Every finding on record at The Culpeper

Based on staff interview, facility document review, and clinical record review, the facility staff failed to complete quarterly MDS (minimum data set) assessments in a timely manner for four of 26 residents in the survey sample, Residents #1, #48, #36 and #51. The findings include: 1. For Resident #1 (R1), the facility staff failed to complete the resident's quarterly MDS with an ARD (assessment reference date) of 9/7/23 within 14 days. A review of R1's clinical record revealed a quarterly MDS assessment with an ARD of 9/7/23. Further review of R1's clinical record revealed the MDS was not completed until 9/30/23 (23 days). On 10/17/23 at 2:50 p.m., an interview was conducted with RN (registered nurse) #1 (the MDS coordinator). RN #1 stated MDS assessments should be completed within 14 days from the ARD. RN #1 stated she references the CMS (Centers for Medicare and Medicaid Services) RAI (Resident Assessment Instrument) manual when completing MDS assessments. On 10/18/23 at 12:27 p.m., ASM (administrative staff member) #1,the executive director and ASM #2, the director of nursing were made aware of the above concern. The CMS RAI manual documented, Completion Timing: - For all non-Admission OBRA (Omnibus Budget Reconciliation Act) and PPS (Prospective Payment System) assessments, the MDS Completion Date (Z0500B) must be no later than 14 days after the Assessment Reference Date (ARD). 2. For Resident #48 (R48), the facility staff failed to complete the resident's quarterly MDS with an ARD of 8/17/23 within 14 days. A review of R48's clinical record revealed a quarterly MDS assessment with an ARD of 8/17/23. Further review of R48's clinical record revealed the MDS was not completed until 9/15/23 (29 days). On 10/17/23 at 2:50 p.m., an interview was conducted with RN (registered nurse) #1 (the MDS coordinator). RN #1 stated MDS assessments should be completed within 14 days from the ARD. RN #1 stated she references the CMS (Centers for Medicare and Medicaid Services) RAI (Resident Assessment Instrument) manual when completing MDS assessments. On 10/18/23 at 12:27 p.m., ASM (administrative staff member) #1,the executive director and ASM #2, the director of nursing were made aware of the above concern. 3. For Resident #36 (R36), the facility staff failed to complete the resident's quarterly MDS with an ARD of 8/31/23 within 14 days. A review of R36's clinical record revealed a quarterly MDS assessment with an ARD of 8/31/23. Further review of R36's clinical record revealed the MDS was not completed until 9/18/23 (18 days). On 10/17/23 at 2:50 p.m., an interview was conducted with RN (registered nurse) #1 (the MDS coordinator). RN #1 stated MDS assessments should be completed within 14 days from the ARD. RN #1 stated she references the CMS (Centers for Medicare and Medicaid Services) RAI (Resident Assessment Instrument) manual when completing MDS assessments. On 10/18/23 at 12:27 p.m., ASM (administrative staff member) #1,the executive director and ASM #2, the director of nursing were made aware of the above concern. 4. For Resident #51 (R51), the facility staff failed to complete the resident's quarterly MDS with an ARD of 8/24/23 within 14 days. A review of R51's clinical record revealed a quarterly MDS assessment with an ARD of 8/24/23. Further review of R51's clinical record revealed the MDS was not completed until 9/18/23 (25 days). On 10/17/23 at 2:50 p.m., an interview was conducted with RN (registered nurse) #1 (the MDS coordinator). RN #1 stated MDS assessments should be completed within 14 days from the ARD. RN #1 stated she references the CMS (Centers for Medicare and Medicaid Services) RAI (Resident Assessment Instrument) manual when completing MDS assessments. On 10/18/23 at 12:27 p.m., ASM (administrative staff member) #1,the executive director and ASM #2, the director of nursing were made aware of the above concern.

Based on observation, staff interview, and facility documentation review, the facility failed to prepare and store food in a sanitary manner in one of two nourishment refrigerators, the rehab to home unit refrigerator, and in one of two facility kitchens, the main kitchen. The findings include: The facility staff failed to maintain a clean main kitchen, and failed to store food safely in the main kitchen and in the rehab to home unit refrigerator. On 10/16/23 at 10:15 a.m., observation was made of the main facility kitchen. The upper oven contained a large amount of baked-on grease and dark particles on the doors, sides, bottom and back. The areas around the burners on the stove contained cooked-on grease, and a large amount of crumbs and dark black debris. OSM (other staff member) #1, the director of dining services, stated: It all could use a good cleaning. She stated the oven and stove get a deep cleaning weekly, but should also be spot cleaned after each use. In the walk in freezer, a 10 by 10 plastic container of red frozen material rested on a shelf. There was no label on the container to indicate the use-by date or what the red material was. OSM #1 stated the material in the plastic container should have been labeled, and needed to be discarded. She stated all items in the walk-in freezer should be labeled. On 10/17/23 at 3:22 p.m., observation was made of the nourishment refrigerator on the rehab to home unit. The refrigerator contained a small plastic container of potstickers and a small container of sauce. Neither container was labeled. The freezer contained a bag of chocolate covered coffee beans; the bag was not labeled. On 10/18/23 at 9:37 a.m., OSM #1 stated the unit nourishment refrigerators were the responsibility of the dining services staff. She stated the dining services staff are supposed to check the unit refrigerators and freezers each time they deliver food to the units. On 10/18/23 at 12:27 p.m., ASM (administrative staff member) #1, the executive director, #2, the director of nursing, ASM #3, the assisted living administrator, and LPN (licensed practical nurse) #1, the quality improvement nurse, were informed of these concerns. A review of the facility policy, Cleaning and Sanitation of Dining and Food Service Areas, revealed, in part: The food and nutrition services staff will maintain the cleanliness and sanitation of the dining and food service areas through compliance with a written, comprehensive cleaning schedule .Staff will be trained in the frequency of cleaning, as necessary .Staff will be held accountable for cleaning assignments. A review of the facility policy, Food Storage, revealed, in part: Frozen Foods .All foods should be covered, labeled, and dated. All foods will be checked to assure foods will be consumed by their use by dates or discarded. No further information was provided prior to exit.

Based on observation, staff interview, facility document review, and clinical record review, the facility staff failed to implement the comprehensive care plan for three of 26 residents in the survey sample, Residents #34, #12, and #51. The findings include: 1. For Resident #34 (R34), the facility staff failed to implement the care plan which instructed the staff to use a slow sip cup for fluid intake. On the most recent MDS (minimum data set), a significant change assessment with an ARD (assessment reference date) of 6/19/23, R34 was coded as being as being severely cognitively impaired for making daily decisions. He was coded as coughing or choking during meals or when swallowing medications. On 10/16/23 at 3:40 p.m., R34 was observed sitting up in bed. He was drinking a liquid from a regular cup with a standard plastic straw. A two-handled slow sip cup was observed on R34's overbed table adjacent to his bed. RN (registered nurse) #2 was observed walking out of the resident's room as he was finishing sipping the liquid through the straw. A review of R34's clinical record revealed the following physician's order dated 7/6/23: Regular Diet, Mechanical Soft, Ground. Thin Liquids. Slow Sip Cup. The review also revealed the following physician's order dated 6/6/23: Pro-Stat .oral liquid .30 mls (milliliters) by mouth twice a day for skin health. A review of R34's comprehensive care plan dated 9/14/23 revealed, in part: Provide slow sip cup for fluids. On 10/17/23 at 3:35 p.m., LPN (licensed practical nurse) #2 was interviewed. She stated the purpose of the care plan is to tell the staff how best to meet a resident's needs. She stated the nurses and CNAs (certified nursing assistants) are responsible for implement the care plan. On 10/18/23 at 12:27 p.m., ASM (administrative staff member) #1, the executive director, #2, the director of nursing, ASM #3, the assisted living administrator, and LPN #1, the quality improvement nurse, were informed of these concerns. A review of the facility policy, Comprehensive Person-Centered Care Planning, revealed, in part: The resident will receive the services and/or items included in the plan of care. No further information was provided prior to exit. 2. For Resident #12 (R12), the facility staff failed to implement the care plan to apply both right and left palm protectors to prevent pain. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 7/13/23, R12 was coded as requiring the extensive assistance of two staff members for dressing and personal hygiene, and as having impairment in range of motion on both sides of her upper extremities. On 10/16/23 at 11:22 a.m. and 3:36 p.m., R12 was observed in her wheelchair and did not have palm protectors on either hand. On 10/17/23 at 8:34 a.m., R12 was observed in her wheelchair and had a palm protector on her right hand, but not on her left. A review of R12's clinical record revealed the following physician order dated 1/11/23: Bilateral palm protector splints. Apply in morning. Remove at bedtime. Resident to wear throughout the day as resident will allow .For pain r/t (related to) .contracture. The resident's progress notes for 10/16/23 and 10/17/23 contained no information related to the resident's palm protectors. A review of R12's care plan dated 2/11/23 revealed, in part: [R12] wears .bilateral palm protectors during the day .Bilateral palm protectors - apply in the morning and remove at bedtime .for pain. On 10/17/23 at 3:35 p.m., LPN (licensed practical nurse) #2 was interviewed. She stated she is familiar with caring for R12. She stated if there is an order for the palm protectors on both hands, the resident should have them on both hands. She stated the purpose of the care plan is to tell the staff how best to meet a resident's needs. She stated the nurses and CNAs (certified nursing assistants) are responsible for implementing the care plan. On 10/18/23 at 12:27 p.m., ASM (administrative staff member) #1, the executive director, #2, the director of nursing, ASM #3, the assisted living administrator, and LPN #1, the quality improvement nurse, were informed of these concerns. No further information was provided prior to exit. 31753 3. For Resident #51 (R51), the facility staff failed to implement the resident's comprehensive care plan for bowel medication. A review of R51's clinical record revealed a physician's order dated 4/4/23 for a bisacodyl suppository, ten milligrams- administer one suppository rectally one time a day as needed for no bowel movement in three days. R51's comprehensive care plan dated 6/22/23 documented, Potential for Alteration in Bowel Elimination as related to: impaired mobility. Constipation .Administer medication as ordered by the physician . A review of R51's bowel movement records revealed the resident did not have a bowel movement from 7/3/23 until 7/9/23. Further review of R51's clinical record and review of a 24-hour report sheet dated 7/7/23 revealed a suppository was not administered to R51 until 7/7/23 (five days after the resident had not had a bowel movement). On 10/18/23 at 11:18 a.m., an interview was conducted with LPN (licensed practical nurse) #3. LPN #3 stated the purpose of the care plan is that it, Kind of describes what you are supposed to do to take care of them [the residents]. It's the plan of care. LPN #3 stated nurses can access residents' care plans in the computer system. LPN #3 reviewed R51's bisacodyl order and stated a suppository should have been given to the resident within three days of the resident not having a bowel movement. On 10/18/23 at 12:27 p.m., ASM (administrative staff member) #1 (the executive director) and ASM #2 (the director of nursing) were made aware of the above concern.

Based on observation, staff interview, facility document review and clinical record review, the facility staff failed to review and revise the comprehensive care plan for one of 26 residents in the survey sample, Resident #47. The findings include: For Resident #47 (R47), the facility staff failed to review and revise the resident's comprehensive care plan for the use of floor mats. A review of R47's clinical record revealed a physician's order dated 3/16/22 for floor mats next to the bed while the resident is in the bed. R47's comprehensive care plan dated 2/3/22 failed to reveal documentation regarding floor mats. On 10/16/23 at 11:34 a.m. and 10/17/23 at 8:54 a.m., R47 was observed lying in bed. A mat was observed on the right side of the bed, but a mat was not on the left side of the bed. On 10/17/23 at 3:34 p.m., an interview was conducted with LPN (licensed practical nurse) #2. LPN #2 stated the purpose of the care plan is that It tells about how to meet their [residents'] needs the best. LPN #2 stated residents' care plans should be reviewed and revised to include the use of floor mats, so everyone knows to implement the mats. On 10/17/23 at 4:38 p.m., ASM (administrative staff member) #1, the executive director and ASM #2, the director of nursing were made aware of the above concern. The facility policy titled, Comprehensive Person-Centered Care Planning documented, The Care Planning/Interdisciplinary Team is responsible for the review and updating of care plans .

Based on staff interview, facility document review and clinical record review, the facility staff failed to provide care and services to promote a resident's highest level of well-being for one of 26 residents in the survey sample, Resident #51. The findings include: For Resident #51 (R51), the facility staff failed to administer a bisacodyl suppository per the physician's order. A review of R51's clinical record revealed a physician's order dated 4/4/23 for a bisacodyl suppository, ten milligrams- administer one suppository rectally one time a day as needed for no bowel movement in three days. A review of R51's bowel movement records revealed the resident did not have a bowel movement from 7/3/23 until 7/9/23. Further review of R51's clinical record and review of a 24-hour report sheet dated 7/7/23 revealed a suppository was not administered to R51 until 7/7/23 (five days after the resident had not had a bowel movement). R51 did not have a bowel movement until 7/9/23. On 10/18/23 at 11:18 a.m., an interview was conducted with LPN (licensed practical nurse) #3. LPN #3 stated the computer generates a list of residents who have not had a bowel movement in two days. LPN #3 stated if a resident has not had a bowel movement in two days, then the nurses activate standing orders or reach out to the physician. LPN #3 reviewed R51's bisacodyl order and stated a suppository should have been given to the resident three days after not having a bowel movement. On 10/18/23 at 12:27 p.m., ASM (administrative staff member) #1 (the executive director) and ASM #2 (the director of nursing) were made aware of the above concern. The facility policy titled, Constipation/Fecal Impaction documented, IV. Nurse in charge will be notified of signs and symptoms of constipation. Constipation will be treated with oral laxative, suppository or enema as ordered by the physician .

Based on observation, staff interview, facility document review and clinical record review, the facility staff failed to implement a fall intervention for one of 26 residents in the survey sample, Resident #47. The findings include: For Resident #47 (R47), the facility staff failed to implement physician ordered floor mats. A review of R47's clinical record revealed a physician's order dated 3/16/22 for floor mats next to the bed while the resident is in the bed. Further review of R47's clinical record revealed the resident sustained a fall on 1/6/23, 3/4/23, 4/2/23, and 8/16/23. On 10/16/23 at 11:34 a.m. and 10/17/23 at 8:54 a.m., R47 was observed lying in bed. A mat was observed on the right side of the bed, but a mat was not on the left side of the bed. On 10/17/23 at 3:34 p.m., an interview was conducted with LPN (licensed practical nurse) #2. LPN #2 stated the nurses are aware of the need for floor mats via physician's orders and then the nurses tell the certified nursing assistants who needs floor mats. LPN #2 reviewed R47's physician's order for floor mats and stated that if plural floor mats are ordered then that would mean a floor mat should be placed on each side of the bed. On 10/17/23 at 4:38 p.m., ASM (administrative staff member) #1 (the executive director) and ASM #2 (the director of nursing) were made aware of the above concern. The facility policy titled, Fall Management Program documented, Other potential fall preventative interventions for residents at high risk: b) Floor mats .

Based on observation, staff interview, facility document review, and clinical record review, the facility staff failed to apply an adaptive device to prevent pain for one of 26 residents in the survey sample, Resident #12. The findings include: For Resident #12 (R12), the facility staff failed to apply both right and left palm protectors to prevent pain. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 7/13/23, R12 was coded as requiring the extensive assistance of two staff members for dressing and personal hygiene, and as having impairment in range of motion on both sides of her upper extremities. On 10/16/23 at 11:22 a.m. and 3:36 p.m., R12 was observed in her wheelchair, and did not have palm protectors on either hand. On 10/17/23 at 8:34 a.m., R12 was observed in her wheelchair, and had a palm protector on her right hand, but not on her left. A review of R12's clinical record revealed the following physician order dated 1/11/23: Bilateral palm protector splints. Apply in morning. Remove at bedtime. Resident to wear throughout the day as resident will allow .For pain r/t (related to) .contracture. The resident's progress notes for 10/16/23 and 10/17/23 contained no information related to the resident's palm protectors. A review of R12's care plan dated 2/11/23 revealed, in part: [R12] wears .bilateral palm protectors during the day .Bilateral palm protectors - apply in the morning and remove at bedtime .for pain. On 10/17/23 at 3:35 p.m., LPN (licensed practical nurse) #2 was interviewed. She stated she is familiar with caring for R12. She stated if there is an order for the palm protectors on both hands, the resident should have them on both hands. If a resident refuses or will not tolerate them, the nurse should write a progress note indicating this. She stated R12 has contractures in both hands, and the palm protectors can aid in relieving the pain of the contractures. On 10/18/23 at 12:27 p.m., ASM (administrative staff member) #1, the executive director, #2, the director of nursing, ASM #3, the assisted living administrator, and LPN #1, the quality improvement nurse, were informed of these concerns. In response to a request for the facility policy regarding palm protectors, the facility staff provided the policy, Skin Integrity. A review of this policy revealed no information related to applying palm protectors as ordered by the physician. No further information was provided prior to exit.

Based on staff interview, facility document review, and clinical record review, the facility staff failed to maintain a complete and accurate clinical record for one of 26 residents in the survey sample, Resident #51. The findings include: For Resident #51, the facility staff failed to document the administration of a bisacodyl suppository on 7/7/23. A review of R51's clinical record revealed a physician's order dated 4/4/23 for a bisacodyl suppository, ten milligrams- administer one suppository rectally one time a day as needed for no bowel movement in three days. R51's July 2023 MAR (medication administration record) documented the same order. A review of a 24-hour report sheet dated 7/7/23 revealed documentation that R51 was administered a suppository on that date. Further review of R51's clinical record, including the July 2023 MAR and nurses' notes for 7/7/23, failed to reveal documentation that R51 was administered a suppository. On 10/18/23 at 11:18 a.m., an interview was conducted with LPN (licensed practical nurse) #3. LPN #3 stated that if a nurse administers a suppository, the nurse should write a note and sign the medication off on the MAR. On 10/18/23 at 12:27 p.m., ASM (administrative staff member) #1 (the executive director) and ASM #2 (the director of nursing) were made aware of the above concern. The facility policy titled, Medication Administration and Documentation documented, On administering a prn (as needed) med, the nurse charts the administration in e-MAR (electronic medication administration record) and effectiveness .

Based on observation, staff interview, facility document review, and clinical record review, the facility staff failed to use an adaptive feeding device for one of 26 residents in the survey sample, Resident #34. The findings include: For Resident #34 (R34), the facility failed to utilize a slow sip cup for fluids on 10/16/23. On the most recent MDS (minimum data set), a significant change assessment with an ARD (assessment reference date) of 6/19/23, R34 was coded as being as being severely cognitively impaired for making daily decisions. He was coded as coughing or choking during meals or when swallowing medications. On 10/16/23 at 3:40 p.m., R34 was observed sitting up in bed, and was drinking a liquid from a regular cup with a standard plastic straw. A two-handled slow sip cup was observed on R34's overbed table adjacent to his bed. RN (registered nurse) #2 was observed walking out of the resident's room as he was finishing sipping the liquid through the straw. A review of R34's clinical record revealed the following physician's order dated 7/6/23: Regular Diet, Mechanical Soft, Ground. Thin Liquids. Slow Sip Cup. The review also revealed the following physician's order dated 6/6/23: Pro-Stat .oral liquid .30 mls (milliliters) by mouth twice a day for skin health. A review of R34's comprehensive care plan dated 9/14/23 revealed, in part: Provide slow sip cup for fluids. On 10/16/23 at 3:50 p.m., RN #2 was interviewed. She stated she thought R34 was supposed to be using the slow sip cup for fluids since she saw it on the overbed table. She stated: I guess I just didn't realize what he needed at the time. On 10/18/23 at 11:18 a.m., LPN (licensed practical nurse) was interviewed. She stated for R34, his dietary orders, including the slow sip cup, appear at the top of his information when anything about him is accessed on the electronic medical record. She stated his order for a slow sip cup appears as a warning at the top of the screen. On 10/18/23 at 12:27 p.m., ASM (administrative staff member) #1, the executive director, #2, the director of nursing, ASM #3, the assisted living administrator, and LPN #1, the quality improvement nurse, were informed of these concerns. A review of the policy, Adaptive Feeding Program, revealed in part: Nursing staff .will be responsible for observing individualized resident feeding needs and response to any modifications in resident's plan of care. No further information was provided prior to exit.

Based on staff interview, facility document review and clinical record review, the facility staff failed to transmit MDS (minimum data set) assessments in a timely manner for six of 26 residents in the survey sample, Residents #1, #48, #36, #51, #56 and #55. The findings include: 1. For Resident #1 (R1), the facility staff failed to transmit a quarterly MDS with an ARD (assessment reference date) of 9/7/23 within 14 days of completion. A review of R1's clinical record revealed the resident's quarterly MDS assessment with an ARD of 9/7/23 was completed on 9/30/23. Further review of R1's clinical record revealed the MDS was not transmitted until 10/17/23 (17 days). On 10/17/23 at 2:50 p.m., an interview was conducted with RN (registered nurse) #1 (the MDS coordinator). RN #1 stated MDS assessments should be transmitted within 14 days from the completion date. RN #1 stated she references the CMS (Centers for Medicare and Medicaid Services) RAI (Resident Assessment Instrument) manual when transmitting MDS assessments. On 10/18/23 at 12:27 p.m., ASM (administrative staff member) #1,the executive director and ASM #2, the director of nursing were made aware of the above concern. The CMS RAI manual documented, Comprehensive assessments must be transmitted electronically within 14 days of the Care Plan Completion Date (V0200C2 + 14 days). All other MDS assessments must be submitted within 14 days of the MDS Completion Date. 2. For Resident #48 (R48), the facility staff failed to transmit a quarterly MDS with an ARD of 8/17/23 within 14 days after the completion date. A review of R48's clinical record revealed the resident's quarterly MDS assessment with an ARD of 8/17/23 was completed on 9/15/23. Further review of R48's clinical record revealed the MDS was not transmitted until 10/17/23 (32 days). On 10/17/23 at 2:50 p.m., an interview was conducted with RN (registered nurse) #1 (the MDS coordinator). RN #1 stated MDS assessments should be transmitted within 14 days from the completion date. RN #1 stated she references the CMS (Centers for Medicare and Medicaid Services) RAI (Resident Assessment Instrument) manual when transmitting MDS assessments. On 10/18/23 at 12:27 p.m., ASM (administrative staff member) #1,the executive director and ASM #2, the director of nursing were made aware of the above concern. 3. For Resident #36 (R36), the facility staff failed to transmit a quarterly MDS with an ARD of 8/31/23 within 14 days after the completion date. A review of R36's clinical record revealed the resident's quarterly MDS with an ARD of 8/31/23 was completed on 9/18/23. Further review of R36's clinical record revealed the MDS was not transmitted until 10/17/23 (29 days). On 10/17/23 at 2:50 p.m., an interview was conducted with RN (registered nurse) #1 (the MDS coordinator). RN #1 stated MDS assessments should be transmitted within 14 days from the completion date. RN #1 stated she references the CMS (Centers for Medicare and Medicaid Services) RAI (Resident Assessment Instrument) manual when transmitting MDS assessments. On 10/18/23 at 12:27 p.m., ASM (administrative staff member) #1,the executive director and ASM #2, the director of nursing were made aware of the above concern. 4. For Resident #51 (R51), the facility staff failed to transmit a quarterly MDS with an ARD of 8/24/23 within 14 days after the completion date. A review of R51's clinical record revealed the resident's quarterly MDS with an ARD of 8/24/23 was completed on 9/18/23. Further review of R51's clinical record revealed the MDS was not transmitted until 10/17/23 (29 days). On 10/17/23 at 2:50 p.m., an interview was conducted with RN (registered nurse) #1 (the MDS coordinator). RN #1 stated MDS assessments should be transmitted within 14 days from the completion date. RN #1 stated she references the CMS (Centers for Medicare and Medicaid Services) RAI (Resident Assessment Instrument) manual when transmitting MDS assessments. On 10/18/23 at 12:27 p.m., ASM (administrative staff member) #1,the executive director and ASM #2, the director of nursing were made aware of the above concern. 5. For Resident #56 (R56), the facility staff failed to transmit a discharge MDS assessment when the resident discharged to an assisted living apartment on 6/22/23. R56 discharged to an assisted living apartment on 6/22/23. A review of the resident's clinical record failed to reveal a discharge MDS assessment was transmitted. On 10/18/23 at 11:10 a.m., an interview was conducted with RN (registered nurse) #1 (the MDS coordinator). RN #1 stated R56's discharge MDS should have been transmitted and was not. On 10/18/23 at 12:27 p.m., ASM (administrative staff member) #1,the executive director and ASM #2, the director of nursing were made aware of the above concern. 6. For Resident #55 (R55), the facility staff failed to transmit a discharge MDS assessment when the resident discharged to an assisted living apartment on 9/20/23. R55 discharged to an assisted living apartment on 9/20/23. A review of the resident's clinical record failed to reveal a discharge MDS assessment was transmitted. On 10/18/23 at 11:10 a.m., an interview was conducted with RN (registered nurse) #1 (the MDS coordinator). RN #1 stated R55's discharge MDS should have been transmitted and was not. On 10/18/23 at 12:27 p.m., ASM (administrative staff member) #1,the executive director and ASM #2, the director of nursing were made aware of the above concern.

Based on observation, staff interview and facility document review, it was determined the facility staff failed to maintain clean kitchen equipment in one of two kitchens, the main kitchen. The findings include: Observation was made of the main kitchen on 4/5/2022 at 11:28 a.m. The oven racks appeared to be covered in a brown substance. When asked what the cleaning schedule was, OSM (other staff member) #3, the executive chef, stated they should be cleaned on a weekly basis, but may have been missed last week. When asked if they could provide documentation when the ovens were cleaned last, OSM #1, the certified dietary manager, stated it was unlikely that they could provide that. On 4/6/2022 at 10:41 a.m. OSM #1 was asked if they found the documentation of the oven having been cleaned, OSM #1 stated, she doubted [OSM #3] could find that documentation. The facility policy, Cleaning and Sanitizing of Work Surfaces. documented in part, When cleaning fixed equipment, (mixers, slicers, and other equipment that cannot be readily immersed in water), the removable parts are washed and sanitized and non-removable parts are cleaned with detergent and hot water. ASM #1, ASM #2, the director of nursing, and ASM #3, the quality assurance/staff development/infection preventionist nurse were made aware of the above findings on 4/6/2022 at 5:19 p.m. No further information was provided prior to exit.

Based on staff interview, facility document review, and clinical record review, it was determined the facility staff failed to have a complete pain management program for one of 21 residents in the survey sample, Resident # 24 (R24). The facility staff failed to clarify the physician orders, document the location of pain and document the level of pain for R24. The findings include: On the most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date (ARD) of 2/24/2022, the resident scored a 14 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident is not cognitively impaired for making daily decisions. In Section J - Health Conditions - R24 was coded as having frequent pain, the limited her day-to-day activities because of pain. The resident rated the pain as a 6 on a pain scale of 0 to 10, 10 being the worse pain ever felt and zero being no pain. The physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The March 2022 MAR (medication administration record) documented the above medication orders [MEDICAL RECORD OR PHYSICIAN ORDER] 3/19/2022 at 4:44 a.m. - pain scale of 3, no location documented 3/21/2022 at 7:29 p.m. - no pain scale documented, resident complained of body aches. The March 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] 3/14/2022 at 5:00 p.m. -pain scale of 4 - no location documented. 3/19/2022 at 9:15 p.m. - pain level of 6 - no location documented. 3/20/2022 at 4:18 p.m. - pain level of 5 - no location documented. 3/21/2022 at 8:52 p.m. - pain level of 0 - location right hip and knee pain. 3/26/2022 at 3:06 p.m. - pain level of 0 - location right knee. 3/28/2022 at 3:08 p.m. - pain level of 5 - no location documented. Review of the nurse's notes for March failed to document the location or pain scales above. The April 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] 4/1/2022 at 2:03 p.m. - pain scale of 6, no location documented. 4/3/2022 at 4:28 p.m. - pain scale of 3, no location documented. 4/4/2022 at 7:45 p.m. - pain scale of 5, no location documented. 4/6/2022 at 7:47 a.m. - pain scale of 4, no location documented. Review of the nurse's notes for April 2022 failed to evidence documentation of the location of the pain when the medication was administered. The comprehensive care plan dated, 12/21/2021, documented in part, Problem: Alteration in comfort/pain related to .joint pain and right sided pain from falls PTS (prior to admission) that lead to R (right) hip fracture currently NWB (non - weight bearing) on RLE (right lower extremity). The Approaches documented in part, Complete pain assessment upon admission, quarterly and PRN (as needed) and when intensity/location of pain changes. Utilize pain scale to assess for intensity of pain. An interview was conducted with LPN (licensed practical nurse) #1, on 4/6/2022 at 4:53 p.m. When asked the process for giving a pain medication, LPN #1 stated the nurse should assess the resident if in pain, try to do non-pharmacological interventions, offer repositioning, ice or heat packs. LPN #1 stated, skilled residents are alert and oriented and many times refuse non- pharmacological interventions. The above two medication orders were reviewed with LPN #1. LPN #1 stated she knew [R24] didn't have a scale, usually she's in moderate to severe pain, but sometimes [R24] requests the [MEDICATION(S)]. When asked where the pain scale is documented, LPN #1 stated it should be on the MAR. When asked where the location is documented, LPN #1 stated, it's in a note on the MAR. When asked if a pain scale should be documented with the pain medications, LPN #1 stated those medications should have some kind of parameters to give like mild to moderate pain or moderate to severe pain or by the pain scale. The facility policy, Resident Comfort/Pain Management documented in part, The physician and staff in collaboration with the resident/resident's representative will establish a treatment regiment based on considerations of the following: a. The resident's medical condition. b. Current medication regimen. c. Nature, severity and cause of the pain. d. Course of the illness and e. Treatment goals Pain management interventions shall reflect the sources, type and severity of pain . Pain Scale will be used each tine a prn (as needed) pain medication is administered. Pain Scale is posted in each MAR binder. Pain rating will be recorded along with the reason for the medication and with the results. ASM (administrative staff member) #1, the interim administrator, ASM #2, the director of nursing, and ASM #3, the quality assurance/staff development/infection preventionist nurse were made aware of the above findings on 4/6/2022 at 5:19 p.m. No further information was provided prior to exit. (1). This information was obtained from the following website: https://medlineplus.gov/druginfo/meds/a 4.html. (2) This information was obtained from the following website: https://medlineplus.gov/druginfo/meds/a 3.html.

Based on observation, staff interview, resident interview, facility document review and clinical record review, it was determined the facility staff failed to store respiratory equipment in a sanitary manner for two of 21 residents in the survey sample, Residents # 193 (R193) and # 194 (R194). The findings include: 1. For R193, the facility staff failed to store his [CONDITION(S)] (continuous positive airway pressure prevents episodes of airway collapse that block the breathing in people with obstructive sleep apnea and other breathing problems.) (1), in a sanitary manner. On the most recent MDS (minimum data set) assessment, a Medicare assessment, with an ARD (assessment reference date) of 3/25/2022, the resident scored a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident is not cognitively impaired for making daily decisions. Observation was made of R193's room on 4/5/2022 at approximately 1:15 p.m. A [CONDITION(S)] machine was sitting on the night stand. The tubing for the [CONDITION(S)] machine was hanging over the machine with no covering over it. When asked if the staff had given him a bag or something to store the tubing for his [CONDITION(S)] machine when it wasn't in use, R193 stated the staff had not provided anything like that. A second observation was made on 4/6/2022 at 8:15 a.m. and 8:50 a.m. the [CONDITION(S)] machine tubing was again noted hanging over the [CONDITION(S)] machine on the night stand. The comprehensive care plan dated, 4/7/2022, failed to evidence the storage of the [CONDITION(S)] mask/tubing when not in use. An interview was conducted on 4/6/2022 at 4:53 p.m. with LPN (licenses practical nurse) #1. When asked how a [CONDITION(S)] mask/tubing should be stored when it is not in use by the resident, LPN #1 stated it should be stored in a dated Ziploc bag. When asked the purpose of keeping the tubing in the plastic bag, LPN #1 stated it was to keep the germs off of it. The physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . 11-7 (11:00 p.m. to 7:00 a.m.) shift to initiate new Ziploc bag each week. Date when changed. The facility policy, Use and Maintenance of BI-PAP/[CONDITION(S)] Machine failed to evidence documentation of how the tubing/mask is to be stored when not in use. The policy, documented in part, 1. 7-3 (7:00 a.m. to 3:00 p.m. shift) daily - wash BI-PAP/[CONDITION(S)] mask and humidifier chamber daily with soapy water, then rinse and let air dry. ASM #1, ASM #2, the director of nursing, and ASM #3, the quality assurance/staff development/infection preventionist nurse were made aware of the above findings on 4/6/2022 at 5:19 p.m. No further information was provided prior to exit. (1) This information was obtained from the following website: https://medlineplus.gov/ency/article/ 6.htm 2. For R194, the facility staff failed to store a [CONDITION(S)] mask/tubing in a sanitary manner. On the Initial Nursing Assessment, dated, 3/30/2022, R194 was documented as being alert but not oriented. Observation was made of R 194's room on 4/5/2022 at approximately 1:30 p.m. The [CONDITION(S)] machine was observed sitting on the night stand. The tubing/mask were hanging over the machine, not store in any manner. A second observation was made on 4/6/2022 at 2:18 p.m. The resident was in their wheelchair watching TV. The [CONDITION(S)] tubing/mask were hanging over the headboard of the bed. Not in any type of covering. The physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . fill chamber to fill line with distilled water only. 2. To attach the water chamber to device, open top of machine, place chamber in device, chose top and secure. 3. Attach tubing to back of device and other end of the tube to the mask. Switch on device by pressing on/off button at bedtime. The comprehensive care plan dated, 4/3/2022, failed to evidence documentation related to the storage of a [CONDITION(S)] machine. An interview was conducted on 4/6/2022 at 4:53 p.m. with LPN (licenses practical nurse) #1. When asked how a [CONDITION(S)] mask/tubing should be stored when it is not in use by the resident, LPN #1 stated it should be stored in a dated Ziploc bag. When asked the purpose of keeping the tubing in the plastic bag, LPN #1 stated it was to keep the germs off of it. ASM #1, ASM #2, the director of nursing, and ASM #3, the quality assurance/staff development/infection preventionist nurse were made aware of the above findings on 4/6/2022 at 5:19 p.m. No further information was provided prior to exit.

Based on staff interview, facility document review and clinical record review, it was determined the facility staff failed to notify the ombudsman for a transfer to the emergency room for one of 21 residents in the survey sample, Resident #8 (R8). The findings include: On the most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 1/13/2022, the resident scored a four out of 15 on the BIMS (brief interview for mental status) score, indicating the resident is severely cognitively impaired for making daily decisions. The nurse's note dated, 3/27/2022 at 9:39 p.m. documented in part, @ (at) 2100 (9:00 p.m.) this writer heard yelling from resident's room. Upon entering, resident was observed laying on his right side on bathroom floor. Stated, 'he fell while transferring from toilet back to wheelchair.' Denies hitting his head but c/o (complained of) left leg pain. Resident remained on floor with pillows cushioning his head and right arm. Rescue Squad called for further assessment and resident was transferred to[name of hospital] ED (emergency department) for evaluation @ 2200 (10:00 p.m.) Care plan goals sent and written notice of transfer initiated. A request was made on 4/6/2022 at 1:17 a.m. to ASM (administrative staff member) #1, the interim administrator, for the notification to the ombudsman of the transfer to the hospital for R8. An email, documenting the residents that were transferred out of the facility for the month of March 2022, was presented. R8's name was not on the list. An interview was conducted with OSM (other staff member) #2, the social worker, on 4/6/2022 at 3:39 p.m. When asked the process for notifying the ombudsman of transfers out of the facility, OSM #2 stated she completes a form monthly and sends it to the state ombudsman. When asked what type of transfers, OSM #2 stated residents that are transferred out fo the hospital and admitted , if the resident goes to the emergency room and comes back then she never does them. The facility policy, Facility Initiated Transfer and Discharge documented in part, The facility will send a copy of the notice to a representative of the Office of the State Long-Term Ombudsman .Copies of notices for emergency transfers will be sent to the ombudsman, but they may be sent when practicable, such as in a list of residents on a monthly basis. ASM #1, ASM #2, the director of nursing, and ASM #3, the quality assurance/staff development/infection preventionist nurse were made aware of the above findings on 4/6/2022 at 5:19 p.m. No further information was provided prior to exit.

Based on staff interview, facility document review and clinical record review, it was determined the facility staff failed to clarify two physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The findings include: On the Initial Nursing Assessment, dated, 3/30/2022, R194 was documented as being alert but not oriented. The physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A second order dated, 3/30/2022, documented, [MEDICATION(S)] (used to relieve pain, tenderness, swelling and stiffness caused by [CONDITION(S)], [CONDITION(S)] and to relieve other types of short-term pain including pain caused by injuries, surgery and other medical or dental procedures, or medical conditions that last for a limited time.) (2) 200 mg capsule - 200 mg by mouth twice a day as needed for pain. The April 2022 MAR (medication administration record) documented the above orders. The Tylenol was administered once on 4/2/2022 at 7:25 p.m. and the [MEDICATION(S)] was administered on 4/3/2022 at 3:41 p.m. The comprehensive care plan dated, 3/30/2022, documented in part, Problem: Alteration in comfort/pain related to compression deformities at T4 - T 6 (thoracic level 4 - 6), back pain, post fall and hx (history of) repeated falls. The Approach documented in part, Administer pain meds (medications) per MD (medical doctor) order. Evaluate effectiveness of pain management prn (as needed). An interview was conducted with LPN (licensed practical nurse) #1 on 4/6/2022 at 4:53 p.m. The two medication orders were reviewed with LPN #1. When asked how she knows which one to give, LPN #1 stated she had only worked with R194 twice. LPN #1 stated there is no pain scale so I'm not sure which to give for what. When asked if those orders should be clarified, LPN #1 stated, yes. A request for the facility policy on clarifying physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . When asked the standard of practice the facility follows, ASM #2 stated the facility follows their policies. According to Potter and Perry's, Fundamentals of Nursing, 7th edition, page 268 documents the following statements: Clarifying an order is competent nursing practice, and it protects the client and members of the health care team. When you carry out an incorrect or inappropriate intervention, it is as much your error as the person who wrote or transcribed the original order. ASM #1, ASM #2, the director of nursing, and ASM #3, the quality assurance/staff development/infection preventionist nurse were made aware of the above findings on 4/6/2022 at 5:19 p.m. No further information was provided prior to exit. (1). This information was obtained from the following website: https://medlineplus.gov/druginfo/meds/a 4.html. (2) This information was obtained from the following website: https://medlineplus.gov/druginfo/meds/a 2.html.

Based on observation, staff interview and facility document review, it was determined that the facility staff failed to conduct COVID-19 testing in a manner consistent with current standards of practice. RN (Registered nurse) #1 failed to wear eye protection or a gown while conducting COVID-19 testing on RN #2. The findings include: On 9/7/21 at approximately 2:15 p.m., RN #1 was observed conducting COVID-19 testing on RN #2 by inserting a swab into RN #2's nose. RN #1 was observed wearing gloves and a mask but failed to wear eye protection or a gown. On 9/8/21, at 11:51 a.m., an interview was conducted with RN #1 and LPN (licensed practical nurse) #1. RN #1 stated she wears a N95 mask and gloves while conducting COVID-19 testing. When asked if she is supposed to wear anything else, RN #1 stated that is all that she has been wearing. LPN #1 stated a N95 mask, gloves and a disposable gown should be worn while conducting COVID-19 testing. On 9/8/21 at 1:48 p.m., ASM (administrative staff member) #1 (the executive director) and ASM #2 (the director of nursing) were made aware of the above concern. The facility policy titled, COVID-19 Testing- Routine, Symptomatic, and Outbreak documented VI. Conducted Testing .C. Specimen collection will be done using proper infection control procedures and using a surgical N95 fit tested respirator or PAPR (powered air-purifying respiratory), eye protection, gloves, and a gown . The CDC guideline titled, Interim Guidelines for Collecting, Handling, and Testing Clinical Specimens from Persons for Coronavirus Disease 2019 (COVID-19), Updated Dec. 29, 2020 documented, Collecting and Handling Specimens Safely For healthcare providers collecting specimens or working within 6 feet of patients suspected to be infected with [CONDITION(S)]-CoV-2, maintain proper infection control and use recommended personal protective equipment (PPE), which includes an N95 or higher-level respirator (or facemask if a respirator is not available), eye protection, gloves, and a gown, when collecting specimens. This information was obtained from the website: https://www.cdc.gov/coronavirus/2019-ncov/lab/guidelines-clinical-specimens.html No further information was presented prior to exit.

Based on staff interview, facility document review and clinical record review, it was determined that the facility staff failed to provide the necessary care and services, consistent with professional standards of practice, to promote healing and prevent infection of a pressure injury for one of 20 residents in the survey sample, Resident #16. Resident #16 was readmitted to the facility on [DATE], with a stage two pressure injury on the sacrum/buttocks. The facility staff failed to complete ongoing thorough wound assessments including measurements and staging of the pressure injury from 10/30/20 thorough 11/19/20, and from 11/27/20 through 12/10/20, and failed to provide treatment to the pressure injury from 11/7/20 through 11/17/20, with the exception of 11/14/20. On 11/19/20 an assessment of the area, revealed the pressure injury had deteriorated from a stage two to an unstageable pressure injury, resulting in harm. 2. The facility staff failed to administer treatment per physician order [REDACTED]. 3. The facility staff failed to conduct a complete thorough wound assessments including wound measurements of Resident #16's right heel pressure injury from 11/27/20 until 12/10/20, to determine if the wound had improved or declined. The findings include: 1. Resident #16 was admitted to the facility on [DATE]. Resident #16's [DIAGNOSES REDACTED]. Resident #16's quarterly MDS (minimum data set) assessment with an ARD (assessment reference date) of 1/11/21, coded the resident as being cognitively intact. Section G coded the resident as requiring extensive assistance of two or more staff with bed mobility. Section M coded Resident #16 as having one stage three pressure injury (1) and one unstageable suspected DTI (deep tissue injury) (1). Resident #16's comprehensive care plan dated 1/6/21 documented, Actual skin breakdown .Pressure ulcer Stage 3 (1) to coccyx/buttocks, R (right) heel DTI .(A) Nurse to measure and monitor wound status progression or deterioration q (every) week, notify MD (medical doctor) and family of changes. (A) Treatment as ordered . Review of Resident #16's clinical record revealed the resident was readmitted from the hospital on [DATE] with a stage two pressure injury measuring 1 cm (centimeter) in length by 1 cm in width on the sacrum. Nutrashield (2) was applied per physician order [REDACTED]. On 10/28/20, the PA (physician assistant) evaluated the pressure injury and signed an order for [REDACTED]. Further review of Resident #16's clinical record, including nurses' notes, PA notes, nurse practitioner notes and physician notes, failed to reveal any further complete and thorough assessments of the pressure injury, including measurements and staging until 11/19/20 when the pressure injury was documented as unstageable and measured 7.5 cm in length by 3 cm in width. In addition, review of nurses' notes and TARs (treatment administration records) for October 2020 and November 2020, failed to reveal any treatment was provided for the pressure injury from 11/7/20 until 11/13/20 and from 11/15/20 until 11/17/20. Further review of the clinical record revealed a nurse's note dated 11/26/20, which documented in part, He continues to have dk (dark) red/purple area to the buttocks which measures approx (approximately) 6cm x 3cm with small wound which now measures approx 3.5cm x 3cm and wound bed is covered with slougjh (sic) (dead tissue), no odor noted from this area . Review of Resident #16's clinical record including nurses' notes, physician assistant notes, nurse practitioner notes and physician notes failed to reveal any further assessments of the pressure injury until 12/10/20, on this date the pressure injury was documented as unstageable and measured 3 cm in length by 1.6 cm in width. On 2/17/21 at 2:32 p.m., an interview was conducted with RN (registered nurse) #1 (the assistant director of nursing) and LPN (licensed practical nurse) #2 (the quality assurance nurse). RN #1 stated the nurses are responsible for pressure injury assessments but she and LPN #2 conduct audits to ensure the nurses are completing the assessments. RN #1 stated a full skin assessment is conducted for each resident on admission and weekly. RN #1 stated if a pressure injury is observed, then the nurses should complete a full assessment of the wound, contact the physician and obtain a treatment order. RN #1 was asked to describe a full assessment of a pressure injury. RN #1 stated a full assessment consists of the measurement including the length, width and depth, drainage, appearance, tissue type, odor and stage. RN #1 stated a full assessment of a pressure injury should be conducted at least weekly. LPN #2 stated the facility policy documented these assessments should be done weekly unless there is a significant change. On 2/18/21 at 11:15 a.m., a telephone interview was conducted with ASM (administrative staff member) #3, the PA who signed the 10/28/20 order for Greer's goo for seven days then reassess. ASM #3 was asked to describe her role in the assessment and treatment of [REDACTED].#3 stated the initial provider who rounds at the facility evaluates the pressure injury and decides if the injury needs more specialized treatment. ASM #3 stated she provides guidance to the nurses regarding minor wounds but refers advanced wounds to a wound care physician. ASM #3 was asked what the facility nurses' responsibilities were regarding pressure injuries. ASM #3 stated the nurses have protocols for various stages of pressure injuries regarding treatments and dressing changes. ASM #3 was read Resident #16's physician's orders [REDACTED]. ASM #3 stated different providers round at the facility different days of the week. ASM #3 stated she only rounds on Wednesday mornings and the nurses tells her who needs to be seen. ASM #3 stated whoever rounded the day when Resident #16's pressure injury needed to be reassessed needed to reassess the injury but this would have needed to be initiated by the nursing staff. On 2/18/21 at 11:27 a.m., a telephone interview was conducted with LPN #3. LPN #3 stated her role regarding the assessment and treatment of [REDACTED]. LPN #3 stated the assessment of a pressure injury consists of measurements, odor and color. LPN #3 stated nurses evidence wound treatments by signing off the TAR in the computer, documenting a nurse's note and writing the date, time and initials on the wound dressing. LPN #3 was asked if one could say a treatment was done if there was no documentation. LPN #3 stated, No. LPN #3 was read Resident #16's physician's orders [REDACTED]. LPN #3 stated she would assume the last person to sign the treatment for [REDACTED]. On 2/18/21 at 11:53 a.m., a telephone interview was conducted with ASM #2 (the director of nursing), RN #1 and LPN #2. ASM #2, RN #1 and LPN #2 were made aware of the above concerns and asked to gather and provide any additional information. On 2/18/21 at 1:34 p.m., another telephone interview was conducted with ASM #2, RN #1 and LPN #2. ASM #2 stated Resident #16 was extremely non-compliant with care. ASM #2 further stated that the physician is very involved with Resident #16's care and evaluates the resident every week. LPN #2 stated there were multiple nurses' notes that documented Resident #16's pressure injury was red, abraded, and had a foul odor. LPN #2 stated these notes were reflective of an assessment. Review of Resident #16's clinical record revealed multiple nurses' notes, PA notes, NP (nurse practitioner) notes and physician notes that documented Resident #16 was non-compliant with turning and repositioning but failed to reveal the resident was non-compliant with pressure injury assessments and pressure injury treatments. The notes failed to reveal any further complete and thorough assessments of the pressure injury, including measurements and staging until 11/19/20 when the pressure injury was documented as having declined from a stage two, to an unstageable pressure injury that measured 7.5 cm in length by 3 cm in width. Further review of Resident #16's clinical record revealed the NP, PA or physician evaluated the resident on 10/28/20, 10/29/20, 11/5/20, 11/16/20, 11/20/20, 11/23/20, 12/3/20 and 12/10/20. The notes dated 10/28/20, 10/29/20, 11/20/20 and 11/23/20, contained documentation regarding Resident #16's pressure injury but these notes were not written between 10/30/20 and 11/19/20 when there was no evidence of a thorough assessment and the pressure injury declined to unstageable. The notes dated 11/5/20, 11/16/20, 12/3/20 and 12/10/20 did not contain any documentation regarding the pressure injury. The nurses' notes that LPN #2 stated were reflective of a pressure injury assessment were documented as followed: -11/5/20 No new skin issues noted except abrased areas on his buttocks appear worse, skin is peeling in that area, on the scrotum and inner thigh area. He was cleaned and greers goo applied to the areas . -11/9/20 Abraded area remains with redness to buttocks . -11/14/20- Abraded area remains with redness to buttocks. Patch in place . -11/15/20- His buttocks remain red and abrased . -11/17/20- Abraded area remains to buttocks. Patch in place. -11/18/20- Abraded area remains on buttocks, patch in place. -11/22/20- Resident continues to have a [MEDICATION NAME] (sic) Patch to his coccyx and buttocks for open pressure wounds which has a foul odor noted . Review of the clinical record failed to reveal a documented physician order [REDACTED].#16's pressure injury on the dates 11/9 through 11/18/20 noted above. On 2/18/21 at 11:27 a.m., a telephone interview was conducted with LPN #3, the nurse who wrote the 11/5/20 note. When asked what was done other than greer's goo for the worsening area, or if the physician was made aware that the area was declining, LPN #3 stated that was so long ago and she could not remember. On 2/18/21 at 2:39 p.m., a telephone interview was conducted with ASM #4 (Resident #16's physician), regarding the assessment and treatment of [REDACTED].#4 stated he assesses pressure injuries, makes treatment recommendations and takes it from there. ASM #4 stated this is no different than any other health issues. When asked about the nurses' responsibilities for pressure injuries, ASM #4 stated the nurses should assess, document and notify him of any changes. ASM #4, was read Resident #16's 10/28/20, physician's orders [REDACTED]. ASM #4 stated the physician and the nurses were responsible. ASM #4 stated different providers round on different days of the week so he would expect the nurses to remind the providers. ASM #4 stated since approximately mid-December, he visits Resident #16 every week and there have been occasions that he has evaluated the resident's pressure injury. On 2/19/21 at 2:59 p.m., a telephone interview was conducted with LPN #4, the nurse who documented the notes on 11/9/20, 11/14/20, 11/17/20 and 11/18/20. LPN #4 stated a pressure injury assessment consists of the size of the injury, color, slough (dead tissue), the way the area looks, a description of the tissue, any tunneling, measurements and if the treatment is working. LPN #4 stated she does not assess a pressure injury unless the weekly assessment is due or unless she is completing the treatment. LPN #4 was made aware of the notes she documented on 11/14/20, 11/17/20 and 11/18/20 that documented, patch in place. LPN #4 was asked if these notes meant that she completed dressing treatments on these dates or if she was purely documenting that a patch was in place. LPN #4 stated Resident #16's pressure injury treatments are completed on another shift and she does not complete them. LPN #4 stated she was probably just noting that a patch was in place to show treatment was continued from another shift. LPN #4 was made aware there was no documented physician order [REDACTED].#4 stated she could not recall any specific details. On 2/18/21 at 3:30 p.m., a telephone interview was conducted with LPN #6, the nurse who documented the 11/22/20 note. LPN #6 stated a pressure injury assessment consists of odor, drainage, if the wound is open, measurements, depth, undermining and tunneling. LPN #6 stated she documents this information when she completes a pressure injury assessment. On 2/18/21 at 3:52 p.m., another telephone interview was conducted with ASM #4, (Resident #16's physician). ASM #4 stated any time he assesses a resident's pressure injuries, he documents this in his notes. ASM #4 stated if there is no documentation regarding Resident #16's pressure injuries in some of his notes then he did not assess the resident's pressure injuries on those dates. On 2/19/21 at 4:41 p.m., ASM #1 (the administrator), ASM #2, RN #1 and LPN #2 were made aware of the above concerns and the concern for harm. ASM #2 stated she felt that she had showed enough evidence to demonstrate there was no harm and she thought this was a documentation issue. ASM #2 stated she had no additional information to provide. The facility policy regarding pressure areas documented in part, POLICY: To provide optimum treatment to those residents who have developed pressure areas, promote healing and provide comfort .PROCEDURE .5. Clean wounds according to ordered procedure, use clean technique for treatment and dressings unless otherwise specified. 6. Place ordered medication on pressure ulcer. 7. Apply dressing as ordered by physician .10. Pressure Ulcer documentation will occur at least weekly and upon any significant change in pressure ulcer, documentation will include the following: A. Stages. B. Location. C. Size. D. Appearance. E. Drainage. F. Odor. G. Inflammation. H. Undermining . The Pressure Ulcer Treatment Quick Reference Guide by NPUAP concerning pressure ulcer assessment states in part, Asses the pressure ulcer initially and re-assess it at least weekly, documenting findings .A 2-week period is recommended for evaluating progress toward healing. However, weekly assessments provide an opportunity for the health care professional to detect early complications and the need for changes in the treatment plan. With each dressing change, observe the pressure ulcer for developments that may indicate the need for a change in treatment (e.g., wound improvement, wound deterioration, more or less exudate, signs of infection, or other complications) . Assess and accurately document physical characteristics such as location, Category/Stage, size, tissue type (s), wound bed and periwound condition, wound edges, sinus tracts, undermining, tunneling, exudate, necrotic tissue, odor, presence/absence of granulation tissue, and [MEDICATION NAME]. Re-evaluate the pressure ulcer, the plan of care, and the individual if the pressure ulcer does not show progress toward healing within 2 weeks (or as expected given the individual's overall condition and ability to heal) .Signs of deterioration should be addressed immediately. This information was obtained from: National Pressure Ulcer Advisory Panel and European Pressure Ulcer Advisory Panel. Pressure Ulcer Prevention and Treatment: Clinical Practice Guideline. Washington, DC: National Pressure Ulcer Advisory Panel, Second edition published 2014. No further information was presented prior to exit. 2. The facility staff failed to administer treatment per physician order [REDACTED]. A skin evaluation form dated 11/19/20 documented Resident #16 as having an unstageable pressure injury (1) measuring 7.5 cm (centimeters) in length by 3 cm in width on the buttocks. A note signed by the nurse practitioner on 11/23/20 documented, Sacral wound. Total redness approx (approximately) 8-1-cm. 3:00 position: area of stage 2. 12:00 position: area of purplish/blackish? necrotic vs (versus) deep tissue . Review of Resident #16's clinical record revealed a physician's orders [REDACTED]. Apply Santyl to coccyx wound darked (sic) area q (every) day and cover with [MEDICATION NAME] dressing (5). Review of Resident #16's November 2020 and December 2020 TARs and nurses' notes failed to reveal evidence that the treatment was administered on 11/25/20, 12/1/20 and 12/9/20. On these dates, the treatment was not signed off on the TAR as being administered and there were no nurses' notes that documented the treatments were administered. On 2/18/21 at 11:27 a.m., a telephone interview was conducted with LPN (licensed practical nurse) #3. LPN #3 stated her role regarding the assessment and treatment of [REDACTED]. LPN #3 stated nurses evidence wound treatments by signing off the TAR in the computer, documenting a nurse's note and writing the date, time and initials on the wound dressing. When asked if one could say a treatment was done if there was no documentation on the TAR or in the clinical record, LPN #3 stated, No. On 2/18/21 at 11:53 a.m., a telephone interview was conducted with ASM (administrative staff member) #2 (the director of nursing), RN (registered nurse) #1 and LPN #2. ASM #2, RN #1 and LPN #2 were made aware of the above concern and asked to gather and provide any additional information. On 2/19/21 at 4:41 p.m., ASM #1 (the administrator), ASM #2, RN #1 and LPN #2 were made aware of the above concern. No further information was presented prior to exit. 3. The facility staff failed to conduct a complete thorough wound assessments including wound measurements of Resident #16's right heel pressure injury from 11/27/20 until 12/10/20, to determine if the wound had improved or declined. Review of a nurse's note and a skin evaluation dated 11/24/20 revealed Resident #16 acquired a DTI (deep tissue pressure injury) (1) measuring 4 cm in length by 4 cm (centimeters) in width on the right heel. Treatment was initiated per physician order. A nurse's note dated 11/26/20 documented the DTI on the right heel was a small purple blanchable area that measured 4 cm by 3 cm. Further review of Resident #16's clinical record, including nurses' notes, physician assistant notes, nurse practitioner notes and physician notes, failed to reveal any further assessments of the DTI until 12/10/20. A skin evaluation completed on that date documented the DTI was dark purple, non blachable and measured 3cm in length by 3cm in width. On 2/17/21 at 2:32 p.m., an interview was conducted with RN (registered nurse) #1 (the assistant director of nursing) and LPN (licensed practical nurse) #2 (the quality assurance nurse). RN #1 stated the nurses are responsible for pressure injury assessments but she and LPN #2 conduct audits to ensure the nurses are completing the assessments. RN #1 stated a full skin assessment is conducted for each resident on admission and weekly. RN #1 stated if a pressure injury is observed, then the nurses should complete a full assessment of the wound, contact the physician and obtain a treatment order. RN #1 was asked to describe a full assessment of a pressure injury. RN #1 stated a full assessment consists of the measurement including the length, width and depth, drainage, appearance, tissue type, odor and stage. RN #1 stated a full assessment of a pressure injury should be conducted at least weekly. LPN #2 stated the facility policy documented these assessments should be done weekly unless there is a significant change. On 2/18/21 at 11:27 a.m., a telephone interview was conducted with LPN #3. LPN #3 stated her role regarding the assessment and treatment of [REDACTED]. LPN #3 stated the assessment of a pressure injury consists of measurements, odor and color. On 2/18/21 at 11:53 a.m., a telephone interview was conducted with ASM #2 (the director of nursing), RN #1 and LPN #2. ASM #2, RN #1 and LPN #2 were made aware of the above concern and asked to gather and provide any additional information. On 2/19/21 at 2:59 p.m., a telephone interview was conducted with LPN #4. LPN #4 stated a pressure injury assessment consists of the size of the injury, color, slough, the way the area looks, a description of the tissue, any tunneling, measurements and if the treatment is working. LPN #4 stated she does not assess a pressure injury unless the weekly assessment is due or unless she is completing the treatment. LPN #4 stated Resident #16's pressure injury treatments are completed on another shift and she does not complete them. On 2/18/21 at 3:30 p.m., a telephone interview was conducted with LPN #6. LPN #6 stated a pressure injury assessment consists of odor, drainage, if the wound is open, measurements, depth, undermining and tunneling. LPN #6 stated she documents this information when she completes a pressure injury assessment. On 2/19/21 at 4:41 p.m., ASM #1 (the administrator), ASM #2, RN #1 and LPN #2 were made aware of the above concern. No further information was presented prior to exit. References: (1) A pressure injury is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbidities and condition of the soft tissue. Stage 1 Pressure Injury: Non-blanchable [DIAGNOSES REDACTED] of intact skin Intact skin with a localized area of non-blanchable [DIAGNOSES REDACTED], which may appear differently in darkly pigmented skin. Presence of blanchable [DIAGNOSES REDACTED] or changes in sensation, temperature, or firmness may precede visual changes. Color changes do not include purple or maroon discoloration; these may indicate deep tissue pressure injury. Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. This stage should not be used to describe moisture associated skin damage (MASD) including incontinence associated [MEDICAL CONDITION] (IAD), intertriginous [MEDICAL CONDITION] (ITD), medical adhesive related skin injury (MARSI), or traumatic wounds (skin tears, burns, abrasions). Stage 3 Pressure Injury: Full-thickness skin loss Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar (i.e. dry, adherent, intact without [DIAGNOSES REDACTED] or fluctuance) on the heel or ischemic limb should not be softened or removed. Deep Tissue Pressure Injury: Persistent non-blanchable deep red, maroon or purple discoloration Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or [MEDICATION NAME] separation revealing a dark wound bed or blood filled blister. Pain and temperature change often precede skin color changes. Discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury, or may resolve without tissue loss. This information was obtained from the website: https://cdn.ymaws.com/npiap.com/resource/resmgr/online_store/npiap_pressure_injury_stages.pdf (2) Nutrashield is used to treat skin conditions. This information was obtained from the website: https://www.woundsource.com/product/remedy-olivamine-nutrashield (3) Greer's goo is used to treat skin conditions. This information was obtained from the website: http://www.thoracentesis.science/2020/01/Greersgoo.html (4) Santyl is an ointment used to treat wounds. This information was obtained from the website: https://santyl.com/hcp?gclid=EAIaIQobChMI3cnj6NH27gIVkIzICh07zQG3EAAYASAAEgJ52vD_BwE (5) [MEDICATION NAME] dressings are used to treat wounds. This information was obtained from the website: https://pubmed.ncbi.nlm.nih.gov/ 07/

Based on observation, staff interview, facility document review and clinical record review, it was determined that the facility staff failed to provide respiratory care and services for two of 20 residents in the survey sample, Residents #21 and #12. The facility staff failed to administer oxygen to Residents #21 and #12 per the physician prescribed rate and failed to store Resident #12's nasal cannula in a sanitary manner when not in use. Resident #12's nasal cannula was observed uncovered and coiled over the rear handles on the wheelchair when not in use. The findings include: 1. The facility staff failed to administer oxygen to Residents #21 per the physician prescribed rate of two liters. Resident #21 was admitted to the facility on [DATE] and readmitted on [DATE]. Resident #21's [DIAGNOSES REDACTED]. Resident #21's significant change in status minimum data set assessment with an ARD (assessment reference date) of 1/28/21, coded the resident's cognition as severely impaired. Section O coded Resident #21 as having received oxygen therapy. Review of Resident #21's clinical record revealed a physician's orders [REDACTED]. Resident #21's comprehensive care plan dated 2/8/21 failed to document information regarding oxygen. On 2/16/21 at 11:31 a.m. and 2:05 p.m., Resident #21 was observed lying in bed and receiving oxygen via a nasal cannula connected to an oxygen concentrator. Observation revealed the oxygen concentrator was set at a rate of three and a half liters as evidenced by the center of the ball in the concentrator flow meter positioned on the three and a half liter line. On 2/17/21 at 7:48 a.m., Resident #21 was observed lying in bed and receiving oxygen via a nasal cannula. Observation revealed the oxygen concentrator was set at a rate of three liters as evidenced by the center of the ball in the concentrator flow meter positioned on the three liter line. On 2/17/21 at 1:04 p.m., an interview was conducted with LPN (licensed practical nurse) #1. LPN #1 was asked to describe where the ball in an oxygen concentrator flow meter should be if a resident has a physician's orders [REDACTED]. LPN #1 stated the two liter line should run through the middle of the ball in the flow meter. On 2/17/21 at 2:53 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing) were made aware of the above concern. The oxygen concentrator manufacturer's manual documented in part, 5. Adjust the flow to the prescribed setting by turning the knob on the top of the flow meter until the ball is centered on the line marking the specific flow rate . The facility policy regarding oxygen therapy documented in part, B. O2 (Oxygen) administration. 1. Verification of MD (medical doctor) order .6. Turn on O2 at prescribed rate . No further information was presented prior to exit. 2. a. The facility staff failed to administer Resident # 12's oxygen according to the physician's orders [REDACTED]. Resident # 12 was admitted to the facility with [DIAGNOSES REDACTED]. Resident # 12's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 01/14/2021, coded Resident # 12 as scoring a six on the staff assessment for mental status (BIMS) of a score of 0 - 15, six- being severely impaired of cognition for making daily decisions. Section O Special Treatments, Procedures and Programs coded Resident # 12 for the use of oxygen. On 02/16/21 at approximately 1:52 p.m., an observation revealed of Resident # 12 sitting in their wheelchair in their room receiving oxygen by a nasal cannula (3) connected to an oxygen concentrator. Observation of the oxygen concentrator (4) revealed an oxygen flow rate between two and two-and-a-half liters per minute. On 02/16/21 at approximately 3:25 p.m., an observation of Resident #12's oxygen conducted by another surveyor revealed the oxygen concentrator flow rate was set between two and two-and-a-half liters per minute. On 02/17/21 at approximately 7:45 a.m., an observation revealed Resident # 12 in bed, receiving oxygen by a nasal cannula connected to an oxygen concentrator. The oxygen flow rate on the oxygen concentrator was observed set at between two and two-and-a-half liters per minute. The POS (physician's orders [REDACTED].# 12 documented, Check O2 (oxygen) every shift and report abnormal findings; Oxygen @ (at)_2L (two liters)_mi (per minute)_via (by)_NC (nasal cannula) - Every Shift. Order Date 08/27/2020. Start Date 09/01/2020. The comprehensive care plan for Resident # 12 dated of 04/24/2019 documented, (P) (Problem): Needs O2 (oxygen) related to Related diagnosis/conditions Grade 3 (three) diastolic [MEDICAL CONDITIONS], Severe [MEDICAL CONDITIONS](hypertension), Afib ([MEDICAL CONDITION]), moderate persistent asthma, [MEDICAL CONDITION] fibrosis. Under (A) (Approaches) it documented in part, Administer O2 (oxygen) as ordered by MD (medical doctor). Observe labs (laboratory tests), response to medication and treatments. Start Date 04/24/2019. The facility's eTAR (electronic treatment administration record) dated 02/2021 for Resident # 12 documented, Check O2 every shift and report abnormal findings; Oxygen @_2L_mi_via_NC - Every Shift. Start Date 09/01/2020. Further review of the eTAR revealed documentation indicating that Resident # 12 received oxygen at two liters per minute on 02/16/2021 and 02/17/2021. On 02/17/2021 at approximately 1:05 p.m., an interview was conducted with LPN (licensed practical nurse) # 1 regarding how to read the flow rate on a resident's oxygen concentrator. LPN # 1 stated that the liter line on the flow meter of the oxygen concentrator should pass through the middle of the float ball at the appropriate flow rate. The (Name of Manufacturer) user manual for Resident # 12's oxygen concentrator documented in part, Adjust the flow to the prescribed setting by turning the knob on the top of the flow meter until the ball is centered on the line marking the specific flow rate. The facility's policy Oxygen Therapy documented in part, B. O2 Administration. 10. Inspect equipment regularly for proper functioning. On 02/17/2021 at approximately 2:45 p.m. ASM (administrative staff member) # 1, administrator, ASM # 2, director of nursing, RN (registered nurse) # 1, and LPN (licensed practical nurse) # quality improvement/staff development coordinator, were made aware of the above findings. No further information was provided prior to exit. References: (1) When you're short of breath, it's hard or uncomfortable for you to take in the oxygen your body needs. You may feel as if you're not getting enough air. But shortness of breath can also be a sign of a serious disease. This information was obtained from the website: https://medlineplus.gov/breathingproblems.html. (2) A condition in which the tissue deep in your lungs becomes scarred over time. This tissue gets thick and stiff. That makes it hard for you to catch your breath, and your blood may not get enough oxygen. This information was obtained from the website: https://medlineplus.gov/pulmonaryfibrosis.html (3) Tubing used to deliver oxygen at levels from 1 to 6 L/min. The nasal prongs of the cannula extend approx. 1 cm into each naris and are connected to a common tube, which is then connected to the oxygen source. This information was obtained from the website: http://medical-dictionary.thefreedictionary.com/nasal+cannula. (4) Is a medical device that concentrates oxygen from environmental air and delivers it to a patient in need of supplemental oxygen. This information was obtained from the website: https://www.oxygenconcentratorstore.com/help-center/what-is-the-medical-definition-of-an-oxygen-concentrator/ 2. b. The facility staff failed to store Resident #12's nasal cannula in a sanitary manner when not in use. Resident #12's nasal cannula was observed uncovered and coiled over the rear handles on the wheelchair when not in use. On 02/16/21 at approximately 1:52 p.m., an observation revealed Resident #12 sitting in their wheelchair in their room receiving oxygen by a nasal cannula connected to an oxygen concentrator. Observation of Resident # 12's wheelchair revealed another nasal cannula and oxygen tubing connected to a portable oxygen cylinder on the back of the wheelchair. Further observation of the tubing and nasal cannula revealed it was uncovered and coiled over the rear handles on the wheelchair. On 02/16/21 at approximately 3:25 p.m., an observation conducted by another surveyor revealed the same circumstances as stated above. On 02/17/21 at approximately 7:45 a.m., an observation revealed Resident # 12 in bed and receiving oxygen by a nasal cannula that was connected to an oxygen concentrator. Observation of Resident # 12's wheelchair revealed another nasal cannula and oxygen tubing connected to a portable oxygen cylinder on the back of the wheelchair. Further observation of the tubing and nasal cannula revealed it was uncovered and coiled over the rear handles on the wheelchair. The POS (physician's orders [REDACTED].# 12 documented in part, Oxygen tubing and mask or nasal cannula are to be stored in dated Ziploc bag when not in use. Order Date 08/27/2020. Start Date 09/01/2020. On 02/17/2021 at approximately 1:05 p.m., an interview was conducted with LPN (licensed practical nurse) # 1 regarding the storage of a nasal cannula when it is not in use. LPN # 1 stated that the nasal cannula should be stored in a Ziploc bag when the resident is not using it. When asked why it was important to store the nasal cannula in a Ziploc bag LPN # 1 stated, For infection control purposes. The facility's policy Oxygen Therapy documented in part, Procedure: C9. Oxygen tubing and mask or nasal cannula are to be stored in dated Ziploc bag when not in use. On 02/17/2021 at approximately 2:45 p.m. ASM (administrative staff member) # 1, administrator, ASM # 2, director of nursing, RN (registered nurse) # 1, and LPN (licensed practical nurse) # quality improvement/staff development coordinator, were made aware of the above findings. No further information was provided prior to exit.

Based on observation, resident interview, staff interview, facility document review and clinical record review, it was determined that facility staff failed to develop and implement the comprehensive care plan for two of 20 residents in the survey sample, Residents # 18 and # 12. The facility staff failed to develop a care plan to address the care required for Resident #18's bowel incontinence and failed to implement Resident # 12's comprehensive care plan for the administration of physician ordered oxygen. The findings include: 1. Resident #18 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 1/21/21, Resident #18 was coded as having no cognitive impairment for making daily decisions, having scored 15 out of 15 on the BIMS (brief interview for mental status). She was coded as totally dependent on two facility staff for transfers out of bed. Resident #18 was coded as always incontinent for bowel function. On 2/16/21 at 10:41 a.m., Resident #18 was observed lying in her bed and agreed to be interviewed. When asked if she had any concerns about her care, she stated the staff took excellent care of her, but she wished she had more control of her bowels. Resident #18 stated she can never predict when she will have diarrhea, and it is very frustrating for her. When asked if the staff have offered to assist her to use a bedside commode or her bathroom, she stated, I don't like the bedpan. And I really don't like for them to move me out of bed. A review of Resident #18's clinical record revealed CNA (certified nursing assistant) documentation that Resident #18 had bowel movements almost daily, and that she was incontinent of bowel. Further review of Resident #18's clinical record revealed a bowel function assessment completed most recently on 1/22/21. The assessment documented Resident #18 was incontinent of bowel, and required a mechanical lift for transfers out of the bed. A review of the attending physician's progress note dated 1/8/21 revealed, in part: Functional status: totally dependent .diarrhea: Will stop [MEDICATION NAME] (3) as a potential cause of diarrhea. A review of Resident #18's comprehensive care plan dated 6/17/20, and updated 7/24/20 failed to reveal any information or interventions related to Resident #18's bowel incontinence. On 2/17/21 at 1:05 p.m., RN (registered nurse) #1, the assistant director of nursing, was interviewed. When asked who is responsible for developing the comprehensive care plan for a resident, RN #1 stated, The interdisciplinary team. She stated the MDS Coordinator is the point person for care plan development. When asked the purpose of a care plan, RN #1 stated it is a roadmap of care for all of the staff to use to best care for a resident. When asked if a resident's bowel incontinence should be included in the care plan, RN #1 stated, Yes. Absolutely. The facility MDS Coordinator was not available for interview at the time of the survey. On 2/17/21 at 1:11 p.m., LPN (licensed practical nurse) #1 was interviewed. She stated the resident's care plan should tell you how to take care of the resident so the resident can get where they need to be. A review of the facility policy, Comprehensive Person-Centered Care Planning, revealed, in part: Person centered care is a focus on residents' emotional needs and care preferences, consistent with their lifestyle. The emphasis is on relationships in the care rather than task-centered approaches that focus on physical health of residents .The facility will develop and implement a comprehensive person-centered care plan for each resident, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs as identified throughout the comprehensive Resident Assessment Instrument (RAI) process .Each resident's comprehensive care plan will describe the following: .Services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. On 2/17/21 at 3:10 p.m., ASM (administrative staff member) #1, the administrator, and ASM #2, the director of nursing, were informed of these concerns. No further information was provided prior to exit. REFERENCES (1) [MEDICAL CONDITION] is a general term for chronic, nonreversible lung disease that is usually a combination of [MEDICAL CONDITION] and chronic [MEDICAL CONDITION]. Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and Chapman, page 124. (2) 'Arthritis' literally means joint inflammation. Although joint inflammation is a symptom or sign rather than a specific diagnosis, the term arthritis is often used to refer to any disorder that affects the joints. Joints are places where two bones meet, such as your elbow or knee. This information is taken from the website https://www.niams.nih.gov/health-topics/arthritis#:~:text=Points%20To%20Remember%20About%20Arthritis,disorder%20that%20affects%20the%20joints. (3) Prescription [MEDICATION NAME] is used alone or with other medications to treat the symptoms of [MEDICAL CONDITION] reflux disease (GERD), a condition in which backward flow of acid from the stomach causes heartburn and possible injury of the esophagus (the tube between the throat and stomach) in adults and children 1 year of age and older. This information is taken from the website https://medlineplus.gov/druginfo/meds/a 0.html. 2. The facility staff failed to implement Resident # 12's comprehensive care plan for the administration of physician ordered oxygen. Resident # 12 was admitted to the facility with [DIAGNOSES REDACTED]. Resident # 12's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 01/14/2021, coded Resident # 12 as scoring a six on the staff assessment for mental status (BIMS) of a score of 0 - 15, six- being severely impaired of cognition for making daily decisions. Section O Special Treatments, Procedures and Programs coded Resident # 12 for the use of oxygen. On 02/16/21 at approximately 1:52 p.m., observation revealed Resident # 12 sitting in their wheelchair in their room receiving oxygen by a nasal cannula (3) that was connected to an oxygen concentrator. Observation of the oxygen concentrator (4) revealed an oxygen flow rate between two and two-and-a-half liters per minute. On 02/16/21 at approximately 3:25 p.m., an observation conducted by another surveyor revealed the same circumstances as stated above. On 02/17/21 at approximately 7:45 a.m., observation revealed Resident # 12 in bed, receiving oxygen by a nasal cannula connected an oxygen concentrator. The oxygen flow rate on the oxygen concentrator was observed to be between two and two-and-a-half liters per minute. The POS (physician's order sheet) dated 02/2021 for Resident # 12 documented, Check O2 (oxygen) every shift and report abnormal findings; Oxygen @ (at)_2L (two liters)_mi (per minute)_via (by)_NC (nasal cannula) - Every Shift. Order Date 08/27/2020. Start Date 09/01/2020. The comprehensive care plan for Resident # 12 dated of 04/24/2019 documented, (P) (Problem): Needs O2 (oxygen) related to Related diagnosis/conditions Grade 3 (three) diastolic [MEDICAL CONDITIONS], Severe [MEDICAL CONDITIONS](hypertension), Afib ([MEDICAL CONDITION]), moderate persistent asthma, [MEDICAL CONDITION] fibrosis. Under (A) (Approaches) it documented in part, Administer O2 (oxygen) as ordered by MD (medical doctor). Observe labs (laboratory tests), response to medication and treatments. Start Date 04/24/2019. The facility's eTAR (electronic treatment administration record) dated 02/2021 for Resident # 12 documented, Check O2 every shift and report abnormal findings; Oxygen @_2L_mi_via_NC - Every Shift. Start Date 09/01/2020. Further review of the eTAR revealed documentation indicating that Resident # 12 received oxygen at two liters per minute on 02/16/2021 and 02/17/2021. On 02/17/2021 at approximately 1:05 p.m., an interview was conducted with LPN (licensed practical nurse) # 1 regarding Resident # 12's comprehensive care plan. When asked to describe the purpose of a resident's care plan LPN # 1 stated, The care plan tells you how to take care of the resident. When asked if they were able to see and view a resident's comprehensive care plan LPN # 1 stated yes. After informing LPN # 1 of Resident # 12's care plan in regard to the oxygen flow and the observations described above, of Resident # 12's oxygen flow rate, LPN # 1 stated that the care plan was not implemented for Resident # 12's oxygen therapy. The facility's policy Comprehensive Person-Centered Care Plan documented in part, Procedures: 2. The facility will develop and implement a comprehensive person-centered care plan for each resident, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs as identified throughout the comprehensive Resident Assessment Instrument (RAI) process. 9. The resident will receive the services and/or items included in the plan of care. On 02/17/2021 at approximately 2:45 p.m. ASM (administrative staff member) # 1, administrator, ASM # 2, director of nursing, RN (registered nurse) # 1, and LPN (licensed practical nurse) # quality improvement/staff development coordinator, were made aware of the above findings. No further information was provided prior to exit. References: (1) When you're short of breath, it's hard or uncomfortable for you to take in the oxygen your body needs. You may feel as if you're not getting enough air. But shortness of breath can also be a sign of a serious disease. This information was obtained from the website: https://medlineplus.gov/breathingproblems.html. (2) A condition in which the tissue deep in your lungs becomes scarred over time. This tissue gets thick and stiff. That makes it hard for you to catch your breath, and your blood may not get enough oxygen. This information was obtained from the website: https://medlineplus.gov/pulmonaryfibrosis.html (3) Tubing used to deliver oxygen at levels from 1 to 6 L/min. The nasal prongs of the cannula extend approx. 1 cm into each naris and are connected to a common tube, which is then connected to the oxygen source. This information was obtained from the website: http://medical-dictionary.thefreedictionary.com/nasal+cannula. (4) Is a medical device that concentrates oxygen from environmental air and delivers it to a patient in need of supplemental oxygen. This information was obtained from the website: https://www.oxygenconcentratorstore.com/help-center/what-is-the-medical-definition-of-an-oxygen-concentrator/

Based on observation, staff interview, facility document review and clinical record review, it was determined that the facility staff failed to review and revise the comprehensive care plan for one of 20 residents in the survey sample, Resident #21. The facility staff failed to review and revise Resident #21's comprehensive care plan for oxygen therapy/respiratory care. The findings include: Resident #21 was admitted to the facility on [DATE] and readmitted from the hospital on [DATE]. Resident #21's [DIAGNOSES REDACTED]. Resident #21's significant change in status minimum data set assessment with an ARD (assessment reference date) of 1/28/21, coded the resident's cognition as severely impaired. Section O coded Resident #21 as having received oxygen therapy while not a resident. Review of Resident #21's clinical record revealed a physician's orders [REDACTED]. Resident #21's comprehensive care plan dated 2/8/21 failed to document information regarding oxygen therapy or respiratory care. On 2/16/21 at 11:31 a.m. and 2:05 p.m., Resident #21 was observed lying in bed and receiving oxygen via a nasal cannula. On 2/17/21 at 1:12 p.m., an interview was conducted with RN (registered nurse) #1. RN #1 stated the care plan is a road map of care and tells you who, what, when and where, and goals. When asked if a resident's care plan should be reviewed and revised for the use of oxygen, RN #1 stated, Yes. Should at least have a respiratory portion to their care plan. On 2/17/21 at 2:53 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing) were made aware of the above concern. The facility policy regarding comprehensive person-centered care planning documented in part, 15. The Care Planning/Interdisciplinary Team is responsible for the review and updating of care plans .D. When the resident has been readmitted to the facility from a hospital stay .F. Updates are done with Medical Doctor Order changes . No further information was presented prior to exit.

Based on observation, staff interview, facility document review, clinical record review, and in the course of a complaint investigation, it was determined that the facility failed to follow the physician's dietary order for one of seven residents in the survey sample, Resident #4. Resident #4 had a physician's order stating she should not receive bread. On 10/28/2020, Resident #4 received bread on her dinner tray. She ate the bread, choked on it, and was hospitalized for [REDACTED]. The findings include: Resident #4 was admitted to the facility on [DATE], and most recently readmitted on [DATE] with [DIAGNOSES REDACTED]. On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 10/26/2020, Resident #4 was coded as being impaired for making daily decisions, having scored eight out of 15 on the BIMS (brief interview for mental status). She was coded as requiring the set up help of one staff member for eating. She was coded as having no signs or symptoms of a swallowing disorder on her current diet. On 11/9/2020 at 11:03 a.m., Resident #4 was observed sitting up in a wheelchair in her room. She was dressed and alert; she frequently yelled out for staff members to go in the room and be with her. On 11/9/2020 at 12:52 p.m., Resident #4 was observed sitting up in a wheelchair in her room. A CNA (certified nursing assistant) was in the room assisting her. On 11/9/2020 at 1:24 p.m., Resident #4 was observed sitting up in a wheelchair in her room. LPN (licensed practical nurse) #1 was observed standing in the doorway talking to Resident #4. Resident #4 told LPN #1 that she wanted a hot dog. LPN #1 told Resident #1 that her hot dog would need to be chopped, and that she would not have any bread served with it. Resident #4 agreed to this plan. A review of Resident #4's clinical record revealed the following physician's order dated 10/12/2020: Diet Regular - Cut up meats; NO BREAD. A review of Resident #4's comprehensive care plan dated 10/12/2020 revealed, in part: Provide diet as ordered. See POS (physician order sheet) for current diet order. Regular diets, no bread, cut up meats. A review of Resident #4's clinical record revealed the following progress note dated 10/28/2020: Resident received a sloppy joe for dinner and she is not suppose (sic) to have bread. She immediately started coughing lg (large) amounts of sputum and vomited some of the fluid and became congested. She continued to cough up lg amts of sputum for approx (approximately) one hr (hour). She sat up in WC (wheelchair) two hrs after that incident and congestion and mucous decreased. She was placed in bed with HOB (head of bed) elevated approx (approximately) 8pm and she fell asleep. She woke up approx 9pm and was yelling out for nurse. I went to her rm (room) and she appeared very congested again and was coughing but could not cough anything up. She stated she felt terrible and that she was hurting in her chest. I listened to her lungs and all bases were contested and full of fluid. She has a VS (vital sign) change with T (temperature) 99.1, P (pulse) 88, R (respirations) 28, BP (blood pressure) 148/62, and O2 (oxygen) sat (saturation) at 90%. Resident was alert the whole time and was able to talk continuously but was very SOB (short of breath). O2 was placed on resident via mask at 4L/min (liters per minute). I called (name of nurse practitioner) and told her what had happened and she gave order ok to send to ER (emergency room ) .Resident was send to ER at approx 2145 (9:45 p.m.) via squad with two attendents (sic). Resident was still alert and talking when she left. I did call the dietary dept (department) after this occurred at dinner and spoke to (name of dietary employee) and told her resident is not to have bread and it on her dietary slip that comes on her tray but she continues to be sent bread. The CNAs who gave out the tray did not realize she was not to have bread and it was not highlighted in red that they are use (sic) to seeing on the other floors on her dietary slip. A review of Resident #4's discharge summary from the local hospital dated 11/2/2020 revealed, in part: (Resident #4) is a [AGE] year old female with a history of dementia. Had sloppy Joe for dinner. She choked on it and aspirated. She became hypoxic (2) to 85% on 3 L. It came up to 100%. Patient is brought to the emergency room . X-ray showed evidence of bilateral infiltrate. She is admitted for aspiration pneumonia. It appears that the patient is not supposed to have (bread), but she was given some last night. Patient does not report any chronic swallowing problem. A review of the FRI (facility reported incident) submitted 10/29/2020 by the facility regarding Resident #4 revealed, in part: Events prior to transfer to ER were the following: (Resident #4) ordered a sloppy joe for dinner. Her tray was prepared as ordered by resident and served at dinner. (Resident #4) began to strangle at dinner, which included coughing and vomiting. Staff member noted bread was included with resident's dinner, and staff member removed the bread as it was not part of the resident's diet order. Due to coughing and vomiting during dinner, resident was assisted to remain up in chair with staff present for approximately 2 hours post dinner, to monitor. Resident was assisted to bed, with the head of her bed elevated, at approximately 8pm. Resident woke at approximately 9:00 p.m., complaining of chest pain, congested in all lobes bilaterally to auscultation, hypoxic and coughing. She remained alert with confusion at baseline. NP (nurse practitioner) on call was notified, oxygen was administered and 911 was called. RR (resident representative) was made aware as well. Resident was alert squad left the facility. Per update this morning from the hospital, (Resident #4) was subsequently admitted with aspiration pneumonia, but stable. Today, investigation was initiated to evaluate events leading to hospital admission for aspiration pneumonia. On 11/10/2020 at 3:33 p.m., LPN #2 was interviewed. She was the nurse who worked with Resident #4 on the evening of 10/28/2020. She stated she was aware that Resident #4 was not allowed to have bread, and that the resident was prone to coughing and congestion easily. She stated that her understanding of the tray service was that the trays were assembled in the main kitchen, placed on a cart, delivered on the cart to her unit, and then distributed by CNAs to the residents. She stated Resident #4 was seated in the common dining area that evening. LPN #2 stated, (Resident #4) has dementia and we keep an eye on her. She stated she was passing medications when a CNA reported that Resident #4 was coughing and vomiting. She stated the facts in the nurse note she wrote (quoted above) are correct. She stated when the resident woke up with chest pain, coughing, and a decrease in her blood oxygen level, she called the NP and got an order for [REDACTED]. LPN #2 stated she has received both one-on-one and group education regarding checking trays to make sure the contents match a resident's diet order, basic resident safety, and the meaning of different diets for residents based on diagnosis. She stated she works on all floors of the facility, and that since the incident, she checks all resident trays for residents under her care. On 11/10/2020 at 3:48 p.m., CNA #1 was interviewed. She stated food for residents on Resident #4's unit comes down in carts from the main kitchen. She stated the CNA's role is to take the trays from the cart and deliver the trays to the residents' rooms. CNA #1stated CNAs are responsible for setting up the trays for residents by taking the covers off plates, opening condiments, and assisting with any other items residents need. She stated Resident #4 is able to feed herself. She stated that on 10/28/2020, Resident #4's dinner was not on the first cart to arrive on the unit. CNA #1stated when she returned to check on Resident #4, she already had her food. She stated that before this incident occurred, she could not say she checked every single tray for every single resident's correct diet order. CNA #1stated that since the incident, she checks all resident trays, no matter who served the resident. When asked if, prior to this incident, she was aware that Resident #4 had an order for [REDACTED].#1 stated she now knows this information is located on the resident's printed meal ticket. She stated that once Resident #4 started coughing and vomiting, LPN #2 arrived to check on her, and determined that she had gotten bread on her tray and had eaten some of it. CNA #1 stated, (LPN #2) knew what had happened right away. When asked if she has received any special training since this incident, CNA #1 stated, We have talked about it. She stated she has been told to make sure she is checking the ticket against what is actually on the resident's tray. She stated there is a phone number for the speech therapist posted for staff to call with questions at any time. On 11/10/2020 at 4:50 p.m., OSM (other staff member) #2, a dietary server, was interviewed. She stated she was working on the evening of 10/28/2020, and was the server for Resident #4's unit's meal trays. She stated in the main kitchen, the cook looks at the ticket and puts on the appropriate food. She stated that before this incident, the cook put the lid on the plate immediately, in order to keep the food as warm as possible. OSM #2 stated, Honestly, sometimes I checked the plates and sometimes I did not. She stated that evening, she did not look at Resident #4's plate. She stated she was aware that Resident #4 was not allowed to have bread, but was sometimes confused because the resident is allowed to have muffins, cookies, and other starches. OSM #2 stated, I honestly did not even think about her getting a Sloppy Joe bun. She stated she took the cart to the unit. She stated that since the incident, she has attended two trainings for all dining staff, and two extra trainings for staff members directly involved in the incident with Resident #4. She stated that now, cooks do not put covers on the plates until a second person has checked the plate. She stated there is a sign on sheet in a binder for staff to report any inconsistencies or errors in plate preparation. On 11/10/2020 at 5:01 p.m., OSM (other staff member) #1, a prep cook, was interviewed. She stated she was working the evening of 10/28/2020, and she had prepared Resident #4's plate. She stated the tickets are placed on the tray, and she looks at the ticket and prepares the plate accordingly. The plates are taken to the residents in carts. When asked what the information the meal tickets contain, she stated they contain the resident's name, allergies [REDACTED]. She stated the tickets also contain specific information regarding any foods the resident is not allowed to have or dislikes. OSM #1 stated that prior to this incident, some servers double checked the residents' plates before they were placed on the meal carts, and some servers did not. She stated that since the incident, she never covers a plate once she serves it, and that the servers check all the plates. OSM #1 stated that she and another staff member sign that they have both checked trays. She stated she has received one-on-one education regarding checking meal tickets, and verifying them against what is on the plate. She stated she also understands that she is not to put a cover on any plates until the plates have been double checked by a server. On 11/12/2020 at 8:39 a.m., OSM #3, the assistant director of dining services, was interviewed. She stated the prep cooks are responsible for plating meals for Resident #4's unit. She stated she was a part of the team who investigated the incident, including a root cause analysis. OSM #3 stated there are a few remaining dietary staff members who still need to be trained, and that they are all working on 11/12/2020. She stated they will not be allowed to start work until their education is complete. A review of the facility policy Resident and Patient Meal Service revealed, in part: The menu is planned in conjunction with the RD (registered dietician), who reviews and revises the diet spread sheet .Seasonal changes, holiday meals, theme meals, and resident-preferred changes are made throughout the year. On 11/12/2020 at 10:24 a.m., ASM (administrative staff member) #1, the executive director, ASM #2, the DON (director of nursing), RN (registered nurse) #1, the assistant DON, and LPN #3, the QA (quality assurance) nurse, were informed of these concerns and invited to share any additional information the facility might have. ASM #2 stated, the facility staff self-reported the incident, and immediately investigated it. She stated the plan put into place is multi-faceted. On 11/12/2020 at 8:22 a.m., LPN #3, the QA nurse, was interviewed. She stated that as soon as she became aware of the 10/28/2020 incident with Resident #4, she assembled the key players and initiated not only a corrective action plan, but also a root cause analysis. LPN #3 stated, It was clear we had a system breakdown. She stated Resident #4's meal was plated incorrectly by the prep cook, and the dietary server did not check the plate against the physician's order. She stated the root-cause analysis revealed that the facility's dining tickets changed in August 2020 when the facility began to be serviced by a contract dining services, company. LPN #3 stated that prior to this change, dietary restrictions such as a resident not being allowed to have bread, were highlighted in red. She stated this red highlight was not present in the 10/28/2020 dining tickets. She stated nursing management was not aware of the change in the appearance of the dining tickets, so they were not able to educate and alert their staff. She stated the tickets are now being individually reviewed and color highlighted by staff members because the current dietary software will not allow automatic red highlights. She stated that nursing had also implemented EMR (electronic medical record) changes just prior to 10/28/2020. She stated no one understood the changes that the new EMR required additional steps for information such as a no bread order to appear on a resident's dining ticket. She stated that changes in both dining services and nursing contributed in fundamental ways to Resident #4 receiving bread on her dinner tray on 10/28/2020. LPN #3 stated, It does not take aware our accountability, but we lost some things when we made those changes. She stated all dining supervisors were immediately educated on the new process of a two-person tray check. She stated an educated supervisor was present at every meal since the incident, and that line staff are being educated as quickly as possible. She confirmed that no staff were allowed to work until their education had been completed. On 11/12/2020 at 12:50 p.m., the facility staff provided the surveyor with an updated copy of the document QAPI (Quality Assurance Performance Improvement) Action Plan. A review of this plan revealed, in part: 1. (Resident #4) - When coughing/choking episode began, bread was immediately removed from resident's plate .was admitted to hospital 10/28/2020. Returned to our facility 11/2/2020 .diet profile and select ticket was immediately checked for accuracy. Both were correct, and reflected correct diet, no bread. 2. Other potential - Only one other resident in facility .that has diet order reflecting 'no bread.' (Note: this resident is not in a SNF/NF (skilled nursing facility/nursing facility) licensed bed). All residents have the potential to receive an incorrect diet. Will be addressed through auditing process. Will not just complete on (SNF/NF licensed units), but will also audit (in other locations) . 3. System changes - Education to Dining Supervisors that all trays will be a 2-person procedure to ensure trays are verified for accuracy 10/29/2020. All dining staff education planned and posted: 2-person procedure required (server/cook) 3 meals/day (in SNF/NF licensed beds) .Began 11/2/2020, .Audits will occur for accuracy of diets .each meal, daily X 4 weeks by server and Cook/host. Additionally, dining supervisors will audit for tray/diet accuracy weekly . Nursing staff education will be provided on the following topics: nursing staff must check accuracy of meal tray received to meal ticket/order; immediate notification to nursing management/dining management of noted meal deficient issues .nurses will be informed of where special diet information must be in order for it to pull to the resident profile; nurses will be informed all diet changes require a paper slip to be sent to dining manager every time .begin week of 11/9/2020 . 4. Monitoring/QA Oversight - all dining audits will be forwarded to QA for review of compliance. DON, ADON (assistant director of nursing), QA nurse and evening nurse will together audit 3 meals .per (licensed SNF/NF beds) each week, verifying that what resident receives at mealtime matches their meal ticket. This will occur week of 11/9/2020 X (times) 4 weeks, and then QA will review for compliance and reveal audit schedule/needs. The sign-in sheets for both dining services and nursing department education were reviewed and verified. The other points of the plan of correction as described in this writing were verified with observations and record reviews of Resident #4, and of other current residents with the potential to be affected and through interviews with staff in both dining services and nursing departments as described in this writing. No concerns were identified. On 11/12/2020 at 2:30 p.m., ASM #1, ASM #2, RN #1, and LPN #3 were informed of the concern and findings of harm at past noncompliance PAST NONCOMPLIANCE No further information was provided prior to exit. REFERENCES (1) The infectious [MEDICAL CONDITION] process that occurs after abnormal entry of fluids into the lower respiratory tract is termed aspiration pneumonia. The aspirated fluid can be oropharyngeal secretions, particulate matter, or can also be gastric content. This information is taken from the website https://www.ncbi.nlm.nih.gov/books/NBK 9/. Aspiration may be completely asymptomatic or present with dramatic signs and symptoms that include wheezing, shortness of breath, cyanosis, [MEDICAL CONDITION] and [MEDICAL CONDITION] (low oxygen levels). This information was obtained from the website; https://www.ncbi.nlm.nih.gov/pmc/articles/PMC 54/ (2) A condition in which there is a decrease in the oxygen supply to a tissue. This information is taken from the website https://www.cancer.gov/publications/dictionaries/cancer-terms/def/[MEDICAL CONDITION]. COMPLAINT DEFICIENCY

2.a. The facility staff failed to assess Resident #3 to ensure the resident could safely possess a sharp metal mail opener. Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED].* and glaucoma (eye diseases) **. Resident #3's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 3/5/15, coded the resident's cognition as being moderately impaired. Section G coded Resident #3 as requiring limited assistance of one staff with transfers and walking, and as having no upper or lower extremity impairment. Section E coded the resident as having hallucinations (perceptual experiences in the absence of real external sensory stimuli) and delusions (misconceptions or beliefs that are firmly held, contrary to reality). Review of Resident #3's clinical record revealed a psychiatry consult note dated 10/29/14 that documented, "I have seen and examined for follow up care this 94F ([AGE] year old female) with history of cognitive disorder and Charles Bennet (Bonnet) Syndrome (visual hallucinations caused by impaired vision) ***. Per NF (nursing facility), has not displayed symptoms of mood or behavioral disturbance, but does have ongoing visual hallucinations. No changes in sleep or appetite. She was seen along with her POA (power of attorney). Patient reports mild symptoms of depression including some anhedonia (the reduced ability to experience pleasure) ****, but relieved with companionship, and loss of interest in food. She acknowledges sometimes feeling as if life 'is not worth it.' Her POA explains that much stems from the loss of her husband a few years ago. She denies feeling hopeless, however, her main complaint seems to be ongoing nightmares." Further review of Resident #3's clinical record revealed the following nurse's notes: · 11/29/14- "Resident alert (a c with a horizontal line drawn above it indicating the word 'with') occ. (occasional) confusion, hallucinations, seeing peeping Tom in a window on a windowless wall..." · 12/5/14- "Resident Hallucinating- seeing peeping tom and mad that no one is doing anything about it..." · 12/14/14- "Resident alert (a c with a horizontal line drawn above it indicating the word 'with') periods of confusion. Sometimes has hallucinations & talks to invisible people..." · 12/19/14- "Resident alert, awake very paranoid, has hallucinations and is confused...Resident tells staff that she sees people & talks to people when they are not there..." · 2/11/15- "Resident continues to be alert, awake. Sleeps very hard @ (at) night. Continues to be paranoid. Sees people out of windows. Hallucinating, hearing voices..." · 3/12/15- "Resident alert (a c with a horizontal line drawn above it indicating the word 'with') confusion & paranoia at times..." Resident #3's comprehensive care plan printed on 3/11/15 documented in part, "Suspiciousness, visual hallucinations, paranoia thought to be related to visual deficits, she reports regularly seeing 'a man outside my window.' Staff have checked many times and no one has ever see (sic) the man..." The following observations of Resident #3 and her room were conducted: · 3/24/15 at 1:05 p.m. - Resident #3 was sitting in a recliner in the bedroom, talking about a man coming in the room and out the window. A sharp metal mail opener was observed on a table beside the resident. · 3/24/15 at 3:30 p.m. - Resident #3 was sitting in a recliner in the bedroom. The mail opener was observed on a table beside the resident. · 3/25/15 at 8:10 a.m. - Resident #3 was out of the bedroom. The mail opener was observed on a table. During all observations the resident was not observed being aggressive or physical with staff or other residents. Further review of Resident #3's clinical record failed to reveal the resident had been assessed to ensure she could safely possess the mail opener. On 3/25/15 at 8:45 a.m., an interview was conducted with CNA (certified nursing assistant) #2. CNA #2 stated Resident #3 gets confused, talks to and answers herself. CNA #2 stated the resident sees people from previous relationships but is not aggressive. On 3/25/15 at 11:55 a.m., an interview was conducted with RN (registered nurse) #2. RN #2 stated Resident #3 has hallucinations such as seeing people that aren't there. RN #2 stated the staff has to keep the resident's blinds closed because the resident thinks there is a peeping tom. When asked if Resident #3 was aggressive or physical, RN #2 stated the resident is adamant about not wanting to do anything but does not strike or hit. RN #2 was asked the facility process for evaluating residents for safe possession of sharp objects. RN #2 stated the general rule of thumb is residents should not possess sharp objects. RN #2 stated certain residents can have scissors for short periods of time with supervision. When asked the process for evaluating residents to ensure they can safely possess mail openers, RN #2 stated, "It's sharp. It wouldn't be a good idea." RN #2 stated Resident #3 had reported having a mail opener and someone taking it but she (RN #2) didn't remember seeing it. When asked if Resident #3 could safely possess a mail opener, RN #2 stated, "I wouldn't give it to her. She has too many hallucinations and keeps saying a peeping tom is coming; so no, it's not appropriate." At this time, RN #2 was asked to accompany this surveyor to Resident #3's room. RN #2 was shown the sharp, metal mail opener on the resident's table. RN #2 removed the mail opener and stated, "Oh boy. This is the first time I have seen this." On 3/25/15 at 4:00 p.m., an interview was conducted with ASM (administrative staff member) #2, the director of nursing, regarding the facility process for evaluating residents for safe possession of sharp objects. ASM #2 stated she didn't know if there was a process. ASM #2 stated Resident #3's POA (power of attorney) wanted the resident to be able to read her mail and it was important for the resident's quality of life. On 3/25/15 at 6:30 p.m., the administrator was made aware of the above findings. Policies regarding the above concern were requested. On 3/26/15 at 8:06 a.m., the director of nursing stated the facility did not have the requested policies. *This information was obtained from the website: http://www.nlm.nih.gov/medlineplus/osteoporosis.html **This information was obtained from the website: http://www.nlm.nih.gov/medlineplus/glaucoma.html ***"People with impaired vision sometimes see things that are not there, called visual hallucinations. They may see simple patterns of colors or shapes, or detailed pictures of people, animals, buildings, or landscapes. Sometimes these images fit logically into a visual scene, but they often do not. This condition can be alarming, but don't worry-it is not a sign of mental illness. It is called [DIAGNOSES REDACTED], and it is similar to what happens to some people who have lost an arm or leg. Even though the limb is gone, these people still feel their toes or fingers or experience itching. Similarly, when the brain loses input from the eyes, it may fill the void by generating visual images on its own." This information was obtained from the website: https://www.nei.nih.gov/health/maculardegen/armd_facts ****This information was obtained from the website: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC 80/ 2.b. For Resident #3, the facility staff failed to ensure a physician ordered chair alarm was in place, in all chairs. Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED].* and glaucoma (eye diseases) **. Resident #3's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 3/5/15, coded the resident's cognition as being moderately impaired. Section G coded Resident #3 as requiring limited assistance of one staff with transfers and walking. Section J coded the resident as not having any falls since the prior assessment. Review of Resident #3's clinical record revealed a nurse's note dated 10/13/14 that documented the resident was lowered to the floor in the shower room without injury. A fall risk assessment dated [DATE] documented a score of 16 with a score greater than 4 indicating Resident #3 was at high risk. Resident #3's comprehensive care plan printed on 3/11/15 documented, "Potential for falls r/t (related to) confusion, poor vision, need for assistance with ambulation, incontinence and delusions at times. RESIDENT USES A CHAIR ALARM WHILE IN A CHAIR..." A physician's orders [REDACTED]." Observation of Resident #3 sitting in a chair at a table in the solarium was conducted on 3/25/15 at 8:10 a.m. and 8:45 a.m. During these observations, no chair alarm was present. Staff was present in the room. On 3/25/15 at 8:45 a.m., an interview was conducted with CNA (certified nursing assistant) #2. CNA #2 stated care plans and assignment sheets are used to communicate the type of safety devices that should be used for each resident. CNA #2 stated Resident #3 was supposed to have a chair alarm and a bed alarm. CNA #2 was shown the chair Resident #3 was sitting in. CNA #2 stated, "She walked down here so it's not going to be with her. It's in her wheelchair. The alarm is placed in the recliner chair in the dining room (solarium) after the meal. Usually she sits in the recliner in her room with the alarm. We don't put the alarm in the dining room chair." On 3/25/15 at 11:55 a.m., an interview was conducted with RN (registered nurse) #2. RN #2 stated safety devices come through as a physician's orders [REDACTED]. RN #2 stated Resident #3 was supposed to have a low bed and a chair alarm if in the recliner in the bedroom. RN #2 stated the resident generally walks to the solarium with close supervision for meals. RN #2 was asked what a physician's orders [REDACTED]. RN #2 stated, "It should be all chairs." On 3/25/15 at 6:30 p.m., the administrator and director of nursing were made aware of the above findings. Policies regarding fall prevention, safety devices and following physician's orders [REDACTED]. *This information was obtained from the website: http://www.nlm.nih.gov/medlineplus/osteoporosis.html **This information was obtained from the website: http://www.nlm.nih.gov/medlineplus/glaucoma.html 3. For Resident #2, the facility staff failed to ensure a physician ordered chair alarm was in place, in all chairs. Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED].*, high blood pressure and history of fainting. Resident #2's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 3/12/15, coded the resident's cognition as being severely impaired. Section G coded Resident #2 as being totally dependent of one staff with bed mobility, transfers and locomotion. Section J coded the resident as not having any falls since the prior assessment. Review of Resident #2's clinical record revealed a fall risk assessment dated [DATE] that documented a score of 12 with a score greater than 4 indicating the resident was at high risk. Resident #2's comprehensive care plan printed on 3/17/15 documented in part, "Resident is on a fall prevention program. 6/5/13 Bed and chair alarm after fall w/o (without) injury..." A physician's orders [REDACTED]." On 3/25/15 at 8:08 a.m., Resident #2 was observed alone in a wheelchair in the bedroom. No chair alarm was observed. On 3/25/15 at 8:50 a.m., Resident #2 was observed in a wheelchair in the dining room. No chair alarm was observed. Staff was present in the room. On 3/25/15 at 8:50 a.m., an interview was conducted with CNA (certified nursing assistant) #2. CNA #2 stated care plans and assignment sheets are used to communicate the type of safety devices that should be used for each resident. CNA #2 stated Resident #2 was supposed to have a chair alarm, bed alarm and motion alarm when getting out of bed. CNA #2 was shown Resident #2 sitting in the wheelchair with no alarm in the dining room. CNA #2 stated, "She doesn't have one on." On 3/25/15 at 11:55 a.m., an interview was conducted with RN (registered nurse) #2. RN #2 stated safety devices come through as a physician's orders [REDACTED]. RN #2 stated Resident #2 was supposed to have a chair alarm, motion detector and a bed alarm. On 3/25/15 at 6:30 p.m., the administrator and director of nursing were made aware of the above findings. Policies regarding fall prevention, safety devices and following physician's orders [REDACTED]. *This information was obtained from the website: http://www.nlm.nih.gov/medlineplus/osteoporosis.html Based on staff interview, facility document review and clinical record review, it was determined that the facility staff failed to ensure an environment free from accidents and hazards, and failed to ensure the application of assistive devices to prevent accidents for three of 13 residents in the survey sample, Residents #1, 3 and 2. 1. The facility staff failed to ensure the safe application of a positioning assistive device for Resident #1 and as a result Resident #1 sustained a fracture to the left elbow. CNA (certified nursing assistant) #4 attempted to place an assistive positioning device, a trough, onto Resident #1's wheelchair while the resident was seated in the wheelchair. The trough struck Resident #1's left elbow, causing a fracture. CNA #4 had not received any training on applying and or training on safety while applying wheelchair troughs until after the 12/17/14, incident had occurred. * A trough or wheel chair arm support helps keep arms in position. They can be held in place by metal hinges or other attaching hardware. They can be padded for additional comfort. 2.a. The facility staff failed to assess Resident #3 to ensure the resident could safely possess a sharp metal mail opener. 2.b. For Resident #3, the facility staff failed to ensure a physician ordered chair alarm was in place, in all chairs. 3. For Resident #2, the facility staff failed to ensure a physician ordered chair alarm was in place, in all chairs. The findings include: 1. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #1's most recent MDS (minimum data set) was a significant change assessment with an ARD (assessment reference date) of 1/29/15. Resident #1 was coded on the MDS as having a BIMs (Brief Interview for Mental Status) score of three out of 15. The MDS manual documents that a score of three indicates that the resident's cognition was severely impaired. Section G, Functional Status, coded Resident #1 as having range of motion impairment on one side for both upper and lower extremities. A Facility Reported Incident (FRI) dated 12/18/14 submitted to the office of Licensure and Certification on 12/18/14 was reviewed and documented in part the following: "Incident 12/17/14, Injury: Yes, fractured medial distal left humerus." Under, "Incident Type:" the box beside the word "safety" contained an X and the word "safety", was circled. Beside and under the heading, "Describe incident, including location, and action taken:" was the following: while cna was putting wheel chair arm trough on wheelchair, the trough stuck resident's left elbow- elbow later in the day was noted to be bruised and swollen, elbow & (and) arm x-rayed, Res (resident) to be seen by orthopedics today. CNA #4's name was documented under the heading: "Name of employees involved and their positions:" Documented under, "Employee action initiated or taken:" the following was documented, "Trough removed from w/c (wheelchair) per family request - staff re- educated on safety issue involving trough use - no abuse suspected or defined." The follow up report dated 12/18/14 to the FRI above, submitted to the Office of Licensure and Certification on 12/18/15 was reviewed and documented in part: On December 17, 2014, Certified Nursing Assistant (name of CA #4), was applying left wheel chair arm trough onto wheelchair as per proper protocol and accidentally hit resident's left elbow. No immediate injury noted until around 1:30 pm when the CNA was changing her soiled sweater did the staff notice that the left elbow area was bruised and swollen. Name of physician was notified and ordered an x-ray to the left elbow, left humerus and left forearm. ... x-ray results showed a medial distal left humerus fracture. ... On December 18, 2014, an appointment was made at 11:20 a.m. with name of physician at name of Orthopedics. .... She has a [DIAGNOSES REDACTED]. OLC (Office of Licensure and Certification) ..... were notified. The Physical Therapy department held in-services on two occasions December 18th to assist with re-education of safety while applying wheelchair troughs. Resident returned with husband from name of Orthopedics office by our staff - resident has cast on left arm with ace bandage. ... " A review of the clinical record revealed that Resident #1 sustained a fracture to the medial (closer to the midline) distal (farther from the point of attachment) left humerus (the long bone of the arm that runs from the shoulder to the elbow) on 12/17/14. The investigation conducted by the Director of Nursing at the time of the incident as documented above determined that the fracture occurred when a certified nurse's aide was applying a wheelchair arm trough, an assistive device, onto Resident #1's wheelchair and struck Resident #1's left elbow with the trough. Further review of the clinical record and facility records did not reveal that the certified nurse's aide involved in the incident had been sufficiently trained to work with the assistive device being utilized at the time the incident occurred. A review of the nurse's notes revealed, in part, the following documentation: "12/17/14 2:43 p.m. Resident noted to have swelling to her upper left arm at 2:00 p.m. as well as a bruising to the elbow at the point where the elbow meets the trough measuring 5cm (centimeters) x 2 cm. During her am (morning) shower resident c/o (complaint of) L (left) arm pain to CNA (certified nurse's aide). Nurse examined arm, at that time no bruising or swelling present. Resident had no further complaints during passive ROM (range of motion) to arm or during residents a.m. care. (Physician) notified at 2 p.m. VO (verbal order) received to have the L forearm elbow and humerus. (Mobile imaging company) notified. POA (power of attorney) contacted. He was out with activities. Message was left for him to return call." A review of the clinical record revealed the following documentation, in part, from the mobile imaging company: "Impression: 1. Recent acute (sudden) fracture (break) distal (away from the point of attachment) left humerus (the long bone in the arm between the shoulder and elbow)." Further review of the clinical record revealed a progress note dated, December 18, 2014 completed by the orthopedic physician. The following documentation was provided, in part: "I obtained x-rays of her left arm and shows that she has a left supracondylar fracture (a bone break slightly above the elbow) of her humerus. I recommended that we treat her in a splint and let this heal." On 3/25/15 at 9:10 a.m. an interview was conducted with OSM (other staff member) #6, the therapy program director. OSM #6 was asked about the purpose of a trough on a wheelchair. OSM #6 responded, "The trough provides positioning for someone with lack of control of an upper extremity." OSM #6 was asked specifically about the use of the trough for Resident #1, OSM #6 responded, "She (Resident #1) has left sided neglect related to her stroke. She would often just leave her arm dangling and wouldn't realize where it was in relationship to the rest of her body. The trough would help her maintain a safe positioning of her left arm." OSM #6 was asked how the trough is applied to or removed from the arm of the wheelchair. OSM #6 stated, "The trough just slides along the chair arm. It is padded all around the edges with thick black foam; we usually put extra padding to make it more comfortable for the residents." OSM #6 was asked about staff education for the use of the trough prior to the injury, OSM #6 stated he would have to research and talk to the occupational therapist to determine what education was done prior to the accident. On 3/25/15/ at 11:30 a.m. an interview was conducted with CNA #4. CNA #4 was asked whether or not she was the aide caring for Resident #1 when she sustained a fracture to her left arm. CNA #4 stated that she was. CNA #4 was asked to explain how the fracture occurred. CNA #4 responded, "I had just finished providing her (Resident #1) her morning care and I was putting the trough back on her wheelchair. As I was pushing the trough on the wheelchair arm it hit her (Resident #1's) elbow. I went and told the nurse and she came and did an assessment and she (Resident #1) seemed fine. Later that morning when I was taking her to the bathroom and changing her shirt I noticed that her arm was swollen and bruised so I had the nurse come back and that's when we got the x-ray." CNA #4 was asked whether or not she had received training on the use of the assistive device, the trough. CNA #4 stated, "We received training after this incident on how to take it off and put it back on but I don't remember any training before that." On 3/25/15 at 1:50 p.m. CNA #4 was asked to demonstrate how she had applied the assistive device, the trough, to Resident #1's wheelchair. This demonstration was conducted in the therapy room in the presence of OSM #6, the therapy program director. CNA #4 demonstrated how she stood to the left side of the wheelchair and slid the trough from the back of the arm forward to place the trough on the arm. CNA #4 stated, "The trough was slick and would move quickly along the track and that's how it hit her (Resident #1) elbow." CNA #4 was able to demonstrate how the front of the trough slid along and hit the back of Resident #1's elbow as the trough slid along the track on the arm of the wheelchair. An interview was conducted with ASM (administrative staff member) #2, the DON (the director of nursing), on 3/25/15 at approximately 2:00 p.m. ASM #2 was asked to review the investigative report that was completed by ASM #2 on 12/18/14 and to explain the following entry in the investigation, "The Certified Nursing Assistant (name), was applying the left wheelchair arm trough onto wheelchair while resident was in the wheelchair as per proper procedure and accidentally hit resident's left elbow." ASM #2 responded, "This was an accident, the resident was seated in the wheelchair and the aide accidentally hit the resident's arm with the trough while putting the trough in place." ASM #2 was asked what was meant by "Per proper procedure." ASM #2 was unable to describe what was meant by this as the aide was not witnessed applying the trough, so ASM #2 was unable to determine what procedure was followed. ASM #2 was asked at this time what education had been provided to the aides in regards to the installation and removal of a trough from the wheelchair. ASM #2 was unable to indicate what education had been completed prior to the incident with Resident #1. ASM #2 requested time to do more research. On 3/25/15 at 2:40 p.m. an interview was conducted with OSM #5, the occupational therapist. OSM #5 was asked how long Resident #1 had had the trough in place on her wheelchair, OSM #5 responded, "I placed it on her wheelchair about a month after she arrived at the facility and she's been here close to two years." OSM #5 was asked what type of training the staff received regarding the application and removal of the trough from Resident #1's wheelchair. OSM #5 stated, "We did in-services on 5/15/14 and 5/16/14 that were about transfers and lifting her (Resident #1) but not specific to the trough. I don't remember an in-service regarding the use of the trough. I will continue to look." On 3/25/15 at approximately 6:30 p.m. ASM (administrative staff member) #1, the administrator, and ASM #2, the DON (director of nursing), were made aware of the concerns. A policy was requested at this time regarding the use of assistive devices and staff education. On 3/26/15 at approximately 9:30 a.m. OSM #5 the occupational therapist, provided a facility document dated 7/17/13 and titled "Caregiver training and instructions." The instructions documented, in part, the following: "Keep left hand in trough or on (L) (left) side." There were no other references to the trough in the instructions on how to safely install the trough onto the wheelchair or remove the trough from the wheelchair while the resident was seated in the wheelchair. OSM #5 provided a copy of the occupational therapy discharge summary for Resident #1 dated 7/23/13 which documented, in part, the following: "*See caregiver education/training sheet for details. Level of mobility (x) wheelchair - L arm trough." OSM #5 was asked to provide a copy of the order for the use of the trough. OSM #5 responded, "When a trough is recommended it is verbally communicated to staff and we typically write it in our notes. The trough for Resident #1 was initiated on 7/23/13. Training was done at that time for the staff on positioning and we would have mentioned the trough in relationship to positioning but not necessarily regarding installation and removal of the trough from the wheelchair." OSM #5 was asked what training was provided after the incident had occurred. OSM #5 responded, "We met with all the CNAs and we went over positioning and transfer of residents with a trough on their wheelchair. We talked about removing the trough and installation of the trough and that it was safer to remove the trough during transfer..." OSM #5 was asked whether or not there was a breakdown of the points taught during training, OSM #5 responded, "No, we just had them sign the sheet and we talked about the trough. The aides practiced putting the trough onto the wheelchair and taking it off." A review of the care plan dated 10/30/14 did not reveal any instructions regarding the use of the trough on Resident #1's wheelchair. A care plan for Resident #1 dated 10/30/14 for pain r/t (related to) osteoporosis, was reviewed and revealed nothing about the risk for fracture. No further information was provided prior to the end of the survey. * This information was obtained from: Assistive Technology: Principles and Applications for Communication, by Oliver Wendt, Raymond W. Quist, Lyle L. Lloyd, First edition 2011.