Every finding on record at Three Rivers Health & Rehab Center

Based on staff interview, clinical record review, and facility documentation review, the facility staff failed to provide pneumococcal immunization for 5 residents, Residents #4, #7, #12, #30, and #36, out of 5 residents reviewed for pneumococcal immunization. The findings included: The facility staff failed to provide pneumococcal immunization for Residents #4, #7, #12, #30, and #36. On 2/28/24 at approximately 10:30 AM, clinical record reviews were performed and revealed the following: A. Resident #4, who was admitted to the facility on [DATE], had no documentation with regard to pneumococcal immunization, to include the resident's current pneumococcal vaccination status, offer to provide immunization against pneumococcal infection, or documentation of resident refusal or medical contraindication. B. Resident #7, who was admitted to the facility on [DATE], had no documentation with regard to pneumococcal immunization, to include the resident's current pneumococcal vaccination status, offer to provide immunization against pneumococcal infection, or documentation of resident refusal or medical contraindication. C. Resident #12, who was admitted to the facility on [DATE], had no documentation with regard to pneumococcal immunization, to include the resident's current pneumococcal vaccination status, offer to provide immunization against pneumococcal infection, or documentation of resident refusal or medical contraindication. D. Resident #30, who was admitted to the facility on [DATE], had no documentation with regard to pneumococcal immunization, to include the resident's current pneumococcal vaccination status, offer to provide immunization against pneumococcal infection, or documentation of resident refusal or medical contraindication. E. Resident #36, who was admitted to the facility on [DATE], had no documentation with regard to pneumococcal immunization, to include the resident's current pneumococcal vaccination status, offer to provide immunization against pneumococcal infection, or documentation of resident refusal or medical contraindication On 2/28/24 at approximately 12:30 PM, a group interview was conducted with the Infection Preventionist (IP) and the Director of Nursing (DON). The IP accessed the clinical records for the residents sampled and verified the findings. Both the IP and DON confirmed there was no additional information and the IP stated, it appears to be an oversight. A facility policy was requested and received. On 2/28/24 at approximately 3:00 PM, a review of the facility policy entitled, Pneumococcal Vaccine was conducted. It stated under the subtitle Policy, Residents will be offered pneumococcal vaccines to aid in preventing pneumonia/pneumococcal infections and subtitle, Specific Procedures/Guidance, item 1 read, Prior to or upon admission, residents will be assessed for eligibility to receive the pneumococcal vaccine series, and when indicated, will be offered the vaccine series within thirty (30) days of admission to the facility . and item 2 read, Residents of the long-term care facility will be offered the pneumococcal vaccination upon initial admission . On 2/28/24 at approximately 7:15 PM, the Facility Administrator and Director of Nursing were made aware of the findings. No further information was provided.

Based on observation, staff interview, and facility document review, the facility staff failed to provide Registered Nurse coverage 8 consecutive hours per day for 16 days out of 180 days reviewed. The findings include: Facility staff failed to provide any Registered Nurse (RN) coverage in July 2023 on the 1st, 2nd, 15th, 16th, 29th, and 30th; August 2023 on the 12th and 13th; November 2023 on the 24th, 25th, and 26th; and December 2023 on the 9th, 10th, 23rd, 24th, and 25th. On 2/29/24 at approximately 10:00 AM, the facility's clinical staffing records from 7/1/23 through 12/31/23 were requested and received from the Staffing Coordinator. Review of the records revealed there was no RN coverage on the previously stated dates. On 2/29/24 at approximately 1:30 PM, a group interview was conducted with the Facility Administrator and the Regional [NAME] President of Operations who verified the findings and stated, We do the best we can, I know we have had some gaps in our RN coverage, it is getting better. No further information was provided.

Based on interview, clinical record review and facility documentation, the facility staff failed to ensure residents were free from significant medication errors for one Resident (#106) in a survey sample of 23 Residents. The findings included: For Resident # 106 the facility staff failed to accurately transcribe, and administer medications as ordered by the physician including cardiac medication, and anti-coagulant, inhalers, pain medication, and anti-convulsant medications. A review of the discharge summary from the acute care hospital revealed that Resident #106 was discharged on the evening of 2/16/24 with orders that included but were not limited to: Eliquis 5 mg [an anti-coagulant] tablet take one tablet by mouth two times daily. Keflex 500 mg [an antibiotic] capsule take one capsule by mouth two times daily for one dose. Breo-Elipta 100-25 mg no micrograms/ACT inhaler one puff daily. [for chronic obstructive pulmonary disease) Hydralazine 25 mg tablet take one tablet by mouth three times a day. [blood pressure med] Isosorbide dinitrate 10 mg tablet take one tablet three times daily. [blood pressure med] Lamictal 100 mg tablets take 100 mg by mouth two times daily [seizure medication] Lidocaine patches apply one patch daily. Remove and discard within 12 hours. [pain patch] Nitro stat 0.4 sublingual tablet one tablet under the tongue every five minutes if needed for chest pain. May repeat dose every five minutes for three doses. Entresto 24-26 take two tablets by mouth two times a day. [for congestive heart failure] Trazodone 50 mg tablets take 12.5-25 mg by mouth two times daily. [an antidepressant] On 2/27/23 a review of the MAR (Medication Administration Record) revealed that the following medications were administered inaccurately and / or omitted: Eliquis 5 mg - Dose for 9 PM on 2/16/24 was not given - A review of the stat box contents revealed it was available for use. Keflex 500 mg - Dose for 9 PM on 2/16/24 was not given - A review of the stat box contents revealed it was available for use. Breo-Elipta 100-25 mg Dose for 2/17/23 was not given. Hydralazine 25 mg Dose for 2/16/24 9 PM was not given.A review of the stat box contents revealed it was available for use. Isosorbide dinitrate 10 mg tablet - Doses were not given for 2/16/24 at 9 PM, 2/17/24 at 4 PM and 2/18/24 at 8 AM Lamictal 100 mg tablets take 100 mg by mouth two times daily - is incorrectly transcribed on the MAR as once a day. This medication has been given only once a day and the 9 PM dose on 2/16/24 was not given. Lidocaine patch for pain was not given on 2/17/24 and 2/18/24. Nitro Stat was not added to the MAR until 2/21/24. Trazodone 50 mg tablets take A review of the stat box contents revealed it was available for use. On 2/25/24 at approximately 1:00 PM an interview was conducted with Resident #106 who stated that when she arrived at the facility, she was disappointed to find that she had to wait for some of her medications as they did not have all of them at the facility. When asked if this caused her any stress or unnecessary pain, she stated that it did not. When asked if she felt it harmed her health in any way, she stated that she didn't think it did. On 2/28/24 at approximately 3:45 PM an interview was conducted with the Nurse Practitioner who stated that she expected to be notified of medications that were not available or not given, so that she may have the opportunity to substitute a medication or give additional orders for that resident. On 2/29/24 at 9:30 AM an interview was conducted with Registered Nurse (RN)-C who stated, When a medication is not available from pharmacy or is newly ordered we are supposed to first check the stat box, then call pharmacy and then we call the physician to see if it is ok to hold until its available or if they want to substitute another medication until its available. A review of the facility policy read: Policy # 6.10 -Unavailable Medications Paragraph 3 The nursing staff shall: 1. Notify the attending physician (or on -call physician) of the situation and explain the circumstances, expected availability, and the alternative therapy(ies) available. If the facility nurse is unable to obtain a response form the attending physician or on call physician, the nurse should notify the nursing supervisor and contact the Facility Medical Director for orders and or direction. 2. Obtain new order and cancel/discontinue the order for the non-available med. 3. Notify the pharmacy of the replacement order. On 2/29/24 during the end of day meeting the Administrator was made aware of the findings and no new information as provided.

Based on interview, clinical record review, and facility documentation the facility staff failed to notify physician of pharmacy alerts for ordered medications for one Resident (#106) in a survey sample of 23 Residents. The findings included: On 2/26/24 a review of the clinical record revealed that Resident #106 had pharmacy alerts after the following medications were ordered: -Breo Ellipta Inhalation Aerosol-Powder Breath Activated 100-25MCG/ACT (Fluticasone Furoate-Vilanterol) -Pharmacy Alert - Steroid Allergy -Fluticasone Propionate Nasal Suspension 50 MCG/ACT - Pharmacy Alert Steroid Allergy -Rosuvastatin Calcium Oral Tablet 10 M -Pharmacy Alert Statin Allergy On 2/27/24 at approximately 2:00 PM an interview was conducted with the unit manager, who was shown the electronic health record with the orders pulled up for Resident #106 and was asked what the orange triangle with the exclamation point meant. The unit manager stated that is usually a flag from the pharmacy for an allergy. When asked when the flags appear, she stated that the flags appear after you put in new orders. When asked what the nurses should do when they see this, she stated that they should notify the physician and document if this a true allergy or if this just means it's an intolerance and stated that sometimes a medication might cause a constipation, but you still take it because you need it. It's not an allergy it's an intolerance. When asked to see credible evidence that the physician was made aware of the pharmacy flags on this newly admitted Resident, she could not. She stated that the Resident was admitted after hours, and the on-call provider verified the medications. She was asked if it was accurate to say that the on-call had no prior knowledge of the Resident's allergies and intolerances she stated yes. When asked if the nurse should have contacted the physician, she stated that she should have. On 2/28/24 at approximately 3:45 PM an interview was conducted with the Nurse Practitioner who stated that she would be expected to be notified of medications that were flagged as allergy, she stated that she would. When asked why this is important, she stated that she can vet out whether it is a true allergy or an intolerance and that it would afford her the opportunity to alter the medication orders or substitute a medication or even reach out to Residents and family to find out more about the allergy or intolerance, to see if the benefits outweigh the risk. On 2/29/24 during the end of day meeting the Administrator was made aware of the findings and no further information was provided.

Based on observation, interview, clinical record review, and facility documentation review, the facility staff failed to review and revise care plans for one Resident (#26), in a survey sample of 23 Residents. The findings included: For Resident #26 the facility staff failed to review and revise the care plan after a significant change when the Resident was discharged from Hospice Care. A review of the clinical record revealed that the Resident had been on Hospice and discharged from Hospice on 11/6/23. Resident #26's care plan read as follows: FOCUS: (Resident # 26 name redacted) is at nutritional risk r/t chronic disease including dementia, dysphagia, hypertension, and protein/calorie malnutrition. R receives a mechanically altered diet (pureed) with double portions which is appropriate. Is on hospice and weight loss is expected. Date Initiated: 08/04/2021 Revision on: 02/13/2024. GOAL: (Resident #26) will be encouraged to eat meals and drink fluids as tolerated. Weight loss and fluid imbalance may be a consequence of the dying process. End of life palliative care situations are not compatible with maintaining. normal nutritional parameters. Weight loss is expected. Date Initiated: 08/04/2021 Revision on: 02/13/2024. INTERVENTIONS: Encourage and assist with meal intake, as needed. Date Initiated: 03/22/2022. Honor preferences and requests within diet order. Honor resident's right to refuse food or fluids. Date Initiated: 08/04/2021. Offer meal alternative or substitutions if poor intake is observed. Date Initiated: 08/12/2023. Provide supplements, as ordered. Ensure tid Date Initiated: 04/13/2022 Revision on: 08/12/2023. Provide tray setup at meals and assistance with eating as needed and accepted. Date Initiated: 08/04/2021 Revision on: 11/07/2021. Provide, serve diet as ordered. Monitor intake and record q meal. Date Initiated: 08/04/2021. On 2/29/23 at approximately 6:00 PM an interview was conducted with employee H (MDS Coordinator) who stated that Resident #26 was taken off of Hospice on 11/6/23 and was seen by the Nurse Practitioner. When asked if that would be a considered a significant change in his condition, she stated that it would be. She stated that a significant change MDS was completed. When asked if the care plan should have been updated to include the changes, she stated that it should. When asked to review the care plan she agreed the orders for Resident #26's diet did not match what was in the care plan. She also agreed that the orders for monthly weights should have been restarted along with orders for podiatry, dental consult and mental health consults as needed. She stated that those services were discontinued as is usual when Residents go on Hospice, however they should have been restarted once he was no longer receiving hospice services On 2/29/24 during the end of day meeting the Administrator was made aware of the findings and no new information were provided.

Based on observation, interview, and clinical record review the facility staff failed to provide medication administration per professional standards of quality for one Resident (#106) in a survey sample of 23 Residents. The findings included: For Resident #106 the facility staff failed to ensure orders were accurately verified, transcribed, and medications administered according to physician orders. On 2/25/24 at approximately 1:00 PM an interview was conducted with Resident #106 who stated that when she arrived at the facility, she was disappointed to find that she had to wait for some of her medications as they did not have all of them at the facility. When asked if this caused her any stress or unnecessary pain, she stated that it did not. When asked if she felt it harmed her health in any way, she stated that she didn't think it did. On 2/27/23 a review of the MAR (Medication Administration Record) revealed that the following medications were administered inaccurately and/or omitted: Eliquis 5 mg - Dose for 9 PM on 2/16/24 was not given - A review of the stat box contents revealed it was available for use. Keflex 500 mg - Dose for 9 PM on 2/16/24 was not given - A review of the stat box contents revealed it was available for use. Breo-Elipta 100-25 mg Dose for 2/17/23 was not given. Hydralazine 25 mg Dose for 2/16/24 9 PM was not given. - A review of the stat box contents revealed it was available for use. Isosorbide dinitrate 10 mg tablet - Doses were not given for 2/16/24 at 9 PM, 2/17/24 at 4PM and 2/18/24 at 8 AM Lamictal 100 mg tablets take 100 mg by mouth two times daily - this medication was incorrectly transcribed on the MAR as once a day. This medication has been given only once a day and the 9 PM dose on 2/16/24 was not given. Lidocaine patch for pain was not given on 2/17/24 and 2/18/24. Nitro Stat was not added to the MAR until 2/21/24. Trazodone 50 mg tablets. take 12.5-25 mg twice a day - This order was not transcribed to the MAR On 2/28/24 at approximately 3:45 PM an interview was conducted with the Nurse Practitioner who stated that she expected to be notified of medications that were not available or not given, so that she may have the opportunity to substitute a medication or give additional orders for that Resident. On 2/29/24 at 9:30 AM an interview was conducted with Registered Nurse (RN)-C who stated When a medication is not available from pharmacy or newly ordered we are supposed to first check the stat box, then call pharmacy and then we call the physician to see if it is ok to hold until its available or if they want to substitute another medication until its available. A review of the facility policy read: Policy # 6.10 -Unavailable Medications Paragraph 3 The nursing staff shall: 1. Notify the attending physician (or on -call physician) of the situation and explain the circumstances, expected availability, and the alternative therapy(ies) available. If the facility nurse is unable to obtain a response form the attending physician or on call physician, the nurse should notify the nursing supervisor and contact the Facility Medical Director for orders and or direction. 2. Obtain new order and cancel/discontinue the order for the non-available med. 3. Notify the pharmacy of the replacement order. Nursing2012 Drug Handbook. (2012). [NAME] & [NAME]: Philadelphia, Pennsylvania included: Rights of Medication Administration 1. Right patient 2. Right medication 3. Right dose 4. Right route 5. Right time 6. Right documentation 7. Right reason 8. Right response On 3/1/24 during the end of day meeting the Administrator was made aware of the findings and no further information was provided.

Based on interview, clinical record review and facility documentation the facility staff failed to provide necessary services to maintain good nutrition, grooming, and personal and oral hygiene, for one Resident (#26) in a survey sample of 23 Residents. The findings included: For Resident #26, the facility failed to provide adequate care of fingernails and toenails. On 2/24/24 at approximately 2:00 PM Resident #26 was observed in his bed wearing a hospital gown the sheets were not covering his feet. Resident #26's fingernails were approximately 1/4 inch long and appeared to brown substance under the nails. Resident #26's toenails were thickened and long and in need of cutting. On 2/24/24 at 2:00 PM an interview was attempted with Resident #26 who was unable to follow any of the interview questions. A review of the clinical record revealed an MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 11/13/23 that revealed Resident #26 had a BIMS (Brief Interview of Mental Status) score of 0 indicating severe cognitive impairment. Resident #26 is also unable to transfer self, unable to walk or carry out ADL's independently. He requires max assist with all aspects of care except for eating which he requires supervision and set up. On 2/26/24 at approximately 1:00 PM an interview was conducted with Registered Nurse (RN)-B who stated that if residents need nail care it is provided on their bath day and the CNA's are responsible unless the resident is a diabetic or on blood thinners. When asked about those residents that are diabetic or on anticoagulants, she stated, Usually podiatry services will see those folks. When asked how someone would get to see the podiatrist if they needed services she stated the resident, or family or staff could recommend services be obtained. When asked do they need to get an order for those services she stated, The facility usually has the standing order that says may see podiatry, dental, optometry or mental health services as needed. On 2/29/23 at approximately 6:00 PM an interview was conducted with employee H (MDS Coordinator) who stated that Resident #26 was taken off of Hospice on 11/6/23 and was seen by the Nurse Practitioner. She was asked about podiatry services and she stated that those services are discontinued when residents go on Hospice, however they should have been restarted once he was no longer receiving hospice services. On 2/29/24 during the end of day meeting the Administrator was made aware of the findings and no further information was provided.

Based on interview, clinical record review, and facility documentation review, the facility staff failed to ensure residents were free from unnecessary psychotropic medication for one Resident (#10) in a survey sample of 23 Residents. The findings included: For Resident #10, the facility staff failed to ensure the PRN (as needed) anti-anxiety medication, Lorazepam, was only ordered for 14 days. On 2/28/24 a review of the clinical record revealed that Resident #10 had orders for PRN Ativan, (an anti-anxiety medication), that read as follows: Lorazepam Oral Tablet 0.5 MG - Give 0.5 mg by mouth every 6 hours as needed for agitation This was ordered on 2/6/24 without a stop date. There was no indication in the clinical record of the rationale for continuing the medication. On 2/27/24 an interview was conducted with the DON (Director of Nursing) who stated she was aware of the guidelines from CMS that a PRN (as needed) order for a psychotropic like Ativan could not be ordered for more than 14 days without a stop date and proper documentation for the use of the drug. On 3/1/24 during the end of day meeting the Administrator was made aware of the findings. No further information was provided.

Based on staff interview, Ombudsman interview, family interview, facility documentation review, clinical record review, and in the course of a complaint investigation, the facility staff failed to ensure one resident (Resident #2) was free from significant medication errors in a survey sample of four (4) residents, resulting in harm. For Resident #2, the facility discontinued all of the resident's cardiac, antihypertensive, and blood thinning medications after 30 days resulting in hospitalization for a stroke. The medications were Diltiazem, Metoprolol, and Apixaban anticoagulation (blood thinner) medication for new onset atrial fibrillation. The findings included: Resident #2 was admitted to the facility on [DATE] from the hospital. Diagnoses included, new onset atrial fibrillation, aortic valve stenosis, aortic valve insufficiency, likely acute heart attack, long term use of anticoagulants, hypertension, high cholesterol, mild protein calorie malnutrition, and dementia. Hospital records from 06/26/2023 through 07/03/2023 were reviewed and revealed the following: Resident #2 was discharged from the hospital to the nursing facility with new onset atrial fibrillation with rapid ventricular response on 07/03/2023. The resident was issued the customary 30-day new orders for all medications from a hospitalist doctor after being stabilized in the hospital. This provides for continuity of care for discharge to the nursing facility, and ultimately from the nursing facility to home after rehabilitation. Those orders were for the following: Schedule appointment with Primary Care Doctor (PCP) (name given) as soon as possible for a visit within one week. Schedule appointment with Cardiology Doctor (name given) as soon as possible for visit within one month. Apixaban - anticoagulant Diltiazem - antihypertensive Metoprolol - antihypertensive Atorvastatin - lowers high cholesterol Vitamin D-3 - supplement Calcium - supplement Vitamin B-12 - supplement Multivitamin - supplement Iron - supplement Prilosec - gastric reflux Miralax - constipation Review of Resident #2's clinical record revealed that the Atorvastatin for high cholesterol was only administered one time on 07/04/2023, the day after admission, and discontinued on that same day for an unknown reason as no document reveals the reason for the discontinuance. The 3 cardiac medications, Apixaban (anticoagulant), Diltiazem (antihypertensive), and Metoprolol (antihypertensive) were discontinued after 30 days of use with Diltiazem discontinued on 08/02/2023 after the 8:00 a.m. dose, and the other 2 medications, Apixaban and Metoprolol, after the 8:00 a.m. dose on 08/03/2023. The following 3 cardiac medications were not restarted while Resident #2 was in the nursing facility, prior to rehospitalization , at approximately 11:30 a.m., on 08/14/2023 (11 days later) with a stroke. 1. Diltiazem (antihypertensive) - reduces workload on the vessels and heart, 240 mg, one time per day at 8:00 a.m. 2. Metoprolol (antihypertensive) - reduces workload on the vessels and heart, 25 mg, one half tablet two times per day and 8:00 a.m., and 9:00 p.m. 3. Apixaban (anticoagulant) - blood thinner, prevents blood clots from forming and causing heart attack and stroke, 5 mg, one tablet twice per day at 8:00 a.m., and 9:00 p.m. It is notable to mention that all other 30-day orders were continued in the nursing facility. During interviews it was found that the follow-up appointments ordered for PCP, and Cardiology doctors were never scheduled, nor were those doctors contacted about continuing the cardiac medications. The family was also not contacted and alerted that the cardiac medications were discontinued. Guidance for the administration of Apixaban/Eliquis is given by The National Institutes of Health (NIH), and is as follows: National Institutes of Health & Medline.gov Apixaban reduces the risk of strokes and blood clots. Stopping Apixaban will increase the risk of thrombotic events, like stroke, heart attack, and pulmonary embolus. Resident #2's care plan was reviewed and revealed no focus, nor interventions for the primary diagnosis of atrial fibrillation, anticoagulant therapy, heart attack, and cardiac medication treatment. Nursing progress notes were reviewed, and revealed no notes documenting that the medication had been discontinued, nor that the doctor, or family was ever made aware of the discontinuance. Physician's progress notes were reviewed and revealed on 08/04/2023, the day after the cardiac drugs were discontinued, No aspirin will be on Eliquis for A-fib .full code. After that note, none of the following physician progress notes until the time of discharge for stroke like symptoms indicated the physician was never made aware of the discontinuance of the cardiac medications by staff for Resident #2. Vital sign records and progress notes were reviewed and revealed on the day of discharge, 08/14/2023, back to the hospital for stroke like symptoms, Resident #2's pulse was between 80 and 130 beats per minute, and blood pressure was 130/78. On 08/14/2023, the morning of discharge back to the hospital, between 9:30 a.m. and 11:37 a.m., nursing notes indicated that the Resident #2 was experiencing irregular pulse, altered level of consciousness, weakness/hemiparesis, leaning in wheel chair, slurred speech, and 911. Emergency services was called to transfer Resident #2 to the hospital. At 6:36 p.m., the progress notes documented the facility staff called the hospital emergency room to get a report of the condition of the resident and were told that Resident #2 was admitted for a stroke. Discharge records from the hospital after treatment on 08/16/2023 indicated diagnosis of stroke. Ultimately, Resident #2 was discharged home with family and hospice services. On 09/13/2023 at 11:00 a.m., the Director of Nursing (DON) was interviewed in the conference room and stated she had been unaware that medications had not been given, nor that the doctor and family were not notified of medications being discontinued by staff. The DON was notified at that time of harm to Resident #2. The DON was a new staff member and had recently been hired. The Administrator was at a conference during the survey and was not able to be reached until the time of exit of the survey. At that time, she was made aware of the findings and stated she had nothing further to provide. On 09/13/2023 at approximately 2:00 p.m., during the end-of-day debrief, the Administrator and DON were made aware of the failure of staff to administer cardiac medications resulting in hospitalization and harm. No further information was provided.

Based on staff interview, facility document review, clinical record review, and in the course of a complaint investigation, the facility staff failed to ensure incontinence and wound care was provided timely for 1 resident (Resident #1) of four (4) residents in the survey sample. For Resident #1, the facility staff did not provide incontinence care timely resulting in moisture associated skin damage (MASD), and further failed to care for inguinal dialysis shunt placement site, and sutures in the neck and knee after hospitalization . The findings included: Resident #1 was admitted to the facility on [DATE] with diagnoses including, acute kidney failure, effusion left knee, diabetes type 2, acute embolism of left femoral vein, left knee pain, hypertension, hypothyroidism, venous insufficiency, stroke, and breast cancer. Resident #1's most recent Minimum Data Set Assessment (MDS) with an Assessment Reference Date (ARD) of 03/15/2023 was a 5-day admission assessment. The MDS coded Resident #1 as needing extensive to total staff assistance with toileting, hygiene, and bathing. Resident #1 was also coded as 10 of 15 possible points on a Brief Interview for Mental Status (BIMS), indicating mild cognitive impairment. The resident was coded as frequently incontinent of bowel and bladder. Review of Resident #1's progress notes indicated on 03/10/2023, (Resident name) has surgical wounds left knee two small incisions from knee surgery .baseline care plan has been initiated . The resident's care plan was reviewed and revealed a care plan for potential for skin impairment; however, does not indicate the resident had actual MASD found by staff on 03/23/2023, nor does it mention sutures to her knee after knee surgery in the hospital, nor sutures in her neck. There was also no mention of a femoral artery dialysis shunt placed in Resident #1's inguinal crease (groin) area, and no assessments in the clinical record regarding these. There were no interventions, nor mention of care and treatment of any of the 4 skin issues actually experienced by Resident #1 in the care plan, which would have required an active treatment care plan. Resident #1's physician orders, assessments, medication administration record (MAR), and treatment administration record (TAR), were reviewed and revealed the only skin care orders (3 days after admission) received for the 2 suture locations on 03/12/2023 to clean with normal saline and leave open to air. No assessments of those 2 areas of the skin exists in the clinical record during the 19-day stay, nor is there any indication of suture removal orders during Resident #1's stay. The National Institutes of Health (NIH) gives guidance on sutured wounds, and states as a standard of practice, sutures on the neck should be removed in 7 days, and in the lower extremities overlying a joint 12 to 14 days. If sutures are left in too long it may be difficult to remove them with a potential to reinjure the area, and could increase scar tissue at the site. No orders nor assessments were ever placed in the clinical records for the MASD, and femoral inguinal dialysis shunt area. The first skin impairment note in the clinical record occurred on 03/23/2023, which was a skin evaluation document, described moisture associated skin damage (MASD) right and left buttocks. No other information was given and the form was not completed. No treatments were ordered for the MASD for the rest of Resident #1's 4-day stay before being transferred to another facility on 03/27/2023. Activities of daily living (ADL) records were reviewed and revealed that hygiene and bathing were documented as being provided daily; however, not documented as provided multiple times daily during the resident's stay. Staff stated the facility policy on Perineal Care for Incontinent Residents, was that care would be provided approximately every 2 hours every shift and as needed (PRN), which included removal of wet incontinent briefs, and cleansing. Staff further stated the expectation is to give incontinence care immediately after every incontinent episode. Resident #1 was not afforded timely incontinence care as many times as was needed, as evidenced by the MASD actually acquired after 10 days in the facility. The facility Administrator and Director of Nursing (DON) were made aware of the above findings at the end-of-day debrief on 09/13/2023. No additional information was provided to the surveyor.

Based on staff interview, Ombudsman interview, family interview, facility documentation review, clinical record review, and in the course of a complaint investigation, the facility staff failed to maintain the professional standards of nursing practice for two residents (Residents #2 and #1) in a survey sample of four (4) Residents. 1. For Resident #2, the facility staff discontinued all the resident's cardiac, antihypertensive, and blood thinning medications after 30 days for new onset atrial fibrillation. They also failed to notify the family and doctor of the discontinuance, did not obtain follow-up appointments with the resident's doctors as ordered by a physician, and did not develop nor implement a nursing care plan for cardiac treatment. 2. For Resident #1, the facility staff did not provide incontinence care timely resulting in moisture associated skin damage (MASD), and further failed to care for, and care plan for inguinal dialysis shunt placement site, MASD, and sutures in the neck and knee after hospitalization . The findings included: 1. Resident #2, was admitted to the facility on [DATE] from the hospital. Diagnoses included, new onset atrial fibrillation, aortic valve stenosis, aortic valve insufficiency, likely acute heart attack, long-term use of anticoagulants, hypertension, high cholesterol, mild protein calorie malnutrition, and dementia. Resident #2's most recent Minimum Data Set (MDS) with an Assessment Reference Date (ARD of 07/03/2023 was coded as a 5-day admission assessment. Resident #2 was coded as having a brief interview of mental status (BIMS) score of 6 out of a possible 15, revealing significant cognitive impairment. Resident #2 was also coded as requiring extensive assistance to complete dependence on staff to perform activities of daily living, such as bed mobility, transferring, locomotion, and toileting. Hospital records from 06/26/2023 through 07/03/2023 were reviewed and revealed the following: Resident #2 was discharged from the hospital to the nursing facility with new onset atrial fibrillation with rapid ventricular response on 07/03/2023. The resident was issued the customary 30-day new orders for all medications from a hospitalist doctor after being stabilized in the hospital. The hospital doctor's intention was for the resident to follow-up with the resident's PCP, and cardiology doctors to monitor and continue those orders. This provides for continuity of care for discharge to the nursing facility, and ultimately from the nursing facility to home after rehabilitation. Those orders were for the following: Schedule appointment with Primary Care Doctor (PCP) (name given) as soon as possible for a visit within one week. Schedule appointment with Cardiology Doctor (name given) as soon as possible for visit within one month. Apixaban - anticoagulant Diltiazem - antihypertensive Metoprolol - antihypertensive Atorvastatin - lowers high cholesterol Vitamin D-3 - supplement Calcium - supplement Vitamin B-12 - supplement Multivitamin - supplement Iron - supplement Prilosec - gastric reflux Miralax - constipation Review of Resident #2's clinical record revealed that the atorvastatin for high cholesterol was only administered one time on the day after admission, 07/04/2023, and discontinued on the same day for an unknown reason as no document reveals the reason for the discontinuance. The 3 cardiac medications were discontinued after 30 days of use with Diltiazem discontinued on 08/02/2023 after the 8:00 a.m. dose, and the other 2 medications after the 8:00 a.m. dose on 08/03/2023. The following 3 cardiac medications were not restarted while Resident #2 was in the nursing facility, prior to rehospitalization , at approximately 11:30 a.m., on 08/14/2023 (11 days later) with a stroke. 1. Diltiazem (antihypertensive) - reduces workload on the vessels and heart, 240 milligrams (mg) one time per day at 8:00 a.m. 2. Metoprolol (antihypertensive) - reduces workload on the vessels and heart, 25 mg one half tablet two times per day and 8:00 a.m., and 9:00 p.m. 3. Apixaban (anticoagulant) - blood thinner, prevents blood clots from forming and causing heart attack and stroke, 5 mg one tablet twice per day at 8:00 a.m., and 9:00 p.m. It is notable to mention that all other 30-day orders were continued in the nursing facility. During interviews, it was found that the follow-up appointments ordered for PCP, and cardiology doctors were never scheduled, nor were those doctors contacted about discontinuing the cardiac medications. The family was also not contacted and alerted to the fact that the cardiac medications were discontinued. The Medication and Treatment Administration Record (MAR/TAR) was reviewed for July and August 2023, and revealed nursing signatures indicating the Diltiazem medication had been administered through the morning of 08/02/2023, and the other 2 cardiac drugs were administered up through the morning of 08/03/2023. Guidance for the administration of Apixaban/Eliquis is given by The National Institutes of Health (NIH) (National Institutes of Health & Medline.gov), and is as follows: Apixaban reduces the risk of strokes and blood clots. Stopping Apixaban will increase the risk of thrombotic events, like stroke, heart attack and pulmonary embolus. Resident #2's care plan was reviewed and revealed no focus, nor interventions for the primary diagnosis of atrial fibrillation, anticoagulant therapy, heart attack, and cardiac medication treatment. Nursing progress notes were reviewed, and revealed no notes documenting that the medication had been discontinued, nor that the doctor, or family was ever made aware of the discontinuance. Physician's progress notes were reviewed and revealed on 08/04/2023, the day after the cardiac drugs were discontinued, No aspirin will be on Eliquis for A-fib .full code. After that note, none of the following physician progress notes until the time of discharge (for stroke like symptoms) indicated the physician was never made aware of the discontinuance of the cardiac medications by staff for Resident #2. Vital sign records and progress notes were reviewed and revealed that on the day of discharge 08/14/2023, Resident #2 went back to the hospital for stroke like symptoms. The resident's pulse was between 80 and 130 beats per minute, and blood pressure was 130/78. On the morning of discharge, 08/14/2023, Resident #2 went back to the hospital. The nursing notes indicated between 9:30 a.m., and 11:37 a.m., the resident was experiencing irregular pulse, altered level of consciousness, weakness/hemiparesis, leaning in wheel chair, slurred speech, and 911. Emergency services was called to transfer the resident to the hospital. At 6:36 p.m., the progress notes documented the facility staff called the hospital emergency room to get a report of the condition of the resident and were told that Resident #2 was admitted for a stroke. Discharge records from the hospital after treatment on 08/16/2023 indicated diagnosis of stroke. Resident #2 was discharged home with family and hospice services. On 09/13/2023 at 11:00 a.m., the Director of Nursing (DON) was interviewed in the conference room and stated she was not aware the medications had not been given, the appointments had not been set, there was no cardiac care plan, nor that the doctor and family were not notified of medications being discontinued by staff. The DON was a new staff member and had recently been hired. The Administrator was at a conference during the survey and was not able to be reached until the time of exit of the survey. At that time she was made aware of findings and stated she had nothing further to provide. On 09/13/2023 at approximately 2:00 p.m., at the end of day debrief, the Administrator and DON were made aware of the failure of staff to develop care plans, set follow up appointments, and notify family and doctors of cardiac medication discontinuance. No further information was provided. 2. For Resident #1, the facility staff did not provide incontinence care timely resulting in moisture associated skin damage (MASD), and further failed to care for inguinal dialysis shunt placement site, and sutures in the neck and knee after hospitalization . The findings included: Resident #1 was admitted to the facility on [DATE] with diagnoses including, acute kidney failure, effusion left knee, diabetes type 2, acute embolism of left femoral vein, left knee pain, hypertension, hypothyroidism, venous insufficiency, stroke, and breast cancer. Resident #1's most recent Minimum Data Set Assessment (MDS) with an Assessment Reference Date (ARD) of 03/15/2023 was a 5-day admission assessment. The MDS coded Resident #1 as needing extensive to total staff assistance with toileting, hygiene, and bathing. The resident was also coded as 10 of 15 possible points on a Brief Interview for Mental Status (BIMS), indicating mild cognitive impairment. The resident was coded as frequently incontinent of bowel and bladder. Review of Resident #1's progress notes indicated on 03/10/2023, (Resident name) has surgical wounds left knee two small incisions from knee surgery .baseline care plan has been initiated . The resident's care plan was reviewed and revealed a care plan for potential for skin impairment; however, the care plan does not indicate the resident had actual MASD found by staff on 03/23/2023, nor does it mention sutures to her knee after knee surgery in the hospital, nor sutures in her neck. There was also no mention of a femoral artery dialysis shunt placed in the resident's inguinal crease (groin) area, and no assessments in the clinical record regarding these. There were no interventions, nor mention of care and treatment of any of the 4 skin issues actually experienced by Resident #1 in the care plan, which would have required an active treatment care plan. Resident #1's physician orders, assessments, medication administration record (MAR), and treatment administration record (TAR), were reviewed and revealed the only skin care orders (3 days after admission) received for the 2 suture locations on 03/12/2023 to clean with normal saline and leave open to air. No assessments of those 2 areas of the skin exists in the clinical record during the 19-day stay, nor is there any indication of suture removal orders during the resident's stay. The National Institutes of Health (NIH) gives guidance on sutured wounds, and states as a standard of practice, sutures on the neck should be removed in 7 days, and in the lower extremities overlying a joint 12 to 14 days. If sutures are left in too long, it may be difficult to remove them with a potential to reinjure the area, and could increase scar tissue at the site. No orders nor assessments were ever placed in the clinical records for the MASD, and femoral inguinal dialysis shunt area. The first skin impairment note in the clinical record occurred on 03/23/2023, which was a skin evaluation document, described moisture associated skin damage (MASD) right and left buttocks. No other information was given and the form was not completed. No treatments were ordered for the MASD for the rest of the resident's 4-day stay before being transferred to another facility on 03/27/2023. Activities of daily living (ADL) records were reviewed and revealed that hygiene and bathing were documented as being provided daily; however, not documented as provided multiple times daily during the resident's stay. Staff stated the facility policy on Perineal Care for Incontinent Residents, was that care would be provided approximately every 2 hours every shift and as needed (PRN), which included removal of wet incontinent briefs, and cleansing. Staff further stated the expectation is to give incontinence care immediately after every incontinent episode. Resident #1 was not afforded timely incontinence care as many times as was needed, as evidenced by the MASD actually acquired after 10 days in the facility. The facility Administrator and Director of Nursing (DON) were made aware of the above findings at the end-of-day debrief on 09/13/2023. No additional information was provided to the surveyor.

Based on staff interview, Ombudsman interview, family interview, facility documentation review, clinical record review, and in the course of a complaint investigation, the facility staff failed to ensure a demented resident's responsible party and physician were notified of a change in treatment for one resident (Residents #2) in a survey sample of four (4) residents. For Resident #2, the facility discontinued all of the resident's cardiac, antihypertensive, and blood thinning medications after 30 days, and did not notify the physician, nor family of the discontinuance. These following medications were discontinued: Diltiazem, Metoprolol, and Apixaban anticoagulation (blood thinner) medication for new onset atrial fibrillation. The findings included: Resident #2 was admitted to the facility on [DATE] from the hospital. Diagnoses included, new onset atrial fibrillation, aortic valve stenosis, aortic valve insufficiency, likely acute heart attack, long term use of anticoagulants, hypertension, high cholesterol, mild protein calorie malnutrition, and dementia. Resident #2's most recent Minimum Data Set (MDS) with an assessment reference date (ARD) of 07/10/2023 was coded as a 5-day admission assessment. Resident #2 was coded as having a Brief Interview of Mental Status (BIMS) score of 6 out of a possible 15, revealing significant cognitive impairment. Resident #2 was also coded as requiring extensive assistance to complete dependence on staff to perform activities of daily living, such as bed mobility, transferring, locomotion, and toileting. Hospital records from 06/26/2023 through 07/03/2023 were reviewed and revealed the following: Resident #2 was discharged from the hospital to the nursing facility with new onset atrial fibrillation with rapid ventricular response on 07/03/2023. The resident was issued the customary 30-day new orders for all medications from a hospitalist doctor after being stabilized in the hospital. The hospital doctor's intention was for the resident to follow-up with the resident's PCP and Cardiology doctors to monitor and continue those orders. This provides for continuity of care for discharge to the nursing facility, and ultimately from the nursing facility to home after rehabilitation. Those orders were for the following: Schedule appointment with Primary Care Doctor (PCP) (name given) as soon as possible for a visit within one week. Schedule appointment with Cardiology Doctor (name given) as soon as possible for visit within one month. Apixaban - anticoagulant Diltiazem - antihypertensive Metoprolol - antihypertensive Atorvastatin - lowers high cholesterol Vitamin D-3 - supplement Calcium - supplement Vitamin B-12 - supplement Multivitamin - supplement Iron - supplement Prilosec - gastric reflux Miralax - constipation Review of Resident #2's clinical record revealed that the Atorvastatin for high cholesterol was only administered one time on the day after admission, 07/04/2023, and discontinued on that same day for an unknown reason as no document reveals the reason for the discontinuance. The 3 cardiac medications were discontinued after 30 days of use with Diltiazem discontinued on 08/02/2023 after the 8:00 a.m. dose, and the other 2 medications after the 8:00 a.m. dose on 08/03/2023. The following 3 cardiac medications were not restarted while Resident #2 was in the nursing facility, prior to rehospitalization , at approximately 11:30 a.m., on 08/14/2023 (11 days later) with a stroke. 1. Diltiazem (antihypertensive) - reduces workload on the vessels and heart, 240 milligrams (mg) one time per day at 8:00 a.m. 2. Metoprolol (antihypertensive) - reduces workload on the vessels and heart, 25 mg one half tablet two times per day and 8:00 a.m., and 9:00 p.m. 3. Apixaban (anticoagulant) - blood thinner, prevents blood clots from forming and causing heart attack and stroke, 5 mg one tablet twice per day at 8:00 a.m., and 9:00 p.m. It is notable to mention that all other 30-day orders were continued in the nursing facility. During interviews, it was found that the follow-up appointments ordered for PCP, and Cardiology doctors were never scheduled, nor were those doctors contacted about continuing the cardiac medications. The family was also not contacted and alerted to the fact that the cardiac medications were discontinued. The Medication and Treatment Administration Record (MAR/TAR) was reviewed for July and August 2023, and revealed nursing signatures indicating the Diltiazem medication had been administered through the morning of 08/02/2023, and the other 2 cardiac drugs were administered up through the morning of 08/03/2023. Nursing progress notes were reviewed, and revealed no notes documenting the medication had been discontinued, nor that the doctor, or family was ever made aware of the discontinuance. Physician's progress notes were reviewed and revealed on 08/04/2023, the day after the cardiac drugs were discontinued, No aspirin will be on Eliquis for A-fib .full code After that note, none of the following physician progress notes until the time of discharge (for stroke like symptoms) indicated that the physician was never made aware of the discontinuance of the cardiac medications by staff for Resident #2. On 09/13/2023 at 11:00 a.m., the Director of Nursing (DON) was interviewed in the conference room and stated she had been unaware that medications had not been given, nor that the doctor and family were not notified of medications being discontinued by staff`. The DON was a new staff member and had recently been hired. The Administrator was at a conference during the survey and was not able to be reached until the time of exit of the survey. At that time, she was made aware of findings and stated she had nothing further to provide. On 09/13/2023 at approximately 2:00 p.m., at the end of day debrief, the Administrator and DON were made aware of the failure of staff to notify the doctor and family of the discontinuance of cardiac treatment for Resident #2. No further information was provided.

Based on clinical record review, staff interview, and facility documentation review, the facility staff failed to provide timely notification to the Responsible Party of a change in condition for 1 Resident, Resident #5, in a sample size of 6 Residents. The findings included: For Resident #5, facility staff failed to provide timely notification to the Responsible Party of his fall with injury which occurred on 11/10/23. On 11/16/23 at approximately 4:00 PM, Resident #5's clinical record was reviewed. A progress note dated 11/13/2023 at 8:51 AM documented, RP [Responsible Party] was called and updated about fall on 11/10/23. A progress note dated 11/10/23 at 11:17 PM read, Staff heard someone asking for help, nurse found resident laying on the floor next to his bed, resident was in his chair waiting for his scheduled shower, resident stated he was in no pain, resident has two scratches on the left middle side of his back, left wrist has abrasion from his watch, right thumb is bruised and fourth toe on his right foot was bent back with little bleeding, neuro checks have been started and vital signs are within normal limits, will continue to monitor. At approximately 4:30 PM, an interview was conducted with the Director of Nursing (DON) who confirmed the documentation in Resident #5's clinical record. The DON stated, I would have expected that the Responsible Party for [Resident #5, name redacted] to be notified as soon as possible after taking care of his immediate needs first. A facility policy was requested and received. Review of the facility's policy titled Fall Protocols with a revision date October 1, 2023, page 3, subtitle, Actual Fall item 1a read, The physician/practitioner and the resident representative will be notified of the fall and any change of condition of the resident. Review of the facility's policy titled, Change in a Resident's Condition or Status, original date 8/30/2023, page 2, item 3 read, Unless otherwise instructed by the resident, a nurse will notify the resident's representative when: (a) The resident is involved in any accident or incident that results in an injury including injuries of an unknown source and item 4 read, Except in medical emergencies, notifications will be made within twenty-four (24) hours of a change occurring in the resident's medical/mental condition or status. At approximately 4:45 PM, the Facility Administrator and DON were updated on the findings. No further information was provided.

Based on clinical record review, staff interview, and facility documentation review, the facility staff failed to provide timely notification to the Responsible Party of a change in condition for 1 Resident, Resident #5, in a sample size of 6 Residents. The findings included: For Resident #5, facility staff failed to provide timely notification to the Responsible Party of his fall with injury which occurred on 11/10/23. On 11/16/23 at approximately 4:00 PM, Resident #5's clinical record was reviewed. A progress note dated 11/13/2023 at 8:51 AM documented, RP [Responsible Party] was called and updated about fall on 11/10/23. A progress note dated 11/10/23 at 11:17 PM read, Staff heard someone asking for help, nurse found resident laying on the floor next to his bed, resident was in his chair waiting for his scheduled shower, resident stated he was in no pain, resident has two scratches on the left middle side of his back, left wrist has abrasion from his watch, right thumb is bruised and fourth toe on his right foot was bent back with little bleeding, neuro checks have been started and vital signs are within normal limits, will continue to monitor. At approximately 4:30 PM, an interview was conducted with the Director of Nursing (DON) who confirmed the documentation in Resident #5's clinical record. The DON stated, I would have expected that the Responsible Party for [Resident #5, name redacted] to be notified as soon as possible after taking care of his immediate needs first. A facility policy was requested and received. Review of the facility's policy titled Fall Protocols with a revision date October 1, 2023, page 3, subtitle, Actual Fall item 1a read, The physician/practitioner and the resident representative will be notified of the fall and any change of condition of the resident. Review of the facility's policy titled, Change in a Resident's Condition or Status, original date 8/30/2023, page 2, item 3 read, Unless otherwise instructed by the resident, a nurse will notify the resident's representative when: (a) The resident is involved in any accident or incident that results in an injury including injuries of an unknown source and item 4 read, Except in medical emergencies, notifications will be made within twenty-four (24) hours of a change occurring in the resident's medical/mental condition or status. At approximately 4:45 PM, the Facility Administrator and DON were updated on the findings. No further information was provided.

Based on staff interview, Ombudsman interview, family interview, facility documentation review, clinical record review, and in the course of a complaint investigation, the facility staff failed to develop and implement a baseline care plan for cardiac treatment for two residents (Residents #2 and #1) in a survey sample of four (4) Residents. 1. For Resident #2, the facility did not develop nor implement a cardiac care plan for the primary admitting diagnosis of new onset atrial fibrillation, heart attack, with cardiac doctor oversight, and new cardiac medication therapy. 2. For Resident #1, the facility staff did not provide a baseline care plan for moisture associated skin damage (MASD), care for inguinal dialysis shunt placement site, and sutures in the neck and knee after hospitalization . The findings included: 1. Resident #2 was admitted to the facility on [DATE] from the hospital. Diagnoses included, new onset atrial fibrillation, aortic valve stenosis, aortic valve insufficiency, likely acute heart attack, long term use of anticoagulants, hypertension, high cholesterol, mild protein calorie malnutrition, and dementia. Resident #2's most recent Minimum Data Set (MDS) with an assessment reference date (ARD) of 07/10/2023 was coded as a 5-day admission assessment. Resident #2 was coded as having a Brief Interview of Mental Status (BIMS) score of 6 out of a possible 15, revealing significant cognitive impairment. Resident #2 was also coded as requiring extensive assistance to complete dependence on staff to perform activities of daily living, such as bed mobility, transferring, locomotion, and toileting. Hospital records from 06/26/2023 through 07/03/2023 were reviewed and revealed the following: Resident #2 was discharged from the hospital to the nursing facility with new onset atrial fibrillation with rapid ventricular response on 07/03/2023. The resident was issued the customary 30-day new orders for all medications from a hospitalist doctor after being stabilized in the hospital. The hospital doctor's intention was for the resident to follow-up with the resident's PCP and Cardiology doctors to monitor and continue those orders. This provides for continuity of care for discharge to the nursing facility, and ultimately from the nursing facility to home after rehabilitation. Those orders were for the following: Schedule appointment with Primary Care Doctor (PCP) (name given) as soon as possible for a visit within one week. Schedule appointment with Cardiology Doctor (name given) as soon as possible for visit within one month. Apixaban - anticoagulant Diltiazem - antihypertensive Metoprolol - antihypertensive Atorvastatin - lowers high cholesterol Vitamin D-3 - supplement Calcium - supplement Vitamin B-12 - supplement Multivitamin - supplement Iron - supplement Prilosec - gastric reflux Miralax - constipation Review of Resident #2's clinical record revealed that the Atorvastatin for high cholesterol was only administered one time on the day after admission, 07/04/2023, and discontinued on that same day for an unknown reason as no document reveals the reason for the discontinuance. The 3 cardiac medications were discontinued after 30 days of use with Diltiazem discontinued on 08/02/2023 after the 8:00 a.m. dose, and the other 2 medications after the 8:00 a.m. dose on 08/03/2023. The following 3 cardiac medications were not restarted while Resident #2 was in the nursing facility, prior to rehospitalization , at approximately 11:30 a.m., on 08/14/2023 (11 days later) with a stroke. 1. Diltiazem (antihypertensive) - reduces workload on the vessels and heart, 240 milligrams (mg) one time per day at 8:00 a.m. 2. Metoprolol (antihypertensive) - reduces workload on the vessels and heart, 25 mg one half tablet two times per day and 8:00a.m., and 9:00 p.m. 3. Apixaban (anticoagulant) - blood thinner, prevents blood clots from forming and causing heart attack and stroke, 5 mg one tablet twice per day at 8:00 a.m., and 9:00 p.m. It is notable to mention that all other 30-day orders were continued in the nursing facility. During interviews it was found that the follow-up appointments ordered for PCP and Cardiology doctors were never scheduled, nor were those doctors contacted about continuing the cardiac medications. The family was also not contacted and alerted to the fact that the cardiac medications were discontinued. The Medication and Treatment Administration Record (MAR/TAR) was reviewed for July and August 2023, and revealed nursing signatures indicating the Diltiazem medication had been administered through the morning of 08/02/2023, and the other 2 cardiac drugs were administered through the morning of 08/03/2023. Resident #2's care plan was reviewed and revealed no focus, nor interventions for the primary diagnosis of atrial fibrillation, anticoagulant therapy, heart attack, and cardiac medication treatment, nor follow-up appointment with the cardiac doctor. The family was not involved in the care planning process. Nursing progress notes were reviewed, and revealed no notes documenting the medication had been discontinued, nor that the doctor, or family was ever made aware of the discontinuance. On 09/13/2023 at 11:00 a.m., the Director of Nursing (DON) was interviewed in the conference room and stated she had been unaware that medications had not been given, nor that the doctor and family were not notified of medications being discontinued by staff. The DON was a new staff member and had recently been hired. The Administrator was at a conference during the survey and was not able to be reached until the time of exit of the survey. At that time, she was made aware of findings and stated she had nothing further to provide. On 09/13/2023 at approximately 2:00 p.m., at the end of day debrief, the Administrator and DON were made aware of the failure of staff to develop and implement a cardiac care plan for the resident. No further information was provided. 2. For Resident #1, the facility staff did not provide a baseline care plan for moisture associated skin damage (MASD), care for inguinal dialysis shunt placement site, and sutures in the neck and knee after hospitalization . The Findings included: Resident #1 was admitted to the facility on [DATE] with diagnoses including, acute kidney failure, effusion left knee, diabetes type 2, acute embolism of left femoral vein, left knee pain, hypertension, hypothyroidism, venous insufficiency, stroke, and breast cancer. Resident #1's most recent Minimum Data Set Assessment (MDS) with an Assessment Reference Date (ARD) of 03/15/2023. which was a 5-day admission assessment. The MDS coded Resident #1 as needing extensive to total staff assistance with toileting, hygiene, and bathing. The resident was also coded as 10 of 15 possible points on a BIMS, indicating mild cognitive impairment. The resident was coded as frequently incontinent of bowel and bladder. Review of Resident #1's progress notes indicated on 03/10/2023, (Resident name) has surgical wounds left knee two small incisions from knee surgery .baseline care plan has been initiated . The resident's care plan was reviewed, and revealed a care plan for potential for skin impairment; however, does not indicate the resident had actual MASD found by staff on 03/23/2023, nor does it mention sutures to her knee after knee surgery in the hospital, nor sutures in her neck. There was also no mention of a femoral artery dialysis shunt placed in the resident's inguinal crease (groin) area, and no assessments in the clinical record regarding these. There were no interventions, nor mention of care and treatment of any of the 4 skin issues actually experienced by Resident #1 in the care plan, which would have required an active treatment care plan. Resident #1's physician orders, assessments, medication administration record (MAR), and treatment administration record (TAR), were reviewed and revealed the only skin care orders (3 days after admission) received for the 2 suture locations on 03/12/2023 to clean with normal saline and leave open to air. No assessments of those 2 areas of the skin exists in the clinical record during the 19-day stay, nor is there any indication of suture removal orders during the resident's stay. The National Institutes of Health (NIH) gives guidance on sutured wounds, and states as a standard of practice, sutures on the neck should be removed in 7 days, and in the lower extremities overlying a joint 12 to 14 days. If sutures are left in too long it may be difficult to remove them with a potential to reinjure the area, and could increase scar tissue at the site. No orders nor assessments were ever placed in the clinical records for the MASD, and femoral inguinal dialysis shunt area. The first skin impairment note in the clinical record occurred on 03/23/2023, which was a skin evaluation document, described moisture associated skin damage (MASD) right and left buttocks. No other information was given and the form was not completed. No treatments were ordered for the MASD for the rest of the resident's 4-day stay before being transferred to another facility on 03/27/2023. Activities of daily living (ADL) records were reviewed and revealed that hygiene and bathing were documented as being provided daily; however, not documented as provided multiple times daily during the resident's stay. Staff stated the facility policy on Perineal Care for Incontinent Residents, was that care would be provided approximately every 2 hours every shift and PRN (as needed), which included removal of wet incontinent briefs, and cleansing. Staff further stated the expectation is to give incontinence care immediately after every incontinent episode. Resident #1 was not afforded timely incontinence care as many times as was needed, as evidenced by the MASD actually acquired after 10 days in the facility. The facility Administrator and Director of Nursing (DON) were made aware of the above findings at the end-of-day debrief on 09/13/2023. No additional information was provided to the surveyor.

Based on observation, resident interview, staff interview, clinical record review, and facility documentation review the facility staff failed to prevent, identify, and appropriately treat pressure wounds for 1 Resident (Resident #13) in a sample size of 22 Residents. This resulted in harm to Resident # 13. The findings included: 1. For Resident #13, the facility staff failed to identify, assess, notify provider, and appropriately treat a pressure wound on the left heel resulting in an unstageable pressure wound on the left heel. This is harm. On 07/27/2021 at approximately 10:40 A.M., the active physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . There were no wound treatment orders for the left heel. On 07/28/2021 at 10:37 A.M., an interview with Licensed Practical Nurse D (LPN D) was conducted. When asked about wound treatments for Resident #13, LPN D stated Resident #13 had a wound treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . LPN D and this surveyor then entered Resident #13's room for the skin and wound observation. Following the skin assessment, LPN D removed the soft boots to reveal a foam dressing on each heel. Each foam dressing was dated 07/28/2021. LPN D partially removed the left heel dressing to reveal a wound. A small amount of drainage and a calcium alginate dressing were observed on the inside of the foam dressing [calcium alginate for the left heel was not listed in the physician orders]. When asked to describe the wound bed, LPN D stated, The wound bed is black. LPN D then partially removed the foam dressing on the right heel to reveal the wound. When asked to describe the wound, LPN D stated that it was a necrotic ulcer with mild drainage. On 07/28/2021 at 11:36 A.M., an interview with the nurse practitioner, Employee R, was conducted. When asked about [Resident #13]'s heel wounds, Employee R stated that Resident #13's heels were boggy but when I checked them a few weeks ago, they opened and had purulent drainage. At approximately 11:40 A.M., Employee R, Employee G (the Assistant Director of Nursing (ADON)), and this surveyor entered Resident #13's room for a wound observation. Employee R partially removed the dressing on the right heel. While looking at the right heel wound, Employee R stated that It's worse. Employee R stated that [Resident #13] has eschar here and it's pink around the edges. Employee R then partially removed the dressing on the left heel. When asked to describe the wound, Employee R stated, There's eschar here and pink around the edges. After exiting the room, Employee R stated that she was not aware the wounds looked like this. When asked about the expectation for change in condition, Employee R stated she would expect to be notified if there were changes in wound appearance. When asked what the wound treatment would be had she known, Employee R stated she would consider ordering santyl [a chemical [MEDICATION(S)] agent]. The provider progress notes for Resident #13 were reviewed. The most recent documentation from Employee R, the nurse practitioner, was a progress note dated 05/10/2021. Under the header, Physical Exam and sub-header Skin it was documented, The bilateral foot wounds appear to have started as deep tissue injury to bilateral heels that have now opened. He has the anti-pressure boots on bilaterally. The weekly wound assessments from 03/24/2021 through 07/27/2021 were reviewed. There were no assessments addressing a wound on the left heel. On 07/28/2021 at 3:10 P.M., the Director of Nursing (DON) was notified of the findings. When asked about the expectation for staff if there is a change in condition regarding skin assessments, the DON stated that staff are expected to notify the DON, ADON, and nurse practitioner if there is a change in condition. The DON stated that the area would be assessed or reassessed, that staff would collaborate, develop interventions and have a plan of care. When asked about the expectations of staff for wound assessments, the DON stated the expectation is describe the wound and obtain measurements. When asked about the skin assessments for Resident #13's heels, the DON stated that she will assess, get measurements, and document results today. On 07/28/2021 at approximately 3:30 P.M., the administrator was notified of concerns regarding lack of assessments or wound treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . On 07/29/2021, a document completed by the DON and dated 07/28/2021 at 6:24 P.M. entitled, Weekly Wound Observation was reviewed. The wound assessment for the left heel included description and measurements. The DON documented the left heel wound as a Stage 2 wound when, in fact, it was an unstageable wound with eschar in the wound bed. On 07/29/2021 at 9:30 A.M., an interview with the DON was conducted in the conference room with Surveyors Z, B, C, and E also present. When asked what the stage of Resident #13's left heel wound, the DON stated she would need to change her documentation on the assessment from 07/28/2021 because the left heel wound is unstageable because I can't tell with the macule in the center. On 07/29/2021 at 1:39 P.M., an interview with the Wound Physician, Employee M, was conducted. The Wound Physician verified she examined and treated the bilateral heel wounds for Resident #13 today (07/29/2021). When asked what stage the wounds were, the Wound Physician stated both heels wounds were very similar; and both heel wounds were unstageable because he has black, dry, eschar on both heels. The Wound Physician also stated that the wound edges have started to lift. The Wound Physician also stated some of the eschar was debrided this day but because Resident #13 has limited mobility, the plan is to remove the eschar slowly to allow for healing between visits. On 07/29/2021, the facility staff provided a copy of their policy entitled, Skin Assessment. Section 1 under the header entitled, Policy Explanation and Compliance Guidelines, it was documented, A full body, or head to toe, skin assessment will be conducted by a licensed or registered nurse upon admission/readmission, daily for three days, and weekly thereafter. The assessment may also be performed after a change of condition or after any newly identified pressure injury. On 07/29/2021 at 2:25 P.M., the facility nurse consultant, Employee K, provided an amended copy of the nurse practitioner's note dated 05/10/2021. The amended progress note documented the following: Under the header, Addendum it was documented, In reference to the skin assessment, there is an error in documentation. The left heel is boggy and hyper-pigmented, while the right heel is open with appropriate wound care orders in place. There are bilateral off-loading boots in place and his repositioning is every two hours per standard. He is positioned to alleviate pressure on his heels. On 07/29/2021 by the end of survey, the administrator stated there was no further documentation or information to submit.

Based on observation, staff interview, and facility documentation review, the facility staff failed to store and prepare foods in accordance with professional standards in one out of one facility kitchens. Specifically, the facility staff failed to: 1) measure food temperatures for cold and steam table foods for lunch and dinner on 07/23/2021; and all 3 meals on 07/24/2021, 07/25/2021, and 07/26/2021 (11 out of 12 meals). 2) ensure the #4 walk-in refrigerator, #8 freezer, and #8 low-boy freezer were maintained at acceptable temperature ranges on 07/20/2021- 07/26/2021. 3) ensure dishwasher was reaching acceptable temperatures during the wash and rinse cycles in order to properly sanitize dishes on 07/10/2021, 07/13/2021, 07/21/2021, 07/22/2021, and 07/26/2021. The findings included: On 07/27/2021 at 7:55 A.M., Employee C, a cook, was interviewed in the kitchen. Employee C verified she has worked in the kitchen for [AGE] years. When asked about the temp logs, Employee C presented a log book and stated all the logs are in the one book. Employee C and this surveyor observed the logs for the steam table, refrigerator, freezers, and dishwasher. The following observations were made on each of the logs: 1) The log entitled, Freezer Checklist under the sub-header Month documented, July 21. Under the sub-header Location it was documented, #8 freezer. The document contained a table with columns labeled Date, Temperature, and Initials. The following dates did not have temperatures recorded: 07/20/2021-07/26/2021. 2)The log entitled, Refrigeration Checklist under the sub-header Month documented, July 21. Under the sub-header Location it was documented, #4 walk-in. The document contained a table with columns labeled Date, Temperature, and Initials. The following dates did not have temperatures recorded: 07/20/2021-07/26/2021. 3) The log entitled, Freezer Checklist under the sub-header Month documented, July 21. Under the sub-header Location it was documented, #8 low-boy. The document contained a table with columns labeled Date, Temperature, and Initials. The following dates did not have temperatures recorded: 07/20/2021-07/26/2021. 4) The log dated July 2021 entitled, Dishwashing Machine Form contained a table with columns labeled, Breakfast Temperature, Lunch Temperature, and Dinner Temperature. Each meal had temperatures recorded for wash and rinse cycles. The following days were blank: 07/10/2021, 07/13/2021, 07/21/2021, 07/22/2021, and 07/26/2021. 5) The log entitled, Pot Sink Sanitation Record was blank. When asked where the pages were for the steam table food temperatures for 07/24/2021, 07/25/2021, 07/26/2021, and 07/27/2021, and the missing temperatures on the refrigerator, freezers, and dishwasher logs, Employee C acknowledged they were missing. When asked about the food temperatures missing for lunch and dinner on 07/23/2021, Employee C stated I wasn't here; I'm just getting back. On 07/27/2021 at 8:32 A.M., an interview with the Dietary Manager, Employee E was conducted. When asked why the log entitled, Pot Sink Sanitation Record was blank, Employee E stated that they don't use the pot sink but they use the dishwasher every day. When asked about the expectation the dishwasher temperature log, Employee E stated that staff should be checking the dishwasher temps every day to make sure it reaches the right temperatures so that dishes are being cleaned properly. When asked about the expectation for the other temperature logs, Employee E stated she will have a mandatory meeting with staff and go over the importance of checking the temperatures and writing them down. On 07/27/2021 at 9:02 A.M., the administrator was notified of findings. On 07/29/2021, the facility provided a copy of their policy entitled, Dishwashing Machine Use. An excerpt in Section 8 under the header, Policy Interpretation and Implementation documented, The operator will check temperatures using the machine gauge with each dishwashing machine cycle, and will record the results in a facility approved log. On 07/29/2021, the facility provided a copy of their policy entitled, Food Preparation and Service. In Section 1 under the header, Food Preparation, Cooking and Holding Time/Temperatures, it was documented, The 'danger zone' for food temperatures is between 41 [degrees Fahrenheit] and 135 [degrees Fahrenheit] This temperature range promotes the rapid growth of pathogenic microorganisms that cause foodborne illness. In Section 2 under the header Food Service/Distribution, it was documented, The temperatures of foods held in steam tables are monitored throughout the meal by food and nutrition services staff. On 07/29/2021, the facility provided a copy of their policy entitled, Refrigerators and Freezers. In Section 2 under the header Policy Interpretation and Implementation, it was documented, Monthly tracking sheets for all refrigerators and freezers will be maintained to record temperatures. On 07/29/2021 by the end of survey, the administrator stated they had no further documentation or information to submit.

Based on staff interview and facility documentation review, the facility staff failed to implement their abuse policy regarding the screening of employees for 4 employees (CNA F, CNA G, LPN C, and RN B) in a sample of 25 employee records reviewed. CNA F, CNA LPN C faild to sign their sworn statements timely, or completely. RN B did not have reference checks. The findings included: On 7/28/21, a review of a sample of 25 of the facility's employee files was conducted by Surveyor E. The reviews revealed the following: 1. CNA F's hire date was confirmed as 8/10/20. CNA F signed a sworn statement on 1/23/2021. Therefore, CNA F had not sworn to not having any convictions or pending charges of barrier crimes from 8/10/20-1/23/21, prior to being permitted to provide direct care to Residents. In addition, on the sworn statement signed 1/23/21, CNA F failed to answer questions 2 and 3. These questions asked if he/she had Ever been convicted of a law violation(s) but excluding offenses committed before your eighteenth birthday that were finally adjudicated in a juvenile court or under a youth offender law? Are you the subject of any pending criminal charges? 2. CNA G's hire date was confirmed as 3/4/21. CNA G signed a sworn statement on 5/19/2021. Therefore, CNA G was permitted to work directly with Residents within the facility without having sworn to not having any convictions or pending charges of barrier crimes. CNA G's reference checks prior to hire were blank and not obtained. 3. LPN C's hire date was confirmed as 5/18/21. LPN C signed a sworn statement on 5/10/2021. However, LPN C failed to answer question 2. This question asked if he/she had Ever been convicted of a law violation(s) but excluding offenses committed before your eighteenth birthday that were finally adjudicated in a juvenile court or under a youth offender law? 4. RN B's hire date was confirmed as 5/5/21. Review of RN B's reference checks revealed they were blank and had not been obtained prior to hire. On 7/28/21 at 4:06 PM, Surveyor E met with Employee J, the Human Resources Coordinator and the facility Administrator to review the above noted employee file findings. An interview was conducted with Employee J and she stated the purpose of and importance of a sworn statement is, So they don't make false claims on their background checks and criminal offenses and make sure they don't have a criminal history or barrier crime. On 7/29/21 at approximately 11:00 AM, Surveyor E met with the Facility Administrator and Human Resources Coordinator/Employee J to review the above noted findings and review any additional documents they had to submit. The above noted items were still outstanding/incomplete. On 7/29/21, review of the facility policy titled, Abuse Prevention and Management Policy was conducted. This policy read, Screening a) The organization will screen potential employees for a history of abuse, neglect or mistreating residents i) If employment references cannot be obtained, personal references may be obtained .Virginia Specific Requirements: Screening. A) Each applicant will provide a sworn statement or affirmation disclosing any criminal convictions or any pending criminal chargers, whether within or outside the Commonwealth. The Administrator and Director of Nursing (DON) were made aware of the findings again on 7/29/21, during the end of day meeting. No further information was received.

Based on observation, interview, facility record review the faculty staff failed to provide Residents with a written description of legal rights which includes the names and addresses and phone numbers of State Office of Licensure and Certification, LTC agencies and Ombudsman. The findings included: For the 10 of the 10 Residents attending Resident Council on 7/27/21 at 2:30 PM the facility staff have not verbally told them and have not given them in writing a list of the agencies with which they may file a formal complaint. On 7/27/21 during the Resident Council meeting 10 of the 10 Residents that attended, (including the Resident Council President), stated they did not know how to file a grievance, and they did not know they could file a formal complaint with the Ombudsman, and they did not know they could file a complaint with the State Office of Licensure and Certification. Only 1 Resident out of 10 Residents in attendance knew that the Survey Results were available in the lobby area. On 7/28/21 a review of the new admission packet revealed that there was a document in the packet that outlined the information on grievance procedures, complaints to the State and Ombudsman. The document gave the correct information phone numbers and addresses and was to be signed by the Resident or RP upon admission to the facility. Surveyor C could not locate the signed copy within any of the clinical records of those that attended the Resident Council meeting . 0n 7/28/21 at 12:30 PM an interview was conducted with Employee G who stated that since the change in ownership in February 2021 the facility has limited access to the Resident records prior to February 2021, because they are on the other company's website which only 4 people were given access to and 2 of those no longer work here. On 7/29/21 during the end of day meeting the concerns were expressed to the Administrator and no further information was provided.

Based on Resident and Staff interview, clinical record review and facility documentation the facility staff failed to treat Residents with respect and dignity for 1 Resident (#28) in a survey sample of 22 Residents. For Resident # 28 the facility staff undressed the Resident wrapped her in a sheet, put her in the shower chair and wheeled her down the hall to wait in line for a shower causing Resident to state it feels like punishment. The findings included: Resident number 28, an [AGE] year old woman admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #28's most recent MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 6/7/21, coded the Resident as having a BIMS (Brief Interview of Mental Status) score of 10. Section G coded this resident as (3) extensive assistance with one person physical assist for bed mobility, (4) total dependence for transfers requiring two persons or more physical assistance and the use of mechanical lift, she is coded as (3) extensive assistance one person physical assistance for dressing, she is independent with set up help only for meals, she is coded as (4) total dependent for toileting, and bathing. G0400 functional limitations in range of motion (A) upper extremity impairment on both sides (B) lower extremity coded as to impairment on both sides G0600 mobility devices (C) wheelchair. For walking she is coded as (8) activity did not occur. She is unable to stand or bear weight. She can self-propel with her wheel chair for mobility and is coded as independent for locomotion on and off the unit with the wheelchair. On 7/27/21 at 2:30 PM a Resident Council meeting was held and Resident #28 attended. Resident # 28 was oriented to person, place, time, and situation and she actively participated in the meeting. Resident #28 asked the question Why do I have to have a cat and dog fight to get a shower? When asked about her shower experience she stated that is was horrible. She stated she knew she had the right to get 2 showers a week but she felt she had to fight to get them. She also stated the staff come to her room with the shower chair and undress her, wrap her in a sheet, then push her down the hall in the shower chair dressed only in a sheet. She stated Sometimes there is a line and I have to wait in the hallway dressed like that until the other person in the shower is finished When asked how that made her feel she Why do they punish us like that? That's what it feels like punishment. Resident #28 was asked if she knew why they weren't giving her showers and had she asked that question to staff. Resident #28 and the other simultaneously stated They are Short Staffed. When asked how she knew that they were short staffed she stated, The CNA's tell you, I can't give you a shower we don't have enough staff. A review of the Resident Council Minutes reflect that the slow call bell response times have been mentioned in February 2021, March 2021, April 2021, May 2021, and June 2021. Resident #28 stated When you ring the bell usually someone will come in and say I will be back. They cut off the light and never come back. Resident #28 and Resident # 47 stated they have waited sitting on the bedpan or toilet for up to an hour waiting for staff to return. She also made the comment They should not treat us this way, it just ain't right. On 7/28/21 at approximately 8:45 AM a review of the POC (Point of Care- computer system where the CNA's chart the ADL care for the Residents), revealed the following: Resident #28 - Received 0 Showers - 23 Partial Baths - 3 Bed Baths 07/28/21 11:10 AM Interview conducted with CNA A (an agency CNA) who was asked how she knew which Residents were to get showers that day. CNA A stated they told me that there is a shower list at the nurse's station. She was asked to describe the process of giving a shower to a Resident. She said We go to the room and bring the shower chair, depending on the resident sometimes we use a lift or sit to stand lift and some can transfer with a little assistance. We get them undressed and wrap them in a sheet and take them to the shower room in the shower chair. We bring their toiletries and clean clothes with us. The shower aid will then shower them and get them dressed. 07/28/21 11:16 AM an interview was conducted with CNA's B and C (agency staff - CNA's assigned as Shower Aids) CNA C stated she has been working at the facility for few weeks through agency and states This is the first time I have seen 2 shower aides on one shift, and in general this much staff. Since you all came in yesterday there has been plenty of staff. CNA C was asked if there has been times that showers were not given due to lack of sufficient staffing and she stated that it has happened a lot but they do give the Residents a partial bath instead if they cannot get the showers done. CNA B was asked if she has seen times that there was line of Residents waiting in the hall to get in the shower, she stated, Yes it's happened a few times since I have been here. 07/28/21 10:09 AM, interview was conducted with the Administrator who was asked if there were issues with staffing at the facility, she said At times yes. She was then asked if it impacted the care of the Residents, she said It may put a delay on things like call bell responses. When asked if there were any resident complaints of care due to short staffing she answered, No complaints but they have made the comments about having to wait longer for care. On 7/29/21 approximately 10:00 AM the Administrator submitted a statement in writing about the steps taken to ensure timely call bell answering. The statement read as follows: CALL BELL RESPONSE TIMES Actions taken to mitigate extended call bell response times -Monitoring call bells daily. -Reviewing and making staff aware of the averages and extended wait times -Staff are aware that call bells are to remain on until task has started -Discussion with staff during huddles regarding response times -Document average response times on huddle board (When the system is functioning properly) On 7/29/21 during the end of day meeting the Administrator was made aware of the concerns and no further information was provided.