Every finding on record at The Laurels of University Park

Based on staff interview, clinical record review and facility document review, it was determined that the facility staff failed to evidence professional standards for one of six residents in the survey sample, Resident #2 (R2).The findings include:The facility staff failed to meet professional standards by clarifying the oxycodone orders for R2. R2 was admitted to the facility on [DATE] with diagnosis that included but were not limited to ESRD (end stage renal disease), dialysis, diabetes mellitus and congestive heart failure. The most recent MDS (minimum data set) assessment, a Medicare 5-day assessment, with an ARD (assessment reference date) of 3/3/25, coded the resident as scoring a 14 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired. A review of the MDS Section GG-functional abilities and goals coded the resident as being dependent for bed mobility, transfer, hygiene and supervision for eating. A review of the comprehensive care plan dated 2/27/25 revealed, FOCUS: Resident is at risk for fall related injury and falls related to: left lower extremity fracture. INTERVENTIONS: Keep the resident's environment as safe as possible with: even floors free from spills and/or clutter; adequate lighting; call light within reach, commonly used items within reach, avoid repositioning furniture and keep the bed in the appropriate position. Orient to surroundings as needed.A review of the physician orders dated 2/28/25 revealed, Oxycodone-Acetaminophen Tablet 5-325 MG (Milligrams) Give 1 tablet by mouth every 8 hours as needed for Pain 4-6 Pain. Non-Pharmacological Interventions: Document non-pharmacological interventions used: 1) Massage. 2) Meditation/Relaxation. 3) Positioning. 4)Ice/cold pack. 5) Diversional Activity. 6)Guided Imagery. 7) Rest. 8)Social Interaction. 9)Other ___ -Start Date 02/28/2025 1045 (10:45 AM) -D/C (discontinue) Date 03/18/2025 2137 (9:27 PM).A review of the physician orders dated 3/17/25 revealed, Oxycodone HCl (hydrochloride) ER (extended release) Tablet ER 12 Hour Abuse-Deterrent 10 MG Give 1 tablet by mouth every 12 hours for moderate to severe pain -Start Date 03/17/2025 2100 (9:00 PM) -D/C Date 03/18/2025 1520 (3:20 PM). On 3/17/25 at 10:14 PM, physician, ASM(administrative staff member) #3 progress note revealed, Patient seen in follow up post dialysis treatment feeling weak poor appetite seen in collaboration with wound care nurse patient continues to suffer from a large unstageable sacral wound reviewed pictures with wound care nurse patient earlier screaming in dialysis session secondary to pain after careful review discussion with patient and wife over the phone plan is to administer scheduled long acting oxycodone extended release also patient with assistance and said since the symptoms he is crying he is tearful family requesting antidepressant treatment psychiatric NP(nurse practitioner) consult placed will start patient on Lexapro (2) 10 mg plan of care reviewed at length with patient and wife over the phone.On 3/18/25 at 12:16 PM MAR (medication administration record) administration note revealed, Oxycodone-Acetaminophen Tablet (1) 5-325 MG, Give 1 tablet by mouth every 8 hours as needed for Pain 4-6 Pain-Non-Pharmacological Interventions: Document Non-Pharmacological interventions used: 1) Massage. 2)Meditation/Relaxation. 3)Positioning. 4)Ice/cold pack. 5)Diversional Activity. 6)Guided Imagery. 7) Rest. 8)Social Interaction. 9)Other. Complaint of pain in left leg, rates at a 6.On 3/18/25 2:17 PM LPN (licensed practical nurse) #1, MAR administration note revealed, Oxycodone-Acetaminophen Tablet 5-325 MG Give 1 tablet by mouth every 8 hours as needed for Pain 4-6 Pain-Non-Pharmacological Interventions: Document Non-Pharmacological interventions used: 1) Massage. 2)Meditation/Relaxation. 3)Positioning. 4)Ice/cold pack. 5)Diversional Activity. 6)Guided Imagery. 7) Rest. 8)Social Interaction. 9)Other. PRN (as needed) Administration was: Effective Follow-up Pain Scale was: 3.On 3/18/25 at 3:22 PM LPN #1's progress note revealed, Wife in room, concerned for guest condition. Guest is easy to arouse but is not answering staff questions or talking back. Guest able to grip staff hands with equal strength. Guest asked if he is okay and nods his head yes. Wife asked what she would like to be done, if she feels like guest needs to be sent to the ER, wife states she does not want him to go to the hospital unless necessary medically. Wife informed that the lethargy could be from the new pain medication he started, explained that guest was screaming out in pain from his left leg with ADLS (activities of daily living), therapy and wound care. Vitals obtained and WNL (within normal limits) for guest. BS (blood sugar) 219. MD (medical doctor) notified of guest condition and wife concern, ordered to discontinue scheduled ER oxycodone. RP (responsible party) made aware.On 3/18/25 at 4:41 PM, LPN #1's progress note revealed, Easily aroused by name for medication administration. Guest took Renvela (3) whole with water. Guest thanked nurse after taking the medication. Denies pain at this time and denies needing anything additional.On 3/18/25 at 8:41 PM, RN (registered nurse) #1, progress note revealed, Nurse requested that writer perform brief assessment of resident, stating that he appears lethargic to his baseline since this am. Resident with complex medical history and on dialysis, M, W, F(Monday, Wednesday, Friday). On assessment, BG (blood glucose) 215, resident was responsive to pain and stimuli, was able to respond to his name. Vitals checked and stable to baseline, with the exception of O2 (oxygen) level. O2 saturations were in the mid-high 80s percentage without SOB (shortness of breath) present. Resident placed on O2@ (at) 2 liters by NC (nasal cannula). Resident O2 saturation quickly rose to 98% when placed on O2. Resident placed on continuous L2 monitoring. Will recheck resident in 15 minutes for response to O2 therapy, stimuli and cognitive assessment.On 3/18/25 at 10:20 PM, LPN #3's progress note revealed, The Change In Condition/s (CIC) reported on this CIC Evaluation are/were: Falls Unresponsiveness Seems different than usual Tired, Weak, Confused, or Drowsy. Nursing observations, evaluation, and recommendations are: Guest lethargic most of the day, continued to get more lethargic and less responsive as the day went on. On Call MD notified and ordered to give Narcan (4). 2 doses of Narcan given and guest became more alert. Guest then became restless and agitated, throwing items off of bedside table, flipped bedside table over, gripping at parts on the bed, hitting at staff, repeated yelling out. Guest then fell out the bed and into the floor. Found on left side by the bed. Continued to be aggressive with staff. Primary Care Provider responded with the following feedback: Recommendations: Send to ER (emergency room).On 3/18/25 at 10:28 PM, RN #1's progress note revealed, Writer followed up with on call MD that resident remained very lethargic and difficult to arouse. Unable to administer medications because of lethargy. MD gave order to administer Narcan to determine if the opioid prescribed was causation to the resident's change in condition. First dose of Narcan given by nasal spray, resident opened eyes and went back into deep sleep and not arousable. Second dose administered as ordered and resident immediately opened eyes and began speaking inaudibly, was very confused and agitated. Called MD to report reaction to Narcan. In the interim of calling the MD for an update, the resident was found down on the floor beside his bed. Given orders to send resident to hospital. Family contacted, spoke to wife. Wife requests that he be sent to hospital.On 3/18/25 at 10:53 PM, physician progress note revealed, 3/18 - Patient seen in follow off resting in bed pain significantly improved patient is slightly lethargic arousal to verbal stimuli later notified by nursing staff patient had increased somnolence when his wife was at the bedside narcotic oxycodone extended release just continued patient has agreed to allow more wound care intervention carefully discussed with patient's wife prognosis guarded. Pain symptoms significantly improved with oxycodone. Increased somnolence appears to be due to oxycodone ER - will discontinue after discussion with nursing staff. A review of the physician orders dated 3/18/25 at 9:30 PM revealed, Narcan Nasal Liquid 4 MG/0.1ML (Naloxone HCl) 1 spray in each nostril one time only for opioid side effects until. If 1st does is ineffective, spray an additional spray in the opposite nostril. Wait 2-3 minutes. If ineffective, call MD on call.On 3/19/25 at 5:06 AM, LPN #2's progress note revealed, Call placed to (initials of hospital) for update. Guest being admitted for PNA (pneumonia), ESRD, opioid overdose.A review of the Hospital admission H&P (history & physical) dated 3/19/25 reveals, Patient presented to the ED (emergency department) from the facility after a fall from bed. They reported he received a 'double' of pain medication. He began acting oddly 'not himself', so they administered two doses of nasal Narcan. He then became agitated/combative and 'threw himself' out of the bed and hit his head. No LOC (loss of consciousness). He complained of right temple pain. On arrival, CT (computerized tomography) head negative for acute injury. CXR (chest x-ray) showed unchanged LLL (left lower lobe) pneumonia.A review of the Hospital discharge instructions dated 4/21/25 revealed, Reason for Visit: PNEUMONIA, ESRD, OPIATE OVERDOSE.A review of the fall investigation dated 3/18/25 revealed, Unwitnessed fall out of bed. Guest throwing items, flipped bedside table, gripping bed, hitting at staff. Assisted off the floor and into the bed by three staff members. Guest fighting staff and would not allow staff to obtain vitals.A review of the facility's Post Fall Evaluation form revealed Fell out of bed due to behavior after receiving two Narcan doses. Resident was on his left side beside the bed, gripping assist bar. Bed in lowest position, staff member to sit with resident until ER transport arrives.An interview was conducted on 10/28/25 at 10:45 AM with RN #1. When asked if she remembered R2, RN #1 stated, Yes, I do remember this resident. I was the evening RN supervisor. I make rounds and ask the LPNs what resident concerns they have. (Name of LPN #1) told me she was concerned about (R2) as he was lethargic, and the family had noted this also. (Name of LPN #1) informed me that R2 was started on Oxycodone sometime last evening and was drowsy and not arousable. I called the provider, explained (R2's) medical background and received orders to administer Narcan. I gave first Narcan dose and he opened his eyes then went back to sleep. I did a sternal rub but could not wake him back up. I gave the second dose of Narcan and he woke up. He was in the first room next to the nurse's station, and while I was on the phone with the provider giving an update, could hear noise in (R2)'s room. He had become restless and agitated after second Narcan dose. He turned over the bedside table, and he was on the floor. It was an unwitnessed fall. The provider stated that since the Narcan worked, we could assume that the resident had not been metabolizing the Oxycodone and had overdosed. When RN #1 was asked if there was an order for Oxycodone 5mg/325mg Tylenol give every 8 hours as needed and then an order for a standing every 12 hours Oxycodone 10 mg ER, what would she have done, RN #1 stated, I would have called to clarify the order.An interview was conducted on 10/28/25 at 1:05 PM with ASM #3, the physician for R2. When asked the process for treating pain, ASM #3 stated, Every case is individual. Are we treating acute/chronic or both kinds of pain. I spoke with his wife, and he was not making any therapy progress. He was in severe pain and had a large decubitus. Pain is one of the vital signs for quality care and therapy. These residents are frail, so we are conservative with our treatment. We depend on the nurses to assess the residents and to use their critical thinking skills if the resident does not need the pain medication even if it is scheduled. On 10/28/25 at 1:35 PM an interview was conducted with LPN #3. When asked to describe R2, LPN #3 stated, He came in rehab (rehabilitation) and had wounds, he was alert x(times) two (name and rehab), knew his wife and had dialysis. When shown the MAR (medication administration record) for March 2025 with the orders of Oxycodone ER 10 mg give 1 tablet by mouth every 12 hours for moderate to severe pain and Oxycodone-Acetaminophen tablet 5-325 mg, give 1 tablet by mouth every 8 hours as needed for pain 4-6 pain and asked if the Oxycodone ER 10 mg every 12 hours should have been clarified, LPN #3 stated, Yes, I would have expected the staff to clarify the Oxycodone ER 10 mg give 1 tablet by mouth every 12 hours for moderate to severe pain to include a number range.On 10/28/25 at 2:45 PM, ASM #1, the administrator, ASM #2, the director of nursing and ASM #4, the regional clinical coordinator, were made aware of the findings. A review of the facility's Physician Order policy revealed, Physician orders are obtained to provide a clear direction in the care of the resident. If an order is missing a component the licensed nurse will contact the physician for clarification.No further information was provided prior to exit. References: Oxycodone is used to relieve severe pain. Oxycodone is in a class of medications called opiate (narcotic) analgesics. This information was obtained from the following website: https://medlineplus.gov/druginfo/meds/a682132.htmlLexapro (Escitalopram) is used to treat depression in adults and children and teenagers [AGE] years of age or older. This information was obtained from the following website: https://medlineplus.gov/druginfo/meds/a603005.html. Renvela (Sevelamer) is used to control high blood levels of phosphorus in people with chronic kidney disease who are on dialysis (medical treatment to clean the blood when the kidneys are not working properly). This information was obtained from the following website: https://medlineplus.gov/druginfo/meds/a601248.html. Narcan - Prescription and nonprescription (over the counter) naloxone nasal spray is used along with emergency medical treatment to reverse the life-threatening effects of a known or suspected opiate (narcotic) overdose in adults and children. This information was obtained from the following website: https://medlineplus.gov/druginfo/meds/a616003.

Based on observations, resident/staff interviews, facility document review and clinical record review, it was determined the facility staff failed to develop/implement the care plan for five of 39 residents in the survey sample, Residents #17, #18, #35, #135 and #189. The findings include: 1.The facility staff failed to develop the comprehensive care plan for anticoagulation therapy for Resident #17. Resident #17 was admitted to the facility on [DATE] with diagnosis that included but were not limited to: CHF (congestive heart failure) and DM (diabetes mellitus). A review of the comprehensive care plan dated 4/18/24, which revealed, FOCUS: Resident is at nutritional and/or dehydration risk related to: edema, CHF and DM. Requires therapeutic diet and mechanically altered diet with fluid restriction. INTERVENTIONS: Provide diet as ordered. Fluid Restriction: 1800cc. There is no evidence of anticoagulation therapy on the care plan. A review of the physician's order dated 3/28/24 revealed, Eliquis Oral Tablet 5 MG (milligram) Give 5 mg by mouth every 12 hours. An interview was conducted on 4/24/24 at 9:45 AM with LPN (licensed practical nurse) #3. When asked the purpose of the care plan, LPN #3 stated, it is to develop the plans for the resident to receive care. When asked if anticoagulation therapy should be on the care plan, LPN #3 stated, yes, it should. When asked what should be included, LPN #3 stated, monitoring for bruising/bleeding and notifying the physician if this occurs. On 4/24/24 at 2:05 PM, ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing and ASM #3, the regional quality nurse was made aware of the findings. A review of the facility's Care Planning policy revealed, In addition to care plans based on admission orders, goals for admission and desired outcomes, IDT (interdisciplinary team) assessments, physician orders, dietary needs, therapy services, social services, PASSAR (preadmission screening and resident review) recommendations, and discharge plans the baseline care plans are triggered in PCC (point click care) from the Nursing Comprehensive assessment. No further information was provided prior to exit. 2.The facility staff failed to develop the comprehensive care plan for anticoagulation therapy for Resident #18. Resident #18 was admitted to the facility on [DATE] with diagnosis that included but were not limited to: CHF (congestive heart failure), acute respiratory failure and chronic kidney disease stage III. A review of the comprehensive care plan dated 3/6/24, which revealed, FOCUS: Resident is at nutritional and/or dehydration risk related to: CHF and respiratory failure. Requires therapeutic diet with fluid restriction. INTERVENTIONS: Encourage to follow fluid restriction order: 2000cc. There is no evidence of anticoagulation therapy on the care plan. A review of the physician's order dated 2/29/24 revealed, Apixaban Oral Tablet 2.5 MG (milligram) Give 2.5 mg by mouth two times a day. An interview was conducted on 4/24/24 at 9:45 AM with LPN (licensed practical nurse) #3. When asked the purpose of the care plan, LPN #3 stated, it is to develop the plans for the resident to receive care. When asked if anticoagulation therapy should be on the care plan, LPN #3 stated, yes, it should. When asked what should be included, LPN #3 stated, monitoring for bruising/bleeding and notifying the physician if this occurs. On 4/24/24 at 2:05 PM, ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing and ASM #3, the regional quality nurse was made aware of the findings. No further information was provided prior to exit. 3. The facility failed to develop the comprehensive care plan for dialysis care and to implement the care plan for oxygen therapy for Resident #35. Resident #35 was admitted to the facility on [DATE] with diagnosis that included but were not limited to: ESRD (end stage renal disease), COPD (chronic obstructive pulmonary disease) and diabetes. A review of the comprehensive care plan dated 3/20/24 and revised 4/22/24, which revealed, FOCUS: Resident is at risk for complications related to dialysis due to: End Stage Renal Disease. Resident has a potential for difficulty breathing and risk for respiratory complications related to: Asthma, COPD, SOB (shortness of breath) with exertion and when lying flat. INTERVENTIONS: Observe signs/symptoms of the following: Bleeding, Bruising, Hemorrhage, presence of aneurysm, Bacteremia & septic shock. Document and report abnormal findings to the physician. Oxygen 2LPM continuously. Administer medication & treatments per physician orders. Monitor for ineffectiveness, side effects and adverse reactions, report abnormal findings to the physician. There is no evidence of monitoring for bruit/thrill of fistula. A review of the physician's orders dated 4/11/24, revealed, Oxygen continuous @ 2Liters nasal cannula (lnc). A review of the physician's orders dated 4/23/24, revealed, Hemodialysis Tuesday, Thursday, Saturday. Observe dialysis catheter for bleeding, infection, and catheter caps intact. every shift. Observe dialysis site for thrombosis, bleeding, stenosis, infection, Steal Syndrome, and aneurysm every shift for HD (hemodialysis). An interview was conducted on 4/24/24 at 9:45 AM with LPN (licensed practical nurse) #3. When asked the purpose of the care plan, LPN #3 stated, it is to develop the plans for the resident to receive care. When asked if dialysis care should be on the care plan, LPN #3 stated, yes, it should. When asked what should be included, LPN #3 stated, monitoring the bruit/thrill and for bleeding and notifying the physician if this occurs. When asked if oxygen is set at a rate different from what is in physician orders and on the care plan, has the care plan been implemented, LPN #3 stated, no, it was not implemented. On 4/24/24 at 2:05 PM, ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing and ASM #3, the regional quality nurse was made aware of the findings. No further information was provided prior to exit. 4. The facility staff failed to develop the comprehensive care plan for anticoagulation therapy for Resident #35. Resident #135 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: breast cancer with metastasis to the bone and DM (diabetes mellitus). A review of the comprehensive care plan dated 3/8/24, which revealed, FOCUS: Resident is at risk for is at risk for pain and has acute/chronic pain related to low back pain. INTERVENTIONS: Offer Non-Pharmacological Interventions: 1) Massage, 2) Meditation/Relaxation, 3) Positioning, 4) Ice/cold pack, 5) Diversional Activity, 6) Guided Imagery, 7) Rest, 8) Social Interaction. Administer medications as ordered. Observe for ineffectiveness and side effects, report abnormal finding to the physician. There is no evidence of anticoagulation therapy on the care plan. A review of the physician orders dated 3/8/24 revealed, Apixaban Oral Tablet 5 MG (milligram) Give 1 tablet by mouth two times a day for anticoagulant. An interview was conducted on 4/24/24 at 9:45 AM with LPN (licensed practical nurse) #3. When asked the purpose of the care plan, LPN #3 stated, it is to develop the plans for the resident to receive care. When asked if anticoagulation therapy should be on the care plan, LPN #3 stated, yes, it should. When asked what should be included, LPN #3 stated, monitoring for bruising/bleeding and notifying the physician if this occurs. On 4/24/24 at 2:05 PM, ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing and ASM #3, the regional quality nurse was made aware of the findings. No further information was provided prior to exit. 27660 5. For Resident #189, the facility staff failed to implement the comprehensive care plan to administer treatments for pressure injuries (1). The comprehensive care plan dated, 2/2/2022, documented in part, Focus: (Resident #189) is at risk for impaired skin integrity/pressure injury and currently has PU (pressure ulcer - injury) on admission. The Interventions documented in part, Tx (treatment) as ordered. Sacral Wound The physician order dated, 10/15/2022, documented, Cleanse sacral wound with ns (normal saline) and apply hydrofera blue (3) and secure with island border dsg (dressing) QD (every day; every evening for wound care. The November 2022 TAR (treatment administration record) documented the above order. On 11/12/2022, there was a blank where the treatment was to be documented as completed. The physician order dated 1/8/2023 documented, Cleanse sacral wound with Dakin's solution (4), apply hydrofera blue and secure with island border dsg QD every evening shift for wound care. The January2023 TAR documented the above order. On 1/22/2023 and 1/24/2023, there was a blank where the treatment was to be documented as completed. Review of the nurse's notes failed to evidence documentation as to why the dressings were not completed. Left Heel The physician order dated 10/15/2022, documented, Cleanse wound left heel with NS, apply medihoney (5) with calcium alginate (6) and secure island border dsg every evening shift for wound care. The November 2023, TAR documented the above order. On 11/12/2023, there was a blank where the treatment was to be documented as completed. The December 2023 TAR documented the above order. On 12/8/2023 and 12/19/2023, there was a blank where the treatment was to be documented as completed. The January 2023 TAR documented the above order. On 1/4/2023 and 1/5/2023, there was a blank where the treatment was to be documented as completed. The physician order dated 1/7/2023, documented, Cleanse wound left heel with Dakin's, apply Dakin's moistened gauze with gentamicin ointment (antibiotic), wrap with kerlix and secure with retention tape, every evening shift for wound care. The January 2023 TAR documented the above order. On 1/22/2023 and 1252023, there was a blank where the treatment was to be documented as completed. Review of the nurse's notes failed to evidence documentation as to why the dressings were not completed. Right heel The physician order dated, 1/12/2023, documented, Iodine to right heel QD preventative every evening shift. The January 2023 TAR documented the above order. On 1/22/2023 and 1/24/2023, there was a blank where the treatment was to be documented as completed. Review of the nurse's notes failed to evidence documentation as to why the dressings were not completed. An interview was conducted with LPN (licensed practical nurse) #1 on 4/24/2024 at 10:17 a.m. When asked the purpose of the care plan LPN #1 stated it's to assist the resident in their needs. LPN #1 was asked if the care plan should be followed, LPN #1 stated, yes. 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 above concern on 4/24/2024 at 2:03 p.m. No further information was obtained prior to exit. References: (1) Pressure Injury: A pressure injury is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. 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. This information was obtained from the following website: https://cdn.ymaws.com/npuap.site-ym.com/resource/resmgr/npuap_pressure_injury_stages.pdf (2) 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. This information was obtained from the following website: https://cdn.ymaws.com/npuap.site-ym.com/resource/resmgr/npuap_pressure_injury_stages.pdf (3) Hydrofera Blue -- A foam dressing bound with gentian violet and methylene blue (GV/MB) antibacterial agents (Hydrofera Blue; [NAME] Wound Care, Libertyville, IL) has been shown to be effective against a wide spectrum of microorganisms found in wounds, including methicillin-resistant staphylococcus aureus (MRSA), vancomycin-resistant enterococcus VRE and Candida. This information was obtained from the following website: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4717508/ (4) Dakin's solution: Dilute Dakin solution (0.05% to 0.025%) can be used to irrigate, cleanse, or as a component in wet-to-dry dressings to treat or prevent skin and soft tissue infections.[5] This information was obtained from the following website: https://www.ncbi.nlm.nih.gov/books/NBK507916/ (5) Medi - honey (medical honey) Applying honey preparations directly to wounds or using dressings containing honey seems to improve healing. Honey seems to reduce odors and pus, help clean the wound, reduce infection, reduce pain, and decrease time to healing. This information was obtained from the following website: https://medlineplus.gov/druginfo/natural/738.html. (6) Calcium alginate is a highly absorbent, biodegradable alginate dressing derived from seaweed. Alginate dressings maintain a physiologically moist microenvironment that promotes healing and the formation of granulation tissue cover with dry dressing. This information was obtained from the following website: https://www.o-wm.com/content/wonder-calcium-alginate.

Based on staff interview, facility document review and clinical record review, it was determined the facility staff failed to ensure four of 39 residents in the survey sample, received care and services in accordance with professional standards of practice and the comprehensive care plan, Residents #2, #17, #18, and #135. The findings include: 1. For Resident #2, the facility staff failed to follow physician orders for obtaining weights and notifying the provider of a change in weight. The physician order dated, 3/31/2024, documented, Weights in the morning every Mon, Wed, Fri for HF (heart failure). NOTIFY PROVIDED IF WEIGHT GAIN OF 3 LBS (POUNDS) IN 24 HOURS OR 5 LBS IN A WEEK. The MAR (medication administration record) for April 2024, documented the above order. There were no weights documented on 4/5/2024 and 4/12/2024. Further review of the Weight tab in the medical, record failed to evidence weights for those two days. The MAR documented the following weights: 4/15/2024 - 238.2 4/22/2024 - 244.2 An increase of 6.2 pounds in a week. Review of the nurse's notes failed to evidence documentation of notification to the nurse practitioner or physician of the gain of over five pounds in one week. An interview was conducted with LPN (licensed practical nurse) #7 on 4/24/2024 at 10:35 a.m. The above order was reviewed with LPN #7. When asked what the nurse should do with this order, LPN #7 stated they should carry it through. LPN #7 was asked where to document the notification of the physician or nurse practitioner, LPN #7 stated they document it in the communication book and in the nurse's notes. When asked what the blanks on the MAR where there were not any weights documented, LPN #7 stated, It's the golden rule, if not documented not done. The facility policy, Physician Orders, documented in part, Treatment rendered to a resident must be in accordance with the specific standing, written, verbal, or telephone order of a physician or other licensed health professional ordering within their scope of practice and clinical privileges. 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 above concern on 4/24/2024 at 2:03 p.m. No further information was obtained prior to exit. 42183 2. The facility failed to evidence monitoring of anticoagulation side effects for Resident #17. Resident #17 was admitted to the facility on [DATE] with diagnosis that included but were not limited to: CHF (congestive heart failure) and DM (diabetes mellitus). A review of the comprehensive care plan dated 4/18/24, which revealed, FOCUS: Resident is at nutritional and/or dehydration risk related to: edema, CHF and DM. Requires therapeutic diet and mechanically altered diet with fluid restriction. INTERVENTIONS: Provide diet as ordered. Fluid Restriction: 1800cc. A review of the physician's order dated 3/28/24 revealed, Eliquis Oral Tablet 5 MG (milligram) Give 5 mg by mouth every 12 hours. A review of the March and April MAR/TAR (medication administration record/treatment administration record) revealed no evidence of anticoagulation monitoring. An interview was conducted on 4/24/24 at 9:45 AM with LPN (licensed practical nurse) #3. When asked the process for monitoring anticoagulants, LPN #3 stated, we would assess the resident for signs of bruising and bleeding. When asked where the anticoagulation monitoring would be documented, LPN #3 stated, it would be documented on the MAR/TAR. Asked if the documentation was missing what that indicated, LPN #3 stated, it means that it was not done. On 4/24/24 at 2:05 PM, ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing and ASM #3, the regional quality nurse was made aware of the findings. A review of the facility's Anticoagulation Therapy policy revealed, 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. No further information was provided prior to exit. 3. The facility failed to evidence monitoring of anticoagulation side effects for Resident #18. Resident #18 was admitted to the facility on [DATE] with diagnosis that included but were not limited to: CHF (congestive heart failure), acute respiratory failure and chronic kidney disease stage III. A review of the comprehensive care plan dated 3/6/24, which revealed, FOCUS: Resident is at nutritional and/or dehydration risk related to: CHF and respiratory failure. Requires therapeutic diet with fluid restriction. INTERVENTIONS: Encourage to follow fluid restriction order: 2000cc. A review of the physician's order dated 2/29/24 revealed, Apixaban Oral Tablet 2.5 MG (milligram) Give 2.5 mg by mouth two times a day. A review of the March and April MAR/TAR (medication administration record/treatment administration record) revealed no evidence of anticoagulation monitoring. An interview was conducted on 4/24/24 at 9:45 AM with LPN (licensed practical nurse) #3. When asked the process for monitoring anticoagulants, LPN #3 stated, we would assess the resident for signs of bruising and bleeding. When asked where the anticoagulation monitoring would be documented, LPN #3 stated, it would be documented on the MAR/TAR. Asked if the documentation was missing what that indicated, LPN #3 stated, it means that it was not done. On 4/24/24 at 2:05 PM, ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing and ASM #3, the regional quality nurse was made aware of the findings. No further information was provided prior to exit. 4. The facility failed to evidence monitoring of anticoagulation side effects for Resident #135. Resident #135 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: breast cancer with metastasis to the bone and DM (diabetes mellitus). A review of the comprehensive care plan dated 3/8/24, which revealed, FOCUS: Resident is at risk for is at risk for pain and has acute/chronic pain related to low back pain. INTERVENTIONS: Offer Non-Pharmacological Interventions: 1) Massage, 2) Meditation/Relaxation, 3) Positioning, 4) Ice/cold pack, 5) Diversional Activity, 6) Guided Imagery, 7) Rest, 8) Social Interaction. Administer medications as ordered. Observe for ineffectiveness and side effects, report abnormal finding to the physician. A review of the physician orders dated 3/8/24 revealed, Apixaban Oral Tablet 5 MG (milligram) Give 1 tablet by mouth two times a day for anticoagulant. A review of the March and April MAR/TAR (medication administration record/treatment administration record) revealed no evidence of anticoagulation monitoring. An interview was conducted on 4/24/24 at 9:45 AM with LPN (licensed practical nurse) #3. When asked the process for monitoring anticoagulants, LPN #3 stated, we would assess the resident for signs of bruising and bleeding. When asked where the anticoagulation monitoring would be documented, LPN #3 stated, it would be documented on the MAR/TAR. Asked if the documentation was missing what that indicated, LPN #3 stated, it means that it was not done. On 4/24/24 at 2:05 PM, ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing and ASM #3, the regional quality nurse was made aware of the findings. No further information was provided prior to exit.

Based on observation, resident interview, staff interview, and clinical record review, it was determined that facility staff failed to provide respiratory care and services for four of 39 residents in the survey sample, Resident #s (R) R32, R38, R 35 and R2. The findings include: 1a. For R32, the facility staff failed to store a Bi-PAP mask (1) in a sanitary manner. R32 was admitted to the facility with diagnoses that included but were not limited to obstructive sleep apnea (2) and COPD (chronic obstructive pulmonary disease) (3). On the most recent comprehensive MDS (minimum data set), a 5-Day admission assessment with an ARD (assessment reference date) of 01/04/2024, R32 scored 15 out of 15 on the BIMS (brief interview for mental status), indicating R32 was cognitively intact for making daily decisions. On 04/22/2024 at approximately 1:00 p.m., an observation of R32's Bi-PAP mask revealed it was laying on top of the bed side table uncovered. On 04/22/2024 at approximately 2:05 p.m., an observation of R32's Bi-PAP mask revealed it was laying on top of the bed side table uncovered. On 04/23/2024 at approximately 8:20 a.m., an observation of R32's Bi-PAP mask revealed it was laying on top of the bed side table uncovered. The physician's order for R32 dated 04/16/2024 documented in part, Check BI-PAP placement and function on night shift, every night shift for sleep apnea. Order Date: 4/16/2024. On 04/22/2024 at approximately 2:15 p.m., an interview was conducted with R32. When asked about the Bi-PAP mask R32 stated she uses the Bi-PAP at night for sleep apnea. She further stated that the nurse takes it off her in the morning and puts it on her at night. On 04/24/2024 at approximately 10:22 a.m., an interview was conducted with LPN #1 regarding R32's Bi-PAP mask. When informed of the observations of R32's Bi-PAP mask being uncovered LPN #1 stated that it should be placed in a plastic bag when it is not being used. On 04/23/2024 at approximately 4:45 p.m., ASM (administrative staff member) #1, administrator, ASM #2, director of nursing and ASM #3, regional clinical coordinator, were made aware of the above findings. No further information was provided prior to exit. References: (1) Stands for Bi-level Positive Airway Pressure. A BiPAP machine is a non-invasive form of therapy for patients suffering from sleep apnea. It deliver pressurized air through a mask to the patient's airways. The air pressure keeps the throat muscles from collapsing and reducing obstructions by acting as a splint. A BiPAP machines allow patients to breathe easily and regularly throughout the night. This information was obtained from the website: https://www.alaskasleep.com/blog/what-is-bipap-therapy-machine-bilevel-positive-airway-pressure. (2) Sleep apnea is a common disorder that causes your breathing to stop or get very shallow. Breathing pauses can last from a few seconds to minutes. They may occur 30 times or more an hour. This information was obtained from the website: https://medlineplus.gov/sleepapnea.html. (3) Disease that makes it difficult to breath that can lead to shortness of breath. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/copd.html. 1b. For R32, facility staff failed to administer oxygen according to the physician's orders. The physician's order for R32 dated 04/16/2024 documented in part, O2 (oxygen) at 6 LPM (liters per minute) via (by) NC (nasal cannula) when on portable tank, as needed for COPD. Order Date: 04/24/2024. 8:47 a.m. On 04/24/2024 at 10:25 a.m., an observation of R32's oxygen flow meter on portable oxygen cylinder position of the back of R32's wheelchair revealed she was receiving oxygen at four liter per minute. On 04/24/2024 at approximately 10:22 a.m., an interview was conducted with LPN #1 ([NAME]) regarding R32's oxygen flow rate on the portable oxygen cylinder. At 10:25 a.m., an observation conducted with LPN #1 of R32 revealed she was sitting in her wheelchair receiving oxygen by nasal cannula. Further observation with LPN #1 of the portable oxygen cylinder positioned on the back of R32's wheelchair revealed an oxygen flow rate of four liters per minute. After a review of R32's physician's orders for oxygen as stated above LPN #1 stated the flow rate should have been at six liters per minute. The facility's policy Physician's Orders documented in part, Treatment rendered to a resident must be in accordance with the specific standing, written, verbal, or telephone order of a physician or other licensed health professional ordering within their scope of practice and clinical privileges. On 04/23/2024 at approximately 4:45 p.m., ASM (administrative staff member) #1, administrator, ASM #2, director of nursing and ASM #3, regional clinical coordinator, were made aware of the above findings. No further information was provided prior to exit. 2. For R38, facility staff failed to administer Oxygen according to the physician's order. R38 was admitted to the facility with diagnoses that included but were not limited to COPD (chronic obstructive pulmonary disease) (1). On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 02/06/2024, R38 scored 15 out of 15 on the BIMS (brief interview for mental status), indicating R38 was cognitively intact for making daily decisions. Section O Special Treatments, Procedures and Programs coded R38 as receiving oxygen. On 04/23/2024 at 9:47 a.m., an observation of R38 revealed he was laying in bed. Further observation revealed an oxygen concentrator next to his bed running and the oxygen tubing and nasal cannula laying on the floor in front of the oxygen concentrator and R38 not receiving oxygen. At 10:11 a.m., an observation revealed R38 laying in bed and LPN (licensed practical nurse) #1 enter R38's room and spoke with him then left the room. Further observation revealed the oxygen concentrator next to his bed running and the oxygen tubing and nasal cannula laying on the floor in front of the oxygen concentrator and R38 was not receiving oxygen. At 10:14 a.m., LPN #1 re-entered R38's room and provided him a beverage and left the room. Further observation revealed the oxygen tubing and nasal cannula in the same position as stated above and R38 was not receiving oxygen. At 10:28 a.m., an observation revealed LPN #1 entered R38's room, administered his medications then left the room. Further observation revealed R38 was not receiving oxygen. On 04/23/2024 at approximately 10:45 a.m., an interview was conducted with LPN #1. After reviewing the physician's order for R38's oxygen she was asked to explain what was indicated by Oxygen continuous. LPN #1 stated R38 was to receive oxygen all, the time. When informed of the observation stated above LPN #1 stated that R38 refused the oxygen. When asked at what point in time did R38 refuse the oxygen she stated that she asked R38 when she administered his medication. When asked if R38 received his oxygen from 9:47 a.m. to 10:28 a.m., approximately 41 minutes, LPN #1 stated no. When asked if R38 should have been offered his oxygen earlier LPN #1 stated yes. The physician's order for R38 dated 02/06/2024 documented in part, Oxygen Continuous at 2L (two liters) via (by) NC (nasal cannula) while in bed every shift for COPD. Order Date: 2/06/2024. On 04/23/2024 at approximately 4:45 p.m., ASM (administrative staff member) #1, administrator, ASM #2, director of nursing and ASM #3, regional clinical coordinator, were made aware of the above findings. No further information was provided prior to exit. References: (1) Disease that makes it difficult to breath that can lead to shortness of breath. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/copd.html. 42183 3. The facility staff failed to provide respiratory therapy per physician orders for Resident #35. Observations of Resident #35's oxygen setting on 4/22/24 at 12:45 PM and 4/24/24 at 9:30 AM revealed the oxygen setting was at 3 lnc (liters nasal cannula). Resident #35 was admitted to the facility on [DATE] with diagnosis that included but were not limited to: ESRD (end stage renal disease), COPD (chronic obstructive pulmonary disease) and diabetes. A review of the comprehensive care plan dated 4/22/24, which revealed, FOCUS: Resident has a potential for difficulty breathing and risk for respiratory complications related to: Asthma, COPD, SOB (shortness of breath) with exertion and when lying flat. INTERVENTIONS: Oxygen 2LPM continuously. Administer medication & treatments per physician orders. Monitor for ineffectiveness, side effects and adverse reactions, report abnormal findings to the physician. A review of the physician's orders dated 4/11/24, revealed, Oxygen continuous @ 2Liters nasal cannula (lnc). An interview was conducted on 4/22/24 at 12:45 PM with Resident #35. When asked if they knew what their oxygen setting was, Resident #35 stated, it is on 2 liters. An interview was conducted on 4/24/24 at 9:45 AM with LPN (licensed practical nurse) #3. When asked the oxygen setting, LPN #3 stated, it is on 3 lnc, it should be on 2 lnc. When asked where she read the oxygen level, LPN #3 stated, the line should be in the middle of the ball. On 4/24/24 at 2:05 PM, ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing and ASM #3, the regional quality nurse was made aware of the findings. A review of the facility's Use of Oxygen policy revealed, To promote guest/resident safety in administering oxygen. No further information was provided prior to exit. 27660 4. For Resident #2, the facility staff failed to store a BiPap (1) mask in a sanitary manner. On the most recent MDS (Minimum data set) assessment, a quarterly assessment, with an assessment reference date of 4/12/2024, the resident scored a 13 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired for making daily decisions. In Section O - Special Treatments, Procedures and Programs, the resident was coded as using a Non-invasive Mechanical Ventilator. Observation was made of Resident #2's BiPap machine 4/23/2024 at 10:46 a.m. The BiPap mask was hanging over the BiPap machine, not contained or covered. An interview was conducted with Resident #2, she stated the staff hand her, her mask and she puts it on and off but they put it on the machine. Resident #2 further stated she believed the mask should be stored in a bag during the day when it's not in use to keep it clean. The physician order dated, 2/15/2024 documented, BiPap on q(every) hs (hours of sleep) a set by pulmonologist with 3 liters of oxygen. Dx (Diagnosis): Sleep apnea every day and evening shift for sleep apnea. An interview was conducted with LPN (licensed practical nurse) #7 on 4/24/24 at 10:35 a.m. When asked how a BiPap mask is to be stored when not in use, LPN #7 stated the mask is usually put in a zip lock baggies to store them in. 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 above concern on 4/24/2024 at 2:03 p.m. No further information was obtained prior to exit. (1) Positive airway pressure (PAP) treatment uses a machine to pump air under pressure into the airway of the lungs. This helps keep the windpipe open during sleep. Bilevel positive airway pressure (BiPAP or BIPAP) has a higher pressure when you breathe in and lower pressure when you breathe out. This information was obtained from the following website: https://medlineplus.gov/ency/article/001916.htm.

Based on resident interview, staff interview, clinical record review and facility document review, it was determined that the facility staff failed to implement a complete pain management program for three of 39 residents in the survey sample, Resident #s R97, R38 and R135. The findings include: 1. For R97, the facility staff failed to attempt non-pharmacological interventions prior to the administration of a prn (as needed) pain medications of Oxycodone (1) 5mg (five milligrams). On the most recent MDS (minimum data set), an annual assessment with an ARD (assessment reference date) of 04/04/2024, R97 scored 15 out of 15 on the BIMS (brief interview for mental status), indicating R97 was cognitively intact for making daily decisions. Section J Pain Management coded R97 as having occasional pain at a pain level of five out of ten, with ten being the worse pain. The physician order for R97 documented in part, Oxycodone Tablet 5MG. Give 1 (one) tablet by mouth every 8 (eight) hours as needed for pain. Order Date: 11/29/2023. The eMAR (electronic medication administration record) for R97 dated April 2024 documented the physician's orders as stated above. The eMAR revealed that R97 received Oxycodone 5mg on 04/02/2024 at 5:26 a.m. with a pain level of four, 04/07/2024 at 5:00 a.m. with pain level of five, on 04/14/2024 at 8:17 a.m. with a pain level of three, 04/15/2024 at 6:16 a.m. with a pain level of seven, 04/20/2024 at 1:06 a.m. with a pain level of five, 04/21/2024 at 6:44 a.m. with a pain level of four, and on 04/22/2024 at 1:18 a.m. with a pain level of four and at 10:15 p.m. with a pain level of eight. Further review of the April 2024 eMAR failed to document evidence of non-pharmacological interventions for the dates and times listed above. The facility's progress notes for R97 for the dates and times listed above on the eMARs dated 04/01/2024 through 04/23/2024 failed to evidence documentation of non-pharmacological interventions. On 04/23/24 at approximately 10:58 a.m., an interview was conducted with R97 regarding the prn pain medication. When asked if the nursing staff attempt non-pharmacological interventions before administering his prn pain medication R97 stated the nurses try most of the time. On 04/23/2024 at approximately 2:30 p.m., an interview was conducted with LPN (licensed practical nurse) #1. When to describe the procedure for administering prn pain medications LPN #1 stated she would assess the resident, ask the where the location of the resident's pain is, try non-pharmacological interventions, and if the interventions were not effective, administer the medication that was prescribed. LPN #1 further stated that non-pharmacological interventions should always be attempted before administering the prn pain medication. When asked where it would be documented that the non-pharmacological interventions were attempted, she stated in the nursing notes or on the eMAR. LPN #1 was asked to review the eMAR and progress notes for R97 for documented evidence of non-pharmacological interventions being attempted on the above dates. On 04/24/2024 at approximately 10:10 a.m., an interview was conducted with LPN #1 regarding the documentation of non-pharmacological interventions for R97. After reviewing the nursing progress notes and the April 2024 eMAR for the dates and times listed above, LPN #1 stated that it appeared that the interventions were not attempted. The facility's policy Pain Management documented in part, Individualized interventions related to that resident's individual control of pain management should include both pharmacological, non-pharmacological and include Complementary and Alternative Medicine (CAM) pain management interventions. On 04/23/2024 at approximately 4:45 p.m., ASM (administrative staff member) #1, administrator, ASM #2, director of nursing and ASM #3, regional clinical coordinator, were made aware of the above findings. No further information was provided prior to exit. References: (1) Oxycodone is used to relieve moderate to severe pain. This information was obtained from the website: https://medlineplus.gov/druginfo/meds/a682132.html. 2. For R38, the facility staff failed to attempt non-pharmacological interventions prior to the administration of a prn (as needed) pain medications of Oxycodone (1) 5mg (milligrams) and Acetaminophen (2) 650mg. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 02/06/2024, R38 scored 15 out of 15 on the BIMS (brief interview for mental status), indicating R38 was cognitively intact for making daily decisions. Section J Pain Management coded R97 as having occasional pain at a pain level of four out of ten, with ten being the worse pain. The physician order for R38 documented in part, Oxycodone Tablet 5MG. Give 1 (one) tablet by mouth every 8 (eight) hours as needed for pain. Order Date: 2/06/2024 and Acetaminophen Tablet 650MG. Give 2 (two) tablet by mouth every 4 (four) hours as needed for General Discomfort/Pain. Order Date: 2/06/2024. The eMAR (electronic medication administration record) for R38 dated April 2024 documented the physician's orders as stated above. The eMAR revealed that R38 received Oxycodone 5mg Oxycodone on 04/07/2024 at 10:36 a.m. with a pain level of seven, on 04/09/2024 at 11:00 a.m. with a pain level of three, on 04/10/2024 at 10:22 a.m. with a pain level of two, on 04/14/2024 at 9:05 p.m. with a pain level of three, on 04/20/2024 at 1:03 p.m. with a pain level of five and at 11:15 a.m. with a pain level of eight, on 04/21/2024 at 12:22 p.m. with a pain level of five, on 04/23/2024 at 10:24 a.m. with a pain level of three and on 04/24/2024 at 3:15 a.m. with a pain level of seven. The April eMAR further documented R38 received Acetaminophen on 04/04/2024 at 5:52 p.m. with a pain level of two, on 04/05/2024 at 7:06 p.m. with a pain level of three, on 04/09/2024 at 6:30 p.m. with a pain level of four, on 04/12/2024 at 4:20 p.m. with a pain level of five, on 04/19/2024 at 4:43 a.m. with a pain level of four, and on 04/20/2024 at 3:41 p.m. with a pain level of five. Further review of the April 2024 eMAR failed to document evidence of non-pharmacological interventions for the dates and times listed above. The facility's progress notes for R38 for the dates and times listed above on the eMARs dated 04/01/2024 through 04/23/2024 failed to evidence documentation of non-pharmacological interventions. On 04/23/2024 at approximately 2:30 p.m., an interview was conducted with LPN (licensed practical nurse) #1. When asked to describe how they determine which prn (as needed) pain medication to administer a when the physician has ordered two pain medications, LPN #1 stated go by the pain level on the physician's order and use the residents pain level. When asked to describe the procedure she would follow if the physician's orders do not specify the pain level for each prn pain medication LPN #1 stated she would use her nursing judgement. When asked to describe the procedure for administering prn pain medications LPN #1 stated she would assess the resident, ask the where the location of the resident's pain is, try non-pharmacological interventions, and if the interventions were not effective, administer the medication that was prescribed. LPN #1 further stated that non-pharmacological interventions should always be attempted before administering the prn pain medication. When asked where it would be documented that the non-pharmacological interventions were attempted, she stated in the nursing notes or on the eMAR. LPN #1 was asked to review the eMAR and progress notes for R38 for documented evidence of non-pharmacological interventions being attempted on the above dates. On 04/24/2024 at approximately 10:10 a.m., an interview was conducted with LPN #1 regarding the documentation of non-pharmacological interventions for R38. After reviewing the nursing progress notes and the April 2024 eMAR for the dates and times listed above, LPN #1 stated there was no documentation of non-pharmacological interventions being implemented and the order for the prn pain medications should have been clarified with a pain scale. LPN #1 further stated If the non-pharmacological interventions are not documented then they were not done. On 04/23/2024 at approximately 4:45 p.m., ASM (administrative staff member) #1, administrator, ASM #2, director of nursing and ASM #3, regional clinical coordinator, were made aware of the above findings. No further information was provided prior to exit. References: (1) Oxycodone is used to relieve moderate to severe pain. This information was obtained from the website: https://medlineplus.gov/druginfo/meds/a682132.html. (2) Used to relieve mild to moderate pain from headaches, muscle aches, menstrual periods, colds and sore throats, toothaches, backaches, and reactions to vaccinations (shots), and to reduce fever. This information was obtained from the website: https: https://medlineplus.gov/druginfo/meds/a681004.html. 42183 3.The facility failed to provide a complete pain management program for Resident #135. Resident #135 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: breast cancer with metastasis to the bone and DM (diabetes mellitus). A review of the comprehensive care plan dated 3/8/24, which revealed, FOCUS: Resident is at risk for is at risk for pain and has acute/chronic pain related to low back pain. INTERVENTIONS: Offer Non-Pharmacological Interventions: 1) Massage, 2) Meditation/Relaxation, 3) Positioning, 4) Ice/cold pack, 5) Diversional Activity, 6) Guided Imagery, 7) Rest, 8) Social Interaction. Administer medications as ordered. Observe for ineffectiveness and side effects, report abnormal finding to the physician. A review of the physician orders dated 3/8/24 revealed, Pain-Non-Pharmacological Interventions: Document Non-Pharmacological interventions used: 1) Massage. 2) Meditation/Relaxation. 3) Positioning. 4)Ice/cold pack. 5) Diversional Activity. 6) Guided Imagery. 7) Rest. 8) Social Interaction. as needed Document Non-Pharmacological interventions using the corresponding number. A review of the March and April MAR (medication administration record) revealed the section to document Pain-Non-Pharmacological Interventions: Document Non-Pharmacological interventions used: 1) Massage. 2) Meditation/Relaxation. 3) Positioning. 4)Ice/cold pack. 5) Diversional Activity. 6) Guided Imagery. 7) Rest. 8) Social Interaction. as needed Document Non-Pharmacological interventions using the corresponding number was blank for both months. An interview was conducted on 4/24/24 at 9:45 AM with LPN (licensed practical nurse) #3. When asked the process to pain management, LPN #3 stated, we would assess the resident's pain level and implement non-pharmacological pain interventions. If they did not work, we would administer the pain medication ordered. When asked where the non-pharmacological pain interventions would be documented, LPN #3 stated, it would be documented on the MAR. Asked if the documentation was missing what that indicated, LPN #3 stated, it means that it was not done. On 4/23/24 at 4:30 PM, ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing and ASM #3, the regional quality nurse was made aware of the findings. A review of the facility's Pain Management policy revealed, Each resident identified with pain will have a Pain Management Care Plan. The care plan will have: a consistent pain scale to measure the pain and frequency of re-evaluation, a desired level of pain reduction or acceptable level of pain, resident centered functional outcomes, pain monitoring and who will monitor for pain, nursing comfort measures to alleviate pain, potential adverse effects of treatment and individualized interventions related to that resident's individual control of pain management should include both pharmacological, non-pharmacological and include Complementary and Alternative Medicine (CAM) pain management interventions. No further information was provided prior to exit.

Based on observation, staff interview, and facility document review it was determined facility staff failed to store, prepare, and serve food in a sanitary manner in one of one facility kitchens. The findings include: On [DATE] at approximately 11:25 a.m., an inspection of the facility's kitchen was conducted with OSM (other staff member) #4, dietary manager. 1. On [DATE] at approximately 11:35 a.m., an observation of the top shelf inside the walk-in refrigerator revealed five bags of chopped cabbage available for use. Further observation revealed each of the one-gallon zip-loc storage bags had a use-by-date of [DATE]. OSM #4 immediately removed the bags of cabbage from the refrigerator. 2. On [DATE] at approximately 11:38 a.m., an observation of the three-compartment sink in the facility's kitchen revealed two cooking pots, a whisk, a ladle, pair of tongs and a large colander, submerged in the sink compartment labeled Sanitize. OSM #4 was asked to test the level of sanitizer. She removed a test strip from its container, placed it in the sanitized solution and compared the results with the sanitizer color scale. When asked what the sanitizer level was, OSM #4 stated it was 50ppm (parts per million). When asked if that was the correct level of sanitizer for the item soaking in the sink OSM #4 stated no and that it should have been 200ppm. 3. On [DATE] at approximately 11:45 a.m., an observation of the tray line inside the facility's kitchen releveled OSM #5, dietary aide, standing, wearing a beard uncovered at the tray line. Further observation revealed OSM #5 moving resident's trays that were plated with food and beverages, down the tray line to another dietary aide who placed the tray on the food carts. 4. On [DATE] at approximately 1:40 p.m., an observation of the facility's three nourishment rooms was conducted with OSM #4. Observation of the inside of the freezer in the nourishment located on the 200-hallway revealed a box containing a one serving frozen dinner. Observation of the box failed to evidence a resident's name and/or a room number; Observation of the inside of the refrigerator in the nourishment located on the 500-hallway revealed two 16-ounce bottles of soda approximately half full and a 12-ounce bottle of a tropical drink approximately three-quarters full. Observation of the inside of the freezer revealed a box containing a one serving frozen breakfast sausage bowl. Further observation of the above food items failed to evidence a resident's name and/or a room number; Observation of the inside of the refrigerator in the nourishment located on the 300-hallway revealed a one-pound package of lunch meat, 5-ounce container of yogurt, and a package of five strips of uncooked bacon. Observation of the inside of the freezer revealed a five-ounce bowl of ice cream, three slices of lunch meat in a zip-loc bag, a pint size zip-loc bag containing half-a-dozen shrimp, frozen burrito, eight-ounce package of chocolate truffles, a zip-loc bag containing a Salsbury steak, and a one serving frozen dinner. Further observation of the above food items failed to evidence a resident's name and/or a room number. On [DATE] at approximately 1:55 p.m., an interview was conducted with OSM #4. When asked to describe the procedure for food brought in from outside of the facility OSM #4 stated that nursing should label the food item with the resident's name and room number. When asked who was responsible for checking the refrigerators and freezers in the nourishment rooms OSM #4 stated that the dietary aides should be checking the food when they stock the refrigerators with snacks and supplements for the residents. When asked how often the staff stock the refrigerators and freezers, she stated that it is done two times a day and the refrigerators and freezers should be checked each time. On [DATE] at approximately 2:00 p.m., an interview was conducted with OSM #5. When asked to describe the task he was performing at the tray line earlier that day OSM #5 stated he was checking the food on the resident's trays with the resident's meal ticket to make sure the resident was receiving the correct food. When informed of the above observation OSM #5 stated he should have had his beard covered but did not know where the beard guards were kept. When asked if found out where they were kept, he stated and showed the surveyor the beard guards were on top of the hair nets next to the kitchen door. When asked why it was important to have a beard covered, he stated to prevent hair from falling into the food. On [DATE] an interview was conducted with OSM #4. When asked to describe the procedure for keeping expired food items from being available for use she stated the cooks should be checking the items in the walk-in refrigerator daily. When asked to describe the procedure for the ensuring the correct amount of sanitizer is put in the sink OSM #4 stated the sanitizer level should be checked before placing items in the sanitizer. The facility's policy Three Compartment Sink documented in part, 5. Monitor and record sanitizing solution concentration with appropriate test strip: QAC (Quaternary Ammonium Compound) ,d+[DATE] ppm concentration, 60 second contact time (per Manufacturer's Instructions). The facility's policy Dress Code documented in part, 7. Culinary staff must wear hair restraints(e.g.) hair net, hat, and beard restraint) to prevent their hair from contacting exposed food . The facility's policy Food from Outside Sources documented in part, 5. All food brought in is to be checked by the Nurse, Dietary Manager, or Dietician. It must be placed in a sealed container and labeled for the content, the guest's/resident's name, and date the food was received, and an expiration date of 3 (three) days after the food was brought in . On [DATE] at approximately 4:45 p.m., ASM (administrative staff member) #1, administrator, ASM #2, director of nursing and ASM #3, regional clinical coordinator, were made aware of the above findings. No further information was provided prior to exit.

Based on observation, staff interview, facility document review and clinical record review, it was determined the facility staff failed to ensure the privacy of resident information on one of six medication carts. The findings include: An observation was made on 4/22/2024 at 11:32 a.m. of RN (registered nurse) #1 administering medications on the 200 hallway. RN #1 entered a resident room, while leaving her report sheet on top of the cart. The report sheet contained resident's room numbers, names, vital signs, and notes regarding the residents. This information was left where residents or family members could see. While RN #1 was in a room, five residents went past her medication cart and one family member walked by. An interview was conducted with RN #1 on 4/22/2024 at 11:50 p.m. When asked why the document was on the cart, with resident information visible, RN #1 stated she should have turned it over. When asked why, RN #1 stated because of resident privacy. The facility policy, Guest/Resident Rights documented in part, The staff will safeguard the privacy of guests/residents protected health information from improper use and disclosure and will inform the guest/resident both orally and in writing of his or her rights as a resident, as well as the rules and regulations governing the guests/ residents conduct and responsibilities during his or her stay at the facility. 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 above concern on 4/23/2024 at 4:50 p.m. No further information was provided prior to exit.

Based on staff interview, facility document review and clinical record review, it was determined the facility staff failed to provide a bed hold notice upon transfer for two of 39 residents in the survey sample, Resident #2 and Resident #137. The findings include: 1. For Resident #2, the facility staff failed to provide a bed hold notice upon transfer to the hospital on 1/7/2024. The nurse's note dated, 1/7/2024 at 1:09 a.m. documented, Guest called 911 requesting transport. States to paramedics c/o (complaint of) chest pain. Guest did not notify staff at any point of chest discomfort pr SOB (shortness of breath). Guest medicated due to c/o coughing episode only. Guest currently being transported to (Name of hospital). Further review of the clinical record failed to evidence what documents were sent with the resident to the hospital. An interview was conducted with LPN (licensed practical nurse) #7 on 4/24/2024 at 10:35 a.m. When asked what documents are sent with the resident if they are transferred to the hospital, LPN #7 stated she sends the face sheet, medication list, diagnoses list, bed hold policy and the care plan. When asked if the resident calls 911 do you still send the paperwork, LPN #7 stated yet. LPN #7 was asked where you document the paperwork that is sent to the hospital, LPN #7 stated it should be documented in a nurse's note. On 4/24/2024 at 12:37 p.m., ASM (administrative staff member) #3, the regional clinical coordinator, she stated she had no documentation of what papers went to the hospital or evidence of the bed hold. She stated it was a resident-initiated transfer, the resident called 911. When asked if the required papers should still be sent and documented, yes. Should the bed hold be sent also, ASM #3 stated, yes and documented in the clinical record. The facility policy, Bed Hold, documented in part, 2. Within 24 hours of a hospital transfer the Admission Director or designee will contact the Resident and/or Responsible Party regarding the possible length of transfer and offer a bed hold. ASM #1, the administrator, ASM #2, the director of nursing, and ASM #3, were made aware of the above concern on 4/24/2024 at 2:03 p.m. No further information was obtained prior to exit. 2. For Resident #137, the facility staff failed to provide a bed hold notice upon transfer to the hospital on 2/4/2024. The nurse's note dated 2/4/2024 at 6:52 p.m. documented in part, At 10:15 a.m. Resident was brought by her physical therapist this morning concerning her rapid breathing. Physical therapist has stated her respirations was 40. Nurse practitioner has assessed resident signs and her symptoms . Resident is not verbally responding to the nurse. Resident was only just looked at the nurse .Nurse Practitioner has stated to send resident out to the ER (emergency room ) to be evaluated. Writer (nurse) has called 911 and emergency response team has arrived and sent the resident to (name of hospital) at 10:30 A.M. Called RP (responsible party) left voicemail to give the facility a return call. Further review of the clinical record failed to evidence what documents were sent with the resident to the hospital. On 4/24/2024 at 1:19 p.m., ASM #3 presented a copy of the SNF/NF Transfer to hospital form. When asked if it documents the paperwork that was sent with the resident, ASM #3 stated, no. ASM #3 stated, there is no evidence of a bed hold either. ASM #1, the administrator, ASM #2, the director of nursing, and ASM #3, were made aware of the above concern on 4/24/2024 at 2:03 p.m. No further information was obtained prior to exit.

Based on staff interview, clinical record review and facility document review, it was determined that the facility staff failed to ensure accurate MDS assessments for one of 39 residents in the survey sample; Resident #63. The findings include: For Resident #63, the facility staff failed to accurately code the MDS (Minimum Data Set) assessments regarding the administration of insulin. The 3/20/24 quarterly, 9/28/23 quarterly, and 6/28/23 annual MDS assessments were coded as the resident being on insulin, having received one insulin injection during the seven day look back period. The resident was on Trulicity (1), which was not an insulin. The resident was not on any prescribed insulin. A review of the above MDS assessments revealed the following: In Section N - Medications, was documented, Record the number of days that injections of any type were received during the last 7 days or since admission/entry or reentry if less than 7 days. In the box was typed 1 for one day. The next part, Insulin documented, Insulin injections - Record the number of days that insulin injections were received during the last 7 days or since admission/entry or reentry if less than 7 days. In the box was typed 1 for one injection of insulin. A review of the clinical record revealed an order dated 11/8/22 for Trulicity, 0.75 mg (milligrams) / 0.5 ml (milliliters) injection every Tuesday. Further review of the clinical record revealed there were no active insulin orders at the time of any of the above MDS assessments. On 4/24/24 at 10:50 AM, an interview was conducted with RN #2 (Registered Nurse) the MDS nurse. She stated that there were new MDS staff who misunderstood about coding insulin injections. She stated that it was coded incorrectly, and that they probably confused it with insulin because it is an injection used for diabetes. The facility policy, Accuracy of MDS was reviewed. This policy documented, Purpose: The Accuracy of the MDS must be verified to ensure that the residents strengths, weaknesses, status and areas of actual decline or risk of decline are addressed to provide quality care and to develop and individualized plan of care for the resident. Accuracy is also necessary as the MDS is directly responsible and linked to the Medicare Prospective Payment System, state Medicaid reimbursement programs, Quality Indicator Reports, Public Reporting, Research and development of Policies. Procedure: 1. Each individual that completes a section of the MDS must verify accuracy of the MDS as specified by the MDS 3.0 User's manual by: Review of the resident's record, Observation of the resident, Communication with the resident, direct care staff, physician, family and licensed professionals, Any other route by which information needs to be obtained On 4/24/24 at 2:15 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) Trulicity - Dulaglutide injection is in a class of medications called incretin mimetics. It works by helping the pancreas to release the right amount of insulin when blood sugar levels are high. Information obtained from https://medlineplus.gov/druginfo/meds/a614047.html

Based on staff interview, clinical record review and facility document review, it was determined that the facility staff failed to ensure a PASARR was completed accurately for one of 39 residents in the survey sample; Resident #20. The findings include: For Resident #20, the facility staff failed to ensure the PASARR (Pre Admission Screening and Resident Review) was completed accurately to determine if the resident did or did not have a mental condition requiring additional services. A review of the clinical record for Resident #20 revealed a PASARR form, dated 7/20/22. This form documented the following: 2. DOES THE INDIVIDUAL HAVE A CURRENT SERIOUS MENTAL ILLNESS (MI)? Yes No (Check Yes only if each item below are all Yes. If No, do not refer for evaluation of active treatment needs for MI (mental illness) Diagnosis.) a. Is this major mental disorder diagnosable under DSM (Diagnostic and Statistical Manual of Mental Disorders) (e.g., schizophrenia, mood, paranoid, panic, or other serious anxiety disorder; somatoform disorder; personality disorder; other psychotic disorder; or other mental disorder that may lead to a chronic disability)? Yes No b. Has the disorder resulted in functional limitations in major life activities within the past 3-6 months, particularly with regard to interpersonal functioning; concentration, persistence, or pace; and adaptation to change? Yes No c. Does the treatment history indicate that the individual has experienced psychiatric treatment more intensive than outpatient care more than once in the past 2 years or the individual has experienced within the last 2 years an episode of significant disruption to the normal living situation due to the mental disorder? Yes No In the above form, for Question #2, does the individual have a current serious mental illness, was marked Yes. However, each of the following three questions, Items a, b, and c, were all marked No. This was not in accordance with the instructions documented above to Check Yes (for Question #2) only if each item below (a, b, and c) are all Yes. On 4/24/24 at 8:52 AM, an interview was conducted with OSM #1 (Other Staff Member) the Director of Social Services. She stated the PASARR was not completed correctly. She stated that the facility would not know if the resident needed any kind of additional services, based on the way it was completed. She stated that is she saw one come in like that, the facility would have to make an adjustment and do another one because that one was not correct. She stated that the resident either she has a mental illness or she doesn't and the way the PASARR was completed did not reflect which status was accurate for the resident. The facility policy, Pre-Admission Screening and Guest/Resident Review - PASARR Virginia was reviewed. This policy documented, screen all individuals admitted for nursing care to ensure that needs are met to assist the individual in reaching their highest potential. All persons seeking admission to a nursing facility, who are seriously mentally ill and/or have an intellectual/developmental disability, are required to be evaluated to determine if a nursing facility is the appropriate place to receive services Complete: a new Level 1/DMAS 95 (PASARR screening) for the following changes in condition: 1. An incorrect Level 1/DMAS 95 received upon admission . On 4/24/24 at 2:15 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 provide ADL care of a dependent resident to one of 39 residents in the survey sample; Resident #136. The findings include: For Resident #136, the facility staff failed to evidence that ADL care was provided. Resident #136 was admitted to the facility on [DATE] and discharged on [DATE]. A review of the ADL (Activities of Daily Living) record for December 2023 and January 2024 revealed that the resident was to have showers on Mondays and Thursdays. In December 2023 there were seven opportunities for a shower. There were four showers documented. One occasion contained documentation that the resident was unavailable. On two occasions, no shower was documented. In January 2024 there were seven opportunities for a shower. There were four showers documented. On three occasions, no shower was documented. The facility's ADL logs did not include a line item for documenting any bathing outside of shower days. Therefore it could not be determined how much bathing, if any, the resident received outside of showers. On 4/24/24 at 11:43 AM, an interview was conducted with CNA #2 (Certified Nursing Assistant). She stated that regarding showers, it should be documented on the ADL log. She stated that if it was not documented, then she would assume the resident didn't get the shower and the nurse should be notified of it. A policy regarding ADL care - showers/bathing was requested. None was provided. On 4/24/24 at 2:15 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, facility document review, and clinical record review, it was determined the facility staff failed to provide care and services for the treatment of pressure injuries for one of 39 residents in the survey sample, Resident #189. The findings include: For Resident #189, the facility staff failed to evidence, the treatments for pressure injuries (1), were completed per the physician orders. On the most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 11/4/2022, the resident scored a 14 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired for making daily decisions. In Section M - Skin Conditions, the resident was coded as having two stage three pressure injuries (2). Sacral Wound The physician order dated, 10/15/2022, documented, Cleanse sacral wound with ns (normal saline) and apply hydrofera blue (3) and secure with island border dsg (dressing) QD (every day; every evening for wound care. The November 2022 TAR (treatment administration record) documented the above order. On 11/12/2022, there was a blank where the treatment was to be documented as completed. The physician order dated 1/8/2023 documented, Cleanse sacral wound with Dakin's solution (4), apply hydrofera blue and secure with island border dsg QD every evening shift for wound care. The January2023 TAR documented the above order. On 1/22/2023 and 1/24/2023, there was a blank where the treatment was to be documented as completed. Review of the nurse's notes failed to evidence documentation as to why the dressings were not completed. Left Heel The physician order dated 10/15/2022, documented, Cleanse wound left heel with NS, apply medihoney (5) with calcium alginate (6) and secure island border dsg every evening shift for wound care. The November 2023, TAR documented the above order. On 11/12/2023, there was a blank where the treatment was to be documented as completed. The December 2023 TAR documented the above order. On 12/8/2023 and 12/19/2023, there was a blank where the treatment was to be documented as completed. The January 2023 TAR documented the above order. On 1/4/2023 and 1/5/2023, there was a blank where the treatment was to be documented as completed. The physician order dated 1/7/2023, documented, Cleanse wound left heel with Dakin's, apply Dakin's moistened gauze with gentamicin ointment (antibiotic), wrap with kerlix and secure with retention tape, every evening shift for wound care. The January 2023 TAR documented the above order. On 1/22/2023 and 1252023, there was a blank where the treatment was to be documented as completed. Review of the nurse's notes failed to evidence documentation as to why the dressings were not completed. Right heel The physician order dated, 1/12/2023, documented, Iodine to right heel QD preventative every evening shift. The January 2023 TAR documented the above order. On 1/22/2023 and 1/24/2023, there was a blank where the treatment was to be documented as completed. Review of the nurse's notes failed to evidence documentation as to why the dressings were not completed. The comprehensive care plan dated, 2/2/2022, documented in part, Focus: (Resident #189) is at risk for impaired skin integrity/pressure injury and currently has PU (pressure ulcer - injury) on admission. The Interventions documented in part, Tx (treatment) as ordered. An interview was conducted with ASM (administrative staff member) #2, the director of nursing, on 4/23/2024 at 5:01 p.m. When asked what blanks on the TAR indicated, ASM #2 stated, In general, it would indicate the employee did not document the medication or treatment. ASM #2 was asked how you can tell if the nurse did the treatment, ASM #2 stated, It does not disclose if it was done or not. An interview was conducted with LPN (licensed practical nurse) #1 on 4242024 at 10:17 a.m. When asked what a blank on the TAR indicated, LPN #1 stated, if it's not documented it wasn't done. The facility policy, Skin Management documented in part, Guest/residents with wounds and/or pressure injuries and those at risk for skin compromise, are identified, evaluated and provided appropriate treatment to promote prevention and healing. ASM #1, the administrator, ASM #2, the director of nursing, and ASM #3, were made aware of the above concern on 4/24/2024 at 2:03 p.m. No further information was obtained prior to exit. References: (1) Pressure Injury: A pressure injury is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. 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. This information was obtained from the following website: https://cdn.ymaws.com/npuap.site-ym.com/resource/resmgr/npuap_pressure_injury_stages.pdf (2) 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. This information was obtained from the following website: https://cdn.ymaws.com/npuap.site-ym.com/resource/resmgr/npuap_pressure_injury_stages.pdf (3) Hydrofera Blue -- A foam dressing bound with gentian violet and methylene blue (GV/MB) antibacterial agents (Hydrofera Blue; [NAME] Wound Care, Libertyville, IL) has been shown to be effective against a wide spectrum of microorganisms found in wounds, including methicillin-resistant staphylococcus aureus (MRSA), vancomycin-resistant enterococcus VRE and Candida. This information was obtained from the following website: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4717508/ (4) Dakin's solution: Dilute Dakin solution (0.05% to 0.025%) can be used to irrigate, cleanse, or as a component in wet-to-dry dressings to treat or prevent skin and soft tissue infections.[5] This information was obtained from the following website: https://www.ncbi.nlm.nih.gov/books/NBK507916/ (5) Medi - honey (medical honey) Applying honey preparations directly to wounds or using dressings containing honey seems to improve healing. Honey seems to reduce odors and pus, help clean the wound, reduce infection, reduce pain, and decrease time to healing. This information was obtained from the following website: https://medlineplus.gov/druginfo/natural/738.html. (6) Calcium alginate is a highly absorbent, biodegradable alginate dressing derived from seaweed. Alginate dressings maintain a physiologically moist microenvironment that promotes healing and the formation of granulation tissue cover with dry dressing. This information was obtained from the following website: https://www.o-wm.com/content/wonder-calcium-alginate.

Based on staff interview, resident interview, facility document review and clinical record review, it was determined the facility staff failed to provide monitoring for fluid restriction and intake for three of 39 residents, Resident #17, Resident #18 and Resident #35. The findings include: 1.The facility failed to provide monitoring for fluid restriction and intake for Resident #17. Resident #17 was admitted to the facility on [DATE] with diagnosis that included but were not limited to: CHF (congestive heart failure) and DM (diabetes mellitus). A review of the comprehensive care plan dated 4/18/24, which revealed, FOCUS: Resident is at nutritional and/or dehydration risk related to: edema, CHF and DM. Requires therapeutic diet and mechanically altered diet with fluid restriction. INTERVENTIONS: Provide diet as ordered. Fluid Restriction: 1800cc. A review of the physician's orders dated 3/28/24, revealed, Fluid Restriction diet Chopped Meat texture, Regular consistency, 1800ml per day 720 ml nursing/ 1080 ml kitchen for CHF. A review of the March 2024 MAR (Medication Administration Record) did not evidence any fluid restriction. A review of the April 2024 MAR revealed that day shift was allocated 300 ml, evening 300 ml and night shift 120 ml. On 4/13/24 and 4/14/24 day shift documented 330 ml; and on evening shifts 4/6/24, 4/7/24, 4/9/24, 4/11/24, 4/12/24 and 4/13/24 documented 330 ml exceeding the fluid restriction amount. An interview was conducted on 4/24/24 at 9:45 AM with LPN (licensed practical nurse) #3. When asked how fluid restrictions are determined, LPN #3 stated, the physician writes the order then dietary and nursing divide the amount. When asked where evidence of fluid restriction is documented, LPN #3 stated, it would be on the MAR (Medication Administration Record). On 4/24/24 at 2:05 PM, ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing and ASM #3, the regional quality nurse was made aware of the findings. A review of the facility's Fluid Restriction policy revealed, Upon notification of a fluid restriction via physician order, the Dietary Manager meets with the Charge Nurse to determine the amount of total fluid that will be provided by each department. The Dietary Manager visits with the guest/resident and adjusts their beverage preferences to adhere to the fluid restriction. The guest/resident and family are educated on the fluid restriction and documented in the medical record. No further information was provided prior to exit. 2.The facility failed to provide monitoring for fluid restriction and intake for Resident #18. Resident #18 was admitted to the facility on [DATE] with diagnosis that included but were not limited to: CHF (congestive heart failure), acute respiratory failure and chronic kidney disease stage III. A review of the comprehensive care plan dated 3/6/24, which revealed, FOCUS: Resident is at nutritional and/or dehydration risk related to: CHF and respiratory failure. Requires therapeutic diet with fluid restriction. INTERVENTIONS: Encourage to follow fluid restriction order: 2000cc. A review of the physician's orders dated 2/29/24, revealed, No Added Salt diet Regular texture, Thin consistency, small portions per guest request-2000CC FR (fluid restriction). A review of the March and April 2024 MAR revealed missing documentation on following shifts and dates: day shift: 3/24/24, 4/5/24; evening shift: 3/22/24, 3/23/24, 3/25/24, 4/1/24 and night shift: 3/21/24, 3/23/24 and 4/5/24. An interview was conducted on 4/24/24 at 9:45 AM with LPN (licensed practical nurse) #3. When asked how fluid restrictions are determined, LPN #3 stated, the physician writes the order then dietary and nursing divide the amount. When asked where evidence of fluid restriction is documented, LPN #3 stated, it would be on the MAR (Medication Administration Record). On 4/24/24 at 2:05 PM, ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing and ASM #3, the regional quality nurse was made aware of the findings. A review of the facility's Fluid Restriction policy revealed, Upon notification of a fluid restriction via physician order, the Dietary Manager meets with the Charge Nurse to determine the amount of total fluid that will be provided by each department. The Dietary Manager visits with the guest/resident and adjusts their beverage preferences to adhere to the fluid restriction. The guest/resident and family are educated on the fluid restriction and documented in the medical record. No further information was provided prior to exit. 3.The facility failed to provide monitoring for fluid restriction and intake for Resident #35. Resident #35 was admitted to the facility on [DATE] with diagnosis that included but were not limited to: ESRD (end stage renal disease), COPD (chronic obstructive pulmonary disease), CHF (congestive heart failure) and DM (diabetes mellitus). A review of the comprehensive care plan dated 4/18/24, which revealed, FOCUS: Resident is at nutritional and/or dehydration risk related to: CHF, ESRD, COPD and DM. Requires therapeutic diet with fluid restriction. INTERVENTIONS: Provide diet as ordered. Fluid Restriction: 1500cc. A review of the physician's orders dated 4/16/24, revealed, No Added Salt diet Regular texture, Regular consistency, 1500cc Fluid restriction: 800cc dietary/700cc nursing. A review of the April 2024 MAR did not evidence any fluid restriction. An interview was conducted on 4/24/24 at 9:40 AM with Resident #35. When asked if they knew their fluid restriction Resident #35 stated, no, I do not. An interview was conducted on 4/24/24 at 9:45 AM with LPN (licensed practical nurse) #3. When asked how fluid restrictions are determined, LPN #3 stated, the physician writes the order then dietary and nursing divide the amount. When asked where evidence of fluid restriction is documented, LPN #3 stated, it would be on the MAR (Medication Administration Record). On 4/24/24 at 2:05 PM, ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing and ASM #3, the regional quality nurse was made aware of the findings. A review of the facility's Fluid Restriction policy revealed, Upon notification of a fluid restriction via physician order, the Dietary Manager meets with the Charge Nurse to determine the amount of total fluid that will be provided by each department. The Dietary Manager visits with the guest/resident and adjusts their beverage preferences to adhere to the fluid restriction. The guest/resident and family are educated on the fluid restriction and documented in the medical record. No further information was provided prior to exit.

Based on resident and staff interview, resident interview, clinical record review and facility document review, it was determined the facility staff failed to provide dialysis care and services for one of 39 residents in the survey sample, Resident #35. The findings include: The facility failed to provide evidence of monitoring for bruit and thrill for Resident #35. Resident #35 was admitted to the facility on [DATE] with diagnosis that included but were not limited to: ESRD (end stage renal disease) and diabetes. A review of the comprehensive care plan dated 3/20/24, which revealed, FOCUS: Resident is at risk for complications related to dialysis due to: End Stage Renal Disease. INTERVENTIONS: Observe signs/symptoms of the following: Bleeding, Bruising, Hemorrhage, presence of aneurysm, Bacteremia & septic shock. Document and report abnormal findings to the physician. A review of the physician's orders dated 4/23/24, revealed, Hemodialysis Tuesday, Thursday, Saturday. Observe dialysis catheter for bleeding, infection, and catheter caps intact. every shift. Observe dialysis site for thrombosis, bleeding, stenosis, infection, Steal Syndrome, and aneurysm every shift for HD (hemodialysis). A review of Resident #35's medical record evidenced that she went to dialysis on 3/21, 3/23, 3/26, 3/28, hospitalized ,d+[DATE]-[DATE], 4/16, 4/18, 4/20 and 4/23/24. A review of Resident #35's March and April 2024 MAR (medication administration record) and TAR (treatment administration record) revealed no evidence of assessment of bruit and thrill of left arm fistula. An interview was conducted on 4/22/24 at 12:45 PM with Resident #35. When asked if they monitor the bruit and thrill of her fistula, Resident #35 stated, no, I do not believe so. On 4/23/24 at 1:00 PM, ASM (administrative staff member) #2, the director of nursing, stated, we do not have the bruit and thrill evidence for this resident. An interview was conducted on 4/24/24 at 9:45 AM with LPN (licensed practical nurse) #3. When asked where the bruit and thrill are documented, LPN #3 stated, it would be documented on the TAR. Asked if the documentation was missing what that indicated, LPN #3 stated, it means that it was not done. On 4/23/24 at 4:30 PM, ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing and ASM #3, the regional quality nurse were made aware of the findings. A review of the facility's Hemodialysis policy revealed, Evaluate the resident daily for dialysis access site and possible complications, including, but not limited to: a. Evaluation of the access site for: i. Thrombosis or bleeding, ii. Stenosis - small blue/purple veins. Constriction or narrowing within an orifice, iii. Infection - redness, drainage, abscess, warmth of the extremity. b. Thrill- palpation of the fistula site, it can be described as a purring vibration. c. Bruit- a continuous, machine-like sound that can be heard during auscultation with a stethoscope. It can also be described as a whooshing or a high pitched whistling. d. If the resident has a catheter for hemodialysis access, evaluate the catheter and site for: i. Bleeding, ii. Signs of infection, iii. To ensure that the catheter caps are intact. e. Notify physician of absence of bruit or thrill, signs of infection or other irregularity. No further information was provided prior to exit.

Based on observation, staff interview, and facility document review, it was determined the facility staff failed to maintain infection control practices during the medication administration observation for one of three nurses observed. The findings include: Observation was made on 4/22/2024 at 11:32 a.m. of RN (registered nurse) #1 administering medications on the 200 hallway. RN #1 was observed popping two medications out of the medication bubble pack and dropping the pills into her hand. She then put the pills into the medication cup and administered the medications to the resident. An interview was conducted with RN #1 on 4/22/2024 at 11:55 a.m. The above observation was shared with RN #1. She stated she guessed she had done that. When asked should the nurse touch a resident's medications with her hands, RN #1 stated, no. When asked why, RN #1 stated because of sanitary reasons, germs. The facility policy, Medication administration, documented in part, 1 . If medications come into contact with the bare hands of the nurse/med(medication) tech (technician), or with the med cart, the medication should be disposed of per policy and new medications obtained. 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 above concern on 4/23/2024 at 4:50 p.m. No further information was provided prior to exit.

Based on staff interview, facility document review, and clinical record review, the facility staff failed to implement a complete immunization program for one of five residents reviewed for immunizations, Resident #5. The findings include: For Resident #5 (R5) the facility staff failed to provide education for and offer the most recent influenza vaccination. R5 was admitted to the facility on [DATE]. A review of R5's clinical record revealed no evidence that she was educated about or offered the most recent influenza vaccine. On 4/24/24 at 12:34 p.m., ASM (administrative staff member) #2, the director of nursing was interviewed. She stated the assistant director of nursing, who no longer works at the facility, was responsible for making sure all residents were offered the influenza vaccine when it became available in the fall of 2023. She stated residents should have been given a form with the risks and benefits of receiving the vaccine, and provided an opportunity to accept or decline its administration. She stated she could not explain why the staff member responsible for the vaccinations did not follow through with their responsibilities. On 4/24/24 at 2:30 p.m., ASM #1, the administrator, ASM #2, and ASM #3, the regional clinical director, were informed of these concerns. A review of the facility policy, Immunizations: Influenza Vaccination of Guest/Residents, revealed, in part: Beginning in October .Follow standing protocol to administer vaccine. If guest/resident is eligible, obtain an order for the vaccine and provide education. No further information was provided prior to exit.

Based on staff interview, facility document review, and clinical record review, the facility staff failed to implement a complete immunization program for one of five residents reviewed for immunizations, Resident #5. The findings include: For Resident #5 (R5) the facility staff failed to provide education for and offer the most recent COVID vaccination. R5 was admitted to the facility on [DATE]. A review of R5's clinical record revealed no evidence that she was educated about or offered the most recent COVID vaccine. On 4/24/24 at 12:34 p.m., ASM (administrative staff member) #2, the director of nursing was interviewed. She stated the assistant director of nursing, who no longer works at the facility, was responsible for making sure all residents were offered the most recent COVID vaccine when it became available. She stated residents should have been given a form with the risks and benefits of receiving the vaccine, and provided an opportunity to accept or decline its administration. She stated she could not explain why the staff member responsible for the vaccinations did not follow through with their responsibilities. On 4/24/24 at 2:30 p.m., ASM #1, the administrator, ASM #2, and ASM #3, the regional clinical director, were informed of these concerns. A review of the facility policy, COVID-19 Vaccination, revealed, in part: The vaccine administrator will identify residents that would qualify to receive the additional dose of booster dose of COVID-19 vaccine based on CDC (Centers for Disease Control) recommendations .Educate resident or responsible party on additional dose of COVID-19 vaccine. The facility will obtain a signed consent form for the administration of the additional dose of COVID-19 vaccine from the resident .A declination will be signed if consent is not given. No further information was provided prior to exit.

Based on staff interview, facility document review and clinical record review, it was determined the facility staff failed to evidence the required documents were sent to the hospital upon transfer for two of 39 residents in the survey sample, Resident #2 and Resident #137. The findings include: 1. For Resident #2, the facility staff failed to evidence the required documents were sent to the hospital with the resident on 1/7/2024. The nurse's note dated, 1/7/2024 at 1:09 a.m. documented, Guest called 911 requesting transport. States to paramedics c/o (complaint of) chest pain. Guest did not notify staff at any point of chest discomfort or SOB (shortness of breath). Guest medicated due to c/o coughing episode only. Guest currently being transported to (Name of hospital). Further review of the clinical record failed to evidence what documents were sent with the resident to the hospital. An interview was conducted with LPN (licensed practical nurse) #7 on 4/24/2024 at 10:35 a.m. When asked what documents are sent with the resident if they are transferred to the hospital, LPN #7 stated she sends the face sheet, medication list, diagnoses list, bed hold policy and the care plan. When asked if the resident calls 911 do you still send the paperwork, LPN #7 stated yes. LPN #7 was asked where you document the paperwork that is sent to the hospital, LPN #7 stated it should be documented in a nurse's note. On 04/24/2024 at 12:37 p.m., ASM (administrative staff member) #3, the regional clinical coordinator, stated she had no documentation of what papers went to the hospital. She stated it was a resident-initiated transfer, the resident called 911. When asked if the papers sent should still be sent and documented, ASM #3 stated, yes. The facility policy, Transfer and Discharge documented in part, A transfer form is completed, a list of medications and a copy of the care plan goals is sent to the receiving hospital. Nursing documents the transfer in the medical record. ASM #1, the administrator, ASM #2, the director of nursing, and ASM #3, were made aware of the above concern on 4/24/2024 at 2:03 p.m. No further information was obtained prior to exit. 2. For Resident #137, the facility staff failed to evidence the required documents were sent to the hospital with the resident on 2/4/2024. The nurse's note dated 2/4/2024 at 6:52 p.m. documented in part, At 10:15 a.m. Resident was brought by her physical therapist this morning concerning her rapid breathing. Physical therapist has stated her respirations was 40. Nurse practitioner has assessed resident signs and her symptoms . Resident is not verbally responding to the nurse. Resident was only just looked at the nurse .Nurse Practitioner has stated to send resident out to the ER (emergency room ) to be evaluated. Writer (nurse) has called 911 and emergency response team has arrived and sent the resident to (name of hospital) at 10:30 A.M. Called RP (responsible party) left voicemail to give the facility a return call. Further review of the clinical record failed to evidence what documents were sent with the resident to the hospital. On 4/24/2024 at 1:19 p.m., ASM #3 presented a copy of the SNF/NF Transfer to hospital form. When asked if it documents the paperwork that was sent with th resident, ASM #3 stated, no. ASM #1, the administrator, ASM #2, the director of nursing, and ASM #3, were made aware of the above concern on 4/24/2024 at 2:03 p.m. No further information was obtained prior to exit.

Based on staff interview, employee record review, and facility document review, it was determined that the facility staff failed to evidence annual performance reviews were conducted for six of six employee records reviewed. The findings include: On 4/23/24 and on 4/24/24, a request was made for annual evaluations for six CNA's (Certified Nursing Assistant), CNA#3, CNA #4, CNA #5, CNA #6, CNA #7, and CNA #8, for the most recently completed anniversary years. The anniversary years were as follows: CNA #3 was 6/30/22 to 6/30/23 CNA #4 was 3/10/23 to 3/10/24 CNA #5 was 10/2/22 to 10/2/23 CNA #6 was 11/15/22 to 11/15/23 CNA #7 was 10/23/22 to 10/23/23 CNA #8 was 9/2/22 to 9/2/23 On 4/24/24 at 11:00 AM, an interview was conducted with ASM #2 (Administrative Staff Member) the Director of Nursing (DON). She stated that she was not able to locate any of them. She stated that the time frames were prior to her transition to the role of DON. She stated she had been the DON since September, 2023. The facility policy, Staff Development was reviewed. This policy documented, Policy: Staff development includes the planning, coordination, provision, and management of orientation, and inservice activities for facility employees Procedure 9. A competency evaluation will be completed annually for all certified nurse aides / state tested nursing assistants. Training will be added to the calendar based on the weakness identified On 4/24/24 at 2:15 PM, 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 by the end of the survey.

Based on staff interview and facility document review, it was determined that the facility staff failed to ensure that 25 out of 30 staff postings reviewed contained the required daily census information. The findings include: On 4/22/24, The daily staff posting for March 23, 2024 through April 21, 2024 was reviewed. This review revealed that the Census information was not included on 25 of the 30 days reviewed. On 4/22/24 at 3:30 PM, an interview was conducted with ASM #2 (Administrative Staff Member) the Director of Nursing (DON). She stated that the scheduler usually posts the daily staffing but that individual would not be in the facility on 4/22/24 and 4/23/24. She stated that in their absence, she, as the DON, posts it. She stated that the census information should be documented on the posting. She stated that she would be educating the scheduler on documenting the census information. A policy was requested regarding the daily staff posting. None was provided. On 4/24/24 at 2:15 PM, 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 by the end of the survey.

Based on observation, staff interview, clinical record review and facility document review it was determined that the facility staff failed to provide and implement interventions /assistive devices to prevent accidents for two of 50 residents in the survey sample, Resident #42 and #24. 1. The facility staff failed to ensure a safe transfer to prevent injury for Resident #42, who was assessed by PT (physical therapy) on 1/12/18, as non-ambulatory and as requiring Hoyer transfer. On 3/30/18, two CNA's (certified nursing assistants) transferred Resident #42 using a sit to stand lift, the resident fell and sustained *acute left proximal tibia and fibula shaft fractures, resulting in harm. *(Acute- having a rapid onset. Proximal situated nearer to the center of the body or the point of attachment. Tibia is the medial and larger of the two bones of the lower leg, articulating with the femur, Synonym(s): shinbone. Fibula is the lateral and smaller of the two lower bones of the leg. Shaft is long slender part, such as the diaphysis (shaft or central part) of a long bone). (1) 2. The facility staff failed to put a fall mat down while the resident was in bed per the physician orders [REDACTED].#24. The findings include: 1. Resident # 42 was admitted to the facility on [DATE] with a readmission of 04/08/18 with [DIAGNOSES REDACTED]. Resident # 42's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 03/07/18, coded Resident # 42 as scoring a 6 (six) on the brief interview for mental status (BIMS) of a score of 0 - 15, 6 (six) - being severely impaired of cognition for making daily decisions. Resident # 42 was coded as requiring extensive assistance of one staff member for activities of daily living. Under G0120 Bathing Resident # 42 was coded as totally dependent of two staff members. Resident # 42 was coded as requiring extensive assistance of two staff members for transfers- (how the resident moves between surfaces including to or from bed, chair, wheelchair, standing position). Under section G0300 Balance During Transitions and Walking Resident # 42 was coded as 2 (two) - Not steady, only able to stabilize with staff assistance for E. Surface-to-surface transfer (transfer between bed and chair or wheelchair.) Under G0400 Functional Limitations in Range of Motion Resident # 42 was coded, Impairment on both sides of lower extremity (hip, knee, ankle, foot. Resident # 42's MDS (minimum data set), a significant change assessment with an ARD (assessment reference date) of 04/14/18, coded Resident # 42 as scoring a 7 (seven) on the brief interview for mental status (BIMS) of a score of 0 - 15, 7 (seven) - being severely impaired of cognition for making daily decisions. Resident # 42 was coded as requiring extensive assistance of one staff member for activities of daily living. Under Section J1800 Any Falls Since Admission/Entry or Reentry or Prior Assessment documented, Yes. Under J1900 Number of Falls Since Admission/Entry or Reentry or Prior Assessment documented, 1 (one) C. Major injury - bone fracture, joint dislocation, closed head injuries with altered consciousness, subdural hematoma. The Physical Therapy Evaluation and Plan of Treatment dated 01/21/18 for Resident # 42 documented, Current Referral: Reason for Referral/Current Illness: Pt (patient) referred to skilled PT (physical therapy) to assess need for RNP (restorative nursing program) and program development. Musculoskeletal System Assessment: RLE (right lower extremity) = impaired. LLE (left lower extremity) = impaired. General RLE Strength = Hip = impaired; Knee = impaired; Ankle = impaired. General LLE Strength = Hip = impaired; Knee = impaired; Ankle = impaired. Under Functional Mobility Assessment it documented, Transfers = Hoyer transfer. PT (patient) unable to amb (ambulate). Under Assessment Summary, it documented, Clinical Impressions: Pt is TD (totally dependent) with functional mobility and positioning. Pt was previously on RNP and needs a new program to maintain ROM (range of motion) for proper position and skin integrity. Under Reason for Therapy, it documented, Reason for Skilled Services: Pt is not being picked up by skilled services due to no indication to expect a positive functional change. The physician's note dated (MONTH) 23, (YEAR) and signed by the nurse practitioner on (MONTH) 23, (YEAR) documented, Home/Environment Assessment. Living Situation: Other. Home type: Nursing Home. Skilled Nursing Facility: (Name of Nursing Home). Home equipment: Hoyer lift, Wheelchair. The facility's Quarterly Pain/Braden/Falls form for Resident # 42 dated 03/27/2018 documented, 1. Activity: 3. Degree of physical activity; Chairfast (sic.) - Ability to walk severely limited or nonexistent. Cannot bear own weight and/or must be assisted to chair or wheelchair. 4. Mobility: Ability to change and control body position. Very limited - Makes occasional slight changes in body or extremity position but unable to make frequent or significant changes independently. Under Fall Risk it documented, III. Ambulation/Elimination. 1. Resident's ambulation/elimination status. Chair bound/assist with elimination. Gait N/A (non-applicable) - not able to perform function. The comprehensive care plan for Resident # 42 dated,03/13/18 documented, Need. FALLS: At risk for fall related injury R/T (related to) Impaired vision, impaired mobility, Incont (incontinence) [MEDICAL CONDITION] drug use, antidepressant medication for depression and [MEDICAL CONDITION], history of falls, anticonvulsant usage, DX (diagnoses) [MEDICAL CONDITIONS], foot drop, and [MEDICAL CONDITION]. Date Initiated: 03/13/2018. Under Interventions, it documented in part, Encourage guest to wear non-skid foot wear when out of bed. Assist guest as needed. Date Initiated: 03/13/2018 and Lock wheel on wheelchair prior to transfers. Date Initiated: 03/13/2018. Further review of the care plan failed to evidence Hoyer transfer as documented in the 01/21/18 physical therapy evaluation. The nurse's Progress Notes, dated 03/30/2018. 11:15 (a.m.) for Resident # 42 documented, At 11:15 a.m. Guest was in the shower room with two shower aides and they were transferring her from the sit to stand lift, to the shower chair and guest hands slipped off of machine and she fell in the shower. Guest c/o (complaint of) left leg pain and the leg was red and painful when touched. A pillow was placed under her head for comfort and she was not moved from floor until paramedics came. Emergency ambulance were called to come take guest to the hospital. Guest was transported to (Name of Hospital) at 11:30 a.m. RP (responsible party) notified, MD (medical doctor) notified, DON (director of nursing) notified. The nurse's Progress Notes dated 03/31/2018. 01:58 (1:58 p.m.) for Resident # 42 documented, Guest returned from hospital at 6:15 p.m. She has a non-displaced tib/fib (tibia/fibula) fracture and needs to be non-weight bearing for the next 6 (six) weeks. No complaints of pain. The User Manual for the Stand Up Patient Lift documented, The standup lift may be operated by one healthcare professional for all lifting preparation, transferring from and transferring to procedures with a cooperative, partial, weight-bearing patient. However, since medical conditions vary (Name of Company) recommends that the healthcare professional evaluate the need for assistance and determine whether more than one assistant is appropriate in each case to safely perform the transfer. On 06/14/18 at approximately 2:00 p.m., the facility's Incident Report was reviewed. The Incident Report documented, Resident: Resident # 42) Date of Incident 3/30/18; Time of Incident: 11:15 a.m. Type of Occurrence: Witnessed fall. Type of Injury: Left leg discomfort, pain redness. Location: shower room. Was Guest Taken to Hospital? Yes. By Whom? Ambulance - 911 to (Name of Hospital). Equipment Involved, If so, specify: sit to stand. Family and Physician notified on 3/30/18. On 06/14/18 at approximately 2:00 p.m., the facility's Post Fall Report was reviewed. The Post Fall Report was undated and was signed by LPN (licensed practical nurse) # 13. The form documented Incident Date 3/30/18; Time: 11:15; Location: Shower room. Circumstances of Fall: Indicate by circling correct answer for each and explain as indicated: Guest activity: Transferring. Was the guest using assistive device? Yes. Type: Sit to stand. What did the guest say about the event? Guest said her hands slipped off of mechanical device and she fell . Physical Handling. Was staff assisting with transfer or ambulation at the time of the fall? Yes. If yes, describe the situation and assistance being provided: Guest was being transferred from sit to stand to the shower chair and her hands slipped off of the machine and she fell in (sic) the floor because she is unable to bear weight. The Name of Hospital) Orthopedic note dated 03/30/2018 for Resident # 42 documented, Plan: Acute left proximal tibia and fibula shaft fractures - patient is minimally ambulatory at baseline and fractures have minimal displacement so will proceed with non-operative conservative management. Placed in knee immobilizer to accommodate her knee valgus (knee deformity). Needs to remain NWB (non-weight bearing) through left leg for at least 6 wks (six weeks). Bed to chair transfers or transfers with NWB with PT/OT (physical therapy/occupational therapy). OK to discharge back to her regular facility if appropriate for her level of care otherwise will need to be admitted for placement. On 06/14/18 at 2:41 p.m., an interview was conducted with ASM (administrative staff member) # 1, administrator. When asked about the use of the sit to stand lift for transferring Resident # 42, ASM # 1 stated, It probably was not the best choice. On 06/14/18 at 3:08 p.m., an interview was conducted with OSM (other staff member) # 6, director of rehabilitation services. OSM #6 asked was asked the rehabilitation department's role in assessing a resident for the use of a mechanical lift. OSM # 6 stated, Currently when a resident is coming off rehab (rehabilitation) and if there is any change in the resident's care needs, functional mobility, transfer status, a form is completed. A copy is brought to the floor for the staff, and it is brought to the clinical meeting every day and reviewed and discussed, and therapy is conducting in-services and education on the last day of treatment regarding the changes for the resident. When asked about Resident # 42's fall on 03/30/18, OSM # 6 stated, My understanding that it was determined that we should have been using a different lift. When the Regional clinical coordinator reviewed this incident we put a plan into place after reviewing the incident. On 06/14/18 at 4:55 p.m., this surveyor informed, ASM (administrative staff member) # 1, the administrator, of the concern for harm to Resident #42. On 06/15/18 at 8:35 a.m. an interview was conducted with ASM # 1, administrator. ASM # 1 was asked to describe the process the facility used for communicating the recommendations from the rehabilitation department to nursing prior to Resident # 42's fall. ASM # 1 stated, It was a scattered process, no consistency or checks and balances. One can assume that that when the therapist discharged a resident from therapy, they informed the resident's nurse of their recommendations and that it (recommended transfer status) was communicated. I think it is fair to say that both parties (nursing and rehabilitation) had a part in the break down. There was no formal approach. The new approach is, when a resident is coming off rehab (rehabilitation) and if there is any change in the resident's care needs, functional mobility, transfer status the form is completed. A copy is brought to the floor for the staff, and brought to the clinical meeting every day and reviewed and discussed, and therapy is conducting in-services/education on the last day of treatment regarding the changes for the resident. On 06/15/18 at 9:12 a.m., an interview was conducted with ASM (administrative staff member) # 1, administrator. When asked to describe the process for determining what type of mechanical lift was needed for a resident prior to Resident # 42's fall, ASM # 1stated, Upon admission we would use the weight bearing status that was provided in the discharge paperwork from the hospital or a previous facility. If they were admitted from home use the information provided by the family. The problem we had was a lack of communication between therapy and nursing, staff didn't always know the correct transfer procedure or lift to use for a resident. On 06/15/18 at approximately 9:20 a.m., an interview was conducted with OSM # 6, director of rehabilitation services. OSM # 6 reviewed the physical therapy evaluation dated 01/21/18 for Resident # 42. OSM # 6 stated Resident # 42 was evaluated for the restorative nursing program but was not picked up because there wouldn't be a positive functional change. When asked about the Functional Mobility Assessment section of the PT evaluation that documented the use of a Hoyer transfer OSM # 6, stated, They should have used a Hoyer lift. OSM # 6 also verbally concurred with ASM # 1's statements regarding the process the facility used for communicating the recommendations from the rehabilitation department to nursing prior to Resident # 42's fall. OSM # 6 further stated that when a resident was discharged from therapy (including evaluation for restorative), the therapist would tell a staff member what or if there were any changes. We assumed the staff (nursing) would pass the information along. On 06/14/18 and 06/15/18 attempts were made to contact and interview CNA (certified nursing assistant) # 11, by telephone, one of the two CNAs who transferred Resident # 42 using the sit to stand lift on 03/30/18. CNA # 11 failed to return the telephone calls. CNA (certified nursing assistant) # 12, one of the other two CNAs who transferred Resident # 42 using the sit to stand lift on 03/30/18 was on emergency leave and could not be interviewed. LPN (licensed practical nurse) # 13 who completed the facility's Post Fall Report was not available for interview, as she was no longer employed with the facility at the time of the survey. On 06/15/18 at 8:09 a.m., an interview was conducted with CNA # 1. When asked how they determine which mechanical lift should be used to transfer a resident CNA # 1 stated, If the patient can tell us and is able to voice how they transfer that is how we know or their care cards on the inside of their closet in their room. When asked how the lift status is communicated from the rehabilitation department, CNA # 1 stated, Somebody from therapy will meet up with me and tell me. On 06/15/18 at 8:11 a.m., an interview was conducted with RN (registered nurse) # 1. When asked how they determine which mechanical lift should be used to transfer a resident, RN # 1 stated, If they can stand a little bit then they can use sit to stand. If totally dependent then they use the Hoyer. When asked how it is communicated to staff RN # 1 stated, It's on the care card and communicated in report especially if anything new has come along. RN # 1 further stated, The resident's care card is confirmed and updated with lift status and updated using pencil and eraser, therefore the current status on the care card may not reflect the past on the care card. When asked how the lift status is communicated from the rehabilitation department RN # 1 stated, They tell us then we put that in the care card and care plan. (*Noted there was no documented evidence therapy had notified the nursing staff of the need to Hoyer transfer Resident #42 as documented in physical therapy evaluation dated, 01/21/18.) The facility's policy Lift - Hydraulic documented, Policy: A hydraulic lift may be used at the direction of a physician's orders [REDACTED]. At least two staff members are to be present and assist in the use of the hydraulic lift when transferring a guest. The facility's policy Lift Sit-To-Stand documented, Policy: A sit-to-stand lift may be used at the direction of a physician's orders [REDACTED]. On 06/14/18 at approximately 6:15 p.m., ASM (administrative staff member) # 1, administrator, ASM # 2, director of nursing, and ASM # 5, clinical resource specialist, were made aware of the above findings. No further information was provided prior to exit. References: (1) This information was obtained from the website: http://medical-dictionary.thefreedictionary.com/ (2) The term [MEDICAL CONDITION] is often used interchangeably with convulsion. A [MEDICAL CONDITION] is the physical findings or changes in behavior that occur after an episode of abnormal electrical activity in the brain. This information was obtained from the website: https://medlineplus.gov/ency/article/ 0.htm. (3) Stomach contents to leak back, or reflux, into the esophagus and irritate it. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/gerd.html. (4) A buildup of fluid inside the skull that leads to brain swelling. This information was obtained from the website: https://medlineplus.gov/ency/article/ 1.htm. (5) High blood pressure. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/highbloodpressure.html. (6) Depression may be described as feeling sad, blue, unhappy, miserable, or down in the dumps. Most of us feel this way at one time or another for short periods. [MEDICAL CONDITION] is a mood disorder in which feelings of sadness, loss, anger, or frustration interfere with everyday life for weeks or more. This information was obtained from the website: https://medlineplus.gov/ency/article/ 3.htm. 2. The facility staff failed to put a fall mat down while the resident was in bed per the physician orders [REDACTED].#24. Resident #24 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent MDS (minimum data set) assessment, a Medicare 30 day assessment, with an assessment reference date of 4/27/18, coded the resident as rarely understood and rarely understanding others. The resident was coded as having both short and long-term memory difficulties and being severely impaired to make daily cognitive decisions. Resident # 24 was coded as requiring extensive assistance of one or more staff members for all of her activities of daily living. Observation was made on 6/13/18 at 8:36 a.m., 11:29 a.m. 1:23 p.m., 1:47 p.m. and 2:12 p.m., of Resident #24 in bed. The bed was up against the wall on the resident's right side. There was no fall mat down on the resident's left side of the bed. The fall mat was observed folded up at the foot of the bed, leaning against the closet. The physician orders [REDACTED]. The comprehensive care plan dated, 3/30/18 documented in part, Focus: At risk for fall related injury R/T (related to) impaired mobility, [MEDICAL CONDITION] drug use, history of falls, cognitive deficit, Hx (history of) Craniotomy r/t glio[DIAGNOSES REDACTED] (surgery related to the [DIAGNOSES REDACTED]) (2). The Interventions documented in part, Mat to floor next to bed as ordered. An interview was conducted with CNA (certified nursing assistant) #7 on 6/13/18 at 2:12 p.m., the CNA assigned to Resident #24 on 6/13/18. When asked how a CNA knows what assistive devices a resident needs, CNA #7 stated it depends on their [DIAGNOSES REDACTED]. There is a kardex in each of the closet doors. CNA #7 pulled the kardex for Resident #24 out of the closet. The kardex documented a check mark next to Bed against wall and Mat to floor. The above observations of Resident #24 in bed without a fall mat on the floor as noted above were shared with CNA #7. An interview was conducted with LPN (licensed practical nurse) #1 on 6/13/18 at 2:52 p.m. When asked how a CNA knows what assistive devices a resident uses, LPN #1 stated the CNAs use the care card of shift to shift verbal report. Resident #24's kardex was reviewed with LPN #1. When asked what should be done if the kardex documents a fall mat while resident in bed, LPN #1 stated, When the resident is in bed the fall mat should be down. The above observations were shared with LPN #1. The administrator and director of nursing were made aware of the above finding on 6/13/18 at 6:15 p.m. No further information was obtained prior to exit. (1) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and Chapman, page 192. (2) This information was obtained from the following website: https://www.cancer.gov/publications/dictionaries/cancer-terms/def/glio[DIAGNOSES REDACTED]-multiforme

Based on observation, family interview, staff interview, facility document review and clinical record review, it was determined that the facility staff failed to provide the necessary treatment and services to prevent the development, promote healing, and prevent infection of a pressure ulcer for two of 26 residents in the survey sample, Resident #s 13 and 12. 1. On 2/18/17 the facility staff obtained physician orders [REDACTED].#13's sacrum. There was no documentation that provided the stage, size or description of the wound. A treatment was put in place on 2/18/17, and the facility staff administered the treatment as ordered but failed to document any ongoing monitoring of the wound including measurements, to determine whether or not the wound was improving or declining with the ordered treatment. On 3/11/17 the wound declined and was assessed and documented as an unstageable wound*. A new treatment was initiated on 3/11/17 and the facility staff documented that the treatment was administered as ordered. There was no documentation provided to evidence ongoing monitoring of the wound to determine the effectiveness of the treatment between 3/11/17 and 3/23/17 (approximately12 days ), at which time the wound was documented as having no change. No further assessment was documented between 3/23/17 and 3/31/17. On 3/31/17 the wound doctor assessed the wound as containing 85% necrotic tissue (dead tissue (1)) and staged the wound as a Stage 4* pressure injury, resulting in harm. * Pressure Injury: A pressure injury is localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbidities and condition of the soft tissue. Stage 1 Pressure Injury: Non-blancheable [DIAGNOSES REDACTED] of intact skin Intact skin with a localized area of non-blancheable [DIAGNOSES REDACTED], which may appear differently in darkly pigmented skin. Presence of blancheable [DIAGNOSES REDACTED] or changes in sensation, temperature, or firmness may precede visual changes. Color changes do not include purple or maroon discoloration; these may indicate deep tissue pressure injury. Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. This stage should not be used to describe moisture associated skin damage (MASD) including incontinence associated [MEDICAL CONDITION] (IAD), intertriginous [MEDICAL CONDITION] (ITD), medical adhesive related skin injury (MARSI), or traumatic wounds (skin tears, burns, abrasions). Stage 3 Pressure Injury: Full-thickness skin loss Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. Stage 4 Pressure Injury: Full-thickness skin and tissue loss Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible. Epibole (rolled edges), undermining and/or tunneling often occur. Depth varies by anatomical location. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar (i.e. dry, adherent, intact without [DIAGNOSES REDACTED] or fluctuance) on the heel or ischemic limb should not be softened or removed. 2. The facility staff failed to implement pressure ulcer prevention interventions by not floating Resident #12 heels while in bed. The findings include; 1. Resident #13 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident #13's most recent MDS (minimum data set), a significant change assessment with an ARD (assessment reference date) of 2/18/17, coded Resident #13 as having a score of three, out of a possible 15, on the BIMS (brief interview for mental status). Resident #13 was also coded as requiring extensive assistance of one person for activities of daily living and had a stage 2 pressure ulcer that was not present on admission. On 4/11/17 at 4:20 p.m. an interview was conducted with Resident #13's daughter who stated that her mother (Resident #13) had suffered a significant change in condition around the middle of February (2017), that she stopped trying to feed herself and would not get out of bed. Resident #13's daughter stated that the staff discovered a pressure ulcer on her mother's sacrum around this time. On 4/12/17 at 9:50 a.m. LPN (licensed practical nurse) #9 was observed while providing wound care to Resident #13. LPN #9 was assisted by an aide to roll Resident #13 onto her right side, Resident #13 required extensive assistance and her eyes remained closed throughout the procedure and was non-verbal. LPN #9 stated that Resident #13 had a sacral wound. LPN #9 was asked who staged the wounds in the facility. LPN #9 stated that the wound doctor would stage the wound. When asked who would stage a wound if the wound doctor was not consulted, LPN #9 stated that RN (registered nurse) #3, the unit manager, would stage the wound. LPN #9 was asked if she was the wound nurse. LPN #9 stated that she was the wound treatment nurse today and was not always the one who did treatments. When asked how she knew what the specific treatments were for each resident with a wound, LPN #9 stated it was on the MAR (medication administration record) and/or the TAR (treatment administration record). LPN #9 further stated that there was a treatment book that contained the description of the wound being treated as well as the treatment. LPN #9 stated that she could also review (the name of the wound doctor's) notes. LPN #9 had prepared her clean area with the treatments to be applied to Resident #13's wounds; LPN #9 washed her hands and placed clean gloves on, then removed the existing dressing from Resident #13's sacral area. LPN #9 washed her hands and placed clean gloves on her hands. LPN #9 was asked to measure and describe Resident #13's sacral wound. LPN #9 stated that she didn't normally measure wounds and that the unit manager usually did that with the wound doctor. LPN #9 used a cotton bud and obtained the following measurements; Depth of wound 0.7 cm, width of wound 1.9 cm, length of wound 3.0 cm. The wound was open and was observed to with undermining around the circumference of the wound. When asked if there was tunneling and/or undermining in Resident #13's wound, LPN #9 stated that there was none. LPN #9 completed the cleansing of the wound and applied the wound dressing as ordered. A review of Resident #13's admission assessments revealed, in part, the following documentation recorded on the facility document titled Integumentary (skin) Assessment. A diagram of the front of the human body and back of the human body contained multiple hand drawn arrows describing areas of concern on the skin. One such arrow was drawn and pointed to the sacrum on the diagram of the back of the human body with pink blancheable hand written beside the arrow. Below the diagram a nursing note documented, in part, the following; Buttocks, pink, blancheable (sic). No open areas. Skin intact. Signed and dated by the admitting nurse on 1/10/17. A review of Resident #13's clinical record revealed, in part, the facility document, Weekly Skin Assessments which contained a diagram of feet, a diagram of the front and back of the body. The following dates contained entries on this document; - 1/11/17 x2nd (second shift) An arrow was drawn pointing to the right buttock and an illegible word was written beside the arrow. - 1/11/17 x 3rd (third shift) An arrow was drawn pointing to the sacrum and blanch pink was written beside the arrow. The box titled Skin intact was checked. - 1/17/17 An arrow is drawn to the sacrum and Pink blancheable Tx (treatment) - place) written beside the arrow. The box Has existing (circled): wound condition/pressure ulcer was checked and wound condition was circled. - 1/31/17 An arrow was drawn pointing to the sacrum and pink blancha (blancheable) was written beside the arrow. The box Has existing (circled): wound condition/pressure ulcer was checked and wound condition was circled. - 2/7/17 An arrow was drawn pointing to the sacrum and pink written beside the arrow. The box Has existing (circled): wound condition/pressure ulcer was checked and wound condition was circled. -2/16/17 An arrow was drawn pointing to the sacrum and pink blancheable written beside the arrow. The box Has existing (circled): wound condition/pressure ulcer was checked and wound condition was circled. -2/23/17 An arrow was drawn pointing to the sacrum and pinkish area blancheable Tx in place was written beside the arrow. Has existing (circled): wound condition/pressure ulcer was checked and wound condition was underlined. On 3/2/17, 3/9/17 and 3/16/17 the weekly skin assessments are completed and treatment in place was documented alongside an arrow pointing to the sacrum on the diagram and the box for an existing wound condition was checked. -3/23/17 an arrow was drawn pointing to the sacrum and p/u (pressure ulcer) documented alongside the arrow. The box Has existing (circled): wound condition/pressure ulcer was checked and pressure ulcer was circled. -3/30/17 an arrow was drawn pointing to the sacrum and tx (treatment) in place documented alongside the arrow. Pressure ulcer was underlined. - 4/6/17 an arrow was drawn pointing to the sacrum and P/u documented alongside the pressure ulcer. The box Has existing (circled): wound condition/pressure ulcer was checked and both wound condition and pressure ulcer was circled. Further review of Resident #13's clinical record revealed, a facility document titled Pressure Ulcer Record that revealed, in part, a diagram of the human body (front and back) with an arrow drawn to the sacrum. The line entry documentation was as follows: - Initial Wound Description: Describe location, size and appearance of pressure ulcer. Date 3/11/17. Site: Sacrum. Description: area open and cover (sic) (symbol for with) gray/yellow slough. - Date: 3/11/17. Stage: U (unstageable). Length/width/depth in cm (centimeters) 3x3x0.3. Tunneling: (a line drawn through clock face used as a tool to locate the tunneling). Undermining in cm: (a line drawn through this area). Odor: (a line drawn through this area). Drainage: S (serosanguineous (wound drainage most common in deep partial-thickness and full-thickness wounds (2)). Color: gray, yellow, pink. Comments: Santyl (an ointment used on wound beds to help break down dead skin (3)). Signed by a nurse. - Date 3/23/17. Stage: U. Length/Width/Depth in cm: 3x3x0.3. Tunneling: (a line drawn through the clock face). Undermining in cm: A line drawn through. Odor: 0 (none). Drainage: Scant. Color: yellow pink. Comments: Santyl. Signed by RN (registered nurse) #1, a floor nurse. - Date 3/31/17. Stage: IV (Stage 4). Length/Width/Depth in cm: 2.8 x 1.5 x 1.0. Tunneling: (A line drawn through the clock face). Undermining in cm: (A line drawn through). Odor: Foul. Drainage: mod (moderate) serous (serosanguinous). Color: red. Comments: [MEDICATION NAME] (an antibiotic (4)),[MEDICATION NAME](an antibiotic (5)), Dakin's (a type of wound cleanser (6)). Signed by RN #3, the unit manager. - Date: 4/7/17. Stage: IV. Length/Width/Depth in cm: 2.5 x 2.2 x 0.9. Tunneling: no entry. Undermining in cm: 4.2 (cm) at 12:00 (12 0'clock, the location of the undermining as compared to the clock face). Odor: 0 (zero). Drainage: Red serous. Color: Red. Comments: [MEDICATION NAME], Dakins. Signed by RN #3. A review of Resident #13's nursing progress notes revealed, in part, the following documented entries: 2/27/116 10:49 a.m. Wound care done to sacral area. No description documented regarding the wound. Note signed by nurse. 3/15/17 (no time provided). Wound care to sacrum completed, santyl applied and dry dressing. No description documented regarding the wound. Signed by hospice nurse. 3/20/17 11:45 a.m. Wound care completed by facility nurse. No description documented regarding the wound. Signed by nurse. Further review of Resident #13's nursing progress notes revealed, in part, documentation for daily assessments that assessed all clinical systems; including skin. All daily nursing assessments dated 1/10/17 through 2/14/17 documented Resident #13's skin as intact. On 2/16/17 the daily nursing assessment documented Resident #13's skin as warm and dry. The following nursing notes documented skin as follows: - 3/2/17 at 4:39 p.m. Skin assessment completed. Writer informed by hospice nurse that hospice nurse completed treatment to resident sacrum. - 3/9/17 at 1:06 p.m. LOOK BACK . Look Back Period: 7 (seven) days Skin Changes Since Last Assessment: No. Skin Skin WNL (within normal limits). - 3/11/17 10:04 p.m. Late entry for 3/11/17 at 10 a.m., During am (morning) care aide noticed the guest excoriation (skin is scraped or abraded) to her sacrum, excoriation has opened, area now gray & (and) yellow, slough (shedding of dead tissue) to center, area measure's at 3x3x0.3 (centimeters), tx (treatment) change to santyl, rp (responsible party) and md (medical doctor) aware. will continue to for (sic) changes. - 3/16/17 2:26 p.m. SKIN . Skin Intact Skin WNL Skin Warm / Dry. Wound: Yes Location: sacrum . Wound Care: clean sacrum with NS (normal saline), apply santyl and cover with dry dressing. - 3/31/17 4:27 p.m. Guest daughter made aware of (name of wound doctor) evaluating and treatment changes he made to her mother's wound. - 4/6/17 11:15 am. SKIN . Skin WNL Skin Warm / Dry. Wound: Yes Location: sacrum wound Wound Care: [MEDICATION NAME] crushed & applied to wound, then packed w (with)/Dakins soaked packing gauze (sic), cover w/dry dsg (dressing). A review of Resident #13's H&P (history and physical) progress notes documented, that Resident #13 had been seen/examined by a physician on the following dates: 1/19/17; 1/20/17; 1/24/17; 1/30/17; 2/1/17; 2/7/17; 2/27/17; 3/20/17 and 4/6/17. On the note dated 4/6/17 the physician documented, in part, the following; DOS (date of service): 4/6/17. HPI (history of present illness): Seen for 60 days recert (recertification) for debility/weakness. Pt (patient) under Hospice care. Chart reviewed. Pt. comfortable, pleasantly confused. D/w (discussed with) nursing hospice managing her (Resident #13's) sacral wound. Stage IV. Assessment and Plan: 5. Sacral wound. Cont (continue) wound care per Hospice. No further documentation was provided from the medical doctor regarding Resident #13's wound. A review of Resident #13's physician orders [REDACTED]. 1. Cleanse pink, open area to sacrum with NS (normal saline), apply calmaFX (a brand of moisture barrier cream) and dry foam drsg (dressing) every 3 (three) days. Further review of Resident #13's clinical record revealed, in part, the physician order [REDACTED]. - TRTM-TRTM (treatment) Start: 02-18-17 End: 02-27-17 Initial 02-18-17 TREATMENT clean open area to sacrum with n/s apply calmaFX moisture barrier ointment and dry foam dressing q (every) 3 (three) days at day (day) telephone order from (name of medical doctor) (name of nurse) noted on 02-18-17 11:40 pm by (name of nurse). Signed and dated by medical doctor on 3/2/17. - Start 03-11-17 End 03-10-18 Initial 03-11-17 09:40 (am) SANTYL OINTMENT topically daily (day) cleanse sacrum with ns, apply santyl cover (sic) with dry drsg qd (every day) dx (diagnosis): wound wound (sic) healing telephone order from (name of medical doctor), taken by (name of nurse) noted on 03-11-17 9:40 pm by (name of nurse). Signed and dated by medical doctor on 3/13/17. - TRTM -TRTM (treatment) Start: 03-29-17 End: 03-28-18 Initial: 03-29-17 TREATMENT pack sacrum wound w/dakin soaked gauze, cover w/dry dsg. daily (day) telephone order from (name of medical doctor) taken by (name of RN #1) noted on 03-29-17 12:14 pm by (name of RN #1). Signed and dated by medical doctor on 4/7/17. A review of Resident #13's TAR (treatment admission record) dated 2/1/17 to 2/28/17 revealed, in part, the following order: TREATMENT every three days at day for Start: 2/18/17 11:40 pm DC (discontinue): 3/11/17 9:41 pm Extended directions: clean open area to sacrum with n/s apply calmafx moisture barrier ointment ad dry foam dressing q 3 days. The TAR was initialed by a nurse as completed on 2/21/17; 2/24/17; 2/27/17; 3/2/17; 3/5/17; 3/8/17 and 3/11/17. A review of Resident #13's TAR dated 3/1/17 to 3/31/17 revealed, in part, the following orders: - SANTYL OINTMENT daily: topically for wound healing Start: 03-11-17 09:40 pm DC: 03-29-17 12:11 pm Extended Directions: cleanse sacrum with ns, apply santyl cover with dry drsg qd dx: wound. The TAR was initialed by a nurse as completed every day from 3/12/17 through 3/29/17. - TREATMENT daily for Start: 3/29/17 12:14 pm DC: 3/31/17 3:02 pm Extended Directions: pack sacrum wound w/dakin soaked gauze, cover w/dry drsg. The TAR was initialed by a nurse as completed on 3/29/17; 3/30/17 and 3/31/17. A review of Resident #13's progress notes from ASM (administrative staff member) #4, the wound doctor revealed, in part, the following documentation: - Date 3/31/2017 HPI (history of present illness) Statement: At the request of (name of ASM #3, the medical doctor), this [AGE] year old female was seen and evaluated today. She presents with a stage 4 pressure wound of the medial sacrum of at least 1 days (sic) duration. There is moderate serous exudate (discharge). There is no indication of pain associated with this condition. FOCUSED WOUND EXAM. Etiology (quality): Pressure. MDS 3.0 Stage: 4 Duration: > (greater than) 1 (one) days. Wound Size (L x W x D): 2.8 x 1.5 x 1.0 cm. Thick Adherent Devitalized Necrotic Tissue: 85 % (percent). Granulation Tissue: 15 %. Assessment and Plan of Care Recommendations: Stage 4 Pressure Wound of the Medial Sacrum - Initial Evaluation: Add: [MEDICATION NAME] crushed - Once Daily, 1/4 DAKINS moistened gauze - Once Daily, Dry protective Dressing - Once Daily. FOLLOW-UP: Evaluation by wound care specialist within 7 (seven) days with further intervention as indicated. Electronically signed by (name of wound care doctor) on 3/31/2017. - Date 4/7/2017 HPI Statement: She (Resident #13) presents with a stage 4 pressure wound of the medial sacrum of at least 7 days duration. There is light serous exudate. Wound Size: 2.5 x 2.2 x 0.9 cm. Undermining: 4.2 cm at 12 o'clock. Thick Adherent Devitalized Necrotic Tissue: 65 %. Granulation Tissue: 35 %. Wound progress: improved. Electronically signed by (name of wound care doctor) on 4/7/17. A review of Resident #13's admission care plan dated 1/10/17 revealed, in part, the following directions; 3. Pressure Sores/ Skin Care. Goal: Prevent/heal pressure sores/ skin breakdown. The following boxes were checked: Follow facility skin care protocol. Turn every 2 (two) hours and PRN (as needed). Immediately report any redness or skin breakdown to charge nurse / physician. Lift sheet for repositioning. A Braden Scale - For Predicting Pressure Sore Risk dated 1/10/17, documented Resident #13 was scored as a 17 indicating that Resident #13 was at risk. There were no other Braden Scale assessments completed for Resident #13 by the facility staff. A review of Resident #13's comprehensive care plan dated 1/16/17 revealed, in part, the following documentation; Onset/DC (discontinued) 6/30/17. Problems/Conclusions: URINARY: Risk for complications of frequently incontinent of bladder, occasionally incontinent of bowel r/t (related to) decreased physical mobility, weakness 2nd to (secondary to) [MEDICATION NAME] spine compression fx (fracture) s/p (status [REDACTED]. Start 1/19/17. Evaluate skin with each episode and report any redness, skin breakdown, rash, pain, burning, odorous urine, to nurse. Start 1/19/17. Provide skin care for each episode of incontinence. Start 1/19/17. Onset / DC: 3/17/17. Problems/Conclusions: Skin04: Risk for skin impairment r/t decreased physical mobility, weakness 2nd to [MEDICATION NAME] spine compression fx. 4/6/17 Wound tx to sacrum: apply [MEDICATION NAME] 500 mg (milligrams) (crushed) to wound, pack with Dakins soaked packing strip and cover with dry dsg q day. Approaches/Interventions: Pressure reduction mattress on bed. Start 1/19/17. Braden Scale per protocol Start 1/19/17. Use draw sheet or pad prn to help move up in bed. Start 1/19/17. Provide incontinent care with each episode and apply moisture barrier. Start 1/19/17. Conduct weekly head to toe skin assessments, document and report abnormal findings to physician. Start 1/19/17. On 4/12/17 at 2:50 p.m. an interview was conducted with ASM (administrative staff member) #4, the wound care doctor. ASM #4 was asked when he was first asked to look at Resident #13's sacral wound. ASM #4 stated that he learned about the wound at the end of March. ASM #4 was asked if he was made aware of an open area found on February 18, 2017. ASM #4 stated that he was not made aware. ASM #4 was asked who was responsible for notifying him of any open skin areas. ASM #4 stated, It is different people, maybe the unit manager or the nurse. As a consultant I have to be invited to assess a resident's wounds. ASM #4 was made aware that Resident #13 had received an order to treat an open area on her sacrum on 2/18/17 with Santyl and dakins solution. ASM #4 was asked if that was an appropriate treatment. ASM #4 stated that was an appropriate treatment. ASM #4 was asked how frequently such a wound should be assessed and what should the assessment include. ASM #4 stated, The wound should be assessed at least weekly, and the assessment should include a description of the wound base, drainage, surrounding tissue, the presence of any odor and whether or not it (the wound) is getting bigger or smaller, you need to measure it. ASM #4 was asked whether or not the facility staff had provided any information regarding the wound prior to his consultation and assessment on 3/31/17. ASM #4 stated, No, but I don't usually ask, I like to do my own assessment. On 4/12/17 at 3:21 p.m. an interview was conducted with RN #1, a floor nurse. RN #1 was asked to describe the process for the weekly skin assessments. RN #1 stated, We do an assessment every week, it is assigned by the unit manager as to who does which ones. We assess the skin for any new areas of concern as well as old areas. When asked if the areas were measured, RN #1 stated that they were. RN #1 was asked where the measurements were documented. RN #1 stated that if it was a bruise or rash, non-pressure, the measurements would be documented on a skin and wound sheet. If the wound was a pressure wound then the wound would be measured and the information documented on the pressure ulcer report sheet. RN #1 was asked who was responsible for the skin assessment. RN #1 stated, The nurse working with the resident when the skin assessment was due to be done and the nurse who finds a wound (pressure) will measure the wound and enter this onto the pressure ulcer record. RN #1 was asked whether or not the nurse would document anywhere other than the pressure ulcer record. RN #1 stated that the nurse just documents on the pressure ulcer record. RN #1 further stated, Any new area would be noted in the nurse's notes and the note should include that the RP (responsible party) and MD (medical doctor) were notified. RN #1 was asked at what point the wound care doctor would be asked to look at a wound. RN #1 stated, Definitely if the wound is a stage 2. RN #1 was asked to review Resident #13's clinical record, specifically the telephone order written on 2/18/17 that described a pink, open area to the sacrum. RN #1 stated, I don't know what happened on 2/18/17 I was on vacation. She (Resident #13) was on a different hallway on 2/16/17. The ball got dropped between 2/16/17 and 2/23/17, she was moved. RN #1 was asked what a pink, open area on the sacrum signified. RN #1 stated, That would be a pressure ulcer. RN #1 was asked where it should have been documented. RN #1 stated, It should have been documented on the pressure ulcer record. There should have been measurements. RN #1 reviewed Resident #13's pressure ulcer record and stated, There should have been measurements between 2/18/17 and 3/11/17. I would say that there are sheets missing. RN #1 was asked to review the entry on the pressure ulcer record dated 3/11/17. RN #1 was asked whether or not the entry on 3/11/17 described a worsening wound. RN #1 stated, It was an unstageable wound so yes. RN #1 was asked if she entered the description on the pressure ulcer record dated 3/23/17, RN #1 stated that she did. RN #1 was asked who contacted the wound care doctor. RN #1 stated that she thought that the unit manager (name of RN #3) did sometime between 3/23/17 and 3/31/17. RN #1 was asked how often a pressure ulcer should be assessed. RN #1 stated, At least every week. RN #1 was asked whether or not the pressure ulcer found on Resident #13 was assessed weekly between 3/11/17 and 3/31/17. RN #1 stated, Her weekly skin assessments were done but I don't know where the measurements are. On 4/12/17 at 3:58 p.m. an interview was conducted with LPN #4, a floor nurse. LPN #4 was asked to state the process for a weekly skin assessment. LPN #4 stated, I look at the resident head to toe and document on the skin assessment sheet (using the diagrams). If we find anything new we call the doctor to get orders. If we find a pressure ulcer we complete both the skin assessment sheet and the pressure ulcer record. We also write a nurse's note and write that the RP and MD are aware. LPN #4 was asked to review her skin assessment dated [DATE] for Resident #13. LPN #4 stated, I can't remember what it (the wound) looked like then, I was new and didn't know then that I had to put an open area on the pressure ulcer record. LPN #4 continued to review the skin assessment sheets that she had completed and further stated, On 3/2/17 I did a skin assessment and I don't see any measurements. I definitely should have documented measurements. LPN #4 was asked whether or not an assessment should have been completed between 3/11/17 and 3/23/17. LPN #4 stated, Yes, the measurements should have been done on 3/16/17 when I did the assessment. I can't really say that I learned about the pressure ulcer records until a couple of weeks ago. On 4/12/17 at 4:15 p.m. an interview was conducted with ASM #5, the medical doctor. ASM #5 was asked how he would know about a skin issue. ASM #5 stated that the nursing staff would do their assessment then call him. ASM #5 was asked what would happen at that point, ASM #5 stated that he would provide orders and that there should be a plan of care put into place for every wound. ASM #5 further stated, I can generally manage a stage 1 pressure ulcer and a stage 2, but once we get to the stage 3 or higher then I defer to (name of wound care doctor) as he is the specialist. Also if a plan of care to treat a wound was found to not be working then I would expect (name of the wound care doctor) to be called in. Most of the wounds in the building are managed by the wound care doctor. ASM #5 was asked about Resident #13's plan of care for the wound that she developed on her sacrum. ASM #5 stated, I cannot answer why there was no plan of care following the initial evaluation when the staff noted skin breakdown. Some of this is on me as I did not follow up after I gave an order to treat the open area initially. ASM #5 further stated, If there is no evaluation provided in the nurse's notes then it should be in the communication book for me to review. If I am not informed and there is no info (information) then I would not have a plan of care. The staff does work very hard to make sure that things happen quickly. An evaluation should be documented. I was not aware that this wound was progressing so rapidly, we should definitely have had a plan of care. ASM #5 was asked whether or not he was aware that the wound care doctor was not asked to assess the wound until the end of March. ASM #5 stated that he was not aware and that he counted on the nursing staff to contact the wound care doctor. On 4/12/17 at 5:00 p.m. ASM #1, the administrator and ASM #2, the director of nursing, were made aware of the concern for harm. ASM #1 and ASM #2 were asked to provide any information that would evidence that Resident #13's sacral pressure ulcer was monitored for the impact of interventions following initiation and changes in treatment. A policy / protocol for wound identification and management was requested at this time. On 4/12/17 at 5:15 p.m. an interview was conducted with RN #3, the unit manager. RN #3 was asked to describe the process for weekly skin assessments. RN #3 stated, The skin assessments are assigned weekly to a nurse. They are done weekly but not always by the same nurse. The nurse documents what she sees and if there is a skin condition she puts on the skin condition sheet, rashes, bruises, surgical wounds and skin tears would be documented as skin conditions. RN #3 was asked where a pressure ulcer would be documented, RN #3 stated, On the pressure ulcer report. RN #3 was asked what is documented on the pressure ulcer report. RN #3 stated, The size, stage and what it (the wound) looks like in general. RN #3 was asked if anyone reviewed the pressure ulcer report. RN #3 stated, I do, every day. If I see a new pressure ulcer documented I go look at it on the resident and make sure that the treatment is appropriate and notify the wound doctor. RN #3 was asked if she documented her assessment. RN #3 stated, If I look at the wound and decide to change the treatment, the change in the treatment is my documentation. I do not document my findings, but if I have new findings I will document those on the pressure ulcer report. RN #3 was asked if all the nurses had received wound care education. RN #3 stated, They (the nursing staff) get it (wound care education) at orientation, then we have in-services from time to time. When asked when the last in-service was for pressure ulcer identification and management, RN #3 stated that she did not remember, then further stated, Maybe March? RN #3 was asked whether or not she would document w

Based on observation, staff interview, facility document review, clinical record review, and in the course of a complaint investigation, it was determined that the facility staff failed to provide supervision and an environment free of hazards to prevent injury for 1 of 28 residents in the survey sample; Resident #22. The facility staff failed to ensure Resident #22, diagnosed with [REDACTED]. On 6/6/15 at approximately 6:45 p.m. Resident #22 exited the facility through the automatic front doors, unsupervised in her wheelchair and sustained a fall with injury. Resident #22 was transported to a local hospital emergency room and admitted with a fracture of the C1 (first cervical) spine vertebra, extensive nasal bone fractures and laceration to the bridge of the nose and upper lip that required staples and sutures. The findings include: Resident #22 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. The most recent MDS (Minimum Data Set) was an admission assessment with an ARD (Assessment Reference Date) of 4/23/15. The resident was coded as being severely cognitively impaired in ability to make daily life decisions, scoring a 4 out of a possible 15 on the BIMS (Brief Interview for Mental Status) exam. The resident was coded as requiring extensive assistance for bed mobility, transfers, dressing, eating, toileting, hygiene, and bathing; limited assistance for locomotion on and off the unit in a wheelchair; had no functional limits for range of motion, and was incontinent of bowel and bladder. A review of the clinical record revealed the following: A Nursing Admission Assessment (a 2 page form) dated 4/16/15 (day of admission) contained a section for Risk for Falls. This section documented, Total Score of 10 or above deems Guest at risk; initiate Care Plan. The resident scored a 20. The Nursing Admission Assessment further contained a section for Risk for Wandering/Elopement which documented the following questions and responses: 1. This is a new admission ___Yes ___No (yes was checked); 2. Is the Guest independently mobile? (No was written in the line next to the number); 3. Does the Guest have a history of wandering? (No was written in the line next to the number); 4. Is the Guest currently taking any medication which may cause confusion or disorientation? (No was written in the line next to the number); 5. Is the Guest resistant to being placed in a long-term care facility? (No was written in the line next to the number); 6. Are there any indications of dementia? (Yes was written in the line next to the number). A yes answer to any question #2 through #6 means that the Guest is at risk. A yes answer to question #1, AND any other question means that the resident is at high risk; apply bracelet and Care Plan. The resident was not care planned for this nor was a wanderguard bracelet placed on the resident. Nowhere in the clinical record was it documented if the resident did or did not require a wanderguard, or the factors on which that decision was based. Another Admission Nursing Assessment (a 4 page form) dated 4/17/15 documented the following: In the Psychosocial Functioning section was an area for Behavioral Symptoms which contained the following options to check: Wandering, Verbally Abusive, Physically Abusive, Socially inappropriate/Disruptive, Resists Care, and None. A check was placed in the line next to None. In the section Current ADL Status was a section for documenting devices used. This section included, Wheelchair Only, Wheelchair/Propels Self. Neither option was selected. Nothing in this section was completed. In the section Safety was documented Fallen in the past 90 days with a check in the line next to this item. In the section Musculoskeletal was documented, Moves All Extremities with a check in the line next to this item; Assistive Devices with the word 'wheelchair' handwritten in the line next to this item; In the section for Risk for Falls was documented, Total Score of 10 or above deems Guest at risk; initiate Care Plan. The resident scored a 20. The Nursing Admission Assessment further contained a section for Risk for Wandering/Elopement which documented the following questions and responses: 1. This is a new admission ___Yes ___No (yes was checked); 2. Is the Guest independently mobile? (No was written in the line next to the number); 3. Does the Guest have a history of wandering? (No was written in the line next to the number); 4. Is the Guest currently taking any medication which may cause confusion or disorientation? (No was written in the line next to the number); 5. Is the Guest resistant to being placed in a long-term care facility? (No was written in the line next to the number); 6. Are there any indications of dementia? (Yes was written in the line next to the number). A yes answer to any question #2 through #6 means that the Guest is at risk. A yes answer to question #1, AND any other question means that the resident is at high risk; apply bracelet and Care Plan. The resident was not care planned for this nor was a wanderguard bracelet placed on the resident. Nowhere in the clinical record was it documented if the resident did or did not require a wanderguard, or the factors on which that decision was based. A Pre-Restraint Intervention Evaluation dated 4/20/15 documented the following: Guest's cognitive status (check all that apply). Check marks were placed next to the items Alert, Long-term memory deficits, Short-term memory deficits, Poor decision-making. In addition, next to Oriented to the resident was only checked as being oriented to person. She was not oriented to place and time. A Determination of Device Usage form dated 4/20/15 documented, under item #2 Evaluate the guest in the area of each of the following and mark yes or no the resident was marked yes for Can guest propel wheelchair even short distances? The resident was marked no for Is the guest immobile. A Pre-Restraint Intervention Evaluation undated, documented the following: Under Medical symptoms/behaviors/events/clinical findings leading to consideration of device usage (check all that apply) the resident was checked for Guest does not understand safety with standing/transfer and Guest unable to independently stand/transfer/ambulate. Under How often have these medical symptoms/behaviors/events/clinical findings occurred in the last 30 days? (check one) a check was documented for, Continuously. Under Guest's cognitive status (check all that apply). Check marks were placed next to the items Alert, and Poor decision-making. In addition, next to Oriented to the resident was only checked as being oriented to person. She was not oriented to place and time. Under Is guest aware of safety risk at all times of day and night? (check one) No was checked. A Determination of Device Usage form dated 5/7/15 documented, under item #2 Evaluate the guest in the area of each of the following and mark yes or no the resident was marked yes for Can guest propel wheelchair even short distances? The resident was marked no for Is the guest immobile. Further review of the clinical record revealed that on 5/8/15, the resident was started in the Restorative Nursing Program. This form documented the resident as receiving 15 minutes a day for 6 to 7 days per week with the goal of being able to transfer from chair to bed; and from bed to chair. The clinical record revealed a Behavior Data and Analysis document, dated 5/5/15, which documented, Guest added to behavior mtg (monitoring) due to falls. Guest also have intervention in place. Guest wanders in other guest rooms. She can become tearful. Staff will continue to monitor. A review of the care plan revealed one for ADL's (activities of daily living) initiated on 4/27/15, which documented, written in, (undated) the intervention Restorative Nursing. Review of the care plan revealed one for Mood, initiated on 4/27/15, which contained a hand-written problem area, dated 4/28/15, Wanders into other guest's rooms. The clinical record revealed hospital records from the previous facility, which documented, that the resident sustained [REDACTED]. Therapy notes were included (from the hospital at the time of the hip fracture) and reviewed. These notes documented that on 3/20/15, the resident was able to self propel (the wheelchair) 50 feet. The clinical record contained a nurse's note dated 6/7/15 at 1:40 p.m., which documented, Late entry - Writer was on 300 hall passing meds (medications). A nurse from another unit was passing thru hall and said come quick there's an emergency. Writer followed nurse. Guest noted on ground. Guest last seen around 6:30pm in hallway around nurse's station. Guest just came from social dining room. Guest is able to propel w/c by self and normally goes to PM activities by herself or visits other guest's in their rooms. When found on ground guest was noted /c (with) blood coming from nose. Unable to state if she hit her head (secondary to) baseline confusion and dementia. (No) c/o (complaints of) pain or discomfort. MD/RP made aware. Guest sent out to (name of hospital) via EMS. A review of the internal incident report documented the date and time of the incident as 6/6/25 at 6:45 p.m. The injury documented was laceration to nose. The location of the incident was the parking lot. The resident was found on the ground. Continued review of the incident report documented under Circumstances of Fall that guest found in middle of fire lane, w/c (wheelchair) found upright on curb. The internal incident report further documented that the resident's alarm was in place (fall alarm) and was sounding. Further review of the incident report revealed a statement from the DON (Director of Nursing) which documented a conversation she had with the resident's daughter-in-law on 6/7/15, wherein it was asked if the resident had a history of [REDACTED]. On 6/18/15 at 8:16 a.m., an interview was conducted with CNA #4 (Certified Nursing Assistant - the aid that observed the incident). She stated that it was a little after 6:30 p.m., and she was walking past the lobby area, where visitors were congregating and chatting. She looked over in that direction, and saw Resident #22 outside the doors on the concrete patio area in her wheelchair. She noted the resident was alone, with no staff present. She stated it appeared from that distance that the resident's wheelchair was moving (the patio slants downward from the doors, down to the curb at the fire lane). She stated she ran towards the doors, and as she got closer she could definitely see that the resident's wheelchair was moving down towards the curb, and that she was not able to get to the resident in time before the wheelchair got to the curb and the resident was thrown out of it onto the blacktop of the fire lane. She stated she saw that the resident was injured and bleeding, and ran back inside to get help and then back to the resident where she remained until help arrived. On 6/17/15 at 2:06 p.m., an interview was conducted with the DON. She stated that the resident had no previous history of exit-seeking behavior. On 6/18/15 at 10:43 a.m., in an interview with ACS #3 the corporate QA nurse (Administrative/Corporate Staff) and the Administrator, ACS#3 again stated the resident had no exit-seeking behavior. When asked if that was the only criteria for using a wanderguard, the Administrator stated, No. When asked about the admission assessment wherein the resident was scored as requiring a wanderguard, she stated the decision was made that the resident did not require one. When asked where this was documented in the clinical record, the facility was unable to evidence this. (A request was made for evidence of the discussion in any internal meeting documentation. None was provided. At 11:34 a.m., the Administrator stated there was no documentation in the morning meeting notes.) When asked about a resident with a BIMS of a 4 and who was wandering around the facility in a wheelchair, and was care planned as wandering into other residents rooms, they stated at the time of admission, the resident was not mobile in the wheelchair, but mobility increased once the resident was in the Restorative Nursing Program. When asked if the resident should have been reassessed for a wanderguard once she became mobile (after being in the Restorative Nursing Program), the Administrator stated, You could make an argument for that. In discussing the level of supervision for the resident, ACS#3 stated that the facility could not provide one-to-one staff and that this was the resident's home and she had the right to move about freely, and the Administrator stated that it was a dignity issue to put a wanderguard on someone if they did not have exit-seeking behaviors. When it was discussed about a resident who had severe dementia and was not exit-seeking, but just mindlessly wandering about the facility and happen to wander outside through the unsupervised automatic front doors, it was stated that the resident was not on their radar for being one that would require a wanderguard and that in hindsight; she could have been reassessed when she became mobile. On 6/18/15 at 10:25 a.m., an interview was conducted with LPN #8 (Licensed Practical Nurse). She stated that initially (at admission) the resident was not self-propelling herself in her wheelchair, but that she should have been reassessed when she became mobile, as a wandering risk. On 6/18/15 at 11:06 a.m., an interview was conducted with CNA #6 (Certified Nursing Assistant). When given the scenario of a resident with dementia and that was mobile in a wheelchair, she stated that such a resident should be supervised to prevent elopement and that it is neglect if such a resident gets outside unsupervised. On 6/18/15 at 11:08 a.m., an interview was conducted with LPN #9. When given the scenario of a resident with dementia and that was mobile in a wheelchair, she stated that such a resident should be supervised to prevent elopement and that it is neglect if such a resident gets outside unsupervised. She further stated a resident such as this should have a wanderguard on. On 6/17/15, the front lobby area where the resident got out the front automatic doors unsupervised, was monitored from 6:41 p.m. to 8:03 p.m. During this time, the area was not manned by assigned staff. Staff, residents, and visitors were noted to pass by or through the area 44 times, ranging in a time span of a few seconds, up to 11 minutes apart between times someone walked by or through the area. An activity was going on in the dining room adjacent to the lobby. There were windows from the dining room to the lobby. Staff present in the activity room, were not observant of activity in the lobby. The majority of the residents that were observed passing by the area were doing so independent of staff supervision. After 8:00 p.m., the automatic sliding glass front doors were noted to have locked automatically as evidenced by the alarms sounding when the doors were approached. Before this time, there were no alarms as anyone approached the doors unsupervised. There were no wanderguards noted on any residents that came into the lobby area. Prior to 8:00 p.m., the automatic front doors were easily accessible and automatically opened to anyone that approached them. On 6/17/15 at 6:22 p.m., OSM #8 (Other Staff Member #8, the activities assistant) was manning the front desk. When asked about staff monitoring the lobby, she stated there isn't anyone after 6:30 p.m., and that she did not think they (the facility) ever lock the front doors. On 6/18/15 at 8:02 a.m., an interview was conducted with OSM #9 (a weekend receptionist). She stated that on 6/6/15 was the first time she had seen Resident #22 in the lobby area by herself, and that the resident transferred herself from the wheelchair to one of the chairs in the lobby. She stated this was earlier in the day. On 6/18/15 at 8:49 a.m., an interview was conducted with OSM #10, a receptionist. She stated that she works from 8:30 to 4:30. She stated that if she has to leave the desk, she puts the phone on night ring so that it will ring to other extensions in the building; that she is relieved for 30 minutes for lunch but that otherwise if she has to leave the desk, there is no relief for her. She stated she leaves the desk area for bathroom breaks and to make copies or deliver faxes. On 6/18/15 at 11:30 a.m., in an interview with the Administrator and ACS #3, when asked about how the front doors work, and if the resident had a wanderguard on, would the doors have locked? The Administrator stated they (the doors) most likely would have, that the inside door would open, but the second set leading to the outside would have locked and an alarm would have sounded. A review of the hospital records revealed the following: A CT of the head without contrast documented, Impression: No acute intracranial process, hemorrhage, or skull fracture. Moderate diffuse atrophy and chronic small vessel disease. A CT of the C-Spine without contrast documented, Impression: Nondisplaced fracture through the right lamina of the C1 vertebra as described above. No other fracture identified. A CT of the facial bones without contrast documented, Findings/Impression: Extensively comminuted nasal bone fractures. Fragments are displaced leftward. Adjacent soft tissue gas is noted suggesting a possible penetrating injury. No additional fracture. No sinus fluid. No orbit lesion is evident. Advanced degenerative changes noted in both temporomandibular joints (pair of joints connecting the mandible of the jaw to the temporal bone of the skull*). Further review of the hospital record revealed the following note from a consult physician about the injuries: A CT of the C-spine reported nondisplaced fracture through the right lamina of the C1 vertebrae. The pt (patient) was seen and I spoke to neurosurgeon (name of doctor). Rec (recommends) just cont (continue) the soft collar and activity as tolerated. As per his notes: Impression: Closed head injury with cervical C1 arch fracture since it is unilateral and it only involves the arch, this is a stable fracture. There is absolutely no surgical intervention necessary and I suspect that she would be very uncomfortable in a hard cervical collar and I do believe it is necessary to place her in that soft collar for comfort only, can be used if necessary. I discussed this with the emergency room physician, there being no further neurosurgical intervention necessary. In addition, the history and physical note documented, ENT:.lacerations bridge of nose and area between upper lip and nose.Procedures: Laceration Management. Location of wound: bridge of nose and upper lip through and through.number of sutures/staples: 8.number of sutures subcutaneous: 6.Closure layers: 2. On 6/17/15 at 3:30 p.m., the Administrator and ACS #3 were made aware of the concern for harm. From Fundamentals of Nursing, 7th edition, 2009; Patricia A. Potter and Anne Griffin Perry; Mosby, Inc; Page 5: Client safety is a priority in health care. You need to protect clients from physical and emotional injury by continually assessing for and eliminating safety hazards. According to Fundamentals of Nursing, Fifth Edition, Lippincott, Williams, & Wilkins, page 1258, Safety becomes a primary concern for clients with progressively impaired judgment. In institutional settings, safety measures for clients with chronic confusion involve frequently checking on clients and interacting with them.supervising wandering behavior; gently redirecting lost or wandering clients; providing secured locks or alerting systems for elevators and door; providing motion detection devices that can be applied to the client or to the bed to signal nursing staff when movement occurs; staying with clients who are agitated; and removing items that may be potentially harmful from the area .The desire for wandering behaviors intensifies, falls are not prevented, and risk of serious injury from falls increases. May long-term care facilities are becoming more creative in their safety management. Innovations such as enclosed courtyards provide unlimited access for clients with dementia to wander within a protected confine. COMPLAINT DEFICIENCY * This information was obtained from the website: <http://medical-dictionary.thefreedictionary.com/temporomandibular+joint>