Every finding on record at South Bay Post Acute Care

Based on interview and record review, the facility failed to ensure physician (MD) ordered wound care treatments for pressure ulcer ((localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence) were implemented as directed for one of three sampled residents (Resident 1). As a result, Resident 1's pressure ulcer on the sacrum (the base of the spine or simply the bottom of the back) increased in size and placed Resident 1 at risk for worsening skin integrity, potential infection, delayed healing, and further complications related to pressure ulcer progression.Findings: A review of Resident 1's admission Record indicated Resident 1 was re-admitted to the facility on [DATE] (initial admission 2/8/26-2/24/26) with diagnoses which included history of Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). A record review of Resident 1's Minimum Data Set (MDS- nursing facility assessment tool) dated 3/26/26 indicated that Resident 1 had memory problems with Physician progress note dated 2/20/26 indicated, .UTA [unable to assess] fully due to confusion. A record review of Resident 1's Minimum Data Set (MDS- nursing facility assessment tool) dated 3/29/26 indicated, Resident 1 had moderate cognitive (the mental processes that take place in the brain, including thinking, attention, language, learning, memory, and perception) deficits with poor decision making and required cues/supervision. On 4/13/26 at 11 A.M., an interview and record review was conducted with the Wound Nurse (WN). The wound nurse stated that Resident 1's initial admission [DATE]) included a skin assessment on the sacrum as an open wound that measured 3 cm (centimeters) by 3 cm. The wound nurse stated that rounds with the Wound Physician (MD) were completed on a weekly basis.The first Wound MD notes dated 2/10/26 indicated, Resident 1 had a deep tissue pressure injury (a pressure injury is localized damage to the skin and underlying soft tissue when there isn't an open wound, but the tissues beneath the surface have been damaged that can look like a bruise) that measured .Sacrum: 7.5 [centimeters] x2x0 Deep Tissue Pressure Injury Persistent non-blanchable deep red, maroon or purple discoloration. Weekly Instructions from the Wound MD notes on 2/8/26 through 2/24/26 indicated, .Primary Dressing/ Apply.Calcium alginate [natural, seaweed-based dressing used to treat heavily draining wounds] - to sacrum.Medihoney [medical-grade honey intended for wound care] gel - to sacrum.Dressing/Apply or cover with.Foam dressing.Dressing Change/Application Frequency. Daily.and as needed.Support Surface Group 2 mattress [i.e. low air-loss (LAL- designed to distribute the patient's body weight over a broad surface area and help prevent skin breakdown) mattress]. Wound MD measurements on 2/17/26 to the sacrum indicated, .Sacral 3.2x1.9x0 Area 6.08. Wound MD measurements on 2/24/26 to the sacrum indicated, a wound size of .3.5x4x0. The WN stated that Resident 1's wound MD instructions were not carried out as instructed for the month of February 2026. The WN stated it was important that wound care recommendations/instructions and follow up treatments were carried out as directed to prevent further deterioration of Resident 1's sacrum pressure ulcer, reduce the risk of complications, and promote wound healing. The WN stated that Resident 1's diabetes (elevated blood glucose) contributed to impaired circulation and decreased tissue perfusion (flow of blood to tissues and organs), which placed Resident 1 at increased risk for delayed healing and worsening of the pressure injury when treatments were not implemented as ordered. A record review of Resident 1's treatment orders for pressure ulcer management indicated: .Low air loss mattress therapeutic for skin management and comfort with setting as manufacture and as tolerated by the resident. Check placement and functioning for skin management every shift ordered 3/15/26. A record review of Resident 1's treatment orders for the sacrum pressure ulcer indicated: .Sacrum pressure injury. Cleanse site with quarter strength dakins sol (highly diluted, specialized bleach mixture to clean wounds), pat dry, apply medihoney, cover with calcium alginate and foam dressing. every day shift for WOUND MANAGEMENT ordered 3/01/26. A record review of Resident 1's Wound MD notes dated 3/24/26 to the sacrum pressure ulcer indicated, measurements .Sacral [sacrum] 13x10.5x0 Area 136.5 Unstageable Pressure Injury (a full-thickness tissue loss where the wound base is obscured by necrotic tissue (slough or eschar). On 4/11/26 at 3 P.M., an interview with the Director of Nursing (DON) was conducted. The DON stated MD ordered wound treatments were expected to be implemented as directed, based on the Wound MD's assessment and treatment plan. The DON stated that timely initiation and consistent implementation of ordered wound care were important to prevent complications, including worsening size, infection, and delayed healing. The DON further stated Resident 1's hospital history, the resident was evaluated for palliative (specialized medical care focused on providing relief from the symptoms, pain, and stress of a serious illness) care prior to the first admission [DATE]); however, ordered treatments were still required to be implemented to promote optimal skin integrity and prevent avoidable deterioration of the pressure injury. A review of the facility's policy and procedure titled, Policy / Procedure - Nursing Administration-Wound Management (undated), indicated .Treatments ordered by the physician will be used as ordered. If no improvement, the physician will be called for an evaluation

Based on observation, interview, and record review, the facility failed to provide clear indications (a valid reason to use a certain medication) for two of three sampled residents ' (Resident 1 and Resident 2) controlled pain medications (medications with high abuse potential). As a result of this deficient practice, Resident 1 and Resident 2 were at risk of receiving unnecessary controlled pain medications which may lead to misuse. Findings: 1. Resident 1 was admitted to the facility on [DATE], with the diagnosis which included cellulitis (a skin infection) of the right leg per facility's Admission Record. A review of Resident 1 ' s physician ' s orders dated 3/21/25, indicated: Oxycodone HCL Oral Tablet (a type of strong pain reliever that could be habit-forming if not used exactly as prescribed) 5 MG (milligrams). Give 1 tablet by mouth every 6 hours as needed for moderate pain level 4-6 (pain scale that utilize numbers used to evaluate a person ' s perceived pain level). Oxycodone HCL Oral Tablet 5 MG (Oxycodone HCL). Give 2 tablets by mouth every 6 hours as needed for severe pain level 7-10. These orders included the parameter for use, but did not include the indication of the controlled medications. A review of Resident 1 ' s Progress notes, titled eMAR-Medication Administration Note, dated 5/13/25 at 9:59 A.M., indicated oxycodone was given for .lower back pain A review of Resident 1 ' s Progress notes, titled eMAR-Medication Administration Note, dated 5/11/25 at 6:39 P.M., indicated oxycodone was given for .buttock pain A review of Resident 1 ' s Progress notes, titled eMAR-Medication Administration Note, dated 5/10/25 at 8:46 P.M., indicated oxycodone was given for .generalized pain A review of Resident 1 ' s Progress notes, titled eMAR-Medication Administration Note, dated 5/9/25 at 3:46 P.M., indicated oxycodone was given for .Resident c/o [complained of] pain. A review of Resident 1 ' s Progress notes, titled eMAR-Medication Administration Note, dated 5/7/25 at 9:25 P.M., indicated oxycodone was given. There was no documented location of pain. A review of Resident 1 ' s Progress notes, titled eMAR-Medication Administration Note, dated 5/6/25 at 7:16 P.M., indicated oxycodone was given. There was no documented location of pain. 2. Resident 2 was admitted to the facility on [DATE], with diagnosis which included right femur (thigh bone) fracture per facility's Admission Record. A review of Resident 2 ' s physician ' s orders dated 5/4/25, indicated: Hydrocodone-Acetaminophen Oral Tablet (a type of strong pain reliever that could be habit-forming if not used exactly as prescribed) 5-325 MG. Give 1 tablet by mouth every 4 hours as needed for moderate pain level 4-6. Hydrocodone-Acetaminophen Oral Tablet 10-325 MG. Give 1 tablet by mouth every 4 hours as needed for severe pain level 7-10. These orders included the parameter for use, but did not include the indication of the controlled medications. A review of Resident 2 ' s Progress notes, titled eMAR-Medication Administration Note, dated 5/13/25 at 4:55 A.M., indicated Hydrocodone-Acetaminophen was given for .pain in her leg. A review of Resident 2 ' s Progress notes, titled eMAR-Medication Administration Note, dated 5/12/25 at 9:54 P.M., indicated Hydrocodone-Acetaminophen was given for Pt [patient] reported 7/10 pain numeric scale There was no documented location of pain. A review of Resident 2 ' s Progress notes, titled eMAR-Medication Administration Note, dated 5/12/25 at 7:09 A.M., indicated Hydrocodone-Acetaminophen was given for Resident wants her pain pill for her leg. A review of Resident 2 ' s Progress notes, titled eMAR-Medication Administration Note, dated 5/10/25 at 7:22 P.M., indicated Hydrocodone-Acetaminophen was given. There was no documented location of pain. A review of Resident 2 ' s Progress notes, titled eMAR-Medication Administration Note, dated 5/9/25 at 8:32 A.M., indicated Hydrocodone-Acetaminophen was given. There was no documented location of pain. A review of Resident 2 ' s Progress notes, titled eMAR-Medication Administration Note, dated 5/8/25 4:35 A.M., indicated Hydrocodone-Acetaminophen was given for .LE (lower extremity) pain On 5/13/25 at 12:08 P.M., an interview and record review was conducted with Licensed Nurse (LN) 1. LN 1 reviewed Resident 1 and Resident 2 ' s physician ' s orders and stated that the orders needed to be updated because they were missing the indication for use. LN 1 stated the physician ' s orders for controlled pain medications, should be more specific to prevent medication misuse. On 5/13/25 at 12:23 P.M., an interview and record review was conducted with the Assistant Director of Nursing (ADON). The ADON stated a complete medication order should include a clear indication of use. The ADON stated clear indications were important to prevent unnecessary use of controlled medications. The ADON reviewed Resident 1 ' s eMAR-Medication Administration Notes and stated Resident 1 ' s oxycodone was administered for different locations of pain. The ADON stated he was unsure what condition Resident 1 ' s oxycodone was intended to treat. The ADON stated Resident 1 and Resident 2 ' s controlled medication orders needed to be clarified with the physician to include a clear indication for their use. On 5/13/25 at 1:56 P.M., an interview was conducted with the Director of Nursing (DON). The DON stated controlled pain medication orders should be written with clear and specific indications of use. The DON stated this was important because a change of condition could be missed when a resident has a new pain. The DON stated the new pain may be different from what the physician had originally intended the medication to treat. On 5/13/25 at 4:29 P.M., an interview and record review was conducted with the DON. The DON stated the facility did not have a Policy and Procedure for unnecessary medication, but the facility followed Physician Orders Policy and Procedure. A review of the facility ' s undated policy titled Physician Orders, indicated, .7. Orders for medications must include: . E. Reason or problem for which given.

Based on observation, interview, and record review, the facility failed to accurately document a pain assessment result and controlled pain medication (medications with high abuse potential) administration in the Medication Administration Record (MAR) for one of three sampled residents (Resident 1). As a result of this deficient practice, Resident 1 ' s MAR did not accurately reflect the care and treatment provided to the resident. Findings: Resident 1 was admitted to the facility on [DATE], with diagnosis which included cellulitis (a skin infection) of the right leg per facility's Admission Record. A review of Resident 1 ' s physician ' s orders dated 3/21/25, indicated: Oxycodone HCL Oral Tablet (a type of strong pain reliever that could be habit-forming if not used exactly as prescribed) 5 MG (milligrams). Give 1 tablet by mouth every 6 hours as needed for moderate pain level 4-6 (pain scale that utilizes numbers used to evaluate a person ' s perceived pain level). Oxycodone HCL Oral Tablet 5 MG (Oxycodone HCL). Give 2 tablets by mouth every 6 hours as needed for severe pain level 7-10. A review of Resident 1 ' s Controlled Drug Record (CDR) dated 5/12/25 at 8:12 P.M., indicated two tablets of Oxycodone HCL Oral Tablet 5 MG were removed from the locked medication cart by Licensed Nurse (LN) 3. A review of Resident 1 ' s MAR dated 5/12/25 at 8:12 P.M., indicated one tablet of Oxycodone HCL Oral Tablet 5 MG was administered to Resident 1 by LN 3. The MAR also indicated Resident 1 had a pain level rated 4/10. On 5/13/25 at 3:23 P.M., an interview and record review was conducted with LN 3. LN 3 reviewed Resident 1 ' s MAR and CDR dated 5/12/25 at 8:12 P.M. LN 3 stated he administered two tablets of oxycodone for a pain level of 7 to Resident 1. LN 3 stated the documentation on the MAR was incorrect. On 5/13/25 at 4:25 P.M., an interview with the Director of Nursing (DON) was conducted. The DON stated Resident 1 ' s pain assessment and oxycodone administration should have been documented accurately. A review of the facility ' s undated policy titled Policy Procedure Documentation and Charting, indicated, It is the policy of this facility to provide an accurate account of documentation of the resident ' s clinical care and/or status in the clinical record

Based on observation, interview, and record review, the facility failed to ensure one resident ' s (Resident 2) controlled medications were secured and disposed of after discharge to the hospital. This deficient practice had the potential to result in drug diversion. Findings: Review of Resident 2 ' s Admission Record indicated Resident 2 was admitted on [DATE] to facility with diagnoses including: Sepsis (widespread infection), Acute Respiratory Failure with Hypoxia (Difficulty breathing), and Opioid (pain medication) Dependence. Review of Resident 2 ' s Medication Administration Record (MAR) indicated that Resident 2 received Hydromorphone HCL (Narcotic Pain Medication) 3 x 8 Milligrams(MG) tablets every 6 hours for Chronic Pain and Alprazolam(Anti-anxiety medication) and 1x O.5 MG tablet once a day in the morning for anxiety. On 1/9/24 at 10:30 A.M., an interview with Administrator (ADM) was conducted. ADM stated facility investigation found the following: All of Resident 2 ' s medication were held in the medicine cart including narcotics at the time of discharge on 12/17/23. On 12/22/23, Licensed Nurse (LN) 1 made a note on narcotics to hold the medications in anticipation of Resident 2 ' s return and placed note with medications in narcotic box in medication cart. LN 1 went on vacation from 12/22/23 to 12/26/23 and when she returned the medication was not there. Resident 2 returned to facility on 12/30/23, but never missed medication according to ADM. LN 1 reported medications missing on 1/5/24 to ADM, and investigation was done. ADM stated that the facility ' s investigation found all the Resident 2 ' s medication was gone, narcotics and regular medications. ADM stated that all nurses assigned to that medication cart were interviewed, and no one had a memory of the medication being stored there. ADM stated a nursing in-service was done on 1/5/23 the same day medication was discovered missing. ADM stated that the narcotic sheet was revised to include documenting the narcotic count, and the count of resident ' s medication cards. On 1/9/24 at 10:50 A.M., an interview with LN 1 was conducted. LN 1 stated that she normally worked with Resident 2. LN 1 stated that if a resident was discharged to a hospital, the LN should give the medications to the Director of Nursing (DON) to be destroyed. LN 1 stated that it was best practice on the Long-Term Care unit to keep medications in the cart if a resident was discharged to the hospital for a short term stay, 2-3 days, as it often took a long time to get the medications when they returned. LN 1 stated Resident 2 was discharged on [DATE] and Resident 2 ' s medications were bundled and put behind the active resident ' s medications in the locked drawer of medication cart. LN 1 stated on 12/22/23 she received a call from hospital that Resident 2 would be returning to facility in a few days. LN 1 stated she put a note on Resident 2 ' s medication to hold it there in anticipation of Resident 2 returning from the hospital. LN 1 stated she reported to the night shift (NOC) nurse that she would be coming back and to hold Resident 2 ' s medication in the cart. LN 1 stated that she thought at that time that the best practice would be to keep the medications in the cart. LN 1 stated she estimated there were 30-40 pills of oxycodone left when she last saw them. LN 1 stated the last time she saw the pills was on 12/22/23 at 3:30 P.M. LN 1 stated when she came back to work on 12/26/23 and the medication was not there, so she checked with the Director of Staff Development (DSD) who was the DON Designee (Acting DON) at the time, if the medications were destroyed. LN 1 stated DSD did not know Resident 2 ' s medications were in the cart after discharge and had not destroyed any medication that month. LN 1 stated that the policy and procedure for drug storage/disposal when a resident is discharged to the hospital was to turn the narcotics into the DON or DON designee within 24 hours for storage and destruction. LN 1 stated the importance of turning in discharged patient ' s controlled medication was to prevent drug diversion. On 1/9/24 at 11:55 A.M. a concurrent observation of medication cart, review of MARs and interview with LN 2 was conducted. A review of the LN 2 ' s process for controlled medications administration and storage was reviewed for Resident 2, Resident 4, and Resident 5. LN 2 stated that if a resident is discharged the controlled medications should be given to the DON for storage prior to destruction. LN 2 stated that she would not hold onto medications when a resident is discharged . LN 2 stated that if the medications were held onto after a resident ' s discharge, they could be taken or lost. On 1/9/24 at 12:50 P.M, an interview was conducted with the DSD. DSD stated that a report from LN 1 was made about Resident 2 ' s controlled medications after LN 1 discovered they were missing. Resident 2 was readmitted [DATE] and the licensed nurse could not find her original medications. The DSD stated that when Resident 2 was discharged to hospital, the LN is supposed to give the narcotics to the DON /DON designee, and the DON/ DON designee will put the controlled medications in the safe box in her office until the pharmacist comes in to do the destruction of controlled medications with the DON. DSD stated when controlled medications are destroyed, it is recorded in a log. DSD stated that there was no record of Resident 2 ' s narcotics being destroyed by DON and the Pharmacist. DSD stated the LN should have given the narcotics to DON for destruction when Resident 2 was discharged to hospital. DSD stated the importance of giving narcotics to DON when a resident is discharged to the hospital, is to prevent someone from taking the controlled medications of that resident. On 1/10/24 at 7:45 A.M., an interview was conducted with LN 3. LN3 stated he was the night shift nurse the day that Resident 2 was discharged . LN 3 stated that on the night of 12/22/23, Resident 2 had already been discharged . LN 3 stated he had done the controlled substance count for the medication cart. LN 3 stated the count included Resident 2 ' s medication with outgoing evening nurse LN 4. LN 3 stated he was unsure if Resident 2 ' s controlled medications were there, and he thought they were included in the count. LN 3 stated that when a resident is discharged to the hospital, he will leave the medication bundled together in the medication cart in the back of the locked drawer of the medication cart, but remove the medication from the count sheet. LN 3 stated that discharged resident ' s controlled medications should be turned in to the DON or DON designee when possible. LN 3 stated that turning in narcotics to DON would prevent someone from taking the discharged resident ' s medication. On 1/10/24 at 7:57 A.M. an interview with LN 4 was conducted. LN 4 stated that she was the nurse who discharged Resident 2 to the hospital that day on 12/17/23. LN 4 stated she remembered Resident 2 ' s medications all bundled in the back of the medication cart used for controlled medication. LN 4 stated they will typically count all the controlled medication in the drawer every shift including the medication for discharged residents. LN 4 stated she saw the bundle of medications that day after resident was discharged . LN 4 stated when Resident 2 was discharged to the hospital, the nurses usually will put the discharged resident ' s medication toward the back of the locked drawer, until they can give the medications to the DON/DON designee the medication to store prior to destruction by DON and pharmacist. LN 4 stated that an accepted practice on the Long-Term Care/Custodial side of the facility was that nurses keep the medication in cart when the discharged resident is expected to come back to the facility in 2-3 days from hospital. LN 4 stated this is an, accepted practice because it can take up to 4-8 hours to get medications from the pharmacy. LN 4 stated the importance of giving medications to DON after discharge is to prevent controlled medication from being misplaced or taken. On 1/10/24 at 10:19 A.M., an interview with the Pharmacy Consultant (PC) was conducted. PC stated that the expectation is to keep the controlled medication available, but in a secure area with limited access to controlled medication. PC stated that LN who discharged the resident should have given controlled medications to the DON to put in a secured lock box where they could be logged and stored until monthly destruction of narcotics by DON and PC. PC stated the importance of securely storing a discharged resident ' s controlled medication was to prevent drug diversion. On 1/10/24 at 10:45 A.M., an interview with LN 5 was conducted. LN 5 stated that the LN ' s on long term side usually hold controlled medication in the locked drawer in medication cart for 2-3 days or when the resident is expected to come back from the hospital, and medication is still counted in the count. LN 5 stated the expectation was that they would give the medication to the DON for storage before destruction after waiting the 2-3 days. LN 5 stated that she thought the policy was to give the controlled medication to the DON after the resident was discharged . LN 5 stated holding the controlled medications of a discharged resident was a practice they did on the long term/custodial side of the facility, and that they did it mainly because it took a long time to get medications on re-admission. LN 5 stated the importance of giving a discharged resident ' s controlled medication to the DON in timely manner was to prevent drug diversion. On 1/25/24 at 9:36 A.M. an interview with DON was conducted. DON stated that the expectation was the LNs should have turned the medication in to her for locked storage in her office prior to destruction as soon as they could. DON stated that if resident was discharged on a weekday, the LN could give controlled medications that day, or if discharged on night shift, by the next morning. DON stated if resident discharged on a Friday night or over weekend, the LN should turn the controlled medications into her by Monday morning. A review of day of discharge (12/17/23) and day of reporting missing medication (1/5/24) was conducted with the DON. The DON stated that this was an unacceptable practice. DON stated that the importance of timely disposition of discharged resident ' s controlled medication was to prevent drug diversion. Review of policy entitled Narcotic Count dated 2023, indicated .III. Disposal of Medication .2. Medications that are Discontinued by the physician and are controlled medications, will be removed from the eMAR, physically removed from the medication cart after being counted and signed by two staff members, then given to the Director of Nursing/Designee for storage until destruction occurs . Review of policy entitled Medication Storage in the Facility dated January 2022, indicated .IE1: Controlled Substance Disposal .C. All controlled substances remaining in the facility after a resident has been discharged or the order is discontinued, as disposed of 1) In the facility by the director of nursing and/or consultant pharmacist

Based on interview and record review, the facility failed to ensure staff promptly answered resident call lights and met resident's needs in a timely manner for two residents interviewed on the initial tour of the facility and three of seven residents from the confidential group interview. This failure could potentially affect these residents' physical and psychosocial well-being. Findings: 1. Resident 42 had a Brief Interview for Mental Status (BIMS) score of 12 (on a scale of 0-15, with 15 being the most cognitively intact), according to the resident's Minimum Data Set (MDS- a resident assessment tool) assessment, dated 9/28/22. This MDS assessment also indicated Resident 42 required extensive assistance with bed mobility. During an interview with Resident 42 on 11/14/22 at 3:18 P.M., the resident stated that it took 30-40 minutes for staff to answer the call light on some night shifts. Resident 42 stated the long wait time had been on the weekends, but not all the time. Resident 42 stated she had called to be repositioned in bed when she had to wait so long. Resident 86 had a BIMS of 15, according to the resident's MDS assessment dated [DATE]. This MDS assessment also indicated Resident 86 required extensive assistance with transfers and toilet use. During an interview with Resident 86 on 11/15/22 at 9:22 A.M., the resident stated that when she used her call light, it took almost an hour to answer. Resident 86 stated she needed help to get to and from the bedside commode. The resident stated she had in the past soiled her brief with urine while having to wait for assistance. Resident 86 further stated yesterday, she had to wait a long time to be helped off the bedside commode, and it became uncomfortable because the bars pushed into her skin. During an interview with certified nursing assistant (CNA) 14 on 11/17/22 at 4:40 P.M., CNA 14 stated she usually worked the night shift. CNA 14 stated that depending on the shift, sometimes the night shift was understaffed. During an interview with the administrator and director of nursing on 11/21/22 at 5 P.M., the administrator stated that leadership did rounds with residents daily and concerns regarding call lights had not come up. The administrator further stated that they did not directly ask residents about call lights. 38512 2. A confidential resident meeting was conducted on 11/15/22. Seven residents were in attendance, and stated they attended monthly meetings regarding areas of concern. Residents stated when they used their call lights, staff would call through the intercom and tell them to turn off their call light. Residents stated the more often the call light was used, the more the staff left residents alone. Residents stated when staff responded to call lights, some would say they were not assigned to them. Residents stated call light response had not improved since it was brought up in their monthly meetings. Per a review of the Resident Council meeting minutes from September, October and November of 2022, Residents had documented concerns regarding call light response. No response from Administration was documented on the minutes regarding the concerns.

Based on interview and record review, the facility failed to ensure all staff were trained regarding behavioral health. Only 17 licensed nurses were in-serviced according to the in-service sign-in sheet. As a result, there was a potential for staff to not have the knowledge to care for residents with behavioral health issues. Findings: An interview was conducted on 11/16/22, 9:52 a.m., with CNA 5. CNA 5 stated she was currently caring for a resident with diagnosis of post- traumatic stress disorder (PTSD - a mental condition that is triggered by a terrifying event). CNA 5 stated she did not receive training regarding how to care for residents who have PTSD. An interview was conducted on 11/21/22 at 9:50 a.m. with the Director of Staff Development (DSD). The DSD stated she was unsure if trauma training had been provided to staff. The DSD stated all staff including housekeeping, and maintenance should receive training on behavioral health to avoid triggering a resident's trauma. A record review of the facility's In-service Attendance Record, titled, Trauma & Informed Care/ Behavioral Monitoring Mgt, dated 2/20/22, was conducted. The record indicated that the in-service was provided to 17 licensed nurses and no other disciplines attended the in-service. On 11/21/22 at 3:48 p.m., the DON was interviewed. The DON stated all staff should be trained regarding trauma and PTSD. The DON stated it was important to know how to care for residents with a diagnosis of PTSD. During an interview on 11/21/22, 4:57 p.m. with the DON, the DON stated the facility did not have P&P specific for trauma and/or PTSD training.

Based on interview and record review, the facility did not assure staff assisted Resident 66 in timely manner to maintain continence (ability to control movements of the bowels and bladder). As a result, Resident 66 became incontinent (lost control of bowel or bladder) and felt as if she had been ignored and disrespected. Findings: Per the facility's Admission Record, Resident 66 was admitted on [DATE]. Per Resident 66's brief mental status exam on the quarterly assessment, dated 9/23/22, the resident had the capacity to make decisions about her care. On 11/16/22 at 3:53 P.M., an interview was conducted with Resident 66. Resident 66 stated a couple of weeks ago on the evening shift, she had to wait to go to the toilet, but could not wait and ended becoming incontinent. Resident 66 stated she asked three CNAs for help, and they all said they were busy. Resident 66 stated she had to wait 30 minutes and felt as if people were ignoring her. Resident 66 stated I kept saying, excuse me, excuse me can you take me to the bathroom. I could not hold it. I finally exploded and the administrator came to help me but by then I had already gone in my pants. On 11/16/22 at 4:37 P.M., an interview was conducted with CNA 22. CNA 22 stated Resident 66 would be really humiliated if she had to go in her pants. CNA 22 stated CNAs should take the time to take Resident 66 to the restroom. On 11/16/22 at 4:38 P.M., an interview was conducted with LN 21. LN 21 stated Resident 66 would be very upset if she was incontinent. LN 21 stated that was why she took her to the bathroom. On 11/17/22 at 12:10 P.M., an interview was conducted with the Director of Staff Development (DSD). The DSD stated it was important to take Resident 66 to the bathroom so that she was not incontinent. The DSD stated it would make Resident 66 feel bad as if she was not important and was ignored. Per the facility's policy, dated 11/2021, titled Resident Rights, Dignity and Privacy, .It is the policy of this facility that all resident be treated with kindness, dignity, and respect .

Based on observation, interview, and record review, the facility failed to ensure a self-administration assessment was accurate for one of one resident (Resident 33) reviewed for self-administration of medication. This failure increased the potential for the unsafe self-administration of medications, and the duplication of administered medications for Resident 33. Findings: Resident 33 was admitted to the facility on [DATE] with diagnoses to include Congestive Heart Failure (CHF - a serious condition in which the heart doesn't pump blood as efficiently as it should), Chronic Obstructive Pulmonary Disease (COPD - a chronic inflammatory lung disease that causes obstructed airflow from the lungs), and Asthma (a condition in which a person's airways become inflamed, narrow, swollen, and produce extra mucus, which makes it difficult to breathe), per the History & Physical, dated 2/10/22. On 11/14/22 at 9:16 a.m., Resident 33 was observed in her bed laying on her left side with a nebulizer (a drug delivery device used to administer medication in the form of a mist inhaled into the lungs) mask covering her nose and mouth. Resident 33's eyes were closed. The nebulizer cup was empty, and the nebulizer machine was on. On 11/14/22 at 10:18 a.m., Resident 33 was observed in her bed laying on her left side with the nebulizer mask on her chin. The nebulizer machine was on. On 11/14/22 at 11:50 a.m., Resident 33 was observed in her bed laying on her left side with her eyes closed, and the nebulizer mask was on her neck. The nebulizer machine was on. On 11/14/22 at 12:05 p.m., Resident 33 was observed in her bed laying on her back with her eyes closed, left leg was dangling off the bed, and the nebulizer machine was on. The resident's lunch tray was at the overbed table. On 11/14/22 at 1:00 p.m., Resident 33 was observed instilling the nebulizer liquid medication into the nebulizer cup through an opening attached to the mask. Resident 33 stated she administered her own breathing treatment because staff did not know what they were doing. Resident 33 stated the medication was left on her bedside table. There was no nurse at bedside. During an interview on 11/14/22, at 1:02 p.m., with LN 2, LN 2 stated she prepared the nebulizer treatment for Resident 33. Resident 33 stated she poured out what LN 2 put in the nebulizer cup and replaced it with the one that was left at her bedside. During an interview on 11/16/22, at 3:54 p.m., with LN 6, LN 6 stated he poured the Albuterol (a medication used to treat patients with Asthma, Bronchitis, Emphysema, and other lung diseases) for Resident 33. LN 6 stated, at times he would hand Resident 33 the Albuterol and she (Resident 33) poured it in the nebulizer cup herself. LN 6 stated he was not aware of Resident 33 keeping medications at bedside. LN 6 stated LN 7 informed him yesterday that an assessment and care plan were completed for Resident 33 to self-administer her medication. LN 6 stated LN 7 informed him that the physician was notified, and a lock box was given to the resident. LN 6 stated Resident 33 was to notify the nurse if she used the medication. LN 6 stated there should be a physician's order for self-administration, and this should be documented in the MAR. LN 6 stated he did not see a lock box in the resident's room. LN 6 stated Resident 33 had the capacity to recall the frequency of medication use. LN 6 stated Resident 33 could remember when to administer the medication, however Resident 33 would not follow the physician's order if she was to administer the medication herself. On 11/17/22, at 9:36 a.m., LN 7 was interviewed. LN 7 stated she completed the Self-Administration of Medication assessment for Resident 33. LN 7 stated Resident 33 had COPD and always requested for a breathing treatment. LN 7 stated Resident 33 asked for the nebulizer at least every hour. LN 7 stated she did not review the facility's policy and procedure prior to completing the Self Administration Assessment. LN 7 stated she showed Resident 33 how to use the Advair (a prescription medication used to treat Asthma) inhaler (a hand-held, portable device that deliver medication to the lungs), and Resident 33 return demonstrated. LN 7 stated the order for the inhaler was one puff twice a day. LN 7 stated she showed Resident 33 how to use the nebulizer, how to twist the cup, place the medication mask on her face, turn on the machine, and place the mask in a plastic bag for infection control. The LN 7 stated she informed Resident 33 to keep the medications in the lock box, and to call for the nurse if she needed a breathing treatment. LN 7 stated LN 6 knew the combination for the lock box, and not Resident 33. LN 7 stated she determined Resident 33 had the capacity to self- administer medications. LN 7 stated she gave Resident 33 three medications to place in the box. LN 7 stated resident was not compliant with medication direction and will not follow physician's order. LN 7 stated she called the physician to inform him of Resident 33's request to have the medication at the bedside. LN 7 stated the IDT (a coordinated group of professionals from several different field), had the meeting on 11/15/22 which included the physician, DON, and herself (LN 7). During a concurrent record review and interview on 11/17/22, at 10:00 a.m., with LN 7, LN 7 stated the progress notes for Resident 33 dated 11/15/22 did not indicate IDT attendance on the notes. On 11/17/22, at 4:04 p.m., Resident 33 was observed in laying on her bed watching TV. A small white box with a light blue top, with a combination lock was observed on top of her overbed table. Resident 33 stated the box was to keep her medication for her breathing treatment. Resident 33 stated she did not request for the locked box, and only the nurses had the combination. The LN-Self Administration of Medications- Initial Evaluation, dated 11/15/22 was reviewed with the LN 7 on 11/21/22, at 11:12 a.m. LN 7 stated number 8 of the evaluation form was inaccurate. The assessment indicated Resident 33 was fully capable to correctly document self-administration of medications. LN 7 stated she did not observe Resident 33 document self-administration of her medication. LN 7 stated Resident 33 also did not demonstrate securing storage for the medication, as indicated on the assessment form. LN 7 stated Resident 33 did not demonstrate documenting the administration of PRN (as needed) medication, as indicated on the assessment form. During an interview with the DON, on 11/21/22 at 11:12 a.m., the DON stated she just gave the lock box to Resident 33 on 11/20/22. The DON stated an assessment was done for residents who requested self-administration, and an IDT meeting was held. The DON stated Resident 33 knew how often the medication should be taken. The DON stated she did not know if Resident 33 could follow directions. The DON stated the box had a padlock for Resident 33 to call for the nurse when she needed the medication. The DON stated the combination was not given to Resident 33 because she might self-administer more than what was needed. During a review of the facility's P&P titled, Care and Treatment, Self-Administration of Medications, without a date, the P&P indicated, 1. If a resident desire to participate in self-administration, the interdisciplinary team will assess .Nursing will be responsible for recording self-administered doses in the resident's medication administration record.

Based on observation, interview, and record review, the facility failed to ensure two of two residents' (241 and 33) belongings were inventoried and not lost. These belongings included: 1. Resident 241's right hearing aid was missing. 2. Resident 33's partial upper dentures were missing. These failures could affect the care of these residents by limiting Resident 241's hearing and communication abilities, limiting Resident 33's ability to eat, and increasing the resident's risk for weight loss. Findings: 1. Resident 241 was admitted to the facility on [DATE] with diagnoses that included unspecified dementia per the facility's Admission Record. Dementia is a mental disorder that causes a person to lose the ability to think, remember, learn, make decisions, or solve problems. On 11/14/22 at 9:32 A.M., Resident 241's family member (FM) was sitting in a chair beside the resident in bed. The FM stated Resident 241 had dementia that had recently been getting worse, and he was the responsible party (RP) who made decisions for the resident. The FM stated Resident 241 wore hearing aids and was admitted to the facility with only the right one because the left one had been out for repair. Resident 241's FM further stated the resident's right hearing aid was missing shortly after admission. The resident's FM stated it was reported to the staff, and the facility was investigating the loss. According to a review of Resident 241's Social Services Assessment/Evaluation, dated 11/8/22, .Summary: .wears hearing aids in the right ear . During an interview with certified nursing assistant (CNA) 11 on 11/16/22 at 9:18 A.M., CNA 11 stated Resident 241 was cognitively confused. CNA 11 stated Resident 241 lost her right hearing aid. Without hearing aids, the CNA had to be near the resident and speak loudly and clearly, and then the resident seemed to hear and understand. CNA 11 stated, Hearing aids are so small, and they are easily lost. CNA 11 further stated when residents went back to bed, she asked residents to put their hearing aids in a box labeled with their name and gave it to the nurses to lock up in the medication cart. During an interview with the social services director (SSD) on 11/17/22 at 9:15 A.M., the SSD stated she was notified on 11/14/22 that Resident 241's hearing aid was missing. The SSD stated that the hearing aid was not found after a thorough search of the resident's room, laundry, and the facility. The SSD stated after talking to the resident's FM, the hearing aid went missing on either 11/10 or 11/12/22. The SSD further stated the resident's FM was not interested in being reimbursed for the hearing aid, so the SSD entered a detailed note into Resident 241's medical record and did not complete a Theft/Loss report. According to a Social Services note, dated 11/16/22 at 4:59 P.M., .SS (social services) saw a hearing aid in the box and [FM] stated that hearing aid is for the left ear that was brought today after being repaired. SS continues to search room and did not find right hearing aid. SS made [FM] aware of the admission packet form Resident Hearing Aids, Dentures and Glasses. [FM] read the form with E-Signature of [resident]. [FM] stated that regardless of the form, [resident] hardly wears the hearing aids anyways stating that the left hearing aid has been in facility all day and [resident] does not care to have them on. [FM] requested for SS to drop the hearing aid case . During an interview with Resident 241's FM on 11/17/22 at 9:40 A.M., the FM stated a facility staff came in yesterday to look again in the room for the resident's missing hearing aid. The resident's FM stated the staff member showed him a form that the facility was not responsible for lost hearing aids, with the resident's signature. Resident 241's FM stated that the resident could not make decisions or sign any forms due to dementia. The FM stated he did not want to argue with the facility but would like to be reimbursed for the lost hearing aid. According to a review of Resident 241's undated Inventory of Personal Effects, only one shirt was added to the inventory and signed by the resident's FM. Additionally, there was no date or facility representative signature at the bottom of the document. In the Items Acquired After Original Entry section, the left hearing aid was added on 11/16/22. During an interview with CNA 11 on 11/17/22 at 9:53 A.M., CNA 11 stated on admission, CNAs inventoried resident belongings with the licensed nurse (LN) and the resident or responsible party. Additionally, CNA 11 stated they looked for hearing aids and always asked residents if they were wearing hearing aids or dentures. CNA 11 further stated the CNA who did the inventory was to sign the form after the resident or RP signed it. During an interview with the director of nursing (DON) on 11/21/22, the DON stated staff were expected to ask if residents had hearing aids and include them on the admission inventory. The DON stated staff were also supposed to sign the inventory after the resident or RP signed. The DON stated the SSD was following up on the replacement or reimbursement for Resident 241's lost hearing aid. During an interview with the SSD on 11/21/22 at 3:31 P.M., the SSD stated there had been no further follow-up since the last interview on 11/17/22. According to a review of the facility's undated policy titled Inventory of Personal Effects, Policy: It is the policy of the facility to take reasonable steps to protect the personal property of the residents. Purpose: To maintain an inventory for the personal effects of the resident. Procedures: 1. On Admission- A. When a resident is admitted to the facility, an inventory of the resident's personal effects shall be done by a staff member of the facility. The inventory should include the recording of all personal clothing, valuable articles, etc. which are brought into the facility with the resident and retained by the resident. These personal effects shall be recorded on the Inventory of Personal Effects form. B. Following completion of the inventory, the indicated form shall be signed by the resident and responsible party and by the staff member . 46235 2. Resident 33 was admitted to the facility on [DATE] with diagnoses to include Congestive Heart Failure (CHF - a serious condition in which the heart doesn't pump blood as efficiently as it should), per History & Physical, dated 2/10/22. During observation and interview on 11/14/22, at 12:27 p.m., Resident 33 was in her room having lunch. Resident 33 stated she had no teeth but had dentures that were lost 3 months ago. Resident 33 stated she informed the head nurse and was told they will look for them. On 11/17/22, at 10:27 a.m., CNA 4 was interviewed. CNA 4 stated Resident 33 had dentures but refused to wear them. CNA 4 stated Resident 33 had no problems chewing. CNA 4 stated if a resident had missing dentures, she would report it to social services. CNA 4 stated she had not seen Resident 33 wear her dentures in the last 2 weeks. CNA 4 stated she never asked Resident 33 the reason for not wearing her dentures. On 11/17/22, at 10:42 a.m., a joint interview and record review of an undated Inventory of Personal Effects, document was conducted with CNA 4. CNA 4 acknowledged that the document indicated dentures were not marked as one of Resident 33's personal belongings. During a review of the Social Services Assessment/Evaluation V 2 document dated 2/5/21, the document indicated Resident 33 wore a partial, upper denture. During an interview on 11/17/22, at 11:22 a.m., with the SSD, the SSD stated Resident 33 had partial upper dentures upon admission to the facility. The SSD stated if a resident had missing dentures, she would start an investigation, instruct the nurses to check the medication carts, check the laundry, and refer the resident to the dentist. The SSD stated she was informed today (11/17/22) by the LN 7 that Resident 33's dentures were missing. During a review of the facility's undated P&P titled, Admission/Discharge/Transfer, Personal Effects, Inventory of, the P&P indicated The inventory should include the recording of all personal clothing, valuable articles, etc. which are brought into the facility with the resident and retained by the resident. These personal effects shall be recorded on the Inventory of Personal Effects form.

Based on interview and record review, the facility failed to ensure the Pre-Admission Screening and Resident Review Level II (PASRR II - an evaluation of the resident's psychiatric treatment requirements) was followed up and completed for one of one resident (Resident 17) reviewed for PASRR. As a result, there was potential for a failure to coordinate the PASRR recommendations to Resident 17's assessment and care planning. Findings: Resident 17 was readmitted to the facility on [DATE] with diagnoses that included Schizoaffective Disorder (a mental illness that is marked by a combination of schizophrenia symptoms, such as hallucinations or delusions, and mood disorder symptoms, such as depression or mania), Post-Traumatic Disorder (PTSD - a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event), and Major Depressive Disorder (a mental disorder characterized by pervasive low mood, low self-esteem, and loss of interest or pleasure in normally enjoyable activities), per the Admission Record. A review of Resident 17's PASRR Level I (a screening tool for further psychiatric care) completed on 9/15/21 indicated a PASRR Level II was required. During an interview and concurrent record review on 11/21/22 at 3:20 p.m., with LN 7, LN 7 stated she was responsible for completing PASRRs. LN 7 stated a copy of the Level I was provided to the resident and sent to the PASRR agency. LN 7 stated a PASSR staff called her to verify Resident 17's diagnosis, any behavioral episodes, and if the resident had Dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life). LN 7 stated Resident 17 received a letter, dated 1/4/22 from PASRR which indicated, unable to complete due to isolation. LN 7 stated PASRRs were completed annually, and that she did not complete Resident 17 this year. LN 7 stated she did not follow up on Resident 17's PASRR Level II after the resident was removed from isolation. LN 7 stated it was important to follow up on the PASRR Level II to identify the resident's needs and properly place the resident if indicated. During an interview on 11/21/22 at 3:48 p.m., with the DON, the DON stated the purpose of completing the PASRR was to identify the care for the resident and meet the resident's psychosocial needs. During a review of the facility's undated policy and procedure (P&P) titled, Resident Assessment, PASRR, the P&P indicated, Based upon the assessment, the facility will ensure proper referral to appropriate state agencies for the provision of specialized services to residents with ID/RC (Intellectual Disability or Related Condition) or SMI (Serious Mental Illness).

Based on observation, interview and record review, the facility failed to update or revise care plans for two of three residents reviewed for care planning (8, 78). This failure had the potential to result in delayed care, miscommunication among caregivers, and decreased physical well-being of the residents. Findings: 1. Resident 8 was admitted to the facility on [DATE] with diagnoses to include dementia (a disorder causing memory problems and impaired reasoning) and muscle weakness, per the facility Admission Record. On 11/14/22 at 11:19 A.M., a concurrent observation and record review of Resident 8 was conducted. Resident 8 was in bed, with a fall mat (a protective pad) on the floor next to the bed. The Resident Matrix (a document used to identify care needs) indicated Resident 8 had fallen within the past 90 days. According to a review of Resident 8s IDT (Interdisciplinary Team, a group of healthcare professionals), Resident 8 had fallen twice within the last year. On 5/1/22 Resident 8 was found on the floor, with new interventions of providing a safe and hazard free environment, with the call light within reach and the bed in the lowest position. On 10/29/22 Resident 8 had a fall when a staff member transferred him to a chair by lifting him manually without a mechanical device. An IDT note, dated 11/3/22, indicated, Resident requires mechanical device 2-person assistance in transfer .Continue plan of care and update the care plan. A Falls care plan, initiated 12/9/21, indicated a goal of, Will be free of falls through the review date of 1/21/23. The intervention of 2-person assistance in transfers was not listed as an intervention. On 11/21/22 at 10:25 A.M., an interview was conducted with LN 6. LN 6 stated care plans were used to focus care on the needs of the resident, and based on their goals and plan of action for achieving them. LN 6 stated it was important to have accurate care plans to provide good care and meet the resident's goals. On 11/21/22 at 12:20 P.M., a concurrent interview and record review was conducted with the DON. The DON stated the care plans need to be updated so staff know what interventions were required to keep the resident safe. Per the DON, the IDT was responsible for updating the care plan. The DON reviewed the Falls care plan and stated, I missed this one. My expectation is that updates to the care plan get done during the IDT meeting. We could have another fall if we don't put new interventions in place. 2. Resident 78 was admitted to the facility on [DATE] per the facility Admission Record. On 11/14/22 at 11:08 A.M., a concurrent interview and record review was conducted with Resident 78. Resident 78 stated he had been admitted to the facility with a catheter (a device inserted into the bladder to collect urine), but it had been discontinued to prepare him for discharge. The catheter was listed on the MDS Indicator section of the survey facility data. On 11/21/22 a record review was conducted. Resident 78's care plan listed the catheter as a current focus of care, with goals of no catheter-related trauma. On 11/21/22 at 10:25 A.M., a concurrent interview and record review was conducted with LN 6. Per LN 6, care plans were used to focus care on the needs of the resident, and based on their goals and plan of action for achieving them. LN 6 stated it was important to have accurate care plans to provide good care and meet the resident's goals. LN 6 reviewed Resident 78's care plans, and stated, We should have updated the care plan to match the discontinued catheter order. The nurses are responsible for updating the care plans, and this one was not updated. This might cause confusion among the health care providers. On 11/21/22 at 12:20 P.M., an interview was conducted with the DON. The DON stated care plans were used to identify patient needs, and if a catheter was removed, the care plan should have been resolved. Per the DON, If we don't resolve the care plan it could cause confusion among the caregivers. Per an undated facility policy, titled Care Planning/Care Conference, .4. Care plan will be revised as needed .

Based on interview and record review, the facility failed to develop a plan for discharge for one of four residents reviewed for care planning (Resident 49). This failure had the potential to result in an unsafe discharge, and placed Resident 40 at risk for prolonged admission to the facility. Findings: Resident 49 was admitted to the facility on [DATE] with diagnoses to include muscle weakness, per the facility Admission Record. On 11/14/22 at 11:51 A.M., an interview was conducted with Resident 49. Resident 49 stated she had been at the facility almost a year, but still had no plans for discharging. Resident 49 stated she would like to be discharged back to her previous neighborhood but nobody had discussed finding her a place to live. According to Resident 49's Brief Interview for Mental Status (BIMS, an assessment tool, dated 9/1/22), Resident 49's score was 15, indicating intact cognition. On 11/30/21, an IDT met for Resident 49's initial care conference. Per the IDT, Resident 49's plan for discharge was for placement in the community. On 1/14/22, a Social Services admission assessment indicated Resident 49's discharge plan was to discharge to the community with home health needs to be determined upon discharge. On 2/4/22, a care plan was initiated, indicating Resident 49 wished to be discharged to her prior living arrangements. Goals were written for a pre-discharge plan to be established with the resident and caregivers, with revisions to the plan as needed. No discussion or revisions were documented. On 5/24/22, a Social Services quarterly assessment indicated Resident 49 now resided at the facility, and no discharge was anticipated. On 8/24/22, a Social Services quarterly assessment indicated Resident 49 resided at the facility and no discharge was anticipated. On 11/17/22 at 4:38 P.M., an interview was conducted with the SSD. The SSD stated discharge planning started when a resident was admitted to the facility. Per the SSD, the facility needed to evaluate the resident's abilities to live independently, and work with them to find an appropriate place to live upon discharge. The SSD stated the discussion about discharge should happen quarterly at the IDT meetings. Per the SSD, the IDT had not documented why Resident 49's discharge plan had changed or whether Resident 49 understood or not. The SSD stated she was not aware Resident 49 wanted to discharge elsewhere. On 11/17/22 at 5:05 P.M., an interview was conducted with the DON. The DON stated a discharge plan needed to reflect the resident's goals and staff interventions to help them meet their goals. The DON stated, I don't see the IDT discussed the discharge with the resident. This could cause an unsafe discharge. Per an undated facility policy, titled Care Planning/Care Conference, .4. Care plan will be revised as needed . Per an undated facility policy, titled Discharge Planning Process, It is the policy of this Facility that the discharge planning process focuses on the resident's discharge goals .c. Include regular re-evaluation of resident .to identify changes that require modification of the discharge plan .

Based on observation, interview and record review, the facility failed provide treatment and care according to professional standards of practice when: 1. The need for a PRN (provided as needed) medication was not assessed for one of one residents reviewed for constipation (Resident 36), and 2. A physician's order to assist a resident up in a chair daily was not followed for one of three residents reviewed for care planning (Resident 49). 3. Blood sugar level checks were not performed before meal intakes for one of 3 residents reviewed for diabetes (a disease in which the body's ability to produce or respond to the hormone insulin is impaired) care. These failures had the potential to place the residents at risk for further medical complications. Findings: 1. Resident 36 was admitted to the facility on [DATE], per the facility Admission Record. On 11/14/22 at 1:13 P.M., a concurrent observation and interview with Resident 36 was conducted. Resident 36 was sitting in a wheelchair in her room, rubbing her abdomen with her hand. Resident 36 stated she had been constipated for three days, and her abdomen felt tight and painful. Resident 36 stated she had informed her nurse of the constipation, and in the past had needed to go to the hospital due to the painful constipation. On 11/16/22 at 9 A.M., a concurrent observation and interview with Resident 36 was conducted. Resident 36 was sitting in a wheelchair outside of a bathroom, and stated she still had not had a bowel movement. On 11/16/22 at 10 A.M., a concurrent interview and record review was conducted with CNA 1. CNA 1 stated she was assigned to Resident 36 often, and Resident 36 was able to tell staff whether she needed to have a bowel movement or not. CNA 1 reviewed an electronic document titled BM (bowel movement) Report. CNA 1 stated, per the BM Report, Resident 36 had a bowel movement on 11/13/22, three days ago. CNA 1 stated the nurses assigned had access to the BM report, and Resident 36 was able to tell nurses when she was constipated. On 11/16/22 at 10:19 A.M., a concurrent interview and record review was conducted with LN 7. LN 7 stated the LN assigned to Resident 36 should assess her daily for constipation. Per LN 7, the nurses would assess for any pattern of constipation on the facility dashboard, and they should check the CNA Task list. LN 7 stated the nurse should write a progress note if constipation has occurred for several days in a row. LN 7 viewed all electronic documents, and stated, The assessment is not here. Her last bowel movement was three days ago. She (Resident 36) has an order for a prn medication for constipation. The LN should go to dashboard and check, and if nothing is documented for three days, that would trigger on the dashboard. The nurse should write a progress note. There's a hole in the process. The information didn't get documented anywhere. We can't administer a prn medication without asking about bowel movements. On 11/16/22, a record review was conducted. On 8/12/22, Resident 36's Brief Interview for Mental Status (BIMS, an assessment tool) score was 14, indicating intact cognition. Resident 36 had four scheduled (given daily) medications ordered for constipation. In addition, Resident 36 had another medication ordered PRN, (as needed) for constipation. A care plan for constipation had been initiated on 1/29/22, and revised on 8/8/22. The Goal written was, Will have a normal bowel movement at least daily . Interventions implemented included following facility protocol for bowel management. On 11/16/22 at 4:50 P.M., an interview was conducted with Resident 36. Resident 36 stated she always informed the medication nurses when she was constipated. Resident 36 stated the nurses did not ask her about needing a PRN medication for constipation when bringing her morning medications. On 11/16/22 at 5:05 P.M., an interview was conducted with the DON. The DON stated all nurses should assess residents at risk for constipation to determine when the last bowel movement was, and to determine the need for a PRN medication. The DON stated, That would be an important part of the nurses' assessment during medication administration. Per an undated facility policy, titled Bowel Care Management, It is the policy of this facility to follow physician orders and implement bowel care interventions .1. Licensed Nurses will monitor bowel movements every shift through the Clinical Dashboard/Clinical Alerts . 2. Resident 49 was admitted to the facility on [DATE] with diagnoses to include muscle weakness, per the facility Admission Record. On 11/14/22 at 11:51 A.M., a concurrent observation and interview was conducted with Resident 49. Resident 49 was sitting up in bed, working on a word puzzle. Resident 49 stated the doctor had ordered for her to be up in her chair daily so she could get ready for discharge. Per Resident 49, staff did not get her up in the chair. Resident 49 stated, How can I get ready for discharge if I can't get into my wheelchair by myself? On 11/17/22 a record review was conducted. On 9/1/22, Resident 49's BIMS score was 15, indicating intact cognition. Per a physician's order, dated 3/3/22, Resident 49 was to be, Up to wheelchair daily. every day shift Per the November Treatment Administration Record (TAR, a list of physician-ordered treatments), LNs signed off the order of Up to wheelchair daily. every day shift every day in November. LN 6 had signed off the TAR for 11/15/22 and 11/16/22. LN 2 had signed off 11/13/22 and 11/14/22. LNs 2 and 6 were not available for interview. Per a facility care plan, initiated 2/6/22, Resident 49, I require assistance/potential to restore function to maximum self-sufficiency for mobility .Will demonstrate the appropriate use of adaptive devices to increase ability in mobility .I am at risk for ADL (activities of daily living, which include getting in and out of bed or a chair) Self Care .Will safely perform .Transfers .Monitor/document/report to MD .any reasons for self-care deficit . No care plan for noncompliance was identified for Resident 49. On 11/17/22 at 10:32 A.M., an interview was conducted with CNA 1. CNA 1 stated she was usually assigned to Resident 49. CNA 1 stated Resident 49 only left the bed to take showers, but had refused to get up in the chair that day. CNA 1 stated she was aware Resident 49 was supposed to get up in the wheelchair daily but had never seen her out of the bed. On 11/17/22 at 11:50 A.M., an interview was conducted with Restorative Nursing Assistants (RNA) 41 and 42. RNA 41 and 42 stated their job was to provide range of motion exercises (ROM) three days a week for Resident 49. RNA 41 stated Resident 49 would complete the exercises, but when encouraged her to sit at the side of the bed she would refuse. RNA 41 stated Resident 49 stayed seated in bed to do her ROM exercises. RNA 42 stated they document the ROM exercises but transferring to a chair was not part of their role as RNAs. On 11/17/22 at 11:04 A.M., a concurrent interview and record review was conducted with LN 7. LN 7 stated if a physician ordered transferring a resident to a chair daily, the CNAs were responsible for the task. Per LN 7, if the resident refused, the CNA should report this to the LN. The LN would then go and discuss the order with the resident and encourage them to complete the transfer. If the resident still refused, the nurse should write a progress note regarding the refusal. LN 7 searched the nurses progress note and stated, There is no documentation (about refusing the order), so we can assume it did not happen. On 11/17/22 at 11:24 A.M., an interview was conducted with LN 42. LN 42 stated if the physician ordered for a resident to be up in the chair daily, the CNA and the LN would be responsible for documenting it. Per LN 42, if a resident refused to comply, the nurse would document the refusal in the progress notes and contact the physician if there was a pattern of noncompliance. LN 42 stated the nurses should create a care plan the noncompliance so staff, including the physician, would be aware. On 11/17/22 at 11:50 A.M., an interview was conducted with the DON. The DON stated if a resident refused to comply with a physician's order, the nurse should inform the physician. The DON stated, We did not communicate that. The order is in the TAR so the nurse can sign it off when the resident has gotten up in the chair, but based on the TAR it would appear she got up in the chair daily. Nurses should not sign off treatments that did not occur. The risk of noncompliance could be a decline (in her health) or her skin integrity could be compromised. This is not our goal for the resident. Per an undated facility policy, titled Charting and Documentation, .The resident's clinical record is an account of treatment, care, response to care .Importance and use of the record: Provides a multidisciplinary record of the physical and mental status of the resident . 46235 3. Resident 33 was admitted to the facility on [DATE] with diagnoses to include Diabetes type 2 ((a disease in which the body's ability to produce or respond to the hormone insulin is impaired), according to the History & Physical, dated 2/10/22. On 11/14/22, at 12:52 PM, LN 2 was observed checking Resident 33's blood sugar. LN 2 stated Resident 33's blood sugar was 206 and administered Humulin R insulin (a hormone created by the pancreas that controls the amount of glucose in the bloodstream). During an interview and record review on 11/16/22, at 3:54 p.m. with LN 6, LN 6 stated Resident 33 had an order for insulin. LN 6 reviewed Resident 33's MAR and stated the physician's order indicated to Hold if BS (blood sugar) 80 or below, but there was no order to conduct fingerstick blood sugar checks. LN 6 stated he assumed the physician wanted a blood sugar check. LN 6 stated he checked Resident 33's blood sugar before the resident ate her meals. LN 6 stated if the resident's blood sugar was checked after a meal, it would be inaccurate and abnormally high. Concurrent review of Resident 33's blood sugar in the MAR, dated 11/14/22, indicated a result of 206 mg/dl (milligram per deciliter). An interview and concurrent record review of Resident 33's physician's order was conducted on 11/21/22, at 10:20 a.m. with LN 2. LN 2 stated the resident's orders indicated inject 24 units of Regular insulin in the morning, and 18 units in the evening. LN 2 stated the order read to hold for blood sugar of 80 mg/dl or less. LN 2 stated she administered 2 units Regular insulin in addition to 24 units Regular insulin on 11/14/22 at 7:33 AM. LN 2 stated at 12:26 p.m., she administered 2 units of Regular insulin. LN 2 was not able to show in the computer what the resident's blood sugar was before administering the insulin. LN 2 stated blood sugars were checked based on the times indicated next to the medication in the MAR. Concurrent review of Resident 33's MAR indicated no physician's order for blood sugar check. LN 2 stated the standard of practice for checking blood sugar was before a resident ate. LN 2 stated the amount of insulin to be given to the resident was dependent on the resident's blood sugar level. LN 2 stated blood sugar check should have been done before breakfast for Resident 33. LN 2 stated the physician's order was not complete. LN 2 stated she should have asked the physician when to check the blood sugar. LN 2 stated It was important to know the resident's baseline of Diabetes, which was the normal sugar in the body before breakfast. LN 2 stated it was important to check blood sugars in order for the physician to review, and determine if resident was stable or not. LN 2 stated she assumed she had to check the resident's blood sugar before giving insulin, even though there was no order. LN 2 stated the insulin administered on 11/14/22 after meals was not accurate, and that it was her mistake. During a review of the facility's Consultant Pharmacist's Medication Regimen Review, for Resident 33, dated 4/21/22, indicated, Residents fingerstick readings show very high blood sugars, mainly >200 on most occasions. Please contact MD to adjust diabetic therapy. On 11/21/22 10:46 a.m. an interview was conducted with the DON. The DON stated blood sugar fingerstick should be completed before meals in accordance with the standard of practice. The DON also stated the nurses should follow the physician's order. A review of the facility's undated P&P titled, Nursing Clinical/Diabetes Mellitus Resident, indicated no guidance regarding when to perform blood sugar fingerstick.

Based on observation, interview, and record review, the facility did not ensure a toilet seat was securely attached to the toilet bowl in a communal bathroom used by multiple residents. As a result, multiple residents were at risk for falls due to the instability of the loose toilet seat. Findings: Per the facility's Admission Record, Resident 83 was admitted to the facility on [DATE] with difficulty walking. Resident 83's records were reviewed. Per the physician's history and physical, dated 10/17/22, Resident 83 had the capacity to make her own decisions. On 11/13/22 at 11:50 A.M., an observation and interview with Resident 83 was conducted. Resident 83 was sitting up on the side of her bed. Resident 83 stated she did not have a bathroom in her bedroom, so she used the bathroom down the hall, Resident 83 stated the bathroom was used by several residents on the hall. Resident 83 stated the toilet seat moved from side to side and when she tried to sit on it, she was afraid of falling because it threw her off balance. On 11/14/22 at 12:03 P.M., a concurrent interview with CNA 21 and observation of the toilet referenced by Resident 83 was conducted. CNA 21 observed the toilet seat and then moved it freely from side to side. CNA 21 stated the toilet seat was loose and could lead to a fall. On 11/14/22 at 12:06 P.M., a concurrent interview with the DON and observation of the toilet referenced by Resident 83 was conducted. The DON moved the toilet seat from side to side. The DON stated when the toilet seat was loose, someone could fall or slip off the toilet seat and land on the floor. Per the undated facility policy, titled Care and Treatment, Accident Intervention, .It is the policy of this facility that the resident environment remains as free of accident hazards as possible .

Based on observation, interview, and record review, the facility failed to ensure that one of one residents (31) on intravenous (IV) antibiotic therapy had their PICC line monitored per professional standards and facility policy. A PICC line is a peripherally inserted central catheter that provides access to the large vein carrying blood to the heart to administer medication for long-term use. This failure could potentially increase the risk of infection and delay the identification of catheter-related complications for Resident 31. Findings: Resident 31 was admitted to the facility on [DATE] with diagnoses that included infective endocarditis (a bacterial infection that settles in the heart) and bacteremia (bacteria in the blood), per the facility's Admission Record. During an interview with Resident 31 on 11/14/22 at 10:30 A.M., the resident stated he was receiving antibiotics through the IV in his arm because he had an infection in his blood. An IV site was observed in the resident's right upper arm, with a transparent dressing covering the site, which was labeled and dated. According to a review of Resident 31's Medication Administration Record (MAR), the PICC line was in the resident's right brachial vein (in the upper arm), and the dressing was to be changed every seven days. On 11/16/22 between 12:04 and 12:45 P.M., registered nurse (RN) 12 was observed while changing Resident 31's PICC line dressing. At 12:08 P.M., RN 12 placed a clean towel under Resident 31's arm on top of the bed. At 12:11 P.M., RN 12 put a package of sterile supplies on the resident's bedside table. The bedside table was not cleaned or sanitized before placing the supplies. RN 12 commenced removing the resident's dressing using clean gloves. At 12:22 P.M., RN 12 opened the sterile package on the bedside table and donned (put on) sterile gloves. RN 12 ripped the gloves while donning them. RN 12 removed the torn gloves and obtained a new sterile dressing change kit. RN did hand hygiene after placing the sterile equipment on the towel on the resident's bed. At 12:24 P.M., RN 12 opened the sterile kit, donned sterile gloves, and placed a sterile barrier under Resident 31's arm. At 12: 26 P.M., RN 12 removed a paper tape measure from the sterile kit, measured the PICC line from the insertion site to the cap, and then placed the tape measure back into the sterile kit. At 12:27 P.M., RN 12 removed alcohol wipes from the kit and wiped in a circular motion from the insertion site outward with three separate alcohol wipes. RN 12 cleaned the site in the same manner with a sterile antiseptic applicator from the kit. RN 12 discarded the used alcohol wipes and antiseptic on the bedside table with the other discarded items (dirty dressing, torn gloves, and empty sterile glove packages). At 12:29 PM, RN 12 picked up a closed package from the bedside table (next to the discarded items) and attempted to open the package containing the new dressing. At 12:30 P.M., RN 12, while struggling to open the dressing package, ripped one of the sterile gloves. RN 12 gathered the supplies from the bed, placed them on the bedside table, and removed the torn gloves. At 12:31 P.M., RN 12 placed another sterile dressing kit on the towel, did hand hygiene, opened the sterile package, placed the sterile gloves on top of the empty packages of the previous sterile gloves, and donned the sterile gloves. At 12:34 P.M., RN 12 put a sterile barrier under Resident 31's arm and cleaned the PICC line insertion site by wiping back and forth multiple times over the insertion site with the second alcohol wipe. RN 12 then cleaned the site with the antiseptic, starting at the insertion site, circling outward, then wiping toward the insertion site with the antiseptic. At 12:35 P.M., RN 12 picked up the package with the new dressing from the bedside table and opened the package, and placed the dressing on the insertion site. RN 12 completed the dressing change at 12:45 P.M. During an interview with RN 12 on 11/16/22 at 12:50 P.M., RN 12 stated, My big problem was the sterile gloves were too small. RN 12 further stated he did not do a proper job during the dressing change and did not maintain a sterile field. RN 12 stated he was not aware that he wiped back and forth across the insertion site while cleaning the site. During an interview with RN 13 on 11/17/22 at 11:25 A.M., RN 13 stated that a sterile field must be maintained during the dressing change for a PICC line to decrease the risk of infection. RN 13 further stated when doing a PICC line dressing change, they measured the PICC line but did not document the measurements anywhere in the chart. RN 13 stated they just visually monitored if the tubing was longer than last time. During an interview with the director of nursing (DON) on 11/21/22 at 12 P.M., the DON stated it was necessary to maintain a sterile field when changing a PICC line dressing to decrease the risk of infection. In addition, the DON stated measurements of the PICC line should have been documented on the MAR or progress notes during the dressing change to ensure that the PICC line was in the proper placement. According to a review of the facility's undated policy titled PICC line dressing change, Central Vascular Access Device: Peripherally Inserted Central Catheter (PICC) . Procedure: .F. Dispose old dressings and gloves appropriately. G. Don sterile gloves . According to a review of the facility's undated policy titled Dressing Change for Vascular Access Devices [CVAD], Purpose: To prevent local and systemic infection related to the IV site . Equipment: .Dressing Kit (for midlines and central lines) .Sterile gloves (for midlines and central lines) . Procedure: .For Midlines and all CVADs: . 12. Clean site with three (3) alcohol swabs starting from the center moving outward in an increasing spiral pattern. Clean an area larger than dressing to be applied. 13. Prep site with three (3) povidone iodine swabs starting from the center moving outward in an increasing spiral pattern. Clean an area larger than dressing to be applied . 19. Suggested charting: Site assessment .External length, if indicated, for device .

Based on observation, interview and record review, the facility failed to ensure a physician's order for oxygen therapy was followed for one of one resident (Resident 33) reviewed for respiratory care. As a result, Resident 33 was provided with more oxygen than what the physician ordered, which had the potential to cause respiratory problems for the resident. Findings: Resident 33 was admitted to the facility on [DATE] with diagnoses to include Congestive Heart Failure (CHF - a serious condition in which the heart doesn't pump blood as efficiently as it should), Chronic Obstructive Pulmonary Disease (COPD - a chronic inflammatory lung disease that causes obstructed airflow from the lungs), and Asthma (a condition in which a person's airways become inflamed, narrow, swollen, and produce extra mucus, which makes it difficult to breathe), according to the History & Physical, dated 2/10/22, and the Order Summary Report. On 11/16/22, at 4:31 p.m., a concurrent observation of Resident 33's oxygen concentrator (a medical device used to provide oxygen) was conducted with LN 6. The oxygen concentrator was observed at 3.5 liter/minute. LN 6 stated the physician's orders indicated 2 liters/minute. A concurrent record review of Resident 33's physician's order, dated 11/13/22 was conducted with LN 6 on 11/16/22. The order indicated Continuous O2 (oxygen) at 2 liters per minute via nasal cannula. During an interview on 11/21/22, at 11:45 a.m., with the DON, the DON stated staff was not following physician's order regarding Resident 33's oxygen. The DON stated, Resident 33 can have respiratory problems, and too much can harm the resident. During a review of the facility's undated P&P titled, Licensed Nurse Procedures, Oxygen Administration (Mask, Cannula, Catheter), the P&P indicated, It is the policy of this facility that oxygen therapy is administered, as ordered by the physician or as an emergency measure until the order can be obtained.

Based on observation, interview and record review, the facility failed to ensure one of four residents reviewed for dialysis (a process to remove waste products from the blood) had a dressing removed as ordered by the physician (Resident 36). This failure had the potential to cause damage or injury to the dialysis site. Findings: Resident 36 was admitted to the facility on [DATE] with diagnoses to include dependence on renal dialysis (a need for dialysis due to kidney failure), per a facility Admission Record. On 11/14/22 at 3:03 P.M., an interview was conducted with Resident 36. Per Resident 36, dialysis was scheduled on Tuesdays, Thursdays and Saturdays. Resident 36 stated the nurses usually removed the dressing from her dialysis access site when she returned at night. On 11/16/22 at 9:37 A.M., a concurrent observation and interview was conducted with Resident 36. Resident 36 stated she had returned from dialysis the previous night. Resident 36 stated the night nurse did not remove the dressing from her access site. Resident 36 pulled her arm from her shirt sleeve and demonstrated the intact dressing, with tape around the dressing and upper arm. On 11/16/22 at 9:40 A.M., an interview was conducted with LN 6. Per LN 6, the evening shift nurses would be responsible for removing the dressing from Resident 36's access site. LN 6 stated the order was for the dressing to be removed four to six hours after dialysis was completed. On 11/16/22 at 9:42 A.M., a concurrent interview and observation was conducted with LN 6 and Resident 36. LN 6 assisted Resident 36 in removing her arm from her shirt, and observed the dressing still in place. Per LN 6, The dressing is still here. The physician ordered for nurses to remove the dressing within four to six hours after dialysis, but the evening shift must have missed it. This could cause her access site to clot, and then she would not be able to receive her dialysis. On 11/16/22 at 10:31 A.M., a concurrent interview and record review was conducted with LN 7. LN 7 stated she was the charge nurse. Per LN 7, there was an order for the nurse to remove the dressing in the Treatment Administration Record (TAR). LN 7 viewed the TAR for the 11/15/22 dressing removal, and stated, It is signed off by (LN 41), he documented it was off. Leaving the dressing on could cause a clot. The nurses need to follow the physician's orders. On 11/16/22 at 4 P.M., an interview was conducted with the DON. The DON stated upon return from dialysis, the LNs were supposed to remove the dressing as ordered by the physician. The DON stated, It is my expectation the nurses follow all physician's order. LN 41 should not sign off something he did not do. On 11/16/22, a record review was conducted. On 5/18/21, the physician ordered to remove the pressure dressing four to six hours after dialysis. Per the order, Refrain from keeping pressure dressing more than 6 hours to minimize risk for access clotting and/or malfunction. Per the TAR, LN 41 had signed off the removal order for the dressing on 11/15/22, indicating he had followed the physician's order. LN 41 was not available for an interview. Per a facility policy, revised March 2009 and titled Dialysis (Renal), Pre and Post Care, It is the policy of this facility to: Assess or evaluate the resident's condition and monitor for complications before and after dialysis treatments .Post Dialysis Care: 1. Upon return to the facility, conduct a post-dialysis evaluation/assessment including but not limited to the evaluation/assessment of the dialysis access site and dressing .3. Post dialysis .access care as ordered .

Based on observation, interview and record review, the facility failed to ensure behaviors related to the use of an antipsychotic was accurately monitored for one of 5 residents (Resident 33) reviewed for unnecessary use of psychotropic medications. As a result, Resident 33's documented behavior showed an increase in behavioral episodes which could potentially result in inappropriate dosing of the antipsychotic medication. Findings: Resident 33 was admitted to the facility on [DATE] with diagnoses to include schizoaffective disorder (a mental illness that is marked by a combination of schizophrenia symptoms, such as hallucinations or delusions, and mood disorder symptoms, such as depression or mania), and bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs), according to Resident 33's face sheet. An interview was conducted with CNA 1 on 11/14/22, at 12:15 p.m. CNA 1 stated Resident 33 preferred to sleep in and not eat breakfast until she wakes up. CNA 1 also stated Resident 33 would get upset if breakfast tray was taken away without Resident 33's consent. On 11/14/22 at 1:00 p.m., Resident 33 was observed instilling the nebulizer liquid medication into the nebulizer cup through an opening attached to the mask. Resident 33 stated she administered her own breathing treatment because staff did not know what they were doing. During an interview on 11/16/22, at 8:38 a.m., with CNA 4, CNA 4 stated Resident 33 liked attention. CNA 4 stated if Resident 33 was given what she needed, she did not use the call light often. CNA 4 stated Resident 33 called a lot for a breathing treatment. CNA 4 stated she sympathized with her residents. CNA 4 stated she gave Resident 33 attention and talked to her prior to care. CNA 4 stated Resident 33 was meaner with other staff, cursed and yelled at them. CNA 4 stated Resident 33 yelled if something was loud or if she could not hear her TV. CNA 4 stated she was able to calm Resident 33 when she explained things. CNA 4 stated she did not observe any changes since admission. CNA 4 stated Resident's yelling would decrease if others talked to her. During an interview on 11/16/22, at 10:37 a.m., with Resident 33, Resident 33 stated that everyone at the facility was nice, but that she had yelled at staff and her doctor. Resident 33 stated, she yelled at them when they told her she could not do something. An interview was conducted on 11/16/22, at 3:54 p.m. with LN 6. LN 6 stated Resident 33 was hard to handle. LN 6 stated Resident 33 got upset if her food tray was taken away without her consent. An interview and joint record review of Resident 33's MAR was conducted on 11/17/22, at 11:00 a.m., with LN 6. LN 6 stated Resident 33 yelled at a CNA on 11/6/22 due to a missing blanket or crayon. LN 6 stated on 11/6/22 Resident 33 stated her blanket was given to another resident. LN 6 stated per the MAR, Resident 33 was being monitored for yelling for no apparent reason related to the use of Seroquel (antipsychotic medication). LN 6 stated there were 3 episodes of Yelling for no apparent reason marked on the MAR for 11/6/22. LN 6 stated Resident 33's yelling on 11/6/22 should not have been considered as Yelling for no apparent reason because Resident 33 was yelling due to her missing blanket and crayon. LN 6 acknowledged that Resident 33's behavior was not monitored accurately. On 11/21/22, at 3:48 p.m., an interview was conducted with the DON. The DON stated Resident 33 was demanding and yelled at times. The DON stated she had observed Resident 33 yelling because she wanted her breathing treatment. The DON stated the physician's order for the use of Seroquel was for Yelling for no apparent reason. The DON stated that Resident 33's behavior for Yelling for no apparent reason was inaccurately monitored because Resident 33 yelled due to her missing items. The DON stated this inaccuracy caused inaccurate information for the physician which could lead to inaccurate medication dosing. A review of the facility's undated P&P title, Psychotropic Drug Use, indicated, .2. The Licensed Nurses shall review the classification of the drug, the appropriateness of the diagnosis, its indication/behavior monitors and related adverse side effects .

Based on interview and record review, the facility failed to ensure care conference documentation was accurate for one of 20 resident (Resident 33) reviewed for accurate medical record. This failure did not provide an accurate representation of the care provided to Resident 33 and had the potential to cause confusion amongst care providers. Findings: Resident 33 was admitted to the facility on [DATE] with diagnoses to include Congestive Heart Failure (CHF - a serious condition in which the heart doesn't pump blood as efficiently as it should), according to the History & Physical, dated 2/10/22, and the Order Summary Report. An interview and joint record review was conducted with the SSD on 11/17/22 at 11:22 a.m. The SSD stated that a care conference was scheduled for Resident 33 on 11/7/22. The SSD stated the care conference was canceled by Resident 33's daughter and was scheduled for a later date. The SSD reviewed the IDT (Interdisciplinary team - a coordinated group of professionals from several different field) Care Plan Review, dated 11/7/22, which indicated that a meeting was held, and the participants included Resident 33, the resident's representative, and the physician. The SSD stated that the documentation was inaccurate and that there was no meeting held on 11/7/22. During a telephone interview on 11/17/22, at 4:05 p.m., with Resident 33's daughter, the resident's daughter stated she canceled the IDT care conference scheduled for 11/7/22. The DON was interviewed on 11/21/22, at 3:34 p.m. The DON stated the inaccurate documentation in the IDT-Care Plan Review, did not reflect the events that occurred, and it caused confusion to health care providers. A review of the facility's undated P&P titled, Nursing Clinical/Charting and Documentation was conducted. The policy indicated, The resident's clinical record is an account of treatment, care, response to care, signs, symptoms, and progress of the resident's condition. It also includes data needed for identification and communication with family/responsible party.

Based on observation, interview, and record review, the facility failed to fully implement infection control standards of practice when one of five staff interviewed was unaware of a resident's (86) transmission-based precautions status. In addition, one staff did not adhere to proper hand hygiene. This failure could expose other residents to potential infection and multi-drug resistant organisms (MDROs). Findings: 1. Resident 86 was admitted to the facility on [DATE] with diagnoses that included sepsis (a potentially life-threatening complication of an infection), resistance to multiple antibiotics, and unspecified E.coli (a bacteria) as the cause of disease classified elsewhere, per the facility's Admission Record. On 11/14/22 at 3:25 P.M., a sign outside Resident 83's room indicated Enhanced Barrier Precautions. According to the Centers for Disease Control and Prevention (CDC), Enhanced Barrier Precautions are an infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high-contact resident care activities. On 11/16/22 at 9 A.M., licensed nurse (LN) 15 was observed inside Resident 86's room, standing beside and talking with the resident. LN 15 was not wearing any personal protective equipment (PPE) while in the resident's room. A sign which indicated Enhanced Barrier Precautions and a cart with PPE were just outside Resident 86's door. During an interview with LN 15 on 11/16/22 at 9:39 A.M., LN 15 stated he was unsure of Resident 86's isolation status. At 9:58 A.M., LN 15 stated the resident was on Enhanced Barrier Precautions due to an MDRO in the urine. During an interview with the infection preventionist (IP) on 11/21/22 at 3 P.M., the IP stated Resident 86 was on Enhanced Barrier Precautions due to a urinary tract infection with an MDRO. The IP stated residents with a history of MDROs required the use of gown and gloves for certain high-contact activities to reduce the risk of transmitting MDRO to other residents. In addition, the IP stated that all nurses and direct care staff needed to know why a resident was under precautions to mitigate MDRO transmission risks. According to a review of the facility's policy titled Transmission Based Precaution and Isolation, dated 9/29/17, It is the policy of [Facility] to implement infection control measures to prevent the spread of communicable diseases and conditions . Prevention and Control of MDRO Transmission: .G. Staff Education: is essential in reducing the transmission of MDROs. Healthcare workers should be informed concerning epidemiology of specific MDROs and the role they, the Healthcare worker, play in reducing the potential for transmission of these as well as other microorganisms. The facility will implement a system to alert staff, residents and visitors that a resident is on transmission based precautions . 46235 2. During observation and interview on 11/14/22, at 2:52 p.m., CNA 3 was observed coming out of room [ROOM NUMBER] and carried a urinal filled with urine, while both hands were gloved. CNA 3 held the urinal with his right hand and closed the door to room [ROOM NUMBER] with his left hand. CNA 3 proceeded to enter the hall restroom and came out holding the urinal with his left hand. CNA 3 turned the doorknob with his right hand to enter room [ROOM NUMBER]. An interview was conducted with the Infection Preventionist (IP) on 11/21/22, at 3:34 p.m. The IP stated staff used the restroom across the hall for room [ROOM NUMBER]. The IP stated he trained staff not to use gloves in the hallway. The IP stated he trained staff to use a barrier on holding a urinal. During a review of the facility's undated P&P, titled, Infection Prevention-Control of Transmission of Infection, the P&P indicated, It is the policy of this facility to implement infection control measures to prevent the spread of communicable diseases and conditions. Standard Precautions- Apply to all contact with resident's blood, body fluids, secretions and excretions .

Based on observation, interview, and record review, the facility failed to ensure care/treatment was provided in accordance with the physician's orders and the resident's written plan of care for two of three residents (Resident 1 and 3) when: 1. Resident 1 was not administered anti-[CONDITION(S)] medications (medications used to prevent seizures; a disorder causing uncontrolled electrical disturbances in the brain) on [DATE], [DATE], [DATE], [DATE], and [DATE]. 2. Resident 3's physician order was not followed related to administering medications when the resident returned from [CONDITION(S)] treatments (process for persons with [CONDITION(S)] that removed wastes and excess fluids from the blood via a machine) on [DATE], [DATE], and [DATE] . This failure caused Resident 1 to experience fear, anxiety, and distress when not receiving her anti-[CONDITION(S)] medications. In addition, Resident 3 had the potential to experience a decline in physical and psychosocial well-being. Findings: 1. A review of Resident 1's Admission Record dated [DATE], indicated the resident was readmitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1's Minimum Data Set Assessment (an assessment tool) dated [DATE], indicated the resident scored 15 out of 15 on the brief interview of mental status (a score of ,d+[DATE] meant the resident was cognitively intact). On [DATE] at 10:22 A.M., an interview was conducted with Resident 1 while inside the resident's room. Resident 1 stated, They don't give me my [CONDITION(S)] medications. Resident 1 stated she took both [MEDICATION(S)] and [MEDICATION(S)] (anti-[CONDITION(S)] medications) to control her seizures. Resident 1 stated she had really bad seizures and had to take both [CONDITION(S)] medications on time every time or she would have a [CONDITION(S)]. Resident 1 stated about two weeks ago ([DATE]), after not receiving her anti-[CONDITION(S)] medications, she experienced a [CONDITION(S)] while in the [CONDITION(S)] clinic. Resident 1 stated she had to be sent to the hospital via 911 and had another [CONDITION(S)] after being brought to the hospital. Resident 1 stated she had to leave the facility every Tuesday, Thursday, and Saturday afternoon around 3 P.M. to go to her [CONDITION(S)] treatments. Resident 1 stated fear of not getting her anti-[CONDITION(S)] medications made her anxious and interfered with her [CONDITION(S)] treatments. Resident 1 stated she would leave [CONDITION(S)] treatment early on some days to make sure she got back to the facility to get her anti-[CONDITION(S)] medications on time. Resident 1 stated if she was not back to the facility on the time the medications were scheduled, she would not be administered her anti-[CONDITION(S)] medications. Resident 1 further stated she was not provided her [MEDICATION(S)] this morning, last night, and yesterday morning. Resident 1 stated it made her feel very anxious going more than 24 hours without taking her [MEDICATION(S)]. Resident 1 started crying and stated, I'm afraid I'll have another [CONDITION(S)]. Resident 1 stated having a [CONDITION(S)] was scary and painful. Resident 1 was still tearful and stated during a [CONDITION(S)] she would lose total control of her body, all her muscles would tighten, and she would shake. Resident 1 stated earlier in [DATE], she went into [CONDITION(S)] (life threatening heart rate) while having a [CONDITION(S)] and CPR (cardio-pulmonary resuscitation, chest compressions and artificial breathing) had to be performed. Resident 1 rubbed her chest and stated her ribs were still sore from having received CPR. Resident 1 stated she was afraid she would die if she had another [CONDITION(S)]. A review of Resident 1's physician's orders dated [DATE], indicated, [MEDICATION(S)] Suspension .Give 4 ml [milliliters] by mouth two times a day for seizures, and [MEDICATION(S)] Solution . Give 1500 mg [milligrams] by mouth two times a day for [CONDITION(S)] prophylaxis [prevention]. A review of Resident 1's progress notes and medication administration record (MAR) for [DATE] indicated the resident did not receive [MEDICATION(S)] on [DATE] and [DATE] due to the medication being unavailable. On [DATE] at 10:52 A.M., a joint observation of licensed nurse (LN) 1's medication cart and interview was conducted with LN 1. LN 1 stated she considered Resident 1 to be an accurate historian who was very alert and very clear. Resident 1 did not have any [MEDICATION(S)] in the medication cart. LN 1 stated Resident 1 had not received her [MEDICATION(S)] and that the facility had run out of the resident's medication. LN 1 stated she had not been able to administer Resident 1's [MEDICATION(S)] this morning (9 A.M. dose for [DATE]) or yesterday morning ([DATE]) because the pharmacy had not delivered it. LN 1 stated when she called the pharmacy, she was informed Resident 1's [MEDICATION(S)] refill was pending an authorization from insurance. LN 1 stated an anti-[CONDITION(S)] medication such as [MEDICATION(S)] was an essential medication. LN 1 stated Resident 1 could have a [CONDITION(S)] if she was not provided [MEDICATION(S)] routinely as ordered by the physician. LN 1 further stated Resident 1 had become upset when her anti-[CONDITION(S)] medication was not available and seems worried. On [DATE] at 12:11 P.M., an interview was conducted with the facility administrator (ADM). The ADM stated Resident 1 should not have missed physician ordered doses of [MEDICATION(S)]. The ADM stated [MEDICATION(S)] was a medication with a therapeutic range (blood level required of the drug to effectively treat the condition) that had to be closely monitored. The ADM stated missed doses could affect the resident's therapeutic level and could cause a [CONDITION(S)]. The ADM stated that was not acceptable. A review of Resident 1's physician's orders dated [DATE], indicated the resident went to the [CONDITION(S)] clinic on Tuesday, Thursday, and Saturdays with scheduled treatment time from 3:55 P.M. until 7:10 P.M. The physician's orders dated [DATE] further indicated Resident 1's evening medications were to be administered to the resident when the resident returned from [CONDITION(S)]. A review of Resident 1's undated written plan of care titled [Resident 1] Has [CONDITION(S)] Disorder, indicated one of the interventions to control seizures was to .Give [CONDITION(S)] medication as ordered by the doctor A review of Resident 1's progress notes and MAR for March and [DATE] indicated the resident did not receive [MEDICATION(S)] and [MEDICATION(S)] on ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], and [DATE] due to the resident being absent from facility while at the [CONDITION(S)] clinic. On [DATE] at 2:27 P.M., a joint interview and record review was conducted with LN 3. LN 3 reviewed Resident 1's MAR for [DATE] (Thursday). LN 3 stated she had coded 8 (absent from facility) for Resident 1's 5 P.M. doses of [MEDICATION(S)] and [MEDICATION(S)]. LN 3 stated both medications had not been given to the resident because she had gone to [CONDITION(S)] treatment. LN 3 stated if the medications were given when the resident came back from [CONDITION(S)], a note would be written to document that. LN 3 reviewed Resident 1's clinical record and stated there was no documentation the resident received her anti-[CONDITION(S)] medications. LN 3 reviewed Resident 1's physician's orders dated [DATE], May hold medications on [CONDITION(S)] days and administer upon return to facility (if not contraindicated). LN 3 stated there was no contraindication on [DATE], and Resident 1 should have been given her evening medications to include her anti-[CONDITION(S)] medications. LN 3 stated the physician's order had not been followed, and it should have been. LN 3 reviewed Resident 1's undated written care plan for [CONDITION(S)] disorder and stated the resident's care plan intervention .Give [CONDITION(S)] medication as ordered by the doctor had not been implemented and should have been. On [DATE] at 3:30 P.M., a joint interview and record review was conducted with LN 2. LN 2 reviewed Resident 1's MAR and stated she had given the last dose of [MEDICATION(S)] to the resident on [DATE] at 5 P.M. LN 2 stated she had faxed the refill to the pharmacy on [DATE]. LN 2 stated Resident 1 had not received [MEDICATION(S)] on [DATE] at 5 P.M. because the medication had not been delivered from the pharmacy. LN 2 reviewed Resident 1's MAR entry for [MEDICATION(S)] administered on [DATE] at 5 P.M. and stated she had charted in error on the resident's MAR. A review of Resident 1's [CONDITION(S)] clinic documentation dated [DATE], indicated, .During [CONDITION(S)] treatment on [DATE] at approximately 4:30 P.M., [Resident 1] seemed anxious stating that staff at the facility did not provide her anti-[CONDITION(S)] medication that day, patient reported that this is not the first time the facility forgets to give her some of her medications or are late providing her meds [medications] . [Resident 1] was crying, she reported feeling worried since she was afraid she was going to get a [CONDITION(S)] as a result of it. [Resident 1] has a history of severe seizures . SW [social worker] called [facility] and spoke with [LN 2]. She was asked if [Resident 1] took her anti-[CONDITION(S)] medication that day and if there was a possibility that one of her staff would bring the medication to the patient [Resident 1] since the patient was anxious and wanted to return without finishing her [CONDITION(S)] treatment. [LN 2] reported no staff was going to be able to deliver the medication . [Resident 1] was informed that staff at [facility name] was not going to be able to deliver the medication. [Resident 1] decided to stop her treatment and [CONDITION(S)] clinic secretary arranged transportation for patient to go back there [to the facility] On [DATE] at 4:20 P.M., a joint interview and record review was conducted with LN 4. LN 4 reviewed Resident 1's [DATE] MAR and stated she coded 8 on [DATE] (Thursday) for the 5 P.M. dose of [MEDICATION(S)] and [MEDICATION(S)]. LN 4 stated there was no documentation Resident 1 was provided her medication when she returned from [CONDITION(S)] treatment. LN 4 stated, if it wasn't documented, it wasn't done. On [DATE] at 4:53 P.M., a joint interview and record review was conducted with LN 5. LN 5 reviewed Resident 1's March and [DATE] MAR for [MEDICATION(S)] and [MEDICATION(S)]. LN 5 stated she had coded 8 for the 5 P.M. dose of [MEDICATION(S)] and [MEDICATION(S)] on ,d+[DATE] (Thursday), ,d+[DATE] (Tuesday), and ,d+[DATE] (Tuesday). LN 5 stated because Resident 1 missed the medication administration time of 5 P.M. on ,d+[DATE], ,d+[DATE], and ,d+[DATE] when she was at [CONDITION(S)] treatment, the medication had not been administered. LN 5 reviewed the physician's order to administer medications when Resident 1 returned to the facility. LN 5 stated she had not been aware of that order. LN 5 stated that order should have been followed and Resident 1 should have been given her medications when she returned from [CONDITION(S)]. On [DATE] at 1:41 P.M., a telephone interview was conducted with [CONDITION(S)] clinic social worker (SW) 1. SW 1 stated on [DATE] (Tuesday) the [CONDITION(S)] physician told her Resident 1 was claiming the facility was not regularly providing the resident's anti-[CONDITION(S)] medications. SW 1 stated she spoke to Resident 1, and the resident told her the facility did not provide her [DATE] morning anti-[CONDITION(S)] medications. SW 1 stated the resident told her that she was afraid of having a [CONDITION(S)] because the medications had not been provided. SW 1 stated she called the facility because Resident 1 started crying and became so distressed and threatened to end [CONDITION(S)] treatment early. SW 1 stated ending [CONDITION(S)] treatment early was not good for a patient. SW 1 further stated on [DATE] (Thursday), Resident 1 did have a [CONDITION(S)] during [CONDITION(S)] treatment and had to be sent out to the hospital via 911. On [DATE] at 2:04 P.M., a telephone interview was conducted with [CONDITION(S)] clinic charge nurse (CN). The CN stated Resident 1 was his patient on [DATE]. The CN stated Resident 1 told him that the facility did not consistently provide her anti-[CONDITION(S)] medications and had not given her any anti-[CONDITION(S)] medications on [DATE]. The CN stated this had concerned him as he knew Resident 1 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The CN stated Resident 1 then proceeded to have a full blown [CONDITION(S)] which lasted 56 seconds. The CN stated when Resident 1 was seizing, she first went spastic, then jerking movements started and the resident stared off to one side and was unresponsive. The CN stated when the [CONDITION(S)] ended Resident 1 could barely talk and could not move her arms. The CN stated the clinic sent Resident 1 to the hospital via 911. The CN stated, It was sad she had to go through that when seizures had a good chance at being prevented with proper med [medication] management. A review of Resident 1's hospital discharge instructions dated [DATE], indicated, .Chief Complaint: [CONDITION(S)] Visit Date: [DATE] [at] 19:08 [7:08 P.M.] . On [DATE] at 9 A.M., another interview was conducted with Resident 1. Resident 1 stated on [DATE] the facility had not given her the morning dose of [MEDICATION(S)] and that afternoon she had a [CONDITION(S)] while at the [CONDITION(S)] clinic. Resident 1 stated on [DATE], she had requested to be sent to the hospital from the [CONDITION(S)] center because she had an aura. Resident 1 stated while at the hospital the evening of [DATE], the hospital administered [MEDICATION(S)] and [MEDICATION(S)] intravenously (injection of medication in a vein). Resident 1 stated the facility did not administer medication to her when she returned to the facility on the evening of [DATE]. A review of Resident 1's progress notes indicated on [DATE] at 7:10 P.M., the [CONDITION(S)] clinic informed the facility Resident 1 had been sent to the hospital, and on [DATE] at 11:16 P.M., the resident returned to the facility. A review of Resident 1's [DATE] MAR indicated on [DATE] and [DATE] the resident's 5 P.M. doses of [MEDICATION(S)] and [MEDICATION(S)] had been administered to the resident while the resident was hospitalized . On [DATE] at 9:45 A.M., a joint interview and record review was conducted with the ADM. The clinical consultant (CC)1 was also present. The ADM stated she had not been aware Resident 1 had a [CONDITION(S)] in the [CONDITION(S)] clinic on [DATE]. The ADM reviewed Resident 1's MAR on [DATE] and [DATE] for the 5 P.M. doses of [MEDICATION(S)] and [MEDICATION(S)] and stated, [Facility staff] can't give meds when a resident's in the hospital. On [DATE] at 12:35 P.M., a joint interview and record review was conducted with the director of staff development (DSD). The DSD reviewed Resident 1's MAR on [DATE] and [DATE] for the 5 P.M., doses of [MEDICATION(S)] and [MEDICATION(S)] and stated nurses documenting these medications were administered while the resident was not in the facility made the MAR suspicious and it could not be taken as fact. The DSD stated, Who knows how many [of Resident 1's] doses have been missed. The DSD reviewed Resident 1's MAR for March and [DATE] and stated the resident did not consistently receive her anti-[CONDITION(S)] medications. The DSD stated, I'd be afraid of having a [CONDITION(S)], too. On [DATE] at 1:10 P.M., a telephone interview was conducted with the facility's pharmacy consultant (PC). The PC stated it was important for a resident diagnosed with [CONDITION(S)] to have received all anti-[CONDITION(S)] medications as ordered by the physician. The PC stated missing dosages of anti-[CONDITION(S)] medications could cause a person to have a [CONDITION(S)]. The PC stated Resident 1 should have received all physician ordered doses of [MEDICATION(S)] and [MEDICATION(S)]. On [DATE] at 2:35 P.M., a joint interview and record review was conducted with the facility's medical director (MD), ADM, and CC 2. The MD reviewed Resident 1's March and [DATE] MAR and stated if Resident 1 had missed anti-[CONDITION(S)] medications for three to four days in a row, that could cause a [CONDITION(S)]. The MD stated he was not aware nurses documented Resident 1's anti-[CONDITION(S)] medications had been given on [DATE] and [DATE] while the resident was out of the facility and on [DATE] when the [MEDICATION(S)] was unavailable. The MD stated Resident 1 should not have missed any doses of [MEDICATION(S)] and [MEDICATION(S)], and the physician's orders should have been followed. The MD stated due to Resident 1's sensitivity to seizures it was even more important that she received the medications as ordered. On [DATE] at 4:38 P.M., an interview was conducted with the director of nursing (DON). The ADM and CC 2 were also present. The DON stated Resident 1's anti-[CONDITION(S)] medications should have been provided to the resident and the physician's order should have been followed. The DON stated it was her expectation for Resident 1's [CONDITION(S)] care plan to have been followed and implemented. 2. A review of Resident 3's Admission Record dated [DATE], indicated the resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 3's order summary report (physician orders) dated [DATE], indicated, the resident received [CONDITION(S)] every Monday, Wednesday, and Friday that was scheduled at 6:30 P.M. through 9:30 P.M. The order summary report also indicated the resident was to be administered his evening medications when he returned to the facility from [CONDITION(S)]. A review of Resident 3's [DATE] medication administration record (MAR) indicated at 9 P.M. on Monday [DATE], Wednesday [DATE], and Friday [DATE], the following evening medications were coded 8 (Absent from facility): insulin (injectable hormone used to regulate blood glucose levels), [MEDICATION(S)] (medication to treat depression), [MEDICATION(S)] (medication to treat [CONDITION(S)] [a mental break from reality]), and [MEDICATION(S)] solution eye drops (used to treat an eye disease). On [DATE] at 12:35 P.M., a joint interview and record review was conducted with the director of staff development (DSD). The DSD reviewed Resident 3's [DATE] MAR and progress notes. The DSD there was no documentation Resident 3 received his 9 P.M. insulin, [MEDICATION(S)], [MEDICATION(S)], and [MEDICATION(S)] solution eye drops on [DATE], [DATE], and [DATE] when he returned from [CONDITION(S)]. The DSD stated Resident 3 should have received his medications when he returned from [CONDITION(S)]. The DSD stated the physician's order had not been followed. On [DATE] at 4:38 P.M., an interview was conducted with the director of nursing (DON). The ADM and CC 2 were also present. The DON stated it was her expectation that medications were provided to residents according to the physician's order. A review of the facility's undated policy titled Medication Administration indicated, .3. Medications must be administered in accordance with the written orders of the attending physician

Based on interview, and record review, the facility failed to perform a skin assessment and accurate documentation of a surgical wound for one of 3 sampled residents (1). In addition, the facility failed to monitor the surgical incision for healing, confirm with the physician (MD) regarding removal of the staples and sutures and obtain specific treatment orders. As a result of these failures, Resident 1 had increased pain. The incision dehisced (split open) and became infected. Resident 1 had to be rehospitalized in order to surgically debride (cleaning and removal of unhealthy tissue) the wound. The surgical procedure was followed by placement of a [DEVICE] (equipment used to drain a wound to promote healing). In addition, it was necessary for Resident 1 to undergo a right [MEDICAL CONDITION] (BKA) revision and closure on 3/11/19. Resident 1 had to remain in the hospital for 22 days and was treated with antibiotics for a [MEDICAL CONDITION] infection (MRSA - a bacterial infection) at the incision site per the hospital record. Findings: Resident 1's clinical record was reviewed on 3/13/19. Resident 1 was admitted to the facility on [DATE], from the acute hospital (GACH) following a right BKA on 1/31/19. Resident 1 was discharged from the hospital with 28 staples and 9 sutures on the right BKA incision. Resident 1 went for a follow up clinic appointment with the General Surgeon on 2/27/19. The General Surgeon identified Resident 1's surgical stump was infected and transferred the resident to the hospital where the resident was readmitted . Per the hospital's Emergency Department Record dated 2/27/19, Resident 1 presented to the hospital with a stump infection. Resident 1 had pain, and foul-smelling discharge from the stump. The staples were still visible in the incision. Per the facility's policy dated May 2007, titled, Wound Management, POLICY . A wound is identified as . Surgical wound . PROCEDURES: 1. A weekly skin assessment will be completed as needed and document in patient's chart. 2. A wound flowsheet will be activated as soon as a wound is identified. Pressure and/or Non-Pressure Weekly Interdisciplinary Team (IDT). 3. Each wound would be measured in centimeters weekly. Measurements, size and depth, drainage, odor, color, and a short statement of progress. 4. Treatment ordered by the physician will be used as ordered. If no improvement, the physician will be called for an evaluation. 5. All treatments involving breaks in the skin require clean technique, unless otherwise ordered by the physician. 6. Wound that appear purulent, at any time, require physician notification and request for Culture and Sensitivity. 7. Any change of condition, notify MD and RP (Responsible Person). Per the facility's admission notes, dated 2/6/19, Licensed Nurse (LN) 2 documented, Head to toe assessment performed. Per item number twelve, Skin integrity, LN 2 documented, Right BKA surgical incision 13 cm with eschar (dead tissue) noted. 28 staples and 9 sutures, no signs of infection or bleeding. There was no documentation in the clinical record the physician was notified upon admission regarding the status of the incision and to verify the date the sutures and staples were to be removed. The facility's care plan interventions for Resident 1, dated 2/7/19, included, Assess and will recognize signs and symptoms (s/s) of infection such as foul purulent drainage, [DIAGNOSES REDACTED] (redness), swelling .devitalize (deprived) tissue . then notify Primary Care Physician (PCP). The care plan did not include the monitoring for Resident 1's surgical incision with staples and sutures nor the date to remove. On 3/13/19 at 1:43 P.M., a joint interview and record review was conducted with LN 1. LN 1 stated the admitting nurse should have performed and documented a skin and wound assessment. LN 1 stated if there were staples or sutures in the incision, they should have been documented and addressed on the care plan. On 3/13/19 at 2:05 P.M., a joint interview and record review was conducted with the Case Manager (CM). The CM stated the LN who did the initial assessment did not address the surgical staples or describe what Resident 1's incision looked like. The CM stated there was no monitoring done of the staples and sutures, and the care plan for the surgical site did not address the staples and sutures. The CM reviewed the Electronic Treatment Record (eTAR) for Resident 1 and acknowledged there was no monitoring done of the resident's staples and sutures. The CM stated a physician's orders [REDACTED]. The CM stated LNs could initiate a surgical staples and sutures monitoring treatment. On 3/13/19 at 2:30 P.M., an interview was conducted with LN 2. LN 2 stated on 2/6/19, she did a partial skin assessment on Resident 1. LN 2 further stated she did not remove the dressing on Resident 1's right stump and assumed the next shift would do the wound treatment. LN 2 stated if there was a wound care treatment order, there should have been a separate monitoring order. On 11/22/19, an interview was conducted with the Director of Nursing (DON). The DON stated the admission process was to remove the dressing, assess the wound, and document the condition of the surgical incision. The DON stated LNs should have been monitoring the surgical wound and the expectation was, They should be documenting the condition of the surgical wound in the daily progress notes. The DON stated LN 2 (Admission Nurse) and WCN 1 (Wound Care Nurse) were not available for interview as they were no longer employed at the facility. Resident 1's clinical record was reviewed on 11/22/19. The facility's LN daily skilled notes from 2/7/19 to 2/27/19 (20 days total) did not address Resident 1's surgical staples or sutures. Per the facility's document titled LN- Skin Ulcer Non-Pressure Weekly section a3a, WCN 1 documented the following information for Resident 1: 2/14/19 - Surgical - [MEDICAL CONDITION] right lower extremity with some black eschar tissue to surgical site 20%, and some [DIAGNOSES REDACTED] (redness and swelling) to surrounding skin. Size in cm (length x width): 0.1 centimeters (cm) x 13 cm. 2/19/19 - Surgical wound with staples and sutures intact. Size in cm (length x width): 0.1 cm x 13 cm. 2/26/19 - Right BKA Surgical wound 30% eschar 70% yellow slough (yellow/white stringy material in the wound bed). Size in cm (length x width): 3 cm x 13 cm. Per the documentation by WCN 1 on 2/26/19, the wound size increased from 0.1 x 13 cm to 3 x 13 cm. In addition, WCN 1 documented on the LN- Skin Ulcer Non-Pressure Weekly, Tolerating tx (treatment) well. Wound is stable. There was no physician notification the wound had increased in size and there was no monitoring of the surgical incision staples and sutures. On 11/26/19 at 12 P.M., a joint interview and record review was conducted with the Director of Staff Development (DSD). The DSD stated, The admitting nurse did not assess the surgical wound. The DSD acknowledged the admitting LN (2) did not document properly. In addition, the DSD stated the care plan should have addressed the interventions for the staples and sutures, and should have been updated when there were any changes in the wound size or condition. The DSD stated if there was a surgical wound, the monitoring of its size and condition was, Automatic and does not require a physician's orders [REDACTED]. The DSD stated if Resident 1's surgical wound had increased in size, it was considered a change in condition and required prompt intervention. The DSD stated documentation of the monitoring would be entered in the Electronic Treatment Record (eTAR). Resident 1's (eTAR) was reviewed on 11/26/19. LNs documented the incision dressing changes, but there was no documentation about the staples and sutures. On 11/26/19 at 12:45 P.M., a joint interview and record review was conducted with the Minimum Data Set (MDS - clinical assessment tool) nurse. The MDS nurse stated the LNs did not documented the condition of the surgical staples and sutures. On 11/26/19 at 1:25 P.M., an interview was conducted with the Social Services Director (SSD). The SSD stated she did not recall the IDT discussing the condition of the surgical wound and the staples and sutures were not mentioned during the meeting. On 11/26/19 at 2:25 P.M., a joint interview and record review was conducted with WCN 2. The WCN 2 stated the admitting nurse (LN 2) should have assessed the surgical wound and document in the Initial Admission Record. WCN 2 reviewed the facility's document titled, LN- Skin Ulcer Non-Pressure Weekly. WCN 2 stated the documentation was inconsistent. WCN 2 acknowledged Resident 1's surgical incision had increased in size. The physician was not notified of the change of condition, and no new treatment orders were obtained. On 12/4/19 at 2:43 P.M., a telephone interview was conducted with LN 4. LN 4 stated she took care of Resident 1 and could not recall the resident having surgical staples. LN 4 stated there should have been a monitoring system for Resident 1's surgical incision which did not require a physician's orders [REDACTED]. On 12/5/19 at 1:40 P.M., a joint interview was conducted with WCN 3 and the DON. WCN 3 stated monitoring and documenting the condition of the surgical wound was a standard practice and did not require a physician's orders [REDACTED]. The DON stated there should also have been surgical incision monitoring done for Resident 1. On 12/13/19 at 7:40 A.M., an observation and interview was conducted with Resident 1. Resident 1 stated she recalled going back to the hospital. While talking, Resident 1 was observed pointing at her right stump. Resident 1 stated, I felt scared, and further stated she did not know what would happen to her. Resident 1's clinical record was reviewed with the DON on 1/7/20. The physician's admission and follow up visit notes dated 2/7/19, 2/12/19, 2/14/19, 2/19/19, and 2/21/19 did not address the surgical incision with staples and sutures and the condition of the RBKA. The DON acknowledged that there was no documentation from the physician indicating the status of the surgical wound. On 1/8/20 at 11:28 A.M., an interview was conducted with the Wound Care Medical Doctor (WCMD). The WCMD stated if a resident was admitted to the facility with no surgical wound treatment orders, It required clarification and an order from the primary care physician, and there should have been some form of communication between the nurses and doctor. The WCMD stated the staples for a RBKA typically came out within two to three weeks after surgery. The WCMD stated she would have expected a notification from the nurses if there was a change in the appearance of a surgical wound, and nurses should have documented the condition of the wound. Per the facility's policy dated May 2007, titled, Skin Monitoring and Management, . 1. RESIDENT ASSESSMENT/EVALUATION .d. All risk factors identified on assessment/chart reviews should be documented in the resident's clinical record and, when appropriate, be addressed through a care plan designed to minimize the possibility of skin breakdown. E. Develop care plan if indicated following the evaluation/assessment. Care plans must be individualized and designed to meet the needs of the particular resident for whom they are being developed .

Based on observation, interview and record review the facility failed to identify and manage potential smoking hazards when: A) One of 18 sampled residents (14) and 7 unsampled residents (22, 87, 15, 39, 70, 62 and 1) were allowed to freely roam the facility with personal smoking materials, which included cigarettes and lighters. B) Ten residents (14, 22, 87, 15, 39, 70, 62, 1, 75 and 79) who were known to smoke were not assessed for their smoking safety. C) The facility processes in place did not require staff supervision of any residents in designated smoking areas. D) The facility did not monitor and ensure that designated smoking areas were utilized according to the facility rules. The facility's systems failure presented a risk that residents who smoked cigarettes could have caught their clothes on fire when lighting cigarettes with a lighter. Residents who smoked also could have caused a fire inside the facility since they were allowed to keep their personal smoking materials in their rooms. These residents who smoked also could have been severely injured since there was no staff supervision and residents were allowed to smoked in non-designated areas. The facility's Administrator was informed of the Immediate Jeopardy on 5/29/13 at 11:50 A.M.. On 5/29/13 at 4:41 P.M. the facility Administrator provided a verbal plan of correction to lift the immediacy of the immediate jeopardy. The plan to ensure resident safety and correction was provided by the Administrator. She stated that the facility's interdisciplinary team (IDT) had met with residents identified (14, 22, 87, 15, 39, 70, 62, 1, 75 and 79) in a group and informed them as a group of the new smoking safety processes that were to be implemented immediately. The Administrator stated that at the meeting that each of the residents provided the facility's IDT with the cigarettes and lighters that they had been carrying with them. The Administrator stated that at the group meeting the IDT informed the residents that their cigarettes and lighters would be kept for them at the central nursing station. The Administrator additionally stated that all residents identified were informed of the new designated smoking areas, the posted signs and the closed receptacles to be used for ashtrays. The Administrator stated that the area signage and setup for smoking was in place and the newly designated area was ready for use. Also, the Administrator stated that the residents were informed that all future smoking would be supervised by staff in accordance with the provided schedule. The Administrator stated that the smoking supervision would be assigned and managed by the charge nurses. The Administrator stated that all residents in attendance at the meeting signed in and acknowledged the new smoking program plan. The Administrator stated that by the end of the work day that all the smoking residents would be assessed individually according to the new smoking safety assessment. During this meeting with the Administrator she stated that an administrative staff member was currently meeting with each resident to ensure that there were no remaining cigarettes and lighters in their rooms. The Administrator stated that next each resident would have an individual IDT meeting and a smoking care plan would be developed. The Administrator reported that the plan included that all staff would receive in-service training regarding the new policy and process for residents who smoke. In addition, the Administrator stated that this training would occur until each and every staff person was in-serviced. The Administrator stated that the new smoking policy provided for the use of smoking aprons. The Administrator stated that two new smoking aprons were now available for use. The facility policy and procedure and safety assessment form were provided and reviewed during the meeting with the Administrator. On 5/30/13 at 11:50 A.M. the facility's Administrator was informed that the IJ was abated. The facility's Administrator provided written documentation of the plan of correction. Additional records provided by the Administrator regarding the new policy and procedure for all residents who smoked included all staff in-service training records which supported that the fact that all staff had been educated regarding the new systems. Facility staff were observed managing and supervising residents who smoked cigarettes as per schedule and in the designated smoking area. Storage of cigarettes and lighters was now being maintained at the central nursing station. Findings: Resident 1 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Resident 14 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Resident 15 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS)( Assessment tool)dated 2/28/13 indicated a cognition score of 10 out of 15. The MDS cognition score is derived out of a brief interview for mental status. Scores less than 15 indicated deficits in a resident's cognitive ability. Resident 22 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the physician's Physical updated dated 3/28/13 Resident 22 had the capacity to understand and make decisions. According to the MDS dated [DATE] Resident 22 scored a 15 out of 15 on the cognition score which indicated that the resident had no cognition problems. According to the minutes of the Patient Care Conference dated 4/16/13 the resident was a smoker. The risk of smoking was explained to the resident but the resident continues to smoke. Resident 22 would have been allowed to keep his personal smoking materials on him. Resident 39 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS dated [DATE] indicated a cognition score of 5 out of 15. The physician history and physical(H&P) dated 10/25/12 indicated that the resident had fluctuating capacity to understand and make decisions. In addition, Resident 39 had visual impairment. Resident 62 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. of Admission. According to the history and physical dated 7/10/12 the resident had the capacity to understand and make decisions for herself. According to the resident activity assessment dated [DATE] Resident 62 was a social smoker. According to the quarterly MDS assessment dated [DATE] Resident 62 scored a 15 out of 15 on the cognition assessment. This meant that Resident 62 would have been allowed to keep her personal smoking materials on her. Resident 70 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS dated [DATE] indicated a cognitive score of 13 out of 15. Resident 75 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. of Admission. The MDS dated [DATE] indicated a score of 4 out of 15 with inattention and disorganized thinking. The H & P dated 3/27/12 indicated that the resident " does not have the capacity to understand and make decisions." Resident 79 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS dated [DATE] indicated a score of 4 out of 15 with inattention and disorganized thinking. The H & P dated 8/31/12 indicated that the resident does not have the capacity to understand and make decisions. Resident 87 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS dated [DATE] indicated a score of 7 out of 10 with inattention and disorganized thinking. The H&P dated 11/22/12 indicated that the resident "has fluctuating capacity to understand and make decisions." On 5/28/13 at 5:36 P.M. a joint observation and interview was conducted with Resident 14, 15 and 87. Resident 14 was out on the back patio and stated that he could smoke there on the smoke break times but was unable to verbalize the smoke break times. During the interview Resident 15 came out to the back patio by wheelchair. Resident 87 was observed to have come to the back patio by wheelchair and was observed with a cigarette in his hand. Resident 87 got Resident 15's attention and pointed to his cigarette. Resident 15 took out her lighter and handed it to Resident 87 who lit his cigarette. Resident 87 gave Resident 15 back her lighter and she lit her cigarette. Resident 15 stated she always keeps her lighter and cigarettes on her. On 5/29/13 at 8:50 A.M. a joint observation and interview was conducted with Resident 14. Resident 14 was observed on the back patio smoking. Resident 14 stated that he kept his lighter on him and buys cigarettes from his friends at the facility. On 5/29/13 at 8:58 A.M. a joint interview and record review of the smoking policy was conducted with the Administrator (Admin). The Admin acknowledged that the residents hold their own smoking materials and that there was no formal smoking assessment done for safety. The Admin further stated that on admission when the residents are assessed the cognition is what determines who keeps their smoking material. The Admin acknowledged that a resident that has fluctuating cognition should have had a separate smoking safety assessment. The facility's policy and procedure titled "Smoking Policy" dated 12/3/01 was reviewed with the Admin. The Admin acknowledged that the policy for smoke times on back patio was after 6 P.M. due to the location of residents' rooms and complaints of cigarette smoke smell that drifted into residents' rooms. The front center patio was for the other times. The policy and procedure indicated the smoke times "AM 2:00-3:00, 6:00-7:00, 8:45-9:45, 11:00-12n (noon); PM 1:30-2:30, 4:00-5:00, 6:30-7:30, 9:00-10:00, 11:00-12 midnight." This same policy and procedure indicated "All other hours will be nonsmoking times in these areas: Any violations, such as smoking in the building or smoking during non-designated smoking hours in the patio or gazebo (change to front center patio) will result in that person's cigarettes being locked up and handed out at the pass times... In addition, alert residents will be allowed to manage their own cigarettes under the following conditions; -The smoking rules are followed as stated. - There is not a medical condition which makes it unsafe..." On 5/29/13 at 9:05 A.M. a joint observation and interview was conducted with the Admin. During a tour of the designated smoking areas, the Admin acknowledged that two residents (1,14) were smoking on the back patio unsupervised and that the back patio was only open for Residents to smoke after 6 P.M. On 5/29/13 at 9:20 A.M. an interview was conducted with the acting director of nursing (ADON) and Admin. The ADON and Admin both acknowledged that there was no assessment done for the ability to smoke without supervision. On 5/29/13 at 11:30 A.M. an interview regarding the facility policy and procedure and practice for residents who smoked, was conducted with certified nursing assistant (CNA) 7. CNA 7 stated that the residents who smoked were able to smoke at any time that they chose. The CNA stated that there were 2 designated smoking areas to choose from. CNA 7 stated that the two designated smoking areas were on the back patio and on the patio beside the side parking lot. CNA 7 stated that residents all carry their own smoking materials (cigarettes and lighters) or they borrow the materials from others. On 5/29/13 at 11:30 A.M. an interview regarding the facility policy and procedure and practice for residents who smoked, was conducted with CNA 8. CNA 8 stated that alert residents carry their own cigarettes and lighters. On 5/29/13 at 11:30 A.M. an interview regarding the facility policy and procedure and practice for residents who smoked, was conducted with licensed nurse (LN) 5 and the social services director (SSD). LN 5 stated that Resident 87 was not able to carry his own cigarettes and the SSD held his smoking materials in his office. The SSD confirmed that Resident 87's cigarettes were maintained in her office. The SSD stated that Resident 87 was permitted to go outside independently with the material to smoke unsupervised after it was provided to him. On 5/29/13 at 11:35 A.M. an interview was conducted with CNA 2. CNA 2 indicated that residents are to be supervised by the charge nurse at designated times. CNA 2 further indicated that residents can smoke on back patio and that the break times were after breakfast and after lunch. On 5/29/13 at 11:50 A.M. an interview was conducted with the Admin and ADON. A review of the residents that smoke at the facility indicated that there was a total of ten residents who smoked cigarettes. The Admin and ADON acknowledged that of those 10 residents 5 were unsafe to smoke unsupervised. One of the 5 (Resident 70) was a compulsive smoker with a significant cognitive deficit. Another 2 of these 5 residents (Resident 75 and 79) had significant cognitive deficits. The remaining two residents (Resident 39 and 87) had fluctuation in cognition. All of which put them at risk of being harmed if left unsupervised to smoke. The ADON and Admin further acknowledged that with Resident 70 being a compulsive smoker, the activity director (AD) had to hold his smoking material due to the resident's behaviors of buying cartons of cigarettes and compulsively smoking unsupervised. On 5/29/13 at 12:20 P.M. a joint observation and interview was conducted with the AD. The AD acknowledged that Resident 70 use to buy cartons of cigarettes and that she did hold his cigarettes but did not hold his cigarettes anymore. Resident 70's room was checked for smoking material by the AD, none was observed. On 5/29/13 at 12:25 P.M. a joint observation and interview was conducted with Resident 70. The AD located Resident 70 in the dinning room eating lunch. When Resident 70 was asked if he had cigarettes on him, he stated "no I need to buy some more." When Resident 70 was asked who held his cigarettes for him, he stated "I keep them in my dresser drawer."