The resident and/or the resident's authorized legal representative must be notified when a resident's RTF account is within $200.00 of exceeding the permitted limit, in addition to any other State Regulation requirements. To satisfy this notice requirement, the Business Office Manager should print the $200 form Notice Letter from National Data Care, obtain the Administrator's signature on same, obtain the Resident's acknowledgement of receipt of such letter (if applicable), and then place a copy of the letter in the facility's Financial Folder. If the resident is unable to sign the acknowledgement, the letter should be sent to the resident's authorized legal representative for completion .If resident is not enrolled in RFMS [Resident Trust Fund Services], the BOM [Business Office Manager] or ABOM [Assistant Business Office Manager] should enroll the resident in RFMS with the auto transfer turned on .Select the desired resident .Enter in the Debit Amount Range fields .$100.00 to $3000.00 if the resident is a Medicaid Resident .$100.00 to $5000.00 if the resident is a Private Pay Resident .Handling monetary property for our residents is a very serious responsibility . 2. Review of the medical record revealed Resident #2 was admitted to the facility on [DATE], with diagnoses including Cerebral Palsy, Anxiety, Schizoaffective Disorder, Diabetes, Seizures, and Pain. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #2 had severe cognitive impairment. Review of the facility's Resident Fund Statement for Resident #2 revealed the Quarterly Statement for the period dated 10/30/2024 - 12/31/2024 had a balance of $4180 .09 and the Quarterly Statement for the period dated 1/1/2025 thru 3/31/2025 had a balance of $4375.49. 3. Review of the medical record review revealed Resident #31 was admitted to the facility on [DATE], with diagnoses including Diabetes, Cellulitis Bilateral Legs, Edema, and Venous Insufficiency. Review of the annual MDS dated [DATE], revealed Resident #31 had a Brief Interview for Mental Status (BIMS) score of 8, which indicated moderate cognitive impairment. Review of the facility's Resident Fund Statement for Resident #31 revealed the Quarterly Statement for the period dated 10/30/2024 - 12/31/2024 listed a balance of $6085.51 and the Quarterly Statement for the period dated 1/1/2025 thru 3/31/2025 listed a balance of $6283.72. During an interview on 5/23/2025 at 11:05 AM, the Business Office Manager (BOM), was asked what's the maximum amount allowed in the resident trust funds. The BOM stated, Two thousand dollars .If the amount is over that, the resident could potentially lose their Medicaid funds . The BOM was asked why the 2 accounts are so high. The BOM stated, I don't know, the family has been sent the 200 dollar letter stating they could potentially lose their Medicaid, and the families are to spend down. The BOM presented two letters that documented Resident #2 and #31 were $200 from the allowed amount, but no documentation was provided that the Residents' families had received a letter.

Based on policy review, medical record review, observation, and interview, the facility failed to provide care and services to promote dignity for 1 of 5 (Resident #36) sampled residents reviewed for activity of daily living (ADL) care when they failed to provide hair care. The findings include: 1. Review of the facility policy titled, Resident Rights, dated 1/31/25, revealed .All residents have the right to be treated with respect and dignity. These rights will be promoted and protected by the facility .All residents will be treated in a manner and in an environment that promotes maintenance and enhancement of quality of life. When providing care and services, the stockholders will respect the resident's individuality and value their input by providing them a dignified existence, through self-determination and communication with the access to persons and services inside and outside the facility .The facility will make every effort to support each resident in exercising his/her right to assure that the resident is always treated with respect, kindness and dignity . 2. Review of the medical record revealed Resident #36 was admitted to the facility 2/27/2025 with diagnoses including Osteomyelitis, Anxiety, Paraplegia, Pressure Ulcer Stage 4 to Sacrum, Neuromuscular Dysfunction of bladder, Spina Bifida, and the Need for Assistance with personal care. Review of the admission Minimum Data Set, dated [DATE], revealed Resident #36 had a Brief Interview for Mental Status score of 15, indicating the resident was cognitively intact, had impairment on one side of the lower extremities, required supervision or touching assistance with eating and dental care, was dependent on staff for moderate assistance of toileting, showering, dressing, and personal hygiene, required maximal staff assistance for rolling left and right, sitting to lying, lying to sitting, and was dependent on staff for chair to bed transfer. Review of the Care Plan dated 2/28/2025, revealed .Resident has a self-care deficit related to impaired physical functioning and medical conditions as evidenced by the need for staff assistance for adequate completion of ADL care, paraplegia, spinal rod, spina bifida, pain, ulcers, infection . Provide the amount of assistance resident needs for completion of ADL care . During an observation and interview in Resident #36's room on 5/21/2025 at 11:00 AM, Resident #36 was lying in bed on her back with her hair pulled up on top of her head in a hair clip. Resident #36's hair was matted from the nape of her neck to the top of her head with an oily appearance. Resident #36 was asked did staff assist and provide her with baths, brushing her teeth, and assist with washing and grooming her hair. Resident #36 stated .I am supposed to get a bed bath twice a week but sometimes that doesn't happen .I have only got my hair washed one time since I've been here .it is so matted and tangled they can't comb it .me and my mom have asked .to cut the matted hair out .she [Director of Nursing (DON)] told us that it was not in her scope of practice to cut my hair and that she could not cut it .I can't sleep properly with this hump [matted hair] in the back of my head .I have to sleep with my head turned to the side. During an interview on 5/22/2025 at 4:00 PM, the DON confirmed Resident #36's hair was matted to her head and had not been maintained by washing or combing it. The DON confirmed that Resident #36 and Resident #36's mother had requested staff to cut (the matted hair) her hair. The DON stated .I know she has matted hair .we don't have the clippers nor a barber here to cut it .and I told them this when they asked me about it . During an interview on 5/22/25 at 5:00 PM, Certified Nursing Assistant (CNA) E was asked is hair grooming and hair washing a part of the ADL care for Resident #36. CNA E stated .yes, it is .I do not wash or brush her [Resident #36] hair .it is tangled and matted all over .don't know if the hair can be detangled . During an interview on 5/28/25 at 7:31 PM, the Administrator was asked who is responsible for ensuring that residents' dignity and rights are maintained or enhanced. The Administrator stated .I am [the Administrator] .

Based on policy review, observation and interview, the facility failed to ensure infection control practices were followed during medication administration for 2 of 8 (Resident #8 and #22) residents observed for Medication Administration when 2 of 7 nurses (Licensed Practical Nurse (LPN) A and LPN B) failed to sanitize reusable equipment. The findings include: 1. Review of the facility policy titled, Infection Control, revised 1/31/2025, revealed .Facility infection control policies and practices are intended to facilitate maintaining a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections .Provide guidelines for the safe cleaning and reprocessing of reusable resident-care equipment . 2. Review of the medical record revealed Resident #22 was admitted to the facility on [DATE], with diagnoses including Cerebral Palsy, Gastrostomy, Methicillin Resistant Staphylococcus Aureus (a bacteria that is resistant to many common antibiotics), and Seizures. Review of the annual Minimum Data Set (MDS) assessment dated [DATE], revealed staff did not perform a Brief Interview for Mental Status (BIMS) due to Resident #22 was severely cognitively impaired and had a feeding tube. Observation during medication administration on 5/20/2025 at 10:21 AM, revealed LPN C entered Resident #22's room to administer Gabapentin (medication used to treat nerve pain) 100 milligrams (mg) via (by way of) the feeding tube. LPN C used the stethoscope that was around her neck to check the resident's feeding tube placement and replaced the stethoscope around her neck. LPN C flushed the feeding tube with 43 milliliters (ml) of water via gravity, administered the medication dissolved in 30 ml of water, and flushed the tube with 100 ml of water. LPN C placed the syringe back in the package and hung the syringe on the pole without rinsing the syringe and exited the resident's room. LPN C was asked should the syringe be cleaned and rinsed after medication administration and should the stethoscope be cleaned after use on a resident. LPN C stated that the syringe is rinsed when the feeding tube is flushed with water and confirmed that the stethoscope should be cleaned after use. 3. Review of the medical record revealed Resident #8 was admitted to the facility on [DATE], with diagnoses including Chronic Obstructive Pulmonary Disease, Diabetes, and Allergic Rhinitis. Review of the quarterly MDS assessment dated [DATE], revealed a BIMS score of 14, which indicated Resident #8 was cognitively intact. Observation during medication administration on 5/21/2025 at 8:20 AM, revealed LPN B entered Resident #8's room to check the Resident's blood pressure prior to medication administration. LPN B checked the Resident's blood pressure with an automatic wrist cuff and placed the wrist cuff in her lab coat pocket after use. LPN B administered medications to Resident #8 and exited the Resident's room, removed the wrist cuff from her pocket and placed it on top of the medication cart. LPN B was asked if the wrist cuff should be cleansed after use. LPN B confirmed that the wrist cuff should be cleansed after use. During an interview on 5/22/2025 at 2:53 PM, the Director of Nursing (DON) confirmed that syringes should be cleansed after use during medication administration and reusable medical equipment should be sanitized after use on a resident.

Based on policy review, medical record review, observation, and interview the facility failed to follow professional standards of practice of Peripherally Inserted Central Catheter (PICC) Infusion therapy, medication administration, and obtain Physicians Orders for 3 of 3 sampled residents (Resident #1, #3 and #4) with a PICC line. The findings include: 1. Review of the facility's policy titled, Vascular Access Devices and Infusion Therapy Procedures Maintaining Patency of Peripheral and Central Vascular Access Devices IV [Intravascular] Flush Policy and Procedure, dated 2011, revealed .Purpose to maintain the patency of all peripheral and central vascular access devices [VADs] .Vascular access devices are flushed after each infusion to clear the infused medication from the catheter lumen. A prescriber's order is needed for all IV fluids. All vascular access devices should be flushed routinely when not in use to maintain patency. Each lumen of a multi-lumen catheter must be flushed individually. Single use flushing systems are used. Vascular access devices should never be forcefully flushed. Patency is assessed using a 10 ml [milliliter] syringe to reduce the risk of catheter damage. Flush vascular access devices with 0.9% preservative free sodium chloride [normal saline] .To succeed with saline flushing, a needleless connector with an anti-reflux design must be placed on the hub of EVERY lumen of EVERY vascular access device/catheter. All connections [IV tubing or syringes] will be made via the needleless connector, NEVER directly to the catheter hub .Procedure Obtain prescriber order for appropriate flush solutions. Refer to the Flush Chart .The flush orders must be written as a complete medication order .Dispose waste per OSHA, CDC, and facility policy. Document the flush in the patient's medication record . Review of the facility's policy titled, Vascular Access Devices and Infusion Therapy Procedures Flush Chart, dated 2011, revealed .Type of IV Device Midline, PICC [Peripherally Inserted Central Catheter] Pre-Use 10 ml Saline Post-Use 10 ml Saline Minimum Intervals for flushing each lumen [whenever lumen is locked with no infusion currently running] 10 ml Saline every 8 hours = PRN [as needed] . Review of the facility's policy titled, Vascular Access Devices and Infusion Therapy Procedures Dressing Change for Vascular Access Devices, dated 2011, revealed .Purpose to prevent local and systemic infection related to the IV catheter .Central venous access device and midline dressing changes will be done at established intervals and immediately if the integrity of the dressing is compromised, if moisture, drainage or blood is present, or for further assessment if infection is suspected. Transparent semi-permeable membrane dressings are changed every 7 days and PRN. If a chlorhexidine impregnated gauze sponge [Biopatch trademark sign] is applied under the transparent dressing, change every 7 days. If a patient is allergic to the transparent dressing and a gauze and tape dressing is used over the site, the gauze dressing must be changed every 48 hours and PRN. Gauze underneath a transparent semi-permeable membrane dressing is considered a gauze dressing .If using a catheter securement device [StatLock trademark] it must be changed with each dressing change . Review of the facility's policy titled, Review of Physicians Orders, dated 6/1/2015 and reviewed 4/14/2021, revealed .It is the standard of this facility that physician orders are reviewed daily to ensure delivery of applicable care, tracking of change of condition and updating of care plans are consistently provided. Guideline: Physician orders be reviewed daily by nursing administration during the Clinical Meeting. New orders in the Electronic Medical Record (EMR), Care Plans, Dietary, etc., will be reviewed by the interdisciplinary team to ensure updates/changes have occurred . Review of the facility's policy titled, Facility Care and Services, dated 5/15/2023, revealed .We provide general nursing care, based on instructions from your physician .Your health and well-being is a team approach: our staff, you, and your physician will develop a Care Plan for the care, support, and services needed [including any therapy] to help meet you identified health needs and personal goals. Your Care Plan will be reviewed periodically. If there is a significant change in your condition, your Care Plan will be updated accordingly, after consultation with you and your physician. If we cannot provide the care your physician orders, we can arrange for you to receive it from another services provider, whether at the facility or offsite through transportation . Review of the facility's policy titled, Medication Administration, dated 2007, revealed .Medications are administered in accordance with written orders of the prescriber . 2. Review of the medical record, revealed Resident #1 was admitted to the facility on [DATE], with diagnoses Malignant Neoplasm of Major Salivary Gland, Diabetes Mellitus Type 2, Tracheostomy, Dysphagia. Review of Resident #1's Admission Note dated 1/12/2023 at 4:18 PM, revealed able to make needs known, speech unclear, ambulated to bathroom x1 assist, gait unsteady, Foley catheter in place draining clear yellow urine, NG [nasogastric] tube in place [a tube inserted through the nose goes down the esophagus to the stomach], PICC line in place, and the PICC line dressing was intact and dry. Review of Resident #1's Nursing Leader Wound Assessment Observation Information dated 1/13/2023 at 1:25 PM, revealed .Central line present yes .Central Line Peripherally Inserted Central Catheter [PICC] .IV dressing intact and dry yes . Review of the Physician's Orders dated 1/12/2023, revealed no documentation of an order for a PICC, maintenance of the PICC line with normal saline flushes or dressing change. Review of Resident #1's nurse's notes date ranges 1/14/2023 - 1/25/2023 revealed no documentation of resident having a PICC line or being provided care for maintenance of a PICC line as per facility policy. The five-day Minimum Data Set (MDS) assessment dated [DATE] documented the resident scored a 15 on the Brief Interview of Mental Status, which indicated cognitively intact for daily decision making. Resident #1 was discharged to the hospital on 1/25/2023. Review of Resident #1's emergency room (ER) Report dated 1/26/2023 at 12:27 AM, revealed .Patient with multiple possible etiologies of SIRS [systemic inflammatory response syndrome] criteria given PICC line to left upper extremity, Foley catheter, skin changes to bilateral feet and NG tube with risk for aspiration pneumonia. High suspicion for aspiration pneumonia given new hypoxia and tachypenic .Will replace Foley with a new Foley and obtain a UA [urinalysis]. PICC line remains in place in the left upper extremity, however family states that this is no longer used . During an interview on 5/24/2023 at 4:51 PM, the Director of Nursing (DON) was asked was the facility aware Resident #1 came from the hospital on admission with a PICC line and did the facility provide maintenance and dressing changes for Resident #1's PICC line. The DON stated .I can't find anything about the PICC line .Evidently she came with one from the hospital based on the admission observation but there is nothing in the record after that .I don't know what happened . The DON confirmed the ER record dated 1/26/2023 at 12:27 AM documented the resident had a PICC line when she came from the facility to the ER. She stated, .Yes . When the DON was asked for clarification Resident #1 had a PICC when admitted to the facility on [DATE] and had a PICC when transferred from the facility to theER on [DATE], she stated, .yes [Resident #1] had PICC while she was here, didn't catch it .It slipped through the cracks, we missed it .I acknowledge it . 3. Review of the medical record, revealed Resident #3 was admitted to the facility on [DATE], with diagnoses End Stage Renal Disease with Dialysis, Anorexia, Congestive Heart Failure, Lupus, Functional Quadriplegia, Ileostomy, Stage 4 Sacral Pressure Ulcer, Severe Sepsis, VRE (Vancomycin Resistant Enterococcus) culture positive, PICC (Peripheral Inserted Central Catheter) Infection, and Seizures. Review of Resident #3's Hospital Discharge Orders dated 4/28/2023, revealed .Daptomycin [Cubicin] 450 mg IV [intravenous] Q [every] 48 H [hours] 14 days .Fluconazole [Diflucan] 200 mg PO [by mouth] Q 24 H 10 days . Review of the facility's Physician's orders dated 4/28/2023 - 5/12/2023, revealed no orders for Daptomycin 350 mg (milligrams) IV daily every other day and no order for Normal Saline (sodium chloride 0.9% 10 ml every shift flush before and after medication administered. Physician's orders also revealed no order for PICC maintenance Normal Saline flush as per facility policy. Review of the Medication Administration Record (MAR) dated 5/10/2023, revealed last normal saline flush dated was 5/10/2023 after antibiotic infusion. Review of the MAR dated 5/12/2023, revealed no documentation of Normal Saline IV flush administered before or after 5/12/2023 medication administration. Review of the MAR dated 5/12/2023 - 5/24/2023, revealed no documentation of PICC maintenance flush of Normal Saline as per facility policy. During an interview on 5/24/2023 at 3:00 PM, when asked about the empty IV bag hanging on the IV pole, the DON stated .yeah that was my antibiotic .I finished that days ago .I don't know why it is still hanging there . When asked did the staff flush the PICC line before medication administration and after, she stated .yes . When asked had the staff flushed the PICC line since the last medication dose, the DON stated .no . Observations in the resident's room on 5/24/2023 at 12:00 PM, revealed Resident #3 was not in the room. In the room were an air mattress with bolster sides, personal items on overbed table, IV pole with empty IV bag and tubing hanging, label read Daptomycin 450 mg. Observations in the resident's room on 5/24/2023 at 3:00 PM, revealed Resident #3 sitting up in Geri chair, alert, and oriented x 3, well kempt, PICC line double lumen in right upper arm, Tesio dialysis catheter in right upper chest wall, positive demeanor, smiling, talkative. During an interview on 5/25/2023 at 2:23 PM, the DON confirmed there was no documentation the IV/PICC line had been flushed before or after Daptomycin administered 5/12/2023. The DON stated, .That's what it looks like .I see exactly what you are seeing . When asked is there an order to flush the PICC for maintenance as per facility policy, the DON stated, .I don't see any order or documentation about a maintenance flush .I see what our policy says . When asked does the facility have a policy for when to change the needleless connector that goes on the hub of the PICC lumen, the DON stated, .we don't have a policy on when to do that . When asked does your facility know the standard of practice of to change the needleless connector on each lumen of the Central Vascular Access Device every seven days, the DON stated, .No, we have no policy . 4. Review of the medical record, revealed Resident #4 was admitted to the facility on [DATE], with diagnoses Acute Pancreatitis with Abscess, Accordion drain tube in back region to drain abscess, Necrotizing Pancreatitis, and Protein Calorie Malnutrition. Resident #4 was transferred to the hospital on 5/21/2023 due to Accordion drain tube not functioning. Review of the Physician's orders dated 5/17/2023 - 5/19/2023, revealed Zosyn [Piperacillin-tazobactam] 3.375 gm/50 ml IV every 8 hours. Vancomycin 1.25 gm in 250 ml IV every 36 hours. Review of the Physician's orders dated 5/17/2023 - 5/19/2023, revealed no orders to flush PICC with Normal Saline before and after IV medication administration. Review of the MAR dated 5/17/2023, revealed no documentation of a Normal Saline flush administered to PICC line before or after administration of Zosyn dose at 10:00 PM. Review of the MAR dated 5/18/2023, revealed no documentation of a Normal Saline flush administered through the PICC line before or after administration of Zosyn doses at 6:00 AM, 2:00 PM, 10:00 PM. Review of the MAR dated 5/18/2023, revealed no documentation of a Normal Saline flush administered through the PICC line before or after administration of Vancomycin dose at 4:00 PM. Review of the MAR dated 5/19/2023 at 2:00 PM, revealed no documentation of Zosyn 2:00 PM dose administered. Review of the MAR dated 5/18/2023 - 5/23/2023, revealed flush PICC twice a day flush before and after medication administration. Observations in Resident #4's room [ROOM NUMBER] B on 5/24/2023 at 11:00 AM, revealed bed made, IV pole with empty IV bag infused medication labeled Zosyn Piperac-tazo 3.375 gm (grams)/50 ml infuse every 8 hours. During an interview on 5/24/2023 at 11:12 AM, when the DON was asked about the IV pole with the empty IV bag labeled with antibiotic still hanging on the IV pole in the Resident's room, the DON stated .She [Resident #4] has been gone since Sunday [5/21/2023] .they should have disposed of that IV bag days ago . During an interview on 5/25/2023 at 2:23 PM, the DON confirmed no documentation of physician's order for Normal Saline flush before and after antibiotic administration through PICC line and missed 2:00 PM dose of Zosyn on 5/19/2023. She stated, .Yeah, I don't know why missed the Zosyn .it looks like the order was discontinued but at the same time rewritten as the original order .there should not have been a missed dose the orders are exactly the same .I don't know why there is no flush order on the physician's orders but it is written on the MAR .there should have been an order to flush for each antibiotic .antibiotic administered different times .We have some work to do .

Based on policy review, medical record review, observation, and interview, the facility failed to provide an accurate and revised Comprehensive Care Plan for 4 of 4 sampled residents (Resident #1, #2, #3 and #4) reviewed with Comprehensive Care Plans. The findings include: 1. Review of the facility's policy titled Comprehensive Care Plans, effective date 4/6/2015 and revised 7/19/2018, revealed .A person-centered Comprehensive Care Plan that includes a measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident. The care plan will include how the facility will assist the resident to meet their needs, goals and preferences .Person-centered care means the facility focuses on the resident as the center of control and supports each resident in making his or her own choices .Each resident's Comprehensive Care Plan is designed to .Incorporate identified problem areas; Incorporate risk factors associated with identified problems .Reflect treatment goals, timetables and objectives in measurable outcomes .Reflect currently recognized standards of practice for problem areas and conditions .The Comprehensive Care Plan will include the goals for admission and desired outcomes gathered from the resident and the resident representative .Care plan interventions are implemented after consideration of the resident's problem areas and their causes .The interventions will reflect action, treatment, or procedure to meet the objectives toward achieving the resident goals .Care plans are ongoing and revised as information about the resident and the resident's condition change. The nurse/Interdisciplinary Team is responsible for the review and updating of care plans. The care plan should reflect the current status of the resident and be updated with changes in the resident's status . Review of the facility's policy titled, Facility Care and Services, dated 5/15/2023, revealed .We provide general nursing care, based on instructions from your physician .Your health and well-being is a team approach: our staff, you, and your physician will develop a Care Plan for the care, support, and services needed [including any therapy] to help meet you identified health needs and personal goals. Your Care Plan will be reviewed periodically. If there is a significant change in your condition, your Care Plan will be updated accordingly, after consultation with you and your physician. If we cannot provide the care your physician orders, we can arrange for you to receive it from another services provider, whether at the facility or offsite through transportation . 2. Review of the medical record revealed Resident #1 was admitted to the facility on [DATE], with diagnoses Malignant Neoplasm of Major Salivary Gland, Diabetes Mellitus Type 2, Tracheostomy, Dysphagia. Review of Resident #1's Admission Observation for Information dated 1/12/2023 at 4:07 PM, revealed .Urinary Catheter yes .type of catheter indwelling .IV Central line present yes, type of IV/Central line PICC, IV dressing intact and dry yes .Nutrition Swallowing Problems none .Tube Feeding yes .Tube Feeding site Nasogastric . Review of Resident #1's Admission Note dated 1/12/2023 at 4:18 PM, revealed able to make needs known, speech unclear, ambulated to bathroom x1 assist, gait unsteady, Foley catheter in place draining clear yellow urine, nasogastric ((NG) - a tube inserted through the nose goes down the esophagus to the stomach) tube in place, Central Peripherally Inserted Central Catheter (PICC), dressing intact and dry yes. Review of Resident #1's Care Plan created date 1/16/2023, revealed Category: Nutritional Status contained no documentation of Resident #1's NG tube and there was no documentation of the indwelling Foley catheter. The five-day Minimum Data Set (MDS) assessment dated [DATE], documented the resident scored a 15 on the Brief Interview of Mental Status, which indicated cognitively intact for daily decision making. Review of Resident #1's Physician's Orders dated 1/18/2023, revealed .MAY HAVE ICE CHIPS AT BEDSIDE AT ALL TIMES Every shift: Day, Night . There was no documentation the care plan was revised 1/18/2023 to include only by mouth intake of ice chips. Review of Resident #1's Care Plan created 1/16/2023 - 1/30/2023 revealed no documentation of a PICC line, care, and maintenance of the line. 3. Review of the medical record revealed Resident #2 was admitted to the facility on [DATE], with diagnoses Cerebral Infarction with right sided Hemiplegia/paresis, Dysphagia, Aphasia, Dysarthria, Hypertension, Atrial Fibrillation and Urinary Retention. Review of Resident #2's Physician's Orders revealed the following: 5/16/2023 Aspirin tablet delayed release 81 mg (milligram) 1 tab oral once a day. 5/16/2023 Brilinta (ticagrelor) tablet 60 mg 1 tab oral twice a day. 5/16/2023 Lasix (furosemide) tablet 40 mg 1 tab oral once a day. 5/16/2023 Xarelto (rivaroxaban) tablet 20 mg 1 tab oral once a day. 5/16/2023 Repatha SureClick (evolocumab) pen injector 140 mg/ml 1 ml subcutaneous once a day on Tue Every 2 weeks. 5/18/2023 Foley Catheter size 18 FR (French) 10 cc (cubic centimeters) balloon to straight drainage. Review of Resident #2's Physician's Orders dated 5/18/2023, revealed .Dietary .Regular, Dys [dysphagia] Puree Special Instructions Porvale cups for all liquids, 1:1 supervision with meals, oral care after meals .General Patient to have 1:1 supervision with meals and provide oral care after eating . Review of Resident #2's Care Plan created dated 5/21/2023, revealed under the Category: Nutritional Status, there was no documentation of Dietary Regular, Dys [dysphagia] Puree Special Instructions Porvale cups for all liquids, 1:1 supervision with meals, oral care after meals. Review of Resident #2's Care Plan created date 5/21/2023 - 5/24/2023, revealed no documentation of Resident #2's Anti-coagulant therapy. 4. Review of the medical record revealed Resident #3 was admitted to the facility on [DATE], with diagnoses End Stage Renal Disease with Dialysis, Anorexia, Congestive Heart Failure, Lupus, Functional Quadriplegia, Ileostomy, Stage 4 Sacral Pressure Ulcer, UTI (Urinary Tract Infection), Severe Sepsis, VRE (Vancomycin Resistant Enterococcus) culture positive, Peripheral Inserted Central Catheter PICC) Infection, and Seizures. Review of Resident #3's Physician's Orders revealed the following: 4/28/2023 Hydrocodone-Acetaminophen Schedule II tablet 10-325 mg 1 tab oral every 6 hours PRN (as needed) 4/28/2023 Remeron (mirtazapine) tablet 30 mg 1 tab once a day HS. 4/28/2023 Cleanse wound to sacrum w/NS (normal saline) or wound cleanser, pat day, apply Medi honey to wound bed and cover w/foam dressing QD and PRN. 4/28/2023 Change PICC Line dressing PRN soiling or dislodgement. Review of Resident #3's Hospital Orders upon discharge back to the facility dated 4/28/2023, revealed .Daptomycin [Cubicin] 450 mg IV Q [every] 48 H [hours] 14 days .Fluconazole [Diflucan] 200 mg PO [by mouth] Q 24 H 10 days . Review of Resident #3's Care Plan created 5/2/2023, revealed the following: Problem At risk for dialysis related complications. There was no documentation of dialysis location or days for dialysis. Problem Category: Skin Integrity. There was no documentation under Approach air mattress. Problem Category: Elimination. There was no documentation under Approach ileostomy and care of. Review of Resident #3's Care Plan created 5/2/2023 - 5/23/2023, revealed the following: There was no documentation of a PICC line, care, and maintenance of the line. Problem Category: Drug Regime, no clinically significant Medication issues identified, or Clinically Significant Medication issues identified There was no documentation of IV antibiotics or by mouth antibiotics. There was no documentation of Infection or Infectious Disease. Observations in the resident's room on 5/24/2023 at 12:00 PM, revealed Resident #3 not in room, air mattress with bolster sides, personal items on overbed table, IV pole with empty IV bag and tubing hanging, label read Daptomycin 450 mg. Observations in the resident's room on 5/24/2023 at 3:00 PM, revealed Resident #3 sitting up in Geri chair, alert, and oriented x 3, well kempt, PICC line double lumen in right upper arm, Tesio dialysis catheter in right upper chest wall, positive demeanor, smiling, talkative. 5. Review of the medical record, revealed Resident #4 was admitted to the facility on [DATE], with diagnoses Acute Pancreatitis with Abscess, Accordion drain tube in back region to drain abscess, Necrotizing Pancreatitis, and Protein Calorie Malnutrition. Resident #4 was transferred to the hospital on 5/21/2023 due to Accordion drain tube not functioning. Review of Resident #4's Physician's orders revealed the following: 5/17/2023 Zosyn [Piperacillin-tazobactam] 3.375 gm (grams)/50 ml IV every 8 hours. 5/17/2023 Vancomycin 1.25 gm in 250 ml IV every 36 hours. 5/17/2023 Oxycodone Schedule II tablet 10 mg 1 tab oral as needed for severe pain every 4 hours PRN. 5/18/2023 PICC Line dressing change every week. Review of Resident #4's Care Plan created 5/18/2023 - 5/21/2023, revealed no documentation of the Accordion drain tube in resident's back region to drain abscess, PICC line care of, flushing and maintenance, IV antibiotics, infection, or infectious disease. 6. During an interview on 5/24/2023 at 4:51 PM, when the DON was asked are the comprehensive care plans for Resident #1, #2, #3 and #4 accurate and patient centered, she stated, .No .not accurate .not patient specific .I see what you are saying about their care plans .that is what it looks like .

Based on policy review, medical record review, and interview, the facility failed to provide an accurate Baseline Care Plan for 4 of 4 sampled residents (Resident #1, #2, #3 and #4) reviewed with Baseline Care Plans. The findings include: 1. Review of the facility's policy titled, Baseline Care Plan Policy, effective date 9/23/2022, revealed .Complete a Baseline Care Plan to promote continuity of care and communication among nursing home stakeholders, increase resident safety, and safeguard against adverse events that are most likely to occur right after admission .Baseline Care Plan will be working tool for the first 48 hours . Review of the facility's policy titled, Admission Assessment and Follow-Up Tool, last revised dated 11/6/2019, revealed .Admission Information (history and physical), including A summary of the individual's recent medical history, including hospitalization s, acute illnesses, and overall status prior to admission. Relevant medical, social, and family history. A list of active medical diagnoses and patient problems (such as recurrent falling or impaired mobility), especially those most related to reasons for admission to the facility and those that are affecting function, behavior, cognition, nutrition, hydration, quality of life, likelihood of functional recovery, and ability to participate in activities and to socialize. Current medications and treatments. Conduct a physical evaluation, including the following systems: .Eyes, Ears, Nose, Throat, Head and Neck, Teeth and Gums, Cardiovascular, Respiratory, Neurological, Musculoskeletal, Gastrointestinal, Genito-Urinary, Skin. Conduct supplemental evaluations .Skin .Reconcile the list of medications from the medication history, admitting orders, the previous medical record, Electronic Medication Administration Record [EMAR], and the discharge summary from the previous institution .Contact the Attending Physician to communicate and review the findings of the initial evaluation and any other pertinent information and obtain admission orders that are based on these findings. Notify other disciplines and departments of the resident's admission . 2. Review of the medical record revealed Resident #1 was admitted to the facility on [DATE], with diagnoses Malignant Neoplasm of Major Salivary Gland, Diabetes Mellitus Type 2, Tracheostomy, Dysphagia. Review of Resident #1's Admission Observation for Information dated 1/12/2023 at 4:07 PM, revealed .Urinary Catheter yes .type of catheter indwelling .IV Central line present yes, type of IV/Central line PICC, IV dressing intact and dry yes .Nutrition Swallowing Problems none .Tube Feeding yes .Tube Feeding site Nasogastric . Review of Resident #1's Admission Note dated 1/12/2023 at 4:18 PM, revealed able to make needs known, speech unclear, ambulated to bathroom x1 assist, gait unsteady, Foley catheter in place draining clear yellow urine, nasogastric (NG) a tube inserted through the nose goes down the esophagus to the stomach) in place, intravenous (IV) Central line present yes, type of IV/Central line Peripherally Inserted Central Line ((PICC) - a tube/line inserted into a major vein that leads to the heart), IV dressing intact and dry yes. Review of Resident #1's 48-Hour Baseline Care Plan dated 1/13/2023 at 10:06 AM, revealed the following: ADL [activities daily living] functioning/Rehab within normal limits? documented, yes [inaccurate], Check history of or observed triggers and proceed to approaches revealed not checked aftercare GI/GU [gastrointestinal/genitourinary], check desired approaches revealed not checked therapy eval and treat per MD order, follow therapy recommendations once eval completed, keep call light within reach and encourage use for assistance. Bowel and Bladder elimination are within normal limits? documented, yes [inaccurate], Check history of or observed triggers and proceed to approaches revealed not checked catheter, check desired approaches revealed not checked Observe for signs and symptoms of UTI [urinary tract infection], catheter care per policy if needed. Dietary is resident at risk for unstable weight? documented, no [inaccurate], Check history of or observed triggers and proceed to approaches revealed not checked Feeding tube, Chewing or swallowing problems, check desired approaches revealed not checked Diet per MD order, Observe weight per MD order, Consult with dietician, Speech Therapy eval and treat per MD order, Tube feeding per dietician recommendations with MD order, Tube flushes per dietician recommendations with MD order. Medication Usage is resident at risk of adverse effects from necessary medications? documented, no [inaccurate], Check history of or observed triggers and proceed to approaches revealed not checked Anti-coagulants, Insulin, Diuretics, check desired approaches revealed not checked Administer meds per MD order, Observe for side effects of medication and notify MD if any noted, If injections, rotate injection sites, and observe for redness, warmth, or edema at sites. Review of Resident #1's Nursing Leader Wound Assessment Observation Information dated 1/13/2023 at 1:25 PM, revealed .IV/Central line present yes .Type of IV/Central Line Peripherally Inserted Central Catheter [PICC] .IV dressing intact and dry yes . Review of the 48 Hour Baseline Care Plan revealed no documentation of Resident #1's PICC line and care of the PICC line. 3. Review of the medical record revealed Resident #2 was admitted to the facility on [DATE], with diagnoses Cerebral Infarction with right sided Hemiplegia/paresis, Dysphagia, Aphasia, Dysarthria, Hypertension, Atrial Fibrillation and Urinary Retention. Review of Resident #2's Physician's Orders revealed the following: 5/16/2023 Aspirin tablet delayed release 81 mg (milligram) 1 tab oral once a day. 5/16/2023 Brilinta (ticagrelor) tablet 60 mg 1 tab oral twice a day. 5/16/2023 Lasix (furosemide) tablet 40 mg 1 tab oral once a day. 5/16/2023 Xarelto (rivaroxaban) tablet 20 mg 1 tab oral once a day. 5/16/2023 Repatha SureClick (evolocumab) pen injector 140 mg/ml 1 ml subcutaneous once a day on Tue Every 2 weeks. Review of Resident #2's 48-Hour Baseline Care Plan dated 5/16/2023 at 7:00 PM, revealed the following: Communication Resident's communication is understood documented, yes [inaccurate], Check history of or observed triggers and proceed to approaches revealed not checked Resident has difficulty making self-understood, Aphasia, check desired approaches revealed not checked, If necessary, ask simple yes/no questions, Allow resident adequate time to respond, Speech Therapy eval and treat as needed. Dietary is resident at risk for unstable weight? documented, no [inaccurate], Check history of or observed triggers and proceed to approaches revealed not checked Chewing or swallowing problems, Requires assistance for eating/drinking, Mechanically altered diet, check desired approaches revealed not checked Diet per MD order, Observe weight per MD order, Consult with dietician, Speech Therapy eval and treat per MD order, Observe meal and fluid intake, Provide adaptive equipment and assistance to ensure adequate meal intake. Medication Usage is resident at risk of adverse effects from necessary medications? documented, no [inaccurate], Review of Resident #2's Physician's Orders dated 5/18/2023, revealed .Dietary .Regular, Dys [dysphagia] Puree Special Instructions Porvale cups for all liquids, 1:1 supervision with meals, oral care after meals .General Patient to have 1:1 supervision with meals and provide oral care after eating . There was no documentation the Baseline Care Plan included the 5/18/2023 physician's dietary orders. 4. Review of the medical record revealed Resident #3 was admitted to the facility on [DATE], with diagnoses End Stage Renal Disease with Dialysis, Anorexia, Congestive Heart Failure, Lupus, Functional Quadriplegia, Ileostomy, Stage 4 Sacral Pressure Ulcer, UTI (Urinary Tract Infection), Severe Sepsis, VRE (Vancomycin Resistant Enterococcus) culture positive, PICC (Peripheral Inserted Central Catheter) Infection, and Seizures. Review of Resident #3's Physician's Orders revealed the following: 4/28/2023 Hydrocodone-Acetaminophen Schedule II tablet 10-325 mg 1 tab oral every 6 hours PRN (as needed) 4/28/2023 Remeron (mirtazapine) tablet 30 mg 1 tab once a day bedtime (HS). 4/28/2023 Cleanse wound to sacrum w/NS (normal saline) or wound cleanser, pat day, apply Medi honey to wound bed and cover w/foam dressing every day (QD) and as needed (PRN). 4/28/2023 Change PICC Line dressing PRN soiling or dislodgement. Review of Resident #3's Hospital Discharge Orders dated 4/28/2023, revealed .Daptomycin [Cubicin] 450 mg IV Q [every] 48 H [hours] 14 days .Fluconazole [Diflucan] 200 mg PO [by mouth] Q 24 H 10 days . Review of Resident #3's Admission Observation dated 4/28/2023 at 10:30 PM, revealed category Special Treatment and Programs while not a resident, Check all of the following treatments, programs, and procedures that were performed during the last 14 days While NOT a Resident revealed IV medications not checked, Infectious Disease Current Infections revealed no checked (inaccurate). Review of Resident #3's 48-Hour Baseline Care Plan dated 4/29/2023 at 4:10 PM, revealed the following: Skin Integrity, check desired approaches revealed not checked Pressure ulcer care, Dressings per MD order. Medication Usage is resident at risk of adverse effects from necessary medications? documented, no [inaccurate], Check history of or observed triggers and proceed to approaches revealed not checked Analgesics/Opioids, Antibiotics, check desired approaches revealed not checked Administer meds per MD order, Observe for side effects of medication and notify MD if any noted. Infectious Disease does resident have an or being treated for infectious process? documented no (inaccurate), Check history of or observed triggers and proceed to approaches revealed not checked Resident receiving IV antibiotics, check desired approaches revealed not checked Administer meds per MD order, Notify MD of adverse effects. Review of the 48 Hour Baseline Care Plan revealed no documentation of Resident #3's PICC line and care of the PICC line. 5. Review of the medical record revealed Resident #4 was admitted to the facility on [DATE], with diagnoses Acute Pancreatitis with Abscess, Accordion drain tube in back region to drain abscess, Necrotizing Pancreatitis, and Protein Calorie Malnutrition. Resident #4 was transferred to the hospital on 5/21/2023 due to Accordion drain tube not functioning. Review of Resident #4's Physician's orders revealed the following: 5/17/2023 Zosyn (Piperacillin-tazobactam) 3.375 gm (grams)/50 ml IV every 8 hours. 5/17/2023 Vancomycin 1.25 gm in 250 ml IV every 36 hours. 5/17/2023 Oxycodone Schedule II tablet 10 mg 1 tab oral as needed for severe pain every 4 hours PRN. 5/18/2023 PICC Line dressing change every week. Review of Resident #4's 48-Hour Baseline Care Plan dated 5/17/2023 at 2:54 PM, revealed the following: Infectious Disease does resident have an or being treated for infectious process? documented no (inaccurate), Check history of or observed triggers and proceed to approaches revealed not checked Resident receiving IV antibiotics, Other Infectious process, check desired approaches revealed not checked Administer meds per MD order, obtain lab work per MD order, Notify MD of adverse effects. Review of the 48 Hour Baseline Care Plan revealed no documentation of Resident #4's PICC line and care of the PICC line. Review of Resident #4's Admission Observation dated 5/17/2023 at 2:54 PM, revealed category Skin IV/Central line Present revealed no (inaccurate), Type of IV/Central line revealed not checked Peripherally Inserted Central Catheter (PICC), IV dressing intact and Dry revealed nothing checked. Review of the 48 Hour Baseline Care Plan revealed no documentation of Resident #4's Accordion drain tube in resident's back region to drain abscess. 6. During an interview on 5/25/2023 at 1:55 PM, when the Director of Nursing (DON) was asked were the Baseline Care Plan for Residents #1, #2, #3, and #4 accurate, she stated .No, not accurate . The DON confirmed the Admission Observations for Resident #3 and #4 were inaccurate.

Amended 6/16/2023 Based on record review, and interview, the facility failed to have a physician's order for a urinary indwelling catheter, an assessment for removal of the urinary catheter, or demonstrate that continued catheterization was necessary for 2 of 2 sampled residents (Resident #1 and #2) with indwelling urinary catheters. The findings include: 1. Review of the medical record revealed Resident #1 was admitted to the facility on [DATE] with diagnoses Malignant Neoplasm of Major Salivary Gland, Diabetes Mellitus Type 2, Tracheostomy, Dysphagia. Review of Resident #1's hospital's discharge back to the facility summary dated 1/12/2023, revealed .foley to bsb [bed side bag] . Review of Resident #1's Admission Note dated 1/12/2023 at 4:18 PM, revealed able to make needs known, speech unclear, ambulated to bathroom x1 assist, gait unsteady, Foley catheter [urinary indwelling catheter] in place draining clear yellow urine, nasogastric ((NG) - a tube inserted through the nose goes down the esophagus to the stomach) tube in place, Peripherally Inserted Central Catheter (PICC) line in place, dressing intact and dry. Review of Resident #1's Admission Observation for Information dated 1/12/2023 at 4:07 PM, revealed .Urinary Catheter yes . The five-day Minimum Data Set (MDS) assessment dated [DATE], documented the resident scored a 15 on the Brief Interview of Mental Status, which indicated cognitively intact for daily decision making. Resident #1 was discharged to the hospital on 1/25/2023. Review of Resident #1's Emergency Report dated 1/26/2023 at 12:27 AM, revealed .Patient with multiple possible etiologies of SIRS [systemic inflammatory response syndrome] criteria given PICC line to left upper extremity, Foley catheter .Will replace Foley with a new Foley and obtain a UA [urinalysis] . During an interview on 5/24/2023 at 5/25/2023 at 2:23 PM, the Director of Nursing (DON) stated, .She [Resident #1] did have a Foley catheter on admission and during her stay here .We don't have an order for it. Missed that one . Record review during the survey revealed Resident #1 did not have a physician's order for the use of the urinary catheter, have a plan of care to assess for removal of the catheter as soon as possible or that the resident's clinical condition demonstrated that continued catheterization was necessary. 2. Review of Resident #2's hospital Urology consult dated 5/12/2023, revealed .Voiding attempts can be attempted as an outpatient or while he is in the skilled nursing [SN] facility . Review of the medical record revealed Resident #2 was admitted to the facility on [DATE], with diagnoses Cerebral Infarction with right sided Hemiplegia/paresis, Dysphagia, Aphasia, Dysarthria, Hypertension, Atrial Fibrillation and Urinary Retention. Review of Resident #2's Physician's order dated 5/18/2023, revealed Foley Catheter size 18 French (FR) 10 cubic centimeters (cm) balloon to straight drainage. Record review during the survey revealed Resident #2 did not have a plan of care to assess for removal of the catheter as soon as possible, voiding attempts per the urology consult, or that the resident's clinical condition demonstrated that continued catheterization was necessary. During an interview on 5/25/2023 at 2:23 PM, the DON was asked what the criteria was to discontinue Resident #2's catheter. The DON stated, .we don't have criteria . The DON was asked was she aware of the hospital Urology consult dated 5/12/2023. The DON stated, .We missed that . The DON was asked if the facility had policies and procedures in place for identification and documentation of clinical indications for the use of a urinary catheter and criteria for the discontinuance of the catheter when the indication for use is no longer present. The DON stated, .No .We don't have a policy and procedure for catheter services or any criteria for indications for catheter use or when to discontinue .We use the [NAME] .how to insert, catheter care and how to remove . There was no assessment for removal of the catheter.

Based on policy review, record review, observations and interviews, the facility failed to follow physician's orders for 3 of 4 sampled residents (Resident #1, #2 and #3) with physician's orders. The findings included: 1. Review of the facility's policy titled, Referral to Rehab dated 2/2006 revised 12/29/2022, revealed .Rehabilitation services are initiated upon a written referral to rehab from a patient's physician or member of the nursing staff and only directed by physician's order [includes telephone orders] . Review of the facility's policy titled, Review of Physicians Orders, dated 6/1/2015 and reviewed 4/14/2021, revealed .It is the standard of this facility that physician orders are reviewed daily to ensure delivery of applicable care, tracking of change of condition and updating of care plans are consistently provided. Guideline: Physician orders be reviewed daily by nursing administration during the Clinical Meeting. New orders in the Electronic Medical Record (EMR), Care Plans, Dietary, etc., will be reviewed by the interdisciplinary team to ensure updates/changes have occurred . Review of the facility's policy titled, Facility Care and Services, dated 5/15/2023, revealed .We provide general nursing care, based on instructions from your physician .Your health and well-being is a team approach: our staff, you, and your physician will develop a Care Plan for the care, support, and services needed [including any therapy] to help meet you identified health needs and personal goals. Your Care Plan will be reviewed periodically. If there is a significant change in your condition, your Care Plan will be updated accordingly, after consultation with you and your physician. If we cannot provide the care your physician orders, we can arrange for you to receive it from another services provider, whether at the facility or offsite through transportation . 2. Review of the medical record revealed Resident #1 was admitted to the facility on [DATE], following discharge from the hospital, with diagnoses Malignant Neoplasm of Major Salivary Gland, Diabetes Mellitus Type 2, Tracheostomy, Dysphagia. Review of Resident #1's hospital DC [Discharge] Info/Summary revealed .Patient [Resident #1] continues to c/o [complain] of difficulty swallowing with ice chips and recommend further ST [speech therapy] follow up for dysphagia therapy .1/12/2023 NPO [nothing by mouth] except for ice chips for comfort. Continue TF [tube feeding] with Jevity 240 cc [cubic centimeters] AC [meals] HS [bedtime] via pump over 1 hr [hour]; flush with 120 cc of water before and after TF [tube feeding] .foley to bsb [bed side bag] . Review of Resident #1's Admission Observation for Information dated 1/12/2023 at 4:07 PM, revealed .Urinary Catheter yes .type of catheter indwelling .IV Central line present yes, type of IV/Central line PICC, IV dressing intact and dry yes .Nutrition Swallowing Problems none .Tube Feeding yes .Tube Feeding site Nasogastric . Review of Resident #1's Admission Note dated 1/12/2023 at 4:18 PM, revealed able to make needs known, speech unclear, ambulated to bathroom x1 assist, gait unsteady, Foley catheter in place draining clear yellow urine, NG [nasogastric] tube in place [a tube inserted through the nose goes down the esophagus to the stomach], Central line PICC, dressing intact and dry yes. The five-day Minimum Data Set (MDS) assessment dated [DATE] documented the resident scored a 15 on the Brief Interview of Mental Status, which indicated cognitively intact for daily decision making. Review of Resident #1's Physician's Orders dated 1/18/2023, revealed .MAY HAVE ICE CHIPS AT BEDSIDE AT ALL TIMES Every shift: Day, Night . There was no documentation Resident #1 received the ordered Speech Therapy (ST) until 1/20/2023. Resident #1 was discharged to the hospital on 1/25/2023. During an interview on 5/26/2023 at 8:49 AM, the Director of Rehabilitation was asked why Resident #1 had not received a ST eval until 8 days after admission. The Director of Rehabilitation stated, .we did not have a full time ST. We only had two part time ST and they were not available. To be honest I did not even know she [Resident #1] needed ST. I was not made aware by the facility. It wasn't until care plan with her daughter and the daughter brought up that she [Resident #1] was supposed to be getting speech therapy . 3. Review of the medical record revealed Resident #2 was admitted to the facility on [DATE], with diagnoses Cerebral Infarction with right sided Hemiplegia/paresis, Dysphagia, Aphasia, Dysarthria, Hypertension, Atrial Fibrillation and Urinary Retention. Review of Resident #2's Physician Orders dated 5/18/2023, revealed .Dietary .Regular, Dys [dysphagia] Puree Special Instructions Porvale cups for all liquids, 1:1 supervision with meals, oral care after meals .General Patient to have 1:1 supervision with meals and provide oral care after eating . Observations in the resident's room [ROOM NUMBER]/24/2023 at 12:03 PM, revealed Resident #2 sitting up in wheelchair, alert and oriented to self, aphasia, attempting to talk but mumble speech became frustrated, sighed and grimace on face, became very frustrated when tried to communicate by talking, able to point with left hand without difficulty. Observations in the resident's room on 5/24/2023 at 1:02 PM, revealed Resident #2 received a lunch meal tray from CNA #1. The tray contained a plate of puree food and a Porvale cup with liquid. Certified Nursing Assistant (CNA) #1 left the room without assisting the Resident 1:1. During an interview on 5/24/2023 at 1:25 PM, CNA #1 was asked was there anything special ordered for Resident #2 when meals were served to the resident. CNA #1 stated, .No, not that I'm aware of .I just got him I don't know of anything .we don't get report at shift change. I don't know what is going on. We have to ask the residents questions to see what is going on . CNA #1 was asked if she was aware the physician had ordered 1:1 supervision with meals and oral care after meals. CNA #1 stated, .I did not know that. Oh, my gosh .I did not stay with him at breakfast and left him at lunch .I did not know . 5. Review of the medical record revealed Resident #4 was admitted to the facility on [DATE], with diagnoses Acute Pancreatitis with Abscess, Accordion drain tube in back region to drain abscess, Necrotizing Pancreatitis, and Protein Calorie Malnutrition. Resident #4 was transferred to the hospital on 5/21/2023 due to Accordion drain tube not functioning. Review of the Physician orders dated 5/17/2023 - 5/19/2023, 5/19/2023 - 5/23/2023 revealed Zosyn (Piperacillin-tazobactam) 3.375 gm/50 ml IV every 8 hours. Review of the Medication Administration Record (MAR) dated 5/19/2023 at 2:00 PM, revealed no documentation of Zosyn 2:00 PM dose administered. During an interview on 5/25/2023 at 2:23 PM, the DON confirmed no documentation of 5/19/2023 2:00 PM dose of Zosyn being administered. She stated, .Yeah, I don't know why missed dose of Zosyn .it looks like the order was discontinued but at the same time rewritten as the original order .there should not have been a missed dose the orders are exactly the same .We have some work to do .

Based on policy review, medical record review, observation, and interview, the facility failed to provide appropriate indwelling urinary catheter care and failed to provide a Physician's Order for an indwelling urinary catheter for 1 of 3 (Resident #1) sampled residents reviewed. The findings include: Closed medical record review revealed Resident #1 was admitted on [DATE] with a readmitted [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Progress Notes dated 9/6/2022, revealed .pt [patient] indwelling foley cath [catheter] draining clear urine to BSB [bedside bag] below level of bladder . Review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #1 had a Brief Interview of Mental Status (BIMS) of 15 indicating he was cognitively intact, was not coded for an indwelling urinary catheter, and required extensive staff assistance for Activities of Daily Living (ADLS). Review of the medical record, revealed there was no physician's orders for an indwelling urinary catheter or for catheter care. Review of the Medication Administration Records dated 9/6/2022 -10/1/2022 there was no documentation of catheter care. During an interview on 10/11/2022 at 1:59 PM, the Interim Director of Nursing (DON) confirmed Resident #1 did not have orders for an indwelling catheter or for catheter care. The DON stated .he [Resident #1] came in with his catheter .

Based on the facility policy, medical record review, and interview, the facility failed to ensure a resident's skin condition was accurately assessed and documented for 3 of 3 sampled residents (Resident #1, #2 and #8) reviewed with pressure ulcers. The findings include: 1. Review of the facility's Skin Integrity Policy, revised 7/11/2022 revealed .A resident with impaired skin integrity receives necessary treatment and services consist with professional standard of practice, to promote healing, prevent infection . Review of the facility's Wound Care policy, last reviewed on 3/25/2021 revealed, . DOCUMENTATION SHOULD INCLUDE . Location and Type of wound or conditions present must be documented (i.e. Pressure Ulcer Stage III-IV .). 2. Closed medical record review revealed Resident #1 was admitted to the facility on [DATE] with a readmission on 9/21/2022 with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the facility Observation Detail List Report, dated 9/6/2022 revealed Resident #1 was at low to moderate pressure ulcer risk. Review of the current physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .Wound Care .Gluteal Folds .Cleanse with wound cleanser and pat dry. Apply skin prep to protect skin .daily and prn [as needed] . Review of the Progress Notes dated 9/8/2022, revealed .DTI [deep tissue injury] to gluteal folds documented . Review of the current physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .Wound Care .gluteal folds .Cleanse with NS [normal saline] and pat dry. Apply skin prep to peri wound and allow to dry Place 4x4 border foam on each gluteal fold mon [Monday], wed [Wednesday], fri [Friday] or PRN . Review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #1 had a Brief Interview of Mental Status (BIMS) of 15 indicating he was cognitively intact and required extensive staff assistance for Activities of Daily Living (ADLS). Review of the facility Observation Detail List Report, dated 9/22/2022 revealed Resident #1 was at high to very high pressure ulcer risk. Review of the Wound Management Detail Report revealed Resident #1 should have had an assessment on 9/14/2022 and 9/21/2022. The pressure ulcer was identified on 9/7/2022. There was no staging or measurements document for Resident #1's pressure ulcer on the week 9/14/2022 and 9/21/2022. Interim DON confirmed when the wound care nurse is off the nurse manager will complete the weekly wound assessment with staging and measurements. The Interim DON confirmed Resident #1 should have had a wound assessment completed on 9/14/2022 and on 9/21/2022. 3. Review of the medical record revealed Resident #2 was admitted to the facility on [DATE] with a readmission on 9/8/2022 with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the facility Observation Detail List Report, dated 7/15/2022 revealed Resident #2 was at high to very high-pressure ulcer risk. Review of physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .cleanse right buttock wound with wound cleanse, pat dry with 4x [times] 4, apply collagen, activate with normal saline, cover with comfort foam daily .prn . Review of the Progress Notes dated 9/2/2022, revealed .One wound had heeled .DTI's have begun to open- slough/ necrotic tissue noted. Santyl ordered for debridement . Review of the admission MDS assessment dated [DATE], revealed Resident #2 had a BIMS of 14 indicating he was cognitively intact and required extensive staff assistance for Activities of Daily Living (ADLS). Review of the Wound Management Detail Report revealed Resident #2 should had an assessment on 8/31/2022 and 9/21/2022. The pressure ulcer was identified on 8/24/2022. There was no staging or measurements document for Resident #2's pressure ulcer on 8/31/2022. 4. Review of the medical record revealed Resident #8 was admitted on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Current physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .Wound treatment cleanse with wound cleanser and pat dry. Apply skin prep to peri-wound and allow today. Place medi-honey to wound bed and secure with foam dressing mon. wed, fri or PRN . Review of the admission MDS assessment dated [DATE], revealed Resident #8 had a BIMS of 14 indicating she was cognitively intact and required supervision for Activities of Daily Living (ADLS). Review of the Progress Notes dated 9/30/2022, revealed .Wound care completed by this writer. Wound progressing well towards heeling [healing]. Decrease slough noted today . Review of the Wound Management Detail Report revealed Resident #2 should had an assessment on 9/21/2022. The Pressure ulcer to gluteal fold was identified on 9/15/2022. There was no staging or measurements document for Resident #8's pressure ulcer on 9/21/2022. During an interview on 10/6/2022 at 12:30 AM, the Wound care nurse confirmed Resident #1's wound should have been assessed on 9/14/2021 and by the Monday on 9/21/2022 with the measurement and staging of the wound. The Wound Care Nurse confirmed Resident #2 should have had a wound assessment on the week of 8/31/2022 and 9/21/2022. The Wound care nurse confirmed Resident #8 should had wound assessment on 9/21/2022. The Wound Care nurse confirmed the wounds should be assessed, measured, and staged weekly on Wednesdays. The Wound Care Nurse confirmed she was on vacation the week of 9/19/2022- 9/23/2022. The Wound Care Nurse confirmed when she is off the wounds should be assessed by the management team. During an interview on 10/11/2022 at 1:59 PM, the Interim Director of Nursing (DON) confirmed the wound assessment with staging and measurement should be completed weekly. The Interim DON confirmed when the wound care nurse is off the management staff should assess, measure and stage the wounds.

Based on medical record review, and interview, the facility failed to accurately assess residents for Indwelling urinary Catheter for 1 of 3 sampled residents (Resident #1) reviewed for accuracy of Minimum Data Set (MDS) assessments. The findings include: Closed medical record, revealed Resident #1 was admitted on [DATE] with a readmitted [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Progress Notes dated 9/6/2022, revealed .pt [patient] indwelling foley cath [catheter] draining clear urine to BSB [bedside bag] below level of bladder . Review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #1 was not coded for an indwelling urinary catheter. During an interview on 10/6/2022 at 2:46 PM, the MDS coordinator confirmed Resident #1 should be coded on the admission MDS dated [DATE] for his indwelling urinary catheter.

Based on policy review, medical record review, and interview, the facility failed to notify the responsible party for 1 of 3 sampled residents (Resident #4) reviewed for resident rights. The findings include: Review of the facility's policy titled, Intra-Facility Transfers, dated 7/30/2018, revealed .The Facility will provide written notice to the resident prior to changing the resident's room or roommate . Review of the medical record, revealed Resident #4 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Dementia, Ventricular Fibrillation, Major Depressive Disorder, Hypertension, and [CONDITION(S)]. Review of the annual Minimum Data Set (MDS) dated [DATE], revealed Resident #4 had a Brief Interview for Mental Status (BIMS) score of 9, indicating he was moderately cognitively impaired. Review of Resident Census revealed that Resident #4 was moved on the following dates: 2/11/2021 from room [ROOM NUMBER]B to 307A, 5/31/2021 to room [ROOM NUMBER]B, 6/4/2021 to room [ROOM NUMBER]A, 7/23/2021 to room [ROOM NUMBER]B, and 7/30/2021 to room [ROOM NUMBER]A. The facility was unable to provide any documentation that the responsible party/family was notified of each room change. During an interview on 8/10/2021 at 11:15 AM, Resident #4's responsible party confirmed that the facility did not notify him when Resident #4 was moved on 4 separate occasions. During an interview on 8/10/2021 at 5:12 PM, the Social Worker stated, .we let the family know first then the resident know .if the family have any concerns, I offer for them to give me a call .I have a form to fill out .it is put in the medical record box . The Social Worker confirmed that the family should have been notified of Resident #4's room changes. During an interview conducted on 8/10/2021 at 5:27 PM the Unit Manger confirmed that documentation of each room change should be documented in Resident #4's chart. During an interview conducted on 8/10/2021 at 5:55 PM, the Administrator confirmed that the responsible party/family should be notified with each room change. During an interview conducted on 8/12/2021 at 8:52 AM, the Director of Nursing (DON) confirmed that the resident was moved 4 times and the responsible party/family should have been notified with each move.

Based on medical record review and interview, the facility failed to accurately assess a pressure injury for 1 of 3 sampled residents (Resident #6) reviewed for pressure ulcers. The findings include: Review of the facility's policy titled, Pressure Ulcer (Injury) Treatment, dated 6/8/2021, revealed .The pressure ulcer treatment program should focus on the following strategies .Assessing the resident and the pressure ulcer (s) .Unstageable Pressure Ulcer .Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough .If slough .is removed, a Stage 3 or Stage 4 pressure ulcer will be revealed . Review of the medical record, revealed Resident #6 was admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the annual Minimum Data Set (MDS) dated [DATE], revealed Resident #6 had a Brief Interview for Mental Status (BIMS) score of 11, which indicated moderately cognitively impaired, and the resident was coded for a Stage II (2) pressure ulcer. Review of Resident #6's Wound Management form revealed, .Date .Observed .07/08/2021 .Stage II [2] Tissue Type Slough .6/29/2021 .Stage I .Tissue Type Slough .6/22/2021 . Stage II .Tissue Type Granulation Tissue .8/5/2021 .Stage II .Tissue Type Granulation Tissue . Review of the Progress Notes dated 7/8/2021, revealed .Received in IDT [Interdisciplinary Team] meeting, resident with stage II to coccyx . Review of the Progress Notes dated 7/29/2021, revealed .Received in IDT meeting, Resident with stage II to coccyx . Review of the Progress Notes dated 8/5/2021, revealed .Received in IDT meeting, resident with stage II to coccyx . Review of the Facility Wound Summary Report, dated 8/5/2021-8/10/2021, revealed .Pressure Ulcer Stage II .Coccyx . for Resident #6. Review of the Named Hospital record dated 8/10/2021, revealed .Wound Assessment .Acquired .7/12/2021 .Classification .Unstageable .Measurements L [length] x [times] W [width] x D [depth] (cm) [centimeters] .3x3.5x1.4 .8/10/2021 .Readmission to the wound center for pressure ulcer of the sacrum .The ulcer shows drainage and maceration with significant amount of deep necrotic slough with malodor .stage 4 .Post debridement Stage noted as .Stage IV [four] . Observation in the resident's room on 8/11/2021 at 3:43 PM, with the Wound Care Nurse, revealed Resident #6 had a deep open pressure injury with gauze packing, that had a small white area to the bottom of the wound bed. Observation in the resident's room on 8/12/2021 at 1:27 PM, with the Medical Director and the Wound Care Nurse, revealed Resident #6 had a stage IV sacral pressure injury measuring 6.0 x 3.5 x 2.6 cm. During an interview on 8/11/2021 at 3:45 PM, the Wound Care Nurse stated, .the wound is different .it was covered with slough on Monday when I changed the dressing last .it was a stage II . During an interview on 8/12/2021 at 10:08 AM, the Director of Nursing (DON) confirmed that the pressure injury was not accurately assessed or staged, and if slough was present in a wound, it would be a full thickness wound and would be a Stage 3 or 4 once the slough was removed. During an interview on 8/12/2021 at 1:30 PM, the Medical Director confirmed that the pressure ulcer to Resident #6's coccyx was a stage IV. The Medical Director confirmed that if a wound was filled with slough it was considered unstageable. The Medical Director confirmed that the Resident #6's pressure injury was not accurately assessed or staged.

Based on policy review, record review, and interview, the facility failed to inform the resident's Responsible Party of missed doctor's appointment for 1 of 3 sampled residents (Resident #1) reviewed for notification. The findings include: Review of the facility's policy titled, Change of Condition At-A-Glance, revised 11/6/2019, showed, .Notify the resident's responsible party of change .following through completed by the facility .document in the EMR (electronic medical records) . Review of medical record, showed Resident #1 had a [DIAGNOSES REDACTED]. Review of the Named Hospital Final Report, dated 11/9/2020, showed, .Findings .Large infected skin of the left perineum .groin with hidradenitis multiple sinus tract connecting the abscesses .Multiple sinus tracts and abscesses at different stages healing in the right perineum and groin . Review of the Nursing Homes DECEMBER Calendar, dated 12/2/2020, showed Resident #1 had an appointment to .(Named Doctors Office) 3 pm (3:00 PM on 12/2/2020) . Review of the Named Doctor's office progress notes dated 12/9/2020, showed, .Chief Compliant follow-up Hidradenitis .Assessment/Plan .Open wound of perineum without complication .Patient has large open wounds of the bilateral perineum .The wounds appear infected .The patient is unable to care for the wounds at home secondary to intellectual disability .The sutures are removed in the office today .I think the patient will need a diverting [MEDICAL CONDITION] to keep the wounds clean . During an interview conducted on 1/5/2021 at 1:56 AM, the Central Supply staff member confirmed that she sets up the appointments for the residents. The Central Supply staff member confirmed that she was at the doctor's office when she was told about Resident #1's refusal and she rescheduled Resident #1's appointment for 12/9/2020. The Central Supply staff member confirmed that she did not notify Resident #1's Responsible Party. During a phone interview conducted on 1/6/2021 at 12:00 PM, the Certified Medical Assistant at the Named Doctor's Office confirmed that Resident #1's wounds had not worsened due to her missed appointment. During a phone interview conducted on 1/6/2021 at 12:10 PM, the Responsible Party confirmed that the facility did not notify him about the change in Resident #1's doctor's appointment. During a phone interview conducted on 1/7/2021 at 9:08 AM, the Director of Nursing (DON) confirmed there was no documentation that the Responsible Party was notified of the change in appointment. The DON confirmed that the staff should attempt to call the Responsible Party 3 times and document the information in the Nurse's Notes.

Based on policy review, medical record review, observation, and interview, the facility failed to provide reasonable accommodations to promote residents' needs for the use of a call light for 1 of 4 sampled residents (Resident #1) reviewed. The findings include: Review of the facility's policy titled, Resident Rights, revised 8/16/2018, showed, .All residents have the right to be treated with respect and dignity. These rights will be promoted and protected by the facility .When providing care and services, the stakeholders will respect the resident's individuality and value their input by providing them a dignified existence, through self-determination and communication with and access to persons and services inside .the facility . Review of the medical record showed, Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Care Plan dated 9/12/2020, showed, .Problem .Cognitive Loss/Dementia .Approach .Explain all care before providing it .Use brief, simple, consistent words, cues . Observation in the resident's room on 10/30/2020 at 11:58 AM, showed Resident #1 was seated in a padded Broda chair next to her bed. Resident #1 stated, .I got to find out who owns this place . During a telephone interview on 11/3/2020 at 1:40 PM, Registered Nurse (RN) #1 was asked if Resident #1 was alert and oriented. RN#1 stated, .no, she has been talking out of her head .she has been recently diagnosed with [REDACTED]. RN #1 was asked about Resident #1's use of the call light. RN #1 stated, .a few days .she was hitting call light over and over again .hit it 3 times within 10 minutes .we have a lot of acuity going on right now .I tried to explain to her and told her we couldn't accommodate her .I don't feel like I was rude to her .I am a straight forward person .the daughter called me and said I was pretty hostile with her mother .I tried to explain to her wasn't being mean .just being realistic with her and we couldn't be in there like that .we can't maintain that .she is a little needy .once that UTI kicked off .it was unmanageable .don't really think she needed something .she just wanted someone in there with her all the time .it is what it is . RN #1 stated, .after we had that conversation, she did decrease (using the call light) .it's been up and down .I'm just a matter of fact .person .direct .I understand she was out of it .but she was being obnoxious . During a phone interview on 11/6/2020 at 9:06 AM, the Director of Nursing (DON) was asked should a resident be told not to use the call light. The DON stated, No, (Resident #1) probably was more confused that day, had just been diagnosed with [REDACTED].within the first hour .then 3 times within 10 minutes .the daughter called me .saying the nurse was rude .saying she (nurse) was only the one on the hall . During a phone interview on 11/6/2020 at 9:10 AM, the Administrator was asked if a resident should be told not to use the call light. The Administrator stated, No . The Administrator confirmed the situation was not handled correctly.

Based on policy review, medical record review, observation, and interview, the facility failed to ensure 2 of 4 (Registered Nurse (RN) #1 and Licensed Practical Nurse (LPN) #1) nurses administered medications with a medication error rate of less than 5 percent (%). A total of 2 errors were observed out of 27 opportunities, resulting in an error rate of 7XXX %. The findings include: 1. The facility's Medication Administration General Guidelines policy dated 9/2018 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 .Verify medication is correct three (3) times before administering the medication . 2. Medical record review revealed Resident #22 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The physician's orders [REDACTED].[MEDICATION NAME] .tablet .500 mg (milligrams) .GIVE 1 TABLET BY MOUTH AS NEEDED Q (every) 6HRS (hours) AS NEEDED . Observations in Resident #22's room on 9/5/19 at 8:25 AM, revealed RN #1 administered [MEDICATION NAME] 500 milligram (mg) 2 tablets by mouth to Resident #22. The administration of [MEDICATION NAME] 500 mg 2 tablets resulted in medication error #1. Interview with RN #1 on 9/6/19 at 8:58 AM in the 400 Hall, RN #1 confirmed he administered 2 [MEDICATION NAME] 500 mg tablets to Resident #22 during his morning medication administration on 9/5/19. RN #1 was asked if he should have only given 1 [MEDICATION NAME] 500 mg tablet according to the physician's orders [REDACTED]. 3. Medical record review revealed Resident #61 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The physician's orders [REDACTED].[MEDICATION NAME] sodium .50mg/ (per) 5 ml (milliliters) GIVE 10 MILLILITER VIA [DEVICE] (gastrostomy tube) 2 TIME(S) DAILY .5:00 (5:00 AM), 17:00 (5:00 PM) . Observations in Resident #61's room on 9/5/19 at 5:29 PM, revealed LPN #1 administered the evening medications to Resident #61 and did not administer the [MEDICATION NAME] sodium. The failure to administer the [MEDICATION NAME] sodium resulted in medication error #2. Interview with LPN #1 on 9/6/19 at 8:57 AM, in the 200 Hall, LPN #1 confirmed she did not administer the [MEDICATION NAME] sodium at 5:00 PM on 9/5/19 as ordered with the evening medications. Interview with the Director of Nursing (DON) on 9/6/19 at 11:43 AM, in the Gathering Room, the DON was asked if she expected nurses to administer medications as ordered by the physician. The DON stated, Yes.

Based on policy review, observation and interview the facility failed to hold and serve cooked foods at the acceptable temperature. The facility had a census of 71 with 68 of those residents receiving a meal tray from the kitchen. The findings included: The facility's Food Temperatures policy documented, .Acceptable serving temperatures are: .meat, entrees > (greater than) or = (equal) to 140 degrees but preferably 140 degrees-165 degrees F (Fahrenheit) .potatoes, pasta, rice > or = to 140 degrees but preferably 140 degrees to 165 degrees F . Observations on 10/17/17 at 5:15 PM at the steam table revealed mashed potatoes at 128 degrees. The Dietary Manager reheated the mashed potatoes to 150 degrees. Interview with the Dietary Manager on 10/17/17 at 5:45 PM in the kitchen, the Dietary Manager was asked what the proper temperature for serving and maintaining hot food items was. The Dietary Manager stated, It should be at least 145. The Dietary Manager was then asked what the process was if an improper temperature was identified. The Dietary Manager stated, It should be reheated to 165 . Interview with the Administrator on 10/18/17 at 8:34 AM in the Administrator's office, the Administrator was asked if the food prepared by dietary staff should be maintained and served to residents at the proper temperature. The Administrator stated, I expect food to meet the proper guidelines before serving.