Every finding on record at The Laurels Of Bon Air

Based on staff interview and clinical record review, it was determined the facility staff failed to administer medications per the physician orders for three of five residents in the survey sample, Residents # 4, #5, and #2.The findings include:1. For Resident #4 (R4), the facility staff failed to administer Calcium Carbonate Chewable Tablets on two occasions in December 2025.The physician order dated, 3/22/2025, documented, Calcium Carbonate Chewable Tablets ( used to treat heartburn, upset stomach) (1) 500 MG (milligrams); Give 1 Tablet by mouth in the morning.The MAR (medication administration record) for December 2025, documented the above order. On 12/5/2025 and 12/26/2025, a blank was on the MAR where there should be documentation of the administration of the medication.An interview was conducted with LPN (licensed practical nurse #1, on 1/6/2026 at 4:45 p.m. LPN #1, LPN #1 stated a nurse evidence they've given medication by checking it off on the MAR. The above MAR was reviewed with LPN #1. LPN #1 stated if it's not documented it wasn't done.ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, and ASM #3, the clinical nurse consultant, were made aware of the above findings on 1/7/2026 at approximately 1:05 p.m.No further information was obtained prior to exit.1. This information was obtained from the following website: https://medlineplus.gov/druginfo/med s/a601032.html 2. For Resident #5 (R5), the facility staff failed to administer Ciprofloxacin (an antibiotic) (1) per the physician orders.The physician order dated, 12/18/2025, documented, Ciprofloxacin HCL (hydrochloride) 500 MG; Give 1 tablet by mouth every 12 hours for UTI (urinary tract infection) for 7 days.The December MAR documented the above order with a start date of 12/19/2025. On 12/19/2025 for the 9:00 a.m. dose and the 9:00 p.m. dose, the boxes were blank.Review of the list of medications in the emergency drug storage system documented the Ciprofloxacin in the emergency back up box.An interview was conducted with LPN (licensed practical nurse #1, on 1/6/2026 at 4:45 p.m. LPN #1, LPN #1 stated a nurse evidence they've given medication by checking it off on the MAR. The above MAR was reviewed with LPN #1. LPN #1 stated if it's not documented it wasn't done.ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, and ASM #3, the clinical nurse consultant, were made aware of the above findings on 1/7/2026 at approximately 1:05 p.m.No further information was obtained prior to exit.1. This information was obtained from the following website: https://medlineplus.gov/druginfo/meds /a688016.html 3. For Resident # 2 (R2) the facility staff failed to administer Lorazepam per the physician order.R2 was admitted to the facility on [DATE] for respite care.The physician order dated, 12/4/2025, documented, Lorazepam Oral Concentrate (used to treat anxiety and agitation) (1), 2 (two) MG/ML (milligrams per milliliter; Give 0.25 ml by mouth every 2 hours for anxiety.The December MAR documented the above order. For 12/4/2025, the medication was scheduled for 4:00 p.m., 6:00 p.m., 8:00 p.m. and 10:00 p.m. The nurse documented that she had given the medication as prescribed at those times. On 12/5/2025 at 4:00 a.m. and 6:00 a.m. doses, it was documented as administered.Review of the Narcotic sign out sheet, for the Lorazepam, documented the nurse only gave two doses on 12/4/2025 at 5:30 p.m. and 7:00p.m. There was no documentation that the medication had been administered at the other scheduled times. On 12/5/2025, it was documented on the narcotic sheet that the resident received the Lorazepam at 12:00 a.m., 2:00 a.m. and what appears to be 6:00 a.m. There is no documented dose at 4:00 a.m.The comprehensive care plan dated, 12/6/2026, documented Iin part, Need: (R2) is at risk for adverse reactions and side effects from antianxiety medications. Interventions: Administer anti-anxiety medications per orders.An interview was conducted with LPN #1 on 1/6/2026 at 4:45 p.m. LPN #1 stated the process to administer a narcotic it to take it out of the narcotic box, sign what you are giving in the narcotic sign out book and then document the dose on the MAR. ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, and ASM #3, the clinical nurse consultant, were made aware of the above findings on 1/7/2026 at approximately 1:05 p.m.No further information was obtained prior to exit.1. This information was obtained from the following website: https://medlineplus.gov/druginfo/med s/a682053.html.

Based on staff interview and clinical record review, it was determined the facility staff failed to maintain a complete and accurate clinical record for two of five residents in the survey sample, Residents #1 and #2.The findings include:1. For Resident #1 (R1), the facility staff failed to document the administration of narcotic medications on the medication administration record (MAR).The physician order dated 12/4/2025, documented, Morphine Sulfate Oral Solution (used to treat pain) (1) 100 MG/5ML (milligrams per 5 milliliters); Give 0.5 ml by mouth every 4 hours as needed for SOB (shortness of breath) or discomfort.The December MAR documented the above order. The MAR documented the medication was only administered on 12/5/2025 at 9:33 a.m.Review of the narcotic sign out sheet, that is not a part of the clinical record, documented the resident had received Morphine on 12/4/2025 at 5:00 p.m. and 9:00 p.m. and again on 12/5/25 at 9:00 a.m. Only the 12/5/2025 at 9:00 a.m. dose was documented in the clinical record.The physician order dated 12/4/2025 documented, Lorazepam Oral Tablet (used to treat anxiety and agitation) (2) 0.5 MG (milligram); Give 1 tablet by mouth every 4 hours as needed for anxiety, restlessness or agitation for 14 days.The December MAR documented the above order. The MAR failed to evidence any documentation that the medication had been administered.Review of the narcotic sign out sheet, that is not a part of the clinical record, documented the resident had received Lorazepam on 12/4/2025 at 5:00 p.m. and 9:00 p.m. and on 12/5/2025 at 1:00 a.m.An interview was conducted with LPN #1 on 1/6/2026 at 4:45 p.m. LPN #1 stated the process to administer a narcotic it to take it out of the narcotic box, sign what you are giving in the narcotic sign out book and then document the dose administered on the MAR. ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, and ASM #3, the clinical nurse consultant, were made aware of the above findings on 1/7/2026 at approximately 1:05 p.m.No further information was obtained prior to exit.1. This information was obtained from the following website: https://medlineplus.gov/druginfo/meds/a682133.html2. This information was obtained from the following website: https://medlineplus.gov/druginfo/med s/a682053.html.2. For Resident #2 that facility staff failed to document or documented when medications were given when not given.The physician order dated 12/4/2025 documented, Morphine Sulfate Solution 20 MG/ML (milligrams per milliliter); Give 0.5 ml by mouth every 2 hours for pain.The December MAR documented the above order. On 12/4/2025 it was documented the nurse administered the Morphine at 4:00 p.m., 8:00 p.m. and 10:00 p.m. Review of the narcotic sign off sheet, failed to evidence the nurse administered the medication at that time. The only Morphine administered was documented on the narcotic sign off sheet was on 12/4/2025 at 6:00 p.m. On 12/5/2025 at 6:00 a.m. and on 12/5/2025 at 2:00 a.m., it was documented that the Morphine was administered. Review of the narcotic sign off sheet, failed to evidence a dose being administered at 6:00 a.m. on 12/5/2025 or 2:00 a.m. on 12/6/2025. On 12/6/2025 at 2:00 a.m. it was documented on the MAR that the Morphine was given. Review of the narcotic sign off sheet failed to evidence documentation that the dose was administered. On 12/6/2025 at 6:00 a.m. the nurse documented on the MAR that the resident was sleeping and did not administer the dose at that time. Review of the MAR documented the nurse did indeed administer the dose at 6:00 a.m.The physician order dated 12/4/2025 documented, Lorazepam Oral Concentrate 2 MG/ML; Give 0.25 ml by mouth every 2 hours for anxiety.The December MAR documented the above order. On 12/6/2025 at 2:00 a.m. the nurse signed off the administration of the Lorazepam. Review of the narcotic sign off sheet failed to evidence the administration of the Lorazepam at 2:00 a.m. On 12/6/2025 at 6:00 a.m. the nurse documented the resident was sleeping and did not administer the medication. Review of the narcotic sign off sheet documented the nurse did give the medication at 6:00 a.m.An interview was conducted with LPN #1 on 1/6/2026 at 4:45 p.m. LPN #1 stated the process to administer a narcotic it to take it out of the narcotic box, sign what you are giving in the narcotic sign out book and then document the dose administered on the MAR. ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, and ASM #3, the clinical nurse consultant, were made aware of the above findings on 1/7/2026 at approximately 1:05 p.m.No further information was obtained prior to exit.

Based on staff interview, facility document review, and clinical record review, the facility staff failed to provide care and services to maintain residents' high level of well-being for three of 14 residents in the survey sample, Residents #4, #11, and #9. The findings include: 1. For Resident #4 (R4), the facility staff failed to verify and transcribe physician's orders in a timely manner upon admission. This resulted in a failure to initiate ceftriaxone (an antibiotic), insulin (used to treat diabetes), and blood sugar monitoring in a timely manner. A review of R4's clinical record revealed the resident was admitted to the facility on [DATE] at 5:14 p.m., with diagnoses that included but were not limited to bacterial meningitis and diabetes. A review of R4's hospital discharge medication list dated 11/18/24 revealed the following orders: -ceftriaxone 2 g (grams) IV (intravenous) every 12 hours through 11/23/24. -insulin glargine (used to treat diabetes) 100 units/ml- inject 8 units into the skin nightly. -insulin lispro (used to treat diabetes) 100 units/ml- inject 0-4 units into the skin four times daily (before meals and nightly). A review of facility physician's orders revealed the following orders: 11/19/24 ceftriaxone 2 g IV every 12 hours. 11/19/24 insulin glargine 100 units/ml- eight units at bedtime. 11/20/24 accuchecks (blood sugar checks) before meals and at bedtime. A review of R4's November 2024 MAR (medication administration record) revealed the resident did not receive ceftriaxone, insulin, or blood sugar monitoring. A nurse's note dated 11/20/24 at 9:47 p.m. documented, Patient husband approached RN (registered nurse) and stated that his wife (patient) had not been given her antibiotic during dayshift. Husband was concerned and stated 'She seems different today and I think its [sic] because of her infection and not receiving the antibiotic.' This RN investigated and found that patient had not been given her morning dose as it was rescheduled. Patient assessed and VSS (vital signs stable), but patient was very confused, notable to be reoriented and unable to follow directions. This RN spoke with husband and husband stated 'I want her to get her antibiotic and then we will see how she dose [sic]. Pm dose given at 7pm and family educated. Husband stated 'I don't feel comfortable with her staying here. Im [sic] so worried about her. I want her to go to (name of hospital) Ed. Provider notified at 8pm after speaking with husband. EMS (Emergency Medical Services) arrived at 2030 (8:30 p.m.) and patient and husband left unit at 2100 (9:00 p.m.). A note signed by the nurse practitioner on 11/19/24 at 11:59 p.m. documented, #Assessment and Plan# DM2 (type two diabetes) FBG (fasting blood glucose [blood sugar check]) not recorded in patient chart. per MAR patient has not received ordered insulin. accuchecks (blood sugar checks) AC/HS (before meals and at night). discharged on glargine 8u (units) sc (subcutaneous) qHS (every night). SSI (sliding scale insulin) orders incomplete thus not transcribed. monitor FBG as ordered and add SSI if warranted. A note signed by the physician on 11/20/24 documented, Discussed at clinical mtg this am- did not receive ceftriaxone- order not entered initially, then when entered not here from pharmacy. Discussed w/admin, nurse and UM. We have 1 gr in stock but not 2 gr- can order for future- was established that I should have been called re issue. On 12/19/24 at 9:15 a.m., LPN (licensed practical nurse) #1, a unit manager, was interviewed. She stated the admitting nurse needs to make sure the medication list provided from the hospital is actually the discharge medications (not a home medication list). She stated the nurse should call the provider for the purpose of reconciling the medications, and to make certain that the facility provider wants all the medications on the discharge list. She stated the facility nurses enter the medication orders in the computer, and the provider reviews the orders the next day. She stated sometimes the admitting nurses are extremely busy and cannot reach the provider right away. She stated any order clarifications are listed in a book which the provider reviews on their next visit. She stated medication reconciliation with the facility provider should happen as soon as the resident gets to the building. On 12/19/24 at 11:59 a.m., ASM (administrative staff member) #3, an attending physician, was interviewed. She stated when a resident is admitted , a facility nurse is responsible for entering the orders into the facility's electronic medical record software. She stated a second nurse (the unit manager or someone else) is responsible for reviewing the orders for accuracy. She stated the facility nurses use the discharge medication list sent with each resident from the hospital. She stated the facility nurses do not call her to verify orders for each resident prior to entering them into the computer and implementing them. She stated she is in the facility Mondays, Wednesdays, and Fridays to see residents, and she reviews medications and signs the orders at that time. She stated it is not a standard for the facility nurses to call her for the purpose of reconciling medications on admission. She stated she was not aware R4 did not receive ceftriaxone until after the resident was discharged , she was not aware R4 did not receive insulin glargine, and anyone receiving insulin should have his or her blood sugar monitored at least twice a day. On 12/20/24 at approximately 9:00 a.m., ASM #1, the administrator, ASM #2, the interim director of nursing, and ASM #5, the regional director of clinical services, were informed of these concerns. The facility policy titled, Physician's Order documented, Physician orders are obtained to provide a clear direction in the care of the resident .A physician or state permitted health care professional must write orders on a Physician Order Sheet and/or prescription pad. If the facility is using an electronic medical record the order will be entered into the EMR (electronic medical record) system .Once the order is verified, the receiving nurse documents the word 'noted' next to the order along with his or her signature, title, and the date the order is noted at the bottom of the interim order sheet as applicable in the facility. Immediately after noting an order, the receiving nurse transcribes it in permanent ink on the MAR . The facility policy titled, Diabetic Management documented, Upon admission the interdisciplinary team evaluates the diabetic resident and implements a plan of care to ensure: Orders are received and are accurate related to blood glucose monitoring and anti-diabetic agents. Blood glucose orders should include parameters to follow and when to notify the physician. No additional information was provided prior to exit. 32642 2. For Resident #11 (R11), the facility failed to initiate Coumadin (a blood thinner) in a timely manner. A review of R11's clinical record revealed she was admitted to the facility on [DATE] at 5:33 p.m. R11's admitting diagnoses included a history of a heart valve replacement and atrial fibrillation (1). A review of R11's hospital discharge records revealed the following as part of a list of the resident's discharge medications: Warfarin (Coumadin) 5 mg (milligram) tab (tablet) .Daily dosage based on INR (2). A review of R11's provider's orders revealed no order for R11's Coumadin until 12/15/24, a delay of approximately 48 hours since the resident's previous dose. On 12/19/24 at 11:59 a.m., ASM (administrative staff member) #3, an attending physician, was interviewed. She stated when a resident is admitted , a facility nurse is responsible for entering the orders into the facility's electronic medical record software. She stated a second nurse (the unit manager or someone else) is responsible for reviewing the orders for accuracy. She stated the facility nurses use the discharge medication list sent with each resident from the hospital. She stated the facility nurses do not call her to verify orders for each resident prior to entering them into the computer and implementing them. She stated she is in the facility Mondays, Wednesdays, and Fridays to see residents, and she reviews medications and signs the orders at that time. She stated it is not a standard for the facility nurses to call her for the purpose of reconciling medications on admission. She stated she was aware that R11 was admitted on Friday, 12/13/24, but did not receive orders for Coumadin until 12/15/24. She stated this resident had just had heart surgery, and that without the daily Coumadin, the resident was at high risk of developing a blood clot. On 12/20/24 at 9:00 a.m., ASM #1, the administrator, ASM #2, the interim director of nursing, and ASM #5, the regional director of clinical services, were informed of these concerns. No additional information was provided prior to exit. References (1) Atrial fibrillation is one of the most common types of arrhythmias, which are irregular heart rhythms. Atrial fibrillation causes your heart to beat much faster than normal. Also, your heart's upper and lower chambers do not work together as they should. When this happens, the lower chambers do not fill completely or pump enough blood to your lungs and body. This can make you feel tired or dizzy, or you may notice heart palpitations or chest pain. Blood also pools in your heart, which increases your risk of forming clots and can leads to strokes or other complications. Atrial fibrillation can also occur without any signs or symptoms. Untreated fibrillation can lead to serious and even life-threatening complications. This information is taken from the website https://www.nhlbi.nih.gov/health-topics/atrial-fibrillation. (2) Prothrombin time (PT) and the associated international normalized ratio (INR) are routinely tested to assess the risk of bleeding or thrombosis and to monitor response to anticoagulant therapy in patients. This information is taken from the National Institutes of Health website https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5569083/. 3. For Resident #9 (R9), the facility staff failed to initiate the monitoring of blood glucose or administration of insulin in a timely manner. A review of R9's clinical record revealed she was admitted [DATE] at 5:17 p.m. The resident was admitted with a diagnosis of diabetes. A review of R11's hospital discharge records revealed an order for short acting insulin to be given on a sliding scale, according to blood glucose monitoring levels. A review of R11's provider's orders revealed no order for R9's glucose monitoring or insulin administration until 12/15/24 at 7:30 a.m. On 12/19/24 at 9:15 a.m., LPN (licensed practical nurse) #1, a unit manager, was interviewed. She stated the admitting nurse needs to make sure the medication list provided from the hospital is actually the discharge medications (not a home medication list). She stated the nurse should call the provider for the purpose of reconciling the medications, and to make certain that the facility provider wants all the medications on the discharge list. She stated the facility nurses enter the medication orders in the computer, and the provider reviews the orders the next day. She stated sometimes the admitting nurses are extremely busy and cannot reach the provider right away. She stated any order clarifications are listed in a book which the provider reviews on their next visit. She stated medication reconciliation with the facility provider should happen as soon as the resident gets to the building. On 12/19/24 at 11:59 a.m., ASM (administrative staff member) #3, an attending physician, was interviewed. She stated when a resident is admitted , a facility nurse is responsible for entering the orders into the facility's electronic medical record software. She stated a second nurse (the unit manager or someone else) is responsible for reviewing the orders for accuracy. She stated the facility nurses use the discharge medication list sent with each resident from the hospital. She stated the facility nurses do not call her to verify orders for each resident prior to entering them into the computer and implementing them. She stated she is in the facility Mondays, Wednesdays, and Fridays to see residents, and she reviews medications and signs the orders at that time. She stated it is not a standard for the facility nurses to call her for the purpose of reconciling medications on admission. She stated if a resident has been getting insulin in the hospital, they should have blood glucose levels checked at least twice a day, and as much as four times a day, depending on the resident's condition. No additional information was provided prior to exit.

Based on staff interview, facility document review, and clinical record review, the facility staff failed to obtain a physician-order laboratory test for one of 14 residents in the survey sample, Resident #12. The findings include: For Resident #12 (R12), the facility staff failed to perform a PT/INR (1) blood test on 12/12/24. A review of R12's clinical record revealed she was admitted to the facility on [DATE] at 5:33 p.m. R11's admitting diagnoses included a history of a heart valve replacement and atrial fibrillation (2). A review of R12's hospital discharge records revealed the following as part of a list of the resident's discharge medications: Warfarin (Coumadin, a blood thinner) 5 mg (milligram) tab (tablet) .Daily dosage based on INR. A review of R12's provider's orders revealed the following order dated 12/2/24: PT/INR one time only for anticoagulant monitoring .Start dated 12/12/24. Further review of R12's clinical record failed to reveal evidence that the laboratory test was completed on 12/12/24. On 12/20/24 at 8:38 a.m., LPN (licensed practical nurse) #1, a unit manager, was interviewed. She stated night shift nurses check to make sure laboratory orders have been entered correctly by the day and evening nurses, based on interactions with providers. She stated each morning, she does a secondary check to make sure all of the lab tests have been completed. She added: I am the last check. She stated on the date R12's PT/INR was due, circumstances prevented her from checking to make sure it had been completed as ordered. She stated the lab was not done as originally ordered by the provider. On 12/20/24 at 9:00 a.m., ASM #1, the administrator, ASM #2, the interim director of nursing, and ASM #5, the regional director of clinical services, were informed of these concerns. A review of the facility policy, Anticoagulant Therapy, revealed, in part: Confirm with the physician the desired INR and/or PT testing schedule and therapeutic range .Initiate and order anticoagulant therapy labs per physician's order. No additional information was provided prior to exit. REFERENCE (1) Prothrombin time (PT) and the associated international normalized ratio (INR) are routinely tested to assess the risk of bleeding or thrombosis and to monitor response to anticoagulant therapy in patients. This information is taken from the National Institutes of Health website https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5569083/. (2) Atrial fibrillation is one of the most common types of arrhythmias, which are irregular heart rhythms. Atrial fibrillation causes your heart to beat much faster than normal. Also, your heart's upper and lower chambers do not work together as they should. When this happens, the lower chambers do not fill completely or pump enough blood to your lungs and body. This can make you feel tired or dizzy, or you may notice heart palpitations or chest pain. Blood also pools in your heart, which increases your risk of forming clots and can leads to strokes or other complications. Atrial fibrillation can also occur without any signs or symptoms. Untreated fibrillation can lead to serious and even life-threatening complications. This information is taken from the website https://www.nhlbi.nih.gov/health-topics/atrial-fibrillation.

Based on observation, staff interview, clinical record review and facility document review, it was determined that the facility staff failed to develop and/or implement the comprehensive care plan for four of 43 residents; Residents #97, #22, #19, and #86. The findings include: 1. For Resident #97, the facility staff failed to implement the comprehensive care plan related to the Foley catheter. A review of the comprehensive care plan revealed one dated 2/12/24 for (Resident #97) is at risk for urinary tract infection and catheter-related trauma: has Indwelling Catheter 16F r/t (related to) chronic obstructive uropathy. This care plan included the intervention, dated 2/13/24 for Ensure the drainage bag is secured properly with a dignity cover in place. On 6/25/24 at 10:21 AM, Resident #97 was observed in her room up in the wheelchair. The Foley catheter bag was hanging under the wheelchair, with the bag mostly laying on the floor. On 6/25/24 at 10:32 AM Resident #97 was observed sitting in the doorway just outside of her room asking a staff member for water. The Foley bag was still noted to be dragging the floor. The staff member did not address the Foley bag on the floor. On 6/25/24 at 10:37 AM, Resident #97 was back in her room. Upon passing by the resident's room, it was noted that the resident was sitting in her wheelchair approximately three quarters of the way to the opposite side of the room from the door, with the Foley catheter bag laying on the floor several feet behind her wheelchair, with the tubing fully stretched from the bag to the resident. On 6/27/24 at 9:28 AM, an interview was conducted with LPN #5 (Licensed Practical Nurse). She stated that the Foley bag should not be on the floor. She stated that risks would include urinary tract infections and urethral trauma. When asked if the care plan intervention to ensure the drainage bag was secured properly was being followed, she stated that it was not. On 6/27/24 at 10:18 AM an interview was conducted with LPN #7. She stated that the resident likes to have the tubing in her pant leg and that makes it difficult to keep the Foley off the floor. She stated that it should be hung higher up on the wheelchair to keep it off the floor. When asked if the care plan intervention to ensure the drainage bag was secured properly was being followed, she stated that it was not. The facility policy, Care Planning documented, Every resident in the facility will have a person-centered Plan of Care developed and implemented that is consistent with the resident rights, based on the comprehensive assessment that includes measurable objectives and time frames to meet a residents medical, nuring, and mental and psychosocial needs . On 6/27/24 at 12:10 PM, ASM #1 (Administrative Staff Member) the Administrator, ASM #2 the Director of Nursing, and ASM #3, the Regional Clinical Coordinator, were made aware of the findings. No further information was provided by the end of the survey. 2. For Resident #22, the facility staff failed to implement the comprehensive care plan to monitor for the use of an anticoagulant medication; and failed to implement the comprehensive care plan to have a fall matt by the bed; and failed to develop a comprehensive care plan for the safety intervention of having the bed by the wall. A. Anticoagulant medication: A review of the clinical record revealed a physician's order dated 2/25/24 for Eliquis (1) Oral Tablet 2.5 MG (milligrams) (Apixaban) Give 1 tablet by mouth two times a day for a fib (atrial fibrillation). There were no orders for consistent (daily or every shift) monitoring of the use of this medication. A review of the MAR (Medication Administration Record) and TAR (Treatment Administration Record) for February through June, 2024, failed to reveal any evidence of this ongoing monitoring. On 6/27/24 at 11:18 AM an interview was conducted with LPN #7 (Licensed Practical Nurse). She stated that monitoring should be done daily and that it should be documented in the progress notes or on the MAR. She stated that risks of anticoagulant medication includes bleeding. When asked what signs of bleeding would she look for, she was not able to identify any. A review of the comprehensive care plan revealed one dated 11/23/22 for Administer medication as ordered. Observe for ineffectiveness and side effects. A second intervention dated 11/23/22 documented, (Resident #22) is at risk for abnormal bleeding/bruising r/t (related to) Medication use: -Anticoagulant. Dx (diagnosis) A Fib. An intervention dated 11/23/22 documented, Observe and report to physician PRN (as needed) s/sx (signs and symptoms) of complications: blood tinged/frank blood in urine, black tarry stools, dark or bright red blood in stools, sudden severe headaches, nausea, vomiting, , diarrhea, muscle joint pain, lethargy, bruising , blurred vision, SOB (shortness of breath), Loss of appetite, sudden changes in mental status, significant or sudden changes in v/s (vital signs), bleeding gums, petechiae, back or abdominal pain and nosebleeds. The facility policy, Care Planning documented, Every resident in the facility will have a person-centered Plan of Care developed and implemented that is consistent with the resident rights, based on the comprehensive assessment that includes measurable objectives and time frames to meet a residents medical, nuring, and mental and psychosocial needs . On 6/27/24 at 12:10 PM, ASM #1 (Administrative Staff Member) the Administrator, ASM #2 the Director of Nursing, and ASM #3, the Regional Clinical Coordinator, were made aware of the findings. No further information was provided by the end of the survey. References: (1) Eliquis is used to help prevent strokes or blood clots in people who have atrial fibrillation and to prevent deep vein thrombosis and pulmonary embolism. Information obtained from https://medlineplus.gov/druginfo/meds/a613032.html B. Fall matt: A review of the physician's orders revealed one dated 4/29/23 for Fall mat to the right side of bed while guest is in bed. A review of the comprehensive care plan revealed one dated 11/22/22 for (Resident #22) is at risk for fall related injury and falls . An intervention dated 5/1/23 documented, Fall matt to right side of bed. On 6/24/24 at 12:42 PM and at 2:54 PM, 6/25/24 at 10:17 AM and on 6/27/24 at 9:13 AM, Resident #22 was observed in bed. There was no fall mat next to the right side of the bed per physician's order. On 6/27/24 at 10:18 AM an interview was conducted with LPN #7. She stated that the physician order and care plan for the fall mat was not being followed as required. The facility policy, Care Planning documented, Every resident in the facility will have a person-centered Plan of Care developed and implemented that is consistent with the resident rights, based on the comprehensive assessment that includes measurable objectives and time frames to meet a residents medical, nuring, and mental and psychosocial needs . On 6/27/24 at 12:10 PM, ASM #1 (Administrative Staff Member) the Administrator, ASM #2 the Director of Nursing, and ASM #3, the Regional Clinical Coordinator, were made aware of the findings. No further information was provided by the end of the survey. C. Bed by the wall: A review of the clinical record revealed a Physical Device Evaluation dated 12/18/22. This evaluation documented that the type of safety device to be used was Bed against the wall and the reason was for Safety awareness. A review of the Siderail Informed Consent dated 12222 (incorrect date format which made it difficult to determine what was the intended date) documented, Bed against (the wall) Left side of the bed. No rails. On 6/24/24 at 12:42 PM and at 2:54 PM, 6/25/24 at 10:17 AM and on 6/27/24 at 9:13 AM, Resident #22 was observed in bed. The bed was noted to be approximately 12 to 18 inches away from the wall on the left side. The bed was not against the wall, per the facility's individualized assessment to implement this safety measure for Resident #22. A review of the comprehensive care plan, including cancelled and resolved items, failed to reveal any evidence of the assessed need of the bed against the wall being care planned. On 6/27/24 at 10:18 AM an interview was conducted with LPN #7. She stated that having the bed against the wall helps prevent the resident from rolling out of the bed and that it should be care planned. She stated that this facility-assessed safety measure was not being implemented. She stated that staff were told not to put any beds against the walls. Further review of the clinical record failed to reveal any evidence of an updated Physical Device Evaluation and informed consent, or any nurse's notes, indicating that Resident #22 was individually evaluated to determine that the safety measure of having the bed against the wall was no longer required. On 6/27/24 at 12:10 PM, ASM #1 (Administrative Staff Member) the Administrator, ASM #2 the Director of Nursing, and ASM #3, the Regional Clinical Coordinator, were made aware of the findings. On 6/27/24 at approximately 12:45 ASM #2 stated that the facility removed the intervention from all residents for the bed against the wall, and that the care plans were updated to remove this. She stated that she didn't think about updating the siderail assessments and consents to reflect this change or to document in nurse's notes to reflect that the beds were to no longer be against the wall. As there was no updated individualized reassessment of Resident #22 to determine if she no longer required having the bed against the wall, this remained a concern that facility assessed intervention was not being implemented and care planned. 3. For Resident #19, facility staff failed to implement the comprehensive care plan to maintain the bed against the wall. On 6/24/24 at 12:48 PM, 6/25/24 at 10:30 AM and 6/27/24 at 9:22 AM, Resident #19 was noted in bed asleep with quarter length sized siderails on both sides of the bed in the upright position. The bed was noted approximately one foot from the wall one side. A review of the Physical Device Evaluation dated 7/19/22 documented, Bed Against the wall. A review of the Siderail Informed Consent dated 7/19/22 documented, Bed by the wall. A review of the comprehensive care plan revealed one dated 1/22/20 for (Resident #19) is at risk for fall related injury and falls . This care plan incldued an intervention dated 4/13/21 for May have one side of bed against wall. The facility policy, Care Planning documented, Every resident in the facility will have a person-centered Plan of Care developed and implemented that is consistent with the resident rights, based on the comprehensive assessment that includes measurable objectives and time frames to meet a residents medical, nuring, and mental and psychosocial needs . On 6/27/24 at 12:10 PM, ASM #1 (Administrative Staff Member) the Administrator, ASM #2 the Director of Nursing, and ASM #3, the Regional Clinical Coordinator, were made aware of the findings. No further information was provided by the end of the survey. On 6/27/24 at approximately 12:45 ASM #2 stated that the facility removed the intervention from all residents for the bed against the wall, and that the care plans were updated to remove this. She stated that she didn't think about updating the siderail assessments and consents to reflect this change or to document in nurse's notes to reflect that the beds were to no longer be against the wall. As there was no updated individualized reassessment of Resident #19 to determine if she no longer required having the bed against the wall, and this intervention remained on the care plan, this remained a concern that facility assessed intervention was not being implemented as care planned. 4. For Resident #86, the facility staff failed to implement the comprehensive care plan to Discuss and record with resident and family, the risks and benefits of bilateral enabler bar use. On 6/25/24 at 10:16 AM, 6/27/24 at 9:08 AM and on 6/27/24 at 9:13 AM, Resident #86 was observed in bed with bilateral quarter length side rails up. A review of the comprehensive care plan revealed one dated 5/4/23 for (Resident #86) is at risk for complications due to they require the use of bilateral enabler bars, does not restrict movement, guest has impaired mobility. This care plan include an intervention dated 5/4/23 for Discuss and record with resident and family, the risks and benefits of bilateral enabler bar use. A review of the clinical record revealed a Siderail Informed Consent dated 12/15/22 that documented, Has no rails at this time. Further review failed to reveal an assessment for the use of the siderails that were observed, and an updated informed consent for the use of the siderails. In addition, there was no evidence that the care planned intervention to Discuss and record with resident and family, the risks and benefits of bilateral enabler bar (side rail) use. was followed, as there was no updated reassessment and consent for the use of the side rails. The facility policy, Care Planning documented, Every resident in the facility will have a person-centered Plan of Care developed and implemented that is consistent with the resident rights, based on the comprehensive assessment that includes measurable objectives and time frames to meet a residents medical, nuring, and mental and psychosocial needs . On 6/27/24 at 12:10 PM, ASM #1 (Administrative Staff Member) the Administrator, ASM #2 the Director of Nursing, and ASM #3, the Regional Clinical Coordinator, were made aware of the findings. No further information was provided by the end of the survey.

Based on staff interview, clinical record review and facility document review, it was determined that the facility staff failed to ensure that one of 43 residents was free of unnecessary medication; Resident #22. The findings include: For Resident #22, the facility staff failed to evidence that consistent ongoing monitoring for the use of an anticoagulant medication was conducted. A review of the clinical record revealed a physician's order dated 2/25/24 for Eliquis (1) Oral Tablet 2.5 MG (milligrams) (Apixaban) Give 1 tablet by mouth two times a day for a fib (atrial fibrillation). There were no orders for consistent (daily or every shift) monitoring of the use of this medication. A review of the comprehensive care plan revealed one dated 11/23/22 for Administer medication as ordered. Observe for ineffectiveness and side effects. A second intervention dated 11/23/22 documented, (Resident #22) is at risk for abnormal bleeding/bruising r/t (related to) Medication use: -Anticoagulant. Dx (diagnosis) A Fib. An intervention dated 11/23/22 documented, Observe and report to physician PRN (as needed) s/sx (signs and symptoms) of complications: blood tinged/frank blood in urine, black tarry stools, dark or bright red blood in stools, sudden severe headaches, nausea, vomiting, , diarrhea, muscle joint pain, lethargy, bruising , blurred vision, SOB (shortness of breath), Loss of appetite, sudden changes in mental status, significant or sudden changes in v/s (vital signs), bleeding gums, petechiae, back or abdominal pain and nosebleeds. A review of the MAR (Medication Administration Record) and TAR (Treatment Administration Record) for February through June, 2024, failed to reveal any evidence of this ongoing monitoring, from the date of the order (2/25/24) through the date of the survey (6/27/24). On 6/27/24 at 11:18 AM an interview was conducted with LPN #7 (Licensed Practical Nurse). She stated that monitoring should be done daily and that it should be documented in the progress notes or on the MAR. She stated that risks of anticoagulant medication includes bleeding. When asked what signs of bleeding would she look for, she was not able to identify any. The facility policy, Anticoagulant Therapy documented, .5. Throughout anticoagulant therapy monitor the resident for signs and symptoms of bleeding. If signs and symptoms of bleeding are noted, hold anticoagulant medication and notify physician immediately On 6/27/24 at 12:10 PM, ASM #1 (Administrative Staff Member) the Administrator, ASM #2 the Director of Nursing, and ASM #3, the Regional Clinical Coordinator, were made aware of the findings. No further information was provided by the end of the survey. References: (1) Eliquis is used to help prevent strokes or blood clots in people who have atrial fibrillation and to prevent deep vein thrombosis and pulmonary embolism. Information obtained from https://medlineplus.gov/druginfo/meds/a613032.html

Based on clinical record review, staff interview and facility document review it was determined that the facility staff failed to ensure that pharmacy recommendations were reviewed and implemented in a timely manner for three of 43 residents in the survey sample, Resident #26, Resident #75 and Resident #29. The findings include: 1. For Resident #26 (R26), the facility staff failed to ensure pharmacy recommendations were reviewed and implemented as needed for the 9/2/2023, 11/3/2023 and 12/5/2023 monthly medication regimen reviews. A review of the monthly pharmacy medication regimen reviews for R26 documented monthly consultations documented in progress notes. The progress notes dated 9/2/2023, 11/3/2023 and 12/5/2023 all documented .See report for any noted irregularities and/or recommendations . On 6/26/2024 at approximately 10:27 a.m., a request was made to ASM (administrative staff member) #1, the administrator for evidence of the pharmacy recommendations with physician and/or facility response for the dates listed above. On 6/26/2024 at approximately 2:25 p.m., ASM #2, the director of nursing provided documentation for additional dates requested and stated that was what she had to provide. The documents provided failed to evidence the recommendations on the dates listed above. On 6/27/2024 at 9:27 a.m., an interview was conducted with ASM #2, the director of nursing. ASM #2 stated that the pharmacist completed the reviews monthly and emailed them to her and the unit manager. She stated that after they printed them out, she and the unit manager worked together to get them completed and then after completion they should be scanned into the medical record. She stated that there were ones that were missing and she could not say with certainty whether or not they had been reviewed. She stated that the purpose of monthly reviews was for the pharmacy to monitor the medications for their appropriateness for the guest and to make sure that monitoring was in place. The facility policy Timeliness of Medication Regimen Review (MRR) Reports dated 9/7/2023, documented in part, .3. The consultant will provide monthly MRR reports addressed to the Medical Director, Director of Nursing and Attending Physician within 3-5 days of completion via secure e-mail or hard copy. 4. The attending physician is expected to review the resident's individual MRR and document and sign the he/she has reviewed the pharmacist's identified recommendations within 14 days of receipt. 5. If the attending Physician does not respond to the resident's MRR report within 14 days, the Director of Nursing will notify the physician of pending MRR reports. 6. If by the 21st day, the attending physician has not yet responded to the resident's individual MRR report, the Director of Nursing will notify the Medical Director to review and respond to the pending MRR reports. 7. If the Medical Director is also the attending physician, the Director of Nursing will escalate the issue to the facility Administrator . On 6/27/2024 at approximately 12:01 p.m., ASM #1, the administrator, ASM #2, the director of nursing and ASM #3, the regional clinical coordinator were made aware of the findings. No further information was provided prior to exit. 2. For Resident #75 (R75), the facility staff failed to ensure pharmacy recommendations were reviewed and implemented as needed for the 9/3/2023, 11/3/2023 and 12/6/2023 monthly medication regimen reviews. A review of the monthly pharmacy medication regimen reviews for R75 documented monthly consultations documented in progress notes. The progress notes dated 9/3/2023, 11/3/2023 and 12/6/2023 all documented .See report for any noted irregularities and/or recommendations . On 6/26/2024 at approximately 10:27 a.m., a request was made to ASM (administrative staff member) #1, the administrator for evidence of the pharmacy recommendations with physician and/or facility response for the dates listed above. On 6/26/2024 at approximately 2:25 p.m., ASM #2, the director of nursing provided documentation for additional dates requested and stated that was what she had to provide. The documents provided failed to evidence the recommendations on the dates listed above. On 6/27/2024 at 9:27 a.m., an interview was conducted with ASM #2, the director of nursing. ASM #2 stated that the pharmacist completed the reviews monthly and emailed them to her and the unit manager. She stated that after they printed them out, she and the unit manager worked together to get them completed and then after completion they should be scanned into the medical record. She stated that there were ones that were missing and she could not say with certainty whether or not they had been reviewed. She stated that the purpose of monthly reviews was for the pharmacy to monitor the medications for their appropriateness for the guest and to make sure that monitoring was in place. On 6/27/2024 at approximately 12:01 p.m., ASM #1, the administrator, ASM #2, the director of nursing and ASM #3, the regional clinical coordinator were made aware of the findings. No further information was provided prior to exit. 3. For Resident #29 (R29), the facility staff failed to ensure pharmacy recommendations were reviewed and implemented as needed for the 7/7/2023, 8/4/2023, 9/4/2023, 11/4/2023, 1/8/2024, 2/5/2024, 3/7/2024 and 5/6/2024 monthly medication regimen reviews. A review of the monthly pharmacy medication regimen reviews for R29 documented monthly consultations documented in progress notes. The progress notes dated 7/7/2023, 8/4/2023, 9/4/2023, 11/4/2023, 1/8/2024, 2/5/2024, 3/7/2024 and 5/6/2024 all documented .See report for any noted irregularities and/or recommendations . On 6/26/2024 at approximately 11:29 a.m., a request was made to ASM (administrative staff member) #1, the administrator for evidence of the pharmacy recommendations with physician and/or facility response for the dates listed above. On 6/27/2024 at approximately 8:20 a.m., ASM #2, the director of nursing provided documentation for additional dates requested and stated that was what she had to provide. The documents provided failed to evidence the recommendations on the dates listed above. On 6/27/2024 at 9:27 a.m., an interview was conducted with ASM #2, the director of nursing. ASM #2 stated that the pharmacist completed the reviews monthly and emailed them to her and the unit manager. She stated that after they printed them out, she and the unit manager worked together to get them completed and then after completion they should be scanned into the medical record. She stated that there were ones that were missing and she was not sure if the ones for R29 had been reviewed. She stated that the purpose of monthly reviews was for the pharmacy to monitor the medications for their appropriateness for the guest and to make sure that monitoring was in place. On 6/27/2024 at approximately 12:01 p.m., ASM #1, the administrator, ASM #2, the director of nursing and ASM #3, the regional clinical coordinator were made aware of the findings. No further information was provided prior to exit.

Based on observation, staff interview, clinical record review and facility document review, it was determined that the facility staff failed to ensure that a current evaluation and consent, including risks and benefits, were in place prior to implementing side rails, for three of 43 residents in the survey sample; Residents #22, #19 and #86. The findings include: 1. For Resident #22, the facility staff failed to ensure that a side rail evaluation and consent, to include risks and benefits, that determined side rails were needed, was completed prior to implementing side rails. On 6/24/24 at 12:42 PM and at 2:54 PM, 6/25/24 at 10:17 AM and on 6/27/24 at 9:13 AM, Resident #22 was observed in bed. Quarter length sized side rails were observed on both sides of the bed in the upright position. A review of the clinical record revealed a Physical Device Evaluation dated 12/18/22. This document documented that the type of safety device to be used was Bed against the wall and the reason was for Safety awareness. The options for any type of side rails were not checked. A review of the Siderail Informed Consent dated 12222 (incorrect date format documented, which made it difficult to determine what was the intended date) documented, Bed against (the wall) Left side of the bed. No rails. None of the options for side rails were checked. Further review failed to reveal any updated evaluation and consent, including risks and benefits, to reflect the use of side rails was determined to be needed. A review of the comprehensive care plan failed to reveal any evidence that the use of the side rails was care planned. On 6/27/24 at 9:28 AM, an interview was conducted with LPN #5 (Licensed Practical Nurse). She stated that there should be a current evaluation and consent for the use of side rails. She stated that if an initial assessment determined side rails were not needed, and then later side rails were implemented, there should have been a reassessment and updated consent before implementing side rails. She stated that the use of side rails should be on the care plan. On 6/27/24 at 10:18 AM an interview was conducted with LPN #7. She also stated that there should be a current evaluation and consent for the use of side rails and that if an initial assessment determined side rails were not needed, and then later side rails were implemented, there should have been a reassessment and updated consent before implementing side rails. She stated that the use of side rails should be on the care plan. The facility policy, Restraint Management documented, 3. A Physical Device Evaluation will be completed prior to initiating a device by a licensed nurse or the interdisciplinary team 5. Any guest/resident using a physical restraint or side rails must have a current, signed restraint consent in the medical record. The facility will explain how the use of the restraint would treat the guest's/resident's medical symptoms and assist the guest/resident in attaining or maintaining his/her highest practicable level of physical and psychosocial well-being. In addition, the facility will explain the potential risks and benefits of that specific restraint in use by the guest/resident, and the least restrictive alternatives that have been attempted. If the responsible party/legal representative is not able to provide signed authorization for use of the restraint, telephone authorization will be documented until written consent is obtained 10. Any guest/resident using side rails will have a current order with the following components: Type of side rails (1/2, 3/4, full, assist bars); Number of side rails to be raised; Reason for use / medical symptom; Guest/resident request for use of side rails (if applicable) . On 6/27/24 at 12:10 PM, ASM #1 (Administrative Staff Member) the Administrator, ASM #2 the Director of Nursing, and ASM #3, the Regional Clinical Coordinator, were made aware of the findings. No further information was provided by the end of the survey. 2. For Resident #19, the facility staff failed to ensure that a side rail evaluation and consent, to include risks and benefits, that determined side rails were needed, was completed prior to implementing side rails. On 6/24/24 at 12:48 PM, 6/25/24 at 10:30 AM and 6/27/24 at 9:22 AM, Resident #19 was noted in bed asleep with quarter length sized side rails on both sides of the bed in the upright position. A review of the Physical Device Evaluation dated 7/19/22 documented, Bed Against the wall. None of the options for side rails were checked. A review of the Siderail Informed Consent dated 7/19/22 documented, Bed by the wall. None of the options for side rails were checked. Further review failed to reveal any updated evaluation and consent, including risks and benefits, to reflect the use of side rails was determined to be needed. A review of the comprehensive care plan failed to reveal any evidence that the use of the side rails was care planned. On 6/27/24 at 9:28 AM, an interview was conducted with LPN #5 (Licensed Practical Nurse). She stated that there should be a current evaluation and consent for the use of side rails. She stated that if an initial assessment determined side rails were not needed, and then later side rails were implemented, there should have been a reassessment and updated consent before implementing side rails. She stated that the use of side rails should be on the care plan. On 6/27/24 at 10:18 AM an interview was conducted with LPN #7. She also stated that there should be a current evaluation and consent for the use of side rails and that if an initial assessment determined side rails were not needed, and then later side rails were implemented, there should have been a reassessment and updated consent before implementing side rails. She stated that the use of side rails should be on the care plan. The facility policy, Restraint Management documented, 3. A Physical Device Evaluation will be completed prior to initiating a device by a licensed nurse or the interdisciplinary team 5. Any guest/resident using a physical restraint or side rails must have a current, signed restraint consent in the medical record. The facility will explain how the use of the restraint would treat the guest's/resident's medical symptoms and assist the guest/resident in attaining or maintaining his/her highest practicable level of physical and psychosocial well-being. In addition, the facility will explain the potential risks and benefits of that specific restraint in use by the guest/resident, and the least restrictive alternatives that have been attempted. If the responsible party/legal representative is not able to provide signed authorization for use of the restraint, telephone authorization will be documented until written consent is obtained 10. Any guest/resident using side rails will have a current order with the following components: Type of side rails (1/2, 3/4, full, assist bars); Number of side rails to be raised; Reason for use / medical symptom; Guest/resident request for use of side rails (if applicable) . On 6/27/24 at 12:10 PM, ASM #1 (Administrative Staff Member) the Administrator, ASM #2 the Director of Nursing, and ASM #3, the Regional Clinical Coordinator, were made aware of the findings. No further information was provided by the end of the survey. 3. For Resident #86, the facility staff failed to ensure that a side rail evaluation and consent, to include risks and benefits, that determined side rails were needed, was completed prior to implementing side rails. On 6/25/24 at 10:16 AM and on 6/27/24 at 9:08 AM, Resident #86 was observed in bed with bilateral quarter length side rails up. A review of the clinical record revealed a Siderail Informed Consent dated 12/15/22 that documented, Has no rails at this time. Further review failed to reveal an assessment for the use of the side rails that were observed, and an updated informed consent for the use of the side rails. A review of the comprehensive care plan revealed one dated 5/4/23 for (Resident #86) is at risk for complications due to they require the use of bilateral enabler bars, does not restrict movement, guest has impaired mobility. This care plan include an intervention dated 5/4/23 for Discuss and record with resident and family, the risks and benefits of bilateral enabler bar use. On 6/27/24 at 9:28 AM, an interview was conducted with LPN #5 (Licensed Practical Nurse). She stated that there should be a current evaluation and consent for the use of side rails. She stated that if an initial assessment determined side rails were not needed, and then later side rails were implemented, there should have been a reassessment and updated consent before implementing side rails. She stated that the care plan was not followed. On 6/27/24 at 10:18 AM an interview was conducted with LPN #7. She also stated that there should be a current evaluation and consent for the use of side rails and that if an initial assessment determined side rails were not needed, and then later side rails were implemented, there should have been a reassessment and updated consent before implementing side rails. She stated that the care plan was not followed. The facility policy, Restraint Management documented, 3. A Physical Device Evaluation will be completed prior to initiating a device by a licensed nurse or the interdisciplinary team 5. Any guest/resident using a physical restraint or side rails must have a current, signed restraint consent in the medical record. The facility will explain how the use of the restraint would treat the guest's/resident's medical symptoms and assist the guest/resident in attaining or maintaining his/her highest practicable level of physical and psychosocial well-being. In addition, the facility will explain the potential risks and benefits of that specific restraint in use by the guest/resident, and the least restrictive alternatives that have been attempted. If the responsible party/legal representative is not able to provide signed authorization for use of the restraint, telephone authorization will be documented until written consent is obtained 10. Any guest/resident using side rails will have a current order with the following components: Type of side rails (1/2, 3/4, full, assist bars); Number of side rails to be raised; Reason for use / medical symptom; Guest/resident request for use of side rails (if applicable) . On 6/27/24 at 12:10 PM, ASM #1 (Administrative Staff Member) the Administrator, ASM #2 the Director of Nursing, and ASM #3, the Regional Clinical Coordinator, were made aware of the findings. No further information was provided by the end of the survey.

Based on observation, resident interview, staff interview, facility document review, and clinical record review, the facility staff failed to provide respiratory care and services for one of 43 residents in the survey sample, Resident #76. The findings include: For Resident #76 (R76), the facility staff failed to administer oxygen at the physician prescribed rate of two liters per minute. A review of R76's clinical record revealed a Brief Interview for Mental Status assessment dated [DATE] that documented the resident was cognitively intact, scoring a 15 out of 15. Further review of R76's clinical record revealed a physician's order dated 6/24/24 for continuous oxygen at two liters per minute. On 6/24/24 at 3:13 p.m., R76 was observed receiving oxygen via nasal cannula at a rate between three and half and four liters per minute, as evidenced by the middle of the ball in the oxygen concentrator flowmeter positioned between the three and half and four-liter lines. On 6/25/24 at 10:46 a.m., R76 was observed receiving oxygen via nasal cannula at a rate between one and half and two liters per minute, as evidenced by the middle of the ball in the oxygen concentrator flowmeter positioned between the one and half and two-liter lines. R76 stated he doesn't know how to adjust his oxygen and he does not adjust his oxygen concentrator flowmeter. On 6/26/24 at 10:03 a.m., an interview was conducted with LPN (licensed practical nurse) #1. LPN #1 stated nurses administer oxygen per the physician's orders and should check the rate of oxygen any time they are in the resident's room. LPN #1 stated the middle of the ball in the oxygen concentrator flowmeter should be on the two-liter line if the physician's order is for two liters. On 6/26/24 at 2:47 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing) were made aware of the above concern. A facility policy regarding oxygen administration was not provided. The oxygen concentrator manufacturer's instructions documented, Note: To properly read the flowmeter, locate the prescribed flowrate line on the flowmeter. Next, turn the flow knob until the ball rises to the line. Now, center the ball on the L/min (liter per minute) line prescribed. No further information was presented prior to exit.

Based on staff interview, facility document review, and clinical record review, the facility staff failed to provide colostomy care and services for one of 43 residents in the survey sample, Resident #127. The findings include: For Resident #127 (R127), the facility staff failed to obtain physician's orders and provide care for the resident's colostomy (1). A review of R127's clinical record revealed a nurse's note dated 6/11/24 that documented the resident was admitted with a colostomy. A review of R127's June 2024 physician's orders failed to reveal any orders regarding the resident's colostomy. Further review of R127's clinical record (including the June 2024 treatment administration record and June 2024 nurses' notes) failed to reveal colostomy care was provided (except for a nurse's note dated 6/14/24 that documented the colostomy bag was intact and changed on 6/13/24, and a nurse's note dated 6/17/24 that documented the colostomy bag was intact and emptied once during that shift). On 6/26/24 at 10:03 a.m., an interview was conducted with LPN (licensed practical nurse) #1. LPN #1 stated there should be physician's orders for colostomy care so nurses know the care is done. LPN #1 stated the orders should consist of checking the colostomy stoma site daily, completing colostomy care every shift, and as needed, and when to change the colostomy wafer and bag. On 6/26/24 at 2:47 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing) were made aware of the above concern. A facility policy regarding colostomy care was not provided. The American Cancer Society documented, The skin around your stoma should always look the same as skin anywhere else on your abdomen. But ostomy output can make this skin tender or sore. Here are some ways to help keep your skin healthy: Use the right size pouch and skin barrier opening. An opening that's too small can cut or injure the stoma and may cause it to swell. If the opening is too large, output could get to and irritate the skin. In both cases, change the pouch or skin barrier and replace it with one that fits well. Change the pouching system regularly to avoid leaks and skin irritation. It's important to have a regular schedule for changing your pouch. Don't wait for leaks or other signs of problems, such as itching and burning. This information was obtained from the website: https://www.cancer.org/cancer/managing-cancer/treatment-types/surgery/ostomies/colostomy/management.html No further information was presented prior to exit. Reference: (1) A colostomy is an opening in the belly (abdominal wall) that's made during surgery. It's usually needed because a problem is causing the colon to not work properly, or a disease is affecting a part of the colon and it needs to be removed. The end of the colon (large intestine) is brought through this opening in the skin to form a stoma. This information was obtained from the website: https://www.cancer.org/cancer/managing-cancer/treatment-types/surgery/ostomies/colostomy/what-is-colostomy.html

Based on clinical record review, staff interview and facility document review, it was determined that the facility staff failed to maintain a complete and accurate medical record for 1 of 43 residents in the survey sample, Resident #323. The findings include: For Resident #323 (R323), the facility staff failed to maintain a complete and accurate medical record documenting the reason for transfer to the emergency roiagnom on [DATE]. Review of R323's progress notes revealed the following: - 4/4/2024 08:37 (8:37 a.m.) Nurses Notes. Note Text: Res. (resident) left via ambulance with emergency services, res. was alert at time of departure, res. POA (power of attorney) called and notified of res. transfer to hospital, res. POA to meet res. at hospital. - 4/4/2024 14:15 (2:15 p.m.) Nurses Notes. Note Text: Writer called [Name of hospital] and was notified that res. was admitted to ICU (intensive care unit). Review of clinical record failed to evidence documentation regarding a change in condition or the reason why R323 was transferred to the hospital on 4/4/2024. On 6/25/2024 at approximately 4:10 p.m., a request was made to ASM (administrative staff member) #1, the administrator for evidence of documentation for the reason why R323 was sent out to the emergency roiagnom on [DATE]. On 6/26/2024 at 9:39 a.m., ASM #2, the director of nursing stated that they did not have anything to provide to evidence why R323 was sent to the hospital. ASM #2 stated that the nurse who sent R323 out to the hospital no longer worked at the facility and could not be interviewed. On 6/26/2024 at 10:04 a.m., an interview was conducted with LPN (licensed practical nurse) #1. LPN #1 stated that when a resident was sent to the emergency room the nurse did an SBAR (situation, background, assessment, recommendation) assessment, a transfer to the hospital nurses note and a change in condition assessment which documented what was going on with the resident. She stated that if the nurses note did not detail what was going on with the resident there should be an assessment documenting what was happening to show why they sent them to the hospital. She stated that this was done for continuity of care for the other staff to know what happened to the resident. The facility policy Medical Records Management dated 3/1/2022 documented in part, . The facility must maintain medical records on each guest/resident, in accordance with accepted professional standards and practice and state and federal law. Medical records must be complete, accurately documented, readily accessible, systematically organized, and maintained in a safe and secure environment. This includes medical records that are kept in an Electronic Medical Record (EMR) format . A complete medical record contains an accurate and functional representation of the guest's/resident's actual experience in the facility . [NAME]-[NAME], Fundamentals of Nursing, 6th edition, [NAME] and [NAME]; page 480, was used as a reference regarding assessments and documentation. The record needs to describe exactly what happened to a client. Nurses need to indicate all assessments, interventions, client responses, instructions, and referrals in the medical record. On 6/27/2024 at approximately 4:30 p.m., ASM #1, the administrator, ASM #2, the director of nursing and ASM #3, the regional clinical coordinator were made aware of the findings. No further information was provided prior to exit.

Based on observation, staff interview, clinical record review and facility document review, it was determined that the facility staff failed to maintain a Foley catheter in a sanitary manner for one of 43 residents in the survey sample; Resident #97. The findings include: On 6/25/24 at 10:21 AM, Resident #97 was observed in her room up in the wheelchair. The Foley catheter bag was hanging under the wheelchair, with the bag mostly laying on the floor. On 6/25/24 at 10:32 AM Resident #97 was observed sitting in the doorway just outside of her room asking a staff member for water. The Foley bag was still noted to be dragging the floor. The staff member did not address the Foley bag on the floor. On 6/25/24 at 10:37 AM, Resident #97 was back in her room. Upon passing by the resident's room, it was noted that the resident was sitting in her wheelchair approximately three quarters of the way to the opposite side of the room from the door, with the Foley catheter bag laying on the floor several feet behind her wheelchair, with the tubing fully stretched from the bag to the resident. On 6/27/24 at 9:28 AM, an interview was conducted with LPN #5 (Licensed Practical Nurse). She stated that the Foley bag should not be on the floor. She stated that risks would include urinary tract infections and urethral trauma. On 6/27/24 at 10:18 AM an interview was conducted with LPN #7. She stated that the resident likes to have the tubing in her pant leg and that makes it difficult to keep the Foley off the floor. She stated that it should be hung higher up on the wheelchair to keep it off the floor. A review of the comprehensive care plan revealed one dated 2/12/24 for (Resident #97) is at risk for urinary tract infection and catheter-related trauma: has Indwelling Catheter 16F r/t (related to) chronic obstructive uropathy. This care plan included the intervention, dated 2/13/24 for Ensure the drainage bag is secured properly with a dignity cover in place. The facility policy, Catheter Associated Urinary Tract Infection Prevention documented, .9. Keep the collection bag and tubing off the floor . On 6/27/24 at 12:10 PM, ASM #1 (Administrative Staff Member) the Administrator, ASM #2 the Director of Nursing, and ASM #3, the Regional Clinical Coordinator, were made aware of the findings. No further information was provided by the end of the survey.

Based on observation, staff interview, facility document review, and clinical record review, the facility staff failed to provide a safe environment for three of 43 residents in the survey sample, Residents #56, #22, and #19. The findings include: 1. For Residents #56 (R56) and #123 (R123), the facility staff failed to store portable oxygen tanks safely in the residents' room. On 6/24/24 at 12:07 p.m. and 6/25/24 at 8:17 a.m., observations were made in the room shared by R56 and R123. Two freestanding portable oxygen tanks were observed along the wall. Neither tank was secured in a rolling cart or any other device. One tank measured 1000 psi (pounds per square inch) of oxygen; the second tank measured just under 1000 psi. On 6/26/24 at 9:10 a.m., LPN (licensed practical nurse) #3 was interviewed. She stated portable oxygen tanks should always be secured in a secure storage rack in the supply room, or on rolling carts if they are any other place in the facility. She stated portable tanks should never be unsecured at all. She stated: Anything could happen. It could fall over, or turn on, or possibly catch on fire. She stated this is a safety concern for residents. On 6/26/24 at 9:47 a.m., CNA (certified nursing assistant) #1 was interviewed. She stated a portable oxygen tank should be stored out of the way. She stated if a tank is empty, it should never be in a resident's room. She stated if the tank has any oxygen remaining in it, the tank should be secured either in a storage bag on the back of a resident's wheelchair, or in a rolling cart. On 6/26/24 at 2:44 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, and ASM #3, the regional clinical coordinator, were informed of these concerns. A review of the facility policy, Oxygen Storage and Assembly, revealed, in part: Oxygen Tank Safety .Secure each tank individually, by a chain, on a cart, or on a stand. No further information was provided prior to exit. 29125 2. For Resident #22, facility staff failed to implement the physician-ordered fall prevention of a fall mat; and failed to implement the facility assessed intervention of having the bed against the wall. A review of the physician's orders revealed one dated 4/29/23 for Fall mat to the right side of bed while guest is in bed. A review of the clinical record revealed a Physical Device Evaluation dated 12/18/22. This evaluation documented that the type of safety device to be used was Bed against the wall and the reason was for Safety awareness. A review of the Siderail Informed Consent dated 12222 (incorrect date format which made it difficult to determine what was the intended date) documented, Bed against (the wall) Left side of the bed. No rails. On 6/24/24 at 12:42 PM and at 2:54 PM, 6/25/24 at 10:17 AM and on 6/27/24 at 9:13 AM, Resident #22 was observed in bed. There was no fall mat next to the right side of the bed per physician's order. In addition, the bed was noted to be approximately 12 to 18 inches away from the wall on the left side. The bed was not against the wall, per the facility's individualized assessment to implement this safety measure for Resident #22. On 6/27/24 at 10:18 AM an interview was conducted with LPN #7. She stated that the physician order and care plan for the fall mat was not being followed as required. Regarding the bed against the wall, she stated that having the bed against the wall helps prevent the resident from rolling out of the bed. She stated that this facility-assessed safety measure was not being implemented. She stated that staff were told not to put any beds against the walls. Further review of the clinical record failed to reveal any evidence of an updated Physical Device Evaluation and informed consent, or any nurse's notes, indicating that Resident #22 was individually evaluated to determine that the safety measure of having the bed against the wall was no longer required. A review of the comprehensive care plan revealed one dated 11/22/22 for (Resident #22) is at risk for fall related injury and falls . An intervention dated 5/1/23 documented, Fall matt to right side of bed. Further review of the comprehensive care plan, including cancelled and resolved items, failed to reveal any evidence of the assessed need of the bed against the wall being care planned. On 6/27/24 at 12:10 PM, ASM #1 (Administrative Staff Member) the Administrator, ASM #2 the Director of Nursing, and ASM #3, the Regional Clinical Coordinator, were made aware of the findings. On 6/27/24 at approximately 12:45 ASM #2 stated that the facility removed the intervention from all residents for the bed against the wall, and that the care plans were updated to remove this. She stated that she didn't think about updating the siderail assessments and consents to reflect this change or to document in nurse's notes to reflect that the beds were to no longer be against the wall. As there was no updated individualized reassessment of Resident #22 to determine if she no longer required having the bed against the wall, this remained a concern that facility assessed intervention was not being implemented. The facility policy, Fall Management documented, Each resident is assisted in attaining/maintaining his or her highest practical level of function by providing the resident adequate supervision, assistive devices, and/or functional programs as appropriate to minimize the risk for falls. Residents will be evaluated by the interdisciplinary team for their risk for falls. A plan of care is developed and implemented based on this evaluation with ongoing review 1. The licensed nurse will evaluate residents for fall risk upon admission, re-admission, quarterly, annually and with a significant change in condition. 2. Residents identified at risk for falls will have an initial plan of care developed to meet each resident's needs. Interventions should be related to the risk factors as well as incorporating resident choice to help minimize the risk of a fall 3. For Resident #19, facility staff failed to maintain the bed against the wall per the comprehensive care plan and side rail evaluation and consent. A review of the Physical Device Evaluation dated 7/19/22 documented, Bed Against the wall. A review of the Siderail Informed Consent dated 7/19/22 documented, Bed by the wall. A review of the comprehensive care plan revealed one dated 1/22/20 for (Resident #19) is at risk for fall related injury and falls . This care plan included an intervention dated 4/13/21 for May have one side of bed against wall. On 6/24/24 at 12:48 PM, 6/25/24 at 10:30 AM and 6/27/24 at 9:22 AM, Resident #19 was noted in bed asleep. The bed was noted to be approximately 12 to 18 inches from the wall one side. The bed was not against the wall, per the facility's individualized assessment to implement this safety measure for Resident #19. On 6/27/24 at 10:18 AM an interview was conducted with LPN #7. She stated that having the bed against the wall helps prevent the resident from rolling out of the bed. She stated that the facility-assessed safety measure was not being implemented. She stated that staff were told not to put any beds against the walls. Further review of the clinical record failed to reveal any evidence of an updated Physical Device Evaluation and informed consent, or any nurse's notes, indicating that Resident #19 was individually evaluated to determine that the safety measure of having the bed against the wall was no longer required. On 6/27/24 at 12:10 PM, ASM #1 (Administrative Staff Member) the Administrator, ASM #2 the Director of Nursing, and ASM #3, the Regional Clinical Coordinator, were made aware of the findings. On 6/27/24 at approximately 12:45 ASM #2 stated that the facility removed the intervention from all residents for the bed against the wall, and that the care plans were updated to remove this. She stated that she didn't think about updating the siderail assessments and consents to reflect this change or to document in nurse's notes to reflect that the beds were to no longer be against the wall. As there was no updated individualized reassessment of Resident #19 to determine if she no longer required having the bed against the wall, this remained a concern that facility assessed intervention was not being implemented. The facility policy, Fall Management documented, Each resident is assisted in attaining/maintaining his or her highest practical level of function by providing the resident adequate supervision, assistive devices, and/or functional programs as appropriate to minimize the risk for falls. Residents will be evaluated by the interdisciplinary team for their risk for falls. A plan of care is developed and implemented based on this evaluation with ongoing review 1. The licensed nurse will evaluate residents for fall risk upon admission, re-admission, quarterly, annually and with a significant change in condition. 2. Residents identified at risk for falls will have an initial plan of care developed to meet each resident's needs. Interventions should be related to the risk factors as well as incorporating resident choice to help minimize the risk of a fall

Based on observation, family interview, facility document review, and clinical record review, the facility staff failed to provide foot care for one of 43 residents in the survey sample, Resident #27. The findings include: For Resident #27 (R27), the facility staff failed to trim the resident's toenails. On 6/24/24 at 1:07 p.m., R27 was observed sitting in a chair in his room. R27was unable to carry on a coherent conversation. R27's daughter was sitting in the room, and expressed concerns about the length of the resident's toenails. R27's daughter removed the shoe and sock from the resident's left foot. The resident's great toe, second toe, and third toenails all extended greater than one inch past the tip of the resident's toes. A review of R27's clinical record revealed no documentation of diagnoses of diabetes or other conditions that would indicate a lack of blood flow to the feet. This review also revealed no orders for foot care, and no documentation of offering for the resident to be sent out for a podiatry consultation. On 6/26/24 at 9:10 a.m., LPN (licensed practical nurse) #3 was interviewed. She stated CNAs are responsible for clipping toenails for residents who are not diabetic, and who do not have a condition contributing to vascular insufficiency in a resident's feet. She stated R27 is on the list to see the podiatrist, but is not sure how long it will be until the podiatrist comes to the facility to see resident. She stated: If his toenails are too long, he shouldn't have to wait. She stated she has not looked at R27's toenails. On 6/26/24 at 9:47 a.m., CNA (certified nursing assistant) #1 was interviewed. She stated she is not allowed to cut a resident's toenails. She stated she has not looked at R27's toenails recently. On 6/26/24 at 2:44 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, and ASM #3, the regional clinical coordinator, were informed of these concerns. On 6/26/24 at 3:10 p.m., ASM (administrative staff member) #2, the director of nursing was interviewed. She stated facility CNAs are not allowed to trim toenails. She further stated that nurses are allowed to trim toenails of nondiabetic residents if they feel comfortable doing so. She stated it is always an option for a resident to be sent out to a podiatrist if the need is urgent or requested. On 6/26/24 at 3:34 p.m., LPN #5 was interviewed. She stated she took care of R27 when he was initially admitted to the facility, but had not seen him in the past week or two. She stated she put the resident on the list to be seen by the podiatrist. She stated she was not sure how long it would be until the podiatrist comes to the facility. A review of the facility policy, Personal Hygiene, revealed, in part: Nail care .Nails should be kept neatly trimmed. No further information was provided prior to exit.

Based on observation, resident interview, staff interview, facility document review, and clinical record review, the facility staff failed to provide care and services to maintain residents' highest level of well-being for two of 43 residents in the survey sample, Residents #104 and #133. The findings include: 1. For Resident #104 (R104), the facility staff failed to initiate and implement treatment for toe wounds that were identified on 6/12/24. A review of R104's clinical record revealed a note signed by the wound care physician on 6/12/24 that documented the resident presented with a wound on the right first toe that measured 1.5 x 0.6 x 0.3 cm (centimeters) and a wound on the left first toe that measured 1.5 x 0.5 x 0.2 cm. The note further document dressing treatment plans to apply a primary dressing of Xeroform gauze three times per week. Further review of R104's clinical record (including physician's orders, the June 2024 treatment administration record, and nurses' notes) failed to reveal any physician's orders for treatments to the R104's toes and failed to reveal evidence that any treatments were implemented for the resident's toes. On 6/26/24 at 2:17 p.m., an interview was conducted with LPN (licensed practical nurse) #2 (the wound care nurse). LPN #2 stated that when the wound care physician writes treatment plans, she or another nurse enters the orders into the computer system then the orders are generated onto the treatment administration record so they can be signed off by a nurse when the treatments are done. LPN #2 reviewed R104's clinical record and stated that she did not see any physician's orders for treatment to the resident's toes but there was supposed to be orders for Xeroform once a week. On 6/26/24 at 2:47 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 titled, Skin Management documented, Residents with wounds and/or pressure injury and those at risk for skin compromise are identified, evaluated and provided appropriate treatment to promote prevention and healing. No further information was presented prior to exit. 32642 2. For Resident #133 (R133), the facility staff failed to provide assessment of and care for two incisions on the resident's leg. On 6/24/24 at 2:19 p.m., R133 was observed sitting up in a wheelchair in his room. The resident stated he was concerned about two incisions on his right leg, both of which were currently closed with staples. He stated these incisions were the result of a surgical procedure he received while he was in the hospital prior to his admission in the facility. R133 showed the surveyor his right leg. An incision along the inner aspect of the resident's right shin measured approximately four inches long, and was closed with staples. A second incision along the inner aspect of his right thigh measured approximately two inches long, and was also closed with staples. The resident stated he was not aware of any staff member assessing the incisions at any time, or of any appointment to have the staples removed. A review of R133's admission nursing assessment dated [DATE] revealed, in part: Location of skin conditions/wounds .right inner thigh has 7 staples intact .right lower shin has 13 staples intact. Further review of R133's clinical record revealed no evidence of regular nursing assessment of these wounds, and no evidence of a plan for the staples to be removed. On 6/26/24 at 11:44 a.m., LPN (licensed practical nurse) #4 was interviewed. She stated she has been taking care of R133 since his admission on 6/20/24. She stated she had seen the two incisions once when she performed his weekly skin assessment. She stated: I'm not sure where the staples or from, or what we are doing for them. She stated she believed there should be some kind of orders for regular assessment, and that facility nursing staff should be assessing the incisions regularly to make sure they are intact, and that there are no signs or symptoms of infection. On 6/26/24 at 2:44 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, and ASM #3, the regional clinical coordinator, were informed of these concerns. No further information was provided prior to exit.

Based on resident interview, clinical record review, staff interview and facility document review, it was determined the facility staff failed to follow professional standards of practice for two of 43 residents in the survey sample, Resident #26 and Resident #323. The findings include: 1. For Resident #26 (R26), the facility staff failed to clarify the physician orders for Tramadol (1) and acetaminophen (2) with numerical pain parameters for administration that were not being followed. On the most recent MDS (minimum data set), a quarterly assessment, with an ARD (assessment reference date) of 6/2/2024, the resident scored a 15 out of 15 on the BIMS (brief interview for mental status) assessment, indicating the resident was cognitively intact for making daily decisions. The assessment documented R26 having almost constant pain and receiving scheduled and as needed pain medications. On 6/24/2024 at approximately 2:15 p.m., an interview was conducted with R26. R26 stated that they managed their pain with medication they took as needed. R26 stated that sometimes they took Tylenol and when they had muscle spasms they took Tramadol. The physician orders documented in part, - Acetaminophen Oral Tablet 325 MG (milligram) (Acetaminophen) Give 2 tablet by mouth every 8 hours as needed for pain 1-4. Order Date: 11/27/2023. - Tramadol HCl Oral Tablet 50 MG (Tramadol HCl) Give 2 tablet by mouth every 6 hours as needed for pain level 5-10. Order Date: 12/07/2023. The eMAR (electronic medication administration record) dated 6/1/2024-6/30/2024 documented the Acetaminophen given on the following dates and times with the pain levels documented. - On 6/1/2024 at 5:55 a.m. for a pain level of 8 and 1:27 p.m. for a pain level of 7. - On 6/2/2024 at 6:21 a.m. for a pain level of 6 and at 6:48 p.m. for a pain level of 8. - On 6/3/2024 at 1:04 p.m. for a pain level of 6 and 10:15 p.m. for a pain level of 8. - On 6/4/2024 at 1:08 p.m. for a pain level of 8. - On 6/7/2024 at 1:19 p.m. for a pain level of 6 and at 10:08 p.m. for a pain level of 7. - On 6/8/2024 at 1:30 p.m. for a pain level of 6 and at 6:55 p.m. for a pain level of 8. - On 6/9/2024 at 3:32 p.m. for a pain level of 9. - On 6/10/2024 at 1:56 p.m. for a pain level of 6 and 10:12 p.m. for a pain level of 7. - On 6/11/2024 at 10:05 p.m. for a pain level of 7. - On 6/12/2024 at 1:29 p.m. for a pain level of 6. - On 6/14/2024 at 9:21 p.m. for a pain level of 6. - On 6/15/2024 at 9:51 p.m. for a pain level of 8. - On 6/16/2024 at 11:40 a.m. for a pain level of 9. - On 6/18/2024 at 1:40 p.m. for a pain level of 5. - On 6/19/2024 at 1:37 p.m. for a pain level of 8. - On 6/20/2024 at 1:44 p.m. for a pain level of 6 and 9:59 p.m. for a pain level of 7. - On 6/21/2024 at 2:01 p.m. for a pain level of 7. - On 6/23/2024 at 8:43 p.m. for a pain level of 7. - On 6/24/2024 at 1:53 p.m. for a pain level of 7. - On 6/25/2024 at 1:57 p.m. for a pain level of 6. The eMAR (electronic medication administration record) dated 6/1/2024-6/30/2024 documented the Tramadol given on the following dates and times with the pain levels documented. - On 6/5/2024 at 5:30 a.m. for a pain level of 1. - On 6/6/2024 at 5:30 a.m. for a pain level of 1. - On 6/8/2024 at 5:30 a.m. for a pain level of 1. - On 6/9/2024 at 5:30 a.m. for a pain level of 1. - On 6/11/2024 at 6:00 a.m. for a pain level of 1. - On 6/13/2024 at 5:30 a.m. for a pain level of 1. - On 6/14/2024 at 5:30 a.m. for a pain level of 1. - On 6/15/2024 at 5:30 a.m. for a pain level of 1. - On 6/17/2024 at 5:30 a.m. for a pain level of 1. - On 6/18/2024 at 5:30 a.m. for a pain level of 1. - On 6/19/2024 at 5:30 a.m. for a pain level of 1. - On 6/20/2024 at 5:30 a.m. for a pain level of 1. - On 6/21/2024 at 5:30 a.m. for a pain level of 1. - On 6/22/2024 at 5:30 a.m. for a pain level of 1. - On 6/23/2024 at 5:30 a.m. for a pain level of 1. - On 6/24/2024 at 5:30 a.m. for a pain level of 1. - On 6/25/2024 at 5:30 a.m. for a pain level of 1. - On 6/26/2024 at 5:30 a.m. for a pain level of 1. On 6/26/2024 at 10:04 a.m., an interview was conducted with LPN (licensed practical nurse) #1. LPN #1 stated pain medications were given as ordered. She stated that if a resident requested pain medication for a pain level that was outside of the ordered pain parameters for the medication she would have to call the physician to clarify the order. She stated that she would call the physician to clarify because it was an order and they would need to decide if it was ok to give. The facility policy, Physician's Order dated 10/20/2023 documented in part, .Physician orders are obtained to provide a clear direction in the care of the resident . In Fundamentals of Nursing 6th edition, 2005; [NAME] A. [NAME] and [NAME] Perry; Mosby, Inc; Page 419. The physician is responsible for directing medical treatment. Nurses are obligated to follow physician's orders unless they believe the orders are in error or would harm clients. Therefore all orders must be assessed if one is found to be erroneous or harmful further clarification from the physician is necessary On 6/26/2024 at approximately 4:30 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing and ASM #3, the regional clinical coordinator were made aware of the findings. No further information was provided prior to exit. Reference: (1) Tramadol immediate-release tablets and oral solution are used as a short-term treatment to relieve severe pain (pain that begins suddenly, has a specific cause, and is expected to go away when the cause of the pain is healed) in people who are expected to need an opioid pain medication and who cannot be controlled by the use of alternative pain medications. Tramadol extended-release tablets and capsules are used to relieve severe and persistent pain in people who are expected to need an opioid pain medication to relieve pain around-the-clock for a long time and who cannot be treated with other pain medications. Tramadol extended-release tablets and capsules should not be used to treat mild or moderate pain, short-term pain, or pain that can be controlled by medication that is taken as needed. Tramadol is in a class of medications called opiate (narcotic) analgesics. It works by changing the way the brain and nervous system respond to pain. This information was obtained from the website: https://medlineplus.gov/druginfo/meds/a695011.html (2) Acetaminophen is used to relieve mild to moderate pain from headaches, muscle aches, menstrual periods, colds and sore throats, toothaches, backaches, reactions to vaccinations (shots), and to reduce fever. Acetaminophen may also be used to relieve the pain of osteoarthritis (arthritis caused by the breakdown of the lining of the joints). Acetaminophen is in a class of medications called analgesics (pain relievers) and antipyretics (fever reducers). It works by changing the way the body senses pain and by cooling the body. This information was obtained from the website: https://medlineplus.gov/druginfo/meds/a681004.html 2. For Resident #323 (R323), the facility staff failed to properly transcribe and monitor blood glucose levels. R323 was admitted to the facility with diagnoses that included but were not limited to Type 2 Diabetes Mellitus (1) and dementia. On the most recent MDS (minimum data set), an admission assessment, with an ARD (assessment reference date) of 4/3/2024, the resident scored a 4 out of 15 on the BIMS (brief interview for mental status) assessment, indicating the resident was severely impaired for making daily decisions. The assessment documented R323 having a diagnosis of diabetes mellitus, not taking insulin and taking a hypoglycemic medication. Review of the physician orders documented in part, - Blood sugars BID (twice a day). Order Date: 03/27/2024. End Date: 04/16/2024 . - Glipizide tablet 5mg (milligram) Give 1 tablet by mouth one time a day for diabetes. Order Date: 03/27/2024. Start Date: 03/28/2024. End Date: 04/16/2024 . The progress notes documented a physician progress note dated 4/3/2024 which documented in part, .Chief Complaint/Reason for this Visit: follow-up post fall . Diabetes Type 2: blood glucose levels not available in record, continue glipizide 5mg po daily. Check fasting blood glucose daily. CMP (comprehensive metabolic panel), Hgb (hemoglobin) A1c 4/4 . Review of the clinical record for R323 documented a blood glucose (sugar) reading of 149 on 4/4/2024 at 5:42 a.m. The clinical record failed to evidence documentation of a blood glucose reading prior to 4/4/2024. Review of the eMAR (electronic medication record) dated 3/1/2024-3/31/2024 and 4/1/2024-4/30/2024 documented in Unscheduled other orders: Blood sugars BID however the eMAR's failed to evidence documentation of any blood glucose results. On 6/26/2024 at 2:00 p.m., an interview was conducted with LPN (licensed practical nurse) #4. LPN #4 stated that when a resident had an order for a blood glucose check it populated on the eMAR and then popped up when it was due during the medication pass. She stated that the nurse obtained the blood glucose and documented it in the eMAR which recorded it in the medical record. She stated that the blood glucose should not be an unscheduled order and may not have been entered correctly and should be clarified. She stated that she did not remember R323 but if there were glucose levels recorded they would populate on the eMAR. On 6/26/2024 at approximately 4:30 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing and ASM #3, the regional clinical coordinator were made aware of the findings. No further information was provided prior to exit. Reference: (1) diabetes mellitus A chronic disease in which the body cannot regulate the amount of sugar in the blood. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/ency/article/001214.htm.

Based on observation, staff interview, clinical record review and facility document review, it was determined that the facility staff failed to review and revise the comprehensive care plan for two of 43 residents in the survey sample; Residents #22 and #19. The findings include: 1. For Resident #22, the facility staff failed to review and revise the comprehensive care plan to include the use of side rails once the facility implemented the use of side rails. A review of the clinical record revealed a Physical Device Evaluation dated 12/18/22. This document documented that the type of safety device to be used was Bed against the wall and the reason was for Safety awareness. The options for any type of side rails were not checked. On 6/24/24 at 12:42 PM and at 2:54 PM, 6/25/24 at 10:17 AM and on 6/27/24 at 9:13 AM, Resident #22 was observed in bed. Quarter length sized side rails were observed on both sides of the bed in the upright position. A review of the comprehensive care plan failed to reveal any evidence that the current use of the side rails was care planned. On 6/27/24 at 9:28 AM, an interview was conducted with LPN #5 (Licensed Practical Nurse). She stated the care plan should have been revised to reflect the current use of side rails. On 6/27/24 at 10:18 AM an interview was conducted with LPN #7. She also stated that the care plan should have been revised to reflect the current use of side rails. The facility policy, Care Planning documented, 1. Resident's will be assessed as they are admitted and readmitted to the nursing facility to determine their physical, psychological, emotional, medical and psychosocial needs. The results of interdisciplinary assessments will be used to develop, review and revise the resident's comprehensive care plans On 6/27/24 at 12:10 PM, ASM #1 (Administrative Staff Member) the Administrator, ASM #2 the Director of Nursing, and ASM #3, the Regional Clinical Coordinator, were made aware of the findings. No further information was provided by the end of the survey. 2. For Resident #19, the facility staff failed to review and revise the comprehensive care plan to include the use of side rails once the facility implemented the use of side rails. A review of the Physical Device Evaluation dated 7/19/22 documented, Bed Against the wall. None of the options for side rails were checked. On 6/24/24 at 12:48 PM, 6/25/24 at 10:30 AM and 6/27/24 at 9:22 AM, Resident #19 was noted in bed asleep with quarter length sized side rails on both sides of the bed in the upright position. A review of the comprehensive care plan failed to reveal any evidence that the current use of the side rails was care planned. On 6/27/24 at 9:28 AM, an interview was conducted with LPN #5 (Licensed Practical Nurse). She stated the care plan should have been revised to reflect the current use of side rails. On 6/27/24 at 10:18 AM an interview was conducted with LPN #7. She also stated that the care plan should have been revised to reflect the current use of side rails. The facility policy, Care Planning documented, 1. Resident's will be assessed as they are admitted and readmitted to the nursing facility to determine their physical, psychological, emotional, medical and psychosocial needs. The results of interdisciplinary assessments will be used to develop, review and revise the resident's comprehensive care plans On 6/27/24 at 12:10 PM, ASM #1 (Administrative Staff Member) the Administrator, ASM #2 the Director of Nursing, and ASM #3, the Regional Clinical Coordinator, were made aware of the findings. No further information was provided by the end of the survey.

Based on observation, resident interview, staff interview, facility document review, and clinical record review, the facility staff failed to implement the baseline care plan for one of 43 residents in the survey sample, Resident #76. The findings include: For Resident #76 (R76), the facility staff failed to implement the resident's baseline care plan for oxygen administration. A review of R76's clinical record revealed a baseline care plan dated 6/11/24 that documented, (Name of R76) has a potential for difficulty breathing and risk for respiratory complications R/T (Related To): COPD (Chronic Obstructive Pulmonary Disease) exacerbation, chronic hypoxic respiratory failure, use of O2 (oxygen). Apply O2 per physician's orders. A Brief Interview for Mental Status assessment dated [DATE] documented R76 was cognitively intact, scoring a 15 out of 15. Further review of R76's clinical record revealed a physician's order dated 6/24/24 for continuous oxygen at two liters per minute. On 6/24/24 at 3:13 p.m., R76 was observed receiving oxygen via nasal cannula at a rate between three and half and four liters per minute, as evidenced by the middle of the ball in the oxygen concentrator flowmeter positioned between the three and half and four-liter lines. On 6/25/24 at 10:46 a.m., R76 was observed receiving oxygen via nasal cannula at a rate between one and half and two liters per minute, as evidenced by the middle of the ball in the oxygen concentrator flowmeter positioned between the one and half and two-liter lines. R76 stated he doesn't know how to adjust his oxygen and he does not adjust his oxygen concentrator flowmeter. On 6/26/24 at 10:03 a.m., an interview was conducted with LPN (licensed practical nurse) #1. LPN #1 stated the purpose of the care plan is so staff can figure out how to best care for the patient. LPN #1 stated nurses can look at the care plan any time to ensure they are implementing it. LPN #1 stated nurses administer oxygen per the physician's orders and should check the rate of oxygen any time they are in the resident's room. LPN #1 stated the middle of the ball in the oxygen concentrator flowmeter should be on the two-liter line if the physician's order is for two liters. On 6/26/24 at 2:47 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 titled, Care Planning documented, Every resident in the facility will have a person-centered Plan of Care developed and implemented . No further information was presented prior to exit.

Based on staff interview and clinical record review, the facility staff failed to maintain an accurate MDS (minimum data set) assessment for one of 43 residents in the survey sample, Resident #121. The findings include: For Resident #121 (R121), the facility staff failed to code the resident's discharge as, planned on the discharge MDS assessment with an ARD (assessment reference date) of 4/5/24. Section A0310 of R121's discharge MDS assessment with an ARD of 4/5/24 documented, F. Entry/discharge reporting: 10. Discharge-return not anticipated. G. Type of Discharge: 2. Unplanned. A review of R121's clinical record revealed a nurse's note dated 4/6/24 that documented the resident discharged home. On 6/26/24 at 11:11 a.m., an interview was conducted with RN (registered nurse) #1 (the MDS coordinator). RN #1 stated she had documented in her book that R121's discharge was planned but she accidentally coded the discharge as unplanned on the MDS assessment. RN #1 stated this was a coding error and she follows the CMS (Centers for Medicare and Medicaid Services) RAI (Resident Assessment Instrument) manual when completing MDS assessments. On 6/26/24 at 2:47 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing) were made aware of the above concern. The CMS RAI manual documented, Coding Instructions for A0310G. Code 1: if type of discharge is a planned discharge. Code 2: if type of discharge is unplanned. No further information was presented prior to exit.

Based on clinical record review, staff interview and facility document review, it was determined that the facility staff failed to evidence notification of the responsible party of a fall for 1 of 43 residents in the survey sample, Resident #323. The findings include: For Resident #323 (R323), the facility staff failed to evidence notification of the responsible party of a fall on 4/2/2024. The admission record for R323 documented a designated responsible party/power of attorney/emergency contact person for the resident with phone number listed. On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 04/3/2024, the resident scored 4 out of 15 on the BIMS (brief interview for mental status) assessment, indicating the resident was severely impaired for making daily decisions. Section J documented R323 having one fall with fracture prior to admission and one fall since admission to the facility with injury but not major injury. The comprehensive care plan for R323 documented in part, [Name of R323] is at risk for fall related injury and falls R/T (related to) fall hx (history), generalized weakness, decreased functional mobility. Date Initiated: 03/28/2024. Review of R323's progress notes revealed the following: - 4/2/2024 23:27 (11:27 p.m.) Note Text: Resident found lying on her right side near the toilet she seemed to be trying to transfer herself to the bathroom. Resident vitals and neurological status taken, resident redirected and taken into bed. She was re educated on using her call bell before trying to transfer. She was noted to have a skin tear to left shin as well as well as a small skin tear and bruising to right rib. The progress notes failed to evidence notification of the responsible party for the fall on 4/2/2024. Review of the fall investigation for R323 documented the physician notified of the fall on 4/2/2024 at 23:23 (11:23 p.m.). On 6/26/2024 at 10:04 a.m., an interview was conducted with LPN (licensed practical nurse) #1. LPN #1 stated that when a resident had a fall they assessed the resident for injury, assisted them back to bed or the chair and notified the responsible party, the director of nursing and the physician. She stated that the responsible party was notified at the same time the physician was notified unless it was in the middle of the night and not emergent and then they notified the responsible party the next morning. On 6/26/2024 at 1:45 p.m., an interview was conducted with LPN #3. LPN #3 stated that he remembered R323 vaguely but did not recall the fall on 4/2/2024 or the progress note written. He stated that if a resident was found on the floor they assessed range of motion, take vital signs, do a skin assessment, check the residents head and assess for any injury. LPN #3 stated that they notified the responsible party and the physician any time a resident fell and documented in the progress notes. On 6/26/2024 at 2:00 p.m., an interview was conducted with LPN #4. LPN #4 stated that when a resident had a fall they assessed them for injury, checked their vital signs, and contacted the physician for further orders. LPN #4 stated that they also notified the responsible party of the fall and documented it in the progress notes. The facility policy Fall Management dated 9/22/2023 documented in part, . The licensed nurse will notify the attending physician and the responsible party of the fall, and document the notification in the medical record . On 6/27/2024 at approximately 4:30 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing and ASM #3, the regional clinical coordinator were made aware of the 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 the facility staff failed to identify, monitor and implement care and services for the prevention, identification, and treatment of [REDACTED].#7 and Resident #3. 1. a. Facility staff failed to identify a pressure injury on Resident #7's left great toe until it was at an advanced stage; the pressure sore was found on 5/2/17, and staged as a Stage III wound, measuring 3 x 3, centimeters in size with a necrotic area in the center, resulting in harm. Facility staff also failed to assess, monitor and measure the wound for three weeks. 1.b. Facility staff failed to monitor, and measure a pressure injury on Resident #7's heel that was found at a Stage II blister on 5/9/17. There were no measurements or monitoring of this wound and it was observed on 5/24/17 with a black area. In addition the facility staff failed to apply heel lift boots as ordered by the physician. 2. The facility staff failed to measure Resident #3's toe pressure ulcer on 4/14/17 and 4/21/17. The findings include: 1. a. Facility staff failed to identify a pressure injury on Resident #7's left great toe until it was at an advanced stage; the pressure sore was found on 5/2/17, and staged as a Stage III wound, measuring 3 x 3, centimeters in size with a necrotic area in the center, resulting in harm. Facility staff also failed to assess, monitor and measure the wound for three weeks. *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. (1) **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. (2) Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. characterized by joint inflammation (5)). The most recent MDS (minimum data set) assessment, a significant change assessment, with an assessment reference date of 3/30/17, coded the resident as scoring a 9 on the BIMS (brief interview for mental status) score, indicating that she was moderately impaired to make daily cognitive decisions. The resident was coded as requiring extensive assistance of one or more staff members for all of her activities of daily living except eating in which she required supervision after set up assistance was provided. In Section M - Skin Conditions, the resident was coded as being at risk for pressure ulcers (injuries) but had no pressure injuries at the time of the assessment. Resident #7 was observed on 5/23/17 at 2:58 p.m., in her bed. She had white cotton socks on her feet and her feet were on a pillow, but her heels were touching the mattress. Resident #7 had no protective boots on her feet. The resident was on top of the covers with a light fleece blanket over her legs; her feet were not under the blanket. Resident #7 was observed on 5/23/17 at 4:50 p.m., in her bed reading a book. Her feet were on a pillow, but her heels were touching the surface of the mattress. She had no shoes or boots on her feet just cotton white socks. Resident #7 stated to this surveyor, I have a sore on my big toe. The resident was on top of the covers with a light fleece blanket over her legs. The resident removed her blanket to show this surveyor her feet with her white socks on. Resident #7 was observed on 5/24/17 at 8:05 a.m. She was resting in bed, with the covers over her. She had no boots on her feet. A physician order [REDACTED].* oint (ointment) and DD (dry dressing) Q (every) day. *Santyl is a sterile enzymatic [MEDICATION NAME] ointment used to that has a unique ability to digest collagen in necrotic tissue. (6) The nurse practitioner's note dated, 5/2/17, documented in part, Chief Complaint: L (left) great toe. Interval History: Staff report ulcer L (left) great toe, denies pain, isn't sure when it occurred. Key Findings: L great toe deformed, stage 3 ulcer 3 x 3, redness surrounding area 5 x 6, necrotic area in center. The nurse's notes documented, 5/5/17 at 3:21 p.m. LATE ENTRY FOR 5/2/17. Late Entry for 5/2/17. This guest noted with area to left great toe. NP (nurse practitioner) notified 5/2/17 at 10:30 a.m. New Treatment initiated. Further review of the clinical record did not reveal any further documentation of the left great toe pressure ulcer. On 5/24/17 at approximately 9:30 a.m. a request was made to the director of nursing, for any skin assessments, wound care measurements or anything related to the pressure wound on Resident #7's left great toe. On 5/24/17 at 1:50 p.m. administrative staff member (ASM) #2, the director of nursing presented three documents for Resident #7. The first two pages were Weekly Skin assessment dated [DATE] through 5/21/17. The first date anything related to the feet was documented was on 5/21/17. The 5/21/17 skin assessment documented, Has new pressure Ulcer - indicate with X and see Pressure Ulcer Record. On the body diagram, an arrow pointed to the left foot and a circle was surrounding the buttocks area. There was no documentation regarding Resident #7's left great toe. The next document presented by ASM #2 on 5/24/17 at 1:50 p.m. documented, Pressure Ulcer Record. This form documented the following: Date: 5/2/17: Site: L great toe; Stage: III; Length/width/depth: 1.8 x 1.6 x 0.1 (measured in centimeters); Odor: none; Drainage: S (serosanguinous); Color: B (black - eschar) R (red). Date 5/24/17: Site: L great toe; Stage: III; Length/width/depth: .3 x .2; Odor: none; Drainage: O (none); Color: redness. There were no measurements from 5/2/17 until 5/24/17, which was done by the unit manager on 5/24/17. On 5/24/17 at 2:18 p.m., a request to speak to the nurse practitioner that first examined the L great toe wound was made to ASM #2, the director of nursing. ASM #2 informed this surveyor that the nurse practitioner was out on emergency medical leave. ASM #2 further stated that the facility had not have a wound care nurse for several weeks. The new wound care nurse started two weeks ago in orientation and her first day on the floor was 5/22/17. The left great toe wound was observed on 5/24/17 at 2:50 p.m. with RN (registered nurse) #3, the wound care nurse. Resident #7's left foot was deformed from her [MEDICAL CONDITION] arthritis. The left great toe, with the pressure ulcer, was bent at a 90 degree angle, at the first joint behind the toenail, and was turned toward the other toes. With this deformity, the nail and top of the first joint of the great toe, was observed as the highest point of Resident #7's foot. (If you make a fist with your hand and bend your thumb so the tip of your thumb touches behind your second knuckle, that is how Resident #7's toe and toes are positioned). RN #3 proceeded to clean the wound with normal saline, and Resident #7 stated, That hurts. RN #3 offered to stop the wound care at this time and get some pain medication, but Resident #7 declined and stated, Just do it PDQ (pretty damn quick). The area was described by RN #3, (who stated she has done wound care for five years), as follows: [DIAGNOSES REDACTED] noted around the border, yellow slough noted, no drainage, rash or odor noted, measuring 1 cm (centimeter) L (length) x 1 cm W (width). Tenderness noted with palpitation. The area of [DIAGNOSES REDACTED] was not blanchable. On 5/24/17 at 3:50 p.m. this surveyor spoke with ASM #1, the administrator, ASM #2, the director of nursing, ASM #3, the QA (quality assurance) manager and RN #3, the wound care nurse. This surveyor expressed concern for this resident's wounds. When asked why there were no measurements from 5/2/17 through 5/24/17, there was a long silence, no one spoke. ASM #1 then stated, We didn't have a wound care nurse at the time. This surveyor asked for the facility staff to provide any information related to this wound. The comprehensive care plan dated, 4/13/17, with a revised on date of 5/2/17, documented, Potential for impaired skin integrity related to decreased mobility, preventative measures to bil (bilateral) heels, Max (maximum) assist - dependent on staff for ADL (activities of daily living), incontinent of B & B (bowel and bladder), Hx (history) of [MEDICAL CONDITIONS] ([MEDICAL CONDITION]). 5/2/17 - area to (L) great toe. The Approaches/Interventions documented in part, Float heels while in bed as guest tolerates. Pressure reduction mattress on bed. Conduct weekly head to toe skin assessments, document and report abnormal findings to physician. Evaluation skin with each episode and report any redness, skin breakdown, rash, pain, burning, odorous urine, to nurse. 5/2/17 - treatment in progress. Review of Resident #7's May 2017 TAR (treatment administration record) documented, Santyl Ointment: daily for wound healing. Extended directions: Cleanse area left great toe with n/s (normal saline) apply Santyl oint (ointment) and dd (dry dressing) q (every) day. The treatment was signed as completed every day except on 5/10/17 and 5/22/17. An interview was conducted with CNA (certified nursing assistant) #5, on 5/24/17 at 3:05 p.m. When asked how often a CNA looks at a resident's skin, CNA #5 stated, Every time I take their clothes off or wash them up. An interview was conducted with LPN (licensed practical nurse) #1, the nurse that documented the L great toe wound initially, on 5/25/17 at 8:47 a.m. LPN #1 was asked to describe the area on Resident #7's left great toe when she found it. LPN #1 stated, It was dark, brown in color. It wasn't opened; it looked like eschar, dark. When asked if there was redness around the area, LPN #1 stated, I don't remember, I remember it was dark like a red light. The resident wasn't eating much and was near death but she had rallied lately. On 5/25/17 at 9:18 a.m. an interview was conducted with ASM #2. ASM #2 was asked about the blanks on the TAR for the treatment of [REDACTED]. ASM #2 stated, The nurses tell me the computer goes down. I believe this is all due to the fluctuation in having a treatment nurse. The former treatment nurse left and now we have a new treatment nurse. Folks didn't have the 'moxie' to do it (the treatments). We don't know if those treatments were done or not done. The old nursing adage - if it ain't documented it wasn't done. On 5/25/17 at 9:37 a.m. ASM #1, ASM #2, and ASM #3 were informed of the concern for harm for Resident #7. ASM #3 stated, We have given you everything we have. This surveyor asked to speak with ASM #4, the attending physician, who was out of town, regarding any knowledge he had of Resident #7's wounds. An interview was conducted with RN #1, the unit manager; on 5/25/17 at 10:00 a.m. RN #1 was asked about the process for assessing resident's skin. RN #1 stated, On admission we check them head to toe for the first three shifts. Then skin assessments are done weekly. If an issue is found we notify the wound care nurse. RN #1 was asked what is expected of staff, if a CNA finds something new or different than before on a resident's skin. RN #1 stated, The CNA informs the nurse. We also have a shower team and they do a 'stop and watch' form to let us know. If they find anything shocking, they come get me. When asked how treatment is implemented for a newly found area, RN #1 stated, We call the doctor and get orders. When asked who completes the weekly wound measurements, RN #1 stated, The wound care nurse measures every week. We had (name of former wound care nurse) and now we have (name of RN #3). When asked who completed the weekly wound measurements while there wasn't a wound care nurse, RN #1 stated, I thought the previous DON (director of nursing) had assigned a treatment nurse to do the treatments and measurements. 5/25/17 at 11:14 a.m. ASM #3 stated she had left a message for ASM #4. On 5/25/17 at 11:35 a.m. ASM #3 informed this surveyor that there was no return call from ASM #4. At 12:07 p.m. on 5/25/17, ASM #3 informed this surveyor that ASM #4 had called and he had not seen Resident #7's wounds to comment on them. The facility policy, Pressure Ulcer Identification and Treatment Protocol documented in part, Stage III: Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscles are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. The depth of a Stage III pressure ulcer varies by anatomical locations. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and Stage III ulcers can be shallow. Interventions: 3. Evaluation the need for pressure reduction relief surface for bed and pressure reduction cushion for chair. Consider low air loss therapy. 5. Turn and reposition every 2 hours or more often if indicated. Use pillow for positioning, avoid skin to skin contact/use pillows or foam wedge to position individual without placing pressure on boney prominences and between boney prominences. If the individual has large Stage III ulcers, a low -air- loss or air-fluidized support surface may be indicated .Evaluate the wound at each dressing change. Document site, stage, length, width, depth (cm), color, treatment and progress at least weekly and if condition of the wound changes. The Pressure Ulcer Treatment Quick Reference Guide by NPUAP states on page 8 concerning pressure ulcer assessment, 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. Page 9 of this reference states, 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]. Page 10 of this reference states, 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 provided prior to exit. (1) This information was obtained from the following website: http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-injury-stages. (2) This information was obtained from the following website: http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-injury-stages. (3) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and Chapman; page 138. (4) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and Chapman; page 124. (5) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and Chapman; page 511. (6) This information was obtained from the following website: http://www.rxlist.com/santyl-drug.htm. 1.b. Facility staff failed to monitor, and measure a pressure injury on Resident #7's heel that was found at a Stage II blister on 5/9/17. There were no measurements or monitoring of this wound and it was observed on 5/24/17 with a black area. In addition the facility staff failed to apply heel lift boots as ordered by the physician. The nurse practitioner's note dated, 5/9/17, documented, Chief Complaint: Left heel. Interval History: Staff reports areas of left heel, complains of increased pain to right heel, states appetite diminished and not eating entire meals, is drinking supplement, discussed with hospice nurse hospice to provide air mattress. Key Findings: Left heel intact bullae (blister; a large bleb in the skin that contains fluid (1)). Assessment and Plan: 2. Bullae - acute- heel lift boots, skin breakdown most likely due to poor nutritional status, will not check labs (laboratory tests) due to hospice status will most likely find protein-calorie malnutrition if drawn. The physician order [REDACTED].* L (left) heel q (every) shift and PRN (as needed). Heel lift boots QD (every day). *Skin Prep is a liquid film-forming dressing that forms a protective film to help reduce friction during removal of tapes and films. The Skin Prep also protects fragile skin. (2) Resident #7 was observed on 5/23/17 at 2:58 p.m., in her bed. She had white cotton socks on her feet and her feet were on a pillow but her heels were touching the mattress. She had no protective boots on her feet. Resident #7 was on top of the covers with a light fleece blanket over her legs; her feet were not under the blanket. Resident #7 was observed on 5/23/17 at 4:50 p.m., in her bed reading a book. Her feet were on a pillow but her heels were touching the mattress. She had no shoes or boots on her feet just cotton white socks. Resident #7 stated to this surveyor, I have a sore on my big toe. The resident was on top of the covers with a light fleece blanket over her legs. Resident #7 removed her blanket to show this surveyor her feet with her white socks on. Resident #7 was observed on 5/24/17 at 8:05 a.m. She was resting in bed. The covers were over her. She had no boots on her feet. She had a pillow under her calves but her heels were resting on the surface of the bed. Review of the nurse's notes did not reveal any documentation regarding the area on Resident #7's left heel. On 5/24/17 at approximately 9:30 a.m. a request was made for any skin assessments, wound care measurements or anything related to the area on the resident's left heel to the director of nursing, ASM #2. On 5/24/17 at 1:50 p.m. administrative staff member (ASM) #2, the director of nursing presented three documents for Resident #7. The first two pages were Weekly Skin Assessment from 2/22/17 through 5/21/17. The first time anything related to the feet was documented was on 5/21/17. The 5/21/17 skin assessment documented, Has new pressure Ulcer - indicate with X and see Pressure Ulcer Record. On the body diagram, an arrow pointed to the left foot and a circle was surrounding the buttocks area. There was no documentation regarding the left heel pressure sore. This was verified with ASM #2, the director of nursing. ASM #2 also verified the facility had no measurements of the left heel pressure sore. On 5/24/17 at 2:18 p.m., a request to speak to the nurse practitioner that first examined the L great toe wound was made to ASM #2, the director of nursing. ASM #2 informed this surveyor that the nurse practitioner was out on emergency medical leave. ASM #2 further stated that the facility had not have a wound care nurse for several weeks. The new wound care nurse started two weeks ago in orientation and her first day on the floor was 5/22/17. Resident #7's left heel was observed on 5/24/17 at 2:50 p.m. with RN (registered nurse) #3, the wound care nurse. The left heel was noted to have a dry area that RN #3 measured as 3 cm x 2.2 cm. A black area, under the skin, was observed and was measured as 1 cm x 1 cm by RN #3. RN #3 stated Resident #7's left heel was soft but not boggy. At this time, Resident #7's heel lift boots were observed in her closet. On 5/24/17 at 3:50 p.m. this surveyor spoke with ASM #1, the administrator, ASM #2, the director of nursing, ASM #3, the QA (quality assurance) manager and RN #3, the wound care nurse. Concern was expressed regarding Resident #7's wounds. When asked why there were no measurements for the area on Resident #7's left heel, there was a long silence and no one responded. ASM #1, then stated, We didn't have a wound care nurse at the time. At this time a request was made for the facility staff to provide any information related to the left heel wound. The wound care nurse documented on 5/24/17 at 4:59 p.m. Assessment of left heel. Soft, dry callused circular area noted 3.0 cm L (length) x 2.2 cm W (width). Black area noted, 1.0 cm L x 1.0 cm W. An interview was conducted with LPN #4 on 5/24/17 at 5:10 p.m. When asked how often a nurse looks at a resident's skin, LPN #4 stated, Weekly. When asked how skin assessments are performed by staff, LPN #4 stated, You provide privacy and then check the resident from head to toe. When asked if staff remove the resident's socks, LPN #4 stated, Absolutely. When asked how staff ensures physician ordered interventions such as heel lift boots are implemented, LPN #4 stated, Every time I go in the room I should be checking to ensure everything that is needed is in place. On 5/24/17 at 5:20 p.m. CNA #3 approached this surveyor and asked which boots Resident #7 was supposed to have on her feet. The CNA was referred to the resident's nurse. The comprehensive care plan dated, 4/13/17 and revised on 5/2/17, documented, Potential for impaired skin integrity related to decreased mobility, preventative measures to bil (bilateral) heels, Max (maximum) assist - dependent on staff for ADL (activities of daily living) are, incontinent of B & B (bowel and bladder), Hx (history) of [MEDICAL CONDITIONS] ([MEDICAL CONDITION]). The Approaches/Interventions documented in part, Float heels while in bed as guest tolerates. Pressure reduction mattress. Conduct weekly head to toe skin assessments, document and report abnormal findings to physician. Evaluation skin with each episode and report any redness, skin breakdown, rash, pain, burning, odorous urine to nurse. 5/9/17 - Tx (treatment) to (L) heel as ordered. 5/9/17 - Heel lift boots as ordered. Review of Resident #7's TAR (treatment administration record) for May 2017 revealed, Treatment every shift and as needed for, Extended directions: Skin prep to left heel. The TAR documented the skin prep was signed off as administered 38 out of the 45 opportunities between 5/9/17 and 5/23/17. A copy of the delivery order for the low air loss mattress dated, 5/9/17, was presented to this surveyor on 5/25/17 at 9:30 a.m. from ASM #2. On 5/25/17 at 8:47 a.m., an interview was conducted with LPN #1, the nurse assigned to Resident #7 on 5/23/17, 5/24/17 and 5/25/17. When asked if she had observed Resident #7's heels on 5/24/17, LPN #1 stated, No. LPN #1 was asked if she recalled when she had last looked at Resident #7's heels. LPN #1 stated, She was up in the wheelchair yesterday to go to the beauty shop. When asked if she looked at the resident's heels on Tuesday, LPN #1 stated, I don't recall. When asked to describe how she applies the skin prep to Resident #7's heel, LPN #1 stated, I lift the heel up, apply the skin prep, fan it dry with my hand and then prop the foot on the pillow. When asked if she looks where she is putting the skin prep, LPN #1 demonstrated lifting the foot up and blindly applying the skin prep, fanning it dry with her hand and then replacing it back on the bed. On 5/25/17 at 9:18 a.m. an interview was conducted with ASM #2. When asked about the blanks on the TAR for the treatment of [REDACTED].#2 stated, The nurses tell me the computer goes down. I believe this is all due to the fluctuation in having a treatment nurse. The former treatment nurse left and now we have a new treatment nurse. Folks didn't have the 'moxie' to do it (the treatments). We don't know if those treatments were done or not done. The old nursing adage - if it ain't documented it wasn't done. An interview was conducted with RN #1, the unit manager, on 5/25/17 at 10:00 a.m. When asked who is responsible for checking to ensure all interventions for pressure ulcers are in place, RN #1 stated, We should check implementations of the care plan on our room rounds each day. When asked if the nurse should be checking for the interventions, RN #1 stated, Yes, they should make sure they are in place when they do their treatments. On 5/25/17 at 9:37 a.m. ASM #1, ASM #2, and ASM #3 were informed of the concern for harm for Resident #7. ASM #3 stated, We have given you everything we have. A request was made to speak with ASM #4, the attending physician, who was out of town, regarding any knowledge he had of Resident #7's wounds. 5/25/17 at 11:14 a.m. ASM #3 stated she had left a message for ASM #4. On 5/25/17 at 11:35 a.m. ASM #3 informed this surveyor that there was no return call from ASM #4. At 12:07 p.m. on 5/25/17, ASM #3 informed this surveyor that ASM #4 had called and he had not seen Resident #7's wounds to comment on them. The facility policy, Pressure Ulcer Identification and Treatment Protocols documented in part, Stage II: Partial thickness skin loss of dermis presenting as a shallow, open ulcer with red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister. This area may present as a shiny or dry, shallow ulcer without slough or bruising Interventions: Position with pillows. Use pillows or foam wedge to position individual without placing pressure on a bony prominence and between bony prominences, (ankles or knees) - remove pressure on heels generally by elevating off the bed (floating the heels) Document site, stage, length, width, depth (cm), color, treatment and progress at least weekly and if condition of the wound changes. (1) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and Chapman; page 94. (2) This information was obtained from the following website: www.allegromedical.com 2. Facility staff failed to measure Resident #3's toe pressure ulcer on 4/14/17 and 4/21/17. Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent MDS (minimum data set), a quarterly assessment, with an ARD of 2/27/17 coded the resident as having a seven out of 15 on the BIMS indicating the resident was severely impaired cognitively. The resident was coded as requiring assistance from staff for all activities of daily living. The resident was coded as not having any open pressure ulcers. Review of the care plan initiated on 10/26/16 and revised on 3/2/17 documented, Problems/Conclusions. Potential for impaired skin integrity .3/2/17 area to (R) great toe. Approaches/Interventions. Conduct weekly head to toe skin assessments, document and report abnormal findings to physician. 3/2/17 - Tx (treatment) in progress. Review of the physician's orders [REDACTED]. Start 03-23-17. Review of the May 2017 TAR (treatment administration record) did not evidence documentation regarding the skin prep treatment to the right great toe. Review of the pressure ulcer record for Resident #3 documented, INITIAL WOUND DESCRIPTION: Date. 3-2-17. Site R (with a circle around it, indicating right) great toe. Description 0.3x (by) 0.3x0 cm (centimeters) purple. Further review of the pressure ulcer record for 4/14/17, 4/21/17 and 4/28/17 did not evidence documentation of the measurements or color of the right great toe pressure ulcer. Review of the nurse's notes for 4/14/17, 4/21/17 and 4/28/17 did not evidence documentation regarding the condition of the right great toe pressure ulcer. On 5/24/17 at 5:40 p.m. a request for Resident #3's pressure ulcer form was requested from ASM (administrative staff member) #3, the regional QA (quality assurance) manager. On 5/25/17 at 8:00 a.m. a copy of Resident #3's pressure ulcer form was left on the table in the conference room. Review of the form documented, 4/28 ----Resolved--- It was signed with the nurse's name and RN (registered nurse) #1, the unit manager's name. An observation was made on 5/25/17 at 8:40 a.m. of Resident #3's feet. The skin on the right great toe was slightly reddened but intact. An interview was conducted on 5/25/17 at 8:45 a.m. with RN #1. When asked the process staff followed when a resident had a pressure ulcer, RN #1 stated, We measure (the wound) on a weekly basis so we can see if there's any improvement or decline or if we need to change the treatment. When asked who was responsible for completing the weekly wound measurements, RN #1 stated, The treatment nurse. When asked to speak with the nurse, RN #1 stated, She's out on sick leave. When asked about the addition of the resolved documentation on 4/28/17, RN #1 stated, I added that last night. I should have put the date on there. I saw that on 4/28 in the nurse's note that is was resolved. When asked why she should have dated the note, RN #1 stated, Why date it? Because that's when I actually wrote that. Review of the nurse's note dated 4/30/17 documented, Late entry for 4/28/2017 Pressure area to right great toe resolved, RP (responsible party) updated. This note was created by: (name of treatment nurse) on [DATE] 7:42PM. On 5/25/17 at 9:30 a.m. ASM #1, the administrator, ASM #2, the director of nursing and ASM #3, the regional QA manager were made aware of the findings. Review of the facility's policy titled, Wound and Skin Management Program did not evidence documentation regarding how often pressure wounds were to be measured. No further information was provided prior to exit. (1)Deep tissue injury is a term proposed by NPAUP to describe a unique form of pressure ulcers. These ulcers have been described by clinicians for many years with terms such as purple pressure ulcers, ulcers that are likely to deteriorate and bruises on bony prominences (Ankrom, 2005). NPAUP's proposed definition, is A pressure-related injury to subcutaneous tissues under intact skin. Initially, these [MEDICAL CONDITION] have the appearance of a deep bruise. This information was obtained from: http://www.npuap.org/wp-content/uploads/2012/01/DTI-White-Paper.pdf

Based on observation, resident interview, staff interview, facility document review, and clinical record review, the facility staff failed to provide the necessary treatment and services to promote healing, and prevent new pressure sores from developing for one of 20 residents in the survey sample, Resident #9. The facility staff failed to implement interventions to promote healing, alleviate pressure and prevent the development of pressure sores for Resident #9. Resident #9 was admitted to the facility on [DATE] with stage I pressure sores on her right and left heel and a scar from a healed pressure sore on the sacrum. The facility staff failed to consistently elevate the resident's heels to alleviate pressure, failed to provide a pressure reduction mattress, failed to change Resident #9's position to alleviate pressure and failed to consistently measure and stage the resident's wounds. On 5/28/15 the left heel wound had declined to an unstagable pressure sore with necrosis and required debridement (surgical removal of non living tissue *) by the wound physician. On 5/28/15 the right heel wound had declined to a stage II pressure ulcer and Resident #9 had a sacral wound that was documented as a stage II and measured: 2.2 x .7 x .2 cm (centimeter). A pressure ulcer is an inflammation or sore on the skin over a bony prominence (e.g., shoulder blade, elbow, hip, buttocks, or heel), resulting from prolonged pressure on the area, usually from being confined to bed. Also called bedsores. Pressure sores. (1) STAGE 1 PRESSURE ULCER: An observable, pressure- related alteration of intact skin, whose indicators as compared to an adjacent or opposite area on the body may include changes in one or more of the following parameters: skin temperature (warmth or coolness); tissue consistency (firm or boggy); sensation (pain, itching); and/or a defined area of persistent redness in lightly pigmented skin, whereas in darker skin tones, the ulcer may appear with persistent red, blue, or purple hues. NON-BLANCHABLE: Reddened areas of tissue that do not turn white or pale when pressed firmly with a finger or device (2) A stage II pressure ulcer is described as partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough (non viable yellow, tan, gray, green or brown tissue; usually moist, can be soft, stringy and mucinous in texture). May also present as an intact or open/ruptured blister. (2) An Unstagable pressure wound is a known wound but not stagable due to coverage of wound bed by slough and/or eschar. Eschar is dead or devitalized tissue that is hard or soft in texture; usually black, brown, or tan in color, and may appear scab-like. Necrotic tissue and eschar are usually firmly adherent to the base of the wound and often the sides/edges of the wound. (2) SUSPECTED DEEP TISSUE INJURY: Purple or maroon area of discolored intact skin due to damage of underlying soft tissue. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue (2). The findings include: Resident #9 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent MDS (minimum data set assessment) a Medicare 14 day assessment, with an assessment reference date of 5/21/15 coded the resident as being cognitively intact to make daily decisions. The resident was coded as requiring extensive assistance of two or more staff members for moving in the bed and transferring from one surface to another surface. The resident required extensive assistance of one staff member for toileting, dressing, personal hygiene and bathing. Resident #9 was coded as having functional limitation in range of motion in both lower extremities. In Section M - Skin Conditions as having one stage II pressure ulcer and two unstagable pressure ulcers. The nursing admission assessment, dated 4/21/15, documented a diagram of the body. An X was placed over both heels. Next to the X was documented, Reddened dry feet. An X was also documented over the sacral area. Next to the X was documented, Old scar r/t (related to) healed sacral ulcer. The Risk for Pressure Ulcers section of the nursing assessment documented the resident with a score of 16. A total score of 17 or below deems Guest at risk; initiate Care Plan. The Admission Care Plan dated, 4/21/15, documented, Pressure Sores/Skin Care. Goal: Prevent/heal pressure sores/skin breakdown. The interventions documented, Follow facility skin care protocol. Turn every 2 hours and PRN (as needed). Preventative measures: (none documented). Immediately report any redness or skin breakdown to charge nurse/physician. Surgical site L hip. Braden Score^ - 16. ^ Braden scale: a summated rating scale made up of six subscales scored from 1-4 (1 for low level of functioning and 4 for the highest level or no impairment). Total scores range from 6-23 (one subscale is scored with values of 1-3, only). The subscales measure functional capabilities of the patient that contribute to either higher intensity and duration of pressure, or lower tissue tolerance for pressure. A lower Braden Scale Score indicates lower levels of functioning and, therefore, higher levels of risk for pressure ulcer development. The comprehensive care plan dated, 4/29/15, documented, Problems: Actual impaired skin integrity related to stage 2 pressure ulcer to sacrum. The Approaches/Interventions documented in part, Treatment as ordered. Pressure reduction surface to bed at all times. Measure area weekly and document it's characteristics in skin log. Provide assistance to reposition frequently and as needed. The comprehensive care plan dated, 5/4/15 documented, Problems/Conclusions: Potential for impaired skin integrity related to impaired mobility. Under the Approaches/Interventions was documented, Float heels while in bed as tolerated. The care plan documented on 5/4/15, Actual impaired skin integrity related to DTI (deep tissue injury*) to left heel. The Approaches/Interventions documented in part, Measure area weekly and document it's characteristics in skin log. Use comfort aids such as pillows to assist with positioning. Pressure reduction surface to bed at all times. Encourage to float heels in bed. The Pressure Ulcer Record documented the following: Left heel: On 4/21/15 L (left) heel redness. The Stage documented I (stage one). There were no wound size measurements. On 4/29/15 the left heel wound was documented as a Stage I. There were no documented measurements of the wound size, color, drainage and nothing under comments. On 5/5/15 there was no documented stage of the left heel wound, and no measurements but under the Comments was documented, Blanchable (when a patient's skin loses redness with pressure***). On 5/8/15 - Stage - DTI (deep tissue injury); size - 2.5 x 2.5 cm; color - purple. On 5/11/15 - Stage - DTI;-size - 4.3 x 3.1cm; color - dark red. On 5/22/15 (twelve days after last documented entry), the left heel wound was documented as Stage: DTI, Length x width - 2.5 x 2.5 cm (centimeter). There was no other documentation, and no nurse signature. (*Note- on 5/28/15, just six days later on 5/28/15 the wound measured 2.4 x 3.0 cm and had declined to an unstagable pressure sore with necrosis and required debridement (surgical removal of non living tissue *) by the wound physician.) R heel: On 4/21/15 R (right) heel redness. The Stage documented I (stage one). There were no wound size measurements. On 4/28/15 - Stage I documented. Nothing else was documented. On 5/3/15 - Nothing documented except Blanchable, On 5/11/15 documented the right heel wound was a DTI (deep tissue injury); the size was documented as 4.3 x 3.1 cm (centimeter). The color was documented as dark red. (*The measurements for 5/11/15 were crossed off after this surveyor reviewed the chart). On 5/22/15, (eleven days after the last assessment), Stage - DTI; size - 3 x 3cm blister. Nothing else documented On 5/28/15 - Stage - none documented; size - none documented; comments - blister, blanchable. No nurse signature. Sacrum: On 4/29/15,Description: open area measuring 1 x .6 cm (centimeter) with red wound bed. On 5/3/15, No stage was documented. The wound size was documented as: 1.1 x .8 cm. The color was documented as Red. On 5/12/15 (nine days after the last assessment) the sacral wound had no stage or size documented, color - pink; under the Comments was documented, Excoriation. On 5/22/15 (10 days after the last assessment) Stage - none documented; size - 2 x 1.5 cm. nothing else documented. The physician's orders [REDACTED]. On 4/22/15, Skin prep to both heels. Protective cream to sacrum every shift. On 5/8/15, Float heels as tolerated. On 5/10/15, Apply dry dsg (dressing) to L (left) heel QD (every day). D/C (discontinue) skin prep to L (left) heel, continue to skin prep R (right) heel. On 5/8/15, Cleanse sacrum with NS (normal saline); apply [MEDICATION NAME] gel, cover with Allevyn qd (every day). [MEDICATION NAME] gel is a 90% water based gel that is useful in softening eschar, in cooling painful wounds and in presence of hair. They provide for moist wound healing and able to absorb a minimal amount of fluid. Generally work well for superficial granulating wounds. Information provided from the facility wound care book entitled, Skin and Wound Care Policy page 74. The nurse's notes were reviewed and revealed the following: On 4/21/15 did not document anything about the heels. On 5/10/15 at 8:04 a.m. Skin Issues: Left heel. On 5/22/15 at 10:53 p.m. Skin intact. Skin - WNL (within normal limits), Skin - warm/dry. Skin issues (none documented), Mucous membranes - moist. The documented treatment to the left heel from 5/10/15 until 5/26/15 was a dry dressing. A physician order [REDACTED].*); apply topically for skin disorder to left heel and dry dressing; daily. The nurse's note dated, 5/26/15 at 10:35 p.m. did not document anything related to the left heel. On 5/27/15 at 3:12 p.m. the resident was observed in her bed. She was asleep on her back with her head of the bed slightly elevated. Her left foot with a dressing was elevated on a pillow. The right foot was resting with the heel on the surface of the bed. Two boots were sitting on the end of the bed. One was a blue pillow soft boot and the other was a harder material, black boot. Neither boot was on the resident. The resident was observed again at 5:02 p.m. awake, in bed on her back with the head of the bed elevated. The left foot was observed up on the pillow. The right heel was observed directly on the surface of the bed. The blue and black boots were observed sitting on the end of the bed in the left corner. At this time the resident was interviewed, and asked if the boots are supposed to be on. Resident #9 stated, Yes. Review of the physician orders, treatment administration record and care plan, did not reveal any orders or documentation that any type of boots were ordered for Resident #9. An interview was conducted with Resident #9 and her husband on 5/27/15 at 5:02 p.m. They stated that they were confused as to why therapy was advising she (Resident #9) be discharged with a hospital bed with an air mattress, when she hasn't been on one (an air mattress) while she was at the facility . On 5/28/15 at 8:12 a.m. the resident was observed in bed, awake, with the head of the bed elevated. She had her breakfast tray in front of her. Both of her feet were resting directly on the surface of the bed. A pillow was located at the foot of the bed, and was not under the resident's feet. Resident #9 stated, That's my new pillow they gave me last night. It's supposed to take the place of the boots. The boots were observed sitting in her wheelchair. An interview with Resident #9 was conducted on 5/28/15 at 9:25 a.m. When asked if the staff consistently turned her from side to side, Resident #9 stated, One time. Only the one aide at night, (name of aide) would put a pillow behind my butt. Nobody else offered to turn me. When asked if she asked to be turned, Resident #9 stated, I can't say I remember asking. When I first got here I was still groggy from the anesthesia. I had to ask my husband people's names repeatedly. But I can't move my legs that well. I can use my arms but it doesn't still propel me off my butt. I need assistance for turning in the bed. On 5/28/15 at 10:01 a.m. the left and right heel wounds and the sacral wound were observed with LPN (licensed practical nurse) #7. The left heel wound was measured to be 2.4 cm (centimeters) by 3.0 cm. The area had brown necrotic tissue in the center of the wound with white slough around 3/4 of the area. The surrounding skin was peeling off. The edges of the wound appeared macerated (white looking from moisture). The Santyl ointment and dressing were applied. The right heel wound was then measured by LPN #7 and she stated it was 4.3 x 3.5 cm. She described the area as a blister. There was a reddened area observed to the lower right of the wound that was blanchable. The wound was not open, the reddened area was half moon shaped in nature. The outer edges had a yellow cast to them. The wound bed was not visible. Observation of the sacral wound was then conducted. The sacral wound area was pink with granulation tissue. LPN #7 measured the wound as: 2.2 x .7 x .2 cm. When asked what stage each wound was (the left and right heel wounds and the sacral wound), LPN #7 stated, I can't stage it, only the RNs (registered nurse) can stage the wounds. When asked if the wound specialist had seen the resident, LPN #7 stated, He's here on Fridays. An interview was conducted with administrative staff member (ASM) #5, the assistant director of nursing, on 5/28/15 at 11:23 a.m. When asked if there should be measurements for a stage I pressure ulcer, ASM #5 stated, Yes. When asked if the facility utilizes a wound doctor, ASM #5 stated, Yes, (ASM #6), the wound care doctor, comes to the facility every Friday. When asked if he had seen (Resident #9), ASM #5 stated, No, she was out of the building when he was here last Friday. When asked who assesses the wounds, ASM #5 stated, The charge nurses. The assistant director of nursing, ASM #5 was then asked if all nurses can stage wounds. ASM #5 stated, Yes, they all have been trained by a representative from (name of company) that supplies our products. When asked if Resident #9's heels should be floated while she was in the bed, ASM #5 stated, Yes. The TAR (treatment administration record) for May 2015 documented, Float heels as tolerated. There were blanks for 5/11/15 and 5/17/15 for the 11:00 p.m. to 7:00 a.m. shift. It was signed off as done for the 5/27/15 3:00 p.m. to 11:00 p.m. shift and 5/28/15 - 7:00 a.m. - 3:00 p.m. shift. An interview was conducted with ASM #5, the assistant director of nursing, on 5/28/15 at 11:23 a.m. regarding the facility policy for the use of air mattresses for residents. ASM #5 stated, If someone has an actual wound or is a strong potential for a pressure ulcer, then we would put them on one (an air mattress). ASM #5 was asked if Resident #9 should have an air mattress. ASM #5 stated, Yes, she has an actual pressure ulcer. ASM # 5 was then asked to verify what type of mattress Resident #9 had on her bed. ASM #5 went to the room looked at Resident #9's mattress and stated, She should have one (an air mattress). I will get one on her bed immediately. An interview was conducted with ASM #2, the director of nursing, on 5/28/15 at approximately 11:40 a.m. regarding what interventions should be put into place for a resident that has an area of pressure ulcer concern on their heels. ASM #2 stated, We should have boots, float heels, treatments. All interventions should be individualized. When asked if a stage I pressure ulcer should be measured, ASM #2 stated, Yes, if measurable. When asked if an area on the heels can be measured, ASM #2 stated, Yes, they can be, ASM #2 was then asked if all nurses can stage wounds. ASM #2 stated, Yes, they have all been taught by (name of product supplier) with live in-service with actual dummies with wounds. They must pass the skills test. ASM #2 (the director of nursing) was then asked if a physician order [REDACTED]. ASM #2 stated, Yes, but we can obtain one quickly from the nurse practitioner or the doctor. ASM #2 was then interviewed about the facility policy for the use of air mattresses for residents. ASM #2 stated, When we have an area of a stage II or greater or if a resident requests one. When asked if Resident #9, with a stage II pressure ulcer on her sacrum should have an air mattress, ASM #2 stated, Yes. At this time the director of nursing was informed that there was not an air mattress on Resident #9's bed and this observation had been confirmed by ASM #5, the assistant director of nursing. The concern for the above wounds was expressed to ASM #2. An interview was conducted on 5/28/15 at 3:59 p.m. with ASM #2, the director of nursing and ASM #3 the corporate nurse. For the left heel wound, ASM #2 and ASM #3 agreed there were no measurements documented for the stage I pressure ulcer. ASM #2 stated that the staging of the left heel wound on 5/10/15 was incorrect staging by the nurse. They ascertained this after interviewing the nurse. ASM #2, the director of nursing and ASM #3, the corporate nurse, both agreed that there were no measurements of the right heel wound on 4/21/15 and 4/28/15. They stated they were unsure why the nurse crossed through her 5/11/15 wound measurements of 4.3 x 3.1 cm (centimeter). ASM #2 and ASM #3, the corporate nurse, stated these (the measurements documented on 5/11/15) were likely the correct measurements for this wound. ASM #3 was asked how often the wounds are to be measured. ASM #3 stated, They should be measured weekly. On 5/28/15 at 6:22 p.m. upon entering the room with ASM #6, the wound care doctor, RN (registered nurse) #2 was in the room. RN #2 stated to this surveyor, Thank you. I've been trying to get them to order one (an air mattress) since she (Resident #9) was first admitted . She cannot turn herself without assistance and she had a scar from a previous one (pressure sore) so that put her at a higher risk. RN #2 was asked how he goes about getting an order for [REDACTED].#6, the wound doctor described the left heel wound as unstagable with necrosis on top of the wound. His measurements were 2.6 cm x 2.6 cm with .3cm depth. He stated there was an odor which was indicative of bacteria on the wound. He then proceeded to debride the left heel of most of the necrotic tissue. The wound doctor then described the right heel wound as a Stage II pressure wound, an intact blister. ASM #6 then proceeded to measure the sacral wound. He stated it was a stage II wound over old scar tissue. The measurements were 1.6 x 2.8 x .1cm. ASM #6 stated he wasn't as worried about the sacral wound with her history and was unsure if an air mattress would have prevented it. On 5/28/15 at 7:02 p.m., an interview was conducted with ASM #6, the wound care doctor regarding what preventative treatments should have been put in place for Resident #9. ASM #6 stated, They should have had pillows and or boots in place for her. She had a [MEDICAL CONDITION]; she has MS ([MEDICAL CONDITION]) and would have been very prone to pressure ulcers. What bothers me with this case is that she had a stage I and it was allowed to go to a stage II. That could have been prevented. ASM #6 stated the reason the left heel was worse than the right heel was because the left leg was compromised with the fractures. When asked if he was aware of her wounds the previous Friday when he was in the building, ASM #6 stated, No, I was not. At the end of the day meeting on 5/28/15 at 7:20 p.m. ASM #1, the administrator, ASM #2, the director of nursing, ASM #3 and ASM #4, the regional director of operations were made aware of the concern. Documentation was requested evidencing Resident #9 was out of the facility on 5/22/15 during the time the wound doctor was in the facility. On 5/29/15 at 8:30 a.m. ASM #2 and ASM #3 presented a time line related to Resident #9's wounds. When asked again for any evidence of the resident leaving the facility on 5/22/15. ASM #3 stated, She wasn't out of the building, he (the wound doctor) missed her. She was here in the building. We called him to come back but he wasn't available at that time. On 5/29/15 at 8:30 a.m. ASM #6's, the wound care doctor progress notes dated 5/28/15 were presented. The Past Medical History documented, Diabetes mellitus without mention of complication - type II or unspecified type - not stated as uncontrolled. [MEDICAL CONDITION], Hypertension, [MEDICAL CONDITION] - unspecified, [MEDICAL CONDITION]. An Unavoidable Pressure Ulcer Physician Documentation form was presented and signed by ASM #6 on 5/28/15. The form had check marks next to the following routine preventative measures indicating they were in place: Consistent turning and positioning use of pressure reduction surface, good skin care, maintain adequate nutrition/hydration as possible. Under the clinical contributing factors was documented: Diabetes, malnutrition and [MEDICAL CONDITION] were checked off. Certain medications or treatments; [MEDICAL CONDITION] with debility, left [MEDICAL CONDITION], chronic [MEDICAL CONDITION] and diabetes. Other factors: Hgb (hemoglobin) less than 12 mg/dl. Pre-[MEDICATION NAME] 13. Previous history of pressure wound on sacrum. An interview was conducted with Resident #9 on 5/29/15 at 9:25 a.m. When asked if her heels had been consistently floated, the resident stated, It's a hit or miss thing. They are always in a hurry when they come in here. That cushion (pointing to the pillow to elevate her heels) would appear and disappear. For a while they were using the blue boot, which I (the resident) brought with me from (name of hospital) and that black boot. When asked if she asked the staff to turn her and elevate her feet, the resident stated, When I first came here, I was still a bit groggy from having had surgery and the anesthesia. I think it takes a bit to get out of your system, so no I didn't ask them but isn't that their job? Resident #9 was then asked if she asked staff to elevate her feet once the grogginess left. Resident #9 stated, Yes, I did but it depended on them. Sometimes they forgot but the boots were supposed to take the place of the pillow. Resident #9 stated, They (her heels) hurt like hell, and yes the staff were aware. Resident #9 stated, I actually like my feet elevated to take away the pain. At 10:28 a.m. on 5/29/15 the administrative team was made aware of the continued concern. ASM #2 stated, I know you witnessed the heels not being floated but we did have interventions in place and with her comorbidities it could have been worse if we hadn't put anything in place. ASM #4 stated, The building was following their protocol and the doctor said they were unavoidable. The facility policy, Wound and Skin Management Program documented, Prevention is defined as the priority for the elemental goal of wound and skin management. Prevention is the focus of the wound and skin management program. There is not better treatment for [REDACTED]. Our basic wound prevention program consists of: 1. Assessment - Identifying those at risk and early detection of signs and symptoms of skin breakdown. 2. Mobility - move them. 3. Hydration - food and water. 4. Support surfaces - in the bed and in the chair. Mobility is a major component for prevention. All nursing staff need to be aware of the special need for turning and positioning those guests at risk.Support Surfaces - in the bed and the chair (amount of pressure is not as significant as length of pressure). Support surfaces alone neither prevent nor heal pressure ulcers. They are to be used as part of a total program of prevention and treatment. A. Symptoms of a pressure ulcer development stem from the adverse affects of external mechanical forces, which are pressure, shearing, friction, moisture and maceration. A. Protect the bed/chair bound individual by ensuring that the support surface in the bed and the chair are pressure reducing/relieving devices.Prevention Matrix - Lack of Sensory Perception - Turn and reposition every two hours. For guest with red and/or mushy heels - float the heels - Place a pillow or similar object under the Achilles' tendon so that the heels are not receiving pressure from any source. Utilize a pressure - reducing mattress. It is required that each guest who has a Braden Scale of 17 or below be on a pressure relieving/reducing mattress. The lower the Braden scale, the greater the need for higher quality pressure reducing mattress, e.g., alternating pressure, air fluidized, low air loss, etc. Turn and reposition every two (2) hours. Monitoring Healing: Nurses will use clinical judgment to assess signs of healing. If a wound does not show progress toward healing within a two week period (or as expected given the individual's overall condition and ability to heal), the guest's treatment plan should be reviewed with the attending physician. Any signs of deterioration should be addressed immediately. General signs of healing may include decrease in length, width or depth; producing less exudate; changes in tissue type from devitalized such as eschar or slough to healthy regenerative tissue such as granulation and [MEDICATION NAME]. The facility guide, Pressure Ulcer Protocol Quick Reference documented, Stage I - Protect. Remove Cause.High friction - apply skin prep to heels/elbows. The reverse of the reference documented, Heel Ulcer Prevention & Management: 1. Guest with impaired circulation are at greatest risk for heel ulcers and need aggressive prevention. 2. The most effective intervention for heel ulcers is to eliminate pressure. The facility policy, Pressure Ulcer Record documented, Policy: All pressure ulcers are to be documented on the pressure ulcer record weekly. Procedure: 1. Initiate the form when a pressure ulcer is identified. One form is completed for each site.4. Record the date and site when first identified. Document in the description the location and appearance of the pressure ulcer. 5. Document the wound stage. 6. Measure the wound in centimeters and record the length, width and depth.9. Document the odor, drainage and color using the documentation key. 10. The comments should address pain, drainage amount; peri wound area and progress or response to treatment. 11. Enter signature in the appropriate column when documentation is completed. The facility policy, Assessment of Wounds documented, Accurate assessment of each and every type of wound is critical to the healing process. A physician - directed multi-disciplinary team is the key to ensuring that each wound is assessed accurately and appropriately. In addition, administrative nurses, as well as staff nurses, are required to be knowledgeable regarding wound assessment, identifying types of wounds, and the correct modality of treatment based on established protocols. treatment of [REDACTED]. Department of Health and Human Services, Publication Number 15, documents, in part: The assessment of an individual with a pressure ulcer is the basis for planning treatment, evaluating treatment effects, and communicating with other caregivers. Initially, the clinician should determine the location, stage, and size of the pressure ulcer. Accurate staging and description of pressure sores is a perquisite to the development and implementation of appropriate, effective treatment protocols and to effective, ongoing monitoring of tissue healing. Use devices that totally relieve pressure on the heels, most commonly by raising the heels off of the bed .And also, .individuals in bed should have a care plan that includes the use of devices that totally relieve pressure on the heels, most commonly by raising the heels off of the bed. According to the U.S. Department of Health and Human Services Public Health Service, Agency for Health Care Policy and Research, Clinical Practice Guidelines, treatment of [REDACTED]. 95-0652 page 24: The Clinical Practice Guidelines treatment of [REDACTED]. Assessment of pressure sore healing. Progress toward healing should be evaluated weekly. If signs of ulcer deterioration are observed sooner (e.g. during daily dressing changes), steps to reverse them should be taken immediately. 9. Reassessment of Treatment Plan and evaluation of Adherence. If the ulcer is not healing, the clinician must reassess the treatment plan and determine whether it is being followed. In particular the clinician should assess whether tissue load management is adequate and should evaluate the extent of adherence to cleansing and dressing . Pressure ulcers should be uniformly described to facilitate communication amongst staff and to ensure adequate monitoring of the progress toward healing. No further information was provided prior to exit. References: *This information was obtained from the website: <http://medical-dictionary.thefreedictionary.com/debridement> **According to Lexi-Comp's Drug Reference Handbooks: Drug Information Handbook for Nursing: 8th Edition 2007 pg. 301 Santyl Enzyme topical debridement. Use- Promotes debridement of necrotic tissue in dermal ulcers. *** This information was obtained from the website: <http://www.definition-of.com/blanchable> ^ This information was obtained from the website: <http://www.nlm.nih.gov/research/umls/sourcereleasedocs/current/LNC_BRADEN/> (1) Barron's Dictionary of Medical Terms for the Non Medical Reader 2006; Mikel A. Rothenberg, M.D. and Charles F. Chapman. Pages: 155, page 206. (2) Centers for Medicare & Medicaid Services; Long-Term Care Facility Resident Assessment Instrument User's Manual; Version 3.0 October 2014, pages M-15, M-18, M-2.