Every finding on record at Silver Memories Health Care

Based on observation and interview, the facility failed to serve food in a sanitary manner related to hair net use for 3 of 4 kitchen observations. (Cook 4)Findings include:During an observation, on 12/18/2025 at 11:30 A.M., [NAME] 4 was standing in the kitchen in front of the stove stirring a pan of ham casserole. She had approximately 6 inches of long strands of hair on both sides of her face, hanging out of her hair net. During an observation, on 12/18/2025 at 11:50 A.M., [NAME] 4 was in the kitchen with approximately 6 inches of long strands of hair on the sides of her face, hanging out of her hair net. The cook was moving around the kitchen and temping food for the steam table. During an observation, on 12/22/2025 at 12:21 P.M., [NAME] 4 was in the kitchen. She had approximately 6 inches of long strands of hair on the sides of her face, hanging out of her hair net. During an interview, on 12/22/25 at 12:47 P.M., the Administrator indicated staff's hair should be in a hair net and not hanging out. The current facility policy titled, Employee Sanitary Practices, with a revision date of 7/2023, was provided by the Administrator on 12/22/2025 at 3:17 P.M. The policy indicated, .Hair nets or caps, covering all of the hair, mist be worn at all times while on duty .3.1-21(i)(3)

Based on interview and record review, the facility failed to maintain complete and accurate resident records related to timely clinical assessments and documented medication administration for 2 of 12 residents reviewed for medical records. (Residents 10 and 6)Findings include: 1. The clinical record for Resident 10 was reviewed on 12/22/2025 at 12:45 P.M. An annual Minimum Data Set (MDS), dated [DATE], indicated the resident was cognitively intact. The resident's diagnoses included, but were not limited to, anxiety, depression, and major depressive order with psychotic symptoms. The resident's current physician's orders included an open-ended order, with a start date of 03/06/2025, for Vraylar (an antipsychotic medication) 4.5 milligrams (mg) daily. The resident's Electronic Medication Administration Record (EMAR) indicated the resident received the medication daily as ordered. During an interview, on 12/23/2025 at 1:20 P.M., the Director of Nursing (DON) indicated when a resident received an antipsychotic medication, an Abnormal Involuntary Movement Scale (AIMS) assessment was required to be completed every six months. The assessment was completed in March 2025. An assessment should have been completed in September 2025. She completed the assessment today. During an interview, on 12/23/2025 at 1:57 P.M., the DON indicated there was not a facility policy related to AIMS assessments, but the facility followed federal guidelines related to required assessments for residents that received antipsychotic medications. 2. The clinical record for Resident 2 was reviewed on 12/19/2025 at 10:56 AM. A Significant Change MDS assessment, dated 11/03/2025, indicated the resident was cognitively intact. The resident's diagnoses included, but were not limited to, fractures, anemia, heart failure, hypertension, diabetes, hip fracture, and depression. The resident's physician's orders included, but were not limited to, the following: -Farxiga (a diabetic medication) 10 mg daily with a start date of 11/20/2025, a current order, and -Farxiga 10 mg daily with a start date of 10/29/2025, and a discontinue date of 12/15/2025. The resident's EMAR indicated the resident received the medication daily as ordered. A Consultant Pharmacist's Medication Regimen Review, dated 12/12/2025, indicated the Farxiga order was entered twice on the EMAR, and one needed to be removed. During an interview, on 12/23/2025 at 2:20 P.M., the DON and pharmacist review the delivery dates and amount of medication with each delivery. The resident had not received the medication twice each day. The order should have been clarified and corrected on the EMAR. During an interview, on 12/23/2025 at 2:25 P.M., Licensed Practical Nurse (LPN) 6 indicated the nurses knew to only give one Farxiga 10 mg tablet not two tablets. The current facility policy titled, MEDICATION ORDERS, was provided by the Administrator on 12/23/2025 at 4:03 P.M. The policy indicated, .The prescriber is contacted to verify or clarify an order (e.g., when the resident has allergies to the medication, there are contraindications to the medication, the directions are confusing).

Based on observation, record review, and interview, the facility failed to provide at least 80 sq ft (square feet) per resident for 2 of 11 resident rooms. (rooms [ROOM NUMBERS]) 1. During an observation of room [ROOM NUMBER] on 12/18/2025 at 11:15 A.M., each of the four residents in this room had adequate space to move about the room and store their belongings. During an observation and interview on 12/18/2025 at 1:58 P.M., room [ROOM NUMBER], a licensed SNF/NF (Skilled Nursing Facility/Nursing Facility) room, was measured at 299 sq ft. This room had 75 sq ft for each of the four residents who resided in the room. The room size was verified by the Maintenance Director. 2. During an observation of room [ROOM NUMBER] on 12/18/2025 at 11:18 A.M., each of the three residents in this room had adequate space to move about the room and store their belongings. During an observation on 12/18/2025 at 2:05 P.M., room [ROOM NUMBER], a licensed SNF/NF room, was measured at 209 sq ft. This room had 69 sq ft for each of the three residents who resided in the room. The room size was verified by the Maintenance Director. During an interview on 12/18/2025 at 11:25 A.M., the Administrator indicated she would like to continue with the room waiver.3.1-19(l)(2)(A)3.1-19(l)(3)3.1-19(l)(8)

Based on observation and interview, the facility failed to follow infection control guidelines related to pericare (privates area cleaning) for 1 of 13 residents reviewed for infection control. (Resident 16)Findings include:During an observation, on 12/22/2025 at 10:40 A.M., Certified Nurse Aides (CNA) 2 and CNA 8 indicated to Resident 16 they were going to provide pericare. The resident was cleansed in the front appropriately. The resident was turned to her right side. There was stool present. CNA 2 wiped the resident from the back to the front multiple times. A new brief was applied, and the resident was made comfortable in her bed. During an interview, on 12/22/2025 at 10:50 A.M., CNA 2 indicated she should have wiped the resident from the front towards her back. The current, undated, facility policy titled, Perineal and/or Incontinence Care, was provided by the Administrator on 12/22/2025 at 3:49 P.M. The policy indicated, .Washing from front to back.3.1-18(b)

Based on interview and record review, the facility failed to accurately address pharmacy recommendations for 1 of 5 residents reviewed for medications. (Resident 6)Findings include:The clinical record for Resident 6 was reviewed on 12/22/2025 at 12:59 P.M. A Quarterly Minimum Data Set (MDS) assessment, dated 12/09/2025, indicated the resident was cognitively intact. The resident's diagnoses included, but were not limited to, anemia, Chronic Obstructive Pulmonary Disorder (COPD), hemiplegia, and depression. A Consultant Pharmacist's Medication Regimen Review, dated 07/16/2025, indicated the following:The resident started taking Benefiber (a prebiotic supplement that supports digestive health) once daily. 1. Please add give with 8 oz fluid to the current directions. This will ensure proper administration to decrease the risk of impaction caused by inadequate fluid intake.2. Please adjust the administration time to be 2 hours before or 2 hours after all other medications. I also recommend adding this to the medication directions, so it does not get changed at a later date. This will ensure this medication will not affect how other medications work. If this was not possible, please address changing therapy with the physician. A handwritten note on the recommendation indicated the medication was discontinued on 06/25/2025.The resident's current medication orders were reviewed on 12/23/2025 at 2:30 P.M., and included, but were not limited to, the following:An open-ended order, with a start date of 07/16/2025, for Benefiber Powder, give one tablespoon by mouth in the morning. The resident's Electronic Medication Administration Record from 07/16/2025 through 12/23/2025 indicated the medication was administered daily at 8:00 A.M., the same time several other morning medications were administered, and lacked directions to administer the medication with 8 ounces of fluid.The current facility policy, titled .Long Term Care Pharmacy.Policy and Procedure., dated 05/20/2020, was provided by the Administrator on 12/23/2025 at 4:02 P.M. The policy indicated, .In collaboration with facility staff, the consultant pharmacist helps to identify, communicate, address, and resolve concerns and issues related to the provision of pharmaceutical services.3.1-25(i)

Based on record review and interview, the facility failed to implement an intervention after a fall for 1 of 13 residents' Care Plans reviewed. (Resident 25)Findings include:The clinical record for Resident 25 was reviewed on 12/22/2025 at 10:14 AM. A Quarterly Minimum Data Set (MDS) assessment, dated 12/12/2025, indicated the resident was severely cognitively impaired. The resident's diagnoses included, but were not limited to, Huntington's disease, seizure disorder, anxiety, and depression. The resident had one fall since the last assessment. A Progress Note, dated 11/14/2025, indicated the resident had slid from her Broda chair (a specialized wheelchair) onto the floor on her buttocks. The fall was observed by a Certified Nurse Aide staff. The resident was assisted to her feet and placed back in the chair. There were no injuries. The clinical record lacked a documented intervention for the fall on 11/14/2025, until 12/19/2025 when a late entry note was placed by the Director of Nursing (DON) at 1:00 P.M. The note indicated the root cause of the fall was movements related to Huntington's disease caused her to slide easily to the floor. A new intervention was to reposition the resident as needed related to her movements related to her Huntington's disease. During an interview, on 12/22/2025 at 12:44 P.M., the DON indicated the care planned intervention should have been documented and implemented sooner than 12/19/2025. The current facility policy titled, Care Planning with a revision date of March 2022, was provided by the Administrator on 12/23/2025 at 9:35 A.M. The policy indicated, .The Interdisplinary team is responsible for the development of resident care plans.Resident care plans are developed according to the timeframes and criteria established.3.1-35(a)

Based on interview and record review, the facility failed to provide appropriate assistance with a mechanical lift device to ensure safe transfers for 1 of 3 residents reviewed for transfer/mobility devices. (Resident B) Findings include:A Quarterly Minimum Data Set (MDS) assessment, dated 9/1/25, indicated Resident B was severely cognitively impaired. The resident's diagnoses included, but were not limited to, non-traumatic brain dysfunction, Alzheimer's disease, and hypertension. The Resident was dependent on staff assistance for all mobility.During an interview, on 9/18/25 at 9:57 A.M., the Administrator indicated Certified Nursing Assistant (CNA) 2 used the full body mechanical lift on Resident B without any additional staff assistance on 8/12/25. The mechanical lifts should always be operated with two staff present, and staff were available to assist if the CNA would have requested for assistance. CNA 2 was discharged from service due to using a mechanical lift improperly.During an interview, on 9/18/25 at 10:42 A.M., CNA 2 indicated that on 8/12/25 she had put Resident B down for bed sometime between 6:00 P.M. to 8:00 P.M. She used the full body mechanical lift to transfer the resident into the bed with no other staff present. During transferring the resident to bed she was removing the sling from the mechanical lift; one of the wheels to the mechanical lift had gotten caught on a cord for the resident's bed causing her to pull the lift away firmly. When she pulled the lift firmly out from overtop of the resident, the top bar of the lift where the lift pad had been hooked began to spin around. She stopped the rotation of the lift bar after she noticed it spinning. Later on her shift around 4:00 A.M., she had used the mechanical lift, a second time by herself, and got the resident up from bed to her wheelchair. She then wheeled the resident out of her room. During an interview, on 9/18/25 at 10:57 A.M., Registered Nurse (RN) 3 indicated she was working with CNA 2 on 8/12/25. She observed CNA 2 bring Resident B out of her room and into the dining room around 4:00 A.M. At that time, she noticed Resident B had purple bruising around her left eye, and a small cut over the bridge of her nose with a small spot of dried blood. When she questioned CNA 2 about the resident's injury, the CNA denied knowing when the injury occurred.The current facility policy, titled Lifting Machine, using a Mechanical, with a revision date July 2017, was provided by the Administrator on 9/18/25 at 2:50 P.M. The policy indicated, .At least two (2) nursing assistants are needed to safely move a resident with a mechanical lift .This deficiency was corrected on 8/19/25, after the facility assessed all residents requiring mechanical lifts, provided education to staff related to proper procedure for transfers, all staff returned proper demonstration of transfers, and ongoing monitoring audit in place for safe transfers. This citation relates to Intake 2588897.3.1-45(a)(1)3.1-45(a)(2)

Based on observation, interview, and record review, the facility failed to follow the manufacturer's guidelines related to the dishwasher temperatures and chemical sanitation for 1 of 2 kitchen observations and failed to maintain the resident snack refrigerator in a sanitary manner related to the storage of undated and unlabeled food and non-food items for 1 of 1 snack refrigerator observed. This deficient practice had the potential to affect 29 of 29 residents who received food from the kitchen or snack refrigerators. Findings include: During the initial kitchen tour on 11/21/24 at 10:48 A.M., with Human Resources (HR) 1, the following was observed: - The thermometer on the dishwasher registered 90 degrees Fahrenheit during the rinse cycle. The sticker on the machine indicated it was supposed to be 120 degrees Fahrenheit. There was no steam rising off of the dishwasher. - A chemical test of the dishwasher solution was conducted with HR 1 and the result was 10 Parts Per Million (PPM). HR 1 indicated it was supposed to be between 50 and 100 PPM. The residents' snack refrigerator, located in the kitchen, contained the following: - A cow print lunch bag with no resident's name or date, - A small gray lunch bag with no resident's name or date that contained a package of pistachios, and - an open box of ice cream sandwiches with no resident's name or date. HR 1 indicated an employee had donated the ice cream sandwiches. HR 1 and the other kitchen staff indicated they did not know to whom the lunch bags belonged to, and HR 1 removed them from the refrigerator. Dietary Aide (DA) 2 indicated they did not monitor the dishwasher temperatures, just the chemical levels. On 11/21/24 at 11:04 A.M., the dishwasher was re-checked and the thermometer on the dishwasher only registered 98 degrees Fahrenheit. HR 1 indicated they would be using the three-sink sanitation system for dishwashing until the dishwasher was fixed. The Administrator was standing at the kitchen door at the time of the second running of the dishwasher and indicated the dishwasher usually had steam coming off of it. No steam was coming off of the dishwasher at the time. During an interview on 11/21/24 at 11:55 A.M., HR 1 indicated all residents in the facility received food from the kitchen. During an interview on 11/25/24 at 1:13 P.M., DA 2 indicated the residents' snack refrigerator was used for overflow of facility meal service items. During an interview on 11/26/24 at 2:07 P.M., the Dietary Manager indicated they tested the chemical level of the dishwasher everyday but did not know where the paper was, they documented the information on, it was not in the kitchen binder. An Out of Order sign remained on the dishwasher for the remaining time of the survey. The dishwasher Operating Manual was provided by the Maintenance Director on 11/26/24 at 1:28 P.M. and included, but was not limited to, the following requirements: - Ensure water temperatures match those listed on machine data plate, - Minimum Wash Temperature 120 degrees Fahrenheit, - Minimum Rinse Temperature 120 degrees Fahrenheit, and - Minimum Chlorine Required (PPM) 50. The Dish Machine Temperature and Sanitizer Log Sample Form for October and November 2024, was provided by the Dietary Manager on 11/26/24 at 2:32 P.M. The record indicated the wash temperature was below the recommended 120 degrees Fahrenheit on the following dates: - 11/02/24, 115 degrees, - 11/03/24, 119 degrees, - 11/04/24, 113 degrees, - 11/06/24, 115 degrees, - 11/08/24, 115 degrees, - 11/09/24, 115 degrees, - 11/10/24, 118 degrees, - 11/14/24, 115 degrees, - 11/15/25, 113 degrees, - 11/16/24, 118 degrees, and - 11/18/24, 115 degrees. The current Food from Outside Sources policy, with a reviewed date of 07/2023, was provided by the Director of Nursing (DON) on 11/26/24 at 10:54 A.M. The policy indicated, .Visitors/family members will label food and beverages with the resident's name, room number and date. All food is to be stored in a suitable container .NO OUTSIDE FOOD WILL BE USED IN THE FOOD SERVICE DEPARTMENT . The current Personal Food Storage policy, dated 2010, was provided by the Dietary Manager on 11/26/24 at 11:34 A.M. The policy indicated, .Food or beverage brought in from outside sources for storage in facility pantries, refrigeration units, or personal room refrigeration units will be monitored by designated facility staff for food safety . 3.1-21(i)(3)

Based on observation, record review, and interview, the facility failed to provide at least 80 sq ft (square feet) per resident for 2 of 11 resident rooms. (rooms [ROOM NUMBERS]) 1. During an observation of room [ROOM NUMBER] on 11/21/24 at 11:15 A.M., each of the four residents in this room had adequate space to move about the room and store their belongings. During an observation and interview on 11/25/24 at 2:08 P.M., room [ROOM NUMBER], located in the licensed Skilled Nursing Facility/Nursing Facility (SNF/NF), was measured at 316 sq ft. This room had 79 sq ft for each of the four residents who resided in the room. The room size was verified by the Maintenance Director. 2. During an observation of room [ROOM NUMBER] on 11/21/24 at 11:20 A.M., each of the three residents in this room had adequate space to move about the room and store their belongings. During an observation on 11/25/24 at 2:11 P.M., room [ROOM NUMBER], a licensed SNF/NF room, was measured at 218 sq ft. This room had 72 sq ft for each of the three residents who resided in the room. The room size was verified by the Maintenance Director. During an interview on 11/26/24 at 1:54 P.M., the Administrator indicated she would like to continue with the room waivers. 3.1-19(l)(2)(A) 3.1-19(l)(3) 3.1-19(l)(8)

Based on observation, interview, and record review, the facility failed to follow infection control guidelines related to isolation for 1 of 5 residents reviewed for isolation. (Resident 20) Findings include: During an observation and interview on 11/21/24 at 1:58 P.M., Resident 20 was propelling herself in her wheelchair out of the room. She indicated she was going to the shower room bathroom. It was a public bathroom that was shared with other residents, she had never used a bedside commode and had always used the public bathroom. During an observation on 11/21/24 at 2:01 P.M., Resident 20 was in the public bathroom in the shower room. Certified Nurse Aide (CNA) 4 donned gloves and the resident stood up from her wheelchair and CNA 4 assisted the resident with pulling her pants and brief down. The CNA removed the resident's soiled brief, placed it in a trash can, gathered a new brief from a shelf, and put it on the resident. When the resident was done, she stood up, and the CNA cleansed her and pulled up her pants. The resident sat back into her wheelchair. The CNA removed her gloves and opened the door for the resident to leave and washed her hands. The toilet was not cleaned after the resident had used it. During an interview on 11/21/24 at 2:08 P.M., CNA 4 indicated she was made aware if a resident was on any isolation precautions from the nurses and managers. If a resident was on isolation, she would wear a gown and gloves. Resident 20 was not on any type of isolation at that time. During an interview on 11/21/24 at 2:11 P.M., RN 3 indicated the shower bathroom was public and 24 of the 29 residents in the building used that bathroom. If a resident had Extended-spectrum B-lactamase (ESBL), a bacteria, in their urine, then they would be placed on isolation. The staff should wear a gown and gloves when assisting the resident to the bathroom. During an interview on 11/21/24 at 2:15 P.M., the Director of Nursing (DON) indicated is a resident had ESBL in their urine then they were placed on Enhanced Barrier Precautions (EBP). When a resident was placed on EBP then the staff were to wear a gown and gloves to provide care. The staff were made aware of resident's being on EBP through report and the signage on the resident door. If a resident had ESBL in their urine, then the bathroom should be disinfected after it was used. The clinical record for Resident 20 was reviewed on 11/21/24 at 1:56 P.M. A Quarterly Minimum Data Set (MDS) assessment, dated 08/30/24, indicated the resident was moderately cognitively impaired. The resident's diagnoses included, but were not limited to, hypertension, diabetes, non-Alzheimer's dementia, seizure disorder, depression, and schizophrenia. A Progress Note, dated 11/14/24 at 2:58 P.M., indicated the resident had a new order for Cipro (an antibiotic) 500 milligrams, twice a day, for 10 days for a Urinary Tract Infection (UTI). The resident was also on contact isolation for 10 days. A Progress Note, dated 11/14/24 at 8:21 P.M., indicated the resident was on an antibiotic for a UTI. The resident remained on contact isolation for ESBL. A Laboratory Report, dated 11/17/24, indicated the resident's urine was positive for ESBP resistance markers. The current facility policy titled, Enhanced Barrier Precautions, dated August 2022, was provided by the DON on 11/22/24 at 2:08 P.M. The policy indicated .Enhanced barrier precautions are utilized to prevent the spread of multi-drug resistant (MDROs) .EBPs employ targeted gown and glove use during high contact resident care activities when contact precautions do not otherwise apply .Gloves and gown are applied prior to performing the high contact resident care activity . 3.1-18(a)

Based on record review and interview, the facility failed to have sufficient nurse staffing for 24 hours hours a day. This deficient practice had the potential to affect 28 of 29 residents that resided in the facility. Findings include: The Labor Detail Reports were provided by the Administrator on 09/11/23 at 2:00 P.M. The reports indicated there was a licensed nurse, providing direct resident care, for less than 24 hours on the following dates and times: - On 01/15/23 there were 23.75 licensed nurse hours in a 24 hour time. - On 01/21/23 there were 23.50 licensed nurse hours in a 24 hour time. - On 01/22/23 there were 23.75 licensed nurse hours in a 24 hour time. - On 01/28/23 there were 23.75 licensed nurse hours in a 24 hour time. - On 02/12/23 there were 23.25 licensed nurse hours in a 24 hour time,. - On 03/03/23 there were 23.75 licensed nurse hours in a 24 hour time. - On 03/24/23 there were 23.75 licensed nurse hours in a 24 hour time. - On 03/26/23 there were 23.75 licensed nurse hours in a 24 hour time. During an interview on 09/11/23 at 2:45 P.M., the Administrator indicated the nurses didn't leave the building for lunch. A thirty minute lunch break was automatically deducted and taken out of their time. She was unsure at the time why the PBJ (Staffing Data Report) showed that they had less than 24 hours nurse coverage. The labor detail reports for nursing was where the information for the PBJ was pulled from. During an interview on 09/14/23 at 2:12 P.M., the Administrator indicated she was unaware that the 30 minute lunch break wasn't included in the nursing hours. The current facility policy titled Staffing with a revised date of October 2017, was provided by the Administrator on 09/14/23 at 3:00 P.M. The policy indicated, .Licensed nurses and certified nursing assistants are available 24 hours a day to provide direct resident care services . 3.1-17(b)

Based on observation, record review, and interview, the facility failed to provide at least 80 sq ft per resident for 2 of 11 resident rooms. (rooms [ROOM NUMBERS]) 1. During an observation of room [ROOM NUMBER] on 09/11/23 at 11:15 A.M., each of the four residents in this room had adequate space to move about the room and store their belongings. During an observation and interview on 09/15/23 at 1:08 P.M., room [ROOM NUMBER] (a licensed Skilled Nursing Facility/Nursing Facility [SNF/NF]) was measured at 316 sq ft (square feet). This room had 79 sq ft for each of the four residents who resided in the room. The room size was verified by the Maintenance Director. 2. During an observation of room [ROOM NUMBER] on 09/11/23 at 11:20 A.M., each of the three residents in this room had adequate space to move about the room and store their belongings. During an observation on 09/15/23 at 1:11 P.M., room [ROOM NUMBER] (SNF/NF room) was measured at 218 sq ft. This room had 72 sq ft for each of the three residents who resided in the room. The room size was verified by the Maintenance Director. During an interview on 09/15/23 at 1:14 P.M., the Administrator indicated she would like to continue with the room waivers. 3.1-19(l)(2)(A) 3.1-19(l)(3) 3.1-19(l)(8)

Based on observation, interview, and record review, the facility failed to monitor a dialysis access site for 1 of 1 resident reviewed for dialysis. (Resident 25) Findings include: During an observation on 09/14/23 at 2:54 P.M., Resident 25 was in his wheelchair. A Quarterly MDS (Minimum Data Set) assessment, dated 08/12/23, indicated the resident was severely cognitively impaired. The diagnoses included, but were not limited to, end stage renal disease, anemia, heart failure, hypertension, diabetes, and dependence on renal dialysis. The physician's order for the resident indicated a standard order to inspect the dialysis access site fistula on the left forearm for infection daily. Access the site for bruit and thrill, with a start date of 08/23/23. The August and September 2023 EMAR/ETAR (Electronic Medication Administration Record/Electronic Treatment Administration Record) lacked a physician's order or documentation related to bruit and thrill monitoring. During an interview on 09/13/23 at 2:45 P.M., LPN (Licensed Practical Nurse) 2 indicated the resident went to dialysis three days a week. The resident had a fistula, and the bruit and thrill should be monitored every shift and documented in the EMAR. The nurse would have to check off that she assessed it. She thought the order was a standard order and it didn't show up on the EMAR. During an interview on 09/13/23 at 2:56 P.M., the Administrator indicated the bruit and thrill monitoring should be documented on the EMAR. The current facility policy titled, Hemodialysis Access Care, with a revised date of September 2010, was provided by the Administrator on 09/14/23 at 9:00 A.M. The policy indicated, .Check patency of the site at regular intervals. Palpate the site to feel the thrill or use a stethoscope to hear the whoosh or bruit of blood flow through the access . 3.1-37(a)

Based on observation, interview, and record review, the facility failed to update a resident's fall interventions for 1 of 2 residents reviewed for accidents. (Resident 11) Findings include: During an observation on 09/13/23 at 9:06 A.M., Resident 11 was lying in her bed, awake with the TV on. The clinical record was reviewed on 09/13/23 at 1:30 P.M. A Quarterly MDS (Minimum Data Set) assessment, dated 07/27/23, indicated the resident was severely cognitively impaired. The diagnoses included, but were not limited to, Huntington's disease, non-Alzheimer's disease, seizure disorder, anxiety, and depression. The resident had impairments on both sides of her lower extremities. The Progress Notes, were reviewed and indicated the resident had multiple falls on the following dates and times: - On 12/17/22 at 1:29 P.M., the resident was in the shower with staff. The staff were assisting the resident with a shower. The resident was resisting care and had raised herself up out of the chair lunged forward, landing on the floor in the prone position. She hit the right side of her forehead on the shower floor. The staff called for assistance. The resident had a small hematoma on the right side of her forehead. There were no other injuries noted. Neurological checks were initiated. - On 12/19/22 at 2:05 P.M., the resident was sitting on the floor beside her bed. She indicated she was trying to get her call light that she thought was on the floor. The call light was on the bed. The resident denied hitting her head and neurological checks were initiated. There were no injuries noted. - On 01/22/23 at 12:00 P.M., the resident was found in her bedroom, lying on the floor beside the wheelchair on a pile of blankets. The resident indicated she was trying to reach her call light. Her call light was attached to her clothing and was within reach. There were no injuries noted and neurological checks were initiated. The resident's at risk for falls care plan with an initiated date of 06/09/21, included the followings interventions: - Start date of 06/09/21, anticipate and meet the resident needs. Assure that the call light was within reach and encourage the use it for assistance as needed and provide a prompt response to all requests for assistance. Physical therapy, occupational therapy, and speech therapy evaluate and treat as ordered or as needed. - Start date of 08/02/21, assist the resident repositioning as indicated. - Start date of 09/27/21, educate the resident as indicated that is safer for her to sit in a chair with arms for proper positing. - Start date of 10/05/21, educate the resident/family/caregivers about safety reminders and what to do if a fall occurred and encourage afternoon naps. - Start date of 10/07/21, educate the resident to use her call light to ask for assistance prior to transfers from her chair at bedside. - Start date 10/19/21, adjust tilt and space wheelchair, broda chair, as indicated to position the resident to minimize risk of the resident coming out of the chair due to Huntington's movements. - Start date of 10/20/21, assist the resident as indicated with eating if she was having increased Huntington's movements. - Start date of 10/29/21, educate the resident as indicated on proper behaviors, assist the resident to lie down in bed as indicated for increased Huntington's movements. - Start date of 11/05/21, continue to remind the resident to request assistance from staff. Offer positive reinforcement when she does request assistance. Encourage resident to use light to ask for assistance to get items out of reach. - Start date of 11/12/21, the staff were to keep items within reach as needed. - Start date of 12/05/21, remind the resident as indicated about safety precautions and praise her for being safe. - Start date of 03/13/22, observe the resident as needed while in bed to ensure that she was in the center of the bed or towards the wall. - Start date of 01/30/23, staff were to stand in front or beside the resident while on the commode. - Start date of 05/28/23, place things of need on bed side table close to bed while in bed. The clinical record lacked updated interventions after the resident's falls on 12/17/22, 12/19/22, and 01/22/23. During an interview on 09/13/23 at 2:51 P.M., LPN (Licensed Practical Nurse) 2 indicated the resident had Huntington's disease. The resident required the assistance of two physical staff. The resident falls were documented in risk assessments. During an interview on 09/14/23 at 4:04 P.M., the DON (Director of Nursing) indicated new interventions would be initiated on the care plan and were updated after each fall. During an interview on 09/15/23 at 9:36 A.M., the DON indicated the management team met every morning and would review falls. A progress note would be initiated after the fall and would determine an immediate intervention. The management team would review it and determine if it was an appropriate intervention or if it needed to be changed. There were no documented IDT (Interdisplinary Team) notes for the falls on 12/17/22, 12/19/22, or 01/22/23. There should have been updated interventions after the falls. The current facility policy titled, Falls, with a revised date of 2018 was provided by the DON on 09/15/23 at 12:35 P.M. The policy indicated, .Based on the preceding assessment, the staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address the risks of clinically significant consequences of falling . 3.1-45(a)(2)

Based on observation, interview, and record review, the facility failed to ensure a resident properly utilized a brace device for 1 of 12 residents reviewed for range of motion. (Resident 128) Findings include: On 10/19/22 at 10:04 A.M., Resident 128 was observed in his room in bed. A brace device for the resident's foot was observed on his chair next to his bed. On 10/20/22 at 9:20 A.M., the resident was observed in his room in bed. The resident's foot brace was in the chair next to the resident's bed. On 10/20/22 at 11:44 A.M., the resident was observed in his room sitting up in the chair next to his bed. The resident was wearing a brace on his left foot. On 10/20/22 at 2:42 P.M., the resident was observed in his room in bed. The resident's foot brace was on his chair next to the resident's bed. During an interview on 10/20/22 at 2:52 P.M., CNA (Certified Nurse Aide) 4 indicated the resident wore a brace on his left foot for foot drop. The therapy department would put the brace on the resident when they got him out of bed in the morning or nursing staff would put it on if they got him out of the bed. Sometimes he wore the brace when he was in bed for a little while. The resident's clinical record was reviewed on 10/20/22 at 2:00 P.M. A Quarterly MDS (Minimum Data Set) assessment, dated 09/14/22, indicated the resident was cognitively intact. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident required extensive staff assistance with most ADLs (Activities of Daily Living). The resident's range of motion of their upper and lower extremities was impaired on one side and the resident utilized a wheelchair. The resident's current physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 10/21/22 at 9:03 A.M., Therapy Director 2 indicated the resident's left foot was contracted. His foot was in a state of plantar flexion (the top of the foot pointed away from the leg). The brace brought the foot back to a neutral position. In the mornings, the therapy department would usually get the resident out of bed and into his chair and put the brace in place. The resident brought the brace with him when he was admitted to the facility. He wasn't wearing the brace at first. The therapist came and evaluated the resident and wrote the order for the resident to wear the brace while he was in bed in September 2022. They wanted the resident to wear the brace as much as he could. It was appropriate that the resident wear the brace when he was up in the chair, but he should be wearing it when he was in bed. She thought the resident asked staff to remove the brace when he was in bed. During an interview on 10/21/22 at 9:58 A.M., the DON (Director of Nursing) indicated if a resident refused medication or a treatment, nursing staff would document the refusal in the resident's clinical record, and they would notify the resident's physician. The resident's clinical record lacked documentation the resident refused to wear the brace when in bed. During an interview on 10/21/22 at 9:53 A.M., the resident indicated he didn't mind wearing the brace, and he didn't mind wearing the brace when he was in bed. During an interview on 10/21/22 at 2:17 P.M., the Administrator indicated it was standard nursing practice to follow physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 3.1-42(a)(2)

Based on observation, interview, and record review, the facility failed to follow manufacturer's guidelines related to insulin pen usage for 1 of 12 residents reviewed for quality of care. (Resident 12) Findings include: Medication administration was observed on 10/20/22 at 11:54 A.M., with LPN (Licensed Practical Nurse) 3. The observation indicated the following: - LPN 3 removed Resident 12's insulin pen from the treatment cart, removed the pen cap, applied a new needle, and primed the pen with two units of insulin leaving the cap on the needle. She was unable to visibly see the tip of the needle while holding the pen horizontally. She did not clean the end of the pen before applying the needle to administer 15 units of [MEDICATION(S)] to the resident. During an interview on 10/20/22 at 12:14 P.M., LPN 3 indicated she did not know why she had not cleaned the end of the insulin pen before applying the needle. She would have cleaned the top of a vial of insulin and she would of held the insulin pen upright to prime it. During an interview on 10/21/22 at 1:21 P.M., the DON (Director of Nursing) indicated no residents had recently had any acute concerns related to blood glucose levels. The current [MEDICATION(S)] Package Insert, with a revised date of 09/11/2015, was provided by the DON on 10/21/22 at 1:14 P.M. The insert indicated, .Before each injection .Wipe the Rubber Seal with an alcohol swab. To avoid injecting air and to ensure proper dosing .Turn the dose selector to select 2 units. Hold your Pen with the needle pointing up. Tap the cartridge gently with your finger a few times to make any air bubbles collect at the top of the cartridge. Keep the needle pointing upwards, press the bottom all the way in .A drop of insulin should appear at the needle tip . The current Insulin Pen policy, dated August 5, 2019, was provided by the DON on 10/21/22 at 2:26 P.M. The policy indicated, .Remove the cap from the pen and wipe the attachment area with an alcohol swab .Prime the pen by removing air from the needle by turning the dial to two units .Hold the pen and point the needle up. Gently tap the pen to move the air bubble up to the top of the pen. Press the inject button. You should see insulin appear at the tip of the needle /pen 3.1-47(a)(1)

Based on observation, interview, and record review, the facility failed to follow a physician's order related to a blood pressure medication for 1 of 5 residents reviewed for unnecessary medications. (Resident 19) Findings include: During an observation and interview on 10/20/22 at 11:48 A.M., QMA (Qualified Medication Aide) 5 prepared Resident 19's medications by placing [MEDICATION(S)] (a blood sugar medications) and [MEDICATION(S)] (an antipsychotic medication) into a medication cup and the resident's [MEDICATION(S)] (blood pressure medication) into a separate medication cup. The medications were taken to the resident's room. The QMA obtained the resident's blood pressure, and it was 148/56. The QMA indicated the resident's blood pressure medication would not be administered due to the bottom number being less than 60. The resident had hold parameters on the blood pressure medication to hold the medication if the top number was less than 110 and the bottom number was less than 60. The other medications were administered. The clinical record for Resident 19 was reviewed on 10/18/22 at 1:35 P.M. A Quarterly MDS (Minimum Data Set) assessment, dated 08/22/22, indicated the resident was cognitively intact. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's order, dated 03/22/22 through 10/20/22, indicated the nursing staff were to give the resident [MEDICATION(S)] 10 mg (milligrams), give 2 tablets, by mouth, three times a day for hypertension. The medication was to be held for a blood pressure less than or equal to 110/60 and/or a pulse less than or equal to 60. The August, September, and October 2022 EMAR (Electronic Medication Administration Record) indicated the resident had received the medication on the following dates and times when the blood pressures were out of the parameters: - 08/03/22 at 8:00 A.M., the bottom number was 60, - 08/03/22 at 1:00 P.M., the bottom number was 60, - 08/11/22 at 8:00 A.M., the bottom number was 60, - 08/11/22 at 1:00 P.M., the bottom number was 60, - 08/30/22 at 8:00 A.M., the bottom number was 60, - 08/30/22 at 1:00 P.M., the bottom number was 60, - 09/01/22 at 8:00 A.M., the top number was 104, - 09/01/22 at 1:00 P.M., the top number was 104, - 09/01/22 at 8:00 P.M., the top number was 110, - 09/03/22 at 1:00 P.M., the top number was 110, - 09/29/22 at 8:00 A.M., the top number was 106, - 10/03/22 at 12:00 P.M., no blood pressure was documented, - 10/04/22 at 8:00 A.M. and 12:00 P.M., no blood pressure was documented, - 10/05/22 at 8:00 A.M., no blood pressure was documented, and - 10/15/22 at 8:00 A.M., the top number was 110. During an interview on 10/21/22 at 9:46 A.M., RN 6 had reviewed Resident 19's [MEDICATION(S)] order and indicated the medication should not have been administered if the top number was less than or equal to 110 and the bottom number was less than or equal to 60. It was held when either of the numbers were out of range. The current facility policy, titled Administering Medications with a revised date of December 2012, was provided by the DON (Director of Nursing) on 10/21/22 at 2:10 P.M. The policy indicated, .Medications must be administered in accordance with the orders, including required time frame . 3.1-48(a)(3)

Based on observation, interview, and record review, the facility failed to provide at least 80 square feet(sq ft) per resident for 2 of 11 resident bedrooms in the facility. (Rooms 1 and 3) Findings include: Review of the facility documentation of room size certification, provided by the Administrator, on 10/21/22 at 2:15 P.M., indicated the following room sizes, as observed on facility tour, provided less than 80 square feet per resident: 1. Room 1, SNF/NF (Skilled Nursing Facility/Nursing Facility), was 318.5 sq ft, had the capacity for 4 beds, and equaled 79.6 sq ft per resident. During an observation of Room 1 on 10/21/22 at 10:28 A.M., each resident had adequate space to move about the room and store their belongings. The room measurements were confirmed. 2. Room 3, SNF/NF, was 217.4 sq ft, had the capacity for 3 beds, and equaled 72.5 sq ft per resident. During an observation of Room 3 on 10/21/22 at 10:31 A.M., each resident had adequate space to move about the room and store their belongings. The room measurements were confirmed. These room sizes were verified by the Maintenance Director on 10/21/22 at 2:21 P.M. During an interview on 10/21/22 at 1:29 P.M., the Administrator indicated she would like to continue with the room waiver. 3.1-19(l)(2)(A) 3.1-19(l)(3) 3.1-19(l)(8)

Based on record review and interview, the facility failed to have a physician's order for a code status. This deficient practice effected 1 of 16 residents reviewed for advance directives. (Resident 25) Findings include: The clinical record for Resident 25 was reviewed on [DATE] at 2:00 P.M. The Admission MDS (Minimum Data Set) assessment, dated [DATE], indicated the resident was cognitively intact. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The clinical record lacked documentation for the resident's code status/advanced directives. During an observation and interview on [DATE] at 2:23 P.M., LPN (Licensed Practical Nurse) 5 indicated the code status for a resident should be in the electronic health records, in the front of the paper chart, and on the face sheet. She could not find the code status in Resident 25's chart. During an interview on [DATE] at 2:27 P.M., the Activities Director indicated Resident 25's code status should be in the front of their chart and it was not. If there was no code status documented, the resident would be identified as a full code. During an interview on [DATE] at 2:40 P.M., the ADON (Assistant Director of Nursing) indicated the written order for the resident's code status was in the physician binder awaiting signature. There was no code status form in his chart indicating his desired code status nor was there an order in his electronic health record. There should be documentation in his chart identifying his code status prior to [DATE]. The current Cardiopulmonary Resuscitation (CPR)/Do Not Resuscitate (DNR) policy, with an effective date of ,d+[DATE], was provided by the Administrator on [DATE] at 2:44 P.M. The policy indicated, .Upon admission to the facility the Resident and/or Responsible Party will be provided with the facility's Code Classification Form . 3.,d+[DATE](4)(B)(7)

Based on observation, interview, and record review, the facility failed to follow physician's orders for wound treatments for 1 of 1 resident reviewed for non-pressure related skin alterations (Resident 8), and follow manufacturer's guidelines related to insulin pen usage for 1 of 9 residents observed for medication administration. (Resident 15) Findings include: 1. Resident 8's diabetic ulcer was observed on 08/26/21 at 9:00 A.M. The ADON (Assistant Director of Nursing) removed the current dressing, exposing the wound. The wound was on the top of the third toe on the left foot. It was a dime sized area, with a dry, brown, wound bed. The skin around the wound was dry and flaky. There was no drainage or signs or symptoms of infection. There were a few small, scattered scabs on the top of the resident's foot. The ADON indicated the resident tended to pick at her skin. They wrapped the resident's entire foot to discourage picking. The clinical record for Resident 8 was reviewed on 08/24/21 at 9:33 A.M. A Quarterly MDS (Minimum Data Set) assessment, dated 06/22/21, indicated the resident was cognitively intact. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident had no wounds on her skin during the assessment review period. An Initial Wound Evaluation, dated 07/29/21, indicated the resident had a diabetic ulcer on her left toe that measured 2.0 cm (centimeters) x 2.2 cm x less than 0.1 cm. There was a black circle inside the wound that measured 1.0 cm x 2.0 cm. There was no drainage. 50% of the wound was epithelial tissue (pink tissue that occurs when the epidermis regenerates over a wound surface), 5% was slough (dead tissue, usually yellow or white in color), and 45% was necrotic tissue (dead tissue, usually brown or black in color). The Nurse Practitioner was updated, and treatment orders were received. A physician's order, with a start date of 07/29/21, indicated staff were to cleanse the resident's left toe with [MEDICATION(S)], apply a wound/burn gel, cover the wound with a foam pad, and wrap the wound with a gauze bandage every morning and at bedtime. The July 2021 EMAR (Electronic Medication Administration Record) lacked documentation the wound treatment was administered on the following dates and times: - 07/29/21 at 8:00 P.M., - 07/30/21 at 8:00 A.M. and 8:00 P.M., and - 07/31/21 at 8:00 A.M. The Weekly Skin Tracking Log for the resident was reviewed and included the following: On 08/05/21, the wound on the resident's toe measured 1.0 cm x 1.5 cm. There were no signs of infection. The wound bed was pink in color. On 08/16/21, the wound on the resident's toe measured 0.7 cm x 1.0 cm. There were no signs of infection. The wound bed was pink in color. On 08/20/21, the wound on the resident's toe measured 0.5 cm x 0.8 cm. There were no signs of infection. The wound bed was pink in color. During an interview on 08/26/21 at 2:39 P.M., the Administrator indicated there was no specific facility policy for following physician's orders. Following the physician's orders was standard nursing practice. 2. During an observation on 08/24/21 at 11:17 A.M., LPN (Licensed Practical Nurse) 5 retrieved Resident 15's Novolog insulin pen from a medication cart. She reviewed the resident's insulin orders and dialed up 15 units of insulin. She went into the resident's room and administered the insulin in the resident's abdomen. She did not prime the insulin pen prior to the medication administration. During an observation on 08/26/21 at 11:22 A.M., LPN 5 retrieved Resident 15's Novolog insulin pen from a medication cart. She reviewed the resident's insulin orders and dialed up 15 units of insulin. She went into the resident's room and administered the insulin in the resident's abdomen. She did not prime the insulin pen prior to the medication administration. During an interview on 08/26/21 at 11:35 A.M., LPN 5 indicated she did not prime the insulin pen before she used it. She only ever primed the pen if it was a new pen that was being used for the first time. She was not sure if the pen needed to be primed before each use, but she would find out. During an interview on 08/26/21 at 11:38 A.M., the ADON indicated an insulin pen needed to be primed before each use. The clinical record for Resident 15 was reviewed. The resident did not suffer any ill effects related to the improper use of the insulin pen. The current facility policy, titled INSULIN PENS POLICY AND PROCEDURE, with an effective date of 08/05/2019, was provided by the Administrator on 08/26/21 at 2:36 P.M. The policy indicated, .Prime the pen by removing air from the needle by turning to two units .Gently tap the pen to move the air bubble up to the top of the pen .press the inject button. You should see a drop of insulin appear at the tip of the needle/pen . The current Novolog package insert, with a revised date of 11/2019, was provided by the Administrator on 08/26/21 at 2:38 P.M. The insert indicated, .Before each injection .To avoid injecting air and to ensure proper dosing .Turn the dose selector to select 2 units. Hold your insulin .Flex Pen with the needle pointing up. Tap the cartridge gently with your finger a few times to make any air bubbles collect at the top of the cartridge. Keep the needle pointing upwards, press the bottom all the way in .A drop of insulin should appear at the needle tip .Keep the needle in the skin for at least 6 seconds . 3.1-37(a) 3.1-47(a)(1)

Based on record review and interview, the facility failed to treat a UTI (Urinary Tract Infection) appropriately and in a timely manner which resulted in a resident being transferred and admitted to the local hospital [MEDICAL CONDITION] (an infection in your blood). This deficient practice affected 1 of 2 residents reviewed for UTI's. (Resident 16) Findings include: The clinical record for Resident 16 was reviewed on 07/31/19 at 9:53 [NAME]M. A Quarterly MDS (Minimum Data Set) assessment, dated 05/24/19, indicated the resident was cognitively intact. The resident's [DIAGNOSES REDACTED]. A progress note, dated 03/07/19 at 2:14 P.M., indicated the resident's urine contained sediment and was tea colored. The MD was notified and new orders were obtained to start [MEDICATION NAME] (an antibiotic medication) 100 mg (milligrams) by mouth, twice a day, for 5 days, and obtain a UA (urinalysis). A progress note, dated 03/08/19 at 2:41 [NAME]M., indicated the urine specimen was obtained per indwelling catheter for the laboratory. The urine was tea colored with a foul odor. A Urine Culture and Sensitivity report, dated 03/08/19, indicated the resident had a colony count of greater than 100,000 cfu/ml (colony forming unit per milliliter) the organisms E.Coli and [MEDICATION NAME] faecalie (Group D) in her urine. [MEDICATION NAME] was only effective to the organism [MEDICATION NAME] faecalie (Group D) and was not effective for the organism E. Coli. A progress note, dated 03/09/19 at 5:21 P.M., indicated the resident continued on antibiotics. Her indwelling catheter was intact and had dark yellow urine with sediment. A progress note, dated 03/10/19 at 12:50 [NAME]M., indicated the resident continued on antibiotics. Her indwelling catheter was patent and draining medium yellow urine. A progress note, dated 03/10/19 at 4:21 P.M., indicated the resident's indwelling catheter was draining dark yellow urine with sediment. The resident had been encouraged to drink more water. A progress note, dated 03/10/19 at 5:20 P.M., indicated the resident continued on the antibiotic for a UTI. The UA results were received and faxed to the MD. Staff were waiting on the culture results. The laboratory indicated the results should be ready tomorrow morning. A progress note, dated 03/11/19 at 5:49 [NAME]M., indicated the resident continued on antibiotics. Her indwelling catheter was patent and draining medium yellow urine. A progress note, dated 03/11/19 at 9:51 [NAME]M., indicated the UA culture results were received from the laboratory. The primary care physician was updated. A progress note, dated 03/12/19 at 10:33 [NAME]M., indicated the resident's indwelling catheter was leaking a moderate amount of urine this morning when the head of the bed was elevated 90 degrees. The resident continued on antibiotic therapy for a UTI without adverse reactions noted. Her temperature was 97 degrees Fahrenheit. Her indwelling catheter was draining dark amber urine to the drainage bag. The urine was noted with a strong odor. The resident was encouraged to drink non-caffeinated fluids. A progress note, dated 03/12/19 at 12:01 P.M., indicated a notification was received from the primary care physician that they had received the UA results. There were no new orders at the time and the physician wanted to wait for the final culture results. A progress note, dated 03/14/19 at 1:23 P.M., indicated the resident's antibiotics were discontinued due to the fact that the original order date was only for 5 days and the regimen had been completed. The laboratory was called again for the culture and sensitivity results. The sensitivity would be faxed again per the laboratory. A progress note, dated 03/15/19 at 1:07 [NAME]M., indicated the resident's indwelling catheter was patent and draining dark yellow urine. The staff continued to wait for the culture and sensitivity results. The culture and sensitivity report was faxed from the facility to the MD on 03/15/19. A progress note, dated 03/15/19 at 11:42 [NAME]M., indicated the culture and sensitivity results were obtained from the laboratory and faxed to the physician along with a notice that the resident continued to be slightly confused at that time. The facility staff were awaiting further orders. A progress note, dated 03/17/19 at 02:06 [NAME]M., indicated the resident's indwelling catheter was patent and draining dark yellow urine with sediment in the drainage tubing. The resident was encouraged to drink fluids. A progress note, dated 03/18/19 at 2:06 [NAME]M., indicated the resident's indwelling catheter was patent and draining dark yellow urine. The resident was encouraged to drink fluids. A progress note, dated 03/19/19 at 3:00 [NAME]M., indicated the resident's indwelling catheter was patent and draining dark yellow urine. The resident was encouraged to take fluids and they were taken well. A progress note, dated 03/19/19 at 8:56 [NAME]M., indicated the resident was alert to person and place but had to be cued to the time and date. Her urine was clear yellow in the indwelling catheter tubing and cloudy in the collection bag. There was a strong odor present to the urine. The resident was educated on the benefits of non-caffeinated fluid choices. The resident stated understanding. The facility staff were waiting on further orders from the MD related to UA results. A progress note, dated 03/19/19 at 12:57 P.M., indicated a new order was received from the MD to obtain the following laboratory results on the next laboratory day; a chem 14, CBC (complete blood count), and ESR(Erythrocyte Sedimentation Rate). The facility staff spoke with the staff at MD office related to UA results and continued waiting further orders. A communication form from the MD dated 03/19/19 indicated the following: .3/19/19 at 9:35 [NAME]M., (an employee at the facility) stated the pt (Resident 16) still has a nasty UA and finished the [MEDICATION NAME] (antibiotic medication) and is still in (a) state of confusion at times and times she is clear. (The employee) states she is sleeping a lot and the .(family member) is concerned . .3/19/19 at 5:04 P.M., MD indicated .I had wanted a CBC and chem 14 back but I don't see those results yet .Looking in her medications it looks like [MEDICATION NAME] (an antibiotic medication) would also cover both organisms. For right now put her [MEDICATION NAME] mg twice a day while we await the lab work . A progress note, dated 03/19/19 at 7:43 P.M., indicated new orders were received from the physician to [MEDICATION NAME](an antibiotic medication) 500 mg, by mouth twice a day while waiting for the laboratory work related to the UTI. A progress note, dated 03/20/19 at 9:40 [NAME]M., indicated the resident received her antibiotic that morning for a UTI per the MD orders. The medication was obtained from the EDK (Emergency Drug Kit). The resident was scheduled for laboratory tests that morning. A progress note, dated 03/20/19 at 11:13 [NAME]M., indicated the serum laboratory tests were obtained per the MD order and sent to the laboratory. A progress note, dated 03/20/19 at 3:07 P.M., indicated a call was received from the laboratory and indicated the serum laboratory results were received but the name on the tube was smeared. The laboratory would need to redraw the blood test on the next laboratory day. The resident was scheduled for the morning laboratory draw. There was no stop date on [MEDICATION NAME] at this time related to the MD awaiting serum laboratory results. A progress note, dated 03/21/19 at 1:20 [NAME]M., indicated the resident's indwelling catheter was in place draining clear amber urine. The laboratory results were faxed to the MD on 03/21/19. The clinical record lacked documentation that the facility followed up with the physician related to the laboratory results on 03/21/19 in regard to changing the antibiotic medication for the UTI. A progress note, dated 03/22/19 at 3:04 [NAME]M., indicated the resident's indwelling catheter was patent and draining dark yellow urine. A progress note, dated 03/22/19 at 10:30 [NAME]M., indicated the resident's indwelling catheter was draining yellow urine to the drainage bag. Fluids were encouraged. A progress note, dated 03/23/19 at 2:24 [NAME]M., indicated the resident's indwelling catheter was patent and draining dark yellow urine. Fluids were encouraged. A progress note, dated 03/25/19 at 7:39 [NAME]M., indicated the resident had an indwelling catheter that was in place and draining clear amber urine. A progress note, dated 03/26/19 at 2:23 [NAME]M., indicated the resident's indwelling catheter was patent and draining dark yellow urine. Fluids were encouraged. A progress note, dated 03/27/19 at 12:41 [NAME]M., indicated the resident continued on an antibiotic. Her indwelling catheter was patent and draining dark yellow urine. A progress note, dated 03/27/19 at 10:08 [NAME]M., indicated the resident's indwelling catheter was draining cloudy yellow urine to the collection bag. Non-caffeinated fluids were encouraged. A progress note, dated 03/28/19 at 1:37 [NAME]M., indicated the resident'[MEDICATION NAME] regimen was finished for the UTI. The resident's indwelling catheter was draining clear amber urine. A progress note, dated 03/28/19 at 4:59 P.M., indicated the resident stated she was having occasional squeezing pain in her chest. A new order was obtained to send the resident to the ER (emergency room ). A progress note, dated 03/28/19 at 10:17 P.M., indicated the resident was being admitted to the local hospital [MEDICAL CONDITION] secondary to a UTI and [MEDICAL CONDITION]. The hospital records, dated 03/28/19, indicated the resident's laboratory results indicated she had E.Coli in her urine. The clinical impression from the ER report indicated the resident was septic secondary to a UTI. .The ER doctor spoke with the internal medicine doctor and were in agreement to admit the resident to the ICU (Intensive Care Unit) . The hospital discharge instructions, dated 03/31/19, indicated .Discharge Diagnosis .E.Coli UTI [MEDICAL CONDITION] . During an interview on 07/31/19 at 2:59 P.M., the ADON (Assistant Director of Nursing) indicated an acceptable timeframe to receive a urine culture and sensitivity back from the laboratory was 72 hours. If it was not received back in 72 hours then the laboratory should be called for the results. During an interview on 08/01/19 at 1:47 P.M., the ADON indicated an appropriate timeframe to start an antibiotic would be 24 hours after receiving laboratory results. During an interview on 08/01/19 at 2:25 P.M., the DON (Director of Nursing) indicated if it was after hours or the weekend there was a physician on call that could be notified of changes in condition and laboratory results. The current facility policy titled Change in a Resident's Condition or Status and dated 04/2012 was provided by the Administrator on 07/31/19 at 9:25 [NAME]M. The policy indicated, .Our facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status . The current facility policy titled Guidelines for Physician Notification for Change in Condition Overview and dated 4/11/06 was provided by the Administrator on 07/30/19 at 3:37 P.M. The policy indicated, .PROMPT NOTIFICATION FOR ACUTE PROBLEMS-These situations require direct communication with the physicians and may not be faxed. The following symptoms, signs and laboratory values should prompt the nurse to notify the physician as soon as possible, either directly or by beeper. If you do not obtain a response from the physician, call the designated alternate physician. If you still do not receive a response, notify the Medical Director for further instructions .Laboratory Results .Any of the following abnormal reports .Positive urine culture > (greater than) 100,000 col/ml (colony per ml) of a pathogen .only if the resident has symptoms and is not on treatment; or the pathogen is not sensitive to antibiotics which has been prescribed . 3.1-41(a)(2) 3.1-37(a)