Every finding on record at Signature Healthcare of Norfolk

Based on staff interviews, clinical record review and facility document review, the facility staff failed to ensure 1 of 59 residents (Resident #236) in the survey sample were free of significant medication errors. The findings included: The facility staff failed to ensure the significant medication Lopressor (used to treat high blood pressure) 25 mg was administered twice a day to Resident #326 from 11/14/20 through 11/20/20. Resident #236 was admitted to the facility on [DATE] and transferred to an acute care setting on 11/24/20. The resident did not return to the nursing facility. Diagnosis included but are not limited to Congestive Heart Failure (CHF) and Hypertension (high blood pressure). Resident #236's Minimum Data Set (MDS - an assessment protocol) an admission assessment with an Assessment Reference Date of 11/17/20 coded Resident #236's Brief Interview for Mental Status (BIMS) scored a 15 out of a possible score of 15 indicating no cognitive impairment. Resident #236's person-centered care plan created on 11/15/20 and revised on 11/20/20 identified the resident with health-related issues related to cardiovascular, respiratory and diabetes complications. The goal set for the resident by the staff was that the resident will not develop complications. Some of the interventions/approaches the staff would use to accomplish this goal is to start Lopressor 25 mg by mouth twice a day and to administer medication as ordered. A review of Resident #236's hospital discharge summary dated 11/12/20 included an order to administer Metoprolol (Lopressor) 25 mg twice a day for high blood pressure. A review of Resident #236's clinical record to include the Physician Order Summary (POS) and Medication Administration Record (MAR) revealed the medication Lopressor was not started until 11/20/20. The clinical record indicated an Event Detail report dated 11/20/20 indicated a medication error related to Resident #236's high blood pressure medication (Lopressor) was not entered into the system on 11/13/20 indicating Resident #236 missed 13 does of her blood pressure medication. Further review of the Event Detail report documents the physician was made aware with a new order to start Lopressor 25 mg twice a day for high blood pressure. An interview was conducted with the Director of Nursing (DON) who was the MDS Coordinator when the medication error occurred on 11/13/20. She stated she was doing a chart audit review when she compared Resident #236's discharge order with the admission orders and discovered the resident's Lopressor 25 mg twice a day was omitted from the admission orders. She stated she immediately informed the physician on 11/20/20 with a new order to start Lopressor 25 mg twice a day. A final meeting was held with the Administrator, Director of Nursing, Assistant Director of Nursing, [NAME] President of Operations on 07/21/23 at 5:30 p.m. No further information was provided prior to exit. Definitions: -Congestive Heart Failure occurs when the heart muscle doesn't pump blood as well as it should. When this happens, blood often backs up and fluid can build up in the lungs, causing shortness of breath. Certain heart conditions, such as narrowed arteries in the heart (coronary artery disease) or high blood pressure, gradually leave the heart too weak or stiff to fill and pump blood properly (https://www.mayoclinic.org/diseases-conditions/heart-failure/symptoms). -Hypertension is when your blood pressure, the force of your blood pushing against the walls of your blood vessels, is consistently too high (https://medlineplus.gov/ency/article/007365.htm).

Based on family interview, staff interviews, clinical record review and facility documentation review the facility staff failed to invite 1 out of 50 resident (Resident #46) or their Responsible Representative (RR) to attend their person-centered care plan meeting. The findings included: Resident #46 was originally admitted to the nursing facility on 05/14/21. Diagnosis for Resident #46 included but not limited to acute subdural hemorrhage, dementia with behavioral disturbance and anxiety. The Minimum Data Set (MDS - an assessment protocol) an annual assessment with an Assessment Reference Date (ARD) of 04/28/23 coded Resident #46 with a 03 out of a possible score of 15 on the Brief Interview for Mental Status (BIMS), indicating severe cognitive impairment. A phone interview was conducted with Resident #46's Responsible Representative (RR) on 07/19/23 at approximately 12:51 p.m. He stated he had never been invited to attend a care plan meeting for Resident #46. An interview was conducted with the Director of Social Services on 07/21/23 at 3:21 p.m. She stated she was not able to locate anywhere in Resident #46's clinical record that the Resident #46 or their RR were provided their care plan invitation invite/letter for the last 12 months or that care plan meetings were held. She stated care plan meetings should be held every quarter but was not sure why care plan meetings were not held for Resident #46. A final meeting was held with the Administrator, Director of Nursing, Assistant Director of Nursing and [NAME] President of Clinical Operations on 07/21/23 at approximately 5:30 p.m., who were informed of the above findings. No further information was provided prior to exit. The facility's policy titled Comprehensive Care Plan (Last Reviewed: 04/14/21). Guideline: The 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. 3. Each resident has the right to participate in choosing treatment options and will be given the opportunity to participate in the development, review, and revision of their care plan.

Based on record review, interviews, and facility policy review, the facility failed to ensure residents received written discharge notices at the time of transfer to the hospital for four (Resident (R)119, R15, R64, and R70) of six residents reviewed for hospitalization . Findings include: Review of the facility's policy titled, Transfer/Discharge Notice dated 11/01/22 revealed for the Emergent Transfers to Acute Care section, the facility will send a written notice of discharge to the resident and/or resident representative when the resident was transferred/discharged to the hospital. 1. Review of Resident 119's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/16/23 revealed she had a Brief Interview for Mental Status score (BIMS) of 15 out of 15, indicating she was cognitively intact. On 07/18/23 at 1:48 PM, R119 was asked if she was sent to the hospital recently and she stated she had and that she did not get a written transfer. Review of the Census tab of Resident 119's electronic medical record (EMR) revealed the resident was discharged with return expected on 04/15/23 and was returned to the facility on [DATE]. Review of a progress note located in the Progress Note tab dated 04/15/23 at 11:00 AM revealed the resident had increased pain in his distended abdomen. The physician was called, and an order was given to send the resident to the emergency room . Review of progress note located under the Progress Note tab note dated 04/15/23 at 11:41 AM revealed the resident left the facility via stretcher. Review of progress note located under the Progress Note tab note dated 04/16/23 revealed the resident was admitted to the hospital and the admitting diagnosis was unknown. Review of R119's e EMR revealed no documentation that a written discharge notice was sent to the resident and resident representative. 2. Review of R15's quarterly MDS with an ARD of 05/08/23 revealed she had a BIMS score of 10 out of 15 indicating she was moderately cognitively impaired. Review of R15's MDS revealed she had a discharge return expected MDS completed on 02/18/23 and an entry MDS dated [DATE]. On 07/19/23 at 9:02 AM, R15 stated she had gone to the hospital and stayed overnight when she had a port put in her chest. She stated she could not remember if she received a written discharge notice. Review of R15's Census tab in the EMR revealed she was discharged return expected on 02/18/23 and returned to the facility on [DATE]. A nursing progress note under the Progress Note tab dated 02/18/23 at 10:40 PM revealed the resident was ordered to be transported to the hospital and a progress note dated 02/19/23 at 12:48 AM revealed the nurse contacted the emergency department and was told she was being admitted . 3. Review of R64's quarterly MDS with an ARD date of 06/30/23 revealed she had a BIMS score of 15 out of 15 indicating she was cognitively intact. Review of a progress note located under the Progress Note tab dated 06/18/23 at 11:38 AM revealed the resident was transported to the hospital due to having her head down with her chin over her open trach and refusing to allow staff to place the trach collar and refusing to allow staff to complete vital signs and care. The note revealed the physician and the resident's representative was called and she was transported to the hospital. A progress note located under the Progress Note tab dated 06/25/25 at 1:32 PM revealed the resident was readmitted to the facility. Review of R64's Progress Notes tab of the EMR revealed she had a nursing note dated 07/13/23 at 12:00 PM revealing she (R64) was observed on the floor. She stated she was attempting to bend over and pick something up off the floor .The resident communicated via communication board that she had pain in the right knee, and she wanted to go to the hospital. A progress note dated 07/13/23 at 1:00 PM revealed she left for the hospital. Review of R64's EMR revealed no documentation that a transfer/discharge notice was sent to the resident and/or resident representative. On 07/20/23 12:34 PM, the [NAME] President of Clinical Operations (VPO) verified that there was no documentation for the residents identified that the resident and their representative received a written transfer/discharge notice at the time of the transfers/discharge to the hospital. On 07/20/23 1:53 PM the VPO stated the facility did not give the resident or resident representative a written discharge/transfer notice. She stated the facility staff only informed the resident and resident representative verbally of the discharges. 4. Review of R70's Face Sheet located under the Profile tab of the EMR revealed R70 was admitted to the facility on [DATE]. Review of R70's quarterly MDS with an ARD date of 04/21/23 located under the RAI tab indicated R70 had a BIMS score of five out of 15 indicating R70 was severely cognitively impaired. Review of R70's EMR under the Progress Notes tab, dated 03/22/23 revealed, Resident noted exhibiting behaviors on this shift, resident noted vomiting x [times] 1, Loose watery stools x3, combative with staff and wandering in rooms .Resident was noted sweating profusely and breathing fast . writer called 911 due to resident becoming lethargic while pacing towards nurses station and having to be guided to floor to prevent injury .Resident complied with EMTs [Emergency Medical Technicians] .Resident's RP .has been made aware of resident's condition . Review of the facility's policy titled, Transfer/Discharge Notice reviewed 11/01/22 indicated, Policy Statement The appropriate notice will be provided to the resident and/or resident representative if it is necessary to transfer .a resident from a facility. Definitions .Emergent Transfer to Acute Care: Residents who are sent emergently to the hospital are considered facility-initiated transfers because the resident's return is generally expected .Facility-Initiated .Transfer: The facility may decide to .transfer a resident only for the reasons permitted under applicable federal and state law, which may include the following: Transferred .for the sake of the resident .2. In this event, the facility will notify the resident/resident representative in writing of: The reason the facility has initiated the involuntary transfer .to another legally responsible institution. The effective date of the transfer .The location to which the resident is transferred .

Based on observation, interview, and record review, the facility failed to treat residents with respect and dignity by not ensuring the residents' rights to retain personal possessions for two of two sampled residents (Residents (R)52 and R82) reviewed for resident rights. This failure had the possibility to have a negative impact on numerous residents residing in the facility. Findings include: Review of R52's Face Sheet, located under the Profile tab of the electronic medical record (EMR) revealed R52 was admitted to the facility on [DATE] with diagnoses which included flaccid hemiplegia affecting the left non dominant side, cerebral infarction due to unspecified occlusion or stenosis of unspecified cerebral artery, heart failure, type II diabetes, major depressive disorder, major depressive disorder, bipolar disorder, aphasia, and anxiety disorder. Review of R52's annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) date of 05/31/23, located under the RAI tab indicated R52 was extensive assist of one staff member for toileting, supervision of one staff member for bed mobility, independent with transfers and wheelchair mobility, limited assist of one staff member for dressing. The MDS showed Brief Interview for Mental Status (BIMS) score of 14 out of 15 indicating R52 was cognitively intact. Review of R82's Face Sheet, located under the Profile tab of the electronic medical record (EMR) revealed R82 was admitted to the facility on [DATE] with diagnoses which included sepsis, muscle weakness, diverticulitis of intestine, type II diabetes, Parkinson's disease, depression, unspecified dementia, and anxiety disorder. Review of R82's quarterly MDS with an ARD date of 05/30/23, located under the RAI tab indicated R82 was extensive assist of two staff members with transfers and bed mobility; total dependence of one staff member for toileting; extensive assistance of one staff member for dressing. The MDS showed Brief Interview for Mental Status (BIMS) score of 13 out of 15 indicating R82 was cognitively intact. During a resident meeting held on 07/20/23 at 10:00 AM, several of the residents (R56, R2, R50, R61, R82, and R52) in attendance stated the facility laundry had not returned some of their clothing items. The residents said their clothing not being returned to them from the laundry had been an ongoing problem. R52 stated he was missing a hat, jacket, and a red, white, and blue blanket. Review of the Resident Council Meeting Minutes, dated for the past year July 2022 through July 2023 indicated there were 10 different residents with complaints of their clothing items not being returned to them from the laundry. R18 stated he did not send his clothes to laundry anymore because he did not get them back. R89 stated she was missing 21 items. R82 stated he was still missing clothes. R61 stated she was missing clothes. R52 stated he was missing jeans and pants and R50 stated was still missing pants. During an interview on 07/19/23 at 11:15 AM, with a laundry employee (LE), she stated finding a good way to mark a resident's clothing had always been an issue. LE said they now have a labeling machine which should fix the problem. LE was not sure what had been put in place to label all residents' clothing. During an interview on 07/19/23 at 1:25 PM, the Assistant Director of Nursing (ADON) stated the facility purchased a labeling machine and have piloted labeling resident's clothing on the third floor. The ADON said prior to the labeling machine they would encourage residents' family members to label a resident's clothing or would write the resident's name on the back of the clothing item with a permanent marker. The ADON stated the Activities Director (AD) has begun to hold a yard sale every Friday where she was using the labeling machine to label all the clothing items the residents obtain at the yard sale. During an interview on 07/20/23 at 3:50 PM, with the Activities Director to discuss plan for labeling Residents' clothing, the AD stated on Fridays after lunch they brought out clothes that have been donated or unclaimed and let residents look them over and choose clothes for themselves. The AD said she had the labeling machine there and labeled the clothes right at that time. The AD stated they have labeled some of the residents' clothes on the 3rd floor. During an interview on 07/21/23 at 10:30 AM, R52 stated that the facility losing some of his clothing was very frustrating for him especially when the items were a connection to his service in the military. During an interview on 07/21/23 at 11:00 AM, R82 stated when his clothing was not returned to him it was like a burden to me, because I need to get dressed every day.

Based on observation, resident interview, staff interviews, and a clinical record review, the facility staff failed to ensure a dependent resident's activities of daily living (ADL) were completed for 1 of 59 residents (Resident #1), in the survey sample. The findings included: Resident #1 was originally admitted to the facility 7/19/22 and readmitted [DATE] after an acute care hospital stay. The current diagnoses included; malnutrition, hyperparathyroidism, and chronic atrial fibrillation. The annual Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 6/7/23 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 14 out of a possible 15. This indicated Resident #1's cognitive abilities for daily decision making were intact. In section G (Physical functioning) the resident was coded as requiring total care of one person with bathing and toileting, extensive assistance of one person with bed mobility, personal hygiene and dressing, and supervision after set-up with eating. The resident did not transfer or walk. On 7/18/23 at approximately 4:55 p.m., during the initial tour Resident #1 was observed in bed with large white flakes throughout her hair and with long yellow fingernails with some jagged edges. An interview was conducted with Resident #1 on 7/18/23 at approximately 4:58 p.m. The resident stated her fingernails were not cared for because she was required to get out of bed and go down stairs to activities in order to have them filed and painted. The resident also stated her teeth were not brushed and cleaned as often as she desired. Observation of her teeth reveal many broken and discolored teeth. An interview was conducted with the Activities Director on 7/19/23 at approximately 2:10 p.m. The Activities Director stated it is not necessary for a resident to come to an activity for nail care for if they are alerted they will come to the resident. On 7/20/23 at approximately 9:55 a.m., an interview was conducted with Certified Nursing Assistant (CNA) #8, CNA #8 stated it is the assigned CNA's responsibility to wash Resident #1's hair using a shower cap in bed and to provide oral care. CNA #8 also stated the resident does not have to go to activities for nail care for it is provided along with ADL care by the assigned CNA. On 7/21/23 at 9:48 a.m., another interview was conducted with Resident #1, she stated They came in last night filed and painted my fingernails, and washed my hair but the nurse had problems combing my hair out in the back because it was and remains matted. Resident #1 stated her teeth were also brushed before breakfast and her mouth was feeling fresh. On 7/21/23 at approximately 4:30 p.m., a final interview was conducted with the Administrator, Director of Nursing (DON) and Corporate Consultant. The DON stated the resident's hair had been shampooed and a medicated shampoo, had been ordered as well as a special mouthwash and her nails had been filed and painted, since the concerns had been brought to their attention.

Based on observations, resident interviews and staff interview, the facility staff failed to ensure the sink in Resident #120's room drained after use for 1 of 59 residents (Resident #120), in the survey sample. The findings included: Resident #120 was originally admitted to the facility 3/8/23 after an acute care hospital stay. The resident had never been discharged from the facility. The current diagnoses included; high blood pressure, high cholesterol and hypothyroidism. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 6/13/23 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #120's cognitive abilities for daily decision making were intact. In section G (Physical functioning) the resident was coded as requiring physical help of one person with bathing, limited assistance of one person with dressing, supervision of one person with transfers, locomotion, toileting, and personal hygiene, independent after set-up with eating and walking, and independent with bed mobility. On 7/18/23 at approximately 4:35 p.m., during the initial tour the sink in Resident #120's bathroom was observed to be 1/3 full of standing water. An interview was conducted with Resident #120 on 7/18/23 at approximately 4:37 p.m. The resident stated there had been problems with the sink draining completely for many months. The resident also stated the toilet flushes but it is a matter of knowing the trick to hold the handled down until all of the waste is gone out of the commode. He further stated the roommate does not understand how to manage the toilet even though he had explained it to him multiple times. On 7/19/23 at approximately 1:40 p.m., another observation was made of Resident #120's bathroom sink. This time it was 2/3 full with soapy water. Resident #120 stated the roommate left the water running and when he went in, it was almost full. On 7/20/23 at approximately 11:45 p.m., the sink was again observed in Resident #120's room. It was still approximately 2/3 full with standing water, the pipes under the sink had been taken apart and a bucket had been placed beneath the sink to capture water. An interview was conducted with Resident #120 at approximately 11:46 p.m. The resident stated Maintenance was working on the sink but there was no improvement thus, he had given up on the sink getting repaired to drain completely. On 7/20/23 at approximately 4:00 p.m., an interview was conducted with the Maintenance Assistant. He stated they had did all they knew to do to get the sink in Resident #120's room to drain therefore, he felt it was time to bring in services from the outside. On 7/21/23 at approximately 4:30 p.m., a final interview was conducted with the Administrator, Director of Nursing and Corporate Consultant. They had no further comments and voiced no additional concerns about the non-draining sink in Resident #120's room.

Based on staff interviews, clinical record review, and facility documentation, the facility staff failed to immediately inform the physician of the need to assess/evaluate, start, or alter treatment when there was a significant deterioration in the resident's condition for 1 of 59 residents (Resident #46) in the survey sample. The findings included: Resident #46 had four (4) falls between 04/24/23 - 05/22/23 and during that time she had behavioral and neurological changes. She was at risk for major injury related to being on an anticoagulation medication (blood thinner), independent with ambulation, and a diagnosis of dementia. The resident was not assessed after significant behavioral and neurological changes were identified. The resident was transferred to the local emergency room (ER), and diagnosed with subdural hematoma/hemorrhage. Resident #46 was transferred via 911 (emergent) to the local hospital on 05/22/23 due to acute left-sided weakness and altered mental status following a ground-level fall at the nursing facility. A computerized tomography (CT) scan was done to reveal a subdural hematoma/hemorrhage. On 05/23/23, Resident #46 underwent right burr hole subdural hematoma evacuation with subdural drain placement. Resident #46 was originally admitted to the nursing facility on 05/14/21. Diagnosis for Resident #46 included but was not limited to acute subdural hemorrhage, dementia with behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, history of pulmonary embolism (a blood clot in the lungs), and cerebral infarction (stroke). The Minimum Data Set (MDS - an assessment protocol) an annual assessment with an Assessment Reference Date (ARD) of 04/28/23 coded Resident #46 with a 03 out of a possible score of 15 on the Brief Interview for Mental Status (BIMS), indicating severe cognitive impairment. The MDS coded Resident #46 total dependence on one with bathing, limited assistance of one with personal hygiene, supervised with limited assistance of one with dressing and toilet use, supervisor with one assistance with eating and transfer, and independent with bed mobility, locomotion on/off the unit, walking in room and corridor with a steady gait all the time. The most recent Minimum Data Set (MDS - an assessment protocol) a significant change assessment with an Assessment Reference Date (ARD) of 06/12/23 coded Resident #46 with a 03 out of a possible score of 15 on the Brief Interview for Mental Status (BIMS), indicating severe cognitive impairment. The MDS coded Resident #46 total dependence of one with bathing, extensive assistance of one with bed mobility, transfer, dressing, personal hygiene, and toilet use, and supervision with one assistance with eating for Activities of Daily Living (ADL) care. Under section G0300 (Balance during transitions and walking) was coded gait not steady, only able to stabilize with human assistance. Resident #46's person-centered care plan created on 05/24/21 and revised on 06/18/23 identified the resident at risk for falls related to psychotropic medication use. The goal set for the resident by the staff was that the resident will remain free from injury. Some of the interventions/approaches the staff would use to accomplish this goal are to assist with all transfers and mobility, obtain physical therapy (PT) consult as needed, resident is self-ambulatory and attempt to toilet resident every 2-3 hours and as needed. Resident #46's person-centered care plan created on 05/24/21 and revised on 06/18/23 identified the resident receiving anticoagulant therapy (blood thinner) due to a history of Pulmonary Embolism (PE). The goal set for the resident by the staff was that the resident will have no active bleeding. Some of the interventions/approaches the staff would use to accomplish this goal are to observe for signs of active bleeding (nosebleeds, bleeding gums, petechiae (tiny purple spots under the skin), purpura (rash of purple spots under the skin), ecchymosis (bruising) areas, hematoma, blood in urine, blood in stools, hemoptysis, elevated temp, pain in joints, abdominal pain, and epistaxis). A review of Resident #46's Medication Administration Record (MAR) for May 2023 revealed an order to administer Xarelto (blood thinner) 20 mg by mouth daily with dinner (for a history of pulmonary embolism). A nurse's note entered by License Practical Nurse (LPN) #2 on 04/24/23 at 10:47 a.m., documented Resident #46 with swelling and bruising to the left side of the face near the cheek bone. When asked what happened, Resident #46 said she almost fell getting the baby and pointed at the nightstand. The resident denied falling but has a diagnosis of dementia. The nightstand was re-arranged further away from the bed. The physician and Resident Representative (RR) were made aware of the above incident. According to the nurses' note dated 04/25/23 at 3:30 a.m., Resident #46 continued with swelling at the left upper cheek area and now to the outer corner of the left eye. On the same day at 2:49 p.m., Resident #46 was observed with a red spot on the sclera (the white outer layer of the eyeball), and swelling and bruising remained on the left side of the face. Further review of the note did not indicate the physician or Nurse Practitioner (NP) was informed related to the red spot observed on the sclera. On 04/28/23 at 8:22 a.m., a nurses' note entered by LPN #8 documented Resident #46 with increased pain in the left eye. The resident was medicated with Motrin (pain medication) with effective results. Further review of the note did not indicate the physician or NP was informed. A review of Resident #46's nurse's notes revealed on 05/10/23 at 1:45 p.m., the resident was observed with increased agitation. She refused her afternoon medications and vital signs. The note also indicated Resident #46's flooded the bathroom in (room #) with tissue paper and storage equipment. On 05/11/23, according to Resident #46's nurses' note, Resident #46 refused her afternoon medications and vital signs. On the same day, observed with increased agitation. The resident was seen by the Psych Nurse Practitioner (NP). The psych NP note documented resident was being seen today for a follow-up evaluation for a medication check. Resident #46 refusing medication, patient care and not eating. Resident #46 noted with increase paranoia which is something new. New orders were given for Urine Analysis (UA) with Culture and Sensitivity (C&S), Complete Blood Count (CBC) and Basic Metabolic Panel (BMP) in the morning. The psych NP was interviewed on 07/21/23 at 2:51 p.m. He stated he was asked by nursing to see Resident #46 on 05/11/23 for increased agitation/behaviors. He stated he ordered labs on Resident #46 but it was the responsibility of the resident's primary physician to follow up with any necessary treatment. On 05/12/23, a change in condition form was completed on Resident #46. The form identified Resident #46 with increased confusion or disorientation and new or worsened delusions or hallucination. Resident #46 observed requiring more assistance with ADL's. The physician was informed of change in condition. Further review of the clinical record did not reveal a MD or NP visit related to change in condition with Resident #46. A nurses' note entered on 05/14/23 at 8:06 a.m., documented Resident #46 had a fall on the (11-7 shift). At this time, the resident was observed with a limp while dragging her left leg during ambulation. A message was left for the physician but did not indicate the physician returned the call. On 05/14/23 at 10:17 p.m., it was documented in the nurses' notes Resident #46 noted with increased agitation to noise, tremors, and unsteady gait and required two persons assist with care. Further review of the clinical record did not indicate the physician or NP was notified. A review of Resident #46's nurses' note dated 05/15/23 at 6:15 p.m., indicated the resident had been found on the floor in her bathroom without pain or discomfort. The note indicated neuro checks were within normal limits (WNL). A nurses' note dated 05/17/23 at 12:58 p.m., documented day three (3) after an unwitnessed fall indicated Resident #46 required max assist of two (2) person assistance with walking. The note documented the resident had been evaluated by therapy and Resident #46 was unaware of her left lower extremity when moving from sit/stand during therapy sessions. On 07/21/23 at 9:51 a.m., an interview was conducted with the Physical Therapist (PT). He stated Resident #46 was evaluated and picked up by therapy due to requent falls with poor safety awareness. He stated Resident #46 was dragging her left leg; unable to pick that leg up. He stated prior to her falls, Resident #46 was independent with ambulation and did not require an assistance device (walker or wheelchair). Resident #46 was evaluated by PT on 05/17/23. According to the evaluation, Resident #46 was seen for a significant decline in her functional mobility skills and what appears to be left lower extremity hemiplegia (weakness or partial paralysis on one side of the body.) It was documented the resident was unable to ambulate and required max assistance with transfers. It was also documented Resident #46 required the use of a wheelchair and Pommel seat cushion to reduce her risk of falls. On 07/21/23 at 4:14 p.m., an interview was conducted with the Director of Nursing (DON) with five (5) other surveyors present. She stated on 05/14/23, when Resident #46 exhibited increased sleeping, reaching for objects, and observed with tremors, the physician should have been notified. She stated the resident could be having neurological issues. She stated Resident #46 needed further evaluation and a clinical assessment by the physician or NP, but it didn't happen. The DON stated according to the nurses on 05/16/23, Resident #46 is leaning towards the left side and required assistance with ambulation which is abnormal for her. She stated when the NP was informed on 05/17/23 that Resident #46 noted with an increase in leaning to her left side with weakness, Resident #46 needed to be evaluated. The DON stated according to the resident's clinical record, the physician or NP did not assess Resident #46 from 05/12/23 when she first showed a change in condition to include frequent falls until she was discharged to the hospital on 05/22/23 with a subdural hemorrhage. The DON was asked if the physician or NP should have come to evaluate/assess Resident #46 she replied, Absolutely. She stated the facility/provider did not do further assessments to determine what the root cause of the change in condition was for Resident #46's. Resident #46 had an unwitnessed fall in the day room on 05/22/23. She was sent to the local emergency room (ER) via 911 emergence for further evaluation. On the same day at 9:50 p.m., the facility received a call from (name of hospital) informing them that Resident #46 was admitted to the Neuro Intensive Care Unit (ICU). A review of the hospital record revealed Resident #46 presented in the emergency room (ER) on 05/22/23 from (name of nursing facility) for further evaluation due to acute left-sided weakness and altered mental status following a ground-level fall at the nursing facility. The note indicated a subdural hemorrhage/hematoma may have been the result due to the ground-level fall. Over the past several days, Resident #46 had worsening gait instability and falls, and today observed with weakness in her left arm. The note indicated a computerized tomography (CT) scan was done to reveal a subdural hematoma/hemorrhage. On 05/23/23, Resident #46 underwent right burr hole subdural hematoma evacuation with subdural drain placement. The resident remained in the Neuro Intensive Care Unit (ICU) for close monitoring and subdural drain until 05/25/23. A final meeting was held with the Administrator, Director of Nursing, Assistant Director of Nursing, and [NAME] President of Clinical Operations on 07/21/23 at approximately 5:30 p.m. No further information was provided prior to exit. Definitions -Xarelto is used to treat deep vein thrombosis (DVT; a blood clot, usually in the leg) and pulmonary embolism (PE; a blood clot in the lung) in adults. Rivaroxaban is also used to prevent DVT and PE from happening again after initial treatment is completed in adults (https://medlineplus.gov/druginfo/meds). Subdural hemorrhage -A subdural hematoma is a type of bleed inside your head. It's a type of bleed that occurs within your skull but outside the actual brain tissue. Other names for subdural hematoma are subdural hemorrhage or intracranial hematoma. More broadly, it is also a type of traumatic brain injury (TBI). How do subdural hematomas happen? -Head injuries cause most subdural hematomas. If you fall and hit your head or take a blow to the head in a car or bike accident, a sporting activity or have another type of head trauma, you are at risk for developing a subdural hematoma. Are some people more likely to get a subdural hematoma? -People who take blood thinners: Blood thinners slow down the clotting process or prevent blood from clotting at all. If blood doesn't clot, bleeding can be severe and long-lasting, even after a relatively minor injury. Being careful when taking blood thinners: Even minor head injuries can cause a subdural hematoma in people who take blood thinners. What are the symptoms of subdural hematoma? -Because a subdural hematoma is a type of traumatic brain injury (TBI), they share many symptoms. Symptoms of a subdural hematoma may appear immediately following trauma to the head, or they may develop over time - even weeks to months. Signs and symptoms of a subdural hematoma include but are not limited to: -Confusion and drowsiness. -Slurred speech and changes in vision. -Dizziness, loss of balance, difficulty walking. -Weakness on one side of the body. -Memory loss, disorientation, and personality changes, especially in older adults with chronic subdural hematoma. Special note about head injury and symptoms in seniors: -Some of the symptoms of subdural hematoma in older people, like memory loss, confusion, and personality changes, could be mistaken for dementia. The older person may not remember hitting their head. Sometimes, people forget because they are disoriented. Other times, the injury was minor and may have occurred weeks before symptoms appeared. They should still see their healthcare provider for evaluation. What are the treatments for subdural hematoma? -Healthcare providers treat larger hematomas with decompression surgery. A surgeon drills one or more holes in the skull to drain the blood. Draining the blood relieves the pressure the blood buildup causes on the brain (https://my.clevelandclinic.org/health/diseases/21183-subdural-hematoma).

Based on a resident interview, staff interviews, and a clinical record review, the facility staff failed to assist and develop a discharge plan for a resident to make a successful discharge into the community after the initial option failed for 1 of 59 residents (Resident #114), in the survey sample. The findings included: Resident #114 was originally admitted to the facility 11/2/22 and readmitted [DATE] after an acute care hospital stay. The current diagnoses included diabetes and bilateral above the knee amputations secondary to peripheral vascular disease. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 5/2/23 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 13 out of a possible 15. This indicated Resident #114's cognitive abilities for daily decision making were intact. In section G (Physical functioning) the resident was coded as requiring total care of one person with bathing, extensive assistance of one person with personal hygiene, dressing and toileting, limited assistance of one person with bed mobility and transfers, independent with locomotion, and independent with eating after set-up. On 7/18/23 at approximately 4:40 p.m., an interview was conducted with Resident #114. The resident stated he desired to be discharged to an apartment in the community for which he had an application in his possession. The resident stated he would like assistance to complete the application and to help to determine if there are other resources in the community, he may be eligible to receive. A nurse's note dated 4/24/23 at 1:14 p.m., read the resident's daughter was looking to transition the resident back home with equipment and additional care as needed. The daughter also desired to discuss discharge plans further once rehabilitation services had dates in mind. Another nurse's note dated 5/4/23 at 10:26 a.m., read the resident's daughter stated she did not feel this would be the right time for the resident to return home because there was not a caregiver to be with him in the home during the day/night. The note also indicated the daughter stated that there were not reliable family members outside of herself and her husband to assist in providing his care. A review of the resident's care plan revealed a problem which read, return to Community Referral/Discharge. Resident expressed a desire to return to the community dated 5/01/23 and updated on 6/18/23. The goal read resident/resident representative will have access to necessary services to promote his adjustment to his new living environment post discharge from the skilled nursing facility by 9/15/23. The interventions included resident will discharge home with family/caregiver. Anticipated date of discharge is 5/9/23. There had been no modification of the original discharge plan after the daughter changed her mind. A further review of the resident's progress notes failed to reveal other options regarding the resident's discharge to the community therefore an interview was conducted with Social Worker (SW) #1 on 7/20/23 at approximately 10:23 a.m. SW #1 confirmed the resident could make a decision to return to the community and she would explore what planning was in place to assist with his preference. On 7/20/23 at approximately 11:50 a.m., another interview was conducted with SW #1. SW #1 stated she met with the resident, and he expressed his desire to transition back into the community to live independently in a handicapped accessible apartment in a desired location. SW #1 stated the resident came to her office with an application for the apartment complex he was desired, and they telephoned the complex. SW #1 stated they spoke with an apartment complex representative regarding income requirements and the waiting period for an apartment. SW #1 stated she assisted the resident to complete all sections of the application except the income section because the resident and/or the business office did not know or have access to his annual income information. SW #1 stated the Business Office Manager stated the resident's daughter managed his finances. SW #1 stated a message was left for the resident's daughter to verify his annual income and once the information was received the application would be submitted to the apartment complex. On 7/21/23 at approximately 4:30 p.m., a final interview was conducted with the Administrator, Director of Nursing and two Corporate Consultants. The Administrator stated they were awaiting a return call from the resident's daughter with the necessary information to proceed with submission of his application.

The facility staff failed to provide the necessary care and services to monitor, assess and treat one resident timely who presented with sign and symptoms and complications of a Urinary Tract Infection (UTI) for 1 out 59 residents (Resident #46) in the survey sample. The findings included: Resident #46 was originally admitted to the nursing facility on 05/14/21. Diagnosis for Resident #46 included but not limited to acute subdural hemorrhage, dementia with behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. The most recent Minimum Data Set (MDS - an assessment protocol) a significant change assessment with an Assessment Reference Date (ARD) of 06/12/23 coded Resident #46 with a 03 out of a possible score of 15 on the Brief Interview for Mental Status (BIMS), indicating severe cognitive impairment. The MDS coded Resident #46 total dependence of one with bathing, extensive assistance of one with bed mobility, transfer, dressing, personal hygiene, and toilet use and supervision with one assist with eating for Activities of Daily Living (ADL) care. Resident #46's person-centered care plan created on 05/24/21 and revised on 06/18/23 identified the resident experiences bladder/bowel incontinence at times due to dementia. The goal set for the resident by the staff was that the resident will maintain current level of bladder/bowel incontinence and remain free from signs/symptoms (s/s) of Urinary Tract Infection (UTI). Some of the interventions/approaches the staff would use to accomplish this goal is to report any signs of UTI (acute confusion, urgency, frequently, bladder spasms, nocturia, burning, pain/difficulty urinating, nausea, emesis, chills, fever, low/back/flank pain, malaise, foul odor, concentrated urine and blood in urine), provide cueing/supervision assistance for toileting as needed and provide incontinence care after incontinent episodes as needed. On 05/11/23, Resident #46 complained of stomach pain and was administered Motrin (pain medication) 400 mg. On the same day, Resident #46 urinated on herself and on the bathroom floor. The urine noted to have a foul odor. Resident also observed with increased agitation. The resident was seen by the psych Nurse Practitioner (NP) on 05/11/23 with new orders to obtain Urine Analysis (UA) with Culture and Sensitivity (C&S), Complete Blood Count (CBC) and Basic Metabolic Panel (BMP) in the morning. The psych NP was interviewed on 07/21/23 at 2:51 p.m. He stated he was asked by nursing to evaluated Resident #46 on 05/11/23 for increased agitation/behaviors. He stated he ordered labs for blood work and a UA/C&S to rule out an UTI. He stated he ordered labs on Resident #46 but it's the responsibility of the resident's primary physician to follow-up with treatment. On 05/12/23, a change in condition form was completed on Resident #46. The form identified Resident #46 with increased confusion or disorientation, new or worsened delusions or hallucination and blood-tinged urine. The physician was informed of change in condition. Further review of the clinical record did not reveal a MD or NP visit related to change in condition with Resident #46. A nurses' notes dated 05/13/23 at 2:05 p.m., revealed Resident #46 observed with intermittent confusion throughout the day. The note indicated lab results for C&S had not been received. The note indicated the physician was notified of Resident #46's intermittent confusion, but he wanted to wait for the final labs (C&S). During the review of Resident #46's nurses' note dated 05/14/23 at 8:23 a.m., indicated the resident was observed lying on the floor in the bathroom with several spots of urine on the floor. Resident #46 had a bowel movement in the commode with blood noted. The note stated hematuria but also document uncertain where the bleeding was coming from. At 12:30 p.m., Resident #46 was administered Motrin 400 mg for complaints of stomach pain. On the same day at 10:17 p.m., Resident observed to have increased agitation to noise, tremors noted, gait unsteady and required two (2) persons assist with care. Further review of the clinical record did not reveal a MD/NP visit or assessment. The nurses' note dated 05/17/23 at 12:58 p.m., indicated the facility was still waiting for the final urine report for the C&S. The note indicated Resident #46 noted to have hematuria with her bowel movement. NP #1 informed Resident #46 observed with increased behaviors, increased leaning to the left side with weakness and the facility was still waiting for the final urine report. On 05/19/23 at 7:22 a.m., the final urine sensitivity report showed the urine organism growing 50,000 (Escherichia coli). The physician was informed with a new order to start Resident #46 on Keflex (antibiotics) 500 mg every 12 hours x 7 days for UTI. On 05/20/23 at 6:47 p.m., Resident urinated on self while in the day room. Resident was assisted to the bathroom where she noted to have small amount of hematuria in the commode. The clinical note indicated on 05/21/23 at 12:07 a.m., Resident #46 had a bowel movement on the toilet with drips of blood noted. A phone interview was conducted with Resident #46's previous physician on 07/21/23 at 11:13 a.m. The nurses' notes and labs dated from 05/10/23 through 05/22/23 were reviewed with the physician. He was informed of the abnormal urine analysis with hematuria, increased confusion, tremors, and stomach pain. He stated the UA showed evidence of an UTI and should have been treated. He stated it's normal to treat prophylactic hoping the right medication was picked. He stated when the urine sensitivity report is obtained and if the wrong medication was prescribed, that medication will be discontinued and antibiotic that is sensitive to the organism growing will be prescribed. A review of Resident #46's clinical note dated 05/17/2023 at 2:35 p.m., revealed the NP #1 was informed Resident #46 continued with signs/symptoms of UTI, with no new orders. On 07/21/23 at 10:31 a.m., a phone interview was conducted with NP #1. She stated even though the C&S had not returned, the UA noted Resident #46 had a UTI. She stated it is normal to treat the older population if they are showing s/s of a UTI which she did. On 07/21/23 at 4:14 p.m., an interview was conducted with the Director of Nursing (DON) with five (5) other surveyors present who were informed regarding the above findings. She stated when Resident #46 was observed with increased sleeping, reach for objects, tremors, and hematuria, the physician or NP should have been notified. She stated the resident could have had neurological issues, internal bleeding, or possible UTI. She stated Resident #46 needed further evaluation and a clinical assessment by the physician or NP. She stated according to the clinical note written on 05/15/23, Resident #46 was observed with hematuria, the physician or NP should had been notified. She stated the physician or NP was never giving an opportunity to assess or treat Resident #46 for the change in condition. The DON was asked if Resident #46 was evaluated and assessed by physician or NP from 05/12/23 - 05/22/23, she replied, No. She was asked if Resident #46 should have been evaluated related to the continued change in condition, she replied, Absolutely. A final meeting was held with the Administrator, Director of Nursing, Assistant Director of Nursing and [NAME] President of Clinical Operations on 07/21/23 at approximately 5:30 p.m. No further information was provided prior to exit. McGreers definition of Urinary Tract Infection -Urinary tract infection includes only symptomatic urinary tract infections. Surveillance for asymptomatic bacteriuria (defined as the presence of a positive urine culture in the absence of new signs and symptoms or UTI) is not recommended, as this represents baseline status for many residents. Symptomatic urinary tract infection One of the following criteria must be met: The resident does not have an indwelling urinary catheter and has at least three of the following signs and symptoms: -Fever (>38 C) or chills -New or increased burning pain on urination, frequency or urgency -May be new or increased incontinence -New flank or suprapubic pain or tenderness -Change in character of urine [may be clinical (e.g., bloody urine) or as reported by the laboratory (new pyuria or microscopic hematuria). For laboratory changes a previous urinalysis must have been negative. -Worsening of mental or functional status Definitions -Urinary Tract Infection (UTI) is an infection involving any part of the urinary system, including urethra, bladder, ureters, and kidney. ttp://www.cdc.gov/HAI/ca_uti/uti.html). -Urine Analysis (UA) is a test to find germs (such as bacteria) in the urine that can cause an infection. Urine in the bladder. This means it does not contain any bacteria or other organisms (such as fungi) but bacteria can enter the urethra and cause a UTI. http://www.webmd.com/a-to-z-guides/urine-culture). -Culture and Sensitivity (C&S) is sample of urine is added to a substance that promotes the growth of germs. If no germs grow, the culture is negative. If germs grow, the culture is positive. The type of germ may be identified using a microscope or chemical tests. Sometimes other tests are done to find the right medicine for treating the infection. This is called sensitivity testing (http://www.webmd.com/a-to-z-guides/urine-culture).

The facility staff failed to report immediately an allegation of sexual abuse for one resident (Resident #2) in the survey sample of four residents. The findings included: Resident #2 was admitted to the facility on [DATE] with diagnoses of vascular dementia, major depression, unspecified intellectual disabilities, paraplegia\, hypertension, dysphagia, and colostomy. Facility staff failed to report immediately an allegation of sexual abuse. An annual Minimum Data Set (MDS) dated [DATE] accessed this resident in the area of Hearing, this resident was assessed as having unclear speech. In the area of Makes self understood this resident was assessed as understands. In the area of Speech Clarity this resident was assessed having unclear speech. In the area of Cognitive Patterns- Brief Interview Mental Status (BIMS) this resident was coded as a (9). A revised Care Plan dated 08/16/21 indicated: Problems- Active behaviors- Refuses showers, refuses to be repositioned, prefers to lay on back, request to get oob at beginning of month when funds come in. Goal-Resident will have fewer episodes of behaviors: as evidenced by behavior occurring: less than 2 times per week. Approach: Explain care to resident in advance in terms resident can understand. Monitor behavior episodes and attempt to determine underlying cause (s). Consider location, time of day, person involved. Problem: Cognitive Loss/Dementia-resident has a memory/recall problem R/T diagnosis of Vascular dementia. Goal: Resident will not sustain serious injury due to memory/recall deficit. Approach-Explain all care before providing care. Request feedback to ensure understanding. A Facility Reported Incident (FRI) dated 08/04/2021 indicated: Reported date: 08/04/21- incident date: 08/03/21. Resident Involved: Resident #2- Injuries - No- Incident type: Allegation of abuse/mistreat. Describe incident, including location, and action taken: Staff reports resident states he was sexually abuse (sic) last night. Name of employee(s) involved and their positions: unknown Employee action initiated or taken: N/A Notification provided to: Responsible party-08/04/21; Physician-08/04/21; APS-08/04/21; DHP-08/04/21; Law Enforcement-resident declined. A Facsimile (fax) Transmittal form dated 08/04/21 indicated the (State Survey Agency) was notified at 12:57 PM on 08/04/21. A Facility Investigation Summary dated 08/09/21 indicated: Cause to Initiate Investigation: Therapy entered Resident #2's room to remove E-stim and resident, who is extremely aphasic pointed repeatedly to his back side, therapist asked, If he had been abused, said yes, sexually? nodded yes. No description of alleged perpetrator. Investigation: the following witnesses were interviewed: Speech Therapist, (RN) registered nurse Unit Manager and RN (DON) Director of Nursing. Summary of Investigation: Therapy asked (PS) (sic) Unit Manager to evaluate resident. PS also saw resident pointing and asked if it had to do with some colostomy bag recently changed. He nodded yes. Small amount of fluid on brief which (PS) changed. Recommendations: Skin assessments were performed and no areas of concerns were noted. DON reinterviewed resident who denied any kind of assault. A witness statement from OTA/LA dated 08/04/21 indicated: Staff entered Resident #2's room and applied (E-stim) to right shoulder. I noticed he was wearing some hospital gown as previous day. I told him I was going to let the unit manager know that he had not received ADL's. He motioned to me not to go and began pointing to hip/butt area. A (CNA) certified nursing assistant came in and tried to figure out what he was saying. I texted (ST) Speech Therapist to come help as well. I could not figure out what he was trying to say. Another staff came in to help. Staff asked did someone smack you? Resident nodded his head yes. Staff stated she would tell the nurse. Speech Therapist and CNA also left. I told resident I was going to remove the (e-stim) He began gesturing to left hip/but area. I asked was it sexual? He nodded yes. I went to go get (Unit Manager). A witness statement from the Speech Therapist dated 08/04/21 indicated: OTA texted me to help her understand what Resident #2 was attempting to communicate due to severe expressive aphasia. patient best communicates through Y/N questions, gestures and objects. Through Y/N questions, patient reported the following: Yesterday a woman changed him and was rough. Part of the colostomy wrapper was stuck in his brief. He was uncomfortable. Additionally he made swinging motions and hit his bed in irritation of another person. He used gestures to describe an individual as being more tall and wide than average. I texted my boss (Rehab Manager) to speak with me and OTA/LA as soon as possible. Resident further indicated that this person is black. When shown a clock to indicate time frame, Resident #2 consistently pointed to 7 o'clock. Resident was inconsistent with differentiating day and night, even with images. He stated, it not sexual and that he is not any pain. He stated that this has happened before. A witness statement from Unit Manager dated 08/04/21 indicated: Requested by Speech Therapist to come to room [ROOM NUMBER]-B. Resident lying in bed awake. alert, has aphasia. Resident patting left thigh saying back, back, back. Speech Therapist asking resident yes and no questions. Colostomy bag intact on left side, water and bag with no leakage noted. Brief slightly soiled, changed brief. Showed resident colostomy wafer and said yes. Gave him clean brief and he placed wafer in the clean brief. No water noted in previous brief when removed. When ask by (ST) about what happened said yes to last night. No open areas on buttocks, pink area on coccyx from old healed wound. A Skin Integrity Evaluation for Resident #2 conducted at 13:26 on 08/04/21 indicated: There was no signs of skin breakdown, (sore, tender, red, or broken areas). During an interview on 8/25/21 at 10:28 a.m. with the OTA/LA she stated, On August 4, 2021 around 9:50 a.m. she went into Resident #2's room to start treatment for right shoulder pain. Noticed he was wearing the same gown for 2 days and I asked him if he had been bathe and state, no. Told him I was going to find his CNA- Resident began frantically trying to say something asked the Speech Therapist to come and see what he was saying. Two CNA's came in - he gestured to his left hip area. Speech Therapist came to the room. Resident stated, someone had been rough with him. Unit Manager came into the room and gestured toward the colostomy bag. After every thing we went back downstairs to the rehab gym and the Rehab Manager informed the Administrator. During an interview on 8/25/21 at 9:51 a.m. with the Speech Therapist she stated, 'She was called by the OTA/LA around 9:00 a.m. after breakfast. The OTA/LA asked if she could come to room [ROOM NUMBER], because resident was trying to her her something. Went in room - resident pointed to front left side -said no to something about colostomy bag. CNA came into room and asked if it from a person - resident gestured (bigger- black). A second text at (10:17 a.m.) came from the OTA/LA and she asked me to come to the room. OTA/LA stated, Resident #2 stated yes, when asked was it sexual. Rehab Manager was texted at 10:56 a.m. - brought her back into room -reported to CEO at 11:30 a.m. During an interview on 8/24/21 at 3:29 a.m. - with the DON she stated, Told by therapy about an issue of sexual assault on Resident #2. Skin assessment was conducted. When asked did she report to the administrator, this staff stated, no, Therapy had reported. During an interview on 8/25/21 at 9:51 a.m. with the Unit Manager, she stated, the OTA/LA came to her wanted her to do a skin assessment on Resident #2 for sexual abuse. The Unit Manager stated, she did not know the date or time the OTA came to her nor did she document in the clinical records of Resident #2 the incident. The Unit Manager stated the skin assessment did not indicate any bruising, skin was warm and dry. Resident's colostomy bag was intact. Rolled over on front- bottom - no bruising, moister on pad like stool no dilatation of annual area. Resident was cleaned and dried. Unit Manager stated she was trying to use pictures- stated she did not see anything sexual on examine. During an interview at 10:36 a.m. on 8/26/21 with the Administrator he was asked, when was he first informed of the allegation of sexual abuse towards Resident #2. He stated at 12:30 P.M. The Administrator stated he was in a meeting. When asked who should an allegation of abuse be reported to, the administrator stated DON or himself. There is no change of command for reporting abuse. A review of the facility's abuse policy indicated: This policy presumes that all abuse, as defined in this policy, causes physical harm, pain or mental anguish to any resident, even if he or she does not understand the incident, or even if he or she is in a coma. Immediately: All alleged violations involving abuse, neglect, exploitation, or mistreatment are reported immediately, but no later than 2 hours after the allegation is made. If a State reporting requirement establishes a longer reporting time for certain unusual incidents other than abuse or neglect, that reporting time applies only to such incidents. In other words, all allegations and incidents of abuse or neglect, as defined in this policy, will be reported immediately, as defined in this paragraph.

Based on observations, clinical record reviews, staff and resident interviews and review of facility documentation, the facility staff failed to ensure standard and transmission-based precautions were implemented to prevent the development of, and the possible transmission of, a communicable infection (COVID-19) for 4 of 5 residents (Resident #5, #1, #2 and #3) in the survey sample. Additionally, the facility staff failed to maintain 6-feet (ft) physical distancing to prevent possible transmission of infection. The findings include: 1. The following observations were made on Unit 2 on 8/13/20: On 8/13/20 at 1:30 p.m. to 2:35 p.m., Certified Nursing Assistant (CNA) #1 did not wear the facility issues surgical face mask to cover both nose and mouth. CNA # 2 was observed on 8/13/20 at 1:30 p.m. to 2:35 p.m. wearing a one layer personal camouflage patterned face mask that was positioned on her chin. When approached, CNA #2 pulled her face mask over her mouth and nose. At 3:08 p.m., upon exiting the elevator to Unit 2, CNA #2 was seen walking down the hallway passing other residents as well as communicating with staff in hallway and at the nursing station with her personal face mask positioned again on her chin. When the CNA turned and saw this surveyor, once again, she pulled her face mask over her mouth and nose, and said, I am on my way home now. On 8/13/20 at 3:10 p.m., CNA #3 and CNA #4, both working the 3:00 p.m. to 11:00 p.m. shift on Unit 2, were observed wearing their personal face mask. During an interview with the Unit 2 Licensed Practical Nurse (LPN) #1 on 8/13/20 at 3:20 p.m., she stated, We were told to obtain a new surgical face mask at the start of every shift and dispose of it at the end of our shift, no personal face mask. This surveyor observed boxes of surgical masks at the front lobby entry employee screening station. 2. On 8/13/20 at 3:28 p.m. to 3:55 p.m., an Occupational Therapist (OT) and Speech Therapist (ST) were observed working with Resident #5, a new admission on Unit 3. The OT was observed with her surgical face mask positioned on her chin and without eye protection, less than 3 feet in proximity to the resident. The ST properly wore both surgical mask over face and nose, as well as eye protection (goggles). Neither wore gloves or an isolation gown. On 8/13/20 at 4:00 p.m., the Unit 3 LPN #2 stated that Resident #5 was a new admission on 8/11/20 with a [DIAGNOSES REDACTED]. 3. The following observations were made during a medication pass on Unit 4 on 8/13/20 at 4:10 p.m.: Registered Nurse (RN) #1 proceeded to obtain a Finger Stick Blood Sugar (FSBS) on COVID-19 positive Resident (#1). Resident #1 was admitted from the hospital to the nursing facility on 8/9/20 with a [DIAGNOSES REDACTED]. RN #1 retrieved a glucometer machine, test strip, lancet and alcohol wipes to obtain a FSBS from the fourth floor medication cart outside of the COVID-19 area. The RN placed all of the aforementioned items on his personal non-porous clipboard. Prior to entering the resident's room, he failed to don eye protection (face shield or goggles). RN #1 sat the clipboard on the resident's overbed table and proceeded to obtain the FSBS, after which the RN placed all the used items back on the clipboard. After leaving Resident #1's room, the RN removed his isolation gown and gloves and disposed of them in the biohazard receptacle outside of the the resident's room, but left most of the gown on the outside of the receptacle on the floor. RN #1 then proceeded to the fourth floor medication cart, sat the clipboard on the medication cart and with his bare hands disposed of all used items from the FSBS procedure in the sharps container. The RN used a disinfectant wipe on the top side of the glucometer machine, after which he immediately it placed in the drawer of the medication cart. RN #1 did not wash his hands or use alcohol based hand rub (ABHR) prior to donning a new pair of gloves in preparation to obtain a FSBS on another resident who was COVID-19 negative, Resident #2. The RN repeated his same practice as indicated above with Resident #1. He failed to disinfect the clipboard and sat it on the overbed table of Resident #2 who was COVID-19 negative. This practice risked cross-contamination from the COVID-19 positive resident (Resident #1). Resident #2 was admitted to the nursing facility on 12/02/16 with [DIAGNOSES REDACTED]. RN #1 proceeded to obtain a FSBS on a third resident, Resident #3. The RN repeated his same practice as indicated above with Resident #1 and Resident #2. He failed to disinfect the clipboard and sat it on the overbed table of Resident #3 who was COVID-19 negative. This practice continued the risk of cross-contamination from the COVID-19 positive resident (Resident #1). Resident #3 was admitted to the nursing facility on 3/4/16 with [DIAGNOSES REDACTED]. On 8/13/20 at 4:25 p.m., the RN returned to Resident #1 to administer insulin based on results of FSBS and sliding scale orders. RN #1 pulled out of his pant's pocket a fingertip pulse oximeter to monitor the resident's blood oxygen level. The RN stated, I love this. I bought my own from (name of local department store) to use on all the residents that need pulse oximeter checks. It comes in handy to use my own and can just whip it out of my pocket. He placed the tip of the resident's index finger in the device and obtained Resident #1's SpO2 (oxygen saturation). The RN used a disinfectant wipe to clean the top and bottom of the pulse oximeter, but failed to disinfect the inside where the resident placed the tip of his finger. He placed the pulse oximeter device back in the pocket of his pant's pocket. The RN never washed his hands or use ABHR between residents or disinfect the clipboard that he placed on each of the resident's overbed table. In addition, the RN placed used alcohol pad on the clipboard along with an ink pen that he used to write resident information on the report sheet clipped to the front of the clipboard. Following administration of the insulin to Resident #1, the RN took the laptop from the medication cart to nurse's station desk and began to type without removal of his gloves. 4. Throughout the day of 8/13/20, the facility staff was observed not maintaining 6-ft physical distancing while using the one operating elevator. The second elevator had a sign on it that indicated it would be used for emergency situations. Random comments made by staff entering and exiting the elevator revealed that the elevator was slow, they were exhausted having to use the steps between floors, thus they had to group up on the elevator. On 8/13/20 at 6:20 p.m., an interview was conducted with the Administrator and the Director of Nursing (DON). The DON stated according to the facility's infection control policy that surgical face masks were to be worn by all staff on all units and disposed of at the end of their shift, no personal face masks. She stated the only exception would be while caring for COVID-positive resident, new admissions and Persons Under Investigation (PUI), where an N-95 face mask was required. During the above interview, they both stated they expected the rehabilitation staff to wear full Personal Protective Equipment (PPE) to include eye protection, gowns, gloves and an N-95 face mask when evaluating, assessing and or providing therapy to newly admitted residents, as well as COVID-positive residents. The Administrator said, I knew there was some kind of problem during your observation of Resident #5 because the rehab staff inserviced them shortly thereafter. The Administrator was not aware that the staff were not adhering to 6-ft physical distancing on the elevators. RN #1 joined the above interview to review the aforementioned infection control issues that were observed on Unit 4. The DON reviewed the infection control procedures for disaffecting multiple use resident equipment to include the glucometer machine and pulse oximeter device. It was also stated to the RN that he should not use own personal pulse oximeter machine for any resident in the facility. RN #1 stated he did not know he should not use his own pulse oximeter device. The DON instructed the RN on how he should have disinfected both the pulse oximeter and glucometer machine. The RN admitted he failed to wash his hands or use ABHR between residents. RN #1's inservice records were reviewed and verified he had received training in all of the above infection control areas. The facility's policy and procedures titled Standard Precautions dated 10/2018 indicated hand hygiene referred to handwashing with soap or the use of ABHR which does not require access to water. Hand hygiene to be performed with ABHR or soap and water before and after contact with the resident, before performing an aseptic task, after contact with items in the resident's rooms, and after removing PPE. Hands are washed with soap and water whenever in direct or indirect contact with blood or body fluids and after removing gloves. Gloves are removed promptly after use, and before touching non-contaminated items and environmental surfaces. Mask are worn to protect nose and mouth. Eye protection or face shield are worn to protect mucous membranes of eyes. Reusable equipment is not used for the care of more than one resident until it has been appropriately cleaned and reprocessed. The policy and procedures titled Glucometer Cleaning and Disinfecting dated 11/4/19 indicated thoroughly Clean outside surfaces of meter using a lint free cloth dampened with soapy water or IPA Disinfecting-1:10 dilution of water and bleach (or bleach wipe), dampen a paper towel and thoroughly wipe down the meter or use Super Sani-Cloth & Sani-Cloth HB Germicidal disposable wipes. The policy and procedures titled Categories of Transmission-based precautions dated 10/18 indicated for droplet precautions face mask, gloves, gown and eye protection should be worn for risk of spraying respiratory secretions. The policy and procedures titled Novel Coronavirus (COVID-19) revised 5/28/20 indicated all stakeholders will wear a new surgical facemask at the beginning of their shift, while they are in the facility, to be used for one day and discarded at the end of their shift. The policy indicated that anything a resident goes out of the facility for an appointment, [MEDICAL TREATMENT], ER visit or hospitalization , etc., the resident will be placed on isolation for 14 days upon return to the facility on a dedicated unit/wing, cared for by staff wearing full PPE. If the resident goes back out to the ER, doctor appointment, [MEDICAL TREATMENT], etc., their 14 days will start over. While caring for a resident COVID-19 positive, anyone entering the room must wear full PPE, have a gown, gloves, facemask (N-95 respirator) and eye protection (i.e., mask with shield, goggles, etc.) COVID-19 spreads mainly among people who are in close contact (within about 6 feet) for a prolonged period. Spread happens when an infected person coughs, sneezes, or talks, and droplets from their mouth or nose are launched into the air and land in the mouths or noses of people nearby. The droplets can also be inhaled into the lungs. Recent studies indicate that people who are infected but do not have symptoms likely also play a role in the spread of COVID-19. Since people can spread [MEDICAL CONDITION] before they know they are sick, it is important to stay at least 6 feet away from others when possible, even if you or they do not have any symptoms. Social distancing is especially important for people who are at higher risk for severe illness from COVID-19 (https://www.cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/social-distancing.html).

Based on observations, clinical record review, staff interviews and facility documentation, the facility staff failed to ensure infection control measures were consistently implemented to prevent the development and/or transmission of a communicable disease (COVID-19). The findings included: The facility staff failed to ensure social distancing and face coverings/masks were utilized among a group of five residents sitting and/or standing closely together near the nurses station. On 6/08/20 at approximately, 11:25 AM upon entrance onto a non-isolation unit, approximately five residents were observed sitting and standing at close contact near the nurses station. RN (Registered Nurse) #2 redirected the residents back to their rooms saying it's time to eat lunch. On 6/09/20 at approximately 1:00 PM a telephone interview was conducted with CNA (Certified Nursing Assistant) #1. She stated, Resident's are Only wearing masks if leaving off unit, and When sitting at nurses' station, no mask are worn. On 6/09/20 at approximately 1:50 PM a telephone interview was conducted with CNA #2 She stated, They only wear masks if leaving the floor. On 6/10/20 at approximately, 3:25 PM, an interview was conducted with RN (Registered Nurse) #1 concerning the above issues. She stated, Residents choose not to use masks. We have to constantly redirect them. Most of them have dementia, they will take their masks off. *Per CDC Guidance to prevent spread of COVID-19: Actions to take now: Enforce social distancing among residents and ensure all residents wear a cloth face covering for source control whenever they leave their room or are around others, including whenever they leave the facility for essential medical appointments. On 6/11/20 at approximately 12:10 PM, an exit interview was conducted with the Administrator, DON and the Infectious Disease Educator. The administrator stated, We issue masks, especially to our ambulatory residents. To get some of the ambulatory ones to stay compliant has been a battle. They keep them under their chins (The masks) or ear. We redirect them to their rooms.

Based on observation, staff interviews, family interview, clinical record review, facility document review and during the course of a complaint investigation, the facility staff failed to ensure 1 of 16 residents in the survey sample was free from an avoidable fall from the bed during the provision of care, Resident #113. The findings included: Resident #113 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The current MDS (Minimum Data Set) a quarterly with an assessment reference date of 9/10/19 coded the resident as scoring a 14 out of a possible 15 on the Brief Interview for Mental Status indicating the resident's cognition was intact. The resident required extensive assistance of 1 staff for bed mobility and personal hygiene and was totally dependent on two staff for transfers. The comprehensive person centered plan of care identified the resident was a fall risk and had a history of [REDACTED]. The goal was that the resident would remain free of injury. The interventions were revised after the fall on 11/20/19 to include fall mats on both sides of the bed. Previous interventions included physical therapy evaluation, check posture while in the wheelchair, dycem to the wheelchair and observe frequently and place in supervised area when out of bed. A Facility Reported Incident was sent to the State Agency on 11/20/19 indicating the resident fell during the provision of ADL (activities of daily living) care. No injury was noted. An investigation was underway. Both Certified Nurse Aids (CNA) involved with the fall were suspended. The facility final investigation summary indicated the fall was due to a combination of soap and water while bathing the resident and incorrect setting on the air loss mattress. Education was provided to one of the CNA's involved and the second CNA was terminated based on this action and another allegation involving a different resident. The summary indicated the resident had sustained two fractured ribs as a result of the fall per the X-rays obtained at the facility on 11/24/19. The mobile X-ray report dated 11/24/19 conclusion: Acute left 4th and 5th rib fractures, old healed right lateral rib fractures were noted. On 11/24/19 the resident was sent to the emergency room (ER) at a level 1 trauma center for evaluation of complaints of shortness of breath and pain to the left rib. While there the resident underwent [REDACTED]. Both the X-ray and CT came back negative for acute [MEDICAL CONDITION] ribs. The resident was sent back to the facility the same day with new orders for left rib pain management with [MEDICATION NAME] 37.5-325 mg (milligram) one tablet every six hours as needed for pain. This medication was changed to [MEDICATION NAME] 50 mg one tablet every six hours as needed on 11/27/19 due to insurance issues. The Medication Administration Record's (MAR's) for (MONTH) and (MONTH) 2019 evidenced the resident was medicated once for left rib pain on 11/28/19, 11/29/19 and 12/10/19. On 12/11/19 at 12:50 p.m., the Nurse Practitioner was interviewed. She stated she examined the resident on 12/3/19 and did not find any evidence of bruising to the residents left chest area. When asked about the chest X-ray taking at the facility with findings of acute fractures to the left ribs in comparison to the ER findings, she stated, It is not common, but I have seen it with mobile X-rays .we sent him out to be evaluated .there was no documentation from the ER of a lung contusion, it would show up on the CT scan .the CT is more definitive and was negative for acute fractures. On 12/10/19 at 11:25 a.m., the resident was observed asleep in bed on a low air loss mattress. The setting was on the appropriate therapy setting. The bed was in the low position and floor mats were observed on both sides of the bed. At 1:56 p.m., the resident was observed awake in bed, the low air loss mattress was set in the appropriate setting, the bed was in the lowest position and the floor mats were in use. The resident was interviewed and stated he did have a fall out of the bed, but could not recall the exact cause of the fall. The resident was asked if he was experiencing any pain and stated, Yes, he then pointed to the left side of his chest and rated the pain a 6-7 out of a possible 15. The nurse assigned to the resident was informed of the resident's complaint of pain and the resident was administered the 12/10/19 dose of [MEDICATION NAME] 50 mg. On 12/10/19 at 1:08 p.m., the Director of Nursing (DON) was interviewed. She was asked what was the root cause of Resident #113's fall on 11/20/19. She stated that from her investigation the staff failed to put the low air loss mattress setting to hard, and when the second CNA stepped away to discard the soiled bed linen the air in the mattress fluctuated and it pushed the resident off the bed. She further stated, When they go in to do care we tell them to put the bed on hard (autofirm) .this probably would not have happened if she (CNA) would have put it on hard because the resident is not able to roll himself. She stated as a result of the fall staff on that unit were educated by the unit manager and staff educator on how to take care of a resident on a low air low mattress. The DON stated that during orientation the staff are educated on how to take care of a resident on a low air low mattress. She also stated the daughter came in that same day and was upset and reported the fall to Adult Protective Services (APS). APS came to the building later that same day and recommended placement of the fall mats. The DON also stated a new fall intervention was to maintain the bed in the lowest position. A request to review evidence that staff are provided education during orientation on the use of the low air loss mattress while providing care. Prior to exit the DON stated education on the use of the low air low mattress was not included in orientation. On 12/10/19 at 1:49 p.m., the staff educator was interviewed. She stated when moving a resident in a low air loss mattress the setting should be placed on autofirm first, this allows for the bed to be a completely flat surface. If the mattress is not placed on autofirm different areas of the bed will inflate which could potentially make a resident roll out of the bed. On 12/11/19 at 9:45 a.m., CNA #1 was interviewed. She stated that while she was washing the resident's back the other CNA walked towards the door to put soiled linen into the barrel located outside the door. She stated that the resident was on his right side near the edge of the bed the bed inflated on one side .he fell off the bed .it happened so quickly .I always need someone to help turn him. When asked if she had ever had any education on turning a low air mattress setting to autofirm while providing care she stated she had not prior to this incident. On 12/11/19 at 11:06 a.m., the resident was observed asleep in bed, the low air loss mattress was set in the appropriate setting, the bed was in the lowest position and the floor mats were in use. The low air loss mattress instructions provided by the facility read, in part: Autofirm mode provides maximum air inflation designed to assist both residents and caregivers during resident transfer and treatment .When using the mattress system, always ensure that the resident is positioned properly within the confines of the bed .it may be helpful to activate the Autofirm mode to achieve a firm surface for repositioning purposes. The above finding was shared with the Administrator, the DON and the Nurse Consultant during the pre-exit meeting on 12/12/19 at 12:45 p.m. The facility was given ample time to provide additional information prior to exit. No additional information was provided to the survey team for this deficiency. COMPLAINT DEFICIENCY.

Based on clinical record review, facility documentation review, and staff interviews, the facility staff failed to administer the medication, Carvedilol as ordered by the physician and/or designee for 1 of 16 residents (Resident #105), in the survey sample. The findings included: Resident #105 was originally admitted to the facility 1/19/19 and has never been discharged from the facility. The current [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 11/20/19 coded the resident as not having the ability to complete the Brief Interview for Mental Status (BIMS). The staff interview was coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 14 out of a possible 15. This indicated Resident #105's cognitive abilities for daily decision making was intact. Review of Resident #105's physician orders [REDACTED]. Give one tablet by mouth two times daily for heart failure. Review of the Medication Administration Record [REDACTED]. An interview was conducted with Registered Nurse (RN) #3 on 12/11/19, at approximately 2:55 p.m. RN #3 stated often medications aren't available to be administered and if a note was written stating it wasn't available then it wasn't in the medication cart. An interview was conducted with the Acting Director of Pharmacy on 12/12/19, at approximately 11:00 a.m. The Acting Director of Pharmacy stated the last time Resident #105 received the medication Carvedilol 25 milligrams from the pharmacy prior to them receiving the request 12/9/19, was 11/3/19 therefore, it was likely the medication had been out several days when the pharmacy received the request 12/9/19. The Acting Director of Pharmacy stated more and more the insurance companies are not authorizing refills far in advance as they did previously. Review of the unit stat drug box revealed the medication Carvedilol 12.5 milligrams was stocked and three tablets were in the box on 12/9/19. A stat box utilization record revealed two of the three tablets were removed from the stat box at on 12/10/19 at 9:00 a.m., for Resident #105. On 12/12/19, at approximately 12:41 p.m., the above findings were shared with the Administrator, Director of Nursing and the Corporate consultant. An opportunity was given for the facility to present additional information but none was provided. On 12/12/19, at approximately 1:15 p.m., another interview was conducted with Registered Nurse (RN) #3. RN #3 stated on 12/9/19, the stat box was not reviewed to determine if it contained the medication Carvedilol so it could be administered to Resident #105. RN #3 further stated it never crossed his mind that particular drug would be in the stat box for usually antibiotics are the main drugs kept in the stat box.

Based on clinical record review, staff interviews, and facility documentation review the facility's staff failed to ensure the medication [MEDICATION NAME] was available to be administered as ordered to 1 of 16 residents (Resident #108) in the survey sample. The findings included: Resident #108 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent Minimum Data Set (MDS) was a Quarterly with an Assessment Reference Date(ARD) of 11/27/19. The Brief Inter for Mental Status was coded as a 14 out of a possible 15 which indicated Resident #108 was cognitively intact and capable of daily decision making. Under Section N Medications, N0450 Antipsychotic Medication Review Resident #108 was coded a 1 indicating antipsychotics were received on a routine basis. Resident #108's Comprehensive Care Plan was reviewed and is documented in part, as follows: Problem: Start Date 10/8/2019 Category: [MEDICAL CONDITION] Drug Use Resident receives antipsychotic medication [MEDICATION NAME] 100mg (milligrams) BID (twice a day) due to [MEDICAL CONDITION]/[MEDICAL CONDITION] Disorder. Resident #108's current Physician order [REDACTED]. Start Date: 10/7/19- Open Ended [MEDICATION NAME]-Schedule II capsule; 100 mg oral (DX (diagnosis): [MEDICAL CONDITION] disorder, [MEDICAL CONDITION] type) Twice A Day; 4:00-06:00, 17:00-19:00. Resident #108's Medication Administration Record [REDACTED] [MEDICATION NAME]-Schedule II capsule; 100 mg oral 12/9/2019 04:52 [NAME]M. Not Administered: Drug/Item Unavailable, Created By: LPN (Licensed Practical Nurse) #3. [MEDICATION NAME]-Schedule II capsule; 100 mg oral 12/10/2019 06:36 [NAME]M. Not Administered: Drug/Item Unavailable, Comment: reorder Created By: LPN (Licensed Practical Nurse) #4. The facility Stat Mediation Box was reviewed and the medication [MEDICATION NAME] was not available in the box. On 12/10/19 after reviewing the above information with the facility Nurse Consultant, she was asked to bring any further information regarding Resident #108's [MEDICATION NAME] not being available on 12/9/19 and 12/10/19. On 12/11/19 LPN #1 provided the surveyor with a F-755 Unavailable Medication Tool Audit dated 12/10/19 that was removed from the facility's Plan of Correction Book in the conference room which was reviewed and is documented in part, as follows: Resident Name: Resident #108 Medication Unavailable: [MEDICATION NAME] Action Taken: Stat Out-Cart LPN #1 also provided a copy of the Pharmacy Facility Billing Authorization that was dated and signed on 12/10/19 by the Director of Nursing for two [MEDICATION NAME] 100 mg capsules for Resident #108. A Pharmacy Shipping Manifest for Resident #108's two delivered [MEDICATION NAME] capsules was reviewed and indicated that the medication was received in the facility on 12/10/19 at 23:38 (8:38) P.M Resident #108's progress noted dated 12/11/19 at 11:02 [NAME]M. completed by LPN #1 was reviewed and is documented in part, as follows: Name NP (Nurse Practitioner), into view patient on 12/10/19; NO (sic) was made aware that the patient has missed 2 doses of [MEDICATION NAME]-pharmacy was notified; the medication was sent to the facility STAT, the complete 30 day supply is scheduled to be delivered today per the pharmacy representative, Name-mother/RP (responsible party) aware-will continue to follow-up. On 12/11/19 at 11:05 [NAME]M. an interview was conducted with LPN #1 regarding [MEDICATION NAME] that was unavailable on 12/9/19 and 12/10/19. LPN #1 was asked how she determine the medication was not available. LPN #1 stated, By doing the daily audits. I saw the drug was not available and I had the pharmacy stat 2 pills over yesterday that we paid for because they were waiting for insurance approval. LPN #1 was asked for the daily unavailable medication audit for 10/9/19 which was not in the Plan of Correction Book. LPN #1 stated, I will have to see if I can find it. On 12/11/19 at 12:10 P.M. an interview was conducted with the Director of Nursing regarding Resident #108's unavailable [MEDICATION NAME] on 12/9/19 and 12/10/19 and what she would have expected to have happened. The Director of Nursing stated, I would have expected an audit to have be done on 12/9/19 and to have caught it and to have alerted that pharmacy then. I communicated to the pharmacy that if there are insurance issues to go ahead and send the medicines and we will pay for it. There is still a communication breakdown. On 12/11/19 at 1:00 P.M. a phone interview was conducted with LPN #4 regarding Resident #108's [MEDICATION NAME] not being available on 12/10/19. LPN #4 stated, I did not have his [MEDICATION NAME] at 6 [NAME]M. on 12/10/19, so I hit the reorder button that goes directly to the pharmacy. I also reported to the oncoming nurse that we were out of it. On 12/11/19 at 2:00 P.M. a phone interview was conducted with LPN #3 regarding Resident #108's [MEDICATION NAME] not being available on 12/9/19. LPN #3 stated, It was not available, I hit the button to reorder it through the pharmacy. I also passed it on in report and gave a list of a couple other medications that needed to be delivered. I'm also a psychologist and based on the Resident's (Resident #108) [DIAGNOSES REDACTED]. On 12/11/19 at approximately 2:00 P.M. the Director of Nursing provided the surveyor with a F-755 Unavailable Medication Tool Audit dated 12/9/19 that was completed by LPN #1. The Director of Nursing was asked where was the audit located. The Director of Nursing stated, Name (LPN #1) just walked out of her office and handed it to me. The F-755 Unavailable Medication Tool Audit dated 12/9/19 that was completed by LPN #1 was reviewed and is documented in part, as follows: Resident Name: Resident #108 Medication Unavailable: [MEDICATION NAME] Action Taken: Pharmacy Called On 12/11/19 at 2:15 P.M. an interview was conducted with LPN #1 regarding the F-755 Unavailable Medication Tool Audit dated 12/9/19. LPN #1 was asked why wasn't the medication stated out on 10/9/19 instead of 10/10/19 based on the audit that indicated the medication was not available. LPN #1 stated, On 10/9/19 I spoke to Name (Pharmacy Technician) and was told that it would be here that evening. On 10/12/19 at approximately 11:23 [NAME]M. a phone interview was conducted with the Pharmacy Technician and the Acting Pharmacy Director. The Pharmacy Technician was asked if she had spoken to LPN #1 on 12/9/19 regarding the medication [MEDICATION NAME] not being available. The Pharmacy Technician stated, I do not recall taking to her (LPN #1) on 12/9/19 but she did call on 12/10/19 around 2:00 P.M. about the resident being out of [MEDICATION NAME]. It is our policy to document and screen shot all phone conversations and I have that for my conservation with her on 12/10/19. She (LPN #1) said that they were out of compliance because he (Resident #108) was out of [MEDICATION NAME] and State Surveyors were in the building. I told her that the pharmacist said it can't be filled until the following day because it was too early. I sent over an authorization form that was sent back and we sent 2 [MEDICATION NAME] pills over that the facility agreed to pay for. The Acting Pharmacy Director stated, We sent a 30 day supply of the [MEDICATION NAME] over on 11/15/19 that should have carried the resident through 12/15/19 that is why the insurance was not approving it. I also am not aware of any agreement that we will automatically send needed medications to the facility that are insurance denied. It is also out policy to document and screen shot all phone conversations with the facilities and I do not see on for 10/9/19 for the resident's [MEDICATION NAME]. The Pharmacy Technician's Pharmacy Order screen shot and documentation regarding Resident #108's [MEDICATION NAME] discussion with LPN #1 time stamped 12/10/19 at 14:52:22 (2:52) P.M. was reviewed and is documented in part, as follows: Spoke with Name (LPN#1) whom stated will need to get 1 day supply billed to facility and STAT (now). The facility policy titled Medication Ordering and Receiving From Pharmacy Provider, Ordering and Receiving Non-Controlled Medications dated 9/2010 was reviewed and is documented in part, as follows: POLICY: Medications and related products are received from the provider on a timely basis. The nursing care center maintains accurate records of medication order and receipt. PR[NAME]EDURES: 1. Ordering medications from provider pharmacy: b. Reorder routine medications by the re-order date on the label to assure an adequate supply is on hand. On 12/12/19 at 12:41 P.M. a pre-exit conference was held with the Administrator, the Director of Nursing and the Nurse Consultant where the above information was shared. The Director of Nursing stated, If I had known the medication was missing on the 9th, I would have called the pharmacy and realized we have received a 30 day supply on (MONTH) 15th. Then I would have made sure the resident had his medications and begun an investigation to find the missing pills. Prior to exit no further information was provided.

Based on observation, staff interviews, clinical record review and review of the facility policy, the facility staff failed to ensure the necessary treatment, care and services were provided to prevent development of a pressure ulcer for 1 of 63 residents (Resident #11), resulting in harm. Resident #11's sacral pressure ulcer was not identified until it was found at a stage 3. The findings included: Resident #11 was originally admitted to the facility on [DATE]. [DIAGNOSES REDACTED].*Pressure ulcer of other site, unspecified stage. The current Minimum Data Set (MDS), a quarterly assessment with an Assessment Reference Date (ARD) of 07/22/19 coded the resident with a 14 out of a possible score of 15 on the Brief Interview for Mental Status (BIMS) indicating no cognitive impairment. In addition, the MDS coded Resident #11 requiring total dependence of one with bathing, extensive assistance of one with bed mobility, transfer, dressing, toilet use and personal hygiene for Activities of Daily Living care. Resident #11 was coded as always continent of bladder due to indwelling Foley catheter and frequently incontinent of bowel. The MDS with an ARD of 07/22/19 under section M (Skin Condition-M0150) at risk for developing pressure ulcers was coded yes and under section (M1200) skin and treatments was coded for having pressure reducing device for chair and bed. Resident #11 was coded as having no mood, rejection of care or behavioral problems. Resident #11's person-centered comprehensive care plan revised on 07/30/19 documented Resident #11 with multiple pressure ulcers. The goal: Resident's ulcer will heal without complications. Some of the intervention/approaches to manage goal included to assess and record the condition of the skin surrounding the pressure ulcer, keep clean and dry as possible, provide incontinence care after each incontinent episode, treatment per physician order, use pressure reduction when resident is in the chair and bed, use moisture barrier product to perineal area, turn and reposition in bed and chair and conduct a systematic skin inspection weekly. Report any signs of further skin breakdown. A Braden Risk Assessment Report was completed on 09/28/19; the resident scored a thirteen indicating moderate risk for the development of pressure ulcers. Review of the Weekly Skin Integrity Evaluation completed on 10/07/19 by LPN #11 was not coded for a sacral pressure ulcer. The review of the Wound Information Pressure Ulcer form noted evidence of an entry dated 10/09/19 at 6:59 a.m., indicated the following: A new sacrum pressure ulcer measured 6 cm x 4.3 cm with light [MEDICAL CONDITION] (yellow or tan, cloudy and thick exudate (drainage). The tissue type observed with slough, wound edges/margins well defined and pink/normal skin surrounding wound. The review of the Wound Information Pressure Ulcer form noted evidence of an entry dated on 10/16/19-sacrum pressure ulcer measuring 6 cm x 4 cm with 0.1 cm depth with moderate amount of serous (clear, amber, thin and watery) exudate. The tissue bed with slough, wound edges/margins well defined with pink/normal skin surround wound. Review of Resident #11's (MONTH) 2019, Physician Order Sheet and Treatment Administration Record (TAR) did not include a treatment for [REDACTED]. An interview was conducted with the wound nurse, Licensed Practical Nurse (LPN) #7 on 10/24/19 at approximately 10:15 a.m. The wound nurse stated, I observed the pressure ulcer to the sacrum when I turned her over to provide wound care to her existing wounds to her hip/thigh area on 10/09/19. The wound nurse stated, I had to do a double take because of what the wound looked like when I first saw it. The surveyor asked, What did the sacral wound look like? She replied, The wound bed was gray in color (it was a stage III pressure ulcer). The wound nurse said There was no prior documentation of a sacrum/sacral wound until it was first identified by me on 10/09/19. An interview was conducted with Unit Manager, Licensed Practical Nurse (LPN) #3 on 10/24/19 at approximately 11:23 a.m., who stated, I reviewed Resident #11's current physician order sheet and treatment administration record for (MONTH) 2019 and was unable to locate a treatment for [REDACTED]. On 10/24/19 at approximately 11:48 a.m., an interview was conducted with wound nurse (LPN #7) who identified the stage III sacral pressure ulcer on Resident #11. The LPN stated, I found the stage III pressure ulcer to Resident #11's sacrum on 10/09/19. She said, I wrote an order for [REDACTED]. The surveyor asked, Resident #11 was admitted to the hospital on [DATE], did she still have the stage III sacral pressure ulcer prior to her discharge? LPN #7, replied, Yes. Review of the Weekly Skin Integrity Evaluation completed on 10/22/19 by LPN #3 was not coded for a sacral wound pressure ulcer; even though Resident #11's was identified with a stage III on 10/09/19 and the Wound Information Pressure Ulcer form noted evidence of an entry dated on 10/16/19 - sacrum pressure ulcer measuring 6 cm x 4 cm with 0.1 cm depth with moderate amount of serous (clear, amber, thin and watery) exudate. The tissue bed with slough, wound edges/margins well defined with pink/normal skin surround wound. An interview was conducted with LPN #3 on 10/24/19 at approximately 3:00 p.m. The LPN provided routine wound care on Resident #11 on 10/21/19. LPN #3 stated, I was not aware Resident #11 had a sacral wound pressure ulcer. The surveyor asked, Did Resident #11 have any other pressure ulcers? She replied, Yes, but her wounds were on her feet, legs and hip/thigh area so I had no reason to look at her sacrum. The LPN stated, I did not do wound care to a sacral wound, I did not realize she had one. On 10/24/19 at approximately 3:05 p.m., an interview was conducted with LPN #4 who cared for Resident #11 on 10/20/19. The LPN said she was not aware Resident #11 had a sacral pressure ulcer. She stated, I went by the treatment administration record when providing wound care and since the sacral pressure ulcer was not on the treatment record, I did not do a wound treatment to the sacrum. The surveyor reviewed the shower schedule and shower sheets for Resident #11. Resident #11 was scheduled for showers twice weekly on Tuesday and Friday on the 3 PM-11 PM shift. The shower sheet included the following information: the Certified Nursing Assistant (CNA) must complete on all residents shower days and anytime a change is noted/observed on the resident's skin, the caregiver must give skin sheet to a nurse immediately. The surveyor requested the following Certified Nursing Assistant (CNA) skin care alerts on Resident #11's shower days for the month of (MONTH) 2019: 10/01/19, 10/04/19 and 10/08/19. On 10/24/19 at approximately 3:15 p.m., the Unit Manager stated, I was unable to locate any CNA alert skin care sheets for (MONTH) 2019 prior to identifying the sacral pressure ulcer to Resident #11 on 10/09/19. She explained that even if Resident #11 refused to have a shower, her skin checks should have been completed by the CN[NAME] A briefing was held with the Administrator, Director of Nursing (DON) and Cooperate Nurse on 10/24/19 at approximately 4:08 p.m. The surveyor asked, At what stage do you expect for your nurses to first identify a pressure ulcer? The DON replied, When the skin is red, non blanchable or when the skin is reddened but not open. The surveyor asked, If Resident #11 refused or did not receive her bi-weekly showers, should the CNA complete the skin care alert sheets? The DON replied, Yes, the CNA's are still required to do their skin checks. The facility's policy titled Pressure Ulcer Management Resource (Revised 07/24/18). -Guideline Steps to include but not limited to: -5. Inform the physician (and responsible party, as appropriate) of new pressure ulcer. Obtained and initiate treatment orders. Report the following to the physician to include but not limited to: -Current treatment and review of the past treatment, as appropriate. 6. Implement a preventative program to prevent additional new areas from developing. Ensure the preventative measures are listed on the care plan and flow sheets. 8. Initial ulcer care involves debridement, wound cleansing, dressing application, and possible adjunctive therapy. 11. Protect the wound with dressings. A dressing should protect the wound, be biocompatible and provide ideal hydration. The cardinal rule is to keep the ulcer tissue moist and the surrounding intact skin dry to prevent maceration. Definitions: *Pressure Injury: A pressure injury is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear (http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-injury-stages/). *Stage 3 Pressure Injury: Full-thickness skin loss Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. (http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-injury-stages/).

Based on observations and staff interviews, the facility staff failed to handle, prepare and store food in a manner to prevent foodborne illness potentially affecting all residents. The findings included: During the Initial Kitchen Inspection at 10:31 [NAME]M. on 10/22/19 a side salad with a use by date of 10/14/19 was observed in the two door glass refrigerator. Shredded cheese with a use by date of 10/09/19 was observed in the two door glass refrigerator. A French Silk Pie with a use by date of 10/09/19 was observed in the two door glass refrigerator. A container of Tuna with a use by date of 10/10/19 was observed in the two door glass refrigerator. A bag of cooked link sausage with a use by date of 10/19/19 was observed in the two glass refrigerator. A plastic scoop was observed in a 50 pound bag of sugar with the scoop was touching the sugar. The bag was not sealed nor in a container. Boxes of food items were stored on the floor of the dry storage room. The floor was noted to have dirt, debris, spilled food crumbs and paper. Two male staff members were observed in the kitchen handling various food items without beard guards. A Food Service Policy regarding storage, preparation and handling was requested during the survey. No Policy was provided.

Based on observations and staff interview, the facility staff failed to maintain an effective pest control system/program potentially affecting all residents. The findings included: During the kitchen inspection on 10/22/19 at 10:31 [NAME]M. house flies were observed in the kitchen area. Drain flies were observed in the mop room and dishwasher room. Fruit flies and house flies were observed in the conference room. House flies were observed in the dining room area. Flies were observed on all units. During an interview on 10/23/19 at 3:50 P.M. with the Maintenance Director he stated, the drain flies, fruit flies and house flies have been a concern and there is a need for pest control. The Maintenance Director stated The Pest Control company comes out to service the facility. The Maintenance Director stated the flies will be in the building like this until it turns cold out side. A review of the Pest Management policy indicated: Mission-We shall first seek to understand the unique needs of each customer, formulate effective solutions, and implement the actions in a timely professional manner. No further information was provided by facility staff.

Based on clinical record reviews, staff interviews and facility documentation review, the facility staff failed to ensure residents were able to formulate advance directives, obtain advance directives, and/or send them upon transfer to hospital; and have these documents maintained in the clinical record, readily accessible to the direct care staff for 16 of 63 residents in the survey sample (#64, #95, #128, 78, #11, #51, #50, #15, #90, #42, #88, #61, #72, #61, #139 and #124). The findings include: 1. Resident #64 did not have an advance directive readily available for direct care staff. Upon inquiry, an advance directive was located in a file drawer in the business office, not in the clinical record. Additionally, there was no evidence the resident's advance directive was sent with her when the resident was transferred to the local hospital on [DATE] or [DATE]. Resident #64 was admitted to the nursing facility on [DATE] with [DIAGNOSES REDACTED]. Resident #64's most recent Minimum Data Set (MDS) was a significant change in status assessment. The resident scored a 15 out of a possible score of 15 on the Brief Interview for Mental Status (BIMS) which indicated she was fully intact with the skills for daily decision making. On [DATE] at 1:48 p.m., the Unit II Nurse Manager stated, I am not sure if (Resident #64's name) has an advance directive. I have never seen one and don't know where I would find one if she indeed had one. I do know she is a full code. There is no paperwork that we know of that says she wanted one or not. On [DATE] at 2:30 p.m., Resident #64 stated that she had an advance directive about some of her medical care decisions along with being a full code and hoped the facility did not lose her important paperwork. On [DATE] at 10:30 a.m., the Unit II Nurse Manager, Licensed Practical Nurse (LPN) #18 and the Director of Nursing (DON) stated the document related to whether or not a resident wanted an advance directive and that it had been reviewed, should be accessible to the nurses and kept in the clinical record, as well as the advanced directive. On [DATE] at 1:02 p.m., upon inquiry, the Business Office Manager (BOM) stated she searched for an advance directive and found a document titled Advance Directives/Informed Consent form dated [DATE] that indicated the resident did not want to formulate an advance directive. She stated the document was located in the file drawer in the business office. The BOM said the document should be kept on the unit where the resident resided and a copy in the business office. On [DATE] at 3:30 p.m., the BOM returned to present an advance directives form for Resident #64. The BOM stated, I dug to find this resident actually did have an advance directive dated [DATE] that was also in a file drawer in the business office. This should have been on the resident's chart and a copy left in the admissions or business office, as well. We will be fixing this immediately with some education because we don't want any mix-ups. On [DATE] at 4:08 p.m., during the debriefing with the Administrator and DON, the aforementioned issue was readdressed. They stated the facility's policy was not followed that indicated all information about informing the resident of their rights and all rules and regulations regarding decisions concerning medical care, and if they had an advance directives be available and kept in the resident's medical record. The DON stated, A copy of the resident's Advanced Directive should go with them to the hospital and should be documented in their clinical record. The Administrator and the DON stated they would be putting together a training plan for the staff. 2. Resident #95 did not have an advance directive readily available for direct care staff. Upon inquiry, an advance directive was located in a file drawer in the business office, not in the clinical record. The Business Office Manager (BOM) located a document titled Advance Directives/Informed Consent dated [DATE] that was found in a file drawer in the business office that indicated the resident had an advance directive. This advance directive was not found prior to survey exit. The facility could not provide evidence that Resident #95's advance directives were sent with her upon transfer to the local hospital on [DATE] or [DATE]. Resident #95 was admitted to the nursing facility on [DATE] with [DIAGNOSES REDACTED]. Resident #95's most recent Minimum Data Set (MDS) assessment was a significant change in status assessment dated [DATE] and coded the resident on the Breif Summary for Mental Status (BIMS) with a score of 3 out of a possible score of 15 which indicated the resident was severely impaired in the skills needed for daily decision making. On [DATE] at 1:48 p.m., the Unit II Nurse Manager stated she was not sure if Resident #95 had an advance directive. The Unit II Manager stated, I have never seen one and don't know where I would find one if she indeed had one. I do know she is a DNR (do not resusitate). There is no paperwork that we know of that says she wanted one or not. On [DATE] at 10:30 a.m., the Unit II Nurse Manager, Licensed Practical Nurse (LPN) #18 and the Director of Nursing (DON) stated the document related to whether or not a resident wanted an advance directive and that it had been reviewed, should be accessible to the nurses and kept in the clinical record, as well as the advanced directives. On [DATE] at 1:02 p.m., the Business Office Manager (BOM) stated she searched for an advance directive and found a document titled Advance Directives/Informed Consent form dated [DATE] that indicated the resident formulated an advance directive dated ,[DATE]. She stated the Advance Directives/Informed Consent document was located in the file drawer in the business office, but she could not find the advanced directive. The BOM said the documents should be kept on the unit where the resident resided and a copy in the business office. On [DATE] at 3:30 p.m., the BOM stated the facility needed to do some training immediately because she did not want any mix-ups. On [DATE] at 4:08 p.m., during the debriefing with the Administrator and DON, the aforementioned issue was readdressed. They stated the facility's policy was not followed that indicated all information about informing the resident of their rights and all rules and regulations regarding decisions concerning medical care, and if they had an advance directives be available and kept in the resident's medical record. The DON stated, A copy of the resident's Advanced Directive should go with them to the hospital and should be documented in their clinical record. The Administrator and the DON stated they would be putting together a training plan for the staff. 3. Resident #128 did not have evidence readily accessible that the facility had offered the resident an opportunity to formulate an advance directive. Additionally, according to the current physician orders [REDACTED]. Resident #128 was admitted to the nursing facility on [DATE] with [DIAGNOSES REDACTED]. Resident #128's most recent Minimum Data Set (MDS) assessment was a quarterly dated [DATE] and coded the resident on the Breif Summary for Mental Status (BIMS) with a score of 15 out of a possible score of 15 which indicated the resident was intact in the skills needed for daily decision making. On [DATE] at 9:20 a.m., Licensed Practical Nurse (LPN) #19 on Unit III stated she was not sure if Resident #128 had an advance directive, but she knew she was a DNR. LPN #19 stated, I do not know where the DNR form is. It should be located in the front of the resident's chart on the unit. She could not determine if there was paperwork that addressed the resident's right to formulate or refuse advance directives. On [DATE] at 10:30 a.m., the Director of Nursing (DON) stated the document related to whether or not a resident wanted an advance directive and that it had been reviewed with them should be accessible to the nurses and kept in the clinical record, as well as the advanced directives. The DON also stated even though there was a physician's orders [REDACTED]. On [DATE] at 1:02 p.m., upon surveyor inquiry, the Business Office Manager (BOM) stated she could not locate the document titled Advance Directives/Informed Consent form that would indicate the wishes of the resident's representative regarding formulation of an advance directive altough there should have been one in the clinical record. On [DATE] at 3:30 p.m., the BOM stated the facility needed to do some training immediately because she did not want any mx-ups. On [DATE] at 4:08 p.m., during the debriefing with the Administrator and DON, the aforementioned issue was readdressed. They stated the facility's policy was not followed that indicated all information about informing the resident of their rights and all rules and regulations regarding decisions concerning medical care, and if they had an advance directives be available and kept in the resident's medical record. The Administrator and the DON stated they would be putting together a training plan for the staff. 4. Resident #78 was originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent Minimum Data Set (MDS) was a Annual with an Assessment Reference Date (ARD) of [DATE]. Resident #78's Brief Interview for Mental Status (BIMS) was a 13 out of a possible 15 which indicated the resident was cognitively intact and capable of daily decision making. On [DATE] at 10:36 AM, Resident #78's electronic and paper medical record was reviewed for the Advance Directives. Resident #78's Advance Directives were not found in the medical record. On [DATE] a copy of Resident #78's Advance Directives were provided from the Admissions Coordinator who stated, There were in a file in the business office. On [DATE] at approximately 11:30 [NAME]M. an interview was conducted with the Admissions Coordinator regarding the location of the Advance Directives after being obtained from the resident or family. The Admissions Coordinator stated, They have been being kept in the business office in their files, but the new admissions and able to sign electronically and they are being put into the EMR (Electronic Medical Record) so there are accessible to all staff. We are going to do an audit of all the charts. On [DATE] at 7:30 P.M., a pre-exit debriefing was held with the Administrator, Director of Nursing and the Regulatory Care Consultant where the above information was shared. The Administrator stated, Admissions has completed an audit last night for the Advance Directives. Prior to exit no further information was shared. 5. The facility staff failed to ensure that Resident #11's Advanced Directive was sent upon transfer/discharge to the hospital on [DATE]. Resident #11 was originally admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. The current Minimum Data Set (MDS), a quarterly assessment with an Assessment Reference Date (ARD) of [DATE] coded the resident with a 14 out of a possible score of 15 on the Brief Interview for Mental Status (BIMS) indicating no cognitive impairment. On [DATE], according to the facility's documentation, Resident #11, left the facility via ambulance service for a direct admit to the hospital, pending a surgical procedure. The clinical record did not show evidence that Resident #11's Advanced Directive was sent with her when discharged to the hospital. Review of Resident #11's clinical record indicated that there was an Advanced Directive on the chart; however, there was no documentation the form was sent upon residents discharge to the local hospital on [DATE]. The Health Care Instructions document included the following information: I specifically do not wish to receive the following treatments: Cardiopulmonary Resuscitation (CPR), Ventilator or [MEDICAL TREATMENT]. The document was witnessed, signed and dated on [DATE]. An interview was conducted with the Unit Manger on who stated, Resident #11's Advanced Directive should have been sent with her when discharged to the hospital on [DATE] and documented in the resident's nurses notes. The surveyor asked, How would the hospital know Resident #11's wishes not to receive the following: CPR, Ventilator or [MEDICAL TREATMENT] if her Advanced Director was not sent with her when discharged to the hospital, she replied, They don't. The Administrator, Director of Nursing (DON) and Nurse Consultant was informed of the finding during a briefing on [DATE] at approximately 4:08 p.m. The DON stated, A copy of the resident's Advanced Directive should go with them to the hospital and should be documented in their clinical record. The facility's policy titled Discharge or Transfer Summary (Last Revision date: [DATE]). Guidelines include but not limited to: -1. G: For the residents transferred to another provider the following will be documented and communicated to the receiver provider: Advanced Directive Information. 6. The facility staff failed to ensure that Resident #51's advance directive was on the clinical record and valid to include a date and witness signatures. Review of Resident #51's clinical record indicated the resident was admitted to the facility on [DATE] with a re-admit on [DATE] with [DIAGNOSES REDACTED]. Review of the clinical record revealed that there were no advance directive on the chart. On [DATE] 12:33 p.m., an interview with the Director of Social Services was conducted. She was asked where the Advance Directives could be found. She stated they are kept in the Business Office. A request was made to the Business Office Manager to provide the Advance Directive for Resident #51. During the survey the Admission's Coordinator was able to provide a copy of the advance directive that was filed with the resident's admission paperwork information. This copy was not valid and it was not signed, dated and did not have two witness signatures. 7. The facility staff failed to ensure that Resident #50's advance directive was on the clinical record and valid to include two witness signatures. Review of Resident #50's clinical record indicated the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the clinical record revealed that there were not an advance directive on the chart. On [DATE] 12:33 p.m., an interview with the Director of Social Services was conducted. She was asked where the Advance Directives could be found. She stated they are kept in the Business Office. A request was made to the Business Office Manager to provide the Advance Directive for Resident #50. The Businees Office Manager was able to provide a copy of the advance directive that was filed with the resident's admission paperwork information. This copy was not valid as it did not have two witness signatures. 8. The facility staff failed to have an advance directive accessible in Resident #15's clinical record. Resident #15 was originally admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. The current Minimum Data Set (MDS), an annual assessment with an Assessment Reference Date (ARD) of [DATE] coded the resident with a BIMS summary score of 15 out of a possible score of 15 on the Brief Interview for Mental Status (BIMS) indicating no cognitive impairment. A review of the clinical record on [DATE] at approximately, 11:21 AM revealed there was no advanced directive in the clinical record. On [DATE] at approximately 5:06 PM, an interview was conducted with the Marketing Liasion. A copy of Resident #15's advance directive was received. She stated that the advance directive was located in file cabinet in the business office. She was asked how would the staff access the advance directive. She stated, I don't know. On [DATE] at approximately, 4:17 PM, an interview was conducted with the social services worker (Other Staff #14) concerning the location of the advance directive. She stated, It's usually in front of the chart .Physician order [REDACTED]. On [DATE] at approximately, 5:28 PM the pre-exit interview was conducted. Present were the Administrator, the DON (Director of Nursing) and the Corporate Nurse Consultant. The DON stated that the Advance Directive can be found in the patient's chart under the advance directive tab The original should be in the chart. 9. The Facility failed to extend the right to formulate an Advanced Directive. Resident # 90 was admitted to the facility on [DATE] with a readmission occurring on [DATE] with the latest [DIAGNOSES REDACTED]. Resident # 90's MDS (Minimum Data Set), Quarterly Review assessment dated [DATE] coded Resident #90 with a BIM (brief interview of mental status) as 14 out of a possible 15, moderately cognitively impaired with decisions of daily living. On [DATE] at approximately 4:30 p.m., a request for any documentation regarding an Advanced Directive was given to Other Administrative Staff (OS) #6. OS #6 stated We don't have one for him. The facility Administrator was informed of the findings during a briefing on [DATE] at approximately 7:30 p.m. The facility did not present any further information about the findings. 10. The facility failed to extend the right to formulate an Advanced Directive to Resident #42. Resident #42 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident # 42's MDS (Minimum Data Set), Quarterly Review Assessment with an ARD (Assessment Review Date) of [DATE], indicated a BIMS (Brief Interview of Mental Status) score of 12 out of a possible 15, moderately cognitively impaired. On [DATE] at approximately 4:30 p.m., a request for any documentation regarding an Advanced Directive was given to Other Administrative Staff (OS) #6. OS #6 stated We don't have one for him. The facility Administrator was informed of the findings during a briefing on [DATE] at approximately 7:30 p.m. The facility did not present any further information about the findings. 11. Resident #88 was originally admitted on [DATE] with a readmission date of [DATE]. Resident #88's [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of [DATE] coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #88's cognitive abilities for daily decision making were intact. Review of the clinical record didn't reveal written Advanced Directive, but the physician's orders [REDACTED]. Review of the person-centered care plan revealed a care plan dated [DATE] and edited [DATE] with a problem documenting: Advanced Directives, resident desires to be a full code. The goal read: Resident wishes to be a full code which will be followed in the event his heart has stopped through [DATE]. The approaches included: 911 will be called for transfers to the hospital, CPR will be conducted in accordance to the resident's wishes, discuss code status during full life conference quarterly during care plan. No information was included in the medical record concerning what to do if the resident becomes incapacitated, a designated health care surrogate, medical/surgical treatments, feeding restrictions, organ donation, autopsy request or other. On [DATE] at approximately 10:45 a.m., the Social services Director stated the Advanced Directives are managed by the Admission/Marketing staff and if the Advanced Directive is not on the resident's chart it is in a file in the Admission's office. An interview was conducted with the Marketing Director on [DATE] at approximately 1:45 p.m. The Marketing Director stated it was true if the form wasn't on the record it was likely in the Admission's Office but, currently she was conducting a 100% audit and if there wasn't a form in either place they were completing one today. The Admission's Director stated Resident #88 had no Advanced Directive form completed but it was completed today. On [DATE] at approximately 6:00 p.m., the above findings were shared with the Administrator Director of Nursing, and Corporate Consultant. An opportunity was offered to the facility's staff to present additional information but nothing was provided. 12. Resident #61 was originally admitted on [DATE] with a readmission date of [DATE] after an acute hospital stay. Resident #61's [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of [DATE] coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 5 out of a possible 15. This indicated Resident #88's cognitive abilities for daily decision were severely impaired. Review of the clinical record didn't reveal written Advanced Directives but the physician's orders [REDACTED]. Review of the person-centered care plan revealed a care plan dated [DATE] and edited [DATE] with a problem documenting: Advanced Directives, resident desires to be a full code. The goal read: Resident wishes to be a full code which will be followed in the event his heart has stopped through [DATE]. The approaches included: 911 will be called for transfers to the hospital, CPR will be conducted in accordance to the resident's wishes, discuss code status during full life conference quarterly during care plan. No information was included in the medical record concerning what to do if the resident becomes incapacitated, a designated health care surrogate, medical/surgical treatments, feeding restrictions, organ donation, autopsy request or other. On [DATE] at approximately 10:45 a.m., the Social services Director stated the Advanced Directives are managed by the Admission/Marketing staff and if the Advanced Directive is not on the resident's chart it is in a file in the Admission's office. An interview was conducted with the Marketing Director on [DATE] at approximately 1:45 p.m. The Marketing Director stated it was true if the form wasn't on the record it was likely in the Admission's Office but; currently she was conducting a 100% audit and if there wasn't a form in either place they were completing one today. The Admission's Director stated Resident #88 had no Advanced Directive form completed but it was completed today. On [DATE] at approximately 6:00 p.m., the above findings were shared with the Administrator Director of Nursing, and Corporate Consultant. An opportunity was offered to the facility's staff to present additional information but nothing was provided. 13. Resident #72 was originally admitted on [DATE] and had not been discharged since admitted . Resident #72's [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of [DATE] coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #72's cognitive abilities for daily decision making were intact. Review of the clinical record did reveal written Advanced Directives dated [DATE]. It stated I do not choose to formulate or issue Advanced Directives at this time. I want efforts made to prolong my life and warrant life-sustaining treatment to be provided. The current physician's orders [REDACTED]. Further review of the record reveal a Do Not Resuscitate form dated [DATE], signed by the resident and the physician. Review of the person-centered care plan dated [DATE] and edited [DATE], revealed no Advanced Directive care plan. On [DATE] at approximately 10:45 a.m., the Social services Director stated the Advanced Directives are managed by the Admission/Marketing staff and if the Advanced Directive is not on the resident's chart it is in a file in the Admission's office. An interview was conducted with the Marketing Director on [DATE] at approximately 1:45 p.m. The Marketing Director stated it was true if the form wasn't on the record it was likely in the Admission's Office but, currently she was conducting a 100% audit and if there wasn't a form in either place they were completing one today. The Admission's Director stated Resident #88 had no Advanced Directive form completed but it was completed today. On [DATE] at approximately 6:00 p.m., the above findings were shared with the Administrator Director of Nursing, and Corporate Consultant. An opportunity was offered to the facility's staff to present additional information but nothing was provided. 14. Resident #61 was originally admitted on [DATE] with a readmission date of [DATE] after an acute care hospital stay. Resident #61's [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of [DATE] coded the resident as not having the ability to complete the Brief Interview for Mental Status (BIMS). The staff interview was coded for short term memory problems as well as modified independence for decision making in new situations. Review of the clinical record didn't reveal written Advanced Directives but the Marketing Director was able to locate it in the Admission's office. The Advanced Directives form was signed but not dated and read as follows: I do not choose to formulate or issue Advanced Directives at this time. I want efforts made to prolong my life and warrant life-sustaining treatment to be provided. Review of the person-centered care plan revealed a care plan dated [DATE] and edited [DATE] with a problem documenting: Resident has the following Advanced Directives on record, Full code. The goal read: Resident Advanced Directives are in effect, and their wishes and directions will be carried out in accordance with their advanced directives on an ongoing basis through the next review date [DATE]. The approaches included: Discuss Advanced Directives with the resident and/or appointed health care representative, An Advanced Directive can be revoked or changed if the resident and/or appointed health care representative changes their mind about the medical care they want delivered, Advise resident and/or appointed health care representative to provide copies to the facility of any updated Advanced Directives. No information was included in the medical record concerning what to do if the resident becomes incapacitated, a designated health care surrogate, medical/surgical treatments, feeding restrictions, organ donation, autopsy request or other. On [DATE] at approximately 10:45 a.m., the Social services Director stated the Advanced Directives are managed by the Admission/Marketing staff and if the Advanced Directive is not on the resident's chart it is in a file in the Admission's office. An interview was conducted with the Marketing Director on [DATE] at approximately 1:45 p.m. The Marketing Director stated it was true if the form wasn't on the record it was likely in the Admission's Office but, currently she was conducting a 100% audit and if there wasn't a form in either place they were completing one today. The Admission's Director stated Resident #88 had no Advanced Directive form completed but it was completed today. On [DATE] at approximately 6:00 p.m., the above findings were shared with the Administrator Director of Nursing, and Corporate Consultant. An opportunity was offered to the facility's staff to present additional information but nothing was provided. 15. For Resident #139, the facility staff failed to ensure Advance Directives / Informed Consent was reviewed with the resident or resident's responsible party. Resident #139 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Resident #139's Admission Minimum Data Set (MDS an assessment protocol) with an Assessment Reference Date of [DATE] was coded with a BIMS (Brief Interview for Mental Status) score of 14, indicating no cognitive impairment. On [DATE] at approximately 5:30 p.m., an interview was conducted with the Marketing Director in Admissions. A copy of Resident #139's Advanced Directive was requested from the Marketing Director and she stated, The Advanced Directive has not been signed by the resident as of present. The Marketing Director stated, The resident is a new admit and every time I have went to review it with her she has been asleep. The resident's mother is her responsible party and she has not been in to review the form with me. On [DATE] at approximately 4:00 p.m., an interview was conducted with the Social Worker and she stated, I spoke with (Resident Name) and she stated that she wanted to be a Full Code. The Social Worker provided a copy of her conversation in a progress note dated [DATE]. The Administrator, Director of Nursing and Nurse Consultant was informed of the finding on [DATE] at 7:30 p.m. at the pre-exit meeting. The Director of Nursing was asked, What are your expectations regarding Advance Directives? The Director of Nursing stated, I expect the Admissions Department to review the Advance Directive Informed Consent with the resident or resident responsible party upon admission and the nurses to follow up as needed. The Director of Nursing also stated, I expect changes to be made as needed. The facility staff did not present any further information about the finding. 16. For Resident #124, the facility staff failed to ensure that the Advance Directives / Informed Consent reflected the resident's DNR (Do Not Resuscitate) code status. Resident #124 was initially admitted to the facility on [DATE]. Resident #124 was discharged to the hospital on [DATE] and readmitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Resident #124's Quarterly Minimum Data Set (MDS an assessment protocol) with an Assessment Reference Date of [DATE] was coded with a BIMS (Brief Interview for Mental Status) score of 13 indicating no cognitive impairment. On [DATE] a copy of Resident 124's Advance Directives and a copy of the Physician order [REDACTED]. On [DATE] at approximately 5:30 p.m., the facility provided a copy of a Durable Do Not Resuscitate Ord

Based on clinical record reviews, staff interviews, clinical record review, facility documentation review and the facility's policy; the facility's staff failed to covey a copy of the resident's comprehensive care plan goals to the transferring facility for 10 of 63 residents (Resident #88, #112, #78, #64, #95, #128, #32, #11, #94, and #605) in the survey sample. The findings included: The facility's policy titled Discharge or Transfer Summary (Last Revision date: 06/28/19). Guidelines include but not limited to: -1. G: For the residents transferred to another provider the following will be documented and communicated to the receiver provider: Comprehensive Care Plan goals. 1. Resident #88 was originally admitted on [DATE] with a readmission date of [DATE]. Resident #88's [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 9/16/19 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #88's cognitive abilities for daily decision making are intact. Review of the clinical record reveal Resident #88 was discharged from the facility return anticipated to an acute care hospital 7/20/19 for a critical hemoglobin and hematocrit. On 10/23/19 at approximately 1:30 p.m., an interview was conducted with Licensed Practical Nurse (LPN) #1. LPN #1 stated there was no documentation available stating the resident's comprehensive care plan goals were sent with the resident to the hospital at the time of his 7/20/19 discharge. On 10/24/19 at approximately 6:00 p.m., the above findings were shared with the Administrator and Director of Nursing. An opportunity was offered to the facility's staff to present additional information but they did not. 2. Resident #112 was originally admitted on [DATE] with a readmission date of [DATE]. Resident #112's [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 9/20/19 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 5 out of a possible 15. This indicated Resident #88's cognitive abilities for daily decision were severely impaired. Review of the clinical record reveal Resident #112 was discharged from the facility return anticipated to an acute care hospital 7/22/19 after a fall. On 10/23/19 at approximately 2:45 p.m., an interview was conducted with Licensed Practical Nurse (LPN) #2. LPN #2 stated there was no documentation available stating the resident's comprehensive care plan goals were sent with the resident to the hospital at the time of his 7/22/19 discharge. On 10/24/19 at approximately 6:00 p.m., the above findings were shared with the Administrator Director of Nursing, and Corporate Consultant. An opportunity was offered to the facility's staff to present additional information but they did not. 3. Resident #78 was originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent Minimum Data Set (MDS) was a Annual with an Assessment Reference Date (ARD) of 9/6/19. Resident #78's Brief Interview for Mental Status (BIMS) was a 13 out of a possible 15 which indicates the resident is cognitively intact and capable of daily decision making. On 10/22/19 at 11:02 [NAME]M. Resident #78 was asked if he had been to the hospital recently. Resident #78 stated, I went a few months ago the staff were unable to wake me up. Resident #78's Facility Census History was reviewed and is documented in part, as follows: 03/23/2019 Discharge-Return Expected 03/27/2019 Return 05/16/2019 Discharge-Return Expected. 05/21/2019 Return. 08/06/2019 Discharge-Return Expected 08/07/2019 Return On 10/23/19 at 1:45 P.M. the Director of Nursing was asked for documentation to show that the care plan goals were sent with Resident #78 to the hospital for the 3 discharges this year. Resident #78's care plan was reviewed and is documented in part, as follows: Problems: Infection Control, Restorative Nursing, Diabetes, [MEDICAL CONDITION] Drug Use, Falls, Skin Integrity, Elimination, Visual Function, Tremors, Depression, Resists Care, Nutritional Status and Advance Directives. On 10/23/19 at approximately 4:00 P.M. the Director of Nursing stated I don't have any documentation to support that the care plan goals were sent with (Name-Resident #78) for the 3 discharges this year. On 10/24/19 at 7:30 P.M. a Pre-exit debriefing was held with the Administrator, Director of Nursing and the Regulatory Care Consultant where the above information was shared. Prior to exit no further information was shared 4. Resident #64 was admitted to the nursing facility on 7/29/16 with [DIAGNOSES REDACTED]. Resident #64's most recent Minimum Data Set (MDS) was a significant change in status assessment. The resident scored a 15 out of a possible score of 15 on the Brief Interview for Mental Status (BIMS) which indicated she was fully intact with the skills for daily decision making. There was no evidence provided that the facility staff conveyed the summary and goals of the comprehensive plan of care upon transfer/discharge to the local hospital on [DATE] and 7/7/19 for Resident #64. No documentation was included in the transfer summary that indicated the facility staff conveyed to the receiving providers the resident's comprehensive care plan goals at the time of discharge or as soon as possible to the actual time of transfer. On 10/24/19 at 10:30 a.m., the Unit II Nurse Manager stated she was not aware of the process to send a care plan summary and goals when a resident is transferred to the Emergency Department (ED) or hospital. On 10/24/19 at 11:00 a.m., the Director of Nursing (DON) stated, We are not going far enough in the interact form or the discharge summary form that will actually generate the care plan summary goals. You might as well stop searching, we are not sending this document and education will have to take place, as well as draft a facility policy and procedure. On 10/24/19 at 4:08 p.m., during the debriefing with the Administrator and DON, the aforementioned issue was readdressed and no further information was provided prior to survey exit. 5. Resident #95 was admitted to the nursing facility on 1/6/18 with [DIAGNOSES REDACTED]. Resident #95's most recent Minimum Data Set (MDS) assessment was a significant change in status assessment dated [DATE] and coded the resident on the Brief Summary for Mental Status (BIMS) with a score of 3 out of a possible score of 15 which indicated the resident was severely impaired in the skills needed for daily decision making. There was no evidence provided that the facility staff conveyed the summary and goals of the comprehensive plan of care upon transfer/discharge to the local hospital on [DATE] and 9/3/19 for Resident #95. No documentation was included in the transfer summary that indicated the facility staff conveyed to the receiving providers the resident's comprehensive care plan goals at the time of discharge or as soon as possible to the actual time of transfer. On 10/24/19 at 10:30 a.m., the Unit II Nurse Manager stated she was not aware of the process to send a care plan summary and goals when a resident is transferred to the Emergency Department (ED) or hospital. On 10/24/19 at 11:00 a.m., the Director of Nursing (DON) stated, We are not going far enough in the interact form or the discharge summary form that will actually generate the care plan summary goals. You might as well stop searching, we are not sending this document and education will have to take place, as well as draft a facility policy and procedure. On 10/24/19 at 4:08 p.m., during the debriefing with the Administrator and DON, the aforementioned issue was readdressed and no further information was provided prior to survey exit. 6. Resident #128 was admitted to the nursing facility on 5/6/09 with [DIAGNOSES REDACTED]. Resident #128's most recent Minimum Data Set (MDS) assessment was a quarterly dated 9/23/19 and coded the resident on the Brief Summary for Mental Status (BIMS) with a score of 15 out of a possible score of 15 which indicated the resident was intact in the skills needed for daily decision making. There was no evidence provided that the facility staff conveyed the summary and goals of the comprehensive plan of care upon transfer/discharge to the local hospital on [DATE] for Resident #128. No documentation was included in the transfer summary that indicated the facility staff conveyed to the receiving providers the resident's comprehensive care plan goals at the time of discharge or as soon as possible to the actual time of transfer. On 10/24/19 at 9:20 a.m., Licensed Practical Nurse (LPN) #19 on Unit III stated she did not know about sending a summary of the resident's care plan goals when the residents are sent to the Emergency Department (ED) or hospital. On 10/24/19 at 11:00 a.m., the Director of Nursing (DON) stated, We are not going far enough in the interact form or the discharge summary form that will actually generate the care plan summary goals. You might as well stop searching, we are not sending this document and education will have to take place, as well as draft a facility policy and procedure. On 10/24/19 at 4:08 p.m., during the debriefing with the Administrator and DON, the aforementioned issue was readdressed and no further information was provided prior to survey exit 7. Resident #32 was originally admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. The current Minimum Data Set (MDS), an annual assessment with an Assessment Reference Date (ARD) of 08/02/19. Staff assessment for mental status was conducted because resident was unable to complete the interview. Staff assessment for mental status coded the resident as having short-term and long-term memory problems. The Discharge MDS assessments was dated for 04/13/19 - discharged with return anticipated. On 04/13/19, according to the facility's documentation, Resident departed facility with local transport to the local hospital. On 10/24/19 at approximately, 3:21 PM an interview was conducted with LPN #1, Unit Manager. She stated, No care plan summary was sent. A briefing was held with the Director of Nursing (DON), Administrator and with the Corporate Nurse Consultant on 10/24/19 at approximately 5:25 P.M. No further comments were made. 8. The facility staff failed to ensure that Resident #11's Plan of Care Summary to include her care plan goals was sent upon transfer/discharge to the hospital on [DATE]. Resident #11 was originally admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. The current Minimum Data Set (MDS), a quarterly assessment with an Assessment Reference Date (ARD) of 07/22/19 coded the resident with a 14 out of a possible score of 15 on the Brief Interview for Mental Status (BIMS) indicating no cognitive impairment. On 09/16/19, according to the facility's documentation, Resident #11, left the facility via ambulance service as a direct admit to the hospital, pending a surgical procedure. The clinical record did not show evidence that Resident #11's care plan summary to include her goals were sent upon discharge to the hospital or shortly after. An interview was conducted with License Practical Nurse (LPN) #3 on 10/22/19 at approximately 4:10 p.m. The LPN stated, I have never sent the resident's care plan summary when sending them out to the hospital, I was not aware we were suppose to. A briefing was held with the Administrator, Director of Nursing and Cooperate Nurse on 10/24/19 at approximately 4:08 p.m. The facility did not present any further information about the findings. 9. Resident #94 was originally admitted to the facility on [DATE] with a re-admission date of [DATE] with [DIAGNOSES REDACTED]. The current Minimum Data Set an annual with an assessment reference date of 9/17/19 coded the resident as scoring a 9 out of a possible 15 on the Brief Interview for Mental Status, indicating the resident's cognition was moderately impaired. The clinical record failed to evidence documentation that upon transfer to the hospital on [DATE] a copy of Resident #94's care plan was sent along with other required documents. 10/23/19 11:24 a.m., the unit manager was asked to locate documentation of the facility sending the care plan. The unit manager stated, I can not locate any documentation of bed hold or care plan sent with the resident for the last transfer to the hospital. On 10/24/19 the above findings was shared with the Administrator and the Director of Nursing during the pre-exit meeting. 10. Resident #605 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An admission Minimum (MDS) data set [DATE] assessed the resident in the area of Cognitive Patterns as having a Brief Interview for Mental Status (BIMS) score of (13) indicating intact cognition. In the area of Activities of Daily Living (ADL'S) this resident was assessed as requiring total care in the areas of dressing, eating, personal hygiene and toileting. Resident #605 was transferred to the hospital from the facility on 09/22/19. There was no evidence that the facility provided a care plan regarding ongoing care needs to the receiving hospital.

Based on observation, clinical record review, staff interview and facility documentation, the facility staff failed to prevent and identify in a timely manner, a pressure ulcer for 1 of 38 residents in the survey sample, Resident #108, resulting in harm. The facility staff failed to identify Resident #108 had developed a sacral pressure ulcer until it had advanced to a stage 3; measuring 6 centimeters by 4 centimeters by 0.1 centimeters, with dark pink tissue, slough, and right side rolled edges with maceration, which constitutes harm. The findings included: Resident #108 was originally admitted to the facility 4/23/18 and readmitted [DATE] from a local acute care hospital, after repair of a [MEDICAL CONDITION]. The current [DIAGNOSES REDACTED]. The significant change Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 5/31/18 coded the resident as not having the ability to complete the Brief Interview for Mental Status (BIMS). The staff interview was coded for long and short term memory problems as well as severely impaired daily decision making. In section D (Mood) the resident is coded for a poor appetite. In section E (Behavior), Resident #108 is coded for verbal aggression which significantly interferes care, activities and socialization as well as rejection of care 1-3 days each week. In section G (Physical functioning) the resident was coded as requiring total care of 1 with off unit locomotion, personal hygiene and bathing, extensive assistance of 2 people with bed mobility, transfers, dressing, and toileting. She requires extensive assistance of 1 person with on unit locomotion, and supervision after set-up with eating. In section M (Skin Conditions) the resident was coded as at risk for pressure ulcer development but without any unhealed pressure ulcers at stage 1 or greater. The Braden Scale for Predicting Pressure Score Risk; revealed Resident #108 was assessed 5/24/18 and score 13, which means Resident #108 had a moderate risk for pressure ulcer development. The weekly skin integrity evaluation revealed as follows: 5/26/18, the resident had impaired skin to the anterior left trochanter (upper lateral thigh) and left upper leg, 5/30/18, impaired skin to the anterior left trochanter and left upper leg, 6/6/18, a posterior skin condition was observed, site not specified. There was no further documentation or description of the impaired skin integrity on the above dates. On 7/12/18 at approximately 10:50 a.m., an interview was conducted with Licensed Practical Nurse (LPN) #6 who made the observation of the wound. LPN #6, stated she made the initial observation but LPN #3 followed up and completed the initial assessment. It was explained that LPN #6 was not allowed to assess wounds. Only the Unit Managers and the Wound care nurse are allowed to assess and stage pressure ulcers in the facility. LPN #3 is the UM. On 7/12/18, at approximately 11:00 a.m., an interview was conducted with LPN #3. LPN #3 stated she made the follow-up assessment and referred the surveyor to the Pressure Ulcer Record dated 6/6/18. The record revealed the resident had a stage 3 pressure ulcer to the sacrum, measuring 6 centimeters by 4 centimeters by 0.1 centimeters, and with dark pink tissue, slough, and right side rolled edges with maceration. During the interview with LPN #3, the nurse stated Resident #108 is often confused and combative but; 2 staff members are capable of rendering necessary care. LPN #3 further stated, because of Resident #108 behaviors (hitting, spitting and kicking) the facility staff assigns the same staff to the resident whenever possible to achieve a reduction in the exhibited behaviors. A physician's orders [REDACTED]. The Wound Care physician's initial assessment conducted 6/12/18, revealed Resident #108's pressure ulcer measured 2.5 centimeters by 2.0 centimeters by 0.2 centimeters with a moderate amount of sero-sanguinous exudate, 40% thick adherent necrotic tissue and 60% granulation tissue. The Wound Care physician's 6/12/18, note further stated surgical excisional debridement was completed with removal of devitalized tissue, subcutaneous fat and surrounding connective tissue to a depth of 0.3 cm and healthy bleeding tissue was observed. Resident's #108's wound care was observed on 7/13/18 at approximately 11:55 a.m. Resident #108 was very restless but easily redirected by the Certified Nursing Assistant (CNA) accompanying the RN wound care nurse. She reclined on a low air loss bed covered with a draw sheet. The resident wore a Prevalon boot to the left foot only. A small amount of light yellow drainage was observed to old dressing removed from the pressure ulcer. The sacral pressure ulcer measured approximately 1.5 centimeter (length) by 1.5 centimeters (width) by 0.2 centimeters (depth). The pressure ulcer contained a pale pink bed, and the surrounding tissue was without swelling or redness. The resident didn't complain of or show signs of pain during the procedure. There was a care plan in use prior to development of the pressure ulcer. The problem was dated 5/2/18, updated 5/10/18 and updated again 6/12/18. It read Resident is at risk for developing skin breakdown. Needs extensive assist with bed mobility and incontinence secondary to the left [MEDICAL CONDITION]. The goal dated 5/3/18 and updated 5/18/18 read; Resident will have intact skin, free of redness, blisters, or discoloration over boney prominences through the next review date. The interventions read; Report changes in skin status (ie., signs/symptoms of infection, non-healing, new areas) to the physician. Provide diet as ordered and monitor nutritional status and dietary needs; consult Registered Dietitian as needed. Provide pressure relieving or reduction mattress. Complete weekly skin check. Complete Braden Scale Risk Assessment quarterly and as needed. Notify the nurse immediately of any new areas of skin breakdown, redness, blisters, bruises, or discoloration noted during bathing or daily care. Provide incontinence care after incontinence episodes, apply barrier cream as needed. The active care plan dated 6/12/18 read; problem, Resident has a pressure ulcer Stage 3. The goals read; Pressure ulcer will exhibit signs of healing evidenced by decreased size, improved appearance and be free from signs and symptoms of infection by the next 90 days. Resident will not develop any new areas of skin breakdown through next review date. The interventions were; Report changes in skin status (i.e.; signs/symptoms of infection, non healing, new areas) to physician. Discuss non-compliance issues with resident and responsible party. Educate resident/responsible party about pressure ulcer etiology, primary risk factors, treatment, prevention. Observe laboratory/diagnostics as ordered and report results to the physician. Observe effectiveness of response to treatments as ordered. Consult PT for cushion to the wheel chair, Nutritional consult, Wound care specialist consult. Complete weekly skin checks. Complete Braden Scale Risk Assessment quarterly and as needed. Notify nurse immediately of any new areas of skin breakdown, redness, blisters, bruises, discoloration noted during bathing or daily care. Provide diet as ordered and observe nutritional status and dietary needs; consult dietitian as needed. Assist resident as needed to position/shift weight to relieve pressure. Provide pressure reduction mattress (STAT 2/a low air loss bed). Position with pillows to maintain proper body alignment as needed. Float heels in bed. Provide incontinence care after incontinence episodes; apply barrier cream as needed. Avoid skin to skin contact. Minimize pressure over bony prominence's. Use a lifting device/draw sheet to reduce friction. Wound care as ordered by physician. Provide supplemental protein, amino acids, vitamins, minerals as ordered by physician to promote wound healing. Notify resident/responsible party of any new areas of skin breakdown. Observe for pain and medicate as needed per physician's orders [REDACTED].>The facility's undated Pressure Ulcer Risk Assessment document read; the purpose of this procedure is to provide guidelines for assessment and identification of residents at risk for developing pressure ulcer. Risk Assessment- A pressure ulcer risk assessment will be completed upon admission, and then weekly x 1, with significant changes, and quarterly. Skin Assessment- Skin will be assessed for the presence of developing pressure ulcer on a weekly basis or more frequently if indicated. Monitoring- Staff will perform routine skin inspections (with daily care). Nurses are to be notified to inspect the skin if skin changes are identified. Nurses will conduct skin assessments at least weekly to identify changes. On 7/13/18, at approximately 2:30 p.m.,the above findings were shared with the Administrator and Director of Nursing. The Administrator and Director of Nursing acknowledged the stage 3 pressure ulcer and the Administrator stated, now we have a new Wound Care Nurse. Definitions: A Stage 3 pressure ulcer according to the Resident Assessment Instrument Manual (RAI) is a full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. (MONTH) include undermining or tunneling. (RAI Manual, (MONTH) (YEAR), Page M-12) Slough tissue is non-viable yellow, tan, gray, green or brown tissue; usually moist, can be soft, stringy and mucinous in texture. Slough may be adherent to the base of the wound or present in clumps throughout the wound bed. (RAI Manual, (MONTH) (YEAR), Page M-18) Removal of dead or infected tissue from a wound. Debridement can be done with enzymes; mechanically, such as in a whirlpool; or through surgery. (https://search.nih.gov/search?utf8=%E2%9C%93&affiliate=nih&query=debridment&commit=Search) Santyl Ointment is indicated for [MEDICATION NAME] chronic dermal ulcers and severely burned areas. (https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=6b6fbfc6-98fa-46aa-88ef-ab00fbb08ffd) A Prevalon boot offloaded pressure even when the patient is moving. http://www.medline.com/product/Prevalon-Heel-Protectors-by-Sage-Products/Z05-PF /

Based on observations, clinical record review, staff and resident interviews and review of facility documentation, the facility staff failed to ensure 2 of 38 residents (#9 and # 25) in the survey sample were free of accident hazards 1. The facility staff failed to ensure Resident #9 was free of accident hazards due to the resident sustaining second [MEDICAL CONDITION] the upper chest from hot liquids (a cup of noodle soup), which constituted harm for this resident. 2. The facility staff failed to maintain an environment free from accident hazards for one resident (#25) in the survey sample when she ingested paint left accessible to her by a contracted painting company. The findings include: 1. Resident #9 was admitted to the nursing facility on 4/4/14 with [DIAGNOSES REDACTED]. The most recent Minimum Data Set (MDS) assessment was an Annual and coded the resident on the Brief Interview for Mental Status (BIMS) with a score of 15 out of a possible 15 which indicated she was intact with the cognitive skills for daily decision making. The resident was assessed to require set-up help for eating. She was coded to require extensive assistance form two staff for bed mobility, toilet use and bathing. The resident was assessed to require extensive assistance from one staff for dressing and personal hygiene. The assessment coded the resident as mostly bed bound and transferred from bed to wheel chair and back once or twice during the seven day assessment period. The care plan dated 12/2/17 identified a burn to the skin. The goal set by the staff for the resident was that she would have signs of healing. Some of the approaches the staff would use included encouraging the resident to allow staff to rise head of bed during meals, garment protector during meals, weekly documented skin check and follow the physician's orders [REDACTED]. A facility reported incident (FRI) dated 12/1/17 indicated Resident #9 tipped a cup of noodles from soup onto her upper bare chest and sustained *second-degree burns. The physician was notified and *[MEDICATION NAME] cream was ordered as the treatment. Review of clinical record revealed on 12/2/17 the area was assessed by the Director of Nursing (DON) to be 7 centimeters (cm) by (x) 6 cm with no measurable depth at 0 cm with a 2 cm x 2 cm fluid filled blister at the superior aspects of the burn area. It was recorded that the wound base in the upper region of the burn exhibited the formation of yellow *slough, and the lower portion of the burn was bright red. The treatment regimen was changed to *Xeroform dressing due to resident's allergy to Sulfa. The wound care physician added *Santyl to the wound. The nurse's notes indicated the burn healed as of 12/27/17. On 7/12/18 at 2:00 p.m., an interview was conducted with the Administrator and the DON about the aforementioned incident. He stated that he had instituted a plan for all staff to reheat hot liquids in the microwave that included acquiring the temperature of all reheated foods, and to serve hot liquids (i.e., coffee, soup, tea, etc ) at 140-150 degrees and record in logbook. He stated, when he interviewed the Certified Nursing Assistant that prepared the soup for Resident #9, she stated she heated the water in the microwave and poured it into the prepackaged noodles and let it sit for a few minutes and delivered it to the resident. He stated the CNA admitted to him she did not follow the hot liquid protocol and acquire the temperature of the soup prior to delivering it to the resident. The Administrator stated he removed all microwaves from the nursing units and require the staff to have food and liquids reheated, temped and recorded by the kitchen staff prior to delivering the food item or liquids to residents. On 7/13/18 at 11:00 a.m., an interview was conducted with Resident #9. She stated she was not up in the bed when the CNA gave her the noodle soup, sat it on her over-bed table, after which the resident stated she retrieved the cup and tipped it over onto her chest, but there was mostly noodles that spilled onto her chest than liquid. She stated if she eats or drinks hot liquids she wears a drape (apron) to protect her chest because I hate anything up against my neck and my upper chest will always be exposed. The resident was observed in bed with the head on the bed at approximately 45 degrees. The area mid-chest exhibited scarring where the burn had once been. *[MEDICATION NAME] Cream 1% (silver [MEDICATION NAME]) is a topical antimicrobial drug indicated as an adjunct for the prevention and treatment of [REDACTED].pfizermedicalinformation.com/en-us/[MEDICATION NAME]-cream). *Second [MEDICAL CONDITION] the first two layers of skin with signs of deep reddening of the skin, pain, blisters and glossy appearance from leaking fluid with loss of skin (https://www.cdc.gov/masstrauma/factsheets/public/burns.pdf). *Xeroform dressing is a fine mesh gauze impregnated with [MEDICATION NAME] solutions that contain antimicrobial agents to control bacterial growth and to maintain a moist environment at the wound surface which is excellent for the treatment of [REDACTED].ncbi.nlm.nih.gov/pubmed/ 26). *Santyl ([MEDICATION NAME]) This product is used to help the healing [MEDICAL CONDITION] skin ulcers. [MEDICATION NAME] is an enzyme. It works by helping to break up and remove dead skin and tissue. This effect may also help to work better and speed up your body's natural healing process (http://www.webmd.com/drugs/2/drug-9489/santyl-topical/details). 2. Resident #25 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The facility staff failed to maintain an environment free from accident hazards for Resident #25 when she ingested paint left accessible to her by a contracted painting company. A care plan was developed and revised for Resident #25 on 11/13/17 and revised on 5/11/18 which included, Problem, Need, Strength, and Potential Concerns: Behavior problems- impulsiveness, getting up from wheel chair without assistance, sitting on the floor, putting inedible objects into mouth. Goal: Resident will not harm themselves or others secondary to their behavior through the next review date. Approach: Report to physician changes in behavioral status, Reinforce positive behaviors, Observe behavior episodes and attempt to determine underlying cause, Observe and assure surroundings are safe (ie: all inedible objects ie: creams). Jars, etc. have tops and are closed properly, Monitor frequently for safety. A quarterly MDS 3.0 (Minimum Data Set) was composed for Resident #25 on the ARD (Assessment Reference Date) of 1/19/18 which included a BIMS (Brief Interview for Mental Status) score of 6 indicating severely impaired cognition. Resident #25's ADL (Activities of Daily Living) status was listed as needing extensive assistance for self-performance in the areas of bed mobility, transfers, dressing, toilet use and personal hygiene and needing the assistance of 1 facility staff member for bed mobility, transfers, dressing, toileting, and personal hygiene. Resident #25 needed supervision for walking and eating and set up only assistance from staff for eating. An annual MDS 3.0 (Minimum Data Set) was composed for Resident #25 on the ARD of 4/20/18 which included a BIMS score of 6 indicating severely impaired cognition. Resident #25's ADL status was listed as needing extensive assistance for self-performance in the areas of bed mobility, transfers, dressing, toilet use and personal hygiene and needing the assistance of 1 facility staff member for bed mobility, transfers, dressing, toileting, and personal hygiene. Resident #25 needed set up only assistance from staff for eating, and walked without staff assistance. Review of facility documentation dated 3/26/18 noted Resident #25 put some latex paint from a cup the contractor was using to patch a wall in her mouth. She spit it out and was sent to the ER for evaluation, no vomiting, no respiratory symptoms returned from the ER. Paint and all contracting supplies removed from the resident area. Contractor will take all supplies with them when they leave. On 7/10/18 at 10:45 AM Observed pleasantly confused, non-interview able resident sitting on the couch in the hallway with another resident. She appears well groomed and clean. Observation conducted in all rooms and noted no inedible products in the resident areas. On 7/11/18 at 10:16 AM attempted again to interview Resident #25 and noted her as very confused. On 7/11/18 at 10:20 AM an interview was conducted with LPN # 6 who stated the secure unit was being renovated and a contractor had been painting on the unit. The activities department was serving milk shakes that afternoon for the residents. The resident poured some latex paint into a cup and took a sip and spit it out. The contractor was done for the day. On 7/12/18 at 9:50 AM an interview with the Administrator was conducted. He stated the contractor was done with the job that day and took all the supplies with them. When asked if more should have been done to prevent the resident accidental exposure to the hazard, he stated yes. The administrator was asked if there had been any education provided to the contractor about the risks associated with the resident population on a secured unit he stated there was no education provided (to the contractor) before or after the incident. The administrator agreed residents could be at risk from hazards in the environment on the secured unit. A review of the report from the emergency room visit on 3/25/18 at 7:50 PM noted the resident with dementia from (facility name) was sent in because they were worried she (Resident # 25) had consumed, (paint) dried white material was around her mouth and on her gums. No vomiting and no respiratory symptoms. Very pleasant demented so cannot answer any specific questions. D/C (discharge) to nursing home. A document review of the Safety Data Sheet (Required information for hazardous products by the Occupational Safety and Health Administration) for Pro[DATE] Zero V[NAME] Interior latex paint Eg-Shel (paint consumed) noted in part: Ingestion: Wash out mouth with water. Remove dentures if any. If material has been swallowed give small quantities of water. Stop if exposed person feels sick as vomiting may be dangerous. Do not induce vomiting. No Known significant or critical hazards. The facility staff failed to maintain an environment free from accident hazards for Resident #25 when she ingested paint left accessible to her by a contracted painting company.

Based on a resident group interview, clinical record review, observations, staff interviews, and facility document review the facility staff failed to ensure safe coffee temperatures on 7/26/16 to prevent an avoidable accident for Resident #25 resulting in second degree abdominal burns after spilling hot coffee on herself, and on 2/1/17 during the survey the coffee served to Residents #26, #27, #28, #29, and #30 in the dining room at 5:45 p.m. was identified at temperatures sufficient to cause third degree burns resulting in the identification of Immediate Jeopardy. The findings included: On 2/1/17 at 10:30 a.m. during the Resident Group Interview with 15 residents present, the residents were asked about their coffee grievance in their resident council minutes. The resident council president stated, Coffee has been a problem since that lady got burned. On 2/1/17 at approximately 12:00 noon the Administrator was asked if he had a resident that had been burned from hot coffee and if the resident had significant injuries. The Administrator stated, Yes, there was a resident burned after spilling her coffee and she did have a pretty significant burn. The Administrator was asked to see a copy of the Facility Reported Incident (FRI) that was sent to the Office of Licensure and Certification regarding the burn. The Administrator stated, I did not do a FRI because we knew how the injury occurred, it was not an injury of unknown origin. The Administrator was then asked to see his investigation documentation for the burn which was provided. A review of the facility investigation was completed and Resident #25 was added to the survey sample. Resident #25 was a [AGE] year old admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent Minimum Data Set (MDS) assessment was an Annual with an Assessment Reference Date (ARD) of 1/20/17. The Brief Interview for Mental Status (BIMS) was a 15 out of a possible 15 which indicated Resident #25 was cognitively intact and capable of daily decision making. Under Section G Functional Status, G0110 Activities of Daily Living (ADL) Assistance, H. Eating = the resident was coded as being independent with setup help only. Resident #25's Interdisciplinary Care Plan dated 7/26/16 documented in part, as follows: Impaired Skin Integrity 7/26/16-Problem: Resident has disruption of skin surface, not related to pressure *Burn-location-Abdomen. Goal: The resident's disruption of skin surface will remain free from infection and show evidence of healing by- 90 days. Approach: 7/26/16 *Wound care as ordered, see current treatment record and physician's orders [REDACTED]. *Observe for pain and medicate PRN (as needed) per physician's orders [REDACTED].>*Silvadene cream to affected area BID (twice a day). 7/28/16 *D/C (discontinue) silvadene cream BID, silvadene cream to affected area Tuesday, Thursday, and Saturday with telfa and ABD (absorbent breathable dressing) PAD then secure. Bacitracin and xerofoam with ABD and secure Monday, Wednesday, and Friday. (Company Name) wound physicians to evaluate. 7/29/16 *Coffee cup with lid. *Coffee temperature not to exceed 180 degrees. (The 180 degrees was marked out and 150 degrees was added.) 8/4/16 *D/C silvadene, bacitracin to upper abdomen, santyl to lower abdomen, clean with normal saline and cover with telfa and ABD pads. 8/12/16 *D/C Bacitracin, continue santyl to lower abdomen daily. Resolved 8/26/16. The Nursing Assessment for Resident #25 dated 7/26/16 at 12:15 p.m. was reviewed and is documented in part, as follows: Category: Burn (2nd Degree or Greater)- @ (at) 2nd degree Creator Name: (Name) Licensed Practical Nurse (LPN) #1. Indicated Locations: Dining Room. Detailed Description: Resident spilled cup of hot coffee on herself. Description and Patient Assessment: Resident was attempting to drink a cup of coffee, when resident accidentally spilled the hot coffee on herself. Upon assessment noted resident's abdominal area to be red and blistering. Zinc Oxide applied. Burn specific information: *Burn location: Abdominal area. *Cause of burn known: Yes, hot coffee. *Patient knows how burn occurred: Yes, Resident was reaching for coffee cup, when cup spilled over onto residents abdominal area. *Patient location when burn occurred: Dining Room. *Any Additional Information: New order received for Silvadene cream to be applied to affected area BID and as needed until resolved. Diagnosis: [REDACTED]. Vital Signs: *Blood Pressure: 178/108 *Pulse: 88 *Respirations: 18 *Temperature: 98.0 Cognitions: Alert Notifications and Orders: *Doctor: 7/26/16 at 12:20 p.m. *Family: 7/26/16 at 12:30 p.m. *DNS (Director of Nursing Services): 7/26/16 at 12:30 p.m. First aid/treatment Information: Zinc oxide applied to affected area with protective nonstick border gauze applied. Bodily Injuries: Abdominal *Burn: 2nd Degree *Burn Description (5): Hot coffee spilled on resident. *Pain: Yes *Pain Verbal: 5 Nursing Interventions: *Were any new nursing interventions implemented? No Care Plans: Care Plan Reviewed. The SBAR (Situation Background Assessment Recommendation) tool completed by LPN #1 for Resident #25 dated 7/31/16 was reviewed and is documented in part, as follows: Situation: The change in condition, symptoms, or signs observed and evaluated is/are: Resident was burned with hot coffee. This started on: 07/26/2016 Vital Signs: BP (blood pressure) 178/108 Pulse: 88 Resident Evaluation: 1. Mental Status Evaluation: Resident in pain d/t (due to) 2nd degree coffee burn to her abdominal area. 2. Behavioral Evaluation: Depression, Social withdrawal, Resident wants to stay in bed. 6. Abdominal/GI (gastro-intestional) Evaluation: Abdominal Pain, Abdominal Tenderness. 8. Skin Evaluation: Burn, area bright red, and top layer of skin peeling. 9. Pain Evaluation: *Does the resident have pain?: Yes. *Is the Pain?: New, abdominal area. *Intensity of Pain (rate on scale 1-10, with 10 being the worse): 8 *Does the resident show non-verbal signs of pain?: Yes, moaning. Relieved by Tylenol 325 milligrams 2 tablets. Appearance: S/P (status [REDACTED]. The Non Ulcer Skin Condition Assessment completed by the facility wound nurse RN (Registered Nurse) #2 dated 7/28/16 at 4:34 p.m. for Resident #25 was reviewed and is documented in part, as follows: Wound Location: 4-Naval Wound Type: Burn Wound Measurements: 21.0 X 15.0 cm (centimeters). Depth: .1 cm Exudate: Moderate Pain With Treatment: True Pain Scale Score: 1-3 Mild Pain Pain Meds. (medications) Administered: True Treatments: ABD Pad, silvadene BID. Notes: Resident spilled coffee on abdomen and to bilateral legs on 7/26/16 burn now blistered and opened. Resident #25's Nurses Notes were reviewed and are documented in part, as follows: 7/26/16 10:58 p.m.: Resident noted with several blisters to abdomen and left inner thigh, Sites are red and pink. 7/27/16 8:02 p.m.: Resident continue to note several blister intact and open to abdomen and left inner thigh. Site are red and pink. Some amount of drainage was noted but no odor present. 7/28/16 4:39 p.m.: Rec'd (received) this am approximately at 0745 (a.m.) no c/o (complaints) of abd. (abdominal) pain tylenol 325mg given po (by mouth), noted 4 plus erythemia noted to abdominal area, with brown drainage no odor noted some blister noted to be open at this time, treatment done per MD (medical doctor) orders. 7/28/16 5:10 p.m.: Call to update MD on changes to burn. Blisters open pink and yellow areas. No oral ABT (antibiotic) order at this time. MD request Bacitracin and Silvadene Cream alternating days until healed. 7/29/16 12:18 a.m.: Resident awake and alert. Open red areas noted to abdomen with yellow drainage. Dressing placed by wound nurse and remains intact to abdomen. Complained of burning to area. Tylenol given and expressed effectiveness. Adls (activities of daily living) with assist of one. Remained in bed this shift. 7/29/16 1:37 p.m.: Resident alert and responsive, in bed resting quietly. Resident medicated as ordered for pain d/t (due to) s/p (status [REDACTED]. Abdominal area red with yellowish drainage marks noted. 4 fluid filled blisters noted. No odor noted. Treatment rendered. 7/30/16 12:33 p.m.: Resident alert and responsive, skin warm, no s/s (signs or symptoms) of distress noted. Treatment rendered for abdominal area d/t s/p coffee burn. Area remains red, fluid filled blisters have erupted, drainage noted, no odor noted. Resident medicated as ordered for c/o (complaint of) pain, with good result noted. 7/31/16 9:59 p.m.: Resident in bed, Medication tolerated denies any discomfort. MD in, and assess resident sites. New order was noted for Ultram PRN (as needed). 8/3/16 2:23 p.m.: Resident in bed alert and responsive, skin warm. Resident medicated for pain d/t s/p burn with good result. Abdominal dressing in place. Wound Dr. (Doctor) to Assess and Tx. (treat). 8/5/16 11:55 a.m.: (Name of Resident #25) has started with restorative nursing for transfers and self care. She has refused to participate and is being treated at this time for 3rd degree burns to her abdomen. Will continue to encourage to participate, and monitor for any further decline. Resident #25's physician progress notes [REDACTED]. F/up (follow-up) Coffee Burn to Abdomen. Patient stated was in dining room when happened. Stated someone handed her cup of coffee and it spilled. Wound Nurse called me last week, reports looking better. She has been using silvadene cream and just recently changed to bacitracin ointment (6) as healing well. A. (Assessment) 1. Coffee Burn to Abdomen, 2nd degree Burn (7). 2. Bipolar P. (Plan) Continue current treatment and wound care. Resident #25's Physician order [REDACTED]. 7/26/16: Silvadene cream (8) to apply to affected area BID and PRN until resolved. 7/28/16: 1. D/C Silvadene Cream BID. 2. Apply silvadene cream to affected area on Tuesday, Thursday, and Saturday with telfa and ABD and secure. 3. Apply bacitracin and xeroform with ABD and secure to affected area on Monday, Wednesday, Friday, and Sunday until resolved. 7/28/16: (Name of Wound Care Specialist Group), wound physician to evaluate. 7/29/16: OT (occupational therapy) evaluate and treat. 7/31/16: Ultram 50mg po q (every) 6 hours prn times 2 weeks then d/c. 8/1/16: PT (physical therapy) evaluate and treat. 8/4/16: D/C Silvadene, Bacitracin to upper abdomen/santyl to lower abdomen. Santyl (8) to lower affected area on abdomen, cleanse with normal saline and cover with telfa then abd pads daily. 8/12/16: D/C Bacitracin to upper abdomen. Santyl daily to lower abdomen and cover daily cleanse with NS (normal saline). 8/24/16: D/C Santyl to abdomen area resolved. Resident #25's Physician Wound Care Specialist Evaluations were reviewed and documented in part, as follows: 8/11/16: History of Present Illness: CHIEF COMPLAINT: Patient has a wound on their abdomen. STATEMENT: At the request of (Name of Resident #25's Attending Physician) this [AGE] year old female was seen and evaluated today. She presents with a burn wound of the left abdomen of at least 1 days duration. There is moderate serous exudate. Physical Exam: Abdomen: Wound. Burn Wound Of The Left Abdomen: FOCUSED WOUND EXAM (SITE 1) ETIOLOGY: Burn WOUND SIZE (L (length) x W (width) x D (depth): 2.0 x 15.0 x Not Measured cm. SURFACE AREA: 30.00 cm squared. EXUDATE: Moderate Serous THICK ADHERENT BLACK NECROTIC TISSUE (ESCHAR): 70% SKIN: 30% ADDITIONAL INFORMATION: Non black eschar DRESSINGS: Santyl-Once Daily REASON FOR NO DEBRIDEMENT: Debridement refused. Assessment and Plan: BURN WOUND OF THE LEFT ABDOMEN INVESTIGATIONS: The total length of this visit was 39 minutes and greater than 50% were spent in counseling and coordination of care specific to A Burn Wound Of The Left Abdomen. New patient, who was burned from hot coffee on the abdomen- now with large burn on her stomach-still with non-black eschar present--Refuses debridement today. Will soften up the eschar for possible debridement next week. 8/16/16: History of Present Illness: CHIEF COMPLAINT: Patient has a wound on their abdomen. STATEMENT: At the request of (Name of Resident #25's Attending Physician) this [AGE] year old female was seen and evaluated today. She presents with a burn wound of the left abdomen of at least 5 days duration. There is moderate serous exudate. Physical Exam: Abdomen: Wound. Burn Wound Of The Left Abdomen: FOCUSED WOUND EXAM (SITE 1) ETIOLOGY: Burn WOUND SIZE (L (length) x W (width) x D (depth): 1.0 x 13.5 x Not Measured cm. SURFACE AREA: 13.50 cm squared. EXUDATE: Moderate Serous THICK ADHERENT BLACK NECROTIC TISSUE (ESCHAR): 25% SKIN: 75% WOUND PROGRESS: Improved DRESSINGS: Santyl-Once Daily REASON FOR NO DEBRIDEMENT: Debridement refused. Assessment and Plan: BURN WOUND OF THE LEFT ABDOMEN- IMPROVED EVIDENCED BY DECREASED SURFACE AREA. 8/23/16: History of Present Illness: CHIEF COMPLAINT: Patient has a wound on their abdomen. STATEMENT: At the request of (Name of Resident #25's Attending Physician) this [AGE] year old female was seen and evaluated today. She presents with a burn wound of the left abdomen of at least 12 days duration. There is exudate. Prior healing wound has improved and required confirmation of current clinical status and evaluation with preventive recommendations to prevent recurrence. Physical Exam: Abdomen: Normal Burn Wound Of The Left Abdomen: FOCUSED WOUND EXAM (SITE 1) ETIOLOGY: Burn WOUND PROGRESS: Resolved Assessment and Plan: BURN WOUND OF THE LEFT ABDOMEN- (RESOLVED ON 8/23/2016)-RESOLVED. Resident #25's Weekly Skin assessment dated [DATE] at 1:06 p.m. was reviewed and documented in part, as follows: Wound Location: Naval Wound Type: Scar Status: Still Present Comments: Abdomen scar measures L (length) 7 x W (Width) 20 cm from previous documented burn. The facility investigation Witness Statements of Resident #25's Coffee Burn were reviewed and documented in part, as follows: 7/26/16 RN #1 Unit Manager 4th Floor: I was coming out of the kitchen and (Name of Resident #25) had just been served coffee and she kept moving up to the table and back from table that she was sitting at. Then she attempted to grab her coffee and knocked it over instead with her hand onto herself. She then yelled I'm on fire and I told her to come with me so that she could be assessed by a nurse. I took her upstairs with me on elevator and made sure she got beck to 2nd floor and then I told nurse to assess her because she spilled coffee on herself. 7/26/16 CNA (Certified Nursing Assistant) #1: I gave the resident coffee in plastic cup. I filled it halfway. I left her went to another table to serve, heard her yelling turned around and look the coffee was running off the table and she told me she had spilled the coffee on her. 7/26/16 Morning Kitchen Supervisor: During lunch time (Name of Resident #25) was served her juice and coffee in Styrofoam cup. As we were pouring other residents drinks, we heard (Name of Resident #25) scream. Both of us turned into her direction and realized she had spilled her cup of coffee in her lap. (Name of CNA) began wiping her and pulling her top from against her skin. 7/26/16 LPN #1: To whom it may concern on a Monday during lunch time. (Name of Resident #25) came to me in a very upset state, she was wet from hot coffee. I immediately assisted resident to her room, removed the wet shirt. I assessed the area. At the time of my initial assessment, area was bright red with top layer of skin peeling. I pat dried the area and apply bacitracin ointment to affected area covered with ABD pads. I then notified the MD made him aware of situation. I received a new Tx. (treatment) order. 7/28/16 Wound Nurse RN #2: This writer went to assess burn to abdomen in resident's room. Resident's abdomen showed redness with blisters noted. Open areas with pink/yellow wound bed. Peri-wound redness noted. Moderate ser-sangious drainage noted. Treatment per MD order silvadene daily. After assessment this writer with unit manager Name (LPN #2) place call to MD to see if we could get prophylaxis antibiotic to decrease infection. MD order for bacitracin and silvadene alternate thru out the week was given. Treatment was completed per MD order. On 2/1/17 at 4:30 p.m. an interview was conducted with RN #1 Unit Manager 4th Floor and she was asked to explain what happened the day Resident #25 received a coffee burn. RN #1 stated, I was in the kitchen, getting ready to walk out. (Name of Resident #25) was at the table and was impulsive moving back and forth. The next I knew she was screaming, I'm on fire. I turned around and she had knocked her cup of coffee over. I took her to the 2nd floor to have her assessed. On 2/2/17 at 12:00 noon an interview was conducted with LPN #1 and she was asked to explain what happened the day Resident #25 received a coffee burn. LPN #1 stated, The resident was brought to me on the floor by another nurse. The resident was hysterical, shaking and crying saying coffee spilt on me. I immediately took the resident to her room to assess her. I removed her clothes because she was wet in the abdominal area. She was bright beet red on the abdomen and with in minutes the top layers of skin started peeling. I was a 2nd degree burn. She was in some discomfort, scared and afraid. I gave her something for pain and called the Director of Nursing, the Doctor, and (Name of Responsible Party). On 2/2/17 at 12:20 p.m. an interview was conducted with the Wound Nurse RN #2 and she was asked what day she observed the burn area on Resident #25. RN #2 stated, I heard about the burn. I saw it on 7/28/16 and it was a 2nd degree burn. On 2/2/17 at 12:45 p.m. an interview was conducted with Resident #25 and she was asked to tell the surveyor about the day she was burned by her coffee. Resident #25 stated, I was getting a second cup pf coffee and when I got it, it was boiling hot. When I got it, it spilled on me. It burnt me bad I have a scar and it took a long time to heal. It was burning hot I cried, my skin was peeling off and (Name of LPN #1) kept saying hold your horses. On 2/2/17 at 1:15 p.m. an interview was conducted with LPN #2 and she was asked to describe the appearance of Resident #25's abdominal burn area on 7/28/16 when she was with the Wound Nurse assessing it. LPN #2 stated, I was off when the burn occurred, I went down to look at it with the Wound Nurse. It was red with yellow slough, top layer of skin gone and they had dressed it. We pulled the dressing back and it didn't look the best. (Name of Resident #25) said she was in the dining room at the table, she had gotten coffee,spilled it and burnt herself. Surveyor asked, What degree burn was it? LPN #2 stated, I would say a 2nd degree burn. On 2/2/17 at 1:30 p.m. an interview was conducted with the Morning Kitchen Supervisor and she was asked prior and upto Resident #25 receiving a coffee burn on 7/26/16 how when was the coffee being temped. The Morning Kitchen Supervisor stated, We were only testing the coffee before before it came to the dining room from the kitchen and it was running at 170 degrees. The Administrator provided a Quality Performance/Facility Plan of Action dated 7/29/16 with a completed date of 8/31/16 for review by surveyor and is documented in part, as follows: DEFICIENCY IDENTIFIED: Unsafe practice of using a Styrofoam 16 ounce cup with coffee without a protective lid. 1. Immediate Corrective Action for Residents Affected: -Document efforts to remove the causative factors. (removal of coffee pot) Styrofoam cups for hot liquids. 2. Identification of Residents with potential to be affected: -Nursing to complete a hot liquid assessment on each resident. -Plant operations inspected coffee maker for proper functioning. 3. Measures or systems changes to prevent reoccurrence: -In-service 100% staff on identification of potential risk areas such as common areas without protective lid on cup which exposes all residents for injury. -Remove all coffee pots from the entire building that are not in dining room for inspection and temperature logs documentation. -Dietary Manager will be in-serviced on temperature logs and daily monitoring. -Staff will be educated 100% on Hot Liquid Policy and Procedure. 4. Monitoring changes/systems to ensure no deficient practice: -Plant operations will maintain a weekly check on coffee maker and all other hot beverage appliances to ensure compliance and required temperature. -Random testing of coffee maker temperatures will be conducted weekly and reported to Quality Assurance meeting monthly. -Random testing of coffee being served to residents is in proper cup with lid weekly and submitted. The facility policy and procedure titled SAFE HANDLING AND SERVING TEMPERATURES FOR HOT BEVERAGES revised 7/29/16 that per the Director of Nursing was the policy used to educate staff on Hot Liquids was reviewed and documented in part, as follows: Policy: The temperatures that hot beverages should be served at are governed by palatability and by the risk for a burn. Procedure: 4. Skin on the arms and legs-being less sensitive than the mouth-can suffer a burn before the danger is realized. The elderly who are immobilized in a wheelchair and confused residents are more susceptible. 5. Because of this susceptibility, follow the following safety precautions: a. Serve the hot beverages between 140 and 155 degrees. Dietary should record hot beverage temperatures for every meal. c. Residents at high risk for spillage should be assisted as needed. Recommend using an insulated mug with a lid for all hot beverages when needed. d. A staff member should pour the hot beverages, in a manner that protects the resident's safety. Fill hot beverage mugs to 75% or less of their capacity. g. Transfer hot beverages from the urns or warmer to a serving container which may cause the temperature to drop. 6. When serving hot liquids to residents with behavioral or medical conditions that put them at risk for spills, consider the following: b. Allow hot liquids to cool before serving. The facility HOT LIQUIDS SAFETY EVALUATION for residents was reviewed for Resident #25 and documented in part as follows: Date: 7/29/2016 Risk Factors: checked for Resident #25: Mood-varies over course of day/easily agitated. Behaviors-Frequent impulsive acts/short tempered. Total check marks 2 indicating the resident is at risk for injury from spills of hot liquids. Interventions for Resident #25 dated 7/29/16: -Resident to use cup with lid. -Temperature of liquid not to exceed 180 degrees. -Staff to assist resident with all hot liquids. The Hot Coffee Temperature Logs were reviewed from July 2016 through January 2017. The Dietary Manager stated, These temperatures were the temperature of the coffee coming from the kitchen into the dining room. The Hot Coffee temperatures ranged from the following: Month High Low July 2016 190 174 August 2016 190 173 September 2016 182 170 October 2016 175 170 November 2016 170 170 December 2016 180 170 January 2017 175 170 On 2/1/17 at 5:30 p.m. in the facility dining room with two surveyors present 5 Residents asked and received a cup of coffee during their dinner meal, Residents #26 through #30. After each resident received their cup of coffee, they removed the lids and began drinking the coffee. Two extra cups of coffee were left over and this surveyor immediately asked the Dietary Aide to obtain a coffee temperature. The coffee temperature was 159.9 degrees in the first cup and 161.1 degrees in the second cup. Prior to checking the coffee temperatures the Dietary Aide stated, I checked the temperature of the coffee before I brought it out of the kitchen and it's ok, it was under the 170 degrees. After the Dietary Aide temped the coffee no staff in the dining room proceeded to remove or replace the coffee from the 5 residents drinking coffee. Resident #26 was a [AGE] year old admitted to the facility originally on 4/26/11 and readmitted on [DATE] with [DIAGNOSES REDACTED]. The most recent Minimum Data Set (MDS) assessment was an Annual with an Assessment Reference Date (ARD) of 11/16/16. The Brief Interview for Mental Status (BIMS) was a 15 out of a possible 15 which indicated Resident #26 was cognitively intact and capable of daily decision making. Under Section G Functional Status, G0110 Activities of Daily Living (ADL) Assistance, H. Eating= the resident was coded as needing supervision with setup help only. Resident #27 was a [AGE] year old admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent Minimum Data Set (MDS) assessment was an Annual with an Assessment Reference Date (ARD) of 2/3/17. The Brief Interview for Mental Status (BIMS) was a 15 out of a possible 15 which indicated Resident #27 was cognitively intact and capable of daily decision making. Under Section G Functional Status, G0110 Activities of Daily Living (ADL) Assistance, H. Eating= the resident was coded as being independent with setup help only. Resident #28 was a [AGE] year old admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent Minimum Data Set (MDS) assessment was an Annual with an Assessment Reference Date (ARD) of 1/27/17. The Brief Interview for Mental Status (BIMS) indicated the resident has short and long term memory problems and had modified independence in cognitive skills for daily decision making. Under Section G Functional Status, G0110 Activities of Daily Living (ADL) Assistance, H. Eating= the resident was coded as being independent with setup help only. Resident #29 was a [AGE] year old admitted to the facility originally on 11/17/15 and readmitted on [DATE] with [DIAGNOSES REDACTED]. The most recent Minimum Data Set (MDS) assessment was an Annual with an Assessment Reference Date (ARD) of 11/21/16. The Brief Interview for Mental Status (BIMS) indicated the resident had long term memory problems and was moderately impaired in cognitive skills for daily decision making. Under Section G Functional Status, G0110 Activities of Daily Living (ADL) Assistance, H. Eating = the resident was coded as being independent with setup help only. Resident #30 was a [AGE] year old admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent Minimum Data Set (MDS) assessment was an Annual with an Assessment Reference Date (ARD) of 12/20/16. The Brief Interview for Mental Status (BIMS) was a 15 out of a possible 15 which indicated Resident #30 was cognitively intact and capable of daily decision making. Under Section G Functional Status, G0110 Activities of Daily Living (ADL) Assistance, H. Eating = the resident was coded as being independent with setup help only. On 2/1/17 at 5:50 p.m. this surveyor called the supervisor at the Office of Licensure and Certification, State Department of Health, and informed the supervisor of the above findings and the concern for an Immediate Jeopardy situation due to hot coffee currently still being served in the facility. A return called was received at 6:05 p.m. from the supervisor confirming Immediate Jeopardy for failure to ensure an environment free from accidents and hazards in regards to hot coffee of sufficient temperature to cause tissue injury being available and served to residents. At 6:10 p.m. the Administrator and the Director of Nursing were informed of the above findings and Immediate Jeopardy was called at 6:15 p.m. Based on review and acceptance of the Facility Plan of Action dated 2/1/17, the Immediate Jeopardy was removed on 2/1/17 at 8:15 p.m. The Facility Plan of Action dated 2/1/17 accepted at 8:15 p.m. documented in part as follows: DEFICIENCY IDENTIFIED: Hot Liquid Temperatures ACTIONS: 1. Immediate Corrective Action for Residents Affected: Educating Dietary Employees on new standards. (per Administrator the facility policy and procedure titled SAFE HANDLING AND SERVING TEMPERATURES FOR HOT BEVERAGES revised 7/29/16 was used for inservicing). 2. Identification of Residents with potential to be affected: All residents drinking hot liquids. 3. Measures or systems changes to prevent reoccurrence: -Brew Hot Liquids at 170 degrees -Remove and let set and temp every 15 minutes until it reaches 155 degrees, it will not leave kitchen until it is 155 degrees. -Temperature logs and daily monitoring. 4. Monitoring changes/systems to ensure no deficient practice: Dietary will maintain a daily log on all floors and dining room for compliance and submitted to QAPI (Quality Assurance Performance Improvement) meeting monthly. On 2/3/17 at 11:00 a.m. an interview was conducted with the Dietary Manager. The Dietary Manager was asked what the dietary department had been instructed to do after Resident #25's coffee burn. The Dietary Manager stated, We were told to make sure we checked the temperature of the coffee after it was brewed before it went to the dining room. Maintenance changed the coffee brewer temp to 170 degrees. We let the coffee go out of the kitchen to the dining room at 170 degrees. Surveyor asked, Were you ever told to make sure the coffee was 155 degrees before letting it leave the kitchen? The Dietary Manager stated, I can't remember anything about 155 degrees, but it will be 155 degrees now before it ever leaves the kitchen. On 2/3/17 at 9:30 a.m. an interview was conducted with the Administrator asking him to explain what occurred after the July 2016 Corrective Action Plan after Resident #25 received a 2nd degree burn from hot coffee in regards to communication with the dietary department. The Administrator stated, Dietary was only told to temp the coffee out of the coffee maker then they would send it out to the floors. It was never communicated to dietary to make sure the coffee temp was at 155 degrees before it left the kitchen and entered the dining room. Based on the temperature logs it was still running in the 170's for temps. According to an American Burn Association document titled Fire and Burn Safety for Older Adults Educator's Guide, under the heading General Background Information .Risk Factors .Physical Changes, the document read Older adults experience a myriad of physical and cognitive changes associated with the aging process that makes them more vulnerable to fire and burn injuries . there are significant changes in sensory perception. The ability to see, hear and feel potential fire and burn dangers diminishes proportionally as one gets older .Since older adults also have thinner skin, they

Based on observation, staff interviews, clinical record review and facility document review the facility staff failed to provide the necessary treatment and services, consistent with professional standards of practice, to prevent pressure ulcers from developing for 1 of 54 residents in the survey sample, Resident #12. The facility staff failed to provide appropriate monitoring (1) for Resident #12 who was assessed as at risk for pressure ulcer development. As a result, a newly developed pressure ulcer (2) was not identified until it had advanced to a stage III (3). The left ankle pressure ulcer was first identified on 9/2/16. The findings included: Resident #12 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The significant change MDS (Minimum Data Set) with an assessment reference date of 9/2/16 coded the resident as scoring a 3 out of a possible 15 on the Brief Interview for Mental Status (BIMS), indicating the resident had severely impaired daily decision making skills. The resident required extensive assistance of two staff for bed mobility (how a resident moves to and from lying position, turns side to side, and positions body while in bed). The resident did not exhibit any behaviors that would interfere with resident care or exhibit rejection of care. The resident weighed 172 pounds and did not trigger for weight loss. The resident was coded as having a stage III pressure ulcer. On the Braden Scale Pressure Ulcer Risk Assessments dated 3/15/16 the resident scored a 10, and on 12/23/16 scored a 12. Both scores indicated the resident was at high risk for pressure ulcer development. The comprehensive plan of care dated 3/14/16 identified the resident was at risk for developing skin breakdown due to need of extensive/total assistance with bed mobility and incontinence of bowel and bladder. The goal was the resident will have intact skin, free of redness, blisters, or discoloration over bony prominence through the next review date. Approaches to achieve the goal included; report changes in skin status (i.e., signs and symptoms of infection, non-healing, new areas) to physician, assist PRN (as needed) to reposition/ shift weight to relieve pressure, minimize pressure over bony prominences, complete Weekly Skin Checks, notify nurse immediately of any new areas of skin breakdown, redness, blisters, bruises, discoloration noted during bathing or daily care. A facility internal Event Report dated 9/2/16 evidenced the resident was first identified with a newly developed pressure ulcer-stage III to the left ankle. The pressure ulcer was found by the Restorative Aide during treatment. Predisposing Factors were listed as: Non-Ambulatory, Non-Compliance to Turn and Reposition, Incontinence of Urine and Bowel, and Resists care. Nursing interventions included preventative skin care, elevation/ float heels, protection of body prominences. Additional information listed Prevalon boots (4) reapplied with new ones. Review of the clinical nurses notes, comprehensive plan of care and the current MDS failed to evidence any behaviors of non-compliance with turning and repositioning/ resistance of care; as noted on the aforementioned Event Report. Furthermore, the Director of Nursing (DON) and the Unit 2 (name of unit) nurse manager were not able to provide any evidence to support the resident had exhibited any behaviors of non-compliance with turning and repositioning/ resistance of care. The facility wound nurse assessed the newly developed stage III pressure ulcer on 9/2/16. The ulcer measured 1.5 cm (centimeters) x 1.0 cm x 0.2 cm., tissue types were granulation and slough (5). The wound nurse documented the resident was her own responsible party and was educated on the importance of off loading heels off mattress and new treatment to aide in healing. New physician orders [REDACTED]. The Wound Care Specialist Evaluation dated 9/6/16 read, in part: Stage 3 Pressure Wound of the left lateral (side) ankle, etiology-pressure. Wound size- 1.0 cm x 0.7 cm, depth not measured, 40% black necrotic (6) tissue, 60% granulation. The wound was debrided (7) by surgical excision. Treatment orders were for daily dressing changes with Santyl (a [MEDICATION NAME] ointment) and calcium alginate dressing (a type of dressing that forms into a gel when it comes into contact with liquid) once a day. The Wound Care Specialist evaluated the resident's left ankle pressure ulcer weekly from 9/6/16 through 11/11/16. The wound required surgical excisional debridement to remove dead tissue to aide in healing on the following dates: 9/6, 9/13, 9/20, 9/26, and 10/4/16. The left ankle pressure ulcer was noted as resolved on 11/11/16. On 2/1/17 at 10:00 a.m., and 6:00 p.m. the resident was observed in bed. The resident continued to be confused and speaking nonsensical. The Prevalon boots were on the resident's feet both times. The Treatment Administration Record (TAR) for August 2016 was reviewed. The TAR failed to evidence Resident #12 was provided Prevalon boots and or any other documentation of off loading/ protection of skin to the residents ankles prior to the development of the stage III pressure ulcer. On 2/2/17 from 12:00 p.m. to 1:30 p.m., an interview was conducted with the Director of Nursing (DON) and the above findings was shared. The DON stated all refusals of care are to be documented by the CNAs (Certified Nurse Aides) and reported to the nurse. The nurse was then responsible to revise the plan of care to include this behavior. The pressure ulcer prevention program included the CNAs to observe and monitor for changes in skin condition during the provision of twice weekly showers and daily baths. If a change is observed they are to be reported immediately to the nurse and documented on the shower sheet. The nurse should then go and do a full skin assessment. She stated that the nurses should be checking pressure points during provision of direct care every day. She stated she would have expected the CNAs to have found the skin changes to the residents left ankle prior to it being found at an advanced stage. She further stated, If it was found with blanchable (8) redness we could have got right on it .put on boots right then and there .off load heels, off the surface not just put pillows underneath .have OT (occupational therapy) screen/evaluate for other options for off loading. The DON was asked about monitoring and stated, That's a problem we had been trying to fix, to get the CNAs to do what they say they are doing. The DON stated they had identified concerns with their pressure ulcer prevention program in November (2016). The above findings was further shared with the Administrator and the DON at an end of day briefing on 2/2/17 at 4:20 p.m. A copy of the Performance Improvement Action Plan developed on 11/15/16 was reviewed. In addition to the Action Plan the Administrator stated changes were also made within the clinical nurse managers. The DON stated a 100% body sweep was also conducted (a skin assessment on all residents) at this time, no additional facility acquired pressure ulcers were identified. On the morning of 2/3/17 the DON provided additional information to the survey team for review. This additional information was reviewed with the DON from 12:00 p.m.- 1:20 p.m. The DON stated the facility staff failed to monitor Resident #12's skin (ankles) for changes, stating, It didn't just open up .the resident is dependent on staff to do their job. The Performance Improvement Action Plan dated 11/15/16 read, in part: Topic/Opportunity/Problem: Decrease In House Acquired Pressure Ulcers Action/Interventions: 1. Admitting nurse will complete skin assessment and document and Braden Score within 4 hours of arrival. 2. Assigned nurse will complete weekly skin checks and document in Woundsense (electronic record). 3. Assigned CNA will complete a full body assessment and document on Shower sheet. 4. Daily skin assessment during ADL's. 5. All residents identified as being high risk of breakdown will be placed on a Specialty Mattress according to policy. 6. Frequent rounding on high risk resident to assure all interventions in place. 7. Risk Management meeting held every Friday with IDT (interdisciplinary team). 8. Careplans to be completed with resident specific interventions. 9. Assure communication to line staff of intervention implemented. 10. If a decubitus (pressure ulcer) occur, ensure the following: Assessment of wound and location, Notify MD, responsible party, obtain order for treatment procedure, document in Woundsense, document in event manager, new decubitus and interventions are communicated to line staff, careplan to be updated with new interventions, evaluate for effectiveness of intervention, identify if any other consultations or interventions are required, document response in medical record. Compliant date 1/4/17. There were no other concerns identified during the survey with pressure ulcers. Citation F-314 will be cited as Past Non-Compliance. The facility policy titled Pressure Ulcer Risk Assessment (not dated) read, in part: The purpose of this procedure is to provide guidelines for assessment and identification of residents at risk for developing pressure ulcer. Assessment: 1. Risk Assessment- A pressure ulcer risk assessment will be completed upon admission, and then weekly x 1, with significant changes, and quarterly. 2. Skin Assessment- Skin will be assessed for the presence of developing pressure ulcer on a weekly basis or more frequently if indicated. *3. Monitoring: a. Staff will perform routine skin inspections (with daily care). b. Nurses are to be notified to inspect the skin if skin changes are identified. c. Nurses will conduct skin assessments at least weekly to identify changes. (1) Monitoring - At least daily, staff should remain alert to potential changes in the skin condition & should evaluate & document identified changes. National Pressure Ulcer Advisory Panel (NPUAP) (2) Pressure Ulcer - A pressure ulcer is any lesion caused by unrelieved pressure that results in damage to the underlying tissue(s). (NPUAP) (3) Stage III - Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining or tunneling. (NPUAP) (4) The Prevalon Heel Protector was specifically designed to address the problem of patient movement and its negative effect on heel offloading. Prevalon's unique dermasuede fabric interior gently grips the limb so it remains fully offloaded, even when the patient is moving. http://www.medline.com/product/Prevalon-Heel-Protectors-by-Sage-Products/Z05-PF / (5) Slough tissue is yellow or white tissue that adheres to the ulcer bed in strings or thick clumps, or is mucinous. (RAI-Resident Assessment Instrument) (6) Necrotic (dead) or devitalized tissue that has lost its usual physical properties & biological activity. (NPUAP) (7) Debridement - Debridement is the removal of devitalized/necrotic tissue & foreign matter from a wound to improve or facilitate the healing process. Various debridement methods include: Sharp or surgical debridement refers to removal of foreign material or devitalized tissue by a surgical instrument. (NPUAP) (8) Blanchable skin test- Press on the red, pink or darkened area with your finger. The area should go white; remove the pressure and the area should return to red, pink or darkened color within a few seconds, indicting good blood flow. skilledwoundcare.com/pressure-ulcers

Based on clinical record review, facility documentation and staff interviews the facility staff failed to provide supervision for 1 of 25 residents in the survey sample, Resident #13, resulting in harm. The facility staff failed to provide supervision to prevent an elopement for Resident #13 resulting in harm. The findings included: Resident #13 was a [AGE] year old originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident #13's [DIAGNOSES REDACTED].*Diabetes Mellitus, *Hypertension, *Parkinson's Disease, and *Anoxic Brain Injury secondary to Cardiac Arrest. *Hypoxic [DIAGNOSES REDACTED]: any abnormal condition of the structure or function of brain tissues, due to an acute lack of oxygen supply. *Diabetes Mellitus: a complex disorder of carbohydrate, fat, and protein metabolism that is primarily a result of a deficiency or complete lack of insulin secretion by the beta cells of the pancreas or resistance to insulin. *Hypertension: a common disorder that is a known cardiovascular disease risk factor, characterized by elevated blood pressure over normal values of 120/80 mm Hg (milligrams of mercury) in an adult. *Parkinson's Disease: a slowly progressive degenerative neurologic disorder characterized by resting tremor, pill rolling of the fingers, a masklike facies, shuffling gait, forward flexion of the trunk, loss of postural reflexes, and muscle rigidity and weakness. *Anoxic Brain Injury: an abnormal condition characterized by a local or systemic lack of oxygen to brain tissue causing injury or irreversible death to the brain tissues. The above definitions were derived from Mosby's Dictionary of Medicine, Nursing, and Health Professions 8th Edition. The most recent Comprehensive Minimum Data Set (MDS) assessment was an Annual assessment with an Assessment Reference Date (ARD) of 5/4/15 with a Brief Interview for Mental Status (BIMS) coded as resident is rarely/never understood. Staff was interviewed for mental status which revealed that Resident #13 had long and short term memory problems and was severely impaired in cognitive skills for daily decision making. Under functional Status Resident #13 was extensive one person assist for bed mobility, transfers, walking, and dressing. Resident #13's Comprehensive Care Plan was reviewed. The resident had Interdisciplinary Care Plans in place that included Elopement Risk/Exit Seeking and Behaviors. On 10/6/15 both of the Interdisciplinary Care Plans had been reviewed and documented in part read, as follows: Elopement Risk/Exit Seeking Problem: Resident is at risk for elopement as evidenced by: cognitive impairment, independent mobility/wc (wheelchair), poor decision making skills, exit seeking behavior, wanders oblivious to safety needs. Exhibits exit-seeking behavior as evidenced by trying to elope. Approaches: Use discrete resident identifier, so staff is aware of the resident's elopement risk. Provide staff supervision for resident when attending an out-of-facility activity. Use audible monitoring system to alert staff of exit seeking behaviors. The Care Plan also indicated that Resident #13 had a Wanderguard monitoring bracelet in place until 11/11/15 at which time it was discontinued. Resident #13's Behavior Care Plan documented in part, read as follows: Problem: Behavior Problem Wandering, as evidenced by history of wandering in and out of other residents rooms. Attempting to leave unit. Approaches: Address wandering behavior by walking with or attempt to redirect from inappropriate area; engage in divisional activity. Intervene as needed to protect the rights and safety of others, approach in calm manner; divert attention, remove from situation and take to another location as needed. Both Care Plans were reviewed again on 1/12/16. Resident #13 eloped from the facility on 12/17/15, the Wanderguard monitoring bracelet was removed on 11/11/15; however, based on the Care Plan review on 10/6/15 Resident #13 was identified to have elopement, exit seeking, and wandering behaviors. The Physician's Progress Note dated and signed 10/2/15 documented in part, read as follows: Goes down off floor for activities. Neruo A & O x 1 Person, (alert and orient to person only). Diagnoses: [REDACTED]. Resident #13's Monthly Summary's date 10/10/15, 11/9/15 and 12/9/15 under Cognitive Patterns documented in part, read as follows: Indicators of Delirium: Disorganized thinking checked. Memory: Long-Term Memory problems checked. Daily Decision Making Skills: Moderately Impaired-decisions poor, cues/supervision required. Quarterly Nursing Evaluations for Resident #13 dated 5/6/15, 5/8/15, and 8/4/15 under Elopement Risk Evaluation each placed the resident at risk for elopement. Resident #13's Nurse's Note dated 11/11/15 documented in part, read as follows: Resident wanderguard checks and wanderguard d/c'd (discontinued) secondary to resident no longer being an elopement risk. Resident own R/P (responsible party) and made aware, also emergency contact (name) contacted. MD (doctor) also aware and in agreement. Resident #13's Nurse's Notes were reviewed for 12/17/15 and documented in part, read as follows: 4 p.m. Upon making walking around, resident was not in his room. Per off going staff nurse resident was downstairs participating in activities. 5:35 p.m. Resident was unable to be locate. Code green was called. Facility staff search all units, offices, bathroom and surrounding area, resident was not found. 6:00 p.m. Facility staff began searching the surrounding neighborhood. Resident was unable to be locate. 12/18/15 4:00 a.m. Resident was returned via police who said he was found down by the tracks (railroad tracks) in a puddle of water. Vitals taken 149/96, P (pulse) 92, R (respirations) 16, T (temperature) 94 degrees oral, O2 sats (oxygen saturation) 98 % room air. Resident given blankets to passively warm and transferred to ER (emergency room ) at (hospital) via ambulance on a stretcher after call to 911. Clinical Record review for Resident #13 revealed a Nursing Home To Hospital Transfer Form dated 12/18/15 at 4:00 a.m. documented in part, read as follows: Key Clinical Information Relevant Diagnoses: [REDACTED].>Vital Signs B/P: (blood pressure) 149+/96, HR: (heart rate) 92, R (respirations) 16, Temp: (temperature) 94 degrees Time Taken 4:00 a.m. Risk Alerts: other: wandering. On 1/13/15 the Director of Nursing presented the surveyor a typed timeline of Resident #13's elopement. The timeline documented in part, read as follows: Resident, (Name) on 12/17/15 at 5:10 p.m. exit the facility via wheelchair. He was at an Adhcoc resident council meeting in the dining room located on the first floor. After meeting was completed he waiting to be transported back to the unit. He propelled himself to the front lobby and exit the front door. The receptionist checked the elopement and wandering book for his name and picture which had been removed. On 10/28/15 an elopement evaluation was completed and indicated that he was not at risk. The CNA (Certified Nursing Assistant) who was assigned to him went to the dining room to locate him for dinner. He was unable to be located. The CNA asked the receptionist had she seen (Resident #13) and she stated I saw him go out the front door. The CNA called a Code Green. The facility and grounds was search an he was unable to be located. Staff on duty and off duty staff search for him on foot and by cars. Norfolk Police was notified and they search the entire neighborhood on foot and cars. A silver alert was issued by the police with a picture and a description. The staff continue to search until 12 midnight. Norfolk Police continue to search. I received a call at 3:10 a.m. that the police had located him and they were at the building. I instructed them to take him to (name) hospital for evaluation. I was informed that he was found sleeping beside the railroad tracks. I immediately called his mother at 3:20 a.m. to inform her that he found, where, who, and that I asked the police to take him to ER for evaluation. I informed her that he was talking and no physical harm was noted by police. Name (Resident #13) was admitted to MS (medical -surgical) unit. The local police Incident/Investigation Report dated 12/17/15 was reviewed. The Incident/Investigation Report stated that Resident #13 was a missing person that was last seen at 17:15 (5:15 p.m.) and was reported missing at 18:00 (6:00 p.m.). The Incident/Investigation Report under the narrative section documented in part, read as follows: Complainant reports listed victim wheeled out of facility at approximately 1710 (5:10 p.m.) hours. Staff was unaware he had left the facility until approximately 18:00 (6:00 p.m.) hours when they call PD (police department). Victim has several medical issues and limited mental status. A review of the Prehospital Care Report Summary by the City Fire-Rescue documented in part, read as follows: Call Received 04:11:34 a.m. Dispatched 04:11:41 a.m. En Route 04:14:24 a.m. On Scene 04:22:07 a.m. Patient Contact 04:23:00 a.m. Left Scene 04:27:24 a.m. At Destination 04:28:39 a.m. Clinical: Dispatch Reason: HEAT/COLD/ALERT/W/O (without) 1ST Party (indicates heat was not the issue). Narrative History Text:: Patient with the staff who stated that the PT (patient) was reported missing earlier. Found this morning laying on railroad tracks by police. The PT brought back and the staff wanted him checked out because he was hypothermic. The PT was found out front of the entrance wrapped in blankets. The PT stated he was cold but did not hurt anywhere. Name (local hospital) Emergency Department Physician Provided Note dated 12/18/15 at 5:53 a.m. documented in part, read as follows: Assessment/Differential Diagnosis: [REDACTED]. ED (emergency department) Course/Medical Decision Making: Initial temperature 96.8 and patient changed into dry clothes and warmed repeat temperature 98.1. Patient is awake and answers some questions but is confused and disoriented. Case discussed with name (doctor) who is admitting patient. Comments: Name (Resident #13) presents to the ED via NPD (police department) for medical screening. Patient was found outside lying in a puddle near the railroad track. Patient had been a missing person for several hours, is currently staying at (name of facility) but eloped last night. He currently denies any complaints other than being cold. Physical Exam: Patient present via EMS (emergency medical services) soaked and disheveled and cold. ED Disposition: Admit, I have assessed patient risk. The patient will benefit from observation care. Resident #13 was admitted to the hospital on [DATE] Resident #13's Hospital Discharge Summary dated 12/22/15 documented in part, read as follows: Hospital Course Chief Complaint/History of Present Illness: Name (Resident #13) is a [AGE] year old old male with a PMH (past medical history) of Hypertension, Diabetes Mellitus, Substance Abuse, Hypoxic [DIAGNOSES REDACTED], Cardiac Arrest and status [REDACTED]. He was found outside in the cold lying on the railroad track. He was reported missing since last night from (name of facility). In ED he was hypothermic and found to have elevated WBC (white blood cells). Patient was hydrated, warmed up and was referred for admission to rule out infection. Resident #13 was discharged back to the nursing facility on 12/22/15 after spending 5 days in the hospital. Once the resident returned to the facility a wanderguard bracelet was applied because he was assessed as an elopement risk. *Hypothermia: an abnormal and dangerous condition in which the oral temperature id below 95 degrees or the rectal temperature is below 96 degrees, usually caused by prolonged exposure to cold or damp conditions. Symptoms include drowsiness, lack of coordination, confusion, and uncontrolled shivering. The person may appear to be dead. People who are very old or very young, people who have cardiovascular problems, and people who are hungry, tired, or under the influence of alcohol are most susceptible to hypothermia. hospitalization is necessary for evaluating and treating any metabolic abnormalities that may result from hypothermia. Related factors include exposure to a cool or cold environment, illness or trauma, inability or decreased ability to shiver, malnutrition, inadequate clothing, consumption of alcohol, medications causing vasodilation, evaporation from skin in cool environment, decreased metabolic rate, inactivity, and aging. The above definition was derived from Mosby's Dictionary of Medicine, Nursing, and Health Professions 8th Edition. The facility Administrator provided the surveyor with a copy of the Facility Reported Incident and the Final Report of Elopement that he submitted to the Virginia Department of Heath Office of Licensure and Certification on 12/17/15 and 12/18/15 for Resident #13. The facility Final Report of Elopement for Resident #13 documented in part, read as follows: On 12/17/15 Name (Resident #13) was noticed missing at 5:35 p.m. Tapes were reviewed and resident was observed exiting facility at 5:10 p.m. Aide was looking for Name (Resident #13) and came down to see if he was on the first floor. Elopement Code called and staff searched facility/grounds. Staff assigned to search neighborhood around the building. When we did not find him initially we notified the RP (responsible party), Physician, and Police. Police, Staff, and Detectives searched the area and Silver Alert was issued by Police Department. Resident was found at 3:30 a.m. by workers near commuter train location. 911 notified, Ambulance arrived and transported resident back to facility and was instructed to transport to the hospital where he was admitted for Altered Mental Status. The facility has re-assessed all residents for elopement risk. Elopement book verified accurate, staff educated on elopement risk and LOA (leave of absence) policy. We have added staff for 24 hour coverage to monitor first floor access points. All doors, alarms, and wanderguard system inspected to ensure functionality. Monitoring of residents at risk every 2 hours on Elopement and Wandering Resident Monitoring Form. The facility Administrator provided the surveyor with documentation stating the weather history for 12/17/15 and 12/18/15. On 12/17/15 the highest temperature was 70 degrees and the lowest temperature that day was 54 degrees. On 12/18/15 the highest temperature was 60 degrees and the lowest temperature was 42 degrees with 0.41 inches if precipitation recorded. The Administrator also provided the surveyor with MapQuest documentation indicating how far Resident #13 was found from the facility when the police found him lying on the railroad tracks. Resident #13 was found by the local police department approximately 4:00 a.m. on 12/18/15, 4 minutes and 0.9 miles from then facility in which his care and supervision was entrusted. Resident #13 was missing from the facility for approximately 11 hours. On 1/14/16 at approximately 4:15 p.m. a phone interview was conducted with Resident #13's Attending Physician. During the phone interview the Attending Physician was made aware of Resident #13's documented oral temperature of 94 degrees when he arrived back to the facility on [DATE] by the police department. The Attending Physician was asked what does a temperature like that mean. The Attending Physician stated, He was hypothermic. The surveyor asked, Can hypothermia cause death? The Attending Physician stated, Of course it can if severe enough. The surveyor then asked why Resident #13's wanderguard bracelet was discontinued. The Attending Physician stated, I have no idea why is was discontinued, usually it is at the request of the facility. Facility policy and procedure titled Care of Wandering Resident dated 6/1/15 documented in part, read as follows: 2. *Provide safety within the facility. *Prevent the resident from eloping. 5. Monitor the resident's location with visual checks at a minimum of every 2 hours. Document accordingly. Facility policy and procedure titled Elopement/Wandering dated 6/1/15 documented in part, read as follows: Policy Statement: The intent of the facility is to maintain residents safety by identifying residents who are at risk for wandering/elopement behavior. Guideline: 1. An elopement/wandering assessment will be completed upon admission, located in the nursing admission information packet, and quarterly thereafter. 2. Any resident displaying significant wandering behavior will be assessed for elopement/wandering risk and care planned appropriately. 3. Care plans and individual behavior plans will address wandering as a specific problem. Approaches will be formulated, patterns identified (if any), and the causes determined should be addressed. 4. A wandering/elopement notebook containing pictures and pertinent demographic information will be maintained by social services and kept at the nurses stations. Updates will be done quarterly. The facility submitted a detailed plan of correction which included, in part: 1. Telephone meeting held with family to discuss plans for discharge to secure unit. 12/18/15 All doors, alarms, wander guard bracelets, key pads inspected. 12/15/15 2. 100% of all elopement assessments were reviewed for accuracy and /or completed for each resident assessed to be at risk for elopement. All residents identified as an elopement risk were care planned with interventions specific and appropriate for each resident to match their ability to understand and comprehend. before wanderguard is removed IDT (Interdisciplinary team) will approve. 12/18/15 3. Elopement books kept at front desk and nurses station were checked for face sheets, pictures. Elopement monitoring forms were reviewed for all residents identified as an elopement risk. Social Worker will update elopement books. Activities will take photos for elopement books. MDS coordinator/SS will ensure elopement care plans are in place. The ADON/nursing will bring all new admissions, re-admissions, to the clinical meeting daily to review. 12/18/15 4. All concerns will be addressed immediately and reported to QAPI Committee monthly until 100% compliance is achieved. The facility will conduct elopement drill on each shift to review staff actions immediately then monthly and report findings to the QAPI Committee monthly until 100% compliance is achieved. Leave of Absence Ensure 100% compliance - Everyone leaving building will sign out and have Dr. order for LOA. Residents will sit in the courtyard instead of out front. 12/18/15 A pre-exit interview was conducted with the Administrator and the Director of Nursing where the above information was shared. The Administrator discussed his plan of correction that is currently in place and the fact that there has been no further elopements. The surveyor asked, What would you have expected the staff to have done with the resident after the resident council meeting? The Administrator stated, To have helped him back up to his room, he didn't usually come down. The surveyor asked, Do you think the resident was a appropriately assessed prior to the removal of his wanderguard bracelet? The Director of Nursing stated, No, I thought the wanderguard was still on him. I would not have taken it off him. The surveyor asked, Was there a breakdown in the facility system regarding elopement risk prior to Resident #13 eloping and how has improved? The Administrator stated, Yes there was, but now we have new systems, audits and 24 hour monitoring in place. No further information was provided prior to exit. COMPLAINT DEFICIENCY-PAST NON COMPLIANCE

Based on findings during a complaint investigation, clinical record review, staff interviews, review of the 1/9/15 hospital course of treatment notes, and the facility's policy the facility staff failed to implement orders in accordance with resident needs and failed to monitor after a noted change in condition for 1 of 4 residents (Resident #1), in the survey sample. A). The facility staff failed to implement physician orders [REDACTED]. The facility staff's delay in treatment resulted in Resident #1's admission to an acute care hospital intensive care unit (ICU) by the critical care team on 1/9/15 [MEDICAL CONDITION], a dislocated left hip, hypothermia (subnormal body temperature), a blood sugar of 21 mg (milligrams)/dl (deciliter), and severe [MEDICAL CONDITION] at 5.5 mg/dl. B). The facility staff failed monitor Resident #1 after noting a change in his condition; Resident #1's blood pressure was lower than usual and his mental status was declining. The findings included: Resident #1 was originally admitted to the facility 1/17/14 and readmitted [DATE]. The current [DIAGNOSES REDACTED]. The significant change Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 10/30/14 coded the resident as not completing the Brief Interview for Mental Status (BIMS) and the staff interview was not completed. The significant change Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 10/9/14 coded Resident #1 as completing the Brief Interview for Mental Status (BIMS) and scoring 12 out of a possible 15. This indicates Resident #1 cognitive ability for daily decision making is moderately impaired. In section "G" (Physical functioning) of the 10/9/14 MDS assessment Resident #1 was coded as requiring total care of 2 person with transfers, extensive assistance of 1 with bed mobility, locomotion on the unit, toileting, personal hygiene and bathing. In section "M" (Skin conditions) Resident #1 was coded as having two stage 2 pressure ulcers, two stage 3 pressure ulcers, two stage 4 pressure ulcers and seven unstageable pressure ulcers. During the clinical record review, physician's orders [REDACTED].#1 were reviewed. The orders were for (intravenous) IV fluids 1/2 normal saline to be administered at 75 cubic centimeters per hour, x-ray left femur, fibula, tibia, foot, culture left heel wounds, place peripherally inserted central catheter (PICC) line and keep in, social worker to schedule a follow-up family meeting, consult surgery for [REDACTED].** (PVL) bilateral lower extremities to rule out [MEDICAL CONDITION], [MEDICATION NAME] ([MEDICATION NAME]) 400 mg by mouth two times per day and schedule [MEDICATION NAME] (narcotic [MEDICATION NAME]) 5/325 mg by mouth three times per day. The NP progress note dated 1/7/15 under assessment and plan read: #4 [MEDICAL CONDITION] - IV fluids, place PICC. The NP progress note dated 1/7/15 under wound evaluation read: left heel, left gluteal slough, necrotic, palpable bone, hip drainage, necrotic regions. During the interview with the NP on 1/29/15 at approximately 3:30 p.m. The NP stated she wrote the wrong date on the progress note. The note should have been dated 1/8/15. The nurse's signature on the orders was dated 1/9/15 indicating the orders were not acknowledged until 1/9/15 instead of 1/8/15 and the surveyor noted there were no nurses' notes stating any of the orders had been reviewed, taken off or implemented. Nor was there a nurse's note stating Resident #1's responsible party was notified of the change of condition and provided information regarding the new orders. An interview was conducted with the Director of Nursing (DON) on 1/29/15 at approximately 2:50 p.m. The DON stated on 1/9/15 LPN #2 gave her a transfer form stating Resident #1 was transferred to the hospital in respiratory distress. The DON also stated she was made aware on 1/9/15 the orders written by the Nurse Practitioner (NP) the day before had not implemented. The DON then stated currently there were no new interventions in place to prevent this from reoccurring but effective today in-services would begin. During the interview on 1/29/15 at approximately 2:50 p.m. the surveyor asked the DON if she was aware Resident #1 was diagnosed with [REDACTED]. The DON stated she was aware of the [DIAGNOSES REDACTED]." The surveyor asked the DON to share the investigation which aided her to conclude the dislocation occurred in the hospital. The DON stated "There was no investigation, there were no concerns" with Resident #1's left hip at the time of his discharge to the hospital on [DATE]. The DON then stated the NP ordered an x-ray of Resident #1 left hip because he constantly laid on his left side regardless of how the staff positioned him, "He turns himself back to his left side." An interview was conducted with the NP on 1/29/15 at approximately 3:30 p.m. The NP stated she was extremely disappointed when she learned the orders written on 1/8/15 had not been implemented. The NP stated the facility staff had requested residents who need IV therapy remain at the facility because the facility is equipped to provide skilled care and capable of obtaining most test necessary for diagnosing and treating. The NP stated she was sure Resident #1 did not have a urinary tract infection [MEDICAL CONDITION] because he had just completed a regimen of antibiotic therapy ([MEDICATION NAME]) for a UTI. The NP further stated she [MEDICAL CONDITION] related to the pressure ulcers was the most likely cause of the change in Resident #1 condition because during the assessment the sacral and gluteal wounds were 100% saturated. The NP stated her plan to treat was to "resuscitate (Resident #1's name) [MEDICAL CONDITION] and prevent septic shock." The NP also stated there was +3 [MEDICAL CONDITION] (swelling) to the left lower extremity and the left hip was adducted with deformity and this was a great concern. An interview was conducted with Licensed Practical Nurse (LPN). LPN # 3 on 1/29/15 at approximately 5:00 p.m. LPN #3 stated on 1/8/14 at approximately 10:00 a.m. a call was placed to the attending NP because a change in Resident #1 condition was identified. LPN #3 stated Resident #1 blood pressure was lower than usual at 82/64 and his mental status was declining. LPN #3 stated the NP said she would be in later to assess the Resident and plan treatment. LPN #3 stated the NP had assessed Resident #1 and mentioned some of the orders that would be written to treat Resident #1 condition. LPN #3 stated the NP was still writing the orders when she left the facility at approximately 3:45 p.m. During the 1/29/15 interview at approximately 5:00 p.m. LPN #3 also stated when she reported to work the next morning 1/9/15 at approximately 6:30 a.m. she went immediately to Resident #1's room to assess his condition. LPN #3 stated she was surprised to see there were no IV fluids hanging and Resident #1 was diaphoretic (excessive sweating), with increased respirations, a fever and unresponsive. LPN #3 stated she called for the unit manager to report to the unit, gave Resident #1 oxygen and stayed with him until emergency services intervened. An interview was conducted with LPN #2 on 1/29/15 at approximately 5:45 p.m. LPN #2 stated the orders written by the NP on 1/8/15 were not taken off by the 3 p.m. - 11 p.m. nurse nor by the 11 p.m. - 7 a.m. nurse. LPN #2 further stated prior to attending the 8:30 a.m. clinical meeting she took the x-ray orders off on 1/9/15 and telephoned the NP to report the orders written on 1/8/15 for Resident #1 had not been implemented. LPN #2 also stated while in the clinical meeting on 1/9/15 she received a phone call at approximately 8:45 a.m. to come to the second floor unit because of a significant change in Resident #1 status. Upon arrival LPN #2 stated Resident #1 was in "respiratory distress", had a temperature of 100 degrees, oxygen saturation at 76% and unable to respond. Emergency treatment was initiated i.e.; oxygen at 10 liter per minute via mask and 911 was called. LPN #2 stated the 3 p.m. - 11 p.m. nurses nor the 11 p.m. - 7 a.m. nurses reported concerns with Resident #1 status on their shift from 1/8/15 - 1/9/15. The surveyor did not see nurses' note written regarding Resident #1's status during the 3 p.m. - 11 p.m. shift on 1/8/15 and the nurses' note written on the 11 p.m. - 7 a.m. shift beginning 1/8/15 and ending 1/9/15 stated Resident #1 was "in bed, resting quietly, medications given." The hospital course of treatment revealed Resident #1 presented to the emergency department critically ill; therefore, aggressive emergent treatment was necessary with [MEDICATION NAME] (vasopressor/antihypotensive agent) and IV fluids (intravenous fluids -injected into the vein) for [MEDICAL CONDITION] (low blood pressure), an [MEDICATION NAME] of [MEDICATION NAME] 50% was required for the blood sugar of 21 mg/dl, reheating of his body was crucial because of hypothermia* and administration of 2 units of blood was vital secondary to a hemoglobin of 5.5 mg/dl (normal range for male 13.8 to 17.2 medlineplus.gov). The facility's policy titled 'Daily Review of Physician Orders' dated 12/2010 reads: It is the standard of this facility that physician orders [REDACTED]. It also read; 1. Daily physician order [REDACTED]. 2. The medication administration record/treatment administration record, care plans, dietary, etc will be reviewed to ensure updates/changes have occurred. 4. Residents will be added to respective tracking logs as indicated, i.e.., labs, [MEDICAL CONDITION], restraint, etc. The above findings were shared with the Administrator and Director of Nursing on 1/29/15 at approximately 7:00 p.m. No further information was made available prior to the exit conference on 1/29/15. *Hypothermia is dangerously low body temperature, below 95 ?F/35 ?C (http://www.nlm.nih.gov/medlineplus/ency/article/ 8.htm). **PVL is an ultrasound test used to look at the blood flow in the large arteries and veins in the arms and legs. The test is performed to help diagnose [MEDICAL CONDITION] of the arms and legs, [MEDICAL CONDITION] and [MEDICAL CONDITION]. (http://www.nlm.nih.gov/medlineplus/ency/article/ 5.htm) Complaint Deficiency

Based on staff interview and clinical record review, facility staff failed to ensure that 1 of 25 resident's in the survey sample was free from a significant medication error (Resident's #25). The finding included: The facility staff failed to administer Resident #25's [MEDICATION NAME] (used to help treat, control and prevent [MEDICAL CONDITION]) as ordered by the attending physician resulting in [MEDICAL CONDITION] activity. Resident #25 was [AGE] years old and admitted to the facility on [DATE]. Review of the 7/30/13 admission Minimum Data Set (MDS) evidenced that the resident was cognitively impaired and dependent on the staff for all activities of daily living. Resident #25's [DIAGNOSES REDACTED]. Review of the clinical record evidenced that on 7/17/13 the attending physician wrote the following order: [MEDICATION NAME] 750 MG by Percutaneous Endoscopic Gastrostomy (Peg Tube), every 12 hours. Review of the Plan of Care on Resident #25's clinical record dated 7/19/13 evidenced the follow: (1.) Problem: [MEDICAL CONDITION] Activity, (2.) Goal: will remain safe from [MEDICAL CONDITION] related activity. (3.) Administer medication as ordered. (4.) See current attending physician order [REDACTED]. Review of the clinical record evidenced that on 8/15/13 while sitting in the wheelchair at the nurse's station Resident #25 had a [MEDICAL CONDITION] requiring the nursing staff to provide emergency medical intervention until Resident #25 returned to his normal cognitive baseline. The attending Physician and responsible party (RP) were notified. A nursing note dated 8/15/13 evidenced the following: Resident #25 had been up to chair when he leaned forward and fell to the floor, hitting his head on the floor. Resident #25 then experienced "[MEDICAL CONDITION] activity". Resident #25 head was supported on a pillow. Following [MEDICAL CONDITION] Resident #25 lethargic, pupils equal, no injury noted to head. Resident #25 placed in bed with fall precautions in place. Review of the laboratory results for a [MEDICATION NAME] Level ordered by the attending physician on 8/15/13 evidenced a "none detected" level. Normal ranges are 5.0 ug/ml - 63.0 ug/ml as indicated by the reporting laboratory on 8/19/13. Review of the clinical record evidenced a Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. There was no documentation that Resident #25 experienced any [MEDICAL CONDITION] activity. Review of the clinical record evidenced a MAR indicated [REDACTED]. Further review of the MAR indicated [REDACTED]. A repeat laboratory results for a [MEDICATION NAME] Level ordered by the attending physician on 8/28/13 evidenced a "9.3l detected level". Normal ranges are 5.0 ug/ml - 63.0 ug/ml as indicated by the reporting laboratory on 8/29/13. During an interview with the Nursing Unit Manager on 11/1/13 at 2:40 PM, she stated that when the 8/1/13 MAR indicated [REDACTED]. Resident #25 from 8/1/13 to 8/19/13 missed 38 doses of the ordered [MEDICATION NAME] 750 MG resulting in [MEDICAL CONDITION] activity. COMPLAINT DEFICIENCY