Every finding on record at The Laurels of Willow Creek

Based on staff interview, clinical record review and facility document review, it was determined that the facility staff failed to ensure residents were free from unnecessary medications for four of 37 residents in the survey sample; Residents #100, #88, #91, and #7. The findings include: The facility policy, Anticoagulant Therapy was reviewed. This policy documented, Anticoagulant therapy is utilized as a prophylaxis and treatment of venous thrombosis, pulmonary embolism, thrombotic disorders, Atrial-Fibrillation with embolism and prophylaxis of systemic embolism after Myocardium Infarction. They inhibit the development of a thrombus 5. Throughout anticoagulant therapy monitor the guest/resident for signs and symptoms of bleeding. If signs and symptoms of bleeding are noted, hold anticoagulant medication and notify physician immediately. 1. For Resident #100, the facility staff failed to monitor for the use of an anticoagulant medication. A review of the clinical record revealed an order dated 8/25/23 for Eliquis (1) 5 mg (milligrams) twice daily for seven days; and an order dated 9/2/23 for Eliquis 5 mg once daily. A review of the comprehensive care plan revealed one dated 8/25/23 for (Resident #100) is at risk for abnormal bleeding/bruising R/T (related to): medication use. Anticoagulant. This care plan included the intervention, dated 8/25/23 for Administer medications as ordered. Observe for ineffectiveness and side effects, report abnormal findings to the physician and one dated 8/25/23 for Observe and report to physician PRN (as-needed) s/sx (signs and symptoms) of complications: blood tinged/[NAME] blood in urine, black tarry stools, dark or bright red blood in stools, sudden severe headaches, nausea, vomiting, diarrhea, muscle joint pain, lethargy, bruising, blurred vision, SOB (shortness of breath), Loss of appetite, sudden changes in mental status, significant or sudden changes in v/s (vital signs), bleeding gums, petechiae, back or abdominal pain and nosebleeds. Further review of the clinical record failed to reveal any evidence of nurses monitoring for the use of an anticoagulant medication side effects related to risk of bleeding and bruising and other side effects. On 9/13/23 at 8:35 AM, an interview was conducted with LPN #6 (Licensed Practical Nurse). She stated that nurses should watch for bruising, bleeding, things like that. She stated that monitoring should be throughout the day, not just a one-time check. She stated that it should be documented in the nurse's notes if there are or are not any signs and symptoms and to let the nurse practitioner know if there are any. She stated that if there isn't an order for monitoring, you can ask the doctor and put it in yourself. On 9/13/23 at 8:46 AM, an interview was conducted with LPN #7. She stated that nurses should watch for bruising of any kind, coughing up blood, bleeding profusely from a wound or unusual places, change in condition. She stated that evidence of monitoring is done by charting on progress notes and a skin note. She stated that there should be a note every day even if nothing occurred so others will know what has been going on with the resident. On 9/13/23 at 11:00 AM, an interview was conducted with RN #4 (Registered Nurse), the unit manager. She stated that each shift should be monitoring for side effects of anticoagulant medications. She stated that there should be documentation of the monitoring. She stated that she cannot say it is being monitored; if it is not documented it is not done. On 9/13/23 at 11:23 AM, 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. Reference: (1) Eliquis - Apixaban is used help prevent strokes or blood clots in people who have atrial fibrillation (a condition in which the heart beats irregularly, increasing the chance of clots forming in the body and possibly causing strokes) that is not caused by heart valve disease. Apixaban is also used to prevent deep vein thrombosis (DVT; a blood clot, usually in the leg) and pulmonary embolism (PE; a blood clot in the lung) in people who are having hip replacement or knee replacement surgery. Apixaban is also used to treat DVT and PE and may be continued to prevent DVT and PE from happening again after the initial treatment is completed. Information obtained from https://medlineplus.gov/druginfo/meds/a613032.html 2. For Resident #88, the facility staff failed to monitor for the use of an anticoagulant medication. A review of the clinical record revealed an order dated 8/5/23 for Apixaban (1) (same as Eliquis) 5 mg (milligrams) twice daily for atrial fibrillation. A review of the comprehensive care plan revealed one dated 3/20/23 for (Resident #88) is at risk for abnormal bleeding/bruising R/T (related to): medication use. Anticoagulant. This care plan included the intervention, dated 3/20/23 for Administer medications as ordered. Observe for ineffectiveness and side effects, report abnormal findings to the physician and one dated 3/20/23 for Observe and report to physician PRN (as-needed) s/sx (signs and symptoms) of complications: blood tinged/[NAME] blood in urine, black tarry stools, dark or bright red blood in stools, sudden severe headaches, nausea, vomiting, diarrhea, muscle joint pain, lethargy, bruising, blurred vision, SOB (shortness of breath), Loss of appetite, sudden changes in mental status, significant or sudden changes in v/s (vital signs), bleeding gums, petechiae, back or abdominal pain and nosebleeds. Further review of the clinical record failed to reveal any evidence of nurses monitoring for the use of an anticoagulant medication side effects related to risk of bleeding and bruising and other side effects. On 9/13/23 at 8:35 AM, an interview was conducted with LPN #6 (Licensed Practical Nurse). She stated that nurses should watch for bruising, bleeding, things like that. She stated that monitoring should be throughout the day, not just a one-time check. She stated that it should be documented in the nurse's notes if there are or are not any signs and symptoms and to let the nurse practitioner know if there are any. She stated that if there isn't an order for monitoring, you can ask the doctor and put it in yourself. On 9/13/23 at 8:46 AM, an interview was conducted with LPN #7. She stated that nurses should watch for bruising of any kind, coughing up blood, bleeding profusely from a wound or unusual places, change in condition. She stated that evidence of monitoring is done by charting on progress notes and a skin note. She stated that there should be a note every day even if nothing occurred so others will know what has been going on with the resident. On 9/13/23 at 11:00 AM, an interview was conducted with RN #4 (Registered Nurse), the unit manager. She stated that each shift should be monitoring for side effects of anticoagulant medications. She stated that there should be documentation of the monitoring. She stated that she cannot say it is being monitored; if it is not documented it is not done. On 9/13/23 at 11:23 AM, 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. Reference: (1) Eliquis - Apixaban is used help prevent strokes or blood clots in people who have atrial fibrillation (a condition in which the heart beats irregularly, increasing the chance of clots forming in the body and possibly causing strokes) that is not caused by heart valve disease. Apixaban is also used to prevent deep vein thrombosis (DVT; a blood clot, usually in the leg) and pulmonary embolism (PE; a blood clot in the lung) in people who are having hip replacement or knee replacement surgery. Apixaban is also used to treat DVT and PE and may be continued to prevent DVT and PE from happening again after the initial treatment is completed. Information obtained from https://medlineplus.gov/druginfo/meds/a613032.html 3. For Resident #91, the facility staff failed to monitor for the use of an anticoagulant medication. A review of the clinical record revealed a physician's order dated 9/11/23 for Coumadin (1) 5 mg (milligrams) daily, on Monday, Tuesday, Wednesday, Thursday, and Friday; and an order dated 9/11/23 for Coumadin 9.5 mg Saturday and Sunday, for atrial fibrillation. A review of the comprehensive care plan revealed one dated 8/21/23 for (Resident #91) is at risk for abnormal bleeding/bruising R/T (related to): medication use. Anticoagulant. This care plan included the intervention, dated 8/21/23 for Administer medications as ordered. Observe for ineffectiveness and side effects, report abnormal findings to the physician and one dated 8/21/23 for Observe and report to physician PRN (as-needed) s/sx (signs and symptoms) of complications: blood tinged/[NAME] blood in urine, black tarry stools, dark or bright red blood in stools, sudden severe headaches, nausea, vomiting, diarrhea, muscle joint pain, lethargy, bruising, blurred vision, SOB (shortness of breath), Loss of appetite, sudden changes in mental status, significant or sudden changes in v/s (vital signs), bleeding gums, petechiae, back or abdominal pain and nosebleeds. Further review of the clinical record failed to reveal any evidence of nurses monitoring for the use of an anticoagulant medication side effects related to risk of bleeding and bruising and other side effects. On 9/13/23 at 8:35 AM, an interview was conducted with LPN #6 (Licensed Practical Nurse). She stated that nurses should watch for bruising, bleeding, things like that. She stated that monitoring should be throughout the day, not just a one-time check. She stated that it should be documented in the nurse's notes if there are or are not any signs and symptoms and to let the nurse practitioner know if there are any. She stated that if there isn't an order for monitoring, you can ask the doctor and put it in yourself. On 9/13/23 at 8:46 AM, an interview was conducted with LPN #7. She stated that nurses should watch for bruising of any kind, coughing up blood, bleeding profusely from a wound or unusual places, change in condition. She stated that evidence of monitoring is done by charting on progress notes and a skin note. She stated that there should be a note every day even if nothing occurred so others will know what has been going on with the resident. On 9/13/23 at 11:00 AM, an interview was conducted with RN #4 (Registered Nurse), the unit manager. She stated that each shift should be monitoring for side effects of anticoagulant medications. She stated that there should be documentation of the monitoring. She stated that she cannot say it is being monitored; if it is not documented it is not done. On 9/13/23 at 11:23 AM, 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. Reference: (1) Coumadin - Warfarin is used to prevent blood clots from forming or growing larger in your blood and blood vessels. It is prescribed for people with certain types of irregular heartbeat, people with prosthetic (replacement or mechanical) heart valves, and people who have suffered a heart attack. Warfarin is also used to treat or prevent venous thrombosis (swelling and blood clot in a vein) and pulmonary embolism (a blood clot in the lung). Information obtained from https://medlineplus.gov/druginfo/meds/a682277.html 29843 4. For R7, the facility staff failed to administer a prn (as needed) the pain medication Tramadol (1) within the physician ordered pain level parameters. R7 was admitted with diagnosis that included but not limited to osteoarthritis of the knee (2). The physician order for R7 documented in part, Tramadol HCl (hydrochloride) Tablet 50 MG (milligrams). Give 1 (one) tablet by mouth every 8 (eight) hours as needed for Pain level 6-10. Order Date: 10/25/2022. The eMAR (electronic medication administration record) for R7 dated August 2023 documented the physician order as stated above. Further review of the eMAR revealed that (R7) received 50 mgs of Tramadol for a pain level of five on 08/01/2023, 08/03/2023, 08/05/2023, 08/06/2023, 08/07/2023, 08/15/2023, 08/23/2023, 08/27/2023 and on 08/31/2023. The eMAR for R7 dated September 2023 documented the physician order as stated above. Further review of the eMAR revealed that (R7) received 50 mg of Tramadol for a pain level of five on 09/03/2023, 09/06/2023 and on 09/08/2023. On 09/13/2023 at approximately 11:00 a.m., an interview was conducted with ASM (administrative staff member) #2, director of nursing. After reviewing the physician order, and the August 2023 and September 2023 eMARS she was asked if the pain medication for R7 was administered according to the physician's orders for the dates listed above. ASM #2 stated no, and that the medication was administered outside of the physician's ordered parameters. On 09/12/2023 at approximately 5:07 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) Tramadol is used to relieve moderate to moderately severe pain. This information was obtained from the website: https://medlineplus.gov/druginfo/meds/a695011.html. (2) The most common form of arthritis. It causes pain, swelling, and reduced motion in your joints. It can occur in any joint, but usually it affects your hands, knees, hips, or spine. This information was obtained from the website: https://medlineplus.gov/osteoarthritis.html.

Based on resident interview, staff interview, clinical record review and facility document review, it was determined that the facility staff failed to implement the comprehensive care plan for five of 37 residents in the survey sample; Residents #100, #88, #91, #87, and #7. The findings include: The facility policy, Care Planning was reviewed. This policy documented, Every resident in the facility will have a person-centered Plan of Care developed and implemented that is consistent with the resident rights, based on the comprehensive assessment that includes measurable objectives and time frames to meet a residents medical, nursing, and mental and psychosocial needs . 1. For Resident #100, the facility staff failed to implement the comprehensive care plan for the use of an anticoagulant medication. A review of the clinical record revealed an order dated 8/25/23 for Eliquis (1) 5 mg (milligrams) twice daily for seven days; and an order dated 9/2/23 for Eliquis 5 mg once daily. A review of the comprehensive care plan revealed one dated 8/25/23 for (Resident #100) is at risk for abnormal bleeding/bruising R/T (related to): medication use. Anticoagulant. This care plan included the intervention, dated 8/25/23 for Administer medications as ordered. Observe for ineffectiveness and side effects, report abnormal findings to the physician and one dated 8/25/23 for Observe and report to physician PRN (as-needed) s/sx (signs and symptoms) of complications: blood tinged/[NAME] blood in urine, black tarry stools, dark or bright red blood in stools, sudden severe headaches, nausea, vomiting, diarrhea, muscle joint pain, lethargy, bruising, blurred vision, SOB (shortness of breath), Loss of appetite, sudden changes in mental status, significant or sudden changes in v/s (vital signs), bleeding gums, petechiae, back or abdominal pain and nosebleeds. Further review of the clinical record failed to reveal any evidence of nurses monitoring for the use of an anticoagulant medication side effects related to risk of bleeding and bruising and other side effects. On 9/13/23 at 8:35 AM, an interview was conducted with LPN #6 (Licensed Practical Nurse). She stated that nurses should watch for bruising, bleeding, things like that. She stated that monitoring should be throughout the day, not just a one-time check. She stated that it should be documented in the nurse's notes if there are or are not any signs and symptoms and to let the nurse practitioner know if there are any. She stated that if there isn't an order for monitoring, you can ask the doctor and put it in yourself. When asked if the care plan documented to monitor, how do you evidence that you followed it, she stated, Your documentation. She stated that if there is no documentation evidence then the care plan is not being followed. On 9/13/23 at 8:46 AM, an interview was conducted with LPN #7. She stated that nurses should watch for bruising of any kind, coughing up blood, bleeding profusely from a wound or unusual places, change in condition. She stated that evidence of monitoring is done by charting on progress notes and a skin note. She stated that there should be a note every day even if nothing occurred so others will know what has been going on with the resident. She stated that if there is no evidence of monitoring, then the care plan is not being followed. On 9/13/23 at 11:00 AM, an interview was conducted with RN #4 (Registered Nurse), the unit manager. She stated that each shift should be monitoring for side effects of anticoagulant medications. She stated that there should be documentation of the monitoring. She stated that she cannot say it is being monitored; if it is not documented it is not done. She stated that the care plan is not being followed if it is not documented. On 9/13/23 at 11:23 AM, 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. References: (1) Eliquis - Apixaban is used help prevent strokes or blood clots in people who have atrial fibrillation (a condition in which the heart beats irregularly, increasing the chance of clots forming in the body and possibly causing strokes) that is not caused by heart valve disease. Apixaban is also used to prevent deep vein thrombosis (DVT; a blood clot, usually in the leg) and pulmonary embolism (PE; a blood clot in the lung) in people who are having hip replacement or knee replacement surgery. Apixaban is also used to treat DVT and PE and may be continued to prevent DVT and PE from happening again after the initial treatment is completed. Information obtained from https://medlineplus.gov/druginfo/meds/a613032.html 2. For Resident #88, the facility staff failed to implement the comprehensive care plan for the use of an anticoagulant medication. A review of the clinical record revealed an order dated 8/5/23 for Apixaban (1) (same as Eliquis) 5 mg (milligrams) twice daily for atrial fibrillation. A review of the comprehensive care plan revealed one dated 3/20/23 for (Resident #88) is at risk for abnormal bleeding/bruising R/T (related to): medication use. Anticoagulant. This care plan included the intervention, dated 3/20/23 for Administer medications as ordered. Observe for ineffectiveness and side effects, report abnormal findings to the physician and one dated 3/20/23 for Observe and report to physician PRN (as-needed) s/sx (signs and symptoms) of complications: blood tinged/[NAME] blood in urine, black tarry stools, dark or bright red blood in stools, sudden severe headaches, nausea, vomiting, diarrhea, muscle joint pain, lethargy, bruising, blurred vision, SOB (shortness of breath), Loss of appetite, sudden changes in mental status, significant or sudden changes in v/s (vital signs), bleeding gums, petechiae, back or abdominal pain and nosebleeds. Further review of the clinical record failed to reveal any evidence of nurses monitoring for the use of an anticoagulant medication side effects related to risk of bleeding and bruising and other side effects. On 9/13/23 at 8:35 AM, an interview was conducted with LPN #6 (Licensed Practical Nurse). She stated that nurses should watch for bruising, bleeding, things like that. She stated that monitoring should be throughout the day, not just a one-time check. She stated that it should be documented in the nurse's notes if there are or are not any signs and symptoms and to let the nurse practitioner know if there are any. She stated that if there isn't an order for monitoring, you can ask the doctor and put it in yourself. When asked if the care plan documented to monitor, how do you evidence that you followed it, she stated, Your documentation. She stated that if there is no documentation evidence then the care plan is not being followed. On 9/13/23 at 8:46 AM, an interview was conducted with LPN #7. She stated that nurses should watch for bruising of any kind, coughing up blood, bleeding profusely from a wound or unusual places, change in condition. She stated that evidence of monitoring is done by charting on progress notes and a skin note. She stated that there should be a note every day even if nothing occurred so others will know what has been going on with the resident. She stated that if there is no evidence of monitoring, then the care plan is not being followed. On 9/13/23 at 11:00 AM, an interview was conducted with RN #4 (Registered Nurse), the unit manager. She stated that each shift should be monitoring for side effects of anticoagulant medications. She stated that there should be documentation of the monitoring. She stated that she cannot say it is being monitored; if it is not documented it is not done. She stated that the care plan is not being followed if it is not documented. On 9/13/23 at 11:23 AM, 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. References: (1) Eliquis - Apixaban is used help prevent strokes or blood clots in people who have atrial fibrillation (a condition in which the heart beats irregularly, increasing the chance of clots forming in the body and possibly causing strokes) that is not caused by heart valve disease. Apixaban is also used to prevent deep vein thrombosis (DVT; a blood clot, usually in the leg) and pulmonary embolism (PE; a blood clot in the lung) in people who are having hip replacement or knee replacement surgery. Apixaban is also used to treat DVT and PE and may be continued to prevent DVT and PE from happening again after the initial treatment is completed. Information obtained from https://medlineplus.gov/druginfo/meds/a613032.html 3. For Resident #91, the facility staff failed to implement the comprehensive care plan for the use of an anticoagulant medication. A review of the clinical record revealed a physician's order dated 9/11/23 for Coumadin (1) 5 mg (milligrams) daily, on Monday, Tuesday, Wednesday, Thursday, and Friday; and an order dated 9/11/23 for Coumadin 9.5 mg Saturday and Sunday, for atrial fibrillation. A review of the comprehensive care plan revealed one dated 8/21/23 for (Resident #91) is at risk for abnormal bleeding/bruising R/T (related to): medication use. Anticoagulant. This care plan included the intervention, dated 8/21/23 for Administer medications as ordered. Observe for ineffectiveness and side effects, report abnormal findings to the physician and one dated 8/21/23 for Observe and report to physician PRN (as-needed) s/sx (signs and symptoms) of complications: blood tinged/[NAME] blood in urine, black tarry stools, dark or bright red blood in stools, sudden severe headaches, nausea, vomiting, diarrhea, muscle joint pain, lethargy, bruising, blurred vision, SOB (shortness of breath), Loss of appetite, sudden changes in mental status, significant or sudden changes in v/s (vital signs), bleeding gums, petechiae, back or abdominal pain and nosebleeds. Further review of the clinical record failed to reveal any evidence of nurses monitoring for the use of an anticoagulant medication side effects related to risk of bleeding and bruising and other side effects. On 9/13/23 at 8:35 AM, an interview was conducted with LPN #6 (Licensed Practical Nurse). She stated that nurses should watch for bruising, bleeding, things like that. She stated that monitoring should be throughout the day, not just a one-time check. She stated that it should be documented in the nurse's notes if there are or are not any signs and symptoms and to let the nurse practitioner know if there are any. She stated that if there isn't an order for monitoring, you can ask the doctor and put it in yourself. When asked if the care plan documented to monitor, how do you evidence that you followed it, she stated, Your documentation. She stated that if there is no documentation evidence then the care plan is not being followed. On 9/13/23 at 8:46 AM, an interview was conducted with LPN #7. She stated that nurses should watch for bruising of any kind, coughing up blood, bleeding profusely from a wound or unusual places, change in condition. She stated that evidence of monitoring is done by charting on progress notes and a skin note. She stated that there should be a note every day even if nothing occurred so others will know what has been going on with the resident. She stated that if there is no evidence of monitoring, then the care plan is not being followed. On 9/13/23 at 11:00 AM, an interview was conducted with RN #4 (Registered Nurse), the unit manager. She stated that each shift should be monitoring for side effects of anticoagulant medications. She stated that there should be documentation of the monitoring. She stated that she cannot say it is being monitored; if it is not documented it is not done. She stated that the care plan is not being followed if it is not documented. On 9/13/23 at 11:23 AM, 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. References: (1) Coumadin - Warfarin is used to prevent blood clots from forming or growing larger in your blood and blood vessels. It is prescribed for people with certain types of irregular heartbeat, people with prosthetic (replacement or mechanical) heart valves, and people who have suffered a heart attack. Warfarin is also used to treat or prevent venous thrombosis (swelling and blood clot in a vein) and pulmonary embolism (a blood clot in the lung). Information obtained from https://medlineplus.gov/druginfo/meds/a682277.html 31753 4.a. For Resident #87 (R87), the facility staff failed to implement the resident's comprehensive care plan for pain management. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 9/1/23, the resident scored 15 out of 15 on the BIMS (brief interview for mental status), indicating the resident was cognitively intact for making daily decisions. R87's comprehensive care plan dated 11/12/22 documented, (R87) is at risk for pain r/t (related to) h/o (history of) multiple falls, chronic T12 (thoracic) compression fracture, fibromyalgia, degenerative arthritis, hx (history) ankle pain, back pain, right should contusion, bilateral knees . 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 . A review of R87's clinical record revealed a physician's order dated 1/20/23 for ibuprofen 200 mg (milligrams)- one tablet by mouth every six hours as needed for pain. A review of R87's September 2023 MAR (medication administration record) revealed the resident was administered as needed ibuprofen on 9/1/23, 9/2/23, 9/3/23, 9/4/23, 9/6/23, 9/7/23 and 9/8/23. Further review of R87's clinical record (including the September 2023 MAR and September 2023 nurses' notes) failed to reveal non-pharmacological interventions were offered or attempted on all dates. On 9/12/23 at 1:49 p.m., an interview was conducted with R87, who stated the nurses do not offer non-pharmacological interventions for pain management. On 9/12/23 at 3:20 p.m., an interview was conducted with LPN (licensed practical nurse) #3. LPN #3 stated care plans are individualized because everybody has different needs. LPN #3 stated the care plans tell you about what is needed to be done and if anyone has questions, they can look at the care plans. LPN #3 stated that prior to the administration of an as needed pain medication, nurses should offer interventions such as an ice packs, heating pads or repositioning, and document the offered interventions in the nurses' notes. LPN #3 stated non-pharmacological interventions are not always attempted each time an as needed pain medication is administered because sometimes non-pharmacological interventions cannot be attempted depending on the location or kind of pain, but nurses should try to offer non-pharmacological interventions if they can be attempted. On 9/12/23 at 5:15 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing) were made aware of the above concern. 4.b. For Resident #87 (R87), the facility staff failed to implement the resident's comprehensive care plan for thyroid replacement therapy. R87's comprehensive care plan dated 11/12/22 documented, (R87) is at risk for complications of hypothyroidism such as: intolerance to cold, decreased appetite, weight gain, dry skin, mood changes, constipation, fatigue & bradycardia (low heart rate) .Administer thyroid replacement therapy as ordered . A review of R87's clinical record revealed a physician's order dated 9/6/23 for levothyroxine sodium (1) 75 mcg (micrograms)- one tablet by mouth in the morning for hypothyroidism. A review of R87's September 2023 MAR (medication administration record) revealed the same physician's order for levothyroxine sodium. On 9/10/23 and 9/11/23, the MAR documented the code, 5=Hold./See Nurse Notes Nurses' notes dated 9/10/23 and 9/11/23 documented the medication was not available in the medication cart. Further review of nurses' notes and the September 2023 MAR failed to reveal documentation that levothyroxine sodium was administered to R87 on 9/10/23 and 9/11/23. A review of the facility backup medication supply list revealed levothyroxine sodium 75 mcg tablets were available in the supply. On 9/12/23 at 3:20 p.m., an interview was conducted with LPN (licensed practical nurse) #3. LPN #3 stated care plans are individualized because everybody has different needs. LPN #3 stated the care plans tell you about what is needed to be done and if anyone has questions, they can look at the care plans. LPN #3 stated nurses should re-order medications from the pharmacy when there are five or six pills left. LPN #3 stated if a medication is not available for administration, the medication should be pulled from the backup medication supply, and if the medication is not available in the supply, then the nurses should call the pharmacy and ask for the medication to be sent STAT (immediately). On 9/13/23 at 3:07 p.m. ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing) were made aware of the above concern. Reference: (1) Levothyroxine is used to treat hypothyroidism (condition where the thyroid gland does not produce enough thyroid hormone). This information was obtained from the website: https://medlineplus.gov/druginfo/meds/a682461.html. 29843 5. For Resident #7 (R7) the facility staff failed to implement the comprehensive care plan for the use of non-pharmacological interventions prior to the administration of a prn (as needed) pain medication, Tramadol (1). R7 was admitted with diagnosis that included but not limited to osteoarthritis (2) of the knee. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 07/20/2023, the resident scored 15 out of 15 on the BIMS (brief interview for mental status), indicating R7 was cognitively intact for making daily decisions. Section J Pain Management coded R7 as having frequent pain at a pain level of six out of ten, with ten being the worse pain. The physician order for R7 documented in part, Tramadol HCl (hydrochloride) Tablet 50 MG (milligrams). Give 1 (one) tablet by mouth every 8 (eight) hours as needed for Pain level 6-10. Order Date: 10/25/2022. The eMAR (electronic medication administration record) for R7 dated august 2023 documented the physician's orders as stated above. The eMAR revealed that R7 received 67 doses of Tramadol 50mgs between 08/01/2023 and 08/31/2023 with no evidence of non-pharmacological interventions being attempted and documentation of the location of R7's pain and the type of pain. The eMAR (electronic medication administration record) for R7 dated September 2023 documented the physician's orders as stated above. The eMAR revealed that R7 received 20 doses of Tramadol 50mgs between 09/01/2023 and 09/11/2023 with no evidence of non-pharmacological interventions being attempted prior to the administration of Tramadol for R7. The nursing progress notes for R7 dated 08/01/2023 through 09/11/2023 failed to evidence documentation of non-pharmacological interventions being attempted prior to the administration of Tramadol for R7. R7's comprehensive care plan dated 02/22/2022 documented in part, Need. (R7) actual pain episodes r/t (related to) severe L (left) knee OA (osteoarthritis) with debility, Chronic pain d/t (due to) RA (rheumatoid arthritis), lumbar radiculopathy, h/o (history of) migraines, DM (diabetes mellitus) with neuropathy. Date Initiated: 02/22/2022. Under Interventions it documented in part, 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. 9)Other. Date Initiated: 02/22/2022. On 09/12/23 at approximately 9:21 a.m., an interview was conducted with R7. When asked if the facility staff attempt non-pharmacological intervention prior to administrating Tramadol, R7 stated no. On 9/12/23 at 3:20 p.m., an interview was conducted with LPN (licensed practical nurse) #3. She stated in regard to non-pharmacological interventions, LPN #3 stated nurses should offer interventions such as an ice packs, heating pads or repositioning, and document the offered interventions in the nurses' notes. LPN #3 stated non-pharmacological interventions are not always attempted each time an as needed pain medication is administered because sometimes non-pharmacological interventions cannot be attempted depending on the location or kind of pain, but nurses should try to offer non-pharmacological interventions if they can be attempted. On 09/12/2023 at approximately 5:07 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) Tramadol is used to relieve moderate to moderately severe pain. This information was obtained from the website: https://medlineplus.gov/druginfo/meds/a695011.html. (2) The most common form of arthritis. It causes pain, swelling, and reduced motion in your joints. It can occur in any joint, but usually it affects your hands, knees, hips or spine. This information was obtained from the website: https://medlineplus.gov/osteoarthritis.html.

2. For R7 the facility staff failed to identify the location of the pain, the type of pain and attempts of non-pharmacological interventions prior to the administration of a prn (as needed) pain medication, Tramadol (1). R7 was admitted with diagnosis that included but not limited to osteoarthritis (2) of the knee. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 07/20/2023, the resident scored 15 out of 15 on the BIMS (brief interview for mental status), indicating R7 was cognitively intact for making daily decisions. Section J Pain Management coded R7 as having frequent pain at a pain level of six out of ten, with ten being the worse pain. R7's comprehensive care plan dated 02/22/2022 documented in part, Need. (R7) actual pain episodes r/t (related to) severe L (left) knee OA (osteoarthritis) with debility, Chronic pain d/t (due to) RA (rheumatoid arthritis), lumbar radiculopathy, h/o (history of) migraines, DM (diabetes mellitus) with neuropathy. Date Initiated: 02/22/2022. Under Interventions it documented in part, 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. 9)Other. Date Initiated: 02/22/2022. The physician order for R7 documented in part, Tramadol HCl (hydrochloride) Tablet 50 MG (milligrams). Give 1 (one) tablet by mouth every 8 (eight) hours as needed for Pain level 6-10. Order Date: 10/25/2022. The eMAR (electronic medication administration record) for R7 dated august 2023 documented the physician's orders as stated above. The eMAR revealed that R7 received 67 doses of Tramadol 50 mgs between 08/01/2023 and 08/31/2023, with no evidence of non-pharmacological interventions attempted and no documentation of the location and type of R7's pain. The eMAR (electronic medication administration record) for R7 dated September 2023 documented the physician's orders as stated above. The eMAR revealed that R7 received 20 doses of Tramadol 50 mgs between 09/01/2023 and 09/11/2023 with no evidence of non-pharmacological interventions attempted and no documentation of the location and type of R7's pain. The nursing progress notes for R7 dated 08/01/2023 through 09/11/2023 failed to evidence documentation of non-pharmacological interventions prior to the administration of Tramadol and the location and type of R7's pain. On 09/12/23 at approximately 9:21 a.m., an interview was conducted with R7. When asked if the facility staff attempt non-pharmacological intervention, ask for the location of pain or type of pain prior to administrating Tramadol, R7 stated no. On 9/12/23 at 3:20 p.m., an interview was conducted with LPN (licensed practical nurse) #3. LPN #3 stated that prior to administering an as needed pain medication, the nurses should ask the resident where the pain is, ask the resident if the pain is throbbing or sharp, ask the resident to rate the pain, ask the resident if the pain is new, observe for non-verbal indicators of pain, and document the assessment. LPN #3 stated a complete pain assessment is important because the pain may be something that requires more than just a pain pill. LPN #3 stated the resident may need to be seen by a doctor or transferred out of the facility. In regard to non-pharmacological interventions, LPN #3 stated nurses should offer interventions such as an ice packs, heating pads or repositioning, and document the offered interventions in the nurses' notes. LPN #3 stated non-pharmacological interventions are not always attempted each time an as needed pain medication is administered because sometimes non-pharmacological interventions cannot be attempted depending on the location or kind of pain, but nurses should try to offer non-pharmacological interventions if they can be attempted. On 09/12/2023 at approximately 5:07 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) Tramadol is used to relieve moderate to moderately severe pain. This information was obtained from the website: https://medlineplus.gov/druginfo/meds/a695011.html. (2) The most common form of arthritis. It causes pain, swelling, and reduced motion in your joints. It can occur in any joint, but usually it affects your hands, knees, hips, or spine. This information was obtained from the website: https://medlineplus.gov/osteoarthritis.html. 31753 Based on resident interview, staff interview, facility document review and clinical record review, the facility staff failed to implement a complete pain management program for two of 37 residents in the survey sample, Residents #87 and #7. The findings include: 1. For Resident #87 (R87), the facility staff failed to initiate a complete pain assessment and failed to attempt non-pharmacological interventions when the as needed pain medication ibuprofen was administered on multiple dates in September 2023. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 9/1/23, the resident scored 15 out of 15 on the BIMS (brief interview for mental status), indicating the resident was cognitively intact for making daily decisions. A review of R87's clinical record revealed a physician's order dated 1/20/23 for ibuprofen 200 mg (milligrams)- one tablet by mouth every six hours as needed for pain. A review of R87's September 2023 MAR (medication administration record) revealed the resident was administered as needed ibuprofen on 9/1/23, 9/2/23, 9/3/23, 9/4/23, 9/6/23, 9/7/23 and 9/8/23. Further review of R87's clinical record (including the September 2023 MAR and September 2023 nurses' notes) failed to reveal a completer pain assessment (including location, quality and duration) was completed on all dates and failed to reveal non-pharmacological interventions were offered or attempted on all dates. On 9/12/23 at 1:49 p.m., an interview was conducted with R87. R87 stated that sometimes the nurses ask the resident's pain level prior to administering ibuprofen but the nurses do not ask the location and description of the pain. R87 further stated the nurses do not offer non-pharmacological interventions. On 9/12/23 at 3:20 p.m., an interview was conducted with LPN (licensed practical nurse) #3. LPN #3 stated that prior to administering an as needed pain medication, the nurses should ask the resident where the pain is, ask the resident if the pain is throbbing or sharp, ask the resident to rate the pain, ask the resident if the pain is new, observe for non-verbal indicators of pain, and document the assessment. LPN #3 stated a complete pain assessment is important because the pain may be something that requires more than just a pain pill. LPN #3 stated the resident may need to be seen by a doctor or transferred out of the facility. In regard to non-pharmacological interventions, LPN #3 stated nurses should offer interventions such as an ice packs, heating pads or repositioning, and document the offered interventions in the nurses' notes. LPN #3 stated non-pharmacological interventions are not always attempted each time an as needed pain medication is administered because sometimes non-pharmacological interventions cannot be attempted depending on the location or kind of pain, but nurses should try to offer non-pharmacological interventions if they can be attempted. On 9/12/23 at 5:15 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing) were made aware of the above concern. The facility policy titled, Pain Management documented, 1. Upon admission/re-admission, quarterly, with a significant change in condition and PRN (as needed) residents will be evaluated for pain by the licensed nurse. 2. Additionally, residents will be monitored for the presence of pain and evaluated when there is a change in condition and whenever new pain or an exacerbation of pain is suspected. 3.Observe resident for indicators of pain (refer to table 3), indicators include: -Moaning, crying, and other vocalizations -Wincing or frowning and other facial expressions -Body posture such as guarding or protecting an area of the body, or lying very still -Decrease in usual activities . 5. Ask the resident and observe to determine the frequency of pain: -No pain -Pain less than daily -Pain daily . 7. Ask the resident and observe to determine the location of pain . 9. Each resident identified with pain will have a Pain Management Care Plan. The care plan will have: 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 .

Based on staff interview, facility document review and clinical record review, the facility staff failed to provide pharmacy services for one of 37 residents in the survey sample, Resident #310. The findings include: For Resident #310 (R310), the facility staff failed to ensure multiple medications were available for administration on multiple dates in February 2023. A review of R310'S clinical record revealed a physician's order dated 2/17/23 for alpha-lipoic acid (1) 300 mg (milligrams)- one capsule by mouth one time a day for supplement. A review of R310's February 2023 MAR (medication administration record) revealed the same physician's order for alpha-lipoic acid. On 2/18/23, 2/19/23, 2/20/23, 2/22/23, 2/23/23 and 2/24/23, the MAR documented the code, 5=Hold/See Nurse Notes. A nurse's note dated 2/18/23 documented the staff was waiting for delivery of the medication. A nurse's note dated 2/19/23 documented the medication was not available. A nurse's note dated 2/20/23 documented the medication was held until available. A nurse's note dated 2/22/23 documented the staff was waiting for delivery of the medication. A nurse's note dated 2/23/23 documented the pharmacy stated insurance would not pay for the medication and the facility had to pay. A nurse's note dated 2/24/23 documented the medication was not available. Further review of R310's clinical record revealed a physician's dated 2/17/23 for Flonase (2) nasal suspension 50 mcg (micrograms)- one spray in both nostrils two times a day for allergy. A review of R310's February 2023 MAR revealed the same physician's order for Flonase. For the morning doses on 2/18/23 and 2/22/23, the MAR documented the code, 5=Hold/See Nurse Notes. A nurse's note dated 2/18/23 documented the medication was in route from the pharmacy. A nurse's note dated 2/22/23 documented the medication was in route from the pharmacy and would be given at the next administration time. Further review of R310's clinical record revealed a physician's order dated 2/20/23 for Mirabegron (3) 25 mg- one tablet by mouth two times a day for bladder spasms. A review of R310's February 2023 MAR revealed the same physician's order for Mirabegron. For the morning doses on 2/21/23 and 2/22/23, the MAR documented the code, 5=Hold/See Nurse Notes. A nurse's note dated 2/22/23 documented the staff was waiting for delivery of the medication from the pharmacy. A review of the facility backup medication supply list revealed alpha-lipoic acid, Flonase, and Mirabegron were not available in the supply. On 9/12/23 at 3:20 p.m., an interview was conducted with LPN (licensed practical nurse) #3. LPN #3 stated if a medication is newly ordered, the medication should be pulled from the backup medication supply, and if the medication is not available in the supply, then the nurses should call the pharmacy and ask for the medication to be sent STAT (immediately). On 9/12/23 at 5:15 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing) were made aware of the above concern. The facility policy titled, Medication Administration documented, Medications are administered in accordance with written orders of the attending physician. The facility pharmacy policy titled, Providing Pharmacy Products and Services documented, Pharmacy will provide Facility with the Facility-specific information sheet set forth in the Facility-Specific Information Sheet which details how Facility staff can contact Pharmacy twenty four (24) hours a day, seven (7) day a week. References: (1) People most commonly use alpha-lipoic acid for nerve pain in people with diabetes. This information was obtained from the website: https://medlineplus.gov/druginfo/natural/767.html (2) Flonase is used to relieve allergies. This information was obtained from the website: https://medlineplus.gov/druginfo/meds/a695002.html (3) Mirabegron is used to treat overactive bladder. This information was obtained from the website: https://medlineplus.gov/druginfo/meds/a612038.html

Based on staff interview and clinical record review it was determined that the facility staff failed to maintain an accurate MDS (minimum data set) assessment for one of 37 residents, Resident #103. The findings include: For Resident #103 (R103), the facility staff failed to code the discharge MDS assessment with an ARD (assessment reference date) of 7/3/2023 with the accurate discharge location. On the most recent MDS, the discharge assessment with an ARD of 7/3/2023, the resident was coded as having an unplanned discharge to the community. The progress notes for R103 documented in part, - 7/3/2023 19:16 (7:16 p.m.) Note Text: went to check on guest while awaiting return call from on call [medical provider], guest now c/o (complains of) of pain in lower abdominal area, no specific site; rp (responsible party) in room insisting guest to be sent out, will let np (nurse practitioner) know family choice. - 7/3/2023 19:52 (7:52 p.m.) Note Text: spoke with np told of change in condition and family request and agreed to transfer to hospital per rp request; rescue squad in transporting guest to (Name of hospital) accompanied by rp. On 9/13/2023 at 8:41 a.m., an interview was conducted with RN (registered nurse) #2, MDS nurse. RN #2 stated that they had daily clinical meetings to discuss skilled residents, discuss discharges and unplanned discharges and reviewed the 24 hour reports to find out any residents who were discharged or transferred to the hospital. She reviewed R103's discharge MDS with the ARD of 7/3/2023 and the progress notes dated 7/3/2023 and stated that the MDS was not correct and should have been coded that they went to the hospital. She stated that the MDS needed to be corrected. She stated that they followed the RAI (resident assessment instrument) manual when completing the MDS assessments. According to the RAI Manual, Version 1.16, dated October 2018, section A2100: OBRA Discharge Status, documented in part, Steps for Assessment: 1. Review the medical record including the discharge plan and discharge orders for documentation of discharge location .Code 01, community (private home/apt., board/care, assisted living, group home): if discharge location is a private home, apartment, board and care, assisted living facility, or group home . Code 03, acute hospital: if discharge location is an institution that is engaged in providing, by or under the supervision of physicians for inpatients, diagnostic services, therapeutic services for medical diagnosis, and the treatment and care of injured, disabled, or sick persons . On 9/13/2023 at 9:30 a.m., ASM (administrative staff member) #1, the administrator was made aware of the concern. No further information was provided prior to exit.

Based on observation, resident interview, staff interview, clinical record review, it was determined that the facility staff failed to provide ADL (activities of daily living) for one of 37 residents, Resident #24. The findings include: For Resident #24 (R24), the facility staff failed to provide timely incontinence care. R24 was admitted to the facility with diagnoses that included but were not limited to: muscle wasting and abnormalities of gait and mobility. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 06/20/2023, the resident scored 10 out of 15 on the BIMS (brief interview for mental status), indicating R24 was moderately impaired of cognition for making daily decisions. Under Section H Bladder and Bowel R24 was coded as being always incontinent of urine. On 09/11/23 at 12:35 p.m., an observation revealed that R24 activated the call bell for incontinence care. On 09/11/23 at 12:45 p.m., an observation revealed CNA (certified nursing assistant) #2 entered R24's room, turned off the call and left the room with R24's lunch tray. On 09/11/2023 at 1:00 p.m., an observation revealed LPN (licensed practical nurse) #4 entered R24's room and provided incontinence care. On 09/12/23 at approximately 1:06 p.m., an interview was conducted with CNA (certified nursing assistant) #2. When asked about her entering R24's room at approximately 12:45 p.m., the day before, she stated that she picked up R24's meal tray and that R24 asked if she would clean her up. CNA #2 stated that she told R24 that when she finished picking up the meal trays she would come back and provide incontinence care. When asked what time she finished picking up the meal trays, CNA #2 stated that it was after 1:00 p.m. but could not recall the exact time. When asked how long a resident should wait for incontinence care after informing a staff member, she stated that it should be done right away so the resident is not sitting in a soiled brief. When asked if R24's was on their assignment for Monday 0-9/11/2023, she stated yes. When informed of the above observations and that R24 waited approximately 25 minutes to receive incontinence care after activating her call bell and informing CNA #2, CNA #2 stated that she could have notified the nurse that R24 required incontinence care. On 09/12/23 at approximately 1:33 p.m., an interview was conducted with LPN (licensed practical nurse) #2, unit manager. When asked how long a resident should wait for incontinence care after informing a staff member, she stated that the resident should only have to wait within 15 to 20 minutes. When informed of the above observations LPN #2 stated that the CNA should have let the nurse know R24 required incontinence care. On 09/12/23 at approximately 1:53 p.m., an interview was conducted with LPN #4, MDS nurse. When asked if she entered R24's room on Monday, 09/11/2023 at approximately 1:00 p.m., she stated yes. When asked about providing incontinence care to R24, LPN #4 stated that she provided incontinence care, and that the resident was wet. LPN #4 further stated that she was not aware that R24 had been waiting for incontinence care because she had just walked onto the unit. The facility's policy Routine Resident Care it documented in part, Residents receive the necessary assistance to maintain good grooming and personal/oral hygiene. Under Guidelines to documented in part, 8. Incontinence care is provided timely according to each resident's needs. On 09/12/2023 at approximately 5:07 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, and facility document review it was determined facility staff failed to store food in a sanitary manner in one of one facility kitchens. The findings include: The facility staff failed to close a box containing a bag of breaded fish filets, exposing them to the environment, in one of one walk-in freezers. On 09/11/2023 at approximately 11:45 a.m., an observation of the facility's walk-in freezer was conducted with OSM (other staff member) #1, dietary manager. Observation of the middle shelf on the right side inside the freezer revealed a ten-pound box of breaded fish filets. Observation of the box revealed that the box and the inside packaging was open to the environment. When asked how much was left in the box OSM #1 stated it about half remaining. OSM #1 further stated that the box should have been closed and immediately removed it from the freezer. The facility's policy Food Purchasing and Storage documented in part, All frozen food will be dated, labeled, and wrapped or sealed. Moisture-proof, tightfitting materials will be used to prevent freezer burn. On 09/12/2023 at approximately 5:07 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 staff interview, facility document review and clinical record review, the facility staff failed to provide a diet to meet a resident's needs for one of 37 residents in the survey sample, Resident #310. The findings include: For Resident #310 (R310), the resident was discharged from the hospital on 2/17/23 with a recommendation for a diabetic diet. The facility staff failed to obtain a physician's order for R310's diet until 2/20/23. R310 was served a regular diet until a physician's order for a consistent carbohydrate diet with no added salt was obtained on 2/20/23. A hospital orthopedic surgery progress note dated 2/16/23 documented, Assessment/Plan: Diet: diabetic . R310 was admitted to the facility on [DATE] with a diagnosis of diabetes. A review of R310's physician's orders failed to reveal any dietary orders until 2/20/23. A dietary communication form dated 2/18/23 documented the resident's diet as regular. A facility form titled, Guest/Resident, Family, Employee, and Visitor Assistance Form dated 2/20/23 documented, What is your concern about? Diet. I am diabetic .When did the problem or incident occur? Since 2/17/23. FACILITY RESPONSE: Dietary received a new admission slip for guest on 2/18/23 which is a Saturday, diet slip stated guest was a regular diet. ACTION TO BE TAKEN: Dietary director will go see guest for food preferences . A registered dietician nutritional evaluation dated 2/20/23 documented, Utilizes insulin pump for DM (diabetes mellitus) management, follows a strict CHO (carbohydrate) counting diet for DM . Further review of R310's clinical record revealed a physician's order dated 2/20/23 for a consistent carbohydrate diet with no added salt. On 9/12/23 at 4:59 p.m., an interview was conducted with RN (registered nurse) #3. RN #3 stated that when a resident is admitted to the facility, the nurses usually obtain the resident's diet order from the hospital, are told the diet order during the phone report from the hospital, or the nurses will look through the hospital discharge paperwork which will usually indicate the diet the resident should be provided. RN #3 stated the nurses are responsible for entering the diet order into the computer system and providing a diet communication form to the kitchen on the day of admission. On 9/13/23 at 8:19 a.m., an interview was conducted with OSM (other staff member) #4 (the registered dietician). OSM #4 stated that on the day of admission, the nurses are supposed to enter a diet order into the computer system, and this is usually the diet that the hospital staff has placed the resident on. OSM #4 stated that within a week, she evaluates the resident and changes the diet order if needed. OSM #4 stated she evaluated R310 on 2/20/23 and a consistent carbohydrate diet with no added salt was prescribed on that date. OSM #4 stated this was equivalent to a diabetic diet. On 9/13/23 at 9:01 a.m., an interview was conducted with OSM (other staff member) #5 (the former dietary manager). OSM #5 stated residents' prescribed diets are communicated from the nursing staff to the dietary staff via dietary communication forms. OSM #5 stated the diet that is documented on the communication form and provided to the kitchen is the diet that is entered into the dietary meal tracker system and the diet that is provided. On 9/13/23 at 3:07 p.m. ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing) were made aware of the above concern. The facility policy titled, Diet Orders documented, 1. The Nurse will obtain a Physician order for the type of diet needed upon admission/readmission and when a diet change is needed. 2. The Nurse or Designee will provide a written Diet Order and Communication form of the change to the Dietary department.

Based on observation, resident interview, staff interview, clinical record review, it was determined that the facility staff failed to maintain sufficient nursing staff to ensure a resident's needs were met for one of 37 residents in the survey sample, Resident #24. The findings include: For Resident #24 (R24) the facility staff failed to provide incontinence care due to insufficient nursing staff. R24 was admitted to the facility with diagnoses that included but were not limited to: muscle wasting and abnormalities of gait and mobility. On 09/11/23 at 12:35 p.m., an observation revealed that R24, who resided on the west unit at the facility, activated the call bell for incontinence care. On 09/11/23 at 12:45 p.m., an observation revealed CNA (certified nursing assistant) #2 entered R24's room, turned off the call and left the room with R24's lunch tray. On 09/11/2023 at 1:00 p.m., an observation revealed LPN (licensed practical nurse) #4 entered R24's room and provided incontinence care. The facility's as-worked schedule for 09/11/2023 documented eight certified nursing assistants were scheduled for the 7:00 a.m. to 3:00 p.m. shift, four on the west unit and four on the east unit. On 09/11/23 at 12:57 p.m., an interview was conducted with R24. When asked about CNA #2 entering her room R24 stated that she told CNA #2 that she was wet and needed to be cleaned. On 09/12/23 at approximately 1:06 p.m., an interview was conducted with CNA (certified nursing assistant) #2. When asked about her entering R24's room at approximately 12:45 p.m., the day before, she stated that she picked up R24's meal tray and that R24 asked if she would clean her up. CNA #2 stated that she told R24 that when she finished picking up the meal trays she would come back and provide incontinence care. When asked what time she finished picking up the meal trays, CNA #2 stated that it was after 1:00 p.m. but could not recall the exact time. When asked why R24 had to wait for incontinence care CNA #2 stated that the unit was short staffed and that there were three CNAs for 60 residents. On 09/12/2023 at approximately 4:16 p.m., an interview was conducted with CNA #1, staffing coordinator. When asked to describe the minimal staffing requirements to provide adequate and consistent resident care CNA #1 stated that with the facility census there should be six CNAs on the west unit and six CNAs on the east unit during the 7:00 a.m. to 3:00 p.m. shift and two LPNs (licensed practical nurses) on each unit during the 7:00 a.m. to 3:00 p.m. shift. When asked about the staffing on Monday, 09/11/2023, she stated that there were four CNAs on each of the units, and explained that the facility has had CNAs drop to prn (as needed) status, some have been terminated and CNAs call out. When asked how she addresses the short staffing CNA #1 stated that she calls staff who are off trying to get them to come in to cover and that the facility does not use agency staff. When asked if not enough staff having effects the quality of resident care she stated yes. On 09/12/2023 at approximately 5:07 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 resident interview, staff interview, facility document review and clinical record review, the facility staff failed to promptly resolve a grievance for one of 37 residents in the survey sample, Resident #87. The findings include: For Resident #87 (R87), the facility staff failed to resolve the resident's grievance regarding her roommate. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 9/1/23, the resident scored 15 out of 15 on the BIMS (brief interview for mental status), indicating the resident was cognitively intact for making daily decisions. On 9/11/23 at 2:48 p.m., an interview was conducted with the resident. R87 voiced concern that her roommate is often agitated, swears for hours and bangs on the snack table at different times throughout the day and night. R87 stated this has occurred since she moved into the room (on 8/1/23), her roommate keeps her up during the night, staff is aware, and no one has resolved this concern. At this time, R87's roommate was observed lying in bed and loudly speaking incoherent words. A review of R87's clinical record (progress notes for August 2023 and September 2023) and grievance logs for August 2023 and September 2023 failed to reveal documentation regarding the resident's concern. Nurse practitioner notes dated 8/4/23, 8/6/23 and 9/1/23 documented R87 complained of not sleeping well. On 9/12/23 at 12:50 p.m., an interview was conducted with LPN (licensed practical nurse) #2 (the unit manager). LPN #2 stated R87 has had complaints regarding her roommate and stated she's not getting any sleep. LPN #2 stated she spoke with R87's representative who agrees that the resident tends to say things that aren't true, and the nurses are reporting R87 is sleeping at night. LPN #2 stated she thought R87 wanted to be in a bed by the window, but the roommate didn't want to move, and no other room was available. LPN #2 stated she did not complete a grievance form regarding R87's concern but she spoke with the resident's representative on the previous day and the representative was happy with everything. When asked what has been done to ensure R87's grievance was resolved and the resident was satisfied, LPN #2 stated she has verified with nurses that the resident is sleeping. On 9/12/23 at 5:11 p.m., an interview was conducted with ASM (administrative staff member) #1 (the administrator and grievance officer). ASM #1 stated that anyone including residents, family members or staff can fill out a grievance form then the form is taken to the stand down or morning meetings and discussed. ASM #1 stated the grievance is then assigned to the appropriate discipline and those staff are responsible for investigating the grievance and developing a plan to try to resolve the grievance. ASM #1 stated that after this is done, staff is supposed to talk to the resident and determine if he or she is satisfied. On 9/12/23 at 5:15 p.m., ASM #1 and ASM #2 (the director of nursing) were made aware of the above concern. The facility policy titled, Care Program documented, All concerns/grievances are investigated, resolved, and documented .

Based on observation, resident interview, staff interview, facility document review, and clinical record review, the facility staff failed to ensure all bed rail requirements were met for one of 37 residents in the survey sample, Resident #87. The findings include: For Resident #87 (R87), the facility staff failed to review the risks and benefits of bed rails with the resident and obtain informed consent. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 9/1/23, the resident scored 15 out of 15 on the BIMS (brief interview for mental status), indicating the resident was cognitively intact for making daily decisions. A review of R87's clinical record revealed a physician's order dated 2/17/23 for a right assist bar (bed rail) to aide in turning and repositioning. A physical device evaluation dated 2/20/23 documented the use of an assist bar enabled increased bed mobility and enabled the resident to reposition self. On 9/11/23 at 2:48 p.m., R87 was observed lying in bed with a right assist bar in the upright position. On 9/12/23 at 1:49 p.m., an interview was conducted with R87. When asked, the resident stated that the facility staff had not explained the risks and benefits of the assist bar until about an hour before the interview when a staff member had the resident sign a form. On 9/12/23 at 3:20 p.m., an interview was conducted with LPN (licensed practical nurse) #3. LPN #3 stated the nurses have to get special permission for residents to use assist bars and someone in the nursing department should educate residents about the use of assist bars and obtain informed consent. On 9/12/23 at 5:15 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing) were made aware of the above concern. The facility policy titled, Side Rail/Bed/Mattress Spacing and Mechanical Requirements documented, 2. If a side rail is implemented the facility must obtain informed consent from the resident or if applicable, the resident representative for the use of side rails.

Based on staff interview, clinical record review and facility document review, it was determined that the facility staff failed to evidence communication with the dialysis center for each dialysis visit for one of two residents in the survey sample that received dialysis services; Resident #91. The findings include: For Resident #91, there were no dialysis communication sheets for 8/31/23, 9/2/23 and 9/9/23; and incomplete dialysis communication sheets for 8/29/23 and 9/5/23. The facility policy, Hemodialysis was reviewed. This policy documented, Guests/residents receiving hemodialysis will be assessed pre and post treatment, and receive necessary interventions 4. The facility completes the appropriate section of the hemodialysis communication form prior to guest/resident receiving each dialysis session and again when the guest/resident returns from hemodialysis . A review of the clinical record revealed an order dated 8/21/23 for dialysis on Monday, Wednesday, and Friday; and an order dated 8/30/23 changing the dialysis days to Tuesday, Thursday and Saturday. A nurse's note dated 8/27/23 that documented, Guest notified writer that his dialysis has changed to Tue, Thur and Sat (Tuesday, Thursday, Saturday) starting on Tue 8/29/2023 This is in support of the above order changing the dialysis days. The information was not included on the dialysis communication sheet from the dialysis center to the facility on [DATE]. It is not documented if this change was initiated by the dialysis center on 8/25/23 or by the resident in the days following dialysis on 8/25/23. A review of the dialysis communication log revealed the communication sheet dated 8/29/23 did not contain any communication from the dialysis center to the facility and did not contain the resident's name to validate that it was even for this resident. The dialysis sheet dated 9/5/23 did not contain the resident's name to validate that it was applicable for this resident. Further review revealed there was no communication sheets dated 8/31/23, 9/2/23 and 9/9/23. On 9/12/23 at 4:10 PM, an interview was conducted with LPN #1 (Licensed Practical Nurse). She stated that there should be completed communication sheets for every visit so that each facility knows what is going on with the resident. On 9/13/23 at 11:00 AM, an interview was conducted with RN #4 (Registered Nurse), the unit manager. She stated that dialysis communication sheets should be completed for each visit by the facility and the dialysis center. On 9/13/23 at 11:23 AM, 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. On 9/13/23 at 11:23 AM, 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.

Based on clinical record review, staff interview and facility document review, it was determined that the facility staff failed to notify the physician medications not ordered and/or administered, for two of 37 residents in the survey sample, Resident #225 and Resident #87. The findings include: 1. For Resident #225 (R225), the facility staff failed to notify the physician when a medication, for the treatment of urinary retention, from a consulting physician was ordered. R225 was admitted with diagnoses that included but were not limited to benign prostatic hyperplasia (1). A urology office visit note for R225 documented in part, 11/25/2022 - Office visit: General. The patient was accompanied by his son . Under Prescription(s) Today it documented in part, Dutasteride (2) 0.5 mg (milligram) capsule (dutasteride) Take 1 (one) capsule by mouth as directed at 9 am (9:00 a.m.) daily. Under Plan it documented in part, We had a discussion regarding addition of 5-alpha reductase inhibitor (3) . The prescription slip from the urologist dated 11/25/2022 at 3:58 p.m. documented in part, Dutasteride 0.5 mg capsule. Dispense 30 (thirty) capsules. Take (one) capsule by mouth as directed at 9 AM daily. The facility physician's order for R225 documented in part, Dutasteride Capsule 0.5 MG. Give 1 capsule by mouth at bedtime for benign prostatic hyperplasia. Order Date: 11/28/2022. The eMAR (electronic medication administration record) for R225 dated November 2022 revealed the first dose of Dutasteride wasn't administered until 11/28/2022. The nurse practitioner's (NP) note for R225 dated 11/28/2022 at 1:53 p.m., documented in part, A/P (assessment/plan) . Dutasteride added 11/28 . Review of the facility's nursing progress notes dated 11/25/2022 through 11/27/2022 failed to evidence documentation of notification to the physician or NP of R225 consulting physician's order. On 09/12/2023 at approximately 3:43 p.m., an interview was conducted with LPN (licensed practical nurse) #8. When asked to describe the procedure when a resident brings in a prescription for a medication from a provider outside of the facility she stated that the nurse should put order in computer, talk to the physician or NP if they are in the building or call them to let them know the resident has a new prescription, put the script in the doctors book and call the pharmacy if the medication is not available in the facility. When asked if they recalled R225 and when R225's son brought him back to the facility from a urology appointment on 11/25/2022 she stated yes. LPN #8 stated that R225 and his son came back from an appointment between 7:00 p.m. and 8:00 p.m. with a prescription for urinary retention. LPN #8 further stated she did not call the physician. On 09/13/2023 at approximately 11:00 a.m., an interview was conducted with ASM (administrative staff member) #2, director of nursing. When asked about R225 not receiving Dutasteride when it was ordered by the urologist, ASM #2 stated that the resident arrived around 8:00 p.m., the script was handed to the nurse and faxed it to the pharmacy but did not notify the on-call provider. She further stated that the NP was notified on the following Monday, 11/28/2022, and R225 received his first dose that day. When asked if there was a delay in R225 receiving his medication ASM #2 stated yes. When asked if the physician or NP was notified that R225 did not receive the medication of Dutasteride she stated no. On 09/13/2023 at approximately 3:00 p.m., ASM (administrative staff member) #1, administrator, and ASM #2, director of nursing, were made aware of the above findings. No further information was provided prior to exit. References: (1) An enlarged prostate. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/enlargedprostatebph.html. (2) Used alone or with another medication (tamsulosin [Flomax]) to treat benign prostatic hyperplasia (BPH; enlargement of the prostate gland). May reduce the chance of developing acute urinary retention. This information was obtained from the website: https://medlineplus.gov/druginfo/meds/a603001.html. (3) A class of medication used in the management and treatment of benign prostatic hyperplasia (BPH). This information was obtained from the website: https://www.ncbi.nlm.nih.gov/ 31753 2. For Resident #87 (R87), the facility staff failed to notify the physician when the medication levothyroxine sodium (1) was not available for administration on 9/10/23 and 9/11/23. A review of R87's clinical record revealed a physician's order dated 9/6/23 for levothyroxine sodium 75 mcg (micrograms)- one tablet by mouth in the morning for hypothyroidism. A review of R87's September 2023 MAR (medication administration record) revealed the same physician's order for levothyroxine sodium. On 9/10/23 and 9/11/23, the MAR documented the code, 5=Hold/See Nurse Notes. Nurses' notes dated 9/10/23 and 9/11/23 documented the medication was not available in the medication cart. Further review of nurses' notes and the September 2023 MAR failed to reveal documentation that levothyroxine sodium was administered to R87 on 9/10/23 and 9/11/23 and failed to reveal documentation that R87's physician was notified. On 9/12/23 at 3:20 p.m., an interview was conducted with LPN (licensed practical nurse) #3. LPN #3 stated the physician should be notified when a medication is not available for administration because sometimes the physician can give another order. On 9/12/23 at 5:15 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing) were made aware of the above concern. Reference: (1) Levothyroxine is used to treat hypothyroidism (condition where the thyroid gland does not produce enough thyroid hormone). This information was obtained from the website: https://medlineplus.gov/druginfo/meds/a682461.html

Based on observation, staff interview, and clinical record review, it was determined that facility staff failed to provide respiratory care and services in a sanitary manner for one of 37 residents in the survey sample, Residents #21. The findings include: For Resident #21 (R21), the facility staff failed to store a CPAP (continuous positive airway pressure) (1) mask in a sanitary manner. R21 was admitted to the facility with diagnoses that included but were not limited to chronic obstructive sleep apnea (2). On the most recent comprehensive MDS (minimum data set), an annual assessment with an ARD (assessment reference date) of 07/14/2021, R21 scored 15 out of 15 on the BIMS (brief interview for mental status), the resident was cognitively intact for making daily decisions. Section O Special Treatments, Procedures and Programs coded R21 for CPAP while a resident. On 09/11/23 at approximately 12:32 p.m., an observation of R21's room revealed a CPAP mask laying on the over-the-bed table uncovered. On 09/11/23 at approximately 4:30 p.m., an observation of R21's room revealed a CPAP mask laying on the over-the-bed table uncovered. On 09/12/23 at approximately 9:00 a.m., an observation of R21's room revealed a CPAP mask laying on the over-the-bed table uncovered. The physician's order for R21 documented in part, CPAP to be on when laying down as tolerated set at prescribed settings. every shift for hypoxia. Start Date: 06/15/2021. On 09/12/23 at approximately 9:01 a.m., an interview was conducted with R#38. When asked about the storage of the CPAP mask she stated that the facility have not provided a bag to store it in and that she is unable to reach the mask and relies of the staff to place the mask in a bag. On 09/13/2023 at approximately 11:00 a.m., an interview was conducted with ASM (administrative staff member) #2, director of nursing. After informed of the above observations she was asked how a resident's CPAP mask should be stored when it is not being used. ASM #2 stated that it should be covered to keep it clean. On 09/12/2023 at approximately 5:07 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) 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. The forced air delivered by CPAP (continuous positive airway pressure) prevents episodes of airway collapse that block the breathing in people with obstructive sleep apnea and other breathing problems. This information was obtained from the website: https://medlineplus.gov/ency/article/001916.htm. (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.

Based on staff interview, clinical record review and facility document review, it was determined that the facility staff failed to provide care and services for the treatment of pressure injuries for one of 37 residents in the survey sample; Resident #205. The findings include: The facility policy, Skin Management was reviewed. This policy documented, Upon admission/re-admission all guests/residents are evaluated for skin integrity by completing a baseline total body skin evaluation documented in the electronic medical record 4. Guests/residents admitted with any skin impairment will have: Appropriate interventions implemented to promote healing, A physician's order for treatment, and Wound location, measurements and characteristics documented The facility staff failed to document descriptions, measurements, and staging of two wounds after the initial admission documentation, until the wound care physician saw the resident approximately seven days after admission; and, failed to evidence that treatment was initiated until two days after admission. Resident #205 was admitted to the facility on [DATE] and discharged on [DATE]. A review of the admission MDS (Minimum Data Set) dated 8/24/22, revealed the resident was admitted with two stage-two pressure wounds. Review of the clinical record failed to reveal any evidence of where the MDS staging came from as it was not documented anywhere. Also, the clinical record failed to reveal evidence that treatment was initiated upon admission and for the first two days of admission. A review of the clinical record revealed the following orders and administration of those orders, in chronological order of the order date: An order 8/18/22 for wound consult as-needed. The wound physician notes were reviewed. The wound physician saw the resident on 8/22/22, 8/31/22, 9/14/22, and 9/21/22. An order 8/18/22 for right buttock - cleanse with normal saline, pat dry, cover with medihoney foam every day shift. A review of the TAR (Treatment Administration Record) for August 2022 revealed this order was discontinued on 8/20/22 and was administered as ordered. An order 8/20/22 for bilateral buttocks - cleanse with normal saline, pat dry, cover with medihoney foam every day shift for wound. A review of the TAR for August 2022 revealed this order was discontinued on 8/24/22 and was administered as ordered. An order 8/24/22 left buttock - cleanse with normal saline, pat dry, cover with medihoney and foam every day shift. A review of the TAR for August and September 2022 revealed this order was discontinued on 9/8/22 and was administered as ordered. An order 8/24/22 right buttock - cleanse with normal saline, pat dry, cover with medihoney and foam every day shift for wound. A review of the TAR for August and September 2022 revealed this order was discontinued on 9/8/22 and was administered as ordered. An order 9/8/22 barrier cream to bilateral buttocks every shift. A review of the TAR revealed this order was discontinued upon discharge and was completed as ordered except one time out of 42 opportunities it was not documented. There was no evidence whether it was done and not documented or was not done. There was no evidence that this resulted in any negative impact on the resident. Further review of the clinical record revealed the following notes and assessments, in chronological order: The admission nurse's note dated 8/17/22 documented the resident arrived at 8:15 PM and that there was a .right buttock open red area 1 cm open area on left buttock approximately 1 cm wide . The nurse practitioner note dated 8/18/22, the initial assessment of this resident, did not address the wounds. A skin assessment dated [DATE] at 4:02 PM documented Number of new skin conditions: 0. Comments: open area to buttocks The nurse practitioner note dated 8/20/22 at 4:01 PM documented, .skin: .Bilateral buttock wounds wound care order updated The nurse practitioner note dated 8/22/22 at 10:14 AM documented, .buttocks wounds assessed, dressing lifted . The nurse practitioner note dated 8/24/22 at 12:23 PM documented, .seen in bed, wounds assessed with wound MD, b/l (bilateral) buttocks wounds healing well . The wound physician note dated 8/24/22 documented, .Stage 3 pressure wound right buttock .Wound Size (L x W x D) 2.9 x 1.6 x 0.1 .Stage 3 pressure wound of the left buttock .Wound Size (L x W x D) 3 x 2.1 x 0.1 . The wound physician note on 8/24/22 was the first with complete measurements, staging, and description of the wounds, which was approximately seven days after admission. There was no evidence of measurements other than the one centimeter documented on admission which was not a complete measurement, any description other than red and open area on admission, and any staging of these wounds prior to this note. In addition, there was no evidence that any wound treatment was initiated upon admission when the wound was initially identified, until approximately 16 hours after admission, and the first application of this treatment was not documented until 8/19/22, per the August 2022 TAR. The wound physician note dated 8/31/22 documented, .Stage 3 pressure wound right buttock .Wound Size (L x W x D) 1.4 x 0.9 x 0.1 .Stage 3 pressure wound of the left buttock .Wound Size (L x W x D) 2.6 x 0.5 x not measureable . The next wound physician note was dated 9/14/22. This note documented that as of 9/14/22, both wounds were resolved. There were no other wounds on this review note. On 9/13/23 at 8:52 AM, an interview was conducted with LPN #6 (Licensed Practical Nurse). She stated that when a resident is admitted with wounds, the wounds should be assessed, cleaned and dressed. She stated that staff should obtain wound orders for it, implement the orders, and the next morning the unit manager and the doctor go in and do their assessment. She stated that wounds should be accurately documented as to what the resident has and where they are located, a detailed description of the wound and treatment should be initiated right away. She stated that when staff assess a wound, they are going to have to dress it, and that treatment orders should have been obtained immediately. On 9/13/23 at 9:52 AM, an interview was conducted with ASM #4 (Administrative Staff Member), the nurse practitioner. She stated that the wounds were healed. She did not have any concerns regarding the wound treatment. On 9/13/23 at 10:10 AM, an interview was conducted with ASM #5, the wound care physician. He did not recall the resident and was unable to speak to the pressure wounds prior to his initial evaluation of the wound, approximately one week after admission. On 9/13/23 at 10:46 AM, an interview was conducted with RN #2 (Registered Nurse), the MDS nurse. She stated that when the resident was admitted , he came in with two open areas. She stated that she made her own observations of the resident's wounds in order to stage them for the MDS because there was no staging documented in the clinical record. She stated that she does not know what day she made the observation but that typically, she does her observations and interviews on or close to the ARD (Assessment Reference Date) of the MDS. The ARD for the admission MDS was 8/24/22, the same day as the wound care physician's first visit. She stated that her observations and interviews would not have been done the day of or in the day or two following admission; it would have been closer to the ARD date. On 9/13/23 at 11:00 AM, an interview was conducted with RN #4, the unit manager. She stated that the initial skin check and then two more in the next 24 hours should be done-at admission and each following shifts for two more times. She stated that documentation should be as descriptive as possible. She stated that the nurse practitioner or physician should then go in and see the wounds to verify what stage they are. She stated that RN's are able to stage wounds but not everyone is comfortable. She stated that she tries to see all wounds in the first 24 hours. She stated that she would do a description and her own clinical opinion on what the stage is. She stated that there should have been treatment initiated and a note that wound care was provided and that orders should have been obtained on admission to get something started. She stated that there should be documentation on wound sizing, description, and staging. She stated that there should have been better documentation of the wound and wound care initiated and a note that wound care was provided even if there wasn't an order in place yet. On 9/13/23 at 11:23 AM, 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.

Based on staff interview, facility document review and clinical record review, the facility staff failed to follow professional standards of practice for three of 37 residents in the survey sample, Residents #87, #55 and #225. The findings include: 1. For Resident #87 (R87), the facility staff failed to administer the medication levothyroxine sodium (1) 75 mcg (micrograms) per physician's order on 9/10/23 and 9/11/23. A review of R87's clinical record revealed a physician's order dated 9/6/23 for levothyroxine sodium 75 mcg- one tablet by mouth in the morning for hypothyroidism. A review of R87's September 2023 MAR (medication administration record) revealed the same physician's order for levothyroxine sodium. On 9/10/23 and 9/11/23, the MAR documented the code, 5=Hold/See Nurse Notes. Nurses' notes dated 9/10/23 and 9/11/23 documented the medication was not available in the medication cart. Further review of nurses' notes and the September 2023 MAR failed to reveal documentation that levothyroxine sodium was administered to R87 on 9/10/23 and 9/11/23. A review of the facility backup medication supply list revealed levothyroxine sodium 75 mcg tablets were available in the supply. On 9/12/23 at 3:20 p.m., an interview was conducted with LPN (licensed practical nurse) #3. LPN #3 stated nurses should re-order medications from the pharmacy when there are five or six pills left. LPN #3 stated if a medication is not available for administration, the medication should be pulled from the backup medication supply, and if the medication is not available in the supply, then the nurses should call the pharmacy and ask for the medication to be sent STAT (immediately). On 9/12/23 at 5:15 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing) were made aware of the above concern. The facility policy titled, Medication Administration documented, Medications are administered in accordance with written orders of the attending physician. Reference: (1) Levothyroxine is used to treat hypothyroidism (condition where the thyroid gland does not produce enough thyroid hormone). This information was obtained from the website: https://medlineplus.gov/druginfo/meds/a682461.html. 2. For Resident #55 (R55), the facility staff failed to accurately transcribe a physician's order to administer the resident's potassium via PEG (percutaneous endoscopic gastrostomy) tube instead of via mouth. A review of R55's clinical record revealed a physician's order dated 8/17/23 for, Nothing by Mouth diet, Nothing by Mouth texture, Nothing by Mouth consistency. Further review of R55's clinical record revealed a physician's order dated 8/18/23 for potassium chloride liquid 20 milliequivalents/15 milliliters- 20 milliequivalents by mouth three times a day. On 9/12/23 at 3:20 p.m., an interview was conducted with LPN (licensed practical nurse) #3. LPN #3 stated if a resident with a peg tube has a physician's order for nothing by mouth, then medications should be administered via peg, and the order should document that. LPN #3 stated that when the nurses put orders into the computer system, they get used to entering the route as by mouth and someone may have unintentionally entered the wrong route for R55's potassium. Interviews were conducted with nurses who cared for R55. The nurses stated they administer the resident's medications via peg. On 9/12/23 at 5:15 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing) were made aware of the above concern. The facility policy titled, The licensed nurse receiving the order must verify to ensure the order is complete and it includes: Accurate route . 29843 3. For Resident #225 (R225), the facility staff failed to obtain a physician's order as prescribed by the consulting physician for the medication, Dutasteride (1), used for urinary retention. R225 was admitted with diagnoses that included but were not limited to benign prostatic hyperplasia (2). A urology office visit note for R225 documented in part, 11/25/2022 - Office visit: General. The patient was accompanied by his son . Under Prescription(s) Today it documented in part, Dutasteride (2) 0.5 mg (milligram) capsule (dutasteride) Tale 1 (one) capsule by mouth as directed at 9 am (9:00 a.m.) daily. The prescription slip from the urologist for R225 dated 11/25/2022 at 3:58 p.m. documented in part, Dutasteride 0.5 mg capsule. Dispense 30 (thirty) capsules. Take (one) capsule by mouth as directed at 9 AM daily. The facility physician's order for R225 documented in part, Dutasteride Capsule 0.5 MG. Give 1 capsule by mouth at bedtime for benign prostatic hyperplasia. Order Date: 11/28/2022. The eMAR (electronic medication administration record) for R225 dated November 2022 documented the physician's order as stated above, however the first dose of dutasteride wasn't administered until 11/28/2022. The nurse practitioner's (NP) note for R225 dated 11/28/2022 at 1:53 p.m., documented in part, A/P (assessment/plan) . Dutasteride added 11/28 . On 09/12/2023 at approximately 3:43 p.m., an interview was conducted with LPN (licensed practical nurse) #8. When asked to describe the procedure when a resident brings in a prescription for a medication from a provider outside of the facility she stated that the nurse should put order in computer, talk to the physician or NP if they are in the building or call them to let them know the resident has a new prescription, put the script in the doctors book and call the pharmacy if the medication is not available in the facility. When asked if they recalled R225 and when R225's son brought him back to the facility from a urology appointment on 11/25/2022 she stated yes. LPN #8 stated that R225 and his son came back from an appointment between 7:00 p.m. and 8:00 p.m. with a prescription for urinary retention. LPN #8 further stated she did not call the physician. On 09/13/2023 at approximately 9:52 a.m., an interview was conducted with ASM (administrative staff member) #4, nurse practitioner. When asked to describe the procedure she follows when a resident receives a script for a prescription from a provider outside of the facility, she stated that the staff gives the scrip to her the day the resident receives it or the next morning. She further stated that if she were not in the facility the nurse would call the on-call provider. When asked if she recalled R225 and the order for Dutasteride she stated that she did and further stated that that staff could not locate the order and she had them call the pharmacy and verify the order on Monday (11/28/2023). On 09/13/2023 at approximately 11:00 a.m., an interview was conducted with ASM (administrative staff member) #2, director of nursing. When asked about R225 not receiving Dutasteride when it was ordered by the urologist ASM #2 stated that the resident arrived around 8:00 p.m., the script was handed to the nurse and faxed it to the pharmacy but did not notify the on-call provider. She further stated that the NP was notified on the following Monday, 11/28/2022, and R225 received his first dose that day. When asked if there was a delay in R225 receiving his medication ASM #2 stated yes. The facility's grievance form for R225 dated 11/29/2022 documented in part, What is your concern about? Had urology appt (appointment) Friday and brought paperwork and prescription back. Handed to a nurse. Visited Monday morning and medication was not ordered. Concerned this is a setback. When did the problem occur? Friday 11/25/22. Facility Response: NP reached out to urologist and got new script and ordered medication. Action To Be Taken: Writer spoke with nurse. Nurse stated that she received the paperwork, faxed the prescription to the pharmacy and placed in the scan pile. She stated she did not put the order in PCC (point click care - electronic health record. Writer informed nurse that paperwork is to be placed in the MD (medical doctor) book and order put in PCC. On 09/13/2023 at approximately 3:00 p.m., ASM (administrative staff member) #1, administrator, and ASM #2, director of nursing, were made aware of the above findings. No further information was provided prior to exit. References: (1) Used alone or with another medication (tamsulosin [Flomax]) to treat benign prostatic hyperplasia (BPH; enlargement of the prostate gland). May reduce the chance of developing acute urinary retention. This information was obtained from the website: https://medlineplus.gov/druginfo/meds/a603001.html. (2) An enlarged prostate. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/enlargedprostatebph.html. (3) A class of medication used in the management and treatment of benign prostatic hyperplasia (BPH). This information was obtained from the website: https://www.ncbi.nlm.nih.gov/

Based on observation, resident interview, staff interview, clinical record review, it was determined that the facility staff failed to promote dignity for one of 37 residents, Resident #24. The findings include: For Resident #24 (R24), the facility staff failed to uphold the resident's dignity due to not providing timely incontinence care. R24 was admitted to the facility with diagnoses that included but were not limited to: muscle wasting and abnormalities of gait and mobility. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 06/20/2023, the resident scored 10 out of 15 on the BIMS (brief interview for mental status), indicating R24 was moderately impaired of cognition for making daily decisions. Under Section H Bladder and Bowel R24 was coded as being always incontinent of urine. On 09/11/23 at 12:35 p.m., an observation revealed that R24, who resided on the west unit at the facility, activated the call bell for incontinence care. On 09/11/23 at 12:45 p.m., an observation revealed CNA (certified nursing assistant) #2 entered R24's room, turned off the call and left the room with R24's lunch tray. On 09/11/2023 at 1:00 p.m., an observation revealed LPN (licensed practical nurse) #4 entered R24's room and provided incontinence care. On 09/12/23 at approximately 1:06 p.m., an interview was conducted with CNA (certified nursing assistant) #2. When asked about her entering R24's room at approximately 12:45 p.m., the day before, she stated that she picked up R24's meal tray and that R24 asked if she would clean her up. CNA #2 stated that she told R24 that when she finished picking up the meal trays she would come back and provide incontinence care. When asked what time she finished picking up the meal trays, CNA #2 stated that it was after 1:00 p.m. but could not recall the exact time. When asked how long a resident should wait for incontinence care after informing a staff member, she stated that it should be done right away so the resident is not sitting in a soiled brief. When asked if R24's was on their assignment for Monday 9/11/2023, she stated yes. When informed of the above observations and that R24 waited approximately 25 minutes to receive incontinence care after activating her call bell and informing CNA #2, CNA #2 stated that she could have notified the nurse that R24 required incontinence care. When asked if it is dignified to have a resident wait in a soiled brief for approximately 25 minutes, she stated no. On 09/12/23 at approximately 1:33 p.m., an interview was conducted with LPN (licensed practical nurse) #2, unit manager. When asked how long a resident should wait for incontinence care after informing a staff member, she stated that the resident should only have to wait within 15 to 20 minutes. When informed of the above observations LPN #2 stated that the CNA should have let the nurse know R24 required incontinence care. When asked if it is dignified to have a resident wait in a soiled brief for approximately 25 minutes, she stated no. On 09/12/23 at approximately 1:53 p.m., an interview was conducted with LPN #4, MDS nurse. When asked if she entered R24's room on Monday, 09/11/2023 at approximately 1:00 p.m., she stated yes. When asked about providing incontinence care to R24, LPN #4 stated that she provided incontinence care, and that the resident was wet. LPN #4 further stated that she was not aware that R24 had been waiting for incontinence care because she had just walked onto the unit. When asked if it is dignified to have a resident wait in a soiled brief for approximately 25 minutes, she stated no. On 09/13/2023 at approximately 1:00 p.m., an interview was attempted with R24. When asked how she felt being left in a wet brief when she did not receive incontinence care when she asked for assistance, R24 stated that she did not want to speak to the surveyor. On 09/12/2023 at approximately 5:07 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 and facility document review, it was determined that the facility staff failed to post daily nurse staffing information prior to the start of the shift on two of three survey dates. The findings include: The facility staff failed to post nurse staffing information on 9/11/2023 and 9/12/2023 prior to the beginning of the nursing staff work shift. On 9/11/2023 at 2:19 p.m., an observation was made of the facility's lobby which revealed the staff posting dated 9/7/2023. On 9/11/2023 at 4:30 p.m., an observation was made of the facility's lobby which revealed the staff posting dated 9/7/2023. On 9/12/2023 at 8:19 p.m., an observation was made of the facility's lobby which revealed the staff posting dated 9/7/2023. On 9/12/2023 at 10:00 a.m., an interview was conducted with ASM (administrative staff member) #2, the director of nursing. ASM #2 stated that the scheduling coordinator posted the staffing each day when they arrived. She stated that the scheduling coordinator had been working on the floor as an aide so she and the administrator had been assisting to post the staffing. She stated that they filled out a daily staffing sheet from the master schedule and posted it at the front desk in the lobby each morning. She stated that the daily staff posting should be posted each day. ASM #2 was made aware of the observations of the staff posting dated 9/7/2023 observed on 9/11/2023 and 9/12/2023 and stated that she was aware. The facility policy, Required Regulatory Postings revised 4/19/2022 documented in part, .The facility posts the total number and actual hours worked of licensed and unlicensed nursing staff directly responsible for guest/resident care for each shift. The information will be displayed in a prominent location that is clearly visible and accessible by guests/residents, family and staff . Posting Requirements i. The facility will post the data specified above on a daily basis at the beginning of each shift . On 9/12/2023 at approximately 5:10 p.m., ASM #1, the administrator, ASM #2, the director of nursing and ASM #3, the regional clinical coordinator, were made aware of the concern. No further information was presented prior to exit.

Based on resident interview, clinical record review, facility document review, staff interview and in the course of the medication administration observation, the facility staff failed to follow the physician's orders for 4 of 51 residents in the survey sample, Residents #16, #317, and #217; to include one of five residents in medication administration observation, Resident #9. The findings include: 1. On 11/02/2021 at 10:00 p.m. and on 11/03/2021 at 6:00 a.m., the facility staff failed to follow the physician's order for [MEDICATION(S)], resulting in an overdose. Resident # 16 (R16) was administered 5ml (five milliliter) of [MEDICATION(S)] (1), ten times the physician-ordered dose, resulting in (R16's) oxygen saturation dropping to 77%, requiring an administration of [MEDICATION(S)] (2) and being taken to the hospital for further interventions and monitoring. The overdose resulted in harm for Resident #16. (R16) was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 12/22/2021, the resident scored 14 out of 15 on the BIMS (brief interview for mental status), indicating the resident is cognitively intact for making daily decisions. Section J0400 coded (R16) as frequently experiencing pain at a level of five out of 10 during the look back period. On 03/22/22 at approximately 1:11 p.m., (R16) stated that approximately four months ago they were given an overdose of [MEDICATION(S)] and were sent to the hospital. The physician's orders for (R16) documented in part, [MEDICATION(S)] HCl ([MEDICATION(S)]) [MEDICATION(S)] Concentrate 10 MG(milligrams)/ML Give 0.5 ml orally every 8 (eight) hours for pain. Order Date: 11/02/2021 .[MEDICATION(S)] Liquid 4 MG/0.1ML (milliliter) ([MEDICATION(S)] HCl) 0.1 ml in nostril STAT (immediately) for Sedation -Start Date11/03/2021. The comprehensive care plan for (R16) dated 06/15/2021 documented in part, (R16) has pain r/t (related to): muscle weakness, Lung Cancer, [CONDITION(S)] ., Date Initiated: 06/15/2021 .Observe for side effects of pain medication. Date Initiated: 06/15/2021. The facility's nurse's note dated 11/03/2021 documented, 7:25 a.m., Text: Med (medication) error noted during narcotic count at 7:15am. VS (vital signs) at that time 97.2 (temperature) -57 (pulse)-16 (respiration) -116/77 (blood pressure) O2 sat (oxygen saturation) 88-89% on 5L/min (five liters per minute) O2 via (by) NC (nasal cannula). Resident alert and responsive. UM (unit manager) notified of error and residents status. Hospice and MD (medical doctor) notified. New order for [MEDICATION(S)] if O2 sat goes below 80%. CNA in room with resident. VS at 7:30 am 96.9-61-17-128/80 O2 sat 74%. [MEDICATION(S)] given per order at 8:20am (a.m.). O2 sat increased to 87%. VS at 7:45am 97.1-60-18-130/86. MD in and stated to send resident to ER (emergency room ) and increase O2 to 15L (liters) on non-rebreather mask. 911 called for transport. Resident becoming anxious- c/o (complaint of) being cold and shaky. VS at 8am 96.8-59-18-126/86 O2 sat 84%.Resident becoming restless. VS at 8:30am 97.1-71-18-127/88 O2 sat 91%. 911 in to transport at 8:50am. Family notified of residents condition and need to transport to hospital. Author: [Name of LPN (licensed practical nurse)] #2. Further review of the nurse's note revealed a handwritten noted that documented, Nurse during count stated I must have given 5ml instead of .5ml (0.5ml), and signed by LPN # 2. The nurse's note dated 11/03/2021 at 8:36 a.m. documented, VS 97.2-57-16-116/77 O2 sat 88-89% on 5L/min via NC. O2 mask applied. O2 sat 93% but dropped to 77%. Narcaine [sic] given at 8:20am per MD order. O2 sat 91% but dropped to 77%. MD in and stated to send to ER (emergency room ). Hospice notified. VS taken every 15 min. Resident alert and talking but slow. Voices no complaints at this time. The facility form Analysis of Medication Event for (R16) dated 11/03/2021 documented in part, Date of Event: 11-2-21, 11-3-21. Time of Event: 2200 (10:00 p.m.) 6:00 a.m. Medication Given: [MEDICATION(S)]. Dosage Given: 5mL. Route: po (by mouth). Cause of Event: How did the event occur?: Nurse gave wrong dosage X2 (times two) 2200 & (and) 6:00 am. What is the actual effect of the event on the guest? Decrease O2 Sat rate. How was event discovered? During am count by off going nurse and on coming nurse. Name(s) and title(s) of employee(s) involved: [Name of Registered Nurse (RN) #3]. The facility's Controlled Medication Utilization Record for (R16) documented in part, [MEDICATION(S)] [MEDICATION(S)] Concentrate 10 MG/1 (one)ML oral CONC (concentrate) 0.5 ml sublingually (under the tongue) three times daily for pain. Date: 11/2/21. Dose Given: 0.5 cc (cubic centimeter). Signature of Nurse: [Name of RN # 3]. Checked By: gave 5mL. Under Date: 11/3/21 it documented, Dose Given: 0.5 cc (cubic centimeter). Signature of Nurse: [Name of RN # 3]. Checked By: gave 5mL. The Emergency Provider Report for (R16) from [Name of Hospital] dated 11/03/2021 documented in part, Free Text HPI (history of present illness) Notes. Patient with history significant for end-stage lung cancer, [CONDITION(S)], asthma, CAD, [CONDITION(S)], presents to the emergency department for reports of accidental overdose on [MEDICATION(S)]. Patient is on hospice in resides at [Name of Nursing Home], at which a hospice nurse visit him, helps distances [sic] pain medication. Reportedly patient is on known concentration of [MEDICATION(S)], however was supposed to receive 0.5mL this morning, rather he received 5mL accidentally per staff. He then became minimally responsive. EMS (emergency medical services) was called, [MEDICATION(S)] was administered EN (unknown abbreviation) route was immediately brought the patient around. Patient upon arrival reports being diffuse widespread pain, feeling as though he is going to vomit, having diarrhea. Patient denies feeling drowsy or having difficulty breathing currently. No chest pain. No recent fevers. No other medical complaints at this time. The Discharge Summary for (R16) from [Name of Hospital] dated 11/04/2021 documented in part, Hospital Course. [AGE] year old with hx (history) of lung cancer ch (chronic history) resp (respiratory) failure on home O2 5lpm (liters per minute) was under Hospice care at SNF (skilled nursing facility) and was given accidental higher dose of [MEDICATION(S)] 5ml of [MEDICATION(S)] instead of 0.5ml and was noted to have AMS (altered mental status) and increase O2 needs, [MEDICATION(S)] given and pt (patient) was referred to ER, poison control was called by ER provider and was advised to be admitted for observation. HOV [Name of Hospice]) was called and pt will be admitted overnight as GIP (general inpatient) for monitoring. At time of my eval (evaluation) is awake and alert complain gof [sic] pain all over, I was able to switch pt to 5lpm O2 via NC. Pt was placed on monitoring and did well and will proceed with dc (discharge) back to SNF with HOV. Staff at SNF to exercise caution with use of narcotics. On 03/23/2022 at approximately 12:10 p.m. an interview was conducted with LPN # 1 and LPN # 2, unit manager. When asked how the medication error was discovered LPN # 2 stated that when they were doing the medication count on 11/03/2021 for the 7:00 a.m. to 3:00 p.m. shift with RN #3, there was a discrepancy with the [MEDICATION(S)]. There was more was missing than should have been. LPN # 2 stated that RN #3 realized that [Name of R16] received too much [MEDICATION(S)]. When asked how much [MEDICATION(S)] had been administered to R16, LPN # 2 stated that they had received 5 milliliters instead of 0.5 milliliters. LPN # 2 stated that they checked [Name of R16's] vital signs, went back to the nurse's station and informed LPN # 1. LPN # 1 stated they informed LPN # 2 to call and notify hospice due to the fact that (R16) was under hospice care, then they assigned a CNA (certified nursing assistant) in (R16's) room to monitor their oxygen saturation. LPN #1 further stated that they notified the physician and they gave an order and to monitor the oxygen saturation and for [MEDICATION(S)] if the oxygen saturation dropped below 80%. When asked if the [MEDICATION(S)] was used LPN #1 stated that (R16's) oxygen saturation dropped to 77% and that LPN # 2 administered the [MEDICATION(S)]. LPN # 1 further stated that the physician was in the facility at that time, checked (R16's) vital signs and gave an order to have (R16) sent to the hospital by 911 and that by the time the EMTs (emergency medical technicians) arrived (R16's) oxygen saturation was up to 84%. When asked to interview RN #3, LPN # 1 stated that [Name of RN # 3] returned the next day, was supervised during their medication administration, and has never return to the facility. When asked how a nurse ensures the physician's orders are followed for medication administration, LPN # 1 stated that if it is a narcotic they should triple check the narcotic book, with the physician's orders, with the medication and follow the seven rights of medication administration that include the right route, medication, dose, patient, time, documentation and response. On 03/23/2022 at 12:45 p.m., ASM (administrative staff member) # 1, administrator and ASM # 2, director of nursing, were informed of the above findings. On 03/23/2022 at approximately 9:46 a.m., an interview was conducted with ASM #4, nurse practitioner. When asked about the use of [MEDICATION(S)], ASM #4 stated that it is used for pain. When asked what the negative outcome would be if a resident was given an overdose of [MEDICATION(S)], ASM #4 stated they would become too sedated, decrease their respiration and would have low oxygen saturation. When asked about the course of action that would be taken if an overdose occurred, ASM #4 stated that the resident would be monitored. When informed of the above resident and circumstances, ASM #4 stated that it was not their resident and that the actions taken sounded reasonable. On 03/23/2022 at approximately 2:35 p.m., a telephone interview was conducted with ASM #5, (R16's) physician. ASM #5 recalled the circumstances of (R16's) overdose of [MEDICATION(S)] and stated that they received a call from the nurse, gave an order to monitor the oxygen saturation and for [MEDICATION(S)] if the saturation dropped. ASM # 5 stated they were in the facility when the overdose was discovered, saw the oxygen saturation was declining, and sent the resident out to the hospital. On 3/24/22 at 9:01 a.m., an interview was conducted with RN (registered nurse) #2, regarding following physician's orders for medication administration. RN #2 stated nurses should read the MAR (medication administration record), find the medication, read the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . RN #2 stated nurses should follow seven rights of medication administration that include the right individual, medication, dose, time, route, documentation and response. RN #2 stated she obtained this information several years ago from the national institute of health website. On 3/22/22 at 11:42 AM, ASM #2 (Administrative Staff Member) the Director of Nursing, stated the facility uses Lippincott as the Standard of Practice. Fundamentals of Nursing Lippincott Williams and Wilkins- Ambler PA 2007 page 181 Nurses carry a great deal of responsibility for making sure that patients get the right drugs at the right time, in the right dose and by the right routes .this includes accurate documentation and explanation if doses are missed or not administered . The facility's policy Medication Administration documented in part, Physician's Orders - Medications are administered in accordance with written orders of the attending physician. 2. Verify the medication label against the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . a. The nurse is responsible to read and follow precautionary instructions on prescription labels. b. If the label and medication sheet are different and the container is not flagged indicating a change in directions or if there is any other reason to question the dosage or directions, the physician's orders are checked for the correct dosage schedule. No further information was provided prior to exit. References: (1) Used to relieve severe pain in people who are expected to need pain medication around the clock for a long time and who cannot be treated with other medications. This information was obtained from the website: https://medlineplus.gov/druginfo/meds/a 4.html (2) Administered by injection or as a nasal spray to reverse the effects of opioids especially in the emergency treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] .merriam-webster.com/dictionary/[MEDICATION(S)]. 2. The facility staff failed to administer the correct physician prescribed dose of the Pfizer COVID-19 vaccine to Resident #317 (R317). On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 12/20/21, the resident scored 9 out of 15 on the BIMS (brief interview for mental status), indicating the resident is moderately impaired for making daily decisions. A review of R317's clinical record revealed a physician's order dated 12/16/21 for 0.3 ml (milliliters) of the Pfizer COVID-19 vaccine. A medication error report dated 12/16/21 documented R317 was administered 1.8 ml of the Pfizer vaccine. The report further documented the physician was notified, ordered intravenous normal saline at 50 ml per hour for one hour and R317 had no adverse outcome. R 317's comprehensive care plan revised on 12/17/21 documented, [R317] is at risk for adverse reaction r/t (related to) unintentional over dosage of medication. IV (Intravenous) and run NS (normal saline) at 50ml/hr x 1 bag . On 3/24/22 at 8:03 a.m., an interview was conducted with LPN (licensed practical nurse) #3 (the nurse who administered the Pfizer vaccine to R317). LPN #3 stated on 12/16/21, he assisted the assistant director of nursing with administering the Pfizer vaccine to residents. LPN #3 stated he was unclear on the instructions for diluting the medication and he administered the incorrect dose to R317. LPN #3 stated he was given instructions for administering the vaccine but he wasn't aware the medication had to be diluted and this was the first time he had drawn up the medication. On 3/24/22 at 8:21 a.m., an interview was conducted with RN (registered nurse) #1 (the assistant director of nursing). RN #1 stated 12/16/21 was the first day she was charge at the facility and the director of nursing was not present. RN #1 stated on that day, she was completing multiple tasks and LPN #3 offered to assist with the Pfizer vaccines. RN #1 stated that at the time, she was not aware that the director of nursing usually drew up the vaccines and LPN #3 only administered them. LPN #3 stated she thought LPN #3 knew how to draw up the medication but she should have went with him and observed. On 3/24/22 at 9:01 a.m., an interview was conducted with RN (registered nurse) #2, regarding following physician's orders for medication administration. RN #2 stated nurses should read the MAR (medication administration record), find the medication, read the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . RN #2 stated nurses should follow seven rights of medication administration that include the right individual, medication, dose, time, route, documentation and response. RN #2 stated she obtained this information several years ago from the national institute of health website. On 3/24/22 at 9:20 a.m., ASM (administrative staff member) #1 (the administrator) and ASM #3 (the regional director of operations) were made aware of the above concern. The manufacturer's instructions for the Pfizer vaccine administered to R317 documented, Each vial must be thawed and diluted prior to administration. Dilute the vial contents using 1.8 mL of sterile 0.9% Sodium Chloride Injection . No further information was presented prior to exit. 3. The facility staff failed to follow orders for wound care for Resident #217. On the most recent MDS (Minimum Data Set), a 5-day assessment with an ARD (Assessment Reference Date) of 9/9/21, Resident #217 scored a 13 out of 15 on the BIMS (brief interview for mental status), indicating the resident was not cognitively impaired for making daily decisions. The resident was coded as being independent for eating and required limited to extensive assistance for all other areas of activities of daily living. A physician's order dated 9/2/21 documented, Right shin skin prep (1) every shift. A review of the September 2021 TAR (Treatment Administration Record) revealed this order was scheduled for each shift starting on the night shift on 9/2/21 and ended on day shift on 9/19/21 when the resident discharged . This accounted for a total of 50 opportunities of administration. Of these 50 opportunities, there were 5 opportunities that were not documented as being completed and/or refused. A physician's order dated 9/6/21 documented Skin Prep to blister on lower right leg every shift every shift for Prevention. A review of the September 2021 TAR revealed that this treatment was scheduled for each shift starting on evening shift on 9/6/21 and ended on day shift 9/19/21 when the resident discharged . This accounted for a total of 39 opportunities of administration. Of these 39 opportunities, there were 5 opportunities that were not documented as being completed and/or refused. On 3/23/22 at 11:28 AM an interview was conducted with LPN #4 (Licensed Practical Nurse). She stated that if the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #217's comprehensive care plan dated 9/2/21 revealed: Actual impairment to skin integrity r/t (related to) -trauma areas- left outer hand, right shin .Treatment to skin impairment per order. A review of the facility policy, Physician's Orders was reviewed. This policy did not specifically document that physician's orders must be followed, however, it did document, Treatment rendered to a guest/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 3/24/22 at approximately 11:30 AM, ASM #1 (Administrative Staff Member) the Administrator, and ASM #2, the Director of Nursing, were made aware of the findings. No further information was provided by the end of the survey. COMPLAINT DEFICIENCY REFERENCES 1. Skin Prep - A liquid protective barrier wipe designed to form protective film to reduce friction during removal of tapes and films as well as prep skin for drainage tubes, external catheters, surrounding ostomy sites and adhesives formulated to help skin breathe so tape and film adheres better indicated for use on intact skin only. Information obtained from https://www.[MEDICATION(S)].com/jump/product/x/Z05-PF #mrkDocumentation 4. The facility staff failed to follow the physician's order by giving a double dose of a nasal spray to Resident # 9 (R9). On the most recent MDS (minimum data set) assessment, an admission assessment with an ARD (assessment reference date) of 12/30/2021, the resident was coded as scoring a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident is not cognitively impaired for making daily decisions. Observation was made of LPN (licensed practical nurse) #4 administering medications to R9 on 3/23/2022 at 8:15 a.m. LPN #4 administered all of the oral medications and then administered the nasal spray, [MEDICATION(S)] ([MEDICATION(S)]) Nasal Spray (used for the management of nasal symptoms of [MEDICATION(S)] nonallergic[sic] rhinitis) (1). LPN #4 administered two sprays in each nostril. After LPN #4 had finished administering the nasal spray, LPN #4 went back to the medication cart and started to sign out the medications on the MAR (medication administration record). When LPN #4 got to the entry for the administration of the nasal spray, they turned toward the surveyor and stated they made an error, and had given two sprays in each nostril instead of one in each nostril. When asked what they had to do next, LPN #4 stated they needed to contact the nurse practitioner about the error and notify the responsible party. When asked the process for administering medications, LPN #4 stated they had checked the resident's name, medication, dose prior to going into the room. LPN #4 stated they didn't know why they gave the two sprays, and that they were nervous. The physician order dated 12/23/2021 documented, [MEDICATION(S)] Suspension 50 MCG/ACT (micrograms per activation) 1(one) spray in both nostrils one time a day for allergies. The nurse's note dated 3/23/2022 at 8:39 a.m. documented, Writer in room administering [MEDICATION(S)], writer gave two sprays in each nostril instead of one, writer notified NP (nurse practitioner) in facility, no new orders, will monitor guest for any changes. The nurse's note dated, 3/24/2022 at 7:30 a.m. documented, RP (responsible party) made aware of med (medication) error and that no new orders were given by the NP. Review of the comprehensive care plan dated 12/23/2021 failed to reveal information regarding the use of a nasal spray. On 3/24/2022 at 9:01 a.m., an interview was conducted with RN (registered nurse) #2 regarding following physician's orders for medication administration. RN #2 stated nurses should read the MAR (medication administration record), find the medication, read the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . RN #2 stated nurses should follow seven rights of medication administration that include the right individual, medication, dose, time, route, documentation and response. RN #2 stated she obtained this information several years ago from the national institute of health website. ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, and ASM #3, the regional director of operations, were made aware of the above concern on 3/23/2022 at 4:15 p.m. No further information was obtained prior to exit. References: (1) This information was obtained from the package insert of the box for the medication, [MEDICATION(S)] Nasal Spray by West-Ward Pharmaceuticals Corp.

Based on resident interview, clinical record review, facility document review, and staff interview, it was determined that the facility staff failed to ensure a resident was free of a significant medication error for one of 51 residents in the survey sample, Resident #16 (R16). On 11/02/2021 at 10:00 p.m. and on 11/03/2021at 6:00 a.m., facility staff overdosed Resident # 16 R16 by administering 5ml (five milliliters) of [MEDICATION(S)] (1), which was ten times the physician ordered dose, resulting in (R16's) oxygen saturation dropping to 77% and requiring administration of [MEDICATION(S)] (2). The resident was taken to the hospital for further interventions and monitoring. The deficient practice resulted in harm to the resident. The findings include: R16 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 12/22/2021, the resident scored 14 out of 15 on the BIMS (brief interview for mental status), indicating the resident is cognitively intact for making daily decisions. Section J0400 coded R16 as frequently experiencing pain at a level of five out of 10 during the look back period. On 03/22/22 at approximately 1:11 p.m., R16 stated that approximately four months ago they were given an overdose of [MEDICATION(S)] and were sent to the hospital. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Order Date: 11/02/2021 .[MEDICATION(S)] Liquid 4 MG/0.1ML (milliliter) ([MEDICATION(S)] HCl) 0.1 ml in nostril STAT (immediately) for Sedation -Start Date11/03/2021. The comprehensive care plan for R16 dated 06/15/2021 documented in part, R16 has pain r/t (related to): muscle weakness, Lung Cancer, [CONDITION(S)] ., Date Initiated: 06/15/2021 .Observe for side effects of pain medication. Date Initiated: 06/15/2021. The facility's nurse's note dated 11/03/2021 documented, 7:25 a.m., Text: Med (medication) error noted during narcotic count at 7:15am. VS (vital signs) at that time 97.2 (temperature) -57 (pulse)-16 (respiration) -116/77 (blood pressure) O2 sat (oxygen saturation) 88-89% on 5L/min (five liters per minute) O2 via (by) NC (nasal cannula). Resident alert and responsive. UM (unit manager) notified of error and residents status. Hospice and MD (medical doctor) notified. New order for [MEDICATION(S)] if O2 sat goes below 80%. CNA in room with resident. VS at 7:30 am 96.9-61-17-128/80 O2 sat 74%. [MEDICATION(S)] given per order at 8:20am (a.m.). O2 sat increased to 87%. VS at 7:45am 97.1-60-18-130/86. MD in and stated to send resident to ER (emergency room ) and increase O2 to 15L (liters) on non-rebreather mask. 911 called for transport. Resident becoming anxious- c/o (complaint of) being cold and shaky. VS at 8am 96.8-59-18-126/86 O2 sat 84%.Resident becoming restless. VS at 8:30am 97.1-71-18-127/88 O2 sat 91%. 911 in to transport at 8:50am. Family notified of residents condition and need to transport to hospital. Author: [Name of LPN (licensed practical nurse)] #2. Further review of the nurse's note revealed a handwritten noted that documented, Nurse during count stated I must have given 5ml instead of .5ml (0.5ml), and signed by LPN # 2. The nurse's note dated 11/03/2021 at 8:36 a.m. documented, VS 97.2-57-16-116/77 O2 sat 88-89% on 5L/min via NC. O2 mask applied. O2 sat 93% but dropped to 77%. Narcaine [sic] given at 8:20am per MD order. O2 sat 91% but dropped to 77%. MD in and stated to send to ER (emergency room ). Hospice notified. VS taken every 15 min. Resident alert and talking but slow. Voices no complaints at this time. The facility form Analysis of Medication Event for R16 dated 11/03/2021 documented in part, Date of Event: 11-2-21, 11-3-21. Time of Event: 2200 (10:00 p.m.) 6:00 a.m. Medication Given: [MEDICATION(S)]. Dosage Given: 5mL. Route: po (by mouth). Cause of Event: How did the event occur?: Nurse gave wrong dosage X2 (times two) 2200 & (and) 6:00 am. What is the actual effect of the event on the guest? Decrease O2 Sat rate. How was event discovered? During am count by off going nurse and on coming nurse. Name(s) and title(s) of employee(s) involved: [Name of Registered Nurse (RN) #3]. The facility's Controlled Medication Utilization Record for R16 documented in part, [MEDICATION(S)] [MEDICATION(S)] Concentrate 10 MG/1 (one)ML oral CONC (concentrate) 0.5 ml sublingually (under the tongue) three times daily for pain. Date: 11/2/21. Dose Given: 0.5 cc (cubic centimeter). Signature of Nurse: [Name of RN # 3]. Checked By: gave 5mL. Under Date: 11/3/21 it documented, Dose Given: 0.5 cc (cubic centimeter). Signature of Nurse: [Name of RN # 3]. Checked By: gave 5mL. The Emergency Provider Report for R16 from [Name of Hospital] dated 11/03/2021 documented in part, Free Text HPI (history of present illness) Notes. Patient with history significant for end-stage lung cancer, [CONDITION(S)], asthma, CAD, [CONDITION(S)], presents to the emergency department for reports of accidental overdose on [MEDICATION(S)]. Patient is on hospice in resides at [Name of Nursing Home], at which a hospice nurse visit him, helps distances [sic] pain medication. Reportedly patient is on known concentration of [MEDICATION(S)], however was supposed to receive 0.5mL this morning, rather he received 5mL accidentally per staff. He then became minimally responsive. EMS (emergency medical services) was called, [MEDICATION(S)] was administered EN (unknown abbreviation) route was immediately brought the patient around. Patient upon arrival reports being diffuse widespread pain, feeling as though he is going to vomit, having diarrhea. Patient denies feeling drowsy or having difficulty breathing currently. No chest pain. No recent fevers. No other medical complaints at this time. The Discharge Summary for R16 from [Name of Hospital] dated 11/04/2021 documented in part, Hospital Course. [AGE] year old with hx (history) of lung cancer ch (chronic history) resp (respiratory) failure on home O2 5lpm (liters per minute) was under Hospice care at SNF (skilled nursing facility) and was given accidental higher dose of [MEDICATION(S)] 5ml of [MEDICATION(S)] instead of 0.5ml and was noted to have AMS (altered mental status) and increase O2 needs, [MEDICATION(S)] given and pt (patient) was referred to ER, poison control was called by ER provider and was advised to be admitted for observation. HOV [Name of Hospice]) was called and pt will be admitted overnight as GIP (general inpatient) for monitoring. At time of my eval (evaluation) is awake and alert complain gof [sic] pain all over, I was able to switch pt to 5lpm O2 via NC. Pt was placed on monitoring and did well and will proceed with dc (discharge) back to SNF with HOV. Staff at SNF to exercise caution with use of narcotics. On 03/23/2022 at approximately 12:10 p.m. an interview was conducted with LPN # 1 and LPN # 2, unit manager. When asked how the medication error was discovered LPN # 2 stated that when they were doing the medication count on 11/03/2021 for the 7:00 a.m. to 3:00 p.m. shift with RN #3, there was a discrepancy with the [MEDICATION(S)]. There was more was missing than should have been. LPN # 2 stated that RN #3 realized that [Name of R16] received too much [MEDICATION(S)]. When asked how much [MEDICATION(S)] had been administered to R16, LPN # 2 stated that they had received 5 milliliters instead of 0.5 milliliters. LPN # 2 stated that they checked [Name of R16's] vital signs, went back to the nurse's station and informed LPN # 1. LPN # 1 stated they informed LPN # 2 to call and notify hospice due to the fact that R16 was under hospice care, then they assigned a CNA (certified nursing assistant) in (R16's) room to monitor their oxygen saturation. LPN #1 further stated that they notified the physician and they gave an order and to monitor the oxygen saturation and for [MEDICATION(S)] if the oxygen saturation dropped below 80%. When asked if the [MEDICATION(S)] was used LPN #1 stated that (R16's) oxygen saturation dropped to 77% and that LPN # 2 administered the [MEDICATION(S)]. LPN # 1 further stated that the physician was in the facility at that time, checked (R16's) vital signs and gave an order to have R16 sent to the hospital by 911 and that by the time the EMTs (emergency medical technicians) arrived (R16's) oxygen saturation was up to 84%. When asked to interview RN #3, LPN # 1 stated that [Name of RN # 3] returned the next day, was supervised during their medication administration, and has never return to the facility. When asked how a nurse ensures the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 03/23/2022 at 12:45 p.m., ASM (administrative staff member) # 1, administrator, and ASM # 2, director of nursing, were informed of the above findings. On 3/24/22 at 9:01 a.m., an interview was conducted with RN (registered nurse) #2, regarding the facility process for when a medication error occurs. RN #2 stated the nurse should notify the nurse practitioner, notify the responsible party, monitor the resident, and follow orders provided by the nurse practitioner. Review of the facility's documents for an action plan to correct this deficient practice revealed credible evidence that an in-service was conducted on 11/04/2021 for all licensed nurses. The in-service content addressed the facility's policy on medication administration to all RNs and LPNs, including the rights of medication administration. The credible evidence included documentation that management staff conducted medication administration observations with licensed nurse on 11/04/2021 and 11/05/2021. On 03/24/2022 at approximately 9:20 a.m., an interview was conducted with ASM # 1. When asked when the facility was in compliance regarding the in-service and medication administration observations, ASM # 1 stated that the facility was in compliance by 11/19/2021. The pharmacy information sheet for [MEDICATION(S)] documented in part, Dosage Forms and Strengths. Oral concentrate: each mL contains 10 mg of [MEDICATION(S)] [MEDICATION(S)]. Under 10 OVERDOSAGE it documented in part, Clinical presentation: Acute overdose with [MEDICATION(S)] can be manifested by respiratory depression, somnolence progressing to stupor or coma, skeletal- muscle flaccidity, cold and clammy skin, constricted pupils, and in some cases, pulmonary [CONDITION(S)], [CONDITION(S)], [CONDITION(S)], partial or complete airway obstruction, atypical snoring, and death. Marked mydriasis rather than miosis may be seen with [CONDITION(S)] in overdose situations [see Clinical Pharmacology (12.2)]. In severe overdosage, particularly by the intravenous route, apnea, circulatory collapse, [CONDITION(S)], and death may occur. treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Employ other supportive measures (including oxygen, vasopressors) in the management of circulatory shock and pulmonary [CONDITION(S)] as indicated. [CONDITION(S)] or arrhythmias will require advanced life support techniques. The opioid antagonists, Naxolone and Nalmefene, are specific antidotes to respiratory depression resulting from opioid overdose. For clinically significant respiratory or circulatory depression secondary to [MEDICATION(S)] overdose, administer an opioid antagonist. Opioid antagonists should not be administered in the absence of clinically significant respiratory or circulatory depression secondary to [MEDICATION(S)] overdose. Because the duration of reversal would be expected to be less than the duration of action of [MEDICATION(S)] in [MEDICATION(S)] [MEDICATION(S)] [MEDICATION(S)], carefully monitor the patient until spontaneous respiration is reliably reestablished. If the response to opioid antagonists is suboptimal or not sustained, administer additional antagonist as directed in the product's prescribing information.(3). No further information was provided prior to exit. Past noncompliance References: (1) Used to relieve severe pain in people who are expected to need pain medication around the clock for a long time and who cannot be treated with other medications. This information was obtained from the website: https://medlineplus.gov/druginfo/meds/a 4.html (2) Administered by injection or as a nasal spray to reverse the effects of opioids especially in the emergency treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] .merriam-webster.com/dictionary/[MEDICATION(S)]. (3) This information was obtained from the website: https://dailymed.nih.nih.gov.

Based on observation, staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to provide the necessary care and services to prevent the development of a pressure sore for one of 29 residents in the survey sample; Resident #6. Resident #6's skin assessment sheets identified the resident as having an area on her sacrum as marked by an "X" on 11/13/13, 11/14/13, 11/15/13, and 11/22/13. There were no assessments or written descriptions and no documentation of any interventions for the sacral area marked by an "X" anywhere in the clinical record. The physician was not notified of this area for additional monitoring and treatment for [REDACTED]. On 11/29/13, the "Weekly Skin Assessment" sheet documented an "X" over the sacral area and "pink /c (with) slough" was written next to it. A "Pressure Ulcer Record" dated, 11/29/13, documented Resident # 6 was identified with a sacral wound, at a Stage III, "4 x 5" centimeters in size. *A pressure ulcer is an inflammation or sore on the skin over a bony prominence (e.g., shoulder blade, elbow, hip, buttocks, or heel), resulting from prolonged pressure on the area, usually from being confined to bed. Most frequently seen in elderly and immobilized persons, decubitus ulcers may be prevented by frequently change of position, early ambulation, cleanliness, and use of skin lubricants and a water or air mattress. Also called bedsores. Pressure sores. Barron's Dictionary of Medical Terms for the Non Medical Reader 2006; Mikel A. Rothenberg, M.D. and Charles F. Chapman. Page 155. The following is from the National Pressure Ulcer Advisory Panel website at <http://www.npuap.org/pr2.htm> Stage III: Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. Unstageable: Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. The findings include: Resident #6 was most recently readmitted on [DATE] with [DIAGNOSES REDACTED]. The most recent MDS (Minimum Data Set) was a quarterly assessment with an ARD (Assessment Reference Date) of 12/10/13. The resident was coded as cognitively impaired in ability to make daily life decisions. Resident #6 required total assistance for eating (gastrostomy tune); extensive assistance for transfers, dressing, hygiene, and bathing; and was incontinent of bowel and bladder. On 2/4/13 at 4:21 p.m., 2/5/13 at 8:40 a.m., 2/6/13 at 10:15 a.m., and 2/7/13 at 8:30 a.m., the resident was noted in bed lying on her back and the head of the bed was elevated. A review of the clinical record revealed that on her most recent readmission on 11/13/13, the resident scored an 11 on the Braden Scale Risk for Pressure Ulcers. This scale documented that a score of 17 or below meant that a resident was at risk of developing a pressure ulcer. A Review of the POS [REDACTED]"1/2 side rails x2 to assist guest with turning and repositioning" and "apply moisture barrier after each incontinent episode." In addition, an e-order (electronic order) dated 11/13/13 was written for "pressure reducing mattress...." A review of the "Weekly Skin Assessment" sheets revealed the following: On 11/13/13, 11/14/13, and 11/15/13, there was an "X" mark on the sacral region of the figure drawing. The box for "skin intact" was checked. There was no assessment or description of the "X" area such as (pink, red, bruise-like, blanchable/non-blanchable, measurement/size, stage etc.). There were no corresponding nurse's notes that assessed and described the area. Each of the three "Weekly Skin Assessment" sheets were completed by different nurses. There was no other documentation in the clinical record to determine based on an "X" if the area had improved or worsened. In addition, there was no evidence that the physician was notified of this area that was identified on any of these three occasions. A review of the physician's progress notes revealed one dated 11/15/13 that documented, "Skin: no rashes, [MEDICAL CONDITION], no pressure ulcers...." There was no documentation the physician was notified of the area marked by an "X" on the above "Weekly Skin Assessment" sheets. A review of the Shower/Skin Observation sheets, completed by CNA's (Certified Nursing Assistants) revealed that on 11/15/13, there was no area identified by the CNA on the sacral area. As noted above, this contradicted the nurse's assessment on the same day. On 11/19/13, a CNA did not identify on the Shower/Skin Observation sheet anything on the sacral area of the resident. On 11/20/13, a nurse's note documented that the resident was unable to make her needs known. There was no documentation of a sacral area having been identified. On 11/22/13, a CNA identified a red area on Resident # 6's sacral area and wrote that on the shower sheet. On the 11/22/13, "Weekly Skin Assessment" sheet, the nurse documented an "X" on the sacral area, and the "skin intact" box was checked. Again, there was no assessment or description of the "X" area that identifying what it was and what it looked like, such as (pink, red, bruise-like, blanchable/non-blanchable, stage, measurement/size, etc.). There were no corresponding nurse's notes that assessed or described the area. There was no documentation to indicate if the area had improved or worsened. In addition, there was no evidence that the physician was notified of this area that was identified. Review of the clinical record revealed on 11/22/13, an order was obtained for "EPC cream to sacrum q (every) shift. On 2/6/14 at 9:18 a.m., ACS #4, (Administrative/Corporate Staff #4) the Regional Nurse, stated that this order indicated the physician was notified as of this date of the sacral area. However, there continued to be no corresponding nurse's notes or physician's notes evidencing physician notification. On 11/26/13, a Skin/Shower Observation sheet was completed, which documented an "X" on the sacral area. There was no assessment or description provided of the area that was marked. There were no corresponding nurse's notes that assessed or described the area. On 11/29/13, the "Weekly Skin Assessment" sheet documented an "X" over the sacral area and "pink /c (with) slough" was written next to it. In addition on 11/29/13 a "Pressure Ulcer Record" sheet was started. This sheet documented, on 11/29/13, Resident # 6 was identified with a sacral wound, at a Stage III, "4 x 5" centimeters in size. There were no corresponding nurse's notes written related to this finding. A nurse's note that was written on this date did document that the resident was unable to make her needs known. A "Nutritional Risk Score" completed by the dietitian on 11/16/13, three days after being readmitted , documented, the resident scored a "7". The Nutritional Risk Status scale documented that a score of 0-5 was a low risk; 6-10 was a moderate risk; and >11 was a high risk. The dietitian wrote that the resident was a "low nutrition risk. BMI 27. PEG feeding tolerated w/o (without) difficulty. Skin intact. F/U (follow up) as needed." On 11/16/13, the dietitian assessment documented caloric needs of 1840 to 2080 per day and protein needs of 64 to 80 grams per day. The resident was receiving Glucerna 1.5 at 90 milliliters per hour for 14 hours a day to meet these needs at the time of pressure ulcer development. On 2/6/14 at 11:00 a.m., an observation of the wound care was conducted with ACS #6 (Administrative/Corporate Staff #6 - the wound care physician) and LPN #5 (Licensed Practical Nurse #5). ACS stated the wound "looks good" and measured it at 1.4 x 2.0 x 0.1 centimeters. The wound had no odor and moderate serous drainage. Between the physician's visit on 11/15/13, and the weekly assessment done on 11/29/13 the resident was found to have a Stage III pressure sore, the nurse practitioner visited the resident and wrote notes on 11/20/13, 11/22/13, and 11/25/13. There was no documentation in her notes that she was made aware of any concerns of a wound developing on the sacral area. On 2/6/14 at 8:50 a.m., the nurse practitioner was interviewed about the sacral wound and when she was notified. She reviewed her notes and stated that if she was aware of it, she would have documented it in her notes. She was not aware of it before the area was identified as a Stage III on 11/29/13. On 2/6/15 at 9:18 a.m., in an interview with ACS #4, she stated that the facility was doing everything to prevent a pressure sore because the staff was turning and repositioning every two hours, was using a skin protectant after each episode of incontinence, and had a pressure relieving mattress on the bed. When asked for evidence that these things were being consistently implemented for this resident and how the facility knows that these things were done consistently, she stated, "Because it is in the care plan." She also stated when asked further, that "it is true that care plans are not always followed." When interviewed regarding the lack of assessment of the sacral area and notification of the physician that an area was identified, she stated that was just an issue with documentation and communication. She was unable to state how consistent failure in documenting and communicating an assessment of an identified area or developing wound was evidence that the facility did everything possible to prevent the wound from developing to a Stage III. On 2/6/14 at 11:09 a.m., an interview was conducted with the wound care doctor, who began treating the resident's wound on 12/5/13; approximately one week after the Stage III wound was identified. During the interview, it was asked what treatments she would recommend for a pressure area documented as having intact skin. She stated "offloading, foam dressing, barrier cream, and [MEDICATION NAME]." In addition, during this interview, the wound doctor stated that she thought the wound was unavoidable. However, her assessment and treatment of [REDACTED]. She stated the resident had co-morbidities that would make her a risk, including the resident not wanting to be turned. However, those co-morbidities did not address the facility's responsibility to ensure early assessment and notification to initiate treatment sooner. A review of the clinical record failed to reveal any evidence of the resident being non-compliant with turning and repositioning. On 2/6/13 at 10:27 a.m., CNA #10 (Certified Nursing Assistant #10) was observed providing bathing and care to Resident #6. Once she was done, she made a point of stating to the resident, that she was going to be turned towards the window for a while, and positioned a pillow behind the resident's back for support to maintain a side lying position. She had no issues with repositioning the resident. The resident did not express any discomfort or lack of desire to be positioned on her side. A review of the care plan failed to reveal any evidence of the resident being non-compliant with any care, or being turned and repositioned. A review of the wound doctor's note from her first assessment of the wound, dated 12/5/13 revealed the wound was unstageable at that point due to necrotic tissue, and had to be debrided. The wound at that time was documented as 4.6 x 3.3 centimeters in size. In addition, she documented, "Recommendation: Off-Load Wound, Reposition per facility protocol." There was no documentation of the resident having a history of being non-compliant with being turned and repositioned. Each additional note contained the same statement regarding off-loading and did not document that there was a concern with the resident being repositioned. The additional notes were dated 12/12/13, 12/19/13, 1/2/14, 1/9/14, 1/16/14, and 1/23/14. On 2/7/14, a progress note written by the wound doctor on 2/6/13 was provided. This note documented the conversation between this surveyor and the wound doctor, and included her statement on the refusal of the resident to be repositioned. The note further documented that the wound "started with redness and progressed further and the treatment options and offloading were adequately in place." The statement that off-loading was adequately in place contradicted the doctor's statement that the resident was non-compliant with being repositioned; and did not include mention of the additional treatments that she had stated she would have recommended (foam dressing and [MEDICATION NAME]) during interview. On 2/6/14 at 3:23 p.m., an interview was conducted with LPN #12 (Licensed Practical Nurse), who was the nurse that did the assessment dated [DATE]. When asked to review her assessment and to identify what the "X" represented, she stated that it meant she saw something on the sacrum at that time. She stated she could not specifically recall what the area looked like. When asked how she could tell if the area she saw had improved or gotten worse from the previous assessments of 11/13/13 and 11/14/13, she stated that she could not tell because there was nothing on the assessment that documented what the area looked like. It was just marked with an "X". When asked how the next nurse doing an assessment (on 11/22/13) would be able to tell if the area he/she saw on the resident had improved or worsened since LPN #12's assessment, based on the information that LPN #12 documented, LPN #12 stated, "they wouldn't be able to tell. It is not a thorough assessment. I should have written what it looked like." LPN #12 was asked that if she identified an area of concern on the resident's sacral area, who would she notify, and she stated she would tell the on-coming nurse for the next shift. LPN #12 was then specifically asked if she would notify the physician or the unit manager and she stated, "No." On 2/6/14 at 4:18 p.m., LPN #7 was interviewed. LPN #7 was the nurse that identified the pressure sore on 11/29/13 when it was found at a Stage III. LPN #7 stated that the wound was noted with the first brief change of the shift by the CNA and that the CNA reported it to her. She stated she then reported it to the unit manager. When asked about the wound, she stated, "at first it was red for some time, but we knew it would eventually open up." She stated that prior to discovering the area as a Stage III on 11/29/13, it had been "several days" since she last saw it. She stated that the previous time she saw it; it was dark red and blanching. She did not document these observations anywhere in the clinical record or notify the physician. She stated that on 11/29/13, the area was a small open area but a large red area around it that spread to both sides of the resident's buttocks. On 2/5/13 at 3:35 p.m., an interview was conducted with RN #3 (Registered Nurse #3) the unit manager. She stated that the LPN's do not stage a wound; they have to notify the unit manager. They were to write what they saw (red, intact/open, blanchable/non-blanchable, size, etc.). She stated she was not notified of the wound or any red area prior to 11/29/13. On 2/6/13 at 3:00 p.m., another interview was conducted with RN #3. She stated that on 11/29/13, the nurse notified her of the wound and she then went and looked at it, staged it, and notified the physician, and started a Pressure Sore Record. She stated that she was not notified of this wound prior to 11/29/13. When asked about her training for staging wounds, she stated that she does rounds with the wound doctor, who taught her about staging, describing aspects of the wound (slough, eschar, etc.), treatments, and had quizzed her many times on wound identification. She also stated, and provided, a wound identification guide, that was kept on the unit. This guide contained colored photos of different stages of wounds and she was able to use this guide, in addition to personal training from the wound doctor, to stage this wound as a Stage III. A review of the resident's care plan revealed one for "Skin: Potential for impaired skin integrity related to impaired mobility, muscle weakness, incontinence of bowel and bladder and DC: (diagnosis) h/o (history of)[MEDICAL CONDITION](stroke)[MEDICAL CONDITION](high blood pressure), CAD [MEDICAL CONDITIONS] and DM (diabetes)." This care plan was dated 7/8/13 and was most recently revised on 1/31/14. The interventions included, "Pressure reduction mattress on bed. Braden Scale per protocol. Provide incontinent care with each episode and apply moisture barrier. Conduct weekly skin assessments, document and report abnormal findings to physician. Provide assistance with turning and repositioning on rounds. Treatments as ordered." All these interventions were dated 7/8/13. In addition, on 11/29/13 was added, "Air mattress as ordered. Supplements as ordered." On 12/19/13, "F/C (Foley catheter) for wound healing" was added. The care plan did not identify or document the resident was non-compliant with any of the interventions. A review of the facility policy, "Observations to report to the Physician" documented, "Notify the physician of a change in the guest's condition.....Skin Condition:....reddened area.....pressure area....." A review of the facility policy, "Pressure Ulcer Record" documented, "Policy: All pressure ulcers are to be documented on the pressure ulcer record weekly. Procedure: 1. Initiate the form when a pressure ulcer is identified. One form is completed for each site. 2. Identify the pressure ulcer site by placing an "X" on the body image. 3. Place a check mark in the appropriate box (es) indicating risk factors. 4. Record the date and site when first identified. Document in the description the location and appearance of the pressure ulcer. 5. Document the wound stage....." A review of the facility policy "Wound and Skin Management Program" documented, "Prevention is defined as the priority for the elemental goal of wound and skin management. Prevention is the focus of the wound and skin management program. There is no better treatment for [REDACTED]. Our basic wound prevention program consists of: 1. Assessment - Identifying those at risk and early detection of signs and symptoms of skin breakdown. 2. Mobility - Move them. 3. Hydration and Nutrition - Food and water. 4. Support Surfaces - In the bed and in the chair.....Identification of those at risk and for early detection/identification of signs of problems. This can be accomplished by: A. Completing the Braden Scale Assessment - helps in identifying the guest who are at risk....In addition to the Braden Scale, a physical assessment should be done.....B. Shower and Skin Observation Sheets - for early detection/identification. a) The shower and skin observation sheet is to be used twice a week on all guests who receive a shower, whirlpool, or complete bed bath. C. Weekly Skin Assessment - completed by the licensed nurse. D. Care Plan - based on assessment, establish a care plan to include risk factors such as but not limited to: a) Nutritional risk, b) Support surfaces, c) Prevention intervention. No additional policies regarding pressure sore identification, management, treatment, documentation, and notification were provided. On 2/5/14 at 5:11 p.m., at the end of day meeting, the Administrator, Director of Nursing, Assistant Director of Nursing, Regional Nurse, and Regional Director of Operations were made aware of the concern for harm for a pressure sore. treatment of [REDACTED]. Department of Health and Human Services, Publication Number 15, documents, in part: "The assessment of an individual with a pressure ulcer is the basis for planning treatment, evaluating treatment effects, and communicating with other caregivers. Initially, the clinician should determine the location, stage, and size of the pressure ulcer. Accurate staging and description of pressure sores is a perquisite to the development and implementation of appropriate, effective treatment protocols and to effective, ongoing monitoring of tissue healing." According to "Fundamentals of Nursing" 6th edition, Perry and Potter, page 1513; "Early identification of clients at risk and their risk factors aids the nurse in preventing pressure ulcers. Prevention minimizes the impact that risk factors or contributing factors may have on pressure ulcer development....Three major areas of nursing interventions for prevention of pressure ulcers are (1) skin care, which includes hygiene and skin care; (2) mechanical lading and support devices, which include proper positioning and the use of therapeutic surfaces; and (3) education." According to "Fundamentals of Nursing Made Incredibly Easy Lippincott Williams and Wilkins, Philadelphia PA page 23: Nursing documentation is a highly significant issue since documentation is a fundamental feature of nursing care. Patient records are legally valid, and need to be accurate and comprehensive so that care can be communicated effectively to the health care team. Unless the content of documentation provides an accurate depiction of patient and family care, quality of care may not be possible. Many nurses do not realize that what they document or fail to record can produce an enormous effect on the care that is provided by other members of the health care team."