Every finding on record at The Moorings at Lewes

Based on observation and interview it was determined that the facility failed to ensure that food was properly stored, prepared and served in a manner that protects residents from foodborne illness and food contact surfaces are maintained in a sanitary condition. Findings include: 1/18/24 12:15 PM- During a tour of the kitchen, the surveyor observed E6 (District Dining Manager) test the sanitizer level of the solution in three red sanitizing buckets. When E6 tested the sanitizing solution, the test strips from two out of three buckets indicated that the level of chemical concentration in the buckets was not at a sufficient level to provide proper sanitization. 1/18/24 2:43 PM- During a review of the food temperature logs, the surveyor observed the facility kitchen records had no food temperatures recorded for fifty-eight (58) meals out of two-hundred thirty-four (234) meals sampled. Temperatures of cooked foods and cold ready to eat foods were not being consistently recorded prior to being served. Fish, meat and poultry must be heated to an appropriate specific temperature depending on the type of food and the method used to prepare it. Vegetables must be heated to one hundred thirty-five (135) degrees Fahrenheit (F), and cold ready to eat foods must be held below forty-one (41) degrees (F) to maintain food safety. 1/18/24 3:24 PM - Findings were confirmed with E1 (NHA) 1/22/24 at 1:00 PM - Findings were reviewed with E1 (NHA), E2 (DON) and E3 (ADON) at the exit conference.

Based on record review and interview it was determined that for one (R11) out of five residents reviewed for unnecessary medications, the facility failed to limit an as needed (PRN) psychotropic medication to 14 days. Findings include: Review of R11's medical record revealed: 2/14/23 - R11 was admitted to the facility. 1/2/24 - R11 had a Physician's order for clonazepam tablet 0.5 mg give 1 tablet by mouth PRN (as needed), two times a day for agitation and anxiety. There was no end date to the order. 1/22/24 8:58 AM - During an interview, E5 (LPN) stated that the doctor would look back at the behaviors that we document and put in a new order for PRN psychotropic medications. 1/22/24 9:17 AM - During an interview, E3 (ADON) confirmed the current order for the clonazepam did not have a stop date since it was ordered on 1/2/24 and that there was no evidence of an evaluation to extend the use of clonazepam for more than 14 days. 1/22/24 9:55 AM - During an interview, E4 (MD) stated the the of for the medication for 14 days then re-evaluate and if effective, then reorder it. E4 confirmed the clonazepam ordered on 1/2/24 did not have a stop date and did not have any documentation to continue the medication after the 14 day period. The facility failed to provide evidence that R11 was reassessed by the Physician for the need to extend the use of clonazepam for more than 14 days. 1/22/24 at 1:00 PM - Findings were reviewed with E1 (NHA), E2 (DON) and E3 (ADON) at the exit conference.

Based on observation, interview and record review, it was determined that for one (R3) out of one resident reviewed for positioning, the facility failed to ensure that appropriate treatment and services were provided to maintain and/or increase range of motion. Findings include: The following was reviewed in R3's clinical record: 3/18/21 - R3 was admitted to the facility with a history of a stroke with left sided weakness. 1/26/22 - A Quarterly Occupational Therapy screen for services documented there were no changes and therapy services were not indicated at this time for R3. 2/21/22 - Record review of Rehab functional status form documented that R3 was to receive PROM (passive range of motion) to the left upper extremity, AAROM (active assisted range of motion) to the left lower extremity, and AROM (active range of motion) to the right upper and lower extremity for 15 minutes one time a day and signed by nursing. 2/22/22 - A physicians order written for R3 included PROM to the left upper extremity, AAROM to the left lower extremity and AROM to the right upper and lower extremity for 15 minutes one time a day. 4/13/22 - A physicians order documented that a left palm protector was to be applied in the morning after AM care check for signs for ill fit every shift. Remove after PM care or as per resident request patient may remove ad-lib. 10/18/22 - A quarterly MDS assessment documented R3 as having upper and lower impairment to his left upper arm and left hand. 12/19/22 10:46 AM - R3's left hand was observed to be contracted and R3 was not wearing a palm protector. 12/19/22 11:56 AM - R3's left hand was observed resting on his lap and R3 was not wearing palm protector. 12/20/22 1:50 PM - During an interview, R3 revealed, Nobody comes in to do any exercise to my hand. 12/20/22 1:25 PM - During an interview, E9 (CNA) stated, Usually the ROM is getting done when I'm getting him up to go to the bathroom and with his bathing he likes to get washed up in the bathroom, I raise his left arm up to put his shirt on and move his legs to put his pants on. 12/20/22 2:00 PM - During an interview, E7 (Physical Therapy Aide) stated CNA typically does the range of motion. 12.20/22 3:04 PM - During interview, E4 (Certified Unit Manager) stated the nurse signs off that the range of motion is being done. E4 showed the Surveyor where the nurse signs off that the range of motion, was done December 7 through December 20, 2022. 12/21/22 3:45 PM - During an interview, E8 (RN) stated, I don't guide the CNA in how to do range of motion, they have already been educated on how to do it and I can't say how long the range of motion is being done because I don't watch them, but I know it's being done because I know my staff. 12/22/22 9:59 AM - During interview, the Surveyor asked E10 how she does his range of motion E10 (CNA) stated, He has his own way of doing things, he doesn't want you to do a lot for him, but I lift his legs and put a rolled-up washcloth in his left hand. The interviews identified that staff were considering delivering care, including dressing, bathing and toileting to be ROM. There was no evidence that R3 was receiving 15 minutes of ROM (exercise) daily as prescribed. Findings were reviewed with E1 (NHA), E2 (DON) and E3 (ADON) at the exit conference on 12/22/22 at 3:39 PM.

Based on observation, interview and record review, it was determined that for one (R3) out of one resident(s) sampled for accommodation of needs, the facility failed to ensure that R3's call bell was within reach. Findings include: The following observations were made of R3: 3/18/21 - Record review indicated that R3 was admitted to the facility with a history of a stroke with left sided weakness. 10/18/22 - A quarterly MDS assessment documented that R3 was cognitively intact and required assistance for transfers. 12/19/22 10:03 AM - E9 (CNA) knocked on the door and asked R3 if he was ready to get up. 12/19/22 10:46 AM - R3 was sitting up in his recliner with the call bell hanging off the end of the bed out of reach. 12/19/22 10:56 AM - The call light remained hanging off the end of R3's bed. 12/19/22 1:10 PM - An interview with E9 (CNA) confirmed R3's call bell was not in reach after morning care stating, It slipped my mind, I usually give it to him, oh I'm sorry, I forgot. 12/22/22 10:41 AM - E10 (CNA) was observed leaving the room after R3 was up in the recliner and the call bell was not in reach. The call bell was attached to the left side of the bed. The Surveyor informed E10 that R3's call bell was not in reach and E10 confirmed and stated, I forgot. Findings were reviewed with E1 (NHA), E2 (DON) and E3 (ADON) at the exit conference on 12/22/22 at 3:39 PM.

Based on interview and review of facility documentation, it was determined that the facility failed to ensure that the quality assessment and assurance committee (QAA) met at least quarterly to and included all the required members. Findings include: 8/23/17 (latest revision) - The facility's policy for the QAPI (Quality Assurance Performance Improvement) Program states that each (name of the corporation) facility will form a QAPI Committee that meets monthly and will include the Medical Director. 7/27/21 8:30 AM - A review of the attendance sheets from all QAPI committee meetings since 1/1/20, provided by E1 (NHA), revealed that the facility had no QAPI meetings during the months of January through September 2020. The only QAPI meeting the facility conducted in 2020 was on 10/29/20, and the attendance sheet indicated that the Medical Director called in by phone during this meeting. 7/27/21 9:00 AM (approximately) - During an interview, E1 (NHA) confirmed that the facility did not have QAPI meetings during the months of January through September 2020 (even via phone conference calls) which included the required members of the committee such as the Medical Director . 7/29/21 2:25 PM - Findings were reviewed with E1 (NHA), E2 (DON), E3 (ADON), E4 (RN UM), E5 (Clinical Analyst), and E6 (RN Clinical Consultant) during the Exit Conference.

Based on observation, interview and record review, it was determined that, for one (R12) out of one residents sampled for positioning, the facility failed to communicate an Occupational Therapy evaluation and need for therapy services to the physician, resulting in a delay in care and services. Findings include: Review of R12's clinical record revealed: 2/4/20 - R12 was admitted to the facility with a history of a stroke. 6/7/21 - A quarterly MDS assessment documented that R12 required extensive assistance with activities of daily living. 7/15/21 - A scheduled quarterly Occupational Therapy screen was conducted for R12. The therapy communication form to nursing included: Patient noted to have poor positioning in wheelchair. Recommend OT eval and tx (Occupational Therapy evaluation and treatment) to address the same. The follow up to therapy section of the therapy communication form was signed off as noted by E4 (RN, UM) on 7/15/21. There was no evidence that this recommendation was communicated to the physician to initiate treatment. 7/20/21 12:15 PM - During an observation, R12 was in her room leaning to the far left in her wheelchair with her arm over the arm rest and underarm pressed down against the wheelchair arm. 7/20/21 12:33 PM - During an observation, R12 was in the dining room leaning over the left wheelchair arm. 7/20/21 12:52 PM - During an observation, R12 remained in the dining room being assisted with lunch. She continued to lean over the side of the wheelchair. E9 (LPN) was observed pushing R12 in the wheelchair into an upright position each time R12 was given a bite of food, and R12 returned to her leaning position after each bite. 7/26/21 - 12:30 PM - During an additional observation, R12 was in the dining room awaiting lunch and was slumped to the left side of the wheelchair. 7/26/21 1:18 PM -During an interview, E17 (Certified Occupational Therapy Assistant) confirmed that R12 was recently noted with a lateral lean (leaning to the side). 7/26/21 2:05 PM - During an interview, E18 (DOR - Director of Rehabilitation) also confirmed R12's lateral lean. E18 stated there was a therapy recommendation conveyed to nursing last week for R12's leaning to the side in the wheelchair. E18 reported that the communication form from therapy to nursing was on the hard (paper) chart. E18 stated that the loss of trunk control (being able to sit up straight) was something new. E18 stated that she observed R12 last Wednesday (7/21/21) with a pillow next to her in the wheelchair (to help hold her upright). 7/26/21 approximately 2:30 PM - The surveyor identified the 7/15/21 therapy screen in R12's medical record. 7/27/21 - After being interviewed by the surveyor on 7/26/21, an additional therapy communication to nursing form, dated 7/26/21, signed by E18, was added to R12's chart. The comments section at the bottom of the form included: Pending doctor's authorization for Occupational Therapy request. The form was signed as noted by E3 (ADON). 7/27/21 8:40 AM - During an interview, E16 (Occupational Therapy) confirmed the 7/15/21 therapy communication form on R12's chart provided to nursing staff recommended an Occupational Therapy evaluation for poor wheelchair positioning. E16 confirmed an additional 7/26/21 therapy communication to nursing staff on R12's chart included that therapy was still waiting for a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 7/27/21 8:55 AM - During an interview, E3 (ADON) reported that the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . E3 stated that she was not sure why the order was not obtained at the time of the original therapy communication on 7/15/21, and that she would have to look into it. 7/27/21 - A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . For R12, the facility delayed Occupational Therapy treatment and services for positioning in her wheelchair for twelve days. 7/29/21 2:25 PM - Findings were reviewed with E1 (NHA), E2 (DON), E3 (ADON), E4 (RN UM), E5 (Clinical Analyst), and E6 (RN Clinical Consultant) during the Exit Conference.

Based on observation, it was determined the facility failed to ensure that residents were treated with respect and dignity for one randomly observed resident. Findings include: 7/21/21 10:15 AM - During an observation of resident care, E7 (RN) referred to R13 as a feeder. This observation was confirmed with an interview of E7 where he confirmed that he used the term feeder when describing the level of assistance that R13 required for eating. 7/29/21 2:25 PM - Findings were reviewed with E1 (NHA), E2 (DON), E3 (ADON), E4 (RN UM), E5 (Clinical Analyst), and E6 (RN Clinical Consultant) during the Exit Conference.

Based on record reviews and interviews, it was determined that for three (R3, R27 and R28) out of fourteen (14) sampled residents for care plan review, the facility failed to ensure that all required members of the Interdisciplinary Team (IDT) participated in, or provided input to, the formation of resident's care plans. Findings include: 9/11/17 (latest revision) - The facility policy for Resident Care Plan stated that the care planning was systematic, comprehensive, interdisciplinary and timely and directed toward achieving and maintaining each resident's optimal physical, psychosocial and functional status. 1. The following was reviewed in R3's clinical record: 4/10/21 - R3 was admitted to the facility. 7/26/21 Review of the care plan meeting progress note and the interdisciplinary care conference sign in document dated 4/20/21 lacked evidence that the following disciplines were in attendance at the meeting: nurse and nurse's aide with responsibility for the resident, activities, attending physician,and the MDS coordinator. 7/26/21 12:05 PM - An interview with E25 (LPN) and review of R3's clinical record confirmed that the CNAs were not involved in the IDT care planning process. The Surveyor requested evidence of documentation from those unable to attend. The facility failed to provide evidence that the staff unable to attend contributed information for the 4/20/21 care plan meeting. 7/27/21 8:10 AM - Interview with E9 (LPN) confirmed that she discusses the resident with other disciplines, but does not attend care plan meetings. 7/27/21 8:40 AM - Interview with E27 (CNA) confirmed that the CNA's are not involved in the IDT care planning process. 2. Review of R28's clinical record revealed: 6/30/21 - R28 was admitted to the facility. 7/9/21 2:25 PM - A care conference note written by E25 (Case Manager) and the IDT (interdisciplinary team) Care Conference Sign in sheet did not include that R28's CNA, nurse, and physician provided input to the care plan. 7/28/21 2:20 PM - During an interview, when asked how the CNA's and nurses provide input into the residents' care plan, E8 (RN, RNAC) replied that the CNA's document the functional status for ADL (activities of daily living) self-performance for section G of the MDS assessment. E8 added that the care plan meetings are put on the calendar at the nurses station so the CNA's and nurses know that they can give input to me (E8). 7/28/21 2:30 PM - During an interview, when asked how the CNA's and nurses provide input into the residents' care plan, E1 (NHA) stated that this was a very small facility with only 40 beds and we are always talking to each other about the residents; it just may not be documented formally as the CNA's and nurses providing input to the care plan. 3. Review of R27's clinical record revealed: 6/23/21 - R27 was admitted to the facility with an order for [MEDICAL RECORD OR PHYSICIAN ORDER] 7/7/21 3:00 PM - A care conference note written by E25 (Case Manager) and the IDT Care Conference Sign in sheet did not include that R27's CNA, nurse, hospice representative and physician provided input to the care plan. 7/28/21 2:20 PM - In an interview concerning care planning and interdisciplinary team participation, E8 (RN, RNAC) confirmed that hospice does not contribute to the resident's facility plan of care. E8 also provided a copy of the hospice provider's plan of care that was located in the resident's paper chart. 7/29/21 8:30 AM - During an interview, E24 (LPN) was asked if she had input into resident care planning and she stated that three days before the meeting it was posted in a book so the nurses are aware they can provide their input on residents care. 7/29/21 8:40 AM - During an interview, E26 (CNA) stated that she had never been asked if she would like to contribute to resident care planning. She stated she has worked here for three years and she would like to provide input. 7/29/21 2:25 PM - Findings were reviewed with E1 (NHA), E2 (DON), E3 (ADON), E4 (RN UM), E5 (Clinical Analyst), and E6 (RN Clinical Consultant) during the Exit Conference.

Based on record review and interview it was determined that the facility failed to develop a policy that included time frames for the different steps in the drug regimen review process. Findings include: The facility's policy titled Medication Regimen Reviews failed to include time frames for the different steps in the process. 1/3/18 (latest revision) - Review of the facility policy entitled Medication Regimen Reviews revealed the lack of: a. Time frames for the following steps: - When the pharmacist will provide a written report to the Director of Nursing and Physician for each resident. - How soon the pharmacist must contact the physician when he/she identifies an irregularity that requires urgent action to protect the resident. - How long the physician has to respond to the pharmacist's recommendations. b. The requirement that the attending physician must document in the resident's medical record that the identified irregularity was reviewed, what, if any, action was taken to address it, and if there is no change, the attending physician should document his/her rationale in the resident's medical record. 7/29/21 11:40 AM - During an interview, the above findings were reviewed with E2 (DON). 7/29/21 2:25 PM - Findings were reviewed with E1 (NHA), E2 (DON), E3 (ADON), E4 (RN UM), E5 (Clinical Analyst), and E6 (RN Clinical Consultant) during the Exit Conference.

Based on observation, interview and review of other facility documentation it was determined that the facility failed to maintain an infection control program to help prevent the transmission of COVID-19 by contaminating PPE while donning (putting on) and doffing (taking off) PPE and not storing (saving for re-use to conserve) gowns in a manner that prevented contamination of the environment. Findings include: 5/18/2020 (last reviewed) - CDC guidance for strategies to optimize PPE included .Consideration can be made to extend the use of isolation gowns (disposable or cloth) such that the same gown is worn by the same HCP (health care provider) when interacting with more than one patient known to be infected with the same infectious disease when these patients housed in the same location (i.e., COVID-19 patients residing in an isolation cohort) . Review of facility map and COVID-19 surveillance data revealed three residents with symptomatic COVID were housed at the far end of the short hallway with a temporary wall separating them from the symptomatic residents. 10/28/2020 (1210 PM - 1240 PM) - During random observation on the COVID area with symptomatic residents, the following techniques of donning and doffing PPE were observed: - E3 (CNA) removed the face shield E3 was wearing and set it on the arm of an upholstered chair in the hallway using bare hands. Without performing hand hygiene, E3 then removed a gown that was hanging on a hook on room [ROOM NUMBER]'s door by the neck ties that were secured with a knot. The gown was not positioned in a way to keep the outside of the gown from contaminating the door where it was stored. E3 then draped the 'dirty' gown across the back of the same upholstered chair with contaminated bare hands and contaminating another part of the chair. - Without performing hand hygiene, E3 untied the ties at the waist and removed the 'clean' gown by pulling it over her head as the neck ties on this gown were also secured with a knot. E3 hung the' clean' gown on the same hook where the 'dirty' gown was stored, thus contaminating the 'clean' gown. - Without performing hand hygiene, E3 pick up and put on the face shield before entering room [ROOM NUMBER]. - After exiting the room [ROOM NUMBER], E3 removed the face shield and set it on the upholstered chair in the hallway. E3 then untied the waist ties and removed the 'dirty' gown up over her head with bare hands. Without performing hand hygiene, E3 removed the 'clean' gown from the door hook with her right hand while hanging the 'dirty' gown with her left hand onto the same hook. The gowns touched each other in passing. - Two bottles of alcohol hand sanitizer sat on a table near the exit door of the temporary wall. E3 left the area through the temporary plastic wall and performed hand hygiene using the dispenser in the hallway outside the assisted dining room. - E3 returned within a few minutes and removed the 'dirty' gown from the same door and placed the gown on the same chair, removed the face shield and set on the table next to the chair in the hallway. Without performing hand hygiene, E3 removed the 'clean' gown with contaminated hands from the door hook and pulled it on over her head, tied the waist ties and replaced the face mask prior to entering room [ROOM NUMBER]. - Upon exiting the room, E3 removed the face shield and set on the table and lifted the gown up over her head, nearly pulling off the hair covering in the process. Without hand hygiene E3 removed the 'clean' gown from the door hook with one hand and hung the 'dirty' one it its place. Using the same contaminated hands, E3 adjusted the hair covering and put on the face shield. Again hand hygiene was not conducted until after leaving the area even though two pump bottles of alcohol gel were on a table to the right of the exit door in the temporary wall. - E4 (LPN) exited room [ROOM NUMBER], removed and placed the face shield on a table, then pulled the 'dirty' gown up over her head exposing another gown being worn. After determining the surveyor was present, E4 stated that she did not take off the clean gown and wore it underneath. 10/28/2020 (2:40 PM) - During an interview, E5 (Housekeeper) E5 explained that she started cleaning on the negative side and ended up behind the wall (where symptomatic COVID residents reside). When asked about the cleaning schedule for the temporary wall, E5 did not believe there was a schedule since the wall was put up recently, but she would spray it at the end of the shift. 10/28/2020 (2:50 PM) - During an interview with E2 (DON) the surveyor described the aforementioned observations. There was discussion about hand hygiene and the possibility of using separate hooks for clean and dirty gowns. Findings were reviewed with E1 (ED and E2 (DON) 10/28/2020 during the exit conference beginning at approximately 3:20 PM.

Based on observation, interview and review of other facility documentation it was determined that the facility failed to maintain an infection prevention and control program by incomplete collection of surveillance data, improper linen handling and failure to conduct an annual review of infection prevention and control policies. Findings include: 1. Surveillance 3/1/17 - The facility policy entitled Surveillance for Infections included .the criteria for infections are based on the current standard definitions of infections. February - (MONTH) 2019 - Review of surveillance data (line listing) revealed incomplete and inconsistent entries: - February: 7 out of 7 infections were missing the date of onset of the symptoms or whether infection criteria was met; and one UTI without an organism listed. - March: 6 out of 7 entries were missing whether infection criteria was met; one UTI from the hospital lacked a listed organism to monitor for spread in facility; and there was incomplete classification (where infection occurred: community (out of facility) or healthcare (in the facility). Three residents admitted from the hospital had their infections incorrectly categorized as healthcare acquired. - April: two UTIs without an organism identified and incorrectly categorized as community acquired when both residents were in the facility at least 5 days before developing the UTI. - May: one UTI without an organism and incorrectly categorized as community acquired. - July: one UTI without an organism identified; one rectal infection without an organism identified; and both infections were incorrectly identified as healthcare acquired although they were present on admission from the hospital. - August: one UTI without an organism identified from the hospital that was incorrectly listed as community acquired; one UTI without an organism identified which was incorrectly categorized as community acquired when it developed in the facility. 10/17/19 (9:10 AM) - During an interview. E1 (NHA) acknowledged that organisms had not been consistently included in the line listing. 10/18/19 (afternoon) - E1 (NHA) provided urine culture results for several residents randomly selected from the line listing. 10/21/19 - Review of copies of selected line listings provided by E1 (NHA) showed urine culture results (organisms) which were not originally on the line listing, were added to the (MONTH) and (MONTH) 2019 surveillance data. These two organisms were among the random urine cultures provided by the facility on 10/18/19. 10/21/19 (around 8:55 AM) - During an interview E2 (DON), who conducted the surveillance, stated that E2 reviewed all infections to verify if they met McGeer's criteria. 2. Linen 3/1/17 - A facility policy entitled Personal Protective Equipment - Gowns, Aprons and Lab Coats included that personnel must wear a gown, apron or lab coat when performing a task(s) that will likely soil the employee's clothing with blood, body fluids, secretions or excretions. 3/1/17 - A facility policy entitled Handwashing / Hand Hygiene (last revised 7/18/18) included Use of an alcohol-based hand rub containing 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: .Before donning gloves .After removing gloves .Hand hygiene is the final step after removing and disposing of personal protective equipment. The following observations and interviews occurred during the laundry room tour on 10/17/19 between 10:10 AM - 10:30 AM: a. After placing dirty incontinence pads into the washer, E15 (Laundry Aide) removed his/her now-soiled gloves and walked into the clean side of the laundry room to obtain a clean pair of gloves. E15 donned the new pair of gloves without performing hand hygiene. Additionally there were no gowns, aprons or gloves in the dirty side of the laundry. b. The door between the dirty and clean side of the laundry was observed to be propped open. Negative pressure was not maintained in the dirty side to prevent organisms from blowing into the clean side, contaminating the bed linen and towels/washcloths. During an interview on 10/17/19 around 10:15 AM with E15 (Laundry Aide) the surveyor explained the purpose of maintaining negative pressure in the dirty side. E15 admitted the door should be closed, but stated it's easier with it open. After E15 closed the door, the surveyor observed that when the two rectangular clean linen carts and a round container were lined against the wall across from the dryers, around 3-4 inches of a linen cart was in front of the door. In order to open the door from the clean side, the linen cart would have to be moved. If the door was opened from the dirty side, the linen cart would be displaced and pushed further into the room. Additional observations throughout the survey when the door between the clean and dirty sides was propped open. - 10/16/19: 2:18 PM, 2:55 PM and 4:45 PM. - 10/17/19: 9:05 AM and 5:25 PM. - 10/18/19: 7:48 AM, 10:01 AM and 3:56 PM. 10/17/19 (11:45 AM) - During an interview E11 (Support Services supervisor) confirmed that hand hygiene should be performed after removing gloves and that the door should be closed between the clean and dirty rooms. E11 added, When I am in there, they do the right thing. 3. Policies 10/17/19 (9:10 AM) - During an interview with E1 (NHA) to review the infection control program, the surveyor asked for evidence of the last time infection control policies were reviewed. E1 (employed at the facility for several months) stated the review should occur annually, but E1 would check with corporate staff who were in the facility for the survey. No evidence about the review of the infection control policies was provided during the survey. Findings were reviewed with E1 (NHA), E2 (DON), E4 (Clinical Analyst) and E5 (Corporate Nurse) during the exit conference on 10/21/19 beginning at 1:10 PM.

Based on record review, interveiw and review of other facility documentation it was determined that the facility failed to adequately monitor for appropriate antibiotic use. In addition an antibiotic without adequate indication was prescribed for one (R35) out of five residents sampled for medication review. Findings include: 10/23/17 - A facility policy entitled Antibiotic Stewardship (last revised 11/21/17) included Practitioners are requested to prescribe antibiotic therapy only when likely to be beneficial to the elder. Culture and sensitivity reports are reviewed routinely as part of the surveillance of infection. Obtain and review antibiogram for trends of resistance on a routine basis from the facility's laboratory provider. Feedback is given to the physician regarding their individual prescribing patterns of cultures ordered and antibiotics prescribed, as indicated. Cross Refer F684, Example 2, F880 1. Surveillance February - (MONTH) 2019 - Review of surveillance data (line listing) revealed the following UTIs were treated with antibiotics without organisms identified to assist with monitoring infections: - February: one UTI and one [MEDICATION NAME]. - April: two UTIs - May: one UTI. - July: one UTI. - August: two UTIs. 10/17/19 (9:10 AM) - During an interview, E1 (NHA) confirmed that organisms were now being included in the line listing and recently contacted the lab to see about getting the information. 10/21/19 (8:55 AM) - During an interview with E2 (DON) about antibiotic stewardship, E2 stated that E2 looked at the criteria for each infection to verify it met McGeer's criteria. E2 added that the criteria and care paths were available at the nursing station to guide nurses. When asked if there had been any inappropriate antibiotics prescribed and how E2 addressed it with the prescriber, E2 replied there had not been any initiated here, only the hospital. 10/21/19 (9:10 AM) - The surveyor observed, at the nursing station, that McGeer's criteria was in a folder in the front of the file cabinet drawer and the care path binder was on the counter. Review of the binder revealed that each care path provided guidance for the nurse when assessing residents and when the provider should be contacted. Care paths included the areas of: [MEDICAL CONDITION], Fall, Shortness of Breath, Lower Respiratory, Behavior Change, Dehydration, UTI, Gastrointestinal, Fever, Mental Status Change, [MEDICAL CONDITION]. Cross Refer F684, Example 2 2. McGeer's criteria for lower respiratory tract infection included: a. Chest x-ray negative for pneumonia or not performed. b. At least two of the following respiratory symptoms: New/increased cough; New/increased sputum production; Oxygen saturation (pulse oximetry) under 94% on room air or a reduction of over 3% from baseline; New/changed lung examination abnormalities; Pleuritic (lung) chest pain; Respirations 25 or more breaths per minute. c. At least one of the following: Fever; Leukocytosis (increased white blood cells indicating infection); Acute change in mental status from baseline; Acute functional decline. Review of R35's clinical record revealed: 10/7/19 - 10/16/19 - Review of vital signs, nursing notes and test results revealed: - No chest x-ray or blood test results. - Temperatures obtained by tympanic (ear) or temporal (forehead) method ranged from 95.8 to 98.5 indicating no fever). - Respirations ranged from 15-20 breaths per minute. - No pulse oximetry readings after (MONTH) 10. - No documentation of lung sounds. 10/15/19 - Physician / NP / PA Contact note included (hospice name) Hospice recommendations reviewed by MD (physician) and approved. New orders for .(name of antibiotic) to be given twice a day for respiratory infection for seven days. October 2019 - Review of the eMAR showed that R35 started on the antibiotic beginning (MONTH) 16. R35 did meet criteria for lower respiratory infection according to assessments in the facility's clinical record. 10/21/19 (8:45 AM) - During an interview E3 (RNAC) stated that R35 had had some coughing and was unable to get up thick sputum (a mixture of saliva and mucus). 10/21/19 (around 9:05 AM) - During an interview E2 (DON) stated that since a hospice nurse was at R35's bedside around the clock, it would be their observations and not ours. Findings were reviewed with E1 (NHA), E2 (DON), E4 (Clinical Analyst) and E5 (Corporate Nurse) during the exit conference on 10/21/19 beginning at 1:10 PM.

Based on review of the facility's scheduled meal times and interview, it was determined that the facility failed to ensure that the meal time, between dinner and breakfast the following day was no more than (14) hours without evidence of a substantial evening snack and resident group approval. Findings include: Review of the facility's scheduled meal times for all residents in the nursing home, it was documented that the dinner meal was served beginning at 5:00 PM and the breakfast meal was served beginning at 8:00 AM, thus, more than 14 hours from dinner to breakfast the following day. 10/14/19 4:00 PM - An interview with E1 (NHA) confirmed that the facility did not offer a substantial evening snack and confirmed there was 15 hours between dinner and breakfast the following day. 10/17/19 9:30 AM - A subsequent interview with E1 (NHA) confirmed that the facility had no evidence that the residents approved the meal time in which there was greater than 14 hours between dinner and the breakfast the following day. Findings were reviewed with E1 (NHA), E2 (DON), E4 (Clinical Analyst) and E5 (Corporate Nurse) during the exit conference on 10/21/19 beginning at 1:10 PM.

Based on record review, interview, observation and review of other facility documentation it was determined that for three (R5, R19 and R22) out of three residents reviewed for pressure ulcers, the facility failed to ensure that the residents at risk for pressure ulcers or those with pre-existing pressure ulcers, received the care and services to promote healing and to prevent new pressure ulcers from developing. For R5, the facility failed to ensure that new interventions were consistently implemented after R5 had acquired two new pressure ulcers (PUs). For R19 and R22, the facility failed to ensure that their heels were offloaded as directed by the plan of care. Findings include: A facility policy (last revised 11/23/12) entitled Wound and Skin Care, At Risk Residents included that Heels are extremely vulnerable and must be completely off of bed surface. Utilize pillows, foot splints or heel risers. 1. Review of R5's clinical records revealed the following: 10/1/18 - R5 was admitted to the facility without a PU. 10/1/19 thru 10/17/19 - Review of the Activities of Daily Living (ADL) and Caregiver documentation indicated that R5 was turned and repositioned every 2 hours and had a pressure redistribution cushion to all chairs. 8/5/19 (Most recent revision date with an initial implementation date of 10/4/18) - A care plan for the problem of skin integrity documented interventions including weekly wound rounds with wound NP; monitor skin during weekly skin assessment and document new areas; monitor nutritional status; cushions to all chairs where R5 spent the majority of time, encourage to turn and reposition as needed and assist resident as needed, offer to assist me to lie in the bed, but R5 prefers to sleep in recliner, and application of anti itch cream. 10/8/19 - The quarterly MDS assessment documented that R5 was moderately impaired for decision making, required extensive assistance of one staff member for bed mobility, and had no current pressure ulcer. Preventative measures for PU development included pressure redistribution to bed and chair, application of ointment or creams, and R5 was on a turn and reposition program. 10/10/19 (Last revision date) - A review of the Resident Care Map (CNA Care Plan) documented for skin care and to float the heels. 10/13/19 - A progress note, documented a change in condition, in which R5 was shaking, drooling, leaning to the side, and had increased respiration with confusion. E9 (MD) was notified and new orders were obtained for oral antibiotics, chest x-ray and laboratory studies to be performed. 10/14/19 - A Weekly Wound Consultant Assessment conducted by E23 (WCNP) documented the presence of two new PUs; a sacrum DTI and a stage 2 of the right ischium. Recommendations included having the attending physician evaluate the decline and to turn frequently to offload (pressure on the pressure ulcers). There was a lack of evidence that the facility individualized the intervention to turn frequently to offload the affected areas of pressure and they failed to incorporate the intervention into R5's CNA care plan and/or the ADL and Caregiver documentation. 10/17/19 11:30 AM - An interview with E22 (CNA) revealed that most of the time, R5 sat in the wheelchair during the day and only got in bed when he needed to have his leg dressings changed. E22 verbalized that R5 had a special cushion for his wheelchair and recliner and E22 encouraged R5 to offload his bottom. E22 verbalized that she was unaware, since the identification of R5's new PUs on 10/14/19, of any new interventions. 10/17/19 11:57 AM - An interview with E6 (RN) confirmed that the intervention to turn frequently to offload after the identification of the 2 PUs was not incorporated into the CNA electronic documentation system and/or on R5's CNA care plan. 10/21/19 12:55 PM - The surveyor was provided a copy of the (MONTH) 2019 Treatment Administration Record (TAR) by E2 (DON) which documented the following: - 10/14/19 through 10/17/19: Turn & Position by Shift Starting 10/14/19 .Note: Turn and reposition resident frequently to offload pressure. This order was discontinued on 10/17/19. The licensed nurse signed off per shift beginning on day shift on 10/14/19 through the evening shift on 10/17/19. - 10/17/19 through 10/20/19: Turn & Position by Shift Starting 10/17/19 .Note: Turn and reposition resident every two hours. Encourage resident to decrease time OOB (out of bed), position resident to offload pressure on buttocks. The licensed nurse signed off per shift beginning on evening shift on 10/17/19 through the evening shift on 10/20/19. Although the facility transcribed the above in the nurse's TAR beginning on 10/14/19, the facility failed to ensure that the CNA electronic documentation system and/or the CNA Care Plan was updated. The facility failed to ensure that the new interventions to turn frequently to offload areas to the two new PUs were implemented. This was a repeat deficiency from the Annual and Complaint Survey ending 10/28/18. Repeated deficiency from the Annual and Complaint Survey ending 10/24/18 Deep tissue injury may be preceded by tissue that is painful, firm, mushy, boggy (soft), warmer or cooler, as compared to adjacent tissue. https://www.ncbi.nlm.nih.gov/books/NBK2650/table/ch12.t2/ 2. Review of R19's clinical record revealed: 12/11/17 - A care plan for comfort care (last revised 8/29/19) was initiated and included I do not like to be turned and repositioned. I prefer for (sic) be positioned on back. Interventions included several pressure ulcer prevention / relieving strategies: 2/13/18 - elevate both heels from bed, foot cradle; and 8/28/19 - apply skin prep (provides for protection). R19's MDS assessments recorded an intermittent pressure ulcer: - 3/3/19 Annual: 1 unhealed pressure ulcer. - 6/1/19 Quarterly: no pressure ulcer. - 8/29/19 Quarterly: 1 unstageable pressure ulcer (right heel) and R19 needed extensive assistance with bed mobility. 10/14/19 - Wound care documentation showed that R19's right heel had been healed for 6 weeks. Surveyor observations between 10/13/19 - 10/21/19 of R19 wearing white booties, foot cradle in place and heels were lying on the pillow placed beneath both legs/heels. (R19's heels were not offloaded with the pillow underneath the heels) on the following occasions: - 10/14/19: 1045 AM and 1:50 PM. - 10/15/19: 8:20 AM and 2:05 PM. - 10/21/19: 10:50 AM. R19's heels were offloaded on 10/16/19 - 10/18/19 during random observations throughout the day 10/16/19 (around 9:30 AM) - During an observational interview with E13 (CNA) to look at the positioning of R19's feet, both heels were offloaded, hanging over the edge of the pillow under R19's legs. E13 removed R19's right booty and the surveyor observed normal skin color (no redness), however the heel was boggy (soft). 10/21/19 (10:50 AM) - During an observational interview, E14 (LPN) confirmed that both of R19's heels were lying on top of the pillow placed under her legs. E14 moved the pillow upward to allow R19's heels to be elevated/floated. 3. Review of R22's clinical record revealed: 9/19/18 - R22 was admitted to the facility. 10/9/18 - A wound assessment by a facility contracted (NP) documented a history of bilateral heel ulcers. 10/10/18 - R22's care plan documented, I have fragile skin .Float (elevate/offload) heels when in bed 9/6/19 - R22's Braden Scale score documented that R22 was at risk for pressure ulcers. 9/9/19 - R22's annual MDS assessment documented that R22 was severely cognitively impaired, non-ambulatory (did not walk), and required assistance for bed mobility, transfers, eating and toileting. R22 was observed in bed and positioned with heels not offloaded(elevated): - 10/14/19: 10:28 AM, 10:43 AM and 2:40 PM. - 10/15/19: 8:31 AM, 9:13 AM, 1:17 PM and 2:30 PM. - 10/16/19: 9:36 AM, 10:37 AM and 2:50 PM. - 10/17/19: 9:25 AM, 11:33 AM and 2:12 PM. - 10/18/19: 9:05 AM, 10:31 AM and 11:40 AM. 10/21/19 8:28 AM - During and interview and observation E10 (CNA) confirmed that R22's heels were not properly elevated as there was only one pillow under R22's calves which was ineffective to prevent the heels from contact with the mattress/bed. Findings were reviewed with E1 (NHA), E2 (DON), E4 (Clinical Analyst) and E5 (Corporate Nurse) during the exit conference on 10/21/19 beginning at 1:10 PM.

Based on interview, clinical record review, and review of the facility's policy and procedure, it was determined that the facility failed to develop a comprehensive person-centered care plan with measurable goals to address resident's needs for five (R7, R12, R13, R33, and R34) out of 16 residents sampled for investigations. Findings include: Review of the facility's policy and procedure titled Resident Care Plan, with a revision date of 9/11/17, indicated that the policy of the facility was to ensure that the care plan process was systematic, comprehensive, interdisciplinary and timely and directed toward achieving and maintaining each resident's optimal physical, psychosocial and functional status. In addition, the resident's care plan would include measurable objectives and timeframes to meet the resident's medical, nursing, mental and psychosocial needs. Cross refer F684, example #1 1a. Review of R13's clinical record revealed the following: 4/24/19 - R13 was admitted to the facility from the hospital with [DIAGNOSES REDACTED]. 5/11/19 through 10/17/19 - The physician's orders [REDACTED]. 7/18/19 through 10/17/19 - The Resident Vital Signs Report documented R13's FSBS and showed episodes of both [DIAGNOSES REDACTED], as low as 48, and [MEDICAL CONDITION], as high as 600. Although R13 experienced [DIAGNOSES REDACTED] and [MEDICAL CONDITION], there was a lack of evidence of a comprehensive care plan to include interventions for monitoring specific signs and symptoms of hypo and [MEDICAL CONDITION] and the integration of the hypoglycemic protocol as ordered. Cross refer F688, example #1 1b. Review of R13's clinical record revealed the following: 4/24/19 - R13 was admitted to the facility from the hospital. 8/10/19 - A physician's orders [REDACTED]. 8/20/19 - A care plan (initial implementation date of 5/8/19) for problem of I am here for LTC (Long Term Care) because I need help taking care of myself. I do not always know when I need to go to the bathroom. The goal was that I wish to be comfortable and receive the care and support that I need to make the most of my stay at The Moorings in the Health Center. An intervention included Monitor with a frequency of 2 times daily starting 8/20/19. There was a lack of evidence that the goal was measurable because it was unclear what was to be monitored two times a day. 10/16/19 4:03 PM - An interview with E3 (RNAC) confirmed that the 8/10/19 order to ambulate R13 200 feet using a rolling walker and staff supervision was included as an intervention. There was a lack of evidence of a measurable objective for R13's ambulation order as well as the timeframe to meet the objective. 10/21/19 12:45 PM - An interview with E2 (DON) confirmed that the above care plan failed to include measurable objectives and a timeframe to meet the goal for R13's ambulation. Cross refer F688, example #2 2. Review of R33's clinical records revealed the following: 9/27/18 - R33 was admitted to the facility. 11/9/18 - A physician's orders [REDACTED]. 11/10/18 (Initial implementation date of 10/19/18) - A care plan for problem of I am not able to get ready for the day by myself because I have weakness. The goal was that I will be clean, odor free, shaved, dressed, and out of bed daily over the next review period. Interventions included for a CNA to offer to assist R33 to ambulate 120 feet with a rolling walker and contact guard assistance or with stand by assistance twice daily and to document refusals in the administration note. There was a lack of evidence of a measurable objective, as well as the timeframe to meet the objective. 10/21/19 12:45 PM - An interview with E2 (DON) confirmed that the above care plan failed to include measurable objectives and a timeframe to meet the goals for R33's ambulation. 3. Review of R7's clinical record revealed: 1/12/19 - Admission to the facility with severe cognitive impairment. 1/19/19 - A care plan problem entitled, I am in long term care included the goal, I want to have quality of life and to be made comfortable for the remainder of my days. Interventions were varied and involved attending groups, going to the beauty salon, listening to music, participating in therapy dog visits, enjoying padded reclining wheelchair and having room decorated with personal furnishings. This goal was not measurable. 10/21/19 (8:41 AM) - During an interview with E3 (RNAC) about the care plan goal, E3 revealed that the goal was written by the social worker and I usually won't touch (his/hers). 10/21/19 (9:10 AM) - During an interview with E7 (SW) to determine how the goal would be measured to determine if R7 met the goal, E7 stated, I do observations to determine if the resident looks comfortable and has quality of life. The observations are subjective and not measurable. 4. Review of R12's clinical record revealed: 12/11/18 - A care plan problem for I live in long term care because I am dependent on others to care for me included the goal, I want to live out my days in comfort and make the most of my days. Interventions involved enjoying time in the living room area next to the nurses station, napping and resting my head in my lap and don't mind being awakened to be checked on and offered repositions, snacks and drinks. This goal is not measurable. 10/21/19 (8:41 AM) - During an interview with E3 (RNAC) about the care plan goal, E3 revealed that the goal was written by the social worker and I usually won't touch (his/hers). 10/21/19 (9:10 AM) - During an interview with E7 (SW) to determine how the goal would be measured to determine if R7 met the goal, E7 stated, I do observations to determine if the resident looks comfortable and has quality of life. The observations are subjective and not measurable. 5. A review of R34's clinical record revealed: 9/19/19 - R34 was admitted to the facility with a broken right wrist that required a cast. 10/12/19 8:47 AM - A nursing progress note included, Resident is presenting with increasing [MEDICAL CONDITION] (swelling) to right hand. Cast is becoming tight and her pain level is increasing. E9 (MD) notified. New order to send to (named hospital emergency room ) non-emergent for cast removal and replacement. 10/21/19 11:05 AM - During an interview with E1 (NHA), E4 (Clinical Analyst) and E5 (Corporate Nurse), it was confirmed that R34 did not have a comprehensive care plan for a right wrist cast to include monitoring for hand [MEDICAL CONDITION], capillary refill, and skin integrity beneath the cast. Findings were reviewed with E1, E2 (DON), E4 and E5 during the exit conference on 10/21/19, beginning at 1:10 PM.

Based on observation, clinical record reviews, interviews and review of other facility documentation as indicated, it was determined that for one (R13) out of three sampled residents reviewed for insulin investigation, the facility failed to provide treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plans. In addition, the facility failed to ensure collaboration with hospice for one (R35) out of one sampled residents investigated for hospice. Findings include: The manufacturer's prescribing information for [MEDICATION NAME], a fast acting insulin stated .[DIAGNOSES REDACTED] is the most common adverse effect of insulin therapy . (https://www.[MEDICATION NAME].com). The manufacturer's prescribing information for Tresiba, a long acting insulin, stated, . [DIAGNOSES REDACTED] is the most common adverse reaction of insulin, including Tresiba®, and may be life-threatening. Increase monitoring with changes to: insulin dose, co-administered glucose lowering medications, meal pattern, physical activity . (https://www.tresiba.com). What is [DIAGNOSES REDACTED] - [DIAGNOSES REDACTED], also called low blood glucose or low blood sugar, occurs when the level of glucose in your blood drops below normal. For many people with diabetes, that means a level of 70 milligrams per deciliter (mg/dL) or less . - What are the symptoms of [DIAGNOSES REDACTED]? Mild-to-Moderate - shaky or jittery, sweaty, hungry, blurred vision, sleepy or tired, dizzy or lightheaded, confused or disoriented, pale, uncoordinated, irritable or nervous, argumentative or combative, behavior or personality changes, trouble concentrating, weak, fast or irregular heart beat. - Severe - unable to drink or eat, [MEDICAL CONDITION] or convulsions (jerky movements), and unconsciousness) . (https://www.niddk.nih.gov/health-information/diabetes/overview/preventing-problems/low-blood-glucose-[DIAGNOSES REDACTED]#symptoms). Cross refer F656, example #1 Review of R13's clinical record revealed the following: 4/24/19 - R13 was admitted to the facility from the hospital with [DIAGNOSES REDACTED]. 4/24/19 - A list of Standing Orders signed by E13's attending physician included a .Diabetic Emergency Protocol for [DIAGNOSES REDACTED] as follows: [NAME] Check Resident's blood sugar by finger stick: B. If the blood sugar is below the Resident's prescribed parameters (if no parameters have been prescribed, refer to the facility protocol parameters of 70-115) and if: 1. Resident is alert, administer one of the following: 8 ounces of skim milk, 4 ounces of soda (not diet) or 4 ounces of juice (any kind). Recheck the blood sugar after 10 minutes. Notify physician of blood sugar and interventions immediately. Hold insulin/diabetic meds, if ordered. 2. Resident has reduced level of consciousness. Give [MEDICATION NAME] 1 mg I.M. (intramuscular - into the muscle) and recheck blood sugar. If no improvement, . 5/11/19 (Original date) - A physician's orders [REDACTED]. 5/24/19 (Original date) - A physician's orders [REDACTED]. the range of the FSBS and the amount of Novlog insulin was included in the order. 5/28/19 (Original date) - A physician's orders [REDACTED]. 8/29/19 (Original date) - A physician's orders [REDACTED]. 7/18/19 thru 10/10/19 - The electronic Medication Administration Record [REDACTED] - 7/18/19 12:40 PM: 50 - 7/30/19 12:20 PM: 64 - 8/19/19 11:54 AM: 54 - 8/22/19 8:55 AM: 48 - 8/24/19 12:25 PM: 54 - 8/29/19 8:10 PM: 66 - 8/29/19 8:48 AM: 62 - 8/30/19 12:16 PM: 62 - 9/3/19 9:22 PM: 68 - 9/5/19 12:17 PM: 52 - 9/7/19 11:58 AM: 68 - 9/25/19 9:30 AM: 52 - 9/25/19 4:42 PM: 57 - 10/10/19 5:11 PM: 67 In addition, for 10/7/19 at 12:26 PM, the result was documented as out of parameter. 7/18/19 through 10/10/19 - A review of the corresponding progress notes lacked evidence that the facility consistently implemented the hypoglycemic protocol when R13's FSBS was below 70. In addition, there was a lack of evidence whether facility staff identified the presence of signs and symptoms of [DIAGNOSES REDACTED] and closely monitored the resident. 10/17/19 1:44 PM - During an interview with R13's attending physician, E9 (MD) confirmed that R13 had episodes of [DIAGNOSES REDACTED]. E9 reported that in the past, R13 required an insulin pump, however, R13 no longer had the pump and was currently on insulin; routine and sliding scale insulin. 10/18/19 3:45 PM - E1 (NHA) provided an e-mail response from E9 (MD), dated 10/18/19 and timed 2:13 PM, in response to the surveyor's request made earlier at 2:05 PM on 10/18/19. Review of the e-mail and the three page attachment revealed the following: E9 (MD) documented various ways in which the facility staff can notify E9 when R13's FSBS was lower than 70. In the e-mail, E9 further elaborated .Regardless, nursing notes should document sugar low, insulin held, MD informed, crackers/juice given and what the repeat reading was . E9 (MD) provided a print out from the docbook electronic system (physician documentation regarding contact by the facility, not part of the facility's electronic clinical record) for three FSBS below 70: - 8/22/19 at 7:55 AM for FSBS of 48 in which interventions were implemented, however, no repeat FSBS result was documented. - 8/29/19 at 8:47 AM for FSBS of 62 in which interventions were implemented and repeat FSBS was 119. - 8/29/19 at 9:48 PM for FSBS of 66, in which interventions were implemented and repeat FSBS was 147. E9 (MD) documented that he may have been informed and/or was likely informed of 3 of the FSBS results and no message was received and or can't find anything for 4 FSBS results. 10/21/19 10:30 AM - An interview with E5 (Corporate Nurse) was conducted. E5 provided the surveyor additional information related to the implementation of the hypoglycemic protocol. Based on additional evidence, it was determined that the facility failed to have evidence that the protocol was implemented for the following dates and times: - 8/24/19 12:25 PM : FSBS 54 - 9/3/19 9:22 PM: FSBS 68 - 9/5/19 12:17 PM: FSBS 52 - 9/7/19 11:58 AM: FSBS 68 - 9/25/19 4:42 PM: FSBS 57 10/21/19 11:45 AM - The surveyor was informed by E5 (Corporate Nurse) that the facility was unable to provide evidence of the FSBS result for 10/7/19 at 12:26 PM, when the staff documented out of parameter and lastly, the facility was unable to provide evidence that the protocol was implemented when R13's FSBS was 67 on 10/10/19 at 5:11 PM. The facility failed to ensure, when R13 experienced a FSBS below 70, that: - R13 was assessed for the presence or absence of signs and symptoms of [DIAGNOSES REDACTED] and that close monitoring of the resident occurred. - the hypoglycemic protocol was consistently implemented. Cross Refer F697 and F881 2. Review of R35's clinical record revealed: 10/10/19 - A hospice recommendation written on the hospice order sheet included the antipsychotic [MEDICATION NAME] to be given every 4 hours PRN for agitation, hallucinations and/or nausea/vomiting. The facility's physicians' orders included [MEDICATION NAME] to be PRN for dementia with behavioral disturbance. 10/13/19 (9:35 AM) - The facility eMAR documented the PRN [MEDICATION NAME] (pain medication) was requested by hospice nurse for c/o (complaint of) back pain. Hospice records revealed a pre-pain rating score of 6 prior to being medicated for pain. 10/13/19 (4:44 PM) - The eMAR did not include any assessment of behaviors indicating pain or a pain score for this dose of [MEDICATION NAME]. The hospice assessment included moaning, grimacing, restlessness with a pain score of 6 prior to the PRN pain medication. There was no evidence that there was collaboration with hospice staff regarding R35's pain assessment. 10/15/19 (around 9:30 AM) - During an interview H1 (Hospice LPN) showed the surveyor the hospice documentation binder at the bedside. H1 explained that respiration rate was assessed every two hours and that detailed notes about R35's behaviors, medications and care were documented. Surveyor observations throughout the survey (10/14/19 - 10/18/19) revealed that hospice staff would directly interact with facility staff when requesting PRN medications and that the facility nurse would look in on the resident and hospice staff throughout the day. 10/15/19 (6:16 PM) - A physician contact note documented (hospice name) Hospice recommendations reviewed by MD (physician) and approved. Clarified with NP duration of antibiotic therapy. 10/15/19 - The physicians' orders included an antibiotic ([MEDICATION NAME]) to be given twice a day for seven days for a respiratory infection starting 10/16/19. October 2019 - Review of vital signs and nursing notes revealed that R35's temperatures ranged from 97.2 to 98.2 and respiratory rate ranged from 15-20 between 10/12/19 - 10/15/19 which were all within normal range. In the facility record, there were no pulse oximetry readings, no assessment of lung sounds or the presence of a cough or sputum which would indicate a respiratory infection. 10/21/19 (8:41 AM) - During an interview with E3 (RNAC) to review care plans and the presence of a respiratory infection, E3 revealed that R35 had previously been coughing and could not get out the thick sputum. The surveyor informed E3 that assessment of signs and symptoms of a respiratory infection (e.g., fever, change in pulse oximetry, respiration rate or lung sounds) was lacking in R35's clinical record. Findings were reviewed with E1 (NHA), E2 (DON), E4 (Clinical Analyst) and E5 (Corporate Nurse) during the exit conference on 10/21/19 beginning at 1:10 PM.

Based on observation, interview, and review of other facility documentation it was determined that the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety and comply with the Delaware Food Code. Findings include: 1. 10/14/19 (8:10 AM - 8:30 AM) - The surveyor observed several open, undated ready to eat food items during the initial kitchen tour: - Dry Storage: Two bags of mixed nuts (one bag not sealed with plastic wrap). a bag of walnuts, 4-6 small tortillas wrapped in plastic wrap and a bag of cookies. - Walk-in #2 refrigerator: A one gallon container of Italian dressing with approximately 4-5 inches of product remaining. 10/14/19 (8:23 AM) - E17 (Cook) confirmed and discarded the opened, undated ready to eat food. 2. 10/18/19 at 12:47 PM - The surveyor observed E19 (Dining Services Employee), E20 (Dining Services Employee) and E21 (Dining Services Employee) preparing food without proper covering on facial hair. 3. 10/18/19 at 1:05 PM -The surveyor observed E20 (Dining Services Employee) placed raw pieces of poultry (chicken) onto a baking sheet with ungloved hands, then left the prep area without performing proper handwashing before touching other kitchen items. 4. 10/18/19 at 1:27 PM - The surveyor observed the handwashing sink in the Main Kitchen, adjacent to the Bistro doorway with a significant amount of shredded carrots and other food debris in the drain area of the sink. 10/18/19 at 2:45 PM - Findings number 2 - 4 were confirmed by E1 (NHA) and E33 (Director of Dining Services). Findings were reviewed with E1 (NHA), E2 (DON), E4 (Clinical Analyst) and E5 (Corporate Nurse) during the exit conference on 10/21/19 beginning at 1:10 PM.

Based on record review and interview it was determined that for one (R32) out of one sampled residents reviewed for discharge, R32's clinical record lacked evidence that a discharge summary to include a recapitulation of the resident's stay, a final summary of the resident's status, and a reconciliation of all pre-discharge medications with the resident's post-discharge medications was completed. Findings include: The following was reviewed in R32's clinical record: 9/9/19 - R32 was admitted to the facility following a left total knee replacement. 10/4/19 - R32 was discharged home from the facility. Record review lacked evidence of the required elements of a completed discharge summary. 10/21/19 at approximately 12:30 PM - During an interview with E1 (NHA) and E5 (RN), it was confirmed that R32's clinical record lacked evidence of a completed discharge summary to include a recapitulation of the resident's stay, a final summary of the resident's status, and a reconciliation of all pre-discharge medications with the resident's post-discharge medications. Findings were reviewed with E1 (NHA), E2 (DON), E4 (Clinical Analyst) and E5 (Corporate Nurse) during the exit conference on 10/21/19, beginning at 1:10 PM.

Based on interview and record review, it was determined that the facility failed to provide appropriate services to maintain or improve mobility for two (R13 and R33) out of three residents reviewed for limited range of motion or mobility investigations. Findings include: Repeat deficiency from the Annual and Complaint Survey ending 10/24/18. Cross refer F656, example #1b. 1. Review of R13's clinical record revealed the following: 10/24/18 - R13 was admitted to the facility. 8/20/19 - A physician's orders [REDACTED]. 9/1/19 through 10/15/19 - Review of the Treatment Administration Record (TAR) revealed that the facility transcribed the order and scheduled ambulation during the day and evening shifts. During the periods below, the facility documented 0.00 for length of ambulation with no corresponding administration note, thus, there was a lack of evidence that the facility offered to ambulate R13: - 9/1/19 through 9/30/19: 1 out of 30 day shifts and 4 out of 30 evening shifts. - 10/1/19 through 10/15/19: 2 out of 15 evening shifts 10/15/19 (Date of update of the documentation) - The Resident Care Map (CNA care plan) documented to ambulate R13 200 feet with rolling walker and supervision twice a day. 10/16/19 5:00 PM - An interview with E8 (LPN) revealed that she was informed during the current survey that a corresponding note must be completed in the TAR if the length was documented as 0.00. The facility failed to have evidence that R13 was ambulated 200 feet twice a day with a rolling walker, as ordered. Cross refer F656, example #2. 2. Review of R33's clinical record revealed the following: 11/9/18 - A physician's orders [REDACTED]. 7/19/19 through 10/14/19 - Review of the TAR revealed that the facility transcribed the order on 11/9/18 and scheduled to offer the ambulation during day and evening shifts and to document refusals in an administration note. During the periods below, the facility documented 0.00 for length of ambulation with no corresponding administration note, thus, there was a lack of evidence that the facility offered to ambulate R33: - 7/19/19 thru 7/31/19: 7 out of 13 evening shifts. - 8/19/19: 2 out of 31 day shifts and 14 out of 31 evening shifts. - 9/1/19 thru 9/19/19: 1 out of 19 day shifts and 5 out of 19 evening shifts. - 10/1/19-10/15/19 - 1 out of 15 day shifts and 5 out of 15 evening shifts. 10/16/19 4:03 PM - An interview with E3 (RNAC) revealed that on the above shifts in which 0.00 was documented, the facility had no evidence that R33 was offered to be ambulated, as per the physician order. 10/16/19 5:00 PM - An interview with E8 (LPN) revealed that at times during the evening shift, R33 was too weak to ambulate, however, E8 confirmed that he/she had not documented this in the administration note. The facility failed to have evidence that R33 was offered to ambulate with staff assistance twice a day, as ordered. Findings were reviewed with E1 (NHA), E2 (DON), E4 (Clinical Analyst) and E5 (Corporate Nurse) during the exit conference on 10/21/19 beginning at 1:10 PM.

Based on observation it was determined that the facility failed to maintain dignity for one (R35) out of 16 residents sampled for investigations. Findings include: Review of R35's clinical record revealed: R35 was receiving hospice services with a nurse at the bedside 24 hours a day. R35's hospice aide and nurse (H1) were preparing to provide personal hygiene. H1 left the room to obtain linen and left the room door open: - 10/15/19 (8:18 AM): R35 was lying in bed with his/her knees bent and the disposable brief was visible from the hallway. The surveyor was not seen by the hospice aide in the room and the door remained open until H1 returned with the linens and towels. Findings were reviewed with E1 (NHA), E2 (DON), E4 (Clinical Analyst) and E5 (Corporate Nurse) during the exit conference on 10/21/19, beginning at 1:10 PM.

Based on interview, review of resident's clinical record and other facility documentation, it was determined that for one (R8) out of three sampled residents reviewed for abuse, the facility failed to ensure that R8 was free from abuse. This resulted in psychosocial harm which was inflicted when E11(CNA) flicked R8's nipples in retaliation for being pinched by R8. As a result, R8 exhibited signs of being fearful when care was provided. Findings include: Cross refer F607, F608 and F609 #1. The facility policy and procedure (last revised 10/23/18) entitled Abuse (Resident Abuse) included: a. Each new employee shall be oriented to the facility's policies and procedures regarding the prevention, reporting, and investigation process associated with resident abuse. b. The Administrator/DON/Wellness Nurse or designee will assure adequate supervision of staff to identify inappropriate behaviors such as using derogatory language, rough handling, ignoring residents while giving care, and directing residents who need toileting assistance. 6/9/16 - R8 was admitted to the facility with Alzheimer's dementia. 12/14/18 - A quarterly MDS documented a BIMS score of 6 out of 15, which reflected that R8 had severe cognitive impairment. 1/6/19 - At approximately 2:30-2:45 PM (as documented in E12's, CNA written statement), E12 and E13 (CNA) witnessed E11 (CNA) touch R8 inappropriately. 1/6/19 - A written statement from E12 (CNA) included: On 1/6/19 I assisted (E11, CNA) with dressing and changing a resident (R8). As we were sitting (R8) up I noticed (R8) grabbing for something to hold onto. (R8) reached for (E11's) jacket. As (R8) did (reach for E11's jacket), (E11) started to pluck (R8) on (his/her) nipples. I asked (E11) what was (he/she) doing and (E11) stated that (R8) was pinching me. I told (E11) (R8) wasn't, that (R8) was just looking for something to hold onto. (E13, CNA) was at the foot of the bed and witnessed it all. A written statement (undated) from E13 (CNA) included: On (MONTH) 6, 2019 (E12, CNA), (E11, CNA) and I went into (R8's) room to get (R8) dressed and up for the afternoon. (E12) was getting (R8's) clothes out, and I was at the end of the bed when we both heard (R8) yell. I looked up and (E11) had flicked (R8's) nipples more than once. (E12) yelled, 'Are you crazy?' (E11) said, (R8's) pinching me so I'm getting (him/her) back. (E12) stated, (R8's) just looking for something to hold onto. (R8) then started to cry. Later that evening I was doing rounds and (R8) asked to see my face before I touched (him/her). I feel (R8's) frightened now. 1/7/19 (approximately 2:30 PM) - Documentation in the facility reported incident report revealed that E2 (DON) and E3 (RNAC) became aware of the alleged abuse reported by E12 (CNA). 1/7/19 (4:57 PM) - The allegation of abuse for R8 was reported to the State Agency. The facility incident report for the State Agency included: A staff member reported to RNAC and DON that (he/she) witnessed an abusive act committed against a resident. The act occurred on (MONTH) 6, 2019. The staff person alleges that (he/she) and two other staff members were providing care for (R8) and one of the other staff members touched (R8) inappropriately. (R8) is alert and oriented to self only, and unable to validate the occurrence. 1/8/19 - A written statement from E11 (CNA) included: On Sunday the 6th I was with (R8's) aide. (R8) stayed in the bed majority of the day (related to) (R8) not wanting to get up. Close to 3:00 (PM) myself and two other aides went in and asked (R8) if (he/she) was ready to get up. (R8) said yes so we proceeded to get (R8) dressed. While turning (R8) toward me to pull (his/her) pants up, (R8) pinched me under my arm/breast. So I said in a joking matter, 'Owww (R8) that hurts!' And as I turned (R8) back over said I should give you a tittie/boob twister for that and we all laughed. We finished pulling (R8's) pants up, put on (R8's) jacket and put (R8) in (his/her) chair. I pushed (R8) out to the television area. Shortly after that (R8's) daughter came and pushed (R8) back to (R8's) room, rang (the call bell) and said that (R8) wanted to go back to bed. I informed her (the daughter) that I just got (R8) up for the day, so (the daughter) talked (R8) into staying up for dinner. Also, (R8's) favorite football team was about to play, so we assured (R8) that if (he/she) ate in the dining room, we would turn it on. Then I left. Not even 5-10 minutes later (R8's) bell rang again and I answered it. (R8's) daughter said (R8) doesn't want to wait so I said okay. I asked the daughter if she wanted me to put (R8's) night clothes on and (R8) said no. Another aide came in to accompany me if needed (them to assist me with (R8's) care). After (R8) was settled in bed, myself, (R8's) daughter and another aide talked for a few minutes. I also had (R8) on the 3-11 shift, so I undressed (R8), changed (R8) and put (R8's) gown on for bed. While doing this (R8) was yelling, stiffening up, crossing her legs, but I completed the task as usual. I noticed no bruises or anything on (R8), other than the patch on (his/her) butt. E11's statement included that (he/she) was pinched by (R8), although E11's documentation at 3:45 PM on (MONTH) 6, 2019 lacked evidence of any behaviors. 1/10/19 - The facility did not report the allegation to the police until after the State Agency investigator was in the building. 1/18/19 - Research revealed that per the Attorney General Office, Delaware State Police (DSP) will be charging E11 (CNA) with Unlawful Sexual Contact and Abusing a Vulnerable Adult. 2/10/19 - A service letter created by E21 (HR) for E11(CNA) at the time of termination included: The employee was counseled, warned, reprimanded, suspended or discharged as a result of reasonably substantiated incidents involving abuse of patients. 3/12/19 - An annual MDS revealed a BIMS score of 2 out of 15, which reflected that R8 was severely cognitively impaired. 4/5/19 (9:55 AM) - In an interview with E2 (DON), E2 reported that the reason why E12 (CNA) did not report what he/she had witnessed the same day as it occurred, was related to E12 had reported E11 (CNA) for other things at another facility. E2 stated that E12 reported that nothing was done about it (and the witnessed act really bothered E12), so E12 thought that he/she needed to report it the next day. E2 stated that E11 was terminated. E2 reported that the facility could not substantiate abuse of the resident but having two witnesses was enough for E2 to terminate E11. The facility failed to ensure that R8 was free from abuse related to E11 (CNA) flicking R8's nipples during care, which resulted in causing R8 to be apprehensive and fearful during care. Although R8 was cognitively impaired, E11's actions would result in psychosocial harm for any reasonable individual. These findings were reviewed with E2 (DON), E3 (RNAC), E7 (SW), E15 (RN Supervisor), E5 (Corporate Clinical Consultant) and E4 (Clinical Analysis - CIS) on 4/8/19 during the exit conference beginning at 10:35 AM.

Based on record review, interview and review of other facility documentation as indicated, the facility failed to ensure that advanced directives were accurate and congruent in all facility documents for six (R16, R100, R4, R104, R12 and R39) out of the 37 residents residing in the facility on [DATE]. R16, R100, R4, R104 and R39 had current physician's orders for full code in the electronic (computer) medical record (EMR), but the DNR Consent Form on the front of their respective paper chart and signed by the resident or their power of attorney, documented they were a DNR. In addition, all five residents had a red sticker on their chart that said DNR. R12 had a current physician's order for a DNR, but the DNR Consent Form on the front of the chart and signed by R12 and the physician documented the resident was a full code. The code status as recorded in two different documents did not match. This discrepancy put these six (R16, R100, R4, R104, R12 and R39) residents at immediate jeopardy (IJ) of not having a confirmed, accurate code status in the event of a medical emergency. Three (3 of 3 facility nursing staff assigned to direct resident care at the time the IJ was identified, stated they would look in the computer (EMR) to find out if they needed to start CPR (cardiopulmonary resuscitation) if a resident coded. Discrepancies between physician's orders and DNR Consent Forms placed these residents in an immediate jeopardy situation. The IJ was identified on [DATE] at 1:10 PM and was abated on [DATE] at 4:40 PM. Findings include: The facility policy entitled CPR/AED Code Procedure (last revised [DATE]) stated the policy is to provide CPR to all facility residents without a DNR order. The facility policy entitled Advanced Directives (last revised [DATE]) stated that the Director of Nursing Services or designee would notify the Attending Physician of advanced directives so that appropriate orders can be documented in the resident's medical record and plan of care. The facility policy entitled Advanced Care Planning: Advanced Directives and POLST (Physician's Orders for Life Sustaining Treatment) (last revised [DATE]) provided by the facility stated that the Physician/Nurse Practitioner are responsible for the final clarification of treatment preferences and documentation of the appropriate orders on the POLST form. The POLST is not a legal document in the state of Delaware, therefore it cannot be used for physician orders. In addition, no POLST forms were found on the facility charts. 1. Review of R16's clinical record revealed: [DATE] 1:18 PM - During the initial pool record review, a DNR Consent Form was in the front of the chart, signed by R16's POA and a facility nurse on [DATE], and signed by the physician on [DATE]. The signed DNR Consent Form stated R16 is a DNR. A red sticker stating DNR was on R16's chart. However, R16's current physician's orders documented R16 is a full code. [DATE] 3:55 PM - During an interview, both E8 (RN, Educator) and E24 (RN, Charge Nurse) confirmed the physician's order stated R16 was full code, when in fact the resident should be a DNR. E8 then corrected this order and confirmed that facility policy is unless the physician orders state otherwise a resident is a full code. 2. Review of R39's clinical record revealed: [DATE] 10:02 AM - During the initial pool record review, a DNR Consent Form was in the front of the chart, signed by R39 and a facility nurse on [DATE], and signed by the physician on [DATE]. The signed DNR Consent Form stated R39 is a DNR. A red sticker stating DNR was on R39's chart. However, R39's current physician's orders documented R39 as a full code. [DATE] 8:40 AM - Interview with E25 (Social Worker) revealed that the E25 is no longer responsible for entering resident's code status into the computer, and does not know who now has this responsibility. E25 stated that the EMR chart is the most current and reflective of resident's wishes. [DATE] 11:22 AM - During an interview, E9 (Charge RN) stated advance directives should be in both the EMR and the paper chart. E9 thought they were waiting for the physician to sign R39's DNR. When informed that the DNR Consent Form has been signed by the physician, E9 stated there are checklists that are done when a resident is admitted to verify orders are correct, and the night shift is supposed to do chart checks. E9 confirmed that R39 is a DNR and that this one must have been missed. 3. Review of R100's clinical record revealed: [DATE] 11:25 AM - During a record review, the DNR Consent Form was in the front of chart, signed by R100's POA on [DATE] and signed by the physician on [DATE]. The signed DNR form stated R100 is a DNR. A red sticker stating DNR was on the chart. However, R100's physician order documented that the resident is a full code. [DATE] 3:10 PM - Interview with E2 (DON) confirmed the physician's order erroneously stated R100 was a full code, when in fact the resident was a DNR. E2 stated that this order has been corrected. 4. Review of R4's clinical record revealed: [DATE] 11:28 AM - During a record review, the DNR Consent Form was in the front of chart, signed by R4's POA and a facility nurse on [DATE]. The signed DNR form stated that R4 is a DNR. A red sticker stating DNR was on the chart. However, R4's physician order documented that the resident is a full code. [DATE] 3:10 PM - Interview with E2 (DON) confirmed the physician's order erroneously stated R4 was a full code, when in fact the resident was a DNR. E2 stated that this order has been corrected. 5. Review of R104's clinical record revealed: [DATE] 11:29 AM - During a record review, the DNR Consent Form was in the front of the chart, signed by R104's POA and a facility nurse on [DATE] and signed by the physician on [DATE]. The signed DNR form stated that R104 is a DNR. A red sticker stating DNR was on the chart. However, R104's physician order documented that the resident is a full code. [DATE] 3:10 PM - Interview with E2 (DON) confirmed the physician's order erroneously stated R104 was a full code, when in fact the resident was a DNR. E2 stated that this order has been corrected. 6. Review of R12's clinical record revealed: [DATE] 11:30 AM - During a record review, the DNR Consent Form was in the front of the chart, signed by R12 and a facility nurse on [DATE] and signed by the physician on [DATE]. The signed DNR form stated that R12 is a full code. However, R12's EMR header documented that the resident is a DNR. [DATE] 3:10 PM - Interview with E2 (DON) confirmed that R12's EMR header documented the resident as a DNR, when in fact R12 was a full code. E2 stated that this order has been corrected. [DATE] 11:20 AM - 11:36 AM: Interviews with 3 of 3 facility nurses (E9, E11 and E12) assigned to direct resident care at the time the IJ was identified, stated they would look in the computer (EMR) to find out if they needed to start CPR (cardiopulmonary resuscitation) if a resident coded. [DATE] 12:20 PM - During an interview, E9 (RN, Charge Nurse) was asked to demonstrate how to enter Advance Directives in the EMR so that DNR appeared next to the resident's name. E9 entered the code status for R39 under the Advance Directive section of the EMR, but the DNR did not appear on the screen. Around 12:30 PM E4 (Clinical Analyst) joined in the demonstration and stated that the only way for the DNR indication to appear was to enter the code status as an order. E9 stated that s/he had been doing it wrong. [DATE] 12:45 PM - During an interview with E1 (NHA), E2 (DON), E8 (RN, Educator), E4 (Clinical Analyst), and E5 (Regional Nurse Consultant), E5 confirmed that the facility policy is that all residents are a full code unless there is an order in the EMR stating otherwise (e.g., a physician's order for DNR). The survey team explained and identified the six current residents that had conflicting advance directives (code status) and physician's orders in the medical record. Physician orders did not match resident and/or POA signed DNR Consent Forms. The survey team requested the facility to: 1. Immediately conduct an audit of every current residents' chart to verify that code status orders are correct and provide the survey team with a copy of the results. 2. Confirm and correct any discrepancies found. 3. Established the practice of where nursing staff finds code status and enters orders into the EMR. 4. Review current policies and revise as needed to reflect this practice and to prevent reoccurrence. 5. Provide a plan of correction, including staff education. [DATE] 1:10 PM - E2 (DON), E8 (RN, Educator), E4 (Clinical Analyst), and E5 (Regional Nurse Consultant) were notified by the survey team that an IJ was identified when six current residents reviewed were found to have inconsistent advance directives related to their code status in the medical records. [DATE] 3:10 PM - E2 (DON) provided the survey team with a copy of the audit results, confirmed that the errors identified by the survey team were corrected and that no additional discrepancies were found. [DATE] 4:05 PM - During an interview with E1 (NHA), E2 (DON), E8 (RN, Educator), E4 (Clinical Analyst), and E5 (Regional Nurse Consultant), the survey team was provided with a written plan of correction that was being implemented, a revised policy, a plan for nursing staff education and a plan for future auditing. [DATE] 4:35 PM - E8 provided the survey team with a copy of the content of the nursing staff education. [DATE] 4:40 PM - The IJ was abated. The facility failed to ensure that: -Advanced directives/code status for all residents were accurate and congruent in all facility documents. -Facility nurses would be able to locate an accurate and current physician order rgarding DNR status when it was needed in an emergent situation. This finding was reviewed during the exit conference on [DATE] beginning at 1:00 PM with E1 (NHA), E2 (DON) and E8 (Staff Educator) in person, and E4 (Clinical Analyst), E5 (Regional Nurse Consultant) and E23 (Corporate Administrator) by telephone.

Cross Refer F656, Example 1 Based on record review, observation and interview it was determined that the facility failed to provide the care and services to prevent the development of pressure injury/ulcer for one (R36) out of 35 sampled residents. The facility did not complete a Braden Scale on R36's 9/19/18 admission to assess the risk for development of pressure ulcers and did not follow physician orders [REDACTED]. These failures resulted in harm when R36 developed two pressure ulcers (Unstageable to right heel and DTI to left heel). Findings include: The facility policy entitled General Guidelines Wound and Skin Care (last revised 5/4/18) included: - All residents will be assessed by the nurse for risk of skin breakdown using the Braden Scale on admission, readmission, upon major change in condition and quarterly thereafter; - The interdisciplinary plan of care will address problems, goals and interventions directed toward the prevention and/or treatment of [REDACTED]. The facility policy entitled Wound and Skin Care, At Risk Residents (last revised 11/23/12) included the definition of the high risk resident as those scoring 16 or less on the Braden Risk Assessment; Impaired/decreased mobility.Cognitive impairment.Residents at risk will have.skin prep (to heels) every shift. Heels are extremely vulnerable and must be elevated completely off of bed surface. Utilize pillows, foot splints or heel risers. (The facility policy differs from the Braden Scale definition which lists high risk as a score of 12 or less.) Review of R36's clinical record revealed: 9/13/18 - Admission from Assisted Living (AL) with weakness and fever. 9/14/18 - The Braden Scale score of 15 determined that R36 was at risk for pressure ulcer development. 9/17/18 - Discharge back to AL. 9/19/18 - Admission after a fall. 9/19/18 (8:53 PM) - An admission note documented R36 was received at 4:00 PM with swelling to the feet, and was alert and confused. The New Wound Alert form completed on admission reflected scattered bruising to the arms and legs, and redness to the perineal/groin region. There were no other areas identified with redness or pressure injury. There was no evidence the facility completed an admission assessment on 9/19/18. Instead the previous admission assessment from 9/13/18 was in the electronic record. There was no evidence that R36 was assessed or had a Braden Scale completed upon admission to the facility on [DATE]. 9/19/18 - The baseline care plan included interventions to elevate the heels when in bed, weekly skin assessments and skin prep to heels twice a day. It was unclear when skin concern entries were added as individual entries were undated. 9/19/18 - The admission MDS assessment documented R36 had moderate cognitive impairment, required extensive assistance (resident involved in activity, staff provide weight-bearing support) of one staff for bed mobility, was at risk for developing pressure ulcers and had no pressure ulcers. 9/20/18 - A physician's orders [REDACTED]. 9/21/18 - Physicians' orders included skin prep twice a day. However, there was no application site listed. 9/24/18 - The CT scan revealed R36 had a broken pelvis. The physician ordered PRN pain medication. 9/26/18 - A Braden Scale revealed R36 remained at risk for developing pressure ulcers. 9/27/18 - A skin integrity note documented R36 had no pressure ulcers. 10/6/18 (12:28 PM) - A skin integrity note stated dark colored blister noted to right heel measuring 3 cm x 5 cm with clear drainage. R36 was not noted to have pain or discomfort. 10/6/18 - A physician's orders [REDACTED]. 10/9/18 - Wound assessment by a NP consultant described the heels: - Left: 4 cm x 4 cm purple discoloration, skin intact, DTI (deep tissue injury). - Right: 4 cm x 4.5 cm purple, yellow, red discoloration, open with moderate drainage,unstageable. 10/9/18 - Physician orders [REDACTED]. 10/10/18 - A care plan for new areas to bilateral heels, included the following interventions: Skin prep to left heel. Once right heel resolved then skin prep both heels. Encourage/assist with repositioning as needed. Float heels (elevate) when in bed. Weekly wound rounds with measurements, description and documentation of findings. Assess effectiveness of treatment every 2 weeks. Check skin with each care contact and report redness immediately. 10/1/18 - 10/16/18 - Review of CNA documentation for preventative measures revealed 19 out of 48 shifts without documented evidence of offloading heels (None was documented indicating no preventative measures were completed during the shift, or the entry was blank) both before and after the development of the two pressure ulcers as follows: - Before the development of the pressure ulcer on 10/6/18: Night shifts: (MONTH) 1, 2, 3, 4 Evening shifts: 0 Day shifts: (MONTH) 4. - After the development of the pressure ulcer on 10/6/18: Night shifts: (MONTH) 6, 7, 9, 10, 13, and 14 Evening shifts: (MONTH) 6, 8, 11, 12 and 15 Day shifts: (MONTH) 13, 14 and 16. 10/17/18 (2:35 PM) - During observation of wound care by E12 (LPN) the right heel had a superficial circular open area with black tissue along the bottom of the heel in a semi-circular pattern. The left heel looked like a blister had reabsorbed and the skin was intact. R36, with eyes closed, had no facial expression of pain during the wound care observation. A black wedge cushion was positioned under R36's ankles to elevate the heels off the bed. E12 stated that the facility had a bunch of the wedge pillows. During a follow-up interview at 4:25 PM, E12 confirmed R36 had been using the wedge cushion for about a week (making it approximately since 10/10/18). 10/17/18 (4:33 PM) - Interview with E14 (CNA) revealed that when the resident was admitted , he/she had nothing wrong with his/her feet. When asked how R36's feet were offloaded, the CNA stated with pillows. When asked how compliant was R36 with placement of the pillows for offloading, E14 said he/she would leave them (not kick them out). 10/17/18 (4:35 PM) - Interview with E13 (CNA) determined that R36 got them here when referring to the heel pressure ulcers. 10/18/18 (8:15 AM) - R36 was observed in bed lying on his/her back with a foot cradle in place to raise the bed linens off the feet. R36 had a single bed pillow under the calves and knees with the heels directly on the mattress. 10/18/18 (around 3:50 PM) - During an interview with E4 (Clinical Analyst) it was confirmed there was no admission assessment with the Braden Scale completed on 9/19/18. 10/19/18 (around 7:15 AM) - R36 was observed in bed, slightly turned to the left, with a bed pillow beneath the legs but both heels were in contact with the mattress. 10/19/18 (around 7:30 AM) - Interview with E12 (LPN) confirmed that R36's heels had been touching the mattress during the 7:15 AM observation. The LPN stated she saw the surveyor leave the room earlier and readjusted the pillow to elevate the heels off the mattress. The facility failed to: - assess R36's Braden Scale on 9/19/18 as required on admission. - offload heels, as per physician order [REDACTED]. - provide care, consistent with professional standards of practice, to prevent the development of pressure ulcers. These failures resulted in harm when R36 developed two pressure ulcers (unstageable on right heel and DTI on left heel). 10/22/18 (around 4:40 PM) - Findings were reviewed with E2 (DON). Findings were reviewed during the exit conference on 10/24/18 beginning at 1:00 PM with E1 (NHA), E2 and E8 (Staff Educator) in person, and E4, E5 (Regional Nurse Consultant) and E23 (Corporate Administrator) by telephone.

Based on record review, interview and review of other facility documentation it was determined that the facility failed to ensure that one (R80) out of 20 sampled residents was free from significant medication errors. R80 received seven daily doses of [MEDICATION NAME] ([MEDICATION NAME]), an anticoagulant /blood thinner, in spite of two separate orders to hold (not give) the medication when the resident's blood clotting levels (PT/INR) were elevated. The resident experienced [MEDICAL CONDITION] and was hospitalized and treated for [REDACTED]. This citation is past non-compliance. Findings include: Facility policy entitled [MEDICATION NAME], last revised September, 2009: included that routine doses of [MEDICATION NAME] will be given daily at 6:00 PM unless otherwise specified by the medical care provider. - Every resident who is on [MEDICATION NAME] will have an order for [REDACTED].>- The resident may have a routine dosage of [MEDICATION NAME] ordered but must also have an order for [REDACTED].>- All residents receiving [MEDICATION NAME] will have an INR Tracking Form initiated. - All dose adjustments based on the PT/INR will be documented on this Form as will all PT/INR results and the date of the next scheduled PT/INR test. Undated facility instruction sheet entitled Admission Order Reconciliation Process (provided by the facility) included that orders are entered in (name of computer program) and provided specific instructions on entering the orders into the computer. Resumption of Care Order instruction sheet (also undated) documented the process for reactivating orders that have been placed on hold. Review of R80's clinical records and facility investigation packet revealed: [DATE] - R80 was admitted to the facility for rehabilitation after hospitalization with multiple [DIAGNOSES REDACTED]. [DATE] - Hospital records provided a history of R80's INR test results from several days prior to admission to the facility: - [DATE]: 1.41 - [DATE]: 1.91 - [DATE]: 3.08 - [DATE]: 2.88 (Hemoglobin 11.5 gm/dl; Hematocrit 37.1 %) Targeted range for someone taking [MEDICATION NAME] for afib 2 - 3. For females, normal hemoglobin range ,[DATE] mg/dl and normal hematocrit range ,[DATE]% [DATE] - Medication Instructions and Next Dose to be Taken (hospital form): R80 scheduled to receive [MEDICATION NAME] the evening of [DATE]. - Active Medication List (from hospital): Physician handwritten order on bottom of form to give [MEDICATION NAME] and recheck INR Monday ([DATE]) and if that level was between ,[DATE] to keep the same dose of [MEDICATION NAME] and check INR weekly on Mondays. There was no notation on the order by the nurse acknowledging the order. - E4 (LPN) entered the [MEDICATION NAME] order (1:18 PM) in the computer without the physical monitor that provided an area for the nurse to document the INR prior to administration. The [MEDICATION NAME] order was missing the stop date of ,[DATE], when the next blood test was to be performed. - E4 completed the INR Tracking Form with latest INR result, continuation of the current [MEDICATION NAME] dose and next blood test on [DATE]. - E9 (RN) initiated Care plan problems: Risk for falls; Self care deficit; Pain (abdominal); and Risk for complications from [MEDICAL CONDITION]. [DATE] - INR 4.4 - 1:46 PM: E4 faxed test result to E10 (Physician) with no response by end of shift so informed E12 (evening RN). - 6:31 PM: E12 emailed lab test to E10. - 6:33 PM: E10 ordered to hold [MEDICATION NAME] for three days and repeat blood test on [DATE]. - 8:39 PM: E12 entered the INR test in the computer for [DATE]. - 8:43 PM: Nursing Note by E12 documented the order to hold [MEDICATION NAME] for 3 days and date to recheck PT/INR. - INR Tracking Form completed to hold [MEDICATION NAME] until the next blood test. - Review of physician orders [REDACTED]. - R80 was not added to the Alert Charting list to monitor for bleeding. [DATE] - E15 (NP) evaluated R80 for low blood pressure (BP), dizziness and headache. Resident stated would get a headache when blood pressure (BP) was low and had dizziness. Systolic BP usually runs ,[DATE], currently ,[DATE]s. Plan to decrease BP medication dose with parameter to hold if systolic BP under 100. Dizziness and low blood pressure can be signs of blood loss. August, 2017 eMAR - R80's [MEDICATION NAME] was not held for three days as ordered: - [DATE] (8:54 PM) administered by E13 (RN). - [DATE] ((7:13 PM) administered by E11 (LPN). - [DATE] (8:17 PM) administered by E11. [DATE] - Lab result H & H: 10.1 / 30.9 lower than [DATE] testing in the hospital indicating reduced blood count. [DATE] - Cardiac consultation (doctor saw resident in the hospital) documented R80's dizziness and to discontinue a blood pressure medicine, reduce the fluid pill dose and return in ,[DATE] weeks. These medication changes were ordered and transcribed into the computer. [DATE] - Admission MDS Assessment documented R80 received [MEDICATION NAME] seven days in the previous week. [DATE] - Blood Test INR 6.0 (critical high result). Notation on the lab report that lab called facility at 11:10 AM and reported to E4 who read back the result to assure accuracy. - Physician handwritten order on lab report to hold [MEDICATION NAME] and recheck INR on Monday ([DATE]). A notation handwritten next to the physician order [REDACTED]. - 12:29 PM Clinical Nursing Note: E4 wrote PT/INR 6.0 [MEDICATION NAME] on hold per (E10's name) to recheck on Tuesday [DATE] verbal order from (E10's name). - Review of physician orders [REDACTED]. - The INR Tracking Form was not completed to reflect the high INR nor the order to hold [MEDICATION NAME] until the [DATE] lab test. - E4 placed R80 on Alert Charting form to monitor for bleeding. August - September, 2017 eMAR - R80's [MEDICATION NAME] was not held per physician order: - [DATE] (8:35 PM) administered by E11. - [DATE] (7:09 PM) administered by E11. - [DATE] (8:57 PM) administered by E17 (LPN). - [DATE] (9:20 PM) administered by E17. [DATE] Clinical Nursing Note (7:45 PM): E14 (RN) documented the resident reported to daughter that she had black tarry stool but had not reported to her nurse earlier. R80 had been taking [MEDICATION NAME] and [MEDICATION NAME] daily. E15 notified and ordered PT/INR and H & H to be done immediately. When results (INR 4.94 and H & H 6.0 / 18.5 lower than all previous test results) reported, E15 ordered to send R80 by 911 to the local Emergency Department. Daughter and grandson at bedside and followed ambulance. Report called to (name of nurse). [DATE] Medication Errors (facility form) - E14 reviewed chart and discovered, around 4:00 PM, the note written on [DATE] for [MEDICATION NAME] to be held until PT/INR completed on [DATE] but the order was not transcribed into the computer. [DATE] - Transfer sheet to hospital documented R80 received [MEDICATION NAME] daily and had black tarry stools. [MEDICATION NAME] and [MEDICATION NAME] discontinued [DATE]. Hemoglobin 6.0 needs transfusion. INR 4.94. [DATE] (11:23 PM) - E16 (RN) Review of hospital records discovered that ) reported to the State Agency that [MEDICATION NAME] given in error, resident sent to emergency department for evaluation. Condition stable at time of transfer. Review of facility investigation packet discovered statements written by E11, E13 and E17 claimed they were not provided the information to hold the [MEDICATION NAME] during shift change report or prompted by the INR physical monitor on the eMAR to review the INR Tracking Form. [DATE] - E2 (DON) submitted 5-day follow-up to the State Agency that resident returning from the hospital today. Stable. Labs within normal limits. Will resume Med A stay with goal of discharging home. Review of hospital records revealed that on admission to the hospital on [DATE], R80's INR was elevated at 5.2 and hemoglobin was low at 5.5. R80 received 5 separate bags of blood products along with a medication to reverse the effect of the [MEDICATION NAME]. R80 was discharged on [DATE]. During an interview with E2 on [DATE] at 2:45 PM to review the circumstances of R80 receiving seven doses of [MEDICATION NAME] even though there were two separate orders to hold the medication. E2 said we had a process but it was not followed. The physical monitor for INR should be added to every [MEDICATION NAME] order (so box to write INR appears on the eMAR entry for [MEDICATION NAME]) and holding doses / dose change should be transcribed immediately into the computer, then the Clinical Nursing note describing the orders should be written. E2 explained what was happening was the note was written first and the order never was transcribed to the computer. Lack of staff knowledge was identified as a root cause and mandatory education was conducted. Nurses received education starting with the basics of what is an INR and how [MEDICATION NAME] doses are adjusted based on the test result. Both aides and nurses also received training on signs and symptoms of bleeding. During an interview with E14 (RN, Staff Education) on [DATE] at 3:00 PM in the presence of E2, E14 gave the surveyor the list of staff who completed the mandatory training. E14 described the verbal order process which included writing down the order, reading it back to the provider, entering into the computer along with type of order (i.e., telephone/verbal order) and that it was verified (read back to provider) are to be entered in the computer prior to a nursing note describing the order. Upon further questioning, it was determined that the telephone/verbal order could be written on any type of scratch paper. Audit tools were developed and were modified along the way. Auditing began immediately including Anticoagulant Therapy (the presence of bleeding risk care plans for residents receiving blood thinners); PT/INR results with subsequent medication/lab orders and accuracy of their transcription into the computer. E14 provided blank audit tools for [MEDICATION NAME] Protocol implementation, care plan inclusion, Lab Disposition log with staff instructions along with raw data from the audits which began [DATE] and continue to this day. Facility review of the [DATE] audit discovered the following lacked a care plan for bleeding potential and remedied the situation by adding the designated care plan: - 5 residents receiving a blood thinner. - 2 residents receiving a regular strength aspirin. - 9 residents receiving low dose aspirin. During an interview with E14 on [DATE] at 4:05 PM, after review of the raw data revealing several [MEDICATION NAME] orders were entered without the INR physical monitor on the eMAR on [DATE]. When asked what action was taken E14 said s/he would talk to the nurse and personally fix the issue in the computer since having the INR monitor on the eMAR was important. The surveyor asked about the follow up to SS1's INR on [DATE] and E14 stated the lab test was completed and the dose of [MEDICATION NAME] remained the same with the INR to be checked again on [DATE] and that all orders were transcribed correctly. Review of two additional resident's receiving [MEDICATION NAME] discovered no problems or issues with order entry, INR Tracking Form or laboratory testing: - [DATE] : SS1 - [DATE]: SS2 Interview with the following nurses on policy and procedures for [MEDICATION NAME] revealed understanding of admission order, INR Tracking Form, lab testing, computer entry, identification of the physical monitor in the eMAR, use of the [MEDICATION NAME] book, and communication at shift change: - [DATE] (4:20 PM): E19 (evening LPN) - [DATE] (10:28 AM): E4 (day LPN) - [DATE] (11:42 AM): E20 (day LPN) - [DATE] (3:10 PM): E18 (evening LPN) R80 received 7 doses of [MEDICATION NAME] in spite of two separate orders to hold the medication. This resulted in the resident experiencing rectal bleeding, a Hemoglobin of 6.0 and was sent to the hospital for transfusion. The facility had many failures that contributed to this significant medication error: - Physical INR monitor not included when [MEDICATION NAME] order initially transcribed. - Two separate orders to hold [MEDICATION NAME] were not transcribed into the computer. - INR Tracking Form not consistently filled out. - INR Tracking Form not reviewed prior to [MEDICATION NAME] administration. - Alert charting not implemented when [MEDICATION NAME] held [DATE]. Training was conducted during a mandatory nursing boot camp the week of [DATE]. The facility self-identified the significant medication error and implemented corrective measures. This deficiency is past non-compliance corrected as of [DATE]. Findings were reviewed with E1 (NHA) and E2 on [DATE] at approximately 2:50 PM.

Based on record review, interview and review of other facility documentation it was determined that the facility failed to provide the necessary care and services for two (R1 and R2) out of 3 sampled residents. For R1 there was no evidence of ongoing assessment when the resident's condition was declining in the presence of fluctuating blood sugars. This was followed by discontinuation of oral medication for blood sugars followed by periods of rising blood sugar levels. There was lack of evidence of timely response and physician intervention for R1 who experienced a decline in condition. For R2, there was no reassessment during the night shift following an episode of bloody urine. R2 was admitted to the hospital on [DATE] with acute [MEDICAL CONDITION] with [MEDICAL CONDITION]. Findings include: Facility policy and procedure entitled Guidelines for Alert Charting and 24 hour Report (undated) included the following: * Procedure: -- Any nurse can initiate a resident to Alert Charting and begin documentation on the 24 hour report. -- Once resident has been placed on alert charting, nursing will continue to document until event has resolved. All follow up should be documented on the 24 hour report sheet. -- Each shift will document on chart and will intial the alert charting form. -- Once event no longer needs to be charted on, the event will be yellowed out as being discontinued on the form. * Guidelines for alert charting and 24 hour report included abnormal lab results, change in condition (i.e., vomiting, diarrhea, shortness of breath) * The charge nurse, DON/ADON will review all residents on the report and assess each resident to ensure that all appropriate measures have been taken. * Items on the 24 hour report will be communicated to the oncoming shift during change of shift report. 1. Review of R1's paper and electronic clinical records revealed: 5/18/16 - admitted for rehabilitation with multiple [DIAGNOSES REDACTED]. 5/18/16 Physicians' orders included an oral pill once a day for diabetes and a fingerstick to check blood glucose (sugar) daily in the morning (before breakfast). Standing orders included: - protocol for [DIAGNOSES REDACTED] if fingerstick glucose reading under 70. - treat chest pain, shortness of breath, cyanosis with oxygen by nasal cannula and notify physician. The American Diabetes Association (revised 6/17/15) suggested the following targets for most non-pregnant adults with diabetes. More or less stringent (strict) glucose goals may be appropriate for each individual: - Before meals: 80-131. - 1 to 2 hours after beginning of the meal: under 180. Reference: http://www.diabetes.org/living-with-diabetes/treatment-and-care/blood-glucose-control/checking-your-blood-glucose.html 5/20/16 - 5/30/16 - Review of fingersticks in the test section of the electronic record found daily glucose readings ranged from 85 - 212. 5/25/16 - Admission MDS documented the resident was cognitively intact with no hallucinations or behaviors. 5/29/16 (8:27 AM) Nursing Note - Called to room by CNA for R1 complaining of feeling hot. Head felt hot to the touch but rest of skin cool and clammy. No fever. Fingerstick was 52. Orange juice given along with a fig bar. On recheck fingerstick now 60 and resident stated felt fine now. Resident did finish 8 oz of juice. Day nurse will recheck and monitor. Glucose reading documented at 10:57 AM by the day nurse was 88. 5/30/16 physician progress notes [REDACTED]. some trouble breathing that comes and goes, use incentive spirometer every hour while awake .low blood sugar, discontinue (name of oral diabetic medication) (85, 88, 96, 161) and check fingerstick twice a day (before breakfast and dinner). 5/30/16 Physicians Orders included entry to discontinue the oral diabetes medication due to low blood sugar of 44. (It is unclear where the 44 came from since nursing notes recorded a glucose of 52 on 5/29/16 at 8:27 AM.) It is also unclear why the diabetes medicaton was discontinued after only one episode of low blood sugar as documented by pre-breakfast finger sticks. Review of June 2016 fingersticks discovered a rising trend several days after the diabetes medication was stopped on 6/1/16. (AM fingerstick taken before breakfast and PM fingerstick taken before dinner.) - 6/3/16: AM 245, PM 354 - 6/4/16: AM 232, After dinner 405, 8:12 PM 488 - 6/5/16: AM 266, PM 368, 9:15 PM 448 - 6/6/16: AM 432, PM 593 - 6/7/16: AM 350 6/3/16 - Review of June, 2016 faxes sent to the E9 and nursing notes found no evidence that E9 or E11 (NP) were informed of rising glucose levels on June 3. 6/4/16 (8:46 PM) nursing note - Last 5 results (taken twice daily) had been running high. Tonight 405 after dinner and at 8:12 PM was 488. Physician paged (E9). 6/4/16 (9:40 PM) nursing note - E9 gave a one-time order for 4 units of regular insulin which was given. (There was no evidence in the record of fingerstick re-assessment after the insulin administration to determine effectiveness or the need for additional treatment.) 6/5/16 (9:54 PM) nursing note - Pulse oximetry (ox) showing oxygen saturation of blood was 81-82 percent, checked again within 1 minute then placed on 2 liters of oxygen by nasal cannula. Resident did not appear to be in any distress although R1 admitted to feeling a bit short of breath. Pulse ox 95 percent on oxygen. (There was no evidence in the nursing notes or physician faxes that the standing order to notify the physician after the application of oxygen was followed.) According to the Mayo Clinic normal pulse oximetry readings usually range from 95 to 100 percent. Values under 90 percent are considered low. http://www.mayoclinic.org/symptoms/hypoxemia/basics/definition/SYM- 930 6/5/16 (11:45 PM) nursing note - Glucose rechecked at 9:15 PM and was 448. E9 notified and ordered to restart the oral diabetes medication the next morning. (No order to address the current high glucose level of 448.) 6/6/16 NP Progress Note by E11 (NP) - Seen for shortness of breath with low pulse ox and placed on oxygen. Chest x-ray and blood count to be done immediately. For transfusion Wednesday (6/8/16) for chronic blood disorder causing [MEDICAL CONDITION]. Fluid pill ordered as a one-time dose for shortness of breath and [MEDICAL CONDITION] from volume overload. 6/6/16 (11:01 AM) late nursing note written 6/7/16 (11:06 AM) - Pre-breakfast fingerstick 432, resident pale and weak. E11 in to see resident and ordered a one time dose of a fluid pill, a complete blood count test, chest x-ray and vital signs every shift. (No order to address the current high glucose level of 432.) 6/6/16 (fax dated 4:12 PM) - Chest x-ray showed [MEDICAL CONDITION] venous congestion ([MEDICAL CONDITION]) and the possibility of infiltrate (pneumonia) in the left lower lung field. 6/6/16 (untimed) late nursing note written 6/7/16 at 2:53 PM - E9 notified of glucose of 577. (Glucose result in the test section of the electronic record was 593.) E9 informed of orders written by E11 (one-time fluid pill, blood test, chest x-ray, vital signs). (No order to address the current high glucose level of 577 - 593.) 6/7/16 (11:01 AM) nursing note stated Received in bed this morning, trying to climb out of bed, hallucinating, pulse ox 82 percent on 2 liters of oxygen, pulse ox 90 percent when oxygen increased to 3 liters. Looks pale, very weak. Fingerstick (before breakfast) glucose read HI (larger number than glucose meter can determine, often 600). Spouse called and informed of change of condition. E9 called and ordered 6 units insulin now as well as fingerstick glucose before meals and bedtime with sliding scale insulin. Fluid pill ordered daily. All morning meds given. Repeated glucose (before lunch) still HI, re-notified E9 by fax. 6/7/16 (11:24 AM) fax transmittal to E9 - high glucose at 7:30 AM and resident received 6 units of insulin. At 11:30 AM glucose still high. Continues with hallucinations and has left lung sounds indicating fluid in the lung. Pulse ox 93 percent on 2.5 liters of oxygen. No fever. The electronic signature by E9 on the fax was timed at 2:03 PM. Fax sent to facility at 3:35 PM and included the notation was discussed with (first name of E4 (ADON)). 6/7/16 (11:43 AM) nursing note - Glucose continued with HIGH reading, hallucinations continue. R1 with pale color and weakness. Resident and spouse request to be seen at emergency department for evaluation and treatment. E9 notified. 6/7/16 (11:41 PM) nursing note - Resident admitted to hospital with altered mental status and bacterial pneumonia. During an interview with E8 (CN) on 6/16/15 at 9:30 AM E8 demonstrated how to locate times that notes were written and where to find fingersticks in the electronic record. When asked what glucose reading would prompt the nurse to contact the physician, E8 responded over 350 unless otherwise ordered by the doctor. When asked what happens if the doctor does not respond to the call or fax, E8 said if it is a Monday we call the NP. E8 added that staff call the office since the facility does not have E9's cell number. If the doctor does not respond, we keep calling. Depending on resident condition, we'll call 911. E8 added that he's the only doc (doctor) we have. E9 is the primary physician for all residents and is the Medical Director as well. During an interview with E3 (LPN) on 6/16/16 at 9:40 AM when asked about calling the physician for elevated glucose levels, E3 said when calling for high or low, it depends on the order. When asked what the response would be if the glucose is high and there is no insulin coverage ordered, E3 would call the physician immediately. During an interview with E2 (DON) on 6/16/16 at 9:55 AM when the surveyor asked for the policy about physician notification and/or chain of command, E2 confirmed the facility does not have a policy. E2 stated if the doctor does not call back, E2 might call the NP in his office. Surveyor requested policy and procedure for hypo / [MEDICAL CONDITION] as well as physician orders. During an interview with E2 on 6/16/16 at 10:37 AM the surveyor was given a copy of the facility standing orders which included bowel and [DIAGNOSES REDACTED] protocols along with several treatments. E2 stated the facility does not have anything (policy or protocol) for [MEDICAL CONDITION]. Policy of handling admission orders [REDACTED]had been a problem but not when orders are written directly in the computer. During an interview with E2 on 6/16/16 at 12:52 PM to determine how to find out if alert charting was activated on a resident, E2 stated it is not in the chart, but on the 24 hour report. The surveyor requested to see the 24 hour reports from the past 2 weeks. Review of the alert charting forms revealed R1 was not included between 6/3/16 and 6/6/16 during which time the resident's glucose was elevated, pulse ox was low and shortness of breath increased. Review of May and June 2016 physician orders [REDACTED]. However there was no evidence in the treatment section or nursing notes during this time frame that this treatment was ever implemented. Findings from interviews with E2 on 6/17/16 between 9:30 AM and 10:58 AM: - Incentive spirometer should be documented in the treatment section. E2 confirmed there was no proof that the incentive spirometer treatment was performed. - High glucoses on June 3 PM reading of 354; June 6 AM reading of 432 and PM reading of 593 without evidence that the NP or physician were informed. NP note acknowledged the 432 glucose which was not treated. - Low pulse ox reading on June 5 (two days before R1 was sent to the hospital) without evidence that the physician or NP was informed at the time of occurrence. E2 was not able to provide evidence that the low pulse ox on June 5 or the glucose of 593 on June 6 was ever relayed to the physician or NP at the time of occurrence. - E2 said she will try to locate fax verifications about MD notification for the above incidences. 6/22/16 - Review of hospital records showed: - R1 was seen in the emergency department 6/7/16 at 12:36 PM. Fingerstick at 12:37 PM was 511. Chest x-ray and chest CT scan revealed [MEDICAL CONDITIONS] ([MEDICAL CONDITION]), extensive lung abnormality suggesting significant pneumonia and partial collapse of both lungs. - Emergency department history and physical documented [DIAGNOSES REDACTED]. - Treatment included intravenous hydration for dehydration from high glucose, antibiotics for pneumonia, diuretic for [MEDICAL CONDITIONS] and continuous insulin infusion to bring glucose levels down within normal range. - On the morning of 6/8/16 comfort care measures were started including [MEDICATION NAME] infusion for shortness of breath and other medications for nausea, excess saliva and anxiety. The facility failed to follow the plan of care and: - Consistently respond to rising glucose fingersticks over four days and reassess glucose after a one-time dose of insulin was administered. R1 developed NKHS leading to acute [MEDICAL CONDITION] from dehydration due to elevated glucose levels. Acute [MEDICAL CONDITION] leads to fluid build up in the body and lungs ([MEDICAL CONDITION]). http://www.diabetes.org/living-with-diabetes/complications/hyperosmolar-hyperglycemic.html -Implement the order for incentive spirometer every 1 hour while awake for seven days after ordered by the physician. R1 had both lungs that were partially collapsed and developed pneumonia. - Follow the standing order to notify the physician after oxygen was initiated for shortness of breath. R1 developed [MEDICAL CONDITION], pneumonia and partial collapse of both lungs leading to acute [MEDICAL CONDITION]. - Initiate alert charting when the resident's condition changed to assure follow-up on R1's status leading to a delay in treatment. These findings were reviewed with E1 (ED) and E2 on 6/17/16 at 1:30 PM. 2. 2011 Guidelines on oral anticoagulation with [MEDICATION NAME] ([MEDICATION NAME]) - fourth edition by the Agency for Healthcare Research and Quality include the INR goal of 2.5 for persons with afib. http://www.guideline.gov/content.aspx?id= Review of R2's clinical record revealed: 5/26/16 - admitted for rehabilitation with numerous [DIAGNOSES REDACTED]. 6/1/16 (3:23 PM) care plan meeting note - R2, spouse and daughter in attendance. Needs supervision for transfers and toileting. R2 loses balance and is unable to self correct at this point . Continues on [MEDICATION NAME]. 6/5/16 (5:42 AM) nursing note - Had stomach ache early in the shift (night shift) and then stomach was upset. R2 stated had a bowel movement today. Antacid effective to settle stomach. A few hours later R2 had some dry heaves, basin and ginger ale given, no vomiting occurred. fell back asleep. Review of CNA documentation of bowel movements found the resident had a BM on May 27, 28, 31, June 1, 3 and 6. 6/6/16 NP Progress note - Complained of constipation and mid abdominal pain. Check abdominal x-ray. Review of INR tracking for routine [MEDICATION NAME] revealed the following INR results and medication adjustments: - 5/26/16: 1.36, dose remained 5 mg - 5/31/16: 1.59, dose increased to 6 mg - 6/2/16: 2.5, dose remained 6 mg - 6/6/16: 4.39, dose on hold recheck INR 6/9/16 6/7/16 (12:57 AM) nursing note - episode of bloody urine (hematuria) this evening (6/6/16 on evening 3:00 PM - 11:00 PM shift). INR results elevated and [MEDICATION NAME] placed on hold (until a blood test is done 6/9/16). Abdominal x-ray showed normal gas pattern, no abnormalities. R2 denied pain after thorough assessment. Bowel sounds in all 4 quadrants, belly soft with mild distention noted. Encouraged resident to void. Oxygen in place upon assessment and pulse ox 93 percent. Resident continued to deny pain remainder of shift. 6/7/16 at 1:07 AM - Family expressed concerns regarding resident's bloody urine at beginning of evening shift on 6/6/16 and felt R2 was not doing as well as he had been. Called physician who spoke with R2's son by telephone. Abdominal x-ray results (no abnormality) provided to family. R2 complained of being very tired. 6/7/16 (11:22 AM) fax transmittal to E9 - Family states resident hasn't urinated since yesterday. He had bloody urine yesterday. Abdominal x-ray came back negative. Bladder assessment by the nurse was normal (indicating the resident was not retaining urine in the bladder). Reply fax at 3:35 PM included notation to encourage oral fluids, complete blood tests if not done within the last week (electronically signed by E9 6/7/16 at 2:03 PM). 6/7/16 (2:17 PM) nursing note - R2's daughter and granddaughter informed nursing that the resident stated he had not urinated since 5:00 PM on 6/6/16 when it was bloody. Family was advised that abdominal x-ray was negative and R2 did not have a fever. Assessment found abdomen was not distended, denied pain in the area over kidneys or feeling of pressure in the bladder. Bowel sounds present and hypoactive. Fluids were encouraged and taken well. E9 (MD) had been advised by the charge nurse on this shift of the resident's condition. 6/7/16 (2:27 PM) nursing note - E9 made aware of bloody urine from previous shift. Family reported at 10:00 AM that the resident had not urinated since last night. Medication nurse assessed the resident's bladder, R2 denied pain or pressure upon palpation, denied flank pain, bowel sounds positive and bladder was non-palpable. E8 (CN) was called at 11:02 AM and faxed at 11:24 AM. MD was called again at 1:01 PM and 1:48 PM. MD responded (at 2:03 PM per fax) and gave no new orders, but notified the nurse he would be in tonight to see the resident. Resident and wife informed. 6/7/16 (3:20 PM) nursing note - Orders had been given by E9 for STAT blood tests and straight catheterization. If more than 350 mL in the bladder to leave catheter in place. Wife was notified of the orders and informed the nurse that the son spoke with the physician who performed the abdominal aortic aneurysm repair 5/20/16 and that doctor wanted R2 taken to the emergency department right now. The resident, who was his own responsible party, was asked if he would like to be seen at the emergency department and responded yes. R2's son was informed the facility would get the paperwork ready. While printing the papers the nurse saw the family wheeling R2 to the elevator in a wheelchair. The family was asked to wait for the paperwork that the hospital would need but the son stated I'm not waiting, I'm getting my father out of here, he is having trouble breathing. The nurse noted no oxygen tank was hooked up to R2's oxygen tubing and asked the family to let us help. As the elevator door was closing the son stated they were calling 911. E9 made aware. 6/7/16 (11:39 PM) nursing note - Resident was admitted to the local hospital with [MEDICAL CONDITIONS] and [MEDICAL CONDITION]. During an interview with E6 (RN) on 6/14/16 at 3:05 PM E6 stated we don't have a bladder scan. (Bladder scan is a piece of equipment that can determine the amount of urine in the bladder without the need to insert a catheter.) http://www.nursingtimes.net/nursing-practice/clinical-zones/continence/using-bladder-ultrasound-to-detect-urinary-retention-in-patients/ 53.article During an interview with E2 (DON) on 6/16/16 at 9:55 AM E2 confirmed the facility did not have a policy for notification of the physician or a process for when the physician does not respond in a timely manner. During an interview with E2 on 6/16/16 at 12:52 PM to determine how to find out if alert charting was activated on a resident, E2 stated it is not in the chart, but on the 24 hour report. The surveyor requested to see the 24 hour reports from the past 2 weeks. Review of the alert charting forms revealed R2 was not included on 6/6/16 after the resident had bloody urine. During an interview with E3 (LPN) on 6/16/16 at 1:20 PM the nurse showed the surveyor where/how urine color is documented on the Skilled Note Clinical Note screen in the computer. The urine color question was located in the middle of the screen while all other urine related questions were positioned on the left side of the screen. The question allowed for selection of the following urine colors: amber, orange, straw, tea and bloody. E3 stated that day shift documents on residents in even rooms and evening shift documents on residents in odd rooms. The overnight shift does not document but should write a note if something unusual happens. When discussing E9's response when the facility calls about resident concerns, E3 indicated that the physician often does not respond in a timely manner and often E9's response is to monitor the resident. During an interview with E9 on 6/16/16 at 2:36 PM when asked about the expectation for response when the facility calls, E9 stated 1.5 hours. The physician proceeded to say that if he doesn't respond after the first call, the facility should call a second time (to the office during the day). If a third call is needed the facility should go through the answering service to have him paged. E9 indicated the delay in response may be due to a dead cell phone battery or that the phone being locked in the car. According to the physician contacting by fax or phone had been working well. During an interview with E2 on 6/17/16 at 9:40 AM the surveyor discussed the inability to locate a nursing assessment after the evening shift when the bloody urine occurred. Later at 10:58 AM E2 brought a copy of documentation from hematuria episode by evening shift however did not address the lack of reassessment by night shift. There was no evidence in the record that the resident's urine/bladder status was assessed on night shift following the episode of hematuria. 6/17/16 review of hospital records discovered the resident arrived at the emergency department on 6/7/16 at 3:25 PM by private vehicle with acute [MEDICAL CONDITION] and [MEDICAL CONDITION]. [MEDICAL TREATMENT] started. INR 4.81. These findings were reviewed with E1 (ED) and E2 on 6/17/16 at 1:30 PM.