Every finding on record at Twin Lakes Rehabilitation and Nursing

Based on resident interview, staff interview, and clinical record review, the facility staff failed to obtain orders for the care and treatment of a colostomy for one of 20 residents, Resident #67. Findings were: Resident #67 was admitted to the facility with the following diagnoses including but not limited to: diabetes mellitus, hypertension, anxiety, depression, and gastro-esophageal reflux. An annual MDS (minimum data set) with an ARD (assessment reference date) of 04/06/2023 assessed Resident #67 as cognitively intact with a summary score of 14. On 05/02/2023 at approximately 2:15 p.m., Resident #67 was interviewed regarding life in the facility. During the conversation she stated that she had a colostomy. She stated the facility staff provided all the care for the colostomy. The clinical record was reviewed at approximately 4:00 p.m. There were no orders observed for the care of Resident #67's colostomy. The care plan was reviewed and included: Potential for infection/skin breakdown s/t (secondary to) incontinence and colostomy. Interventions included but were not limited to: Ostomy care as ordered. There were no entries on the care plan or the physician orders for the frequency of flange change, size, brand, etc. On 05/03/2023 at approximately 9:00 a.m., the MDS coordinator was in the conference room and was asked about orders for Resident #67's colostomy. She printed out the current/active orders for Resident #67 and stated, I don't see any orders, but the care is being provided .(Name of electronic health record) drops orders off after 365 days .I think that might be what happened. At approximately 10:10 a.m., RN (registered nurse) #4 who was the unit coordinator was interviewed regarding Resident #67's colostomy. She was asked how the nurses knew when to change the flange, what supplies were needed, etc. She stated, We don't have a TAR (treatment administration record) we have a task list. She pulled up the task list for Resident #67 and stated, This says. Reassess Colostomy RUQ (right upper quadrant) Q (every) shift) so we look at it every shift. She was asked if there was a task that told the nurses when the flange was due to be changed and how often She stated, I don't see that .but she has frequent blow outs and we have to change it all the time .her supplies are in her room. A meeting was held with the administrator and the DON (director of nursing) on 05/03/2023 at approximately 11:25 a.m. The above information was discussed. The DON stated she would check and get back to the survey team. At 1:20 p.m., the DON came to the conference room. She stated,I looked and I don't see any orders either .there should have been orders for colostomy care. No further information was obtained prior to the exit conference on 05/03/2023.

Based on observation, staff interview, clinical record review, and facility document review the facility staff failed to follow their infection control policy for hand washing during the care and treatment of a pressure ulcer for one of 20 residents, Resident #58, and failed to follow infection control practices during a medication pass on Unit 1. Findings were: 1. Resident #58 was admitted to the facility with the following diagnoses, including but not limited to: Anemia, protein-calorie malnutrition, dementia, Parkinson's disease, dementia, and sacral Osteomyelitis. A quarterly MDS (minimum data set) with an ARD (assessment reference date) of 03/21/2023, assessed Resident #58 as impaired with long and short term memory, as well as daily decision making skills. The clinical record was reviewed on 05/02/2023 at approximately 11:00 a.m. and included documentation regarding a pressure injury to her sacrum and an unstageable area to her left hip. On 05/03/2023 at approximately 10:00 a.m., RN (registered nurse) #4 and LPN (licensed practical nurse) #2 were observed providing wound care to Resident #58's sacrum and left hip. Resident #58 was on contact isolation, both RN #4 and LPN #2 donned appropriate PPE (personal protective equipment). RN #4 held Resident #58 over on her right side as LPN #2 provided care to the pressure areas. LPN #2 donned non-sterile gloves and removed an old soiled dressing from Resident #58's sacrum. She removed her gloves and went to the bathroom to wash her hands. She returned, donned non-sterile gloves and used cleaned the wound using 4X4's and the prescribed wound cleanser. When she completed cleaning she removed her gloves and went to the bathroom to wash her hands. She returned, donned non-sterile gloves and continued care of the sacral pressure ulcer. She changed gloves two more times while completing the treatment, but did not wash her hands after changing her gloves. When she completed care for the sacral ulcer she provided care to the area on Resident #58's left hip, painting the area with betadine. She did not change gloves or wash her hands before going from one area (sacrum) to the next (hip). After completion of the dressing change RN #4 and LPN #2 were interviewed and asked about hand washing between glove changes. RN #4 stated, Yeah, I guess she could have used some gel to clean her hands. LPN #2 stated, I had already cleaned the area so everything was clean that I was doing . She was asked if she should have washed her hands before going from the sacral area to the left hip. She stated, Yes, I should have .I could have gotten some hand sanitizer off the cart. A meeting was held with the administrator and the DON (director of nursing) on 05/03/2023 at approximately 11:25 a.m. The above information was discussed. The DON stated she would review the policy and get back to the survey team. At 1:20 p.m., the DON came to the conference room. She presented a policy, Hand washing/Hand Hygiene which contained the following: .Use an alcohol-based hand run containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: .After removing gloves .the use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections. The DON stated, She should have washed her hands between glove changes and between care of the two areas. No further information was obtained prior to the exit conference on 05/03/2023. 28106 2. On 5/02/23 at 8:38 AM during a medication pass and pour, license practical nurse (LPN #1) was dispensing medications to Resident #18. While removing medications from the packets, LPN #1 dropped a tablet (Magnesium 400 milligrams) on the medication cart, picked the medication up with bare hand, placed it in the medication cup, and gave it to Resident #18. Prior to the observation LPN #1 had went into Resident #18's room to obtain vital signs, was observed reaching into her pocket to retrieve a marker, and had not cleaned off the medication cart where the medication landed. After the medication pass was completed the above information was presented to LPN #1, LPN #1 nodded her head in understanding, but did not respond. On 5/03/23 at 10:41 AM the DON (director of nursing) was informed of the above finding. The DON verbalized that LPN #1 should have disposed of the medication. A facility policy titled Administering Prepared Medication read in part Don't place tablets or capsules in your hands [ .] On 5/03/23 at 11:24 AM the above information was presented to the DON and administrator. No other information was presented prior to exit conference on 5/3/23.

Based on observation, staff interview and clinical record review, the facility staff failed to administer oxygen at the physician ordered rate for one of twenty residents in the survey sample (Resident #47). The findings include: Resident #47 was observed with oxygen administered at 2.5 lpm (liters per minute) when a physician's order required an administration rate of 4 lpm. Resident #47 was admitted to the facility with diagnoses that included Parkinson's disease, dementia, atrial fibrillation, gout, hypertension, congestive heart failure, arthritis, and depression. The minimum data set (MDS) dated [DATE] assessed Resident #47 with moderately impaired cognitive skills. On 5/2/23 at 11:18 a.m., Resident #47 was observed in bed with oxygen administered at a rate of 2.5 lpm. Resident #47 was observed again on 5/2/23 at 3:16 p.m. and on 5/3/23 at 8:16 a.m. with oxygen administered at 2.5 lpm. Resident #47's clinical record documented a physician's order dated 11/21/22 for continuous oxygen administration via nasal cannula at a rate of 4 lpm. Resident #47's plan of care (revised 5/1/23) documented the resident was at risk of edema and complications related to congestive heart failure. Interventions to prevent complications included, .Oxygen as ordered . On 5/3/23 at 8:18 a.m., the registered nurse (RN #3) caring for Resident #47 was interviewed about Resident #47's oxygen administration rate. RN #3 checked the electronic health record and stated the resident's oxygen was ordered at 4 lpm. On 5/3/23 at 8:21 a.m., accompanied by RN #3, Resident #47's oxygen was observed at 2.5 lpm. RN #3 assessed the resident's oxygen saturation at this time at 97%. RN #3 stated again the oxygen order required administration at 4 lpm. This finding was reviewed with the administrator and director of nursing during a meeting on 5/3/23 at 11:30 a.m.

Based on observation, staff interview, clinical record review, and facility document review the facility staff failed to follow infection control practices during the care and treatment of a pressure ulcer for one of 20 residents, Resident #58. Findings were: Resident #58 was admitted to the facility with the following diagnoses, including but not limited to: Anemia, protein-calorie malnutrition, dementia, Parkinson's disease, dementia, and sacral Osteomyelitis. A quarterly MDS (minimum data set) with an ARD (assessment reference date) of 03/21/2023, assessed Resident #58 as impaired with long and short term memory, as well as daily decision making skills. The clinical record was reviewed on 05/02/2023 at approximately 11:00 a.m. and included documentation regarding a pressure injury to her sacrum and an unstageable area to her left hip. The sacral area was measured on 05/01/2023 with the following measurements documented: 8 cm length, 9 cm width and 1.5 cm depth. Treatment orders were: After cleansing with [NAME] (wound cleanser), then apply Santyl and VASHE to fluffed 4X4 and place in wound bed, cover with abd and secure with tape. Treatment to the left hip was: Clean area with NS then paint left hip eschar well with betadine and allow to air dry. On 05/03/2023 at approximately 10:00 a.m., RN (registered nurse) #4 and LPN (licensed practical nurse) #2 were observed providing wound care to Resident #58's sacrum and left hip. Resident #58 was on contact isolation, both RN #4 and LPN #2 donned appropriate PPE (personal protective equipment). RN #4 held Resident #58 over on her right side as LPN #2 provided care to the pressure areas. LPN #2 donned non-sterile gloves and removed an old soiled dressing from Resident #58's sacrum. She removed her gloves and went to the bathroom to wash her hands. She returned, donned non-sterile gloves and used cleaned the wound using 4X4's and the prescribed wound cleanser. When she completed cleaning she removed her gloves and went to the bathroom to wash her hands. She returned, donned non-sterile gloves and continued care of the sacral pressure ulcer. She changed gloves two more times while completing the treatment, but did not wash her hands after changing her gloves. When she completed care for the sacral ulcer she provided care to the area on Resident #58's left hip, painting the area with betadine. She did not change gloves or wash her hands before going from one area to the next. After completion of the dressing change RN #4 and LPN #2 were interviewed and asked about hand washing between glove changes. RN #4 stated, Yeah, I guess she could have used some gel to clean her hands. LPN #2 stated, I had already cleaned the area so everything was clean that I was doing . She was asked if she should have washed her hands before going from the sacral area to the left hip. She stated, Yes, I should have .I could have gotten some hand sanitizer off the cart. A meeting was held with the administrator and the DON (director of nursing) on 05/03/2023 at approximately 11:25 a.m. The above information was discussed. The DON stated she would review the policy and get back to the survey team. At 1:20 p.m., the DON came to the conference room. She presented a policy, Hand washing/Hand Hygiene which contained the following: .Use an alcohol-based hand run containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: .After removing gloves .the use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections. The DON stated, She should have washed her hands between glove changes and between care of the two areas. No further information was obtained prior to the exit conference on 05/03/2023.

Based on staff interview and clinical record review, the facility staff failed to revise the comprehensive care plan for one of twenty residents in the survey sample (Resident #47). The findings include: Resident #47's care plan was not revised to include interventions for injury prevention following bruising to the resident's hand/finger. Resident #47 was admitted to the facility with diagnoses that included Parkinson's disease, dementia, atrial fibrillation, gout, hypertension, congestive heart failure, arthritis, and depression. The minimum data set (MDS) dated [DATE] assessed Resident #47 with moderately impaired cognitive skills and as requiring total assistance of one person for bed mobility. Resident #47's clinical record documented a nursing note dated 4/15/23 stating the resident's left hand was bruised during ADL (activities of daily living) care. A nursing note dated 5/1/23 documented the resident hit his right ring finger on the bed rail when turned in bed. Resident #47's plan of care (revised 5/1/23) documented the resident had compromised skin integrity due to impaired mobility, upper extremity swelling and was at risk for injury related to side rail use. The care plan was documented, .4/16/23 bruise at fingers on left hand .5/01/23 redness, swelling at right ring finger, with black finger nail . Resident #47's plan of care included no interventions regarding the injuries of 4/16/23 and 5/1/23 other than continue to monitor and was not revised with any actions taken for injury prevention. On 5/3/23 at 9:00 a.m., the registered nurse (RN #2) responsible for MDS and care planning was interviewed about care plan revisions regarding Resident #47's hand positioning issues/injuries. RN #2 stated the unit managers were responsible for adding acute issues to the care plan. On 5/3/23 at 9:12 a.m., the certified nurses' aide (CNA #1) that routinely cared for Resident #47 was interviewed. CNA #1 stated the resident's hands were swollen and required care with positioning during turning/bathing. CNA #1 stated she now used pillows for hand positioning to protect the resident during ADL care and/or turning in bed. On 5/3/23 at 9:15 a.m., the unit manager (RN #1) was interviewed about any care plan updates regarding Resident #47's hand injuries. RN #1 stated the resident was reassessed on 4/23/23 regarding use of bed rails and staff members were now using pillows for positioning and protection during ADL care and turning in bed. RN #1 reviewed the current plan and stated the interventions for injury prevention had not been added to the care plan. RN #1 stated, That's [pillows, bed rail reassessment) not on the care plan. It just says to continue to monitor. This finding was reviewed with the administrator and director of nursing during a meeting on 5/3/23 at 11:30 a.m.

Based on review of employee files, staff interview, and review of facility policy, the facility failed to implement their abuse prevention policy for the screening of new employees. The facility failed to obtain a Sworn Statement from seven of 24 new hired employees. The findings were: At approximately 1:30 p.m. on 5/3/2023, a review of 24 randomly selected personnel files of facility employees hired in the last two years was conducted. Two employees from the Human Resources Department assisted in the review. Documents included in the review were the Sworn Statement, Criminal Record Check, License (if applicable), and References. The review identified seven employees who did not have a Sworn Statement in their individual personnel file. The seven employees included the following: A CNA (Certified Nursing Assistant) hired on 4/13/2023 A CNA hired on 3/27/2023 A CNA hired on 3/17/2023 A CNA hired on 3/13/2023 A CNA hired on 3/6/2023 A CNA hired on 2/6/2023 A LPN (Licensed Practical Nurse) hired on 11/28/2022 The Human Resources (HR) Director explained that with the exception of the CNA hired on 2/6/2023, the other six were contract employees, although not all were from the same contractor. The CNA hired on 2/6/2023 was from an agency. According to the HR Director, the contractors/agency conduct their own background checks, including a criminal record check, license check, and obtaining a Sworn Statement. The HR Director went on to say the contractors/agency provide an attestation that the documents/checks were done, but they do not provide copies of the documents. The second HR staff member stated the facility's HR Department conducts their own criminal record check with the Virginia State Police, as required by law, as well as a license check and a check of references. Those documents were in the personnel files of the above referenced seven employees. Both the HR Director and the second HR staff member indicated they have to specifically request the Sworn Statement from the contractors/agency if they want them. Review of the facility's Abuse policy noted the following: SCREENING: 1.3.1 State licensure and certification agencies, and applicable registries, will be contacted, prior to hire, to validate current licensure or certification requirements and to determine if the potential employee is in good standing with the agency, including disciplinary actions from licensing or registration boards. Each applicant will provide a sworn statement or affirmation disclosing any criminal convictions or any pending criminal charges, whether within or outside the Commonwealth. The Administrator was advised of the findings at 2:00 p.m., prior to the Exit Conference.

Based on observation, staff interview and facility document review, the facility staff failed to store and prepare food in a sanitary manner. Frozen meat patties were stored uncovered and unlabeled in the freezer. Sliced cheese was stored in the refrigerator without a date opened or use by date. The manual can opener in the main kitchen was dirty. The findings include: On 6/8/21 at 11:48 a.m., accompanied by the dietary manager (other staff #2), the kitchen and food storage areas were inspected. Observed in the walk-in freezer was a large bag of frozen turkey sausage patties. The bag was open with the meat patties exposed to air. The turkey sausage patties had no manufacturer's label and no date opened or use by date posted on the bag. Observed in the walk-in refrigerator were 16 slices of cheese in an aluminum pan. The individual slices were in separate Ziploc bags with no date opened, no use by date and no commercial packaging indicating an expiration date. The dietary manager stated the cheese was served last week at an event and should have been discarded. On 6/8/21 at 12:15 p.m., accompanied by the dietary manager (other staff #2) the manual can opener mounted to a prep table was inspected. The can opener had an accumulation of black debris on the blade. The opener bracket mounted to the table also had an accumulation of black debris. On 6/10/21 at 9:20 a.m., the dietary manager was interviewed about the observations of the unsealed/undated turkey patties, undated cheese and the dirty can opener. The dietary manager stated the cheese stored in the Ziploc bags was served last week at a staff gathering. The dietary manager stated the cheese should have been discarded after the event. The dietary manager stated staff failed to reseal and label the bag of frozen turkey patties prior to storing in the freezer and foods were supposed to be labeled when opened. The dietary manager stated the can opener was supposed to be washed at least daily in the dishwasher or as needed. The facility's policy Food and Supply Storage Procedures (#B003-January 2021) documented concerning refrigerated foods, .Use manufacturer's expiration date for products before they are opened .Add the time in the 'opened' column to the date when the food is prepared or opened. Label when product is 'opened' . This policy documented hard cheeses (Parmesan, [NAME], Asiago) were to be used 13 days after opening and all other cheeses except cottage cheese use by 6 days after opening. This policy documented concerning freezer storage life, Use manufacturer's expiration date for products, but do not exceed 1 year .If a case of food is partially used, and the remaining food is exposed to the air .re-label when product is 'opened', to use within 3 months . These findings were reviewed with the administrator and director of nursing during a meeting on 6/9/21 at 4:45 p.m.

Based on observation, resident interview, staff interview, and clinical record review, the facility staff failed to ensure sufficient staffing to provide resident care for 3 of 23 residents in the survey sample, Resident #74, Resident #11, and Resident #33. Resident #74, Resident #11, and Resident #33 did not receive their showers as scheduled. The findings include: 1. Resident #74 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The most recent minimum data set (MDS) dated [DATE] was a quarterly assessment and assessed Resident #74 as cognitively intact for daily decision making with a score of 14 out of 15. Under section G - Functional Status, the MDS assessed Resident #74 total dependent with the assistance of one person for bathing. On 06/09/2021 at 10:30 a.m., Resident #74 was interviewed regarding her quality of life and quality of care at the facility. Resident #74 stated things here are better, my problem is the staffing shortage. I don't always get my scheduled showers. I'm supposed to get them on Tuesday and Friday of each week; however, it all depends on staffing and if there are enough people here. Resident #74 was asked if she missed her regular scheduled shower day was it made up on another day. Resident #74 stated, no, not unless you ask them to and only if there is enough staff then. Resident #74 was asked if she refused her showers. Resident #74 stated, oh, no. I enjoy them. I don't mind a bed bath, but a shower just makes you feel better and cleaner. On 06/09/2021, Resident #74's clinical record was reviewed. Observed on the Bath Type Detail Report for the 30 day period of 05/10/2021 - 06/09/2021 was documentation noting Resident #74 received showers only 4 times within the observed period on 05/11/2021, 05/14/2021, 05/25/2021, 06/01/2021, and a whirlpool on 05/18/2021. The clinical record did not document Resident #74 refusing showers during this time. On 06/09/2021 at 3:43 p.m., the certified nursing assistant (CNA #1) who routinely provides care for Resident #74 was interviewed regarding the shower schedule. CNA #1 was asked if there was a shower schedule. CNA #1 stated, I'm new to this floor. CNA #1 provided a red three-ring binder that consisted of 3 pages categorized by shift (first, second, and third) and included the first-floor room and bed numbers. The pages did not indicate specific days/times for each resident's shower. CNA #1 was asked how did the staff know which day/time was assigned for each resident. CNA #1 stated, by word of mouth from the staff on this unit. CNA #1 was asked how would staff know the shower schedule. CNA #1 stated, if a resident wants a shower then they are given one if we have enough staff, if there isn't enough staff then they are given bed baths. CNA #1 was asked if Resident #74 refused showers. CNA #1 stated, no, not that I know. On 06/09/2021 at 3:55 p.m., a licensed practical nurse (LPN #2) was interviewed regarding the shower schedule. LPN #2 stated, the information is usually shared by word of mouth from the staff because the know the residents and have worked with them. LPN #2 was asked if there was a detailed shower schedule other than the 3 ring binder that was presented. LPN #2 stated, no, not that I'm aware of. On 06/09/2021 at 4:40 p.m., the above information was shared with the administrator and DON during a meeting. The director of nursing (DON) was asked if there was a shower schedule for the first floor. The DON stated, yes, I will get the information and bring it to you. It is located in the Care Tracker system. The DON was asked if staff were familiar with the system. The DON stated, yes, they enter the data into this system so they should be aware. The DON was asked if Resident #74 refused any showers. The DON replied, no, not that I'm aware of. On 06/10/2021 at 7:57 a.m., the DON provided copies of the requested documents. A review of the information included the first-floor schedule that had been observed in the red 3 ring binder. The DON was asked how did staff identify the scheduled shower days. The DON stated, you have the same question as some of our staff. I believe what happened is the shower schedule format was changed somehow. The new unit coordinator is now working to update the shower schedule so that it matches the format of the second floor. This may be part of the reason the resident wasn't receiving her scheduled showers. No additional information was presented to the survey team prior to exit on 06/10/2021. 2. Resident #11 was admitted to the facility on [DATE] with a re-admission on 10/16/19. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The minimum data set (MDS) dated [DATE] assessed Resident #11 as cognitively intact and with total dependence on staff for bathing. On 6/9/21 at 11:20 a.m., Resident #11 was interviewed about quality of life and care on the facility. Resident #11 stated care was ok when there was enough help on the floor. Resident #11 stated he was not receiving showers/whirlpool baths routinely because there was not enough help. Resident #11 stated he usually received a shower/whirlpool during the evenings and sometimes there were only one or two aides on the entire floor. Resident #11 stated that at times he refused showers depending on the day but wanted shower/whirlpool on a regular basis. Resident #11 stated he received bed baths but had a whirlpool bath only a few times since the first of this year. Resident #11's bath records for the last 30 days were reviewed. Resident #11's record documented the resident received 18 bed baths from 5/10/21 through 6/7/21 with no refusals listed. There were no documented showers or whirlpool baths given to Resident #11 during the past month. Resident #11's plan of care (revised 5/5/21) documented resident needed assistance with activities of daily living due to immobility. Interventions to maintain hygiene and grooming included, Needs total assist with bathing, dressing .requires extensive assist with bed mobility, personal hygiene . On 6/9/21 at 3:31 p.m., the certified nurses' aide (CNA #3) that routinely cared for Resident #11 was interviewed. CNA #3 stated Resident #11 was scheduled for showers/whirlpool on the second (evening) shift and she worked mostly days. CNA #3 was not sure why Resident #11 was not receiving showers. On 6/9/21 at 3:35 p.m., the licensed practical nurse (LPN #4) caring for Resident #11 was interviewed. LPN #4 stated she was not sure why the resident was not getting showers. LPN #4 stated the resident went [CONDITION(S)] each Monday, Wednesday and Friday and returned to the facility those days around 6:30 p.m. LPN #4 stated the resident was scheduled for showers on the evening shift. On 6/9/21 at 3:43 p.m., the registered nurse in charge on the second floor (RN #4) and the second shift clinical coordinator (RN #3) were interviewed about Resident #11's showers/whirlpool baths. RN #3 stated it was her understanding the resident was receiving showers and/or whirlpool baths weekly. RN #3 stated she usually monitored the baths/whirlpools but had not looked at it in the past month. RN #3 viewed the resident's bath history for the last 30 days and stated the resident had received only bed baths and no showers. RN #3 stated Resident #11 sometimes refused showers but refusals were supposed to be documented. RN #4 stated call outs by staff were a frequent contributor for showers/whirlpools not being offered or done. RN #4 stated callouts by staff were a daily occurrence and attempts were made to pull staff from other units or call in staff not scheduled to work. RN #3 stated limited staff was the biggest problem contributing to showers/whirlpool baths not being done. RN #3 stated Resident #11's assigned CNA for today's evening shift (6/9/21) just called out this afternoon. RN #3 stated the preference was to have three aides on each floor during the evening shift but some evenings there were only one or two aides on the floor. These findings were reviewed with the administrator and director of nursing during a meeting on 6/9/21 at 4:45 p.m. 3. Resident #33 was admitted to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The most current MDS (minimum data set) was a quarterly assessment with an ARD (assessment reference date) of 4/6/21. Resident #33 was assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . Section G of the most recent MDS indicated Resident #33 needed physical help with transfer for bathing. On 06/08/21 at 12:09 PM Resident #33 was interviewed. During the interview Resident #33 said that she enjoys taking her baths and she is supposed to be getting a bath twice a week but has not been getting them, and when she does get a bath, it feels like the staff are rushing her. Review of Resident #33's Bath Type Detail Report for a 30 day look back period ( 5/11/21 through 6/7/21) documented Resident #33 received a whirlpool bath on 5/11/21, 5/21/21, and 6/1/21, all other documentation indicated that Resident #33 had gotten bed baths. Progress notes were also reviewed and did not indicate Resident #33 was refusing baths. Review of Resident #33's bath schedule indicated Resident #33 was scheduled to receive a bath on Tuesday's and Friday's on the evening shift. On 06/09/21 at 3:43 PM, registered nurse (RN #3 clinical coordinator) and RN #4 floor supervisor were interviewed regarding Resident #33's showers. RN #4 stated that she was the person that monitors showers for the evening shift, but has not been able to monitor this activity for the last month due to just being really busy doing other tasks. RN #3 reviewed Resident #33's shower record and stated that Resident #33 does enjoy her showers and usually does not refuse a shower. RN #3 stated that the main problem was staff call outs that sometimes leave the CNA's short handed. RN #3 said that lately the facility has been having a lot of call outs. RN #4 agreed with the concerns of the amount of staff calling off work. On 06/09/21 at 4:39 PM the above information was presented to the administrator and director of nursing. The administrator said we have our share of call outs but not an excessive amount. No other information was presented prior to exit conference on 6/10/21.

Based on record review, and staff interview the facility staff failed to ensure a complete and accurate record for one of 23 residents in the survey sample, Resident # 87. Findings include: Resident # 87 was admitted to the facility 10/5/17 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The most recent MDS (minimum data set) was a quarterly assessment dated [DATE], and scored the resident as severely impaired in cognition. A review of the closed electronic record (EMR) was conducted 6/9/21 beginning at 9:00 a.m. It was noted that on 3/24/21 the resident expressed pain of the left shoulder. She was seen by the nurse practitioner that day and was ordered Acetaminophen every 4 hours for pain. The MAR (medication administration record) and the pain assessments were then reviewed. The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The pain assessments revealed inconsistent documentation for the evaluation of the effectiveness of the acetaminophen. On 6/9/21 at 11:00 a.m. RN (registered nurse) was interviewed about the assessments. She was asked how staff were assessing Resident # 87's level of pain, and where that was documented. RN #1 stated (name of resident ) wasn't always able to verbalize pain; staff use the 'face scale' to rate pain per the resident's facial grimacing, moaning, restlessness, etc. I'm looking at the assessments and I don't see that documentation either .I see that staff also did not document per shift as should be done. It looks as though she was being treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . We have a problem with documentation; I hate to say it but you are absolutely correct. The facility staff were informed of the above findings during a meeting 6/10/21 beginning at 11:30 a.m. No further information was presented prior to the exit conference.

Based on observation and staff interview, the facility staff failed to dispose of garbage/waste in a sanitary manner. Bags of garbage and a broken blind were on the ground and not contained within the dumpster/compactor. The findings include: On 6/8/21 at 12:15 p.m., accompanied by the dietary manager (other staff #2), the facility's waste/dumpster area was inspected. Three bags of garbage and a broken window blind were on the ground to the right of the dumpster/compactor. The dietary manager was interviewed at the time of the observation about the garbage on the ground. The dietary manager stated the garbage was from the quarantine units and not the kitchen. The dietary manager stated all garbage was supposed to be placed in the dumpster/compactor and not on the ground. The dietary manager stated if the dumpster was not available for some reason, a gray barrel was available for garbage storage until the dumpster/compactor was back in service. This finding was reviewed with the administrator and director of nursing during a meeting on 6/9/21 at 4:45 p.m.

Based on observation, staff interview and clinical record review, the facility staff failed to develop a baseline care plan regarding a PICC (peripherally inserted central catheter) line, for one of 23 residents, Resident #29. Findings include: Resident #29 was originally admitted to the facility on [DATE], with the most current readmission on 06/01/21. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The most recent MDS (minimum data set) was a quarterly assessment dated [DATE]. This MDS assessed the resident with a cognitive score of 15, indicating the resident was intact for daily decision making skills. During an interview with Resident #29 on 06/08/21, the resident was observed with a PICC line in the right antecubital area. Resident #29 stated that it was inserted while she was in the hospital and it was required because she had a toe amputated and was receiving antibiotics for [CONDITION(S)]. The resident's clinical records were reviewed and revealed that Resident #29 was readmitted to facility on 06/01/21 and the PICC line was in place upon admission. The resident's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #29's initial care plan was then reviewed. There was no information regarding the PICC line, the resident receiving antibiotics, or the resident's [CONDITION(S)]. On 06/10/21 at approximately 10:00 AM, the MDSC [MDS Coordinator] was interviewed regarding the resident's initial care plan. The MDSC was asked if the PICC line information should be on the resident's initial care plan. The MDSC stated, It should. The MDSC looked at the initial care plan and stated that it was not a check the box type of care plan, it would have to be added to the care plan. On 06/10/21 at 11:00 AM, the administrator and DON (director of nursing) were made aware in a meeting with the survey team that an initial care plan was not developed for Resident #29 regarding the PICC line. No further information and/or documentation was presented prior to the exit conference on 06/10/21 at 11:45 AM.

Based on resident interview, staff interview, and clinical record review, the facility staff failed to ensure sufficient fluid intake to maintain proper hydration for one of 28 residents in the survey sample, Resident #45. Resident #45 was admitted to the hospital with [REDACTED]. This was identified as harm. The Findings Include: Resident #45 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. The most current MDS (minimum data set) was a initial assessment with an ARD (assessment reference date) of 3/7/19. Resident #45 was assessed with [REDACTED]. On 5/29/19 at 8:45 AM Resident #45 was interviewed. During the interview Resident #45 was asked about being admitted to the hospital. Resident #45 stated that she had recently been admitted to the hospital twice, one time for infection the other time because of dehydration. A central line (Peripherally Inserted Central Catheter (PICC) line) inserted into the chest area was observed. When asked about the PICC line, Resident #45 stated the PICC line was inserted because of receiving fluids each night so that she doesn't get dehydrated. Resident #45 stated that she has dumping syndrome and if she eats or drinks too much at one time the fluids and food dump out into a [MEDICAL CONDITION] without being absorbed. On 5/29/19 Resident #45's clinical chart was reviewed. A nursing note dated 2/20/19 documented Blue lumen (line) PICC torn, red line patent and flushes without difficulty. On call MD (name of nurse practitioner) notified. Advised to call ER (emergency room ) to see if someone is available to replace. Call placed to ER nurse in ER states no one available to replace PICC tonight. States infusion can be run in red lumen. ER nurse stated by being a two line PICC nothing will come out of the blue line because it is a separate line. Staff will secure blue line until able to replace in am. DON (director of nursing) notified. Another clinical note dated 2/23/19 by the emergency department documented Patient has a hx (history) of dumping syndrome and receive around a liter of fluids everyday. Her (Resident #45) PICC line has a hole in it so it can not (sic) be used until it is fixed. She (Resident #45) has not received fluids for 3 days. C/O (complaint of) dehydration, no appetite, HA (headache), stomach pain. A surgery consult dated 2/25/19 evidenced that Resident #45 had a surgical procedure performed (replacement of PICC line) due to a ( .) malfunctioning Groshong (central line) catheter and the patient was unable to use get (sic) IV (intravenous) fluids and is dehydrated on admission ( .) The hospital records also included an image of the torn PICC line and documentation that read note tape on line-there is damage and line is split - port not in use needs replacement of Hickman (central line) split in tubing ( .) continues with heavy producing [MEDICAL CONDITION] which requires fluid replacement. ( .) Note the image showed that there were 2 lines (ports of entry) to the central line (indicating if one line can't be used then the other line can be). A hospital discharge summary evidenced that Resident #45 was discharged back to the facility on [DATE] with a [DIAGNOSES REDACTED]. Resident #45's physician orders [REDACTED].#45 to receive Sodium Chloride 1,000 ML (milliliters) IV bedtime, ( .) use rate of 125 ML per hour ( .) Resident #45 Medication Administration Record [REDACTED]. The MAR indicated [REDACTED]. This documentation was written by three different nurses (a different nurse for each day). Resident #45's care plan (for the time period in question) was then reviewed. A care plan for Dehydration/Fluid Maintenance had been initiated with interventions that included encourage fluids and to give IV fluids nightly. On 05/30/19 at 11:15 AM, license practical nurse (LPN) #9, identified as one of the nurses who were assigned to Resident #45 and did not give IV fluids on one of the nights identified above, was interviewed via telephone. LPN #9 was asked about Resident #45 not receiving fluids during a shift that LPN #9 had worked. LPN #9 stated that the PICC line was torn and couldn't be used. LPN #9 was asked if the second line could be accessed. LPN #9 stated that she thought that there was only one line. It was explained to LPN #9 that according to documentation and an image of the PICC line, there were two access points. LPN #9 stated that she really could not remember but if there were two access lines, then she would have used the other line unless that line could not be accessed. The other nurses that did not give IV fluids were unavailable to interview. One of the nurses no longer worked at the facility and the other nurse was a part-time nurse on an as needed basis and unable to be contacted. On 5/30/19 at 11:45 AM, the director of nursing (DON) was informed of the above concern and was asked to present any additional information regarding physician notification of the fluids being stopped due to torn PICC line or any physician orders [REDACTED]. The DON presented a nursing note dated 2/25/19 (indicating a late entry) that read provider updated on care status: MD (Medical Doctor) was notified due to central line was not in use and resident is on iv fluids. MD gave orders to hold fluids until line is replaced. The date of when the physician was notified was given as 2/21/19. There was no evidence provided that an actual physician order [REDACTED].#45's clinical record to stop the IV fluids, and the MAR indicated [REDACTED]. On 05/30/19 at 3:10 PM the administrator and DON, were informed of concerns about the nursing note indicating that the physician was informed on 2/21/19 and that the physician stated to stop the IV fluids without any indication when a new PICC line was going to be replaced or any order regarding how Resident #45 was going to receive sufficient fluid intake to ensure hydration. The DON stated that the clinical coordinator should have certainly followed up on stopping the fluids and when a PICC line was going to be replaced. On 05/30/19 at 3:21 PM, Resident #45's physician was interviewed via telephone. The physician stated that he was aware that the PICC line could not be use and also stated this has happened before and it usually only takes a day to get a Resident into the hospital so that a new PICC line can be placed. The physician stated that he was aware of Resident #45's dumping syndrome but by encouraging the Resident to drink fluids then there was usually no concern for dehydration for a day but would not be appropriate for a long period of time. The physician stated that he had never seen a PICC line take a long time to be scheduled to get replaced and would think that staff would have let him know that the Resident had not had IV fluids for 3 days. The physician also stated that he was not aware of Resident #45's condition until Resident #45 was admitted to the hospital. The physician stated this was a lesson learned. On 05/30/19 at 3:40 PM, Resident #45 was interviewed regarding going to hospital due to dehydration. Resident #45 stated that the staff didn't give her fluids for 3 evenings and she became dehydrated. Resident #45 stated that she has been dehydrated before and when the feeling comes on then she goes down hill fast. When asked if the staff were giving oral fluids, Resident #45 stated she can't drink that much fluid because she has just a small section of colon and the fluids don't get absorbed and go right through due to dumping syndrome. Resident #45 was asked how long the PICC line had been in place. Resident #45 stated it had been in place since she was admitted to the facility and that it really helps with hydration. No other information was presented prior to exit conference on 5/30/19.

Based on observation, staff interview, clinical record review, the facility staff failed to provide services to prevent an avoidable decline in range of motion for one of 28 residents, Resident #24. Resident #24 suffered an increase in the contractions of her left hand. Restorative nursing was being provided three times per week and was stopped on 03/21/201 pending an evaluation by occupational therapy for a hand orthotic. The evaluation was not done until 03/28/2019. At the time of the evaluation on 03/28/2019, Resident #24's hand had contracted into a fixed fist and the skin on her fingers had fused together. This was identified as harm by the survey team. Findings were: Resident #24 was originally admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. A quarterly MDS (minimum data set) with an ARD (assessment reference date) of 03/04/2019 assessed Resident #24 as having problems with short term memory and daily decision making skills. Initial tour of the facility was conducted on 05/28/2019 at approximately 11:30 a.m. Resident #24 was observed lying in bed. Her left hand was wrapped in gauze. LPN (licensed practical nurse) #4 was in the hallway and was asked about the dressing. She stated, She had an injury .there was some exposed bone. The clinical record was reviewed from 05/28/2019 through 05/30/2019. Observed on the POS (physician order [REDACTED]. The care plan for Resident #24 included the following: LTC ADL (long term care activities of daily living) Function Rehab Outcomes included but were not limited to: Resident Will Not Have a Decline in Level of ADL Function; Interventions included but were not limited to: RNP-PROM BLE in all planes as tolerated. LTC Musculoskeletal Outcomes included but were not limited to: (Name} will not have further decline of her bilateral hand contractions'; (Name} will allow staff to clean, move her bil. hands to prevent further declin in contracture. Interventions included but were not limited to: Position (Name) upper extremities, hands for comfort and to prevent immobility complications. On 05/29/2019 at approximately 2:00 p.m., the wound nurse, LPN (licensed practical nurse) #6 came to the conference room to discuss Resident #24's left thumb. She was accompanied by the DON. LPN #6 stated that occupational therapy had been working with Resident #24 in her room doing range of motion to her hand and had informed her that there was a wound present. It was requested that the occupational therapist that had worked with Resident #24 be brought into the conversation. The COTA (certified occupational therapy assistant) that worked with Resident #24 came to the conference room. She stated, We (occupational therapy) picked her up around the end of (MONTH) for contracture management. At that time her hand was stuck in a fisting position .I first saw her on (MONTH) 2nd .the skin of her thumb and fingers had fused together .I was working with her and she pulled away .her fingers became unstuck and were open at the knuckle of her thumb .it looked like bone .nursing was informed and they started the dressing changes then. The COTA was asked about an order on the POS dated 01/07/2019 for RNP (restorative nursing) -PROM (passive range of motion) in BUE (bilateral upper extremities) in all planes as tolerated by patient. The COTA stated, She had been getting that, but it stopped when therapy came back in. It was requested that the Restorative aide be brought into the conversation. The CNA (certified nursing assistant) #4 who provided restorative nursing care to Resident #24 came to the room. She was asked about Resident #24's left hand. She stated, We got her back in restorative around the end of (MONTH) or the first part of (MONTH) .I did Passive range of motion to her uppers, her arms and hands .when I was working with her there wasn't nothing wrong with her left hand like open areas or anything .her hand was contracted but I could get it open by rubbing it and putting lotion on it to loosen it up .I could move her thumb out and get to her palm, it wasn't stuck in a fist CNA #4 was asked when she stopped providing services. She left the room and returned with documentation. She stated, Here is the referral .we got that on (MONTH) 7 .I saw her three times a week starting (MONTH) 10 .my last visit with her was (MONTH) 21 .therapy was coming in and we can't do restorative if the resident is getting therapy. The referral contained the following information: Restorative Nursing Program Referral .Program: PROM (checked). Goals to Maintain Resident's Current Functional Status: 1. PROM to BUE (bilateral upper extremities) in all planes as tolerated by patient.; Frequency: 3 X week/ 12 weeks (3 times per week for 12 weeks); Start Date: 1-10-19. The form was signed by CNA #4 and the traveling OT who was no longer at the facility. The COTA was asked when Occupational therapy started. She stated, The evaluation was done on (MONTH) 28 .it looks like the request was made on (MONTH) 20 for her to be evaluated for an orthotic for that hand .usually after we get the request it's done in the next day or two .It must have gotten overlooked. The therapist that did the evaluation was a [MEDICATION NAME] and she is not here any more. The COTA and the Restorative CNA were asked what services Resident #24 received to treat her left hand contractures from 03/21/2019, the day of the last restorative visit until the date of the evaluation, 03/28/2019. Neither could provide an answer. The evaluation completed on 03/28/2019 was presented by the COTA. Per the evaluation: Range of Motion .UE ROM (Upper extremities range of motion): RUE ROM = Impaired (contractures and deformities present at all joints, able to grasp items); LUE ROM = Impaired (contractures and joint deformities present at all joints of hand, with flexion. Patient's hand contracted in flexion) .Joints: Shoulder = WFL (within functional limits); Elbow/Forearm = WFL, Wrist = WFL; Hand = Impaired; Shoulder = WFL; Elbow/Forearm = Impaired (contracted in elbow flexion); Wrist = Impaired (contracted in extension); Hand = Impaired (all digits and joints contracted and deformities present, in flexed position). The COTA was asked what a flexed position meant. She stated, Her hand was fixed in a fist. A previous evaluation from OT dated 11/26/2018 was also presented by the COTA. The assessment summary contained the following description of Resident #24, Functional Limitations as a result of Contractures: Patient presents with multiple contractures to her bilateral wrists and digits. Her right wrist contracted in a flexed position and left contracted in a position of extension. Patient exhibits swan neck deformity to digits bilaterally . The COTA was asked what a swan neck deformity was. She stated, Her fingers turned up on the ends. She was asked if there was a decline between the two evaluations. She stated, Yes. The COTA was asked if the delay in the evaluation and lack of restorative during that time could have contributed to the decline. She stated, Yes. The COTA was asked what could have been done to keep Resident #24's hand from becoming fixed in a fist and her fingers stuck together. She stated, Hand hygiene .if you are cleaning the hand and massaging it to help the contractures, the skin won't fuse between the fingers and cause pressure as they rest on each other. She was asked how long it would take for Resident #24's hand to be in that condition if hand hygiene wasn't performed. She stated, Just a couple of days. The COTA was asked if the wound on Resident #24's hand was from pressure. She stated, Yes, from her fist being contracted and fixed. She was asked if she thought it was avoidable. She stated, Yes, if hand hygiene was provided that would have kept her fingers from being stuck together. One of the therapy techs, (OS #10) came into the conference room during the interview. She and the COTA were asked how long they had been doing their jobs and had they ever seen anything like this before. The COTA stated, I've been doing this since (YEAR), I've never seen it happen before. OS #10 stated, I've been doing this for ten years, I've never seen this happen before. During an end of the day meeting on 05/29/2019 with the DON and the administrator, concerns were voiced that per interviews conducted with staff, Resident #24's hand was not fixed in a fist when restorative nursing was working with her. The hand could be opened and the thumb moved. Restorative was discontinued on 03/21/2019. There were no documented interventions from 03/21/2019 until 03/28/2019 when occupational therapy reevaluated her. When the COTA came in the room to do therapy on 04/04/2019, the fingers were stuck together and when Resident #24 pulled away, they became unstuck with resulting full thickness wounds. On 05/30/2019 at approximately 2:55 p.m., the DON, the administrator and the Quality Assurance nurse came to the conference room to discuss Resident #24. The DON stated, We can't explain what happened from (MONTH) 21 through (MONTH) 28, there is no documentation showing what if anything was being done with her hand .but we have information that the therapist and the nurses were working together to treat her after that. The DON was informed that there were no issues with the treatment documented before (MONTH) 21 or after the evaluation on (MONTH) 28, the concern based on staff interviews, was the time frame after restorative was discontinued and the evaluation done seven days later by occupational therapy. The DON stated that she understood. The DON was asked who should have been providing hand hygiene to Resident #24. She stated, The CNA doing her bath should be doing that. The name and phone number of the CNA who had bathed Resident #24 on the night shift was requested. At approximately 3:45 p.m., the requested information for the CNA (CNA #22) who bathed Resident #24 on the night shift for five of seven nights between 03/21/2019 and 03/28/2019 was received. She was contacted via telephone at approximately 4:00 p.m. and interviewed regarding Resident #24. She was asked if she had cared for Resident #24 during the week of 03/21/2019 through 03/28/2019. She stated, Yes. She was asked what care she had provided. She stated, I turn her, I get her something if she needs it and I bathe her. CNA #22 stated, I start at her face and go down. I wash her face, her neck, her chest her arms, her hands, and work my way down all the way to her feet. CNA #22 was asked if she had washed Resident #24's hand. She stated, Yes, I run the wash cloth between her fingers. She was asked if she had done range of motion on Resident #24's left hand. She stated, I run the washcloth in and out between her fingers. She was asked if she had been able to open Resident #24's left hand at all or move her thumb. She stated, I run the washcloth in and out between her fingers. No further information was obtained prior to the exit conference on 05/30/2019.

Based on observation, staff interview, and clinical record review, the facility staff failed to ensure two of 28 residents did not develop pressure ulcers, and failed to ensure one of 28 residents had prevalon boots in place as ordered by the physician. 1. Resident #24 developed full thickness skin loss to her first (thumb) and fourth finger on her left hand. This was identified as harm by the survey team. 2. Resident #5 did not have weekly skin assessments completed by the nursing staff. On 02/01/2019 a Stage III pressure ulcer was discovered on her left heel. This was identified as harm by the survey team. 3. Resident #2 was not wearing physician ordered prevalon boots. Findings include: 1. Resident #24 was originally admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. A quarterly MDS (minimum data set) with an ARD (assessment reference date) of 03/04/2019 assessed Resident #24 as having problems with short term memory and daily decision making skills. Initial tour of the facility was conducted on 05/28/2019 at approximately 11:30 a.m. Resident #24 was observed lying in bed. Her left hand was wrapped in gauze. LPN (licensed practical nurse) #4 was in the hallway and was asked about the dressing. She stated, She had an injury .there was some exposed bone. We are doing dressing changes on it .I'm pretty sure we did an X-ray and nothing was broken. The clinical record was reviewed from 05/28/2019 through 05/30/2019. Observed on the POS (physician order [REDACTED]. A wound team progress note dated 04/12/2019 contained the following information: Visit Information: Called to ck (check) for breakdown of fingers Pain: Patient response screams out when touch (sic) either hand and fights nurse attempting care. Left thumb-thumb may be broken-bone protruding at middle joint-soft-no tone to upper thumb area-all fingers thin and contracted-Some light bleeding at area shown above (referring to picture of injury) and also finger crossing has open tissue. Will need to talk with Dr. about possible X-ray of area and develop plan of care. Cleaned and covered with [MEDICATION NAME] foam and secured . The care plan for Resident #24 included: LTC Skin Intergrity Outcomes included but were not limited to: Skin Integrity Maintained; (Name) will not have further issues from moisture; Minimize risk for skin breakdown r/t (related to) pressure or moisture thru next review'; Interventions included but were not limited to: Apply moisture as needed for dryness; Change dressing to 1st and 4th finger each shift as ordered (Discontinued); [MEDICATION NAME] blue dsg (dressing) to 1st finger wound on Rt (hand) (Discontinued); [MEDICATION NAME] blue dsg to Lt (left thumb) every 3 days. On 05/29/2019 at approximately 10:00 a.m., the DON (director of nursing) was in the conference room to speak with the survey team. She was asked to let the wound nurse know that this surveyor needed to see the dressing change to Resident #24's left hand when it was done. The DON left the room and returned a few minutes later. She stated, The dressing was done early this morning .it is only done every three days and is very painful for the resident, if you want to see it we will do it again. The DON was asked if the dressing could be done the following morning (05/30/2019). She stated she would let the wound nurse know. On 05/29/2019 at approximately 2:00 p.m., the wound nurse, LPN (licensed practical nurse) #6 came to the conference room to discuss the wound on Resident #24's left thumb. She was accompanied by the DON. LPN #6 stated that occupational therapy had been working with Resident #24 in her room doing range of motion to her hand and had informed her that there was a wound present. She stated that she looked at the wound and initiated dressing changes. It was requested that the occupational therapist that had worked with Resident #24 be brought into the conversation. The COTA (certified occupational therapy assistant) that worked with Resident #24 came to the conference room. She stated, We (occupational therapy) picked her up around the end of (MONTH) for contracture management. At that time her hand was stuck in a fisting position .I first saw her on (MONTH) 2nd .the skin of her thumb and fingers had fused together .I was working with her and she pulled away .her fingers became unstuck and were open at the knuckle of her thumb .it looked like bone .nursing was informed and they started the dressing changes then. The COTA was asked about an order on the POS dated 01/07/2019 for RNP (restorative nursing) -PROM (passive range of motion) in BUE (bilateral upper extremities) in all planes as tolerated by patient. The COTA stated, She had been getting that, but it stopped when therapy came back in. It was requested that the Restorative aide be brought into the conversation. The CNA (certified nursing assistant) #4 who provided restorative nursing care to Resident #24 came to the room. She was asked about Resident #24's left hand. She stated, We got her back in restorative around the end of (MONTH) or the first part of (MONTH) .I did Passive range of motion to her uppers, her arms and hands .when I was working with her there wasn't nothing wrong with her left hand like open areas or anything .her hand was contracted but I could get it open by rubbing it and putting lotion on it to loosen it up .I could move her thumb out and get to her palm, it wasn't stuck in a fist CNA #4 was asked when she stopped providing services. She left the room and returned with documentation. She stated, Here is the referral .we got that on (MONTH) 7 .I saw her three times a week starting (MONTH) 10 .my last visit with her was (MONTH) 21 .therapy was coming in and we can't do restorative if the resident is getting therapy. The COTA was asked when Occupational therapy started. She stated, The evaluation was done on (MONTH) 28 .it looks like the request was made on (MONTH) 20 for her to be evaluated for an orthotic for that hand .usually after we get the request it's done in the next day or two .It must have gotten overlooked. The therapist that did the evaluation was a [MEDICATION NAME] and she is not here any more. The COTA and the Restorative CNA were asked what services Resident #24 received to treat her left hand contractures from 03/21/2019, the day of the last restorative visit until the date of the evaluation, 03/28/2019. Neither could provide an answer. The evaluation completed on 03/28/2019 was presented by the COTA. Per the evaluation: Range of Motion .UE ROM (Upper extremities range of motion): RUE ROM = Impaired (contractures and deformities present at all joints, able to grasp items); LUE ROM = Impaired (contractures and joint deformities present at all joints of hand, with flexion. Patient's hand contracted in flexion) .Joints: Shoulder = WFL (within functional limits); Elbow/Forearm = WFL, Wrist = WFL; Hand = Impaired; Shoulder = WFL; Elbow/Forearm = Impaired (contracted in elbow flexion); Wrist = Impaired (contracted in extension); Hand = Impaired (all digits and joints contracted and deformities present, in flexed position). The COTA was asked what a flexed position meant. She stated, Her hand was fixed in a fist. A previous evaluation from OT dated 11/26/2018 was also presented by the COTA. The assessment summary contained the following description of Resident #24, Functional Limitations as a result of Contractures: Patient presents with multiple contractures to her bilateral wrists and digits. Her right wrist contracted in a flexed position and left contracted in a position of extension. Patient exhibits swan neck deformity to digits bilaterally . The COTA was asked what a swan neck deformity was. She stated, Her fingers turned up on the ends. She was asked if there was a decline between the two evaluations. She stated, Yes. The COTA was asked what could have been done to keep Resident #24's hand from becoming fixed in a fist and her fingers stuck together. She stated, Hand hygiene .if you are cleaning the hand and massaging it to help the contractures, the skin won't fuse between the fingers and cause pressure as they rest on each other. She was asked how long it would take for Resident #24's hand to be in that condition if hand hygiene wasn't performed. She stated, Just a couple of days. The COTA was asked if the wound on Resident #24's hand was from pressure. She stated, Yes, from her fist being contracted and fixed. She was asked if she thought it was avoidable. She stated, Yes, if hand hygiene was provided that would have kept her fingers from being stuck together. One of the therapy technicians, (OS #10) came into the conference room during the interview. She and the COTA were asked how long they had been doing their jobs and had they ever seen anything like this before. The COTA stated, I've been doing this since (YEAR), I've never seen it happen before. OS #10 stated, I've been doing this for ten years, I've never seen this happen before. After the interviews discussed above, the DON was asked to present any additional information regarding the pressure area to Resident #24's left thumb. Further review of the clinical record was conducted. A skin integumentary note dated 04/04/2019 contained the following: 1st and 4th finger full thickness skin loss. Yellow and pink tissue noted to both areas. Depth noted to first finger. Resident fighting with staff while trying to assess. Foam dressing applied. Bleeding noted. MD aware. Stated to have treatment nurse address. On 04/12/2019 after the wound nurse evaluated Resident#24, a recommendation was made to send her to the emergency room . Transfer comments on the facility transfer note included: Resident sent to ER due to possible bone exposure to left thumb . The emergency room visit note dated 04/12/2019 included the following: .Patient presents for wound evaluation .open wound of left thumb. Patient digits are significantly contracted. Pt is non-verbal but it is apparent that the area is causing her pain .Musculoskeletal: Upper extremities: All digits malformed due to contractures. Exposed bone to IP joint of left thumb, medial aspect .area is extremely tender when manipulated . An X-ray was obtained. The report included: Two fingers of he left hand were stuck together. When they were separated the fingers, a sore was noted which exposed the bone of the left thumb. Given the degree of the contraction, the left thumb is very limitedly assessed. No gross abnormalities of thumb are noted. There does appear to be a pencil in cup type deformity involving the 5th PIP joint suggesting psoriatic arthritis. Impression: The hand is severely contracted. The left thumb is visualized. No gross abnormalities of the thumb are noted . An orthopedic consult was obtained on 04/15/2019, and contained the following: .Patient is extremely demented .Patient have (sic) deep laceration on dorsal aspect of the thumb. The thumb is deformed and curled up most probably from chronic arthritis. All fingers are deformed .At this point I recommend to continue daily dressing changes. I attempted to call patient's son who is POA (power of attorney) we discussed her treatment options. I suggested attempt to primarily close the laceration versus amputation of the thumb. The thumb is completely nonfunctional because of the significant deformity. The thumb is curled up under the index finger. Open wound can lead to infection and amputation might be better option with [AGE] year-old female patent having complete dementia and significant deformity of the thumb. The son wanted to see if there is any chance for wound will heal by itself. I stated that we can continue daily dressing change and check again within 1 week. If infection develops or wound worsens, then we can consider surgical treatment otherwise will continue daily dressing change by nurse . A follow-up orthopedic appointment on 04/17/2019 contained the following information: .Examination of the left thumb IP joint is difficult given the patient's dementia and combativeness when attempting to examine her left thumb given the amount of pain. The wound was examined by the wound care specialist .she feels minor granulation is starting. She has redressed the wound with [MEDICATION NAME] Blue and has agrees to continue watch and dressing changes every three days . During an end of the day meeting on 05/29/2019 with the DON and the administrator, concerns were voiced that per interviews conducted with staff, Resident #24's hand was not fixed in a fist when restorative nursing was working with her. The hand could be opened and the thumb moved. Restorative was discontinued on 03/21/2019. There are no documented interventions from 03/21/2019 until 03/28/2019 when occupational therapy reevaluated her. When the COTA came in the room to do therapy on 04/04/2019, the fingers were stuck together and when Resident #24 pulled away, they became unstuck with resulting full thickness wounds. They were informed that the injury was being investigated at a harm level. A dressing change was observed on 05/30/2019 with LPN #6. An additional staff member was in the room to assist. LPN #6 used good technique to remove the old dressing. The wound on the left thumb was difficult to visualize as the resident pulled away from the nurse stabilizing her arm. The area that could be seen was open and bright red. At approximately 1:30 p.m., LPN #7 was asked if she could pull the bath record for Resident #24 and ascertain who bathed her from 03/21/2019 through 03/28/2019. She stated that the baths were divided up per shift on the unit. Resident #24 was bathed on the night shift. She pulled the requested information up on the computer. Per the documentation, Resident #24 received a bed bath every night and had one whirlpool bath during that time frame. LPN #7 stated, She has never been in the whirlpool, I don't know why that's there. She was asked if she could tell who bathed her. She stated she would try to run a report and bring the information to the conference room. On 05/30/2019 at approximately 2:55 p.m., the DON, the administrator and the QA (Quality Assurance) nurse came to the conference room to discuss Resident #24. The DON stated, We can't explain what happened from (MONTH) 21 through (MONTH) 28, there is no documentation showing what, if anything, was being done with her hand .but we have information that the therapist and the nurses were working together to treat her after that. The DON was informed that there were no issues with the treatment documented before (MONTH) 21 or after the evaluation on (MONTH) 28, the concern based on staff interviews, was the time frame after restorative was discontinued and the evaluation done seven days later by occupational therapy. The DON stated that she understood. The DON was asked who should have been providing hand hygiene to Resident #24. She stated, The CNA doing her bath should be doing that. The name and phone number of the CNA who had bathed Resident #24 on the night shift was requested. At approximately 3:45 p.m., the requested information for the CNA (CNA #22) who bathed Resident #24 on the night shift for five of seven nights between 03/21/2019 and 03/28/2019 was received. She was contacted via telephone at approximately 4:00 p.m. and interviewed regarding Resident #24. She was asked if she had cared for Resident #24 during the week of 03/21/2019 through 03/28/2019. She stated, Yes. She was asked what care she had provided. She stated, I turn her, I get her something if she needs it and I bathe her. CNA #22 stated, I start at her face and go down. I wash her face, her neck, her chest her arms, her hands, and work my way down all the way to her feet. CNA #22 was asked if she had washed Resident #24's hand. She stated, Yes, I run the wash cloth between her fingers. She was asked if she had done range of motion on Resident #24's left hand. She stated, I run the washcloth in and out between her fingers. She was asked if she had been able to open Resident #24's left hand at all or move her thumb. She stated, I run the washcloth in and out between her fingers. No further information was obtained prior to the exit conference on 05/30/2019. 2. Resident #5 admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. The a quarterly MDS (minimum data set) with an ARD (assessment reference date of 05/18/2019, assessed Resident #24 as being severely impaired in her cognitive status, with a summary score of 05. The clinical record was reviewed on 05/29/2019 at approximately 10:30 a.m. The POS (physician order [REDACTED]. The quarterly MDS of 05/18/2019 documented that Resident #5 was at risk for pressure ulcers. The integumentary section of the clinical record was reviewed. On 02/01/2019, the following was documented: Stage III, 2.2 cm length, 2 cm width, Pressure Ulcer Bed description: Granulation tissue, non-granular, pale, pink, yellow; Pressure Ulcer Exudate Description: Serosanguinous, Small amount, Moderate Amount, Odor absent, Other: dried. The care plan for Resident #5 was reviewed and contained the following: LTC (long term care) Skin Integrity. Outcomes included but were not limited to: Skin Integrity Maintained. Interventions included but were not limited to: Monitor skin condition every shift. On 05/29/2019 at approximately 3:00 p.m., the wound nurse, LPN (licensed practical nurse) #6 was interviewed regarding the pressure ulcer on Resident #5's heel. She stated, We found it (the pressure ulcer) at a Stage three. LPN #6 was asked how often skin assessments were done by the nurses. She stated, They are suppose to be done weekly. She was asked how an area could be found at a stage three if weekly skin assessments were done. She stated, That's what we wondered when it was found. LPN #6 was asked to pull up the weekly skin assessments done prior to 02/01/2019. She looked in the computer and stated, There was one done on 12/05/2018 that documents her contractures and one on 01/02/2019 that documented an abnormality, but that's all that I see. She was asked what the abnormality on 01/02/2019 was. She stated, I can't tell. LPN #6 stated, She was admitted to us with contractures .her left leg crosses over her right at the hip .her legs are crossed scissorlike from the top of her leg .she has prevalon boots and we float her heels but she still got that place on her heel .it's all healed up now. During an end of the day meeting on 05/29/2019 with the DON and the administrator, concerns were voiced that there was no documentation of weekly skin assessments and a pressure ulcer had been found on Resident #5's heel at a stage III. The DON was asked if other than the integumentary screen, was there any place else the weekly skin assessments would be documented. She stated she would look. On 05/30/2019 at approximately 7:30 a.m., LPN #3 was interviewed. She stated that Resident #5's skin was assessed on the night shift. She stated she had documented that abnormality in regard to the resident's thighs. She stated, Her legs are twisted I was documenting about the way her thighs are pushed together .I don't always have her. On 05/30/2019 at approximately 11:15 a.m., Resident #5 was observed with LPN #6. Resident #5 was lying in bed on her back. When the covers were pulled back, her legs were crossed at the hip level, her left foot was on her right side and her right foot was on the left side. She was wearing bilateral prevalon boots. She stated, What are you doing momma? Don't touch my feet momma. LPN #6 explained what she was going to do, she removed the prevalon boot and lifted the left foot revealing the heel which was healed. On 05/30/2019 at approximately 2:45 p.m., the DON was in the conference room. Concerns were voiced regarding the identification of the pressure area discovered at a Stage III on Resident #5's foot. She stated, I know .we had a mock survey in April. They identified problems with the staging of pressure ulcers and weekly skin assessments. I am working on the plan of correction and we have done some education but we aren't done yet. The DON was asked if there was any additional documentation as the survey team was identifying the pressure ulcer as harm. She stated, We don't have anything else. No further information was obtained prior to the exit conference on 05/30/2019. 3. Resident #2 was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. A quarterly MDS (minimum data set) was an ARD (assessment reference date) of 02/18/2019, assessed Resident #2 as severely impaired in her cognitive status, with a summary score of 05. On 05/28/2019 at approximately 12:00 p.m., Resident #2 was observed lying in bed. She was tearful and when asked what was wrong she stated, My foot hurts and my leg .I sprung it .I fell in a hole last night. LPN (licensed practical nurse) #4 was in the hallway and was assigned to Resident #2. She was asked if Resident #2 had any recent falls. She stated, No. She was asked if she knew what had happened to Resident #2's leg and foot. She stated, It looked bruised to me earlier today when I looked at it .she crosses one foot over the other. Resident #2 was observed with LPN #4. LPN #4 lifted the covers, exposing Resident #2's legs. Resident #2 had her right foot resting on top of left foot. A discolored area was observed on top of the left foot. A Skin tear and bruising were noted on the right shin. Steri strips were in place over a skin tear on the left shin. LPN #4 was asked about Resident #2's legs. She stated, Her skin is very fragile .they (CNAs) can tear it when they are taking her clothes off. She was asked what the facility was doing to protect/prevent that from happening. She stated, I can probably get her some protectors to put over them. LPN #4 stated She has an order for [REDACTED].#4 then pointed to her computer screen and the order for the prevalon boots, .Prevalon boots as tolerated . LPN #4 was asked if they were to be on all the time, she stated, Yes. She was asked if she had offered them to her. She stated, I didn't ask her earlier, I don't know about the CNA (certified nursing assistant) I usually try to go through all my orders when I get here, but I haven't gotten to that yet. At approximately 12:35 p.m., CNA #23 was interviewed regarding Resident #2's prevalon boots. She stated, I offered to put her socks on today and she didn't want them .I didn't offer the prevalon boots .she usually won't let you put them on her. Resident #2 was observed with her prevalon boots in place after lunch. At approximately 3:22 p.m., LPN #4 stated, I really don't think that is a bruise on (Name of Resident #2) left foot, I think that is a site of an old skin tear. LPN #4 was asked why Resident #2 was ordered to have prevalon boots. She stated, To keep her from getting breakdown on her heels and to help protect her legs. The POS (physician order [REDACTED]. The care plan for Resident #2 was requested and received. The following information was observed: LTC (long term care) Skin Integrity; Outcomes included but were not limited to: Skin Integrity Maintained. Interventions included but were not limited to: Apply skin moisturizer for dryness; Monitor skin condition every shift. There was no mention of the prevalon boots on the care plan. Resident #2 was observed with her prevalon boots on bilaterally throughout the day on 05/29/2019. During an end of the day meeting on 05/29/2019 with the DON (director of nursing) and the administrator, the above information was discussed. The DON was asked if there was a treatment record that the nurse's used to remind them to check for things like whether or not the prevalon boots were in place. She stated, No. No further information was obtained prior to the exit conference on 05/30/2019.

Based staff interview and facility document review, the facility staff failed to establish an antibiotic stewardship program that included antibiotic use protocols and a system to monitor antibiotic use. Findings include: On 5/29/19 at 10:03 AM, a review of facility's antibiotic stewardship was conducted. The policy did not include written antibiotic protocols for prescribing, including documentation for indications of use, dosage and duration of the antibiotic. There was not any type of tracking or documentation that would describe how tracking will be completed and/or accomplished. A folder was presented with information labeled LTC (long term care) with with typed entries for four months. These entry's were listed by month, no specific dates, which included the resident's name, the symptoms (if any), antibiotic used and some included the duration. These entries did not include the physician prescribing information or additional required information, such as the start date, or stop date. Some of these entries identified the organism, but did not identity how the organisms were identified (i.e. labs, etc). Some of the entries documented that antibiotics were or were not prescribed, and did not correlate the documented information for justification of the use or non use. There was a blank sheet in the back of the folder titled Appendix 9. Loeb's minimum criteria for initiating antibiotic therapy. This sheet had an area for a resident's name, location, date of infection, date of review, and if evaluated or criteria met. Additionally on this form, it listed infections such as UTI (urinary tract infections), respiratory tract infection, skin and soft tissue infection and fever where the focus of infection is unknown. The information did not have specific supporting information to correctly identify and track. Additionally there was also a blank sheet titled nursing home antimicrobial stewardship guide, that provided an area for name, room number, dates, type of infections, results (labs, x-rays), name of clinician, antibiotic name, duration, date, dose and if a change has been made. This information was blank, and id not provide supporting information for any the residents/infections listed. A policy titled, antibiotic stewardship policy documented, 4/29/19 date/reviewed/revised 4/29/19 .a separate Antibiotic Stewardship program will be formed to include antibiotic use protocols and systems for monitoring antibiotic use .based on evidence to meet such goals as set forth .will meet quarterly and review the policy annually or as needed .staff will have clear guidance and education on the principal of optimal and judicious use of antibiotics for residents .minimize .consequences .establishment of an antibiotic stewardship committee .two staff members if possible .DON (director of nursing) .pharmacist .administrator, attending physician, nurse, nurse aide, allied health professional, resident or family .procedure to support and promote antibiotic use protocols, using the Loeb .specifying dose, duration, and indications for use, along with clinical justification, develop and maintain a system to monitor antibiotic use, develop and maintain a system to monitor resistance data. This information in this policy could not be located. On 05/29/19 at 1:44 PM, the infection control specialist was interviewed. The infection control specialist stated that she does infection control for acute and LTC (long term care) and stated that the policy is a working copy of our antibiotic stewardship, and further stated that the policy has not been approved or signed. The infection control specialist was asked what the facility is currently using if they don't have a policy. The infection control specialist stated that she could provide a copy of the hospital policy, but stated, management told us we couldn't use the hospital policy. The infection control specialist stated that this policy just needs to be signed by the administrator and stated that they have done a lot of work on this. The infection control specialist stated that this is just getting underway and that she wished she would have known about this sooner (antibiotic stewardship program). The infection control specialist stated that this program is just getting started and that she has been educating, but the members have not been identified as of yet and they have not met regarding this. The infection control specialist was informed that the antibiotic stewardship requirements have been in effect since (MONTH) (YEAR). The infection control specialist stated that we were under the hospital umbrella and this is brand new for us. The infection control specialist stated that we have been separate from the hospital since (YEAR). The infection control specialist stated that they have been following the policy and went on to say, we are still working on it. On 05/30/19 at 10:02 AM, the infection control specialist was interviewed again and stated that this information will be taken quarterly to the QA (quality assurance) meeting, and stated that the administrator voiced that this is the policy that the facility will use if it is deemed ok. The infection control specialist stated, that before this policy they were using the hospital policy, it had the facility name, but was not specific to the facility. The infection control specialist stated that the antibiotic stewardship program was brought to her in (MONTH) of 2019 to develop a program for this facility alone, separate from the hospital and stated, I am starting to educate on the tracking and trending, the documentation and educating the physicians, the physicians have just received the tool for antibiotic use. The infection control specialist stated that there will be a pharmacy staff on the committee, but they have not developed an actual committee and have not actually had any meetings. No further information and/or documentation was presented prior to the exit conference on 5/30/19 at 5:00 PM to evidence that the facility had developed and/or implemented an antibiotic stewardship programs that addressed the required components for appropriate use, prescribing, and tracking.

Based on staff interview, medication pass and pour observation, and clinical record review, facility staff failed to follow physician orders [REDACTED].#56, #91, #350, #61, #37; and also failed to timely assess vital signs for one of 28 residents in the survey sample, Resident #150. 1. Facility staff failed to follow physician orders [REDACTED].#56. 2. Facility staff failed to follow physician orders [REDACTED].#91. 3. Resident #350 was ordered 400 mg of [MEDICATION NAME] by mouth every day. LPN (licensed practical nurse) #5 administered 200 mg in error. This resulted in a medication error rate of 3.13% (one error/32 opportunities). 4. Facility staff failed to follow physician orders [REDACTED].#61. 5. The facility staff failed to obtain monthly weights for Resident #37 as ordered by the physician. 6. Facility staff failed to timely assess vital signs for Resident #150. Findings included: 1. Resident #56 was originally admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The most recent MDS (minimum data set) was an annual assessment with an ARD (assessment reference date) of 04/05/19. Resident #56 was assessed as severely impaired in her short and long term memory and daily decision making skills. The clinical record of Resident #56 was reviewed on 05/29/19 at 10:00 a.m. Resident #56's POS (physician order [REDACTED].Neurovascular assessment-Leg, Left, every 8 hours, Start 07/24/18 .11/17/18 .Vital signs-weekly (Sun.), 3 365 Day(s), Start: 11/17/18. No neurovascular assessments were located in the clinical record. Vital signs were recorded on 11/27/18, 12/17/18, 12/28/18, 1/11/19, 1/15/19, 1/22/19, 1/29/19, 2/1/19, 2/5/19, 2/8/19, 2/19/19, 2/27/19, 3/15/19, 3/19/19, 4/1/19, 4/2/19, 4/3/19, 4/12/19, 4/15/19, 5/8/19. The DON (director of nursing) was interviewed during a meeting with the survey team on 05/29/19 at approximately 6:00 p.m. on the location of neurovascular assessments, vital sign documentation and what she considers vital signs. The DON stated, I will have to look in the record and get back with you. I consider vital signs to be temperature, pulse, respirations, blood pressure and an O2 sat. On 05/30/19 at approximately 1:00 p.m., the DON stated, I did not find any neurovascular assessments and you are right in that the vital signs are sporadic and incomplete. No further information was received by the survey team prior to the exit conference on 05/30/19. 2. Resident #91 was originally admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The most recent MDS was a quarterly assessment with an ARD of 05/01/19. Resident #91 was assessed as moderately impaired in her cognitive status with a total cognitive score of 08 out of 15. Resident #91's clinical record was reviewed on 05/29/19 at 11:00 a.m. The physician order [REDACTED].Weigh Patient- every week x4; then once a month. Start: 11/05/18 .11/18/18 .Vital signs-weekly (Sun.), x 365 Day(s), Start: 11/18/19 . Subsequent review of documented vital signs and weights included documentation on the following dates: Vital signs: 12/30/18, 2/17/19, 3/3/19, 3/31/19, 4/7/19, 4/28/19, 5/5/19, 5/12/19, 5/19/19. Weights: 12/2/18, 2/18/19, 3/6/19, 5/16/19. No weights were recorded for the months of (MONTH) or April. The DON was interviewed during a meeting with the survey team on 05/29/19 at 6:00 p.m. The DON stated, I consider vital signs to be temperature, pulse, respirations, blood pressure and O2 sats. On 05/30/19 at approximately 1:00 p.m., the DON stated, I did not find any other weights and you are right in that the vital signs are sporadic and incomplete. No further information was received by the survey team prior to the exit conference on 05/30/19. 3. A medication pass and pour observation was conducted on 05/29/2019 beginning at approximately 8:00 a.m. on the first floor of the facility. LPN #5 was observed preparing medications for Resident #350. The medications were in single dose packages. LPN #5 checked the electronic MAR (medication administration record) and then pulled each medication from the med cart drawer. The unopened medications were handed to the surveyor to record, and were then placed on top of the medication cart. After all the medications were pulled and recorded the total number of pills written down by the surveyor were counted and compared with the number of pills on top of the medication cart. A total of seven pills were counted by the surveyor and verified by LPN #5, this included one 200 mg [MEDICATION NAME] tablet. After the count LPN #5 opened each pill and placed them in a medication cup for administration. When the medication pass was completed the medications were reconciled with the clinical record. Observed on the physician order [REDACTED]. LPN #5 administered [MEDICATION NAME] 200 mg during the medication pass observation. LPN #5 awas interviewed at approximately 9:10 a.m. The box of [MEDICATION NAME] belonging to Resident #350 was pulled from the medication cart. Observed on top of the box was a sticker that read: CAUTION DOSAGE STRENGTH DIFFERENT FROM ORDER, USE APPROPRIATE AMOUNT. The label on the box also contained the following: (name of Resident) [MEDICATION NAME] HCL 200 MG TABL (tablets) TAKE 2 TABLETS (underlined in black marker) (400 MG) BY MOUTH DAILY .QTY (quantity) 32. LPN #5 stated, I see that, I thought I gave two pills. LPN #5 was asked if she remembered counting the pills with this surveyor prior to administration and agreeing with the count. She stated, Yes. LPN #5 counted the remaining pills left in the box. There were 13, and per the medication label, 32 had been dispensed. LPN #5 stated, There should be an even number since we are giving them two at a time. LPN #5 was asked what she was going to do. She stated, I'm still in my window, I'll give it or call the doctor and ask him if he just wants her to have one. During an end of the day meeting with the DON (director of nursing) and the administrator the above information was discussed. The DON stated, She gave the other pill. A copy of the facility policy regarding medication pass administration was requested. The facility policy PREPARING AND ADMINISTERING MEDS & USE OF DRUG CART was presented on 05/30/2019. Per the facility policy: Remember the 5 R's-Right: Patient, Medication, Route, Dose, and Time . No further information was obtained prior to the exit conference on 05/30/2019. 4. Resident #61 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. The most current MDS (minimum data set) was a initial assessment with an ARD (assessment reference date) of 5/9/19. Resident #61 was assessed with [REDACTED]. On 5/28/19 at 3:00 PM an interview was conducted with Resident #61. During the interview it was observed that Resident #61 did not have compression hose in place. After the interview, Resident #61's record was reviewed. A physician's orders [REDACTED]. On 05/29/19 at 9:11 AM, Resident #61 was observed sitting in her room without compression hose in place. Resident #61 was interviewed regarding compression hose. Resident #61 verbalized that she (Resident #61) used to wear compression hose years ago, but hasn't worn any for a long time, and stated that her ankles have been swelling lately. On 05/29/19 at 10:02 AM, Registered nurse (RN) #4 was asked to look for Resident #61's compression hose in the room were Resident #61 resided. The compression hose were not located. On 05/29/19 at 10:12 AM, license practical nurse (LPN) #2, assigned to Resident #61, was interviewed regarding compression hose. LPN #2 stated that she had just been made aware that Resident #61 has an order for [REDACTED].>On 05/29/19 at 5:08 PM, the above finding was presented to the director of nursing and administrator. No other information was presented prior to exit conference on 5/30/19. 5. Resident #37 was admitted on [DATE] with [DIAGNOSES REDACTED]. The most recent minimum data set ((MDS) dated [DATE] was an annual assessment and assessed Resident #37 as having long and short term memory problems, moderately impaired for daily decision making and having periods of fluctuating inattention. Resident #37's electronic medical record (EMR) was reviewed on 05/29/19 at 8:00 a.m. Observed was an order for [REDACTED].#37's (EMR) did not document weights monthly as ordered by the physician. For the period of (MONTH) 7, (YEAR) through (MONTH) 29, 2019, there were no weights documented for the months of (MONTH) (YEAR), (MONTH) (YEAR), (MONTH) 2019, (MONTH) 2019 and (MONTH) 2019. On 05/29/19 at 5:08 p.m., during a meeting these findings were reviewed with the administrator & DON. The DON stated she would check in the care tracker system for additional documentation and provide the information the next day. On 05/30/19 at 10:15 a.m., the DON provided a printed copy of Resident #37's weights. The copy documented weights for the months of (MONTH) (YEAR), (MONTH) (YEAR), (MONTH) (YEAR), (MONTH) 2019 and (MONTH) 2019. There were no monthly weights documented for the months of (MONTH) (YEAR), (MONTH) (YEAR), (MONTH) 2019, (MONTH) 2019 and (MONTH) 2019. The DON stated these were all that could be found in the electronic system. On 05/30/19 at 10:25 a.m., the Registered Dietitian (OS #5) who routinely follows Resident #37 was interviewed. OS #5 stated she routinely follows Resident #37 as the resident receives pe[DEVICE] feedings and pleasure foods by mouth. OS #5 was interviewed regarding the physician ordered weights for Resident #37. OS #5 stated she started employment in (MONTH) 2019 and Resident #37 did not have weights documented for the months of (MONTH) (YEAR) through (MONTH) 2019. OS #5 continued and stated from her understanding Resident #37 was on comfort care for a brief period and weights were not obtained and/or documented during that time. OS #5 was asked if there was a physician order [REDACTED].#5 stated staff thought a conversation had taken place about comfort care, and possibly a verbal order had been given, however the actual order was not written. OS #5 stated from her review of the records Resident #37 had not lost any weight and was currently stable at 109# for this month. No additional information was received by the survey team prior to the exit on 05/30/19 at 5:00 p.m. 6. Resident # 150 was admitted to the facility on [DATE], and most recently readmitted at approximately 1:00 p.m. on 11/21/18 with [DIAGNOSES REDACTED]. A thorough review of the resident's Electronic Health Record (EHR) failed to reveal any instructions for the resident's care, any Nurse's Notes regarding the resident's condition on admission, any Nurse's Notes documentation of his vital signs, or any Nurse's Notes of his condition up to, and including, the time of his death. On 5/30/19 at approximately 8:50 a.m., speaking the to the lack of nurse's notes documentation, the Interim Director of Nursing (DON) said, The previous DON did not have staff document (a narrative) in the Clinical Notes (Nurse's Notes). She only had them use the check-off boxes in Cerner (the Electronic Health Record computer program). Resident # 150's vital signs were documented in two area in Cerner, Bedside Data and Vitals, and iView, neither of which were readily available for review by staff. At approximately 5:00 p.m. on 11/21/18, the vital signs for Resident # 150 were recorded in both Bedside Data and Vitals, and iView as follows: Oral temperature 35.6 (Centigrade) on Bedside Data and Vitals, 35.9 (Centigrade) on iView; Pulse 109; Blood Pressure 116/96; Respiration Rate 24; O2 Sats 91%. The resident was noted on iView as receiving oxygen via nasal cannula at 4 liters per minute. The next set of vital signs for Resident # 150 were taken 7 (seven) hours later at approximately Midnight (0000 to 0029 on 11/22/18). His vital signs were recorded under Bedside Data and Vitals, and iView as follows: Oral temperature 36.9 (Centigrade)/98.4 (Fahrenheit); Pulse 72; Blood Pressure 92/66; Respiration Rate 24; O2 Sats 90%. The resident was noted on iView as receiving oxygen via nasal cannula at 4 liters per minute. The following Significant Event Note, Final Report was located in the Clinical Notes section of Resident # 150's Cerner EHR: 11/22/18 0 7:54 a.m. This writer made aware by CNA (Certified Nursing Assistant) (Name) Mr. (Name of Resident # 150) was (gone). (sic) I went down to the room with the vitals machine and found resident had no vitals of life. Resident was white and nail beds were cyanotic upon beginning of my shift. Body was still, cool to touch. I then came back to the desk and made and proceeded to make my phone calls to resident's contacts. Prior to the resident's passing I and the CNA (Name) had been checking o (sic) him due to his low o2 (sats). I was told at the beginning of the shift that the resident had to wear an E-Pap device at all times due to his sits (sic) being in the 60's so we did keep close tabs on him for theis (sic) reason. (NOTE: EPAP, or Expiratory Positive Airway Pressure, is used to create pressure during the exhalation process, providing [MEDICATION NAME] breathing. Ref. www.epap.net.) A Final Report - Discharge by Death. dated 11/22/18 at 4:14 a.m., located in the Cerner EHR, noted the following: Writer called by staff LPN (Licensed Practical Nurse), (Name), @ (at) 0240 (2:40 a.m.). Stated resident had passed and needed RN (Registered Nurse) pronouncement. Writer arrived to pronounce and was informed by staff LPN that CNA had been present at time this occurrence was noted. Writer in to assess resident. Resident presented with epap in place and functioning. Vital signs were checked. He was absent of all, no BP (Blood Pressure), pulse or respirations. No SPO2 (Pulse Oximetry). Resident appears with mouth open, pale in color with cyanotic nail beds to hands/feet. Apical pulse checked = absent, lung sounds checked = absent, bowel sounds checked = absent. Skin temp is cold to touch. This writer pronounced TOD (Time Of Death) @ 0345 (3:45 a.m.). Staff LPN (Name), CNA (Name) present @ bedside. Dr. (Name), MD was notified by staff LPN (Name) At 1:15 p.m. on 5/30/19, the condition of Resident # 150 as noted in the Final Report - Discharge by Death, dated 11/22/18, was reviewed with RN # 1, the Quality Assurance Nurse. Asked if she thought Resident # 150's condition as described was irreversible, RN # 1 said, Yes. At approximately 1:30 p.m. on 5/30/19, the code status of Resident # 150 was discussed with the Interim DON. Advised that the surveyor was unable to locate the resident's code status in Cerner, the Interim DON said, He (Resident # 150) had an established code status, but it wasn't captured by Cerner.

Based on staff interview and clinical record review, the facility staff failed to follow physician orders [REDACTED].# 73. Findings include: Resident # 73 was admitted to the facility 7/17/13 with [DIAGNOSES REDACTED]. The most recent MDS (minimum data set) was an annual assessment dated [DATE] and had the resident coded with moderate cognitive impairment with a total summary score of 11 out of 15. The clinical record was reviewed 5/30/19 at approximately 8:00 a.m. The current POS (physician order [REDACTED]. Further review of the clinical record failed to reveal any documentation of the treatment. On 5/30/19 beginning at 10:35 a.m. during a meeting with facility staff, including the IT (information technology) staff, the survey team expressed the difficulty in locating needed information for the survey process. The IT staff was asked for assistance in locating the documentation for Resident # 73's nephrostomy flushes, and was told it could be in a couple of different places, depending where staff may have documented and that the information may also be in a clinical note. The DON (director of nursing) then stated You (survey team) are not going to find any nursing notes; the previous DON told staff they did not have to do any narrative notes, just to do the check offs in the system. I have changed that, and told the staff to do nursing notes, but I have only been in this position about 2 weeks. The IT staff then provided guidance on where to locate the information for the bladder irrigations, but the forms were blank. The IT staff, who was also an RN (registered nurse) stated That's where the documentation should be; as you know, if it's not documented, it's not done. There were no nursing narrative notes of the nephrostomy tube flushes done. On 5/30/19 at 12:00 p.m. the DON and LPN (licensed practical nurse) # 7, who was the unit manager, were interviewed about the treatment. The DON stated I tried to catch up with the second shift nurse yesterday to ask her about that, but I could never catch up with her; I was here until 8:00 p.m. LPN # 7 stated she had also looked for the documentation, and was unable to find it. The DON provided the phone number for the nurse who worked second shift 5/29/19. On 5/30/19 at 12:15 p.m. LPN # 9 was interviewed via phone. She stated I do not do (name of Resident # 73); that is done on day shift. I do have one bladder irrigation I do on 3-11 shift, but it's not her flushes Interviews with staff on unit 1 failed to reveal if the treatment had been being done for Resident # 73. No further information was provided prior to the exit conference.

Based on staff interview and clinical record review, the facility staff failed to follow physician orders [REDACTED].# 59. Findings include: Resident # 59 was admitted to the facility 4/17/18 with [DIAGNOSES REDACTED]. The most recent MDS (minimum data set) was an annual assessment dated [DATE] and had the resident coded with moderate cognitive impairment with a total summary score of 08 out of 15. The clinical record was reviewed 5/30/19 at approximately 8:00 a.m. The current POS (physician order [REDACTED]. Solution: Normal Saline, Volume 500 ml mixed with 30 cc's of vinegar Monday/Wednesday/Friday. Further review of the clinical record failed to reveal any documentation of the treatment. On 5/30/19 beginning at 10:35 a.m. during a meeting with facility staff, including the IT (information technology) staff, the survey team expressed the difficulty in locating needed information for the survey process. The IT staff was asked for assistance in locating the documentation for Resident # 59's bladder irrigations, and was told it could be in a couple of different places, depending where staff may have documented and that the information may also be in a clinical note. The DON (director of nursing) then stated You (survey team) are not going to find any nursing notes; the previous DON told staff they did not have to do any narrative notes, just to do the check offs in the system. I have changed that, and told the staff to do nursing notes, but I have only been in this position about 2 weeks. The IT staff then provided guidance on where to locate the information for the bladder irrigations, but the forms were blank. The IT staff, who was also an RN (registered nurse) stated That's where the documentation should be; as you know, if it's not documented, it's not done. There were no nursing narrative notes of the bladder irrigation done. On 5/30/19 at 12:00 p.m. the DON and LPN (licensed practical nurse) # 7, who was the unit manager, were interviewed about the treatment. The DON stated I tried to catch up with the second shift nurse yesterday to ask her about that, but I could never catch up with her; I was here until 8:00 p.m. LPN # 7 stated she had also looked for the documentation, and was unable to find it. The DON provided the phone number for the nurse who worked second shift 5/29/19. On 5/30/19 at 12:15 p.m. LPN # 9 was interviewed via phone. She stated I do not do (name of Resident # 59); that is done on day shift. I do have one bladder irrigation I do on 3-11 shift, but it's not her Interviews with staff on unit 1 failed to reveal if the treatment had been being done for Resident # 59. No further information was provided prior to the exit conference.

Based on resident interview, family interview, a resident group interview and staff interview, the facility staff failed to respond to call bells in a timely manner. Residents, the resident council group and family members reported lengthy call bell response with waiting between 30 minutes and up to 1 hour for staff response. The findings include: Resident #43 who was admitted on [DATE] with [DIAGNOSES REDACTED]. The most recent minimum data set ((MDS) dated [DATE] was a quarterly assessment & assessed Resident #43 as cognitively intact for daily decision making with a score of 15. On 05/28/19 during the initial tour Resident #43 was interviewed at 12:18 p.m. regarding quality of life in the facility. Resident #43 stated this past weekend which was Memorial Weekend was the worse. We had 3 CNAs (certified nursing assistants) on this entire second floor, but because the census on the first floor was more and they had staff call outs, one of our CNAs had to go downstairs to help out. Sometimes I've waited three or four hours before I actually see my assigned shift CNA. The nurses will come in but they are so busy they can't get to us all. Resident #43 stated we are short-staffed mostly on the weekends and on third (night) shift. I am incontinent and I try not to complain, but sometimes I have to wait a couple hours before anyone can get to me for a brief change. Resident #43 stated things just seem like they are getting worse with staffing. On 05/28/19 during the initial tour at approximately 12:30 p.m., two other residents were interviewed separately regarding call bell response and time. One resident who was newly admitted stated my only issue is they need more staff. A visiting family member of the resident stated the weekends are the worst. We've had to wait up to 30 minutes before a CNA has come in to help getting her back to bed. The family member stated I just keep ringing the bell and/or go up the hall until I find someone to come help. The second resident who was observed eating lunch stated I know they can't get to all of us at the same time, but having to wait 30-45 minutes for toileting assistance doesn't make sense. I need assistance getting on and off the toilet because I don't want to fall. The staff often tells me ring the bell, but then they either come and turn it off or say I'll be right back and it takes a long time for them to get back.Sometimes I just keep ringing the bell or will call out for someone to come help me. Resident #350 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. There was no MDS completed on this resident at the time of the survey. An interview was conducted on 05/28/2019 at approximately 12:00 p.m. with Resident #350 and her daughter. They were asked about call bell response time. Resident #350 stated, I probably shouldn't say anything, but yesterday when I came back from therapy, they (therapy) left me in my wheelchair and didn't put the call bell over here where I can reach it .I was tired, they had worked me pretty hard in therapy .the nurses never came to check on me and I couldn't call them because I didn't have my call light. I called her (pointing to her daughter) and asked her to call the nurses station and tell them to come put me in the bed. They (the nurse/CNA (certified nursing assistant)) came down here and helped me back to bed. The nurse said therapy never told them I was back. I understand that therapy didn't tell them and therapy didn't put my call bell where I could reach it but I sat here for two hours .I would think somebody would come down here and at least check to see . Resident # 58 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent minimum data set ((MDS) dated [DATE] was a quarterly assessment & assessed Resident #58 as cognitively intact for daily decision making with a score of 15. Resident #58 was interviewed on 05/29/19 at 4:19 p.m. Resident #58 stated that she has been here a year, two years in (MONTH) and the problem is that in the CNA (certified nursing assistant) (named) is getting cocky with me. The resident was asked what that meant and the resident stated that the CNAs don't answer you when you ask a question and they (CNAs) just stare at you, don't answer. They just say roll over, roll over while changing. I feel they don't have patience and they just don't care and they are short staffed. Resident #58 stated that she didn't think they have enough help, and that she has had to wait in here in her bed soaking wet for 45 minutes waiting on them to change her. The resident stated that they are understaffed and that is the problem. Resident #58 stated that this is normally on the early morning shift, when she has to wait for long periods. The resident stated, It shouldn't take them that long, I know they have 25 other people to get to-but this is my time. The resident stated that when the CNAs come in to work on 3-11 shift, they already have a look on their face, they don't want to work and again stated that they, just don't have enough help. On 05/29/19 at 1:30 p.m. a group interview with conducted with 12 cognitive residents in attendance. Residents in the group meeting were asked about call bell response time in the facility. Comments from the group included: I have waited up to for an hour for someone to come and assist me with going to the bathroom. My daughter has had to call the nurses' station to get someone to assist me. They (CNA) will come in the room, turn off the call bell, ask what you need, tell you they will be back and they never come back until you ring the call bell again. I had to wait almost 40 minutes before anyone came to help get me off the toilet after I had finished my business. They (nurses) don't like to see or hear those call bells lights going off, so the any of the staff will come in and turn off the call bell, ask what you want, tell you they will be back or get the right person to help you, but never come back to let you know if and when someone will be in to assist you. I've missed my regular scheduled showers and have to take it the next day because the CNAs will say they are short-staffed or tired. A review of the resident council minutes for the months of (MONTH) 2019, (MONTH) 2019 and (MONTH) 2019 documented concerns with call bell response. On 05/29/19 at 5:08 p.m., these findings were shared with the administrator and director of nursing. On 05/30/19 at 1:55 p.m., the director of nursing (DON) was interviewed regarding staffing and call bell response time. The DON stated the reasonable expectation was for staff to respond to a call bell within 3-5 minutes. The DON stated if the staff person who responded to the call bell was not able to provide the required assistance then they should locate someone immediately to assist the resident. The DON stated residents should not have to wait 30 or more minutes for assistance or for follow-up assistance. On 05/30/19 at 2:30 p.m., the quality assurance/staff development nurse (RN #1) was interviewed regarding training on call bell response and customer service. RN #1 stated since the survey in (YEAR), the facility had provided in-services on call light response times. RN #1 provided copies of the in-service forms dated 6/1/18, 6/19/18, and 6/27/18. RN #1 stated the facility recognized there had been a concern with call light response times and has instructed all staff to respond to a call bell and if they can not meet the need of the resident, they are to locate someone who can assist the resident and follow-up with the resident to let them know a staff member will be with them as soon as possible. No additional information was received by the survey team prior to exit on 05/30/19 at 5:00 p.m.

Based on staff interview and clinical record review, the facility staff failed to ensure an accurate MDS (minimum data set) for one of 28 resident in the survey sample, Resident #63. The facility staff incorrectly coded the resident with the [DIAGNOSES REDACTED]. Findings included: Resident #63 admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Resident #63 had an MDS trigger in the LTCS (long term care software) process for No PASAAR II with diagnosis. The resident's most current MDS (minimum data set) was annual assessment dated [DATE]. The resident did not trigger for anything in Section A1500. Preadmission Screening and Resident Review and did not trigger for anything in Section A.1510 Level II Preadmission Screening and Resident Review Conditions. This MDS did reveal that the resident had a documented [DIAGNOSES REDACTED]. Active Diagnoses. The resident's CAAS (care area assessment summary) section of this MDS was reviewed. The resident did not trigger for mood, behaviors or psychosocial well being. The resident had CAAS worksheets for mood and psychosocial well being, which were reviewed. The CAAS worksheet documented under mood state on the MDS, .relapse of an underlying mental health problem, anxiety disorder, depression (other than [MEDICAL CONDITION]), and [MEDICAL CONDITIONS] . The resident's CCP (comprehensive care plan) was reviewed and did not document anything regarding depression, [MEDICAL CONDITION] and/or anxiety. On 05/29/19 at 4:08 PM, LPN (Licensed Practical Nurse) #1 (who was also the MDS coordinator) was interviewed regarding the above findings, specifically related to a PASAAR Level II for this resident. LPN #1 was made aware of a possible MDS discrepancy. LPN #1 stated that she did not know anything about the PASAAR. The LPN pulled the information up on the computer and stated, that a [DIAGNOSES REDACTED]. LPN #1 stated, Ok, this is my mistake I marked [MEDICAL CONDITIONS] by accident. She does not have that, she has anxiety and depression, but not [MEDICAL CONDITION], I will have to fix that. No further information and/or documentation was presented prior to the exit conference on 5/30/19 at 5:00 PM to evidence that the resident's current status was accurately assessed on this MDS.

Based on observation, staff interview, facility document review, clinical record review, and in the course of a complaint investigation, the facility staff failed to provide supervision and interventions to prevent falls/accidents for five of 23 residents, Resident #34, Resident #5, Resident #187, Resident #25 and Resident #54. This is a complaint deficiency. 1. Facility staff failed to lock the brakes on Resident #34's bed, when providing personal care. Resident #34 was rolled out of the bed, landed on her face and sustained a laceration. She was sent to the emergency room for repair. (Harm). 2. Facility staff failed to provide supervision per physician order [REDACTED].#5. Resident # 5 had a fall from her wheelchair resulting in a fracture (Harm). 3. Resident #187, with a wander prevention device in place, fell after exiting his living unit through a stairwell door with a malfunctioning locking system. Resident #187 was found on the ground floor landing and diagnosed with [REDACTED]. 4. Resident #25, with a history of falls, fell from a reclining chair and experienced an abrasion above his right eye. The resident had not been assessed for use of the reclining chair. There was no prompt review and/or investigation of the fall by facility staff. 5. Resident #54 sustained multiple unwitnessed falls indicating lack of supervision. Findings were: 1. Resident #34 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Her [DIAGNOSES REDACTED]. The most recent MDS (minimum data set) was a quarterly assessment with an ARD (assessment reference date) of [DATE]. Section B - Hearing, Speech, and Vision assessed Resident #34 as being Comatose Persistent vegetative state/no discernible consciousness; therefore, no cognitive status was assessed. Resident #34 was added to the survey sample after being named in a FRI (facility reported incident) received at the State Agency in (MONTH) (YEAR). On [DATE] during initial tour of the facility Resident #34 was observed lying in bed. Bilateral full padded side rails were in the up position on her bed. Bilateral fall mats were beside her bed. The facility reported incident was reviewed on [DATE] at approximately 10:00 a.m. Per the FRI, On [DATE] at 3:05 a.m., CNA (certified nursing assistant) came to the nursing station and reported resident fell in the floor. CNA was changing resident, bed began rolling, and CNA was unable to grasp resident. The resident fell off the bed onto the floor, with her face hitting the floor. Resident suffered a 4.5 cm stellate laceration to mid forehead which was closed with two layers of Dermabond .Interview with staff revealed the fall was caused by a failure of staff to lock the brakes on the resident's bed. Based on the information gathered, we believe this fall could have been prevented. Review of the clinical record included a final report from the emergency department where Resident #34 was treated. Information included, but was not limited to: The patient presents following a fall .rolled out of bed .The character of symptoms is swelling and laceration .Head: On exam: Swelling, laceration, stellate, 4.5 cm, forehead .Procedure notes: 4.5 cm stellate laceration mid forehead closed with 2 layers of DERMABOND using sterile technique . A copy of the facility's investigation of the incident was requested and received. The Post Fall Huddle form contained the following: Contributing factors: Improper bed height and bed unlocked. Witness statements were reviewed. The CNA statement contained the following information: While giving daily care, I turned her over so I could reach the back side while washing and changing she began to come forward. When she started coming forward I attempted to keep her on her bed but with her weight I couldn't hold her up and she fell on the floor. A second witness statement completed by the night shift nurse, contained the following: CNA (name) came running to nursing station stating (name) fell in the floor .found lying face down in the floor-large amount of dark red blood noted from forehead-turned res (resident) over on her side and noted a 4 cm X 3 cm laceration in center of forehead and bleeding from her mouth .lifted back to bed and body check done-no bruises or redness noted .facial swelling noted and cool compresses and pressure dressing applied to laceration .911 called and resident to ER for eval and tx (treatment) .the bed was up in the air with top side rail down and CNA stated he was changing resident and bed started rolling and he couldn't hold her and res slip (sic) off side of bed . The administrator was interviewed on [DATE] at approximately 1:00 p.m. regarding the incident. She stated, The CNA no longer works here .he told the nurse what happened, he didn't have the bed locked, she rolled out and got a laceration on her head. The above information and the recommendation of a possible harm level deficiency was discussed during a meeting with the DON (director of nursing) and the administrator on [DATE] at approximately 2:30 p.m. No further information was obtained prior to the exit conference on [DATE]. 2. Resident # 5 was admitted to the facility [DATE] with [DIAGNOSES REDACTED]. The most recent MDS (minimum data set) was a quarterly review dated [DATE] and had Resident # 5 assessed with [REDACTED]. Under Section G- Functional Status included under G0110'Activities of Daily Living (ADL) Assistance: E. Locomotion on unit: how resident moves between locations in room and adjacent corridor on same floor .If in wheelchair, self-sufficiency once in chair. This section was coded under Self Performance as 7. Activity occurred once or twice. Under Support was coded as 2. One person physical assist. F. Locomotion off unit- how resident moves to and returns from off-unit (activities, dining, therapy). If in wheelchair, self-sufficiency once in chair. This section was coded under Self Performance as 7. Activity occurred once or twice. Under Support was coded as 2. One person physical assist. The electronic medical record (EMR) was reviewed on [DATE] at 7:45 a.m. Nursing narrative notes were as follows: (It should be noted here there was no times given for the events; just a time stamp for when the documentation was entered in the computer system): [DATE]: New order to obtain xray of left hip and left shoulder due to extreme pain/ hollering out . [DATE]: Informed MD of pain/hollering out, obtained new order for xrays, created orders, and put in transportation slip. Awaiting update from MD to see if they are to be sent via 911 today or wait until Monday since radiology doubts they can fit her in today. On [DATE] at 11:00 a.m. RN (registered nurse) # 1 was asked about the documentation of Resident # 5's pain, and what had happened. RN # 1 stated the resident had fallen on [DATE] out of her wheelchair, but did not appear at the time to have incurred any injury. This surveyor asked where the documentation about the fall was located in the nurses' notes. RN # 1 stated Well, we have been told not to document any notes in the computer as the new program is not set up for that type of documentation. We have forms that are checked off and entered; there are some notes but those are usually if there's a significant event .we do documentation by exception, so unless there's something out of the ordinary we are told not to make daily notes. RN # 1 was then asked for the investigation of the fall, a copy of the care plan at the time of the fall, physician orders [REDACTED]. On [DATE] at 2:45 p.m. RN # 1 gave this surveyor a copy of the care plan in place at the time of the fall. RN # 1 stated the administrator had told her a copy of the investigation was not allowed to be copied for this surveyor. RN # 1 was told a copy was not needed, but a review of the investigation could be conducted. The care plan, dated as implemented [DATE] was reviewed. Under Problems was documented Risk for injury: bruises, skin tears, scratches, falls .related to dementia . Under Goals was documented No fall related injuries . Interventions included: Call bell within easy reach .Keep objects in easy reach .Non-skid footwear when out of bed. If (name of resident) has a fall assess each shift for 72 hours for pain, injury . There were no interventions noted for use of the wheelchair. An xray report from the hospital dated [DATE] documented Clinical History: Pain after fall .Findings: .Proximal left femur is suspicious for a minimally impacted subcapital fracture . The ER (emergency room ) physician notes attached to the xray report documented History of Present illness: Pt. unable to provide much history. Onset 5 days ago. The course/duration of symptoms is constant. Type of injury: fall. Location: left hip/shoulder. The character of symptoms is pain . Diagnosis: [REDACTED]. RN # 1 also provided a copy of an incident form completed at the time of Resident # 5's fall. The incident form dated [DATE] revealed the following: Brief factual description: She (Resident # 5) had been observed leaning forward in her wheelchair looking into her drawers and was cautioned to get help. Resident observed a short time later to be on the floor on her left side. She had slipped out of her wheelchair onto the floor. Her wheelchair was not locked to allow for resident mobility. Call light within reach, room lights on, personal items within reach. Under Specific Incident Details was documented: Precaution: bed in low position, call bell in reach. Contributing factors: confused/disoriented. Current diagnosis/condition. Under Outcome Details was documented: Investigation completed by staff onsite. The incident report did not document whether Resident # 4 was wearing non-skid footwear as per her care plan. On [DATE] at 4:20 p.m. the administrator informed this surveyor there was no investigation for the fall. She stated Should there be one? Yes. But we are unable to find it if it was done. From what we could tell at the time, it looked like the fracture was a result of the fall from the wheelchair. The administrator was asked if there was a policy on what was to be done after a fall. She stated there was, and gave this surveyor a copy of a document entitled Fall management: Long term care. Under Documentation included the following: After a fall, complete a detailed incident report to help track frequent resident falls so your facility can implement prevention measures for high-risk residents. In the incident report, note where and when the fall occurred, how you found the resident, and in what position. Include the events preceding the fall, the names of witnesses, the resident's reaction to the fall, and a detailed description of the resident's condition based on the findings. Include the resident's statement of the event . On [DATE] at 8:30 a.m. the DON (director of nursing) gave this surveyor a copy of the physician orders [REDACTED]. The orders were reviewed and noted to include an order dated [DATE] for Patient to sit up on wheelchair as tolerated, everyday supervised from time to time. On [DATE] at 11:15 a.m. this surveyor asked the administrator and DON about the above order, and what was meant by from time to time as written. The administrator and DON stated there should be an actual time on the order. The DON explained There should be a time specified, like from 1 p.m. to 2 p.m., or however long she was to be in the wheelchair, specified, and she should be supervised during that time. I'm not sure why that order was put in that way; I know that at that time we were switching to the new computer system, and nurses from the OB (obstetrics) unit came over and put in a lot of the orders, so that may be why it's like that. I can see if I can get clarification on the order. On [DATE] at 11:50 a.m. the nurse who filled out the incident form, identified as RN # 5, was interviewed. She stated I am not the one who observed her; a CNA saw her and then reported the fall to me; I don't remember who the CNA was now .that was a while back. The administrator, DON (director of nursing), and several nursing staff were made aware of the above findings during a meeting with facility staff [DATE] beginning at 2:30 p.m. It was discussed at that time of the potential for harm associated with the deficiency, and if there were any questions or additional information they could provide. The administrator stated No, I don't think so. No further information was provided prior to the exit conference. 3. Resident #187 was admitted to the facility on [DATE], was re-admitted on [DATE] and died in the facility on [DATE]. [DIAGNOSES REDACTED]. The minimum data set ((MDS) dated [DATE] assessed Resident #187 with moderately impaired cognitive skills. Resident #187's closed clinical record documented a nursing note dated [DATE] at 1:30 p.m. stating, I was alerted by another employee that the resident had fallen down South hall stairs. When I arrived to the scene his wheelchair was at the top of the stairs, wandergaurd (Wanderguard) was still in place on his chair, and so was his sensory pad. He was lying with his arm hanging off the step .took his vital signs and placed him on a stretcher to be transported to the ER (emergency room ) A note dated [DATE] at 11:30 p.m. stated, Report was called from the E.R .was told that the resident had an abrasion to his lt (left) elbow, non displaced [MEDICAL CONDITION] humerus, contusion of abd. (abdominal) wall . The emergency room report dated [DATE] documented, .was rolling down the hallway in his wheelchair like he normally does, and he opened the door to the stairwell and fell down two flights of stairs .Assessment approximately 7 cm (centimeter) skin tear noted to L (left) elbow .Abrasion of elbow - Left, Nondisplaced fracture (avulsion) of lateral epicondyle of left humerus - Suspected, Contusion of abdominal wall . The facility's investigation report to the state agency dated [DATE] documented, Resident found at Ground Level Landing having exited from first Floor Door (south exit). Transferred to ED (emergency department) for evaluation and returned to facility. Finding of nonDisplaced fracture of left humerus. The facility's investigation stated on [DATE] at 1:30 p.m., dietary staff heard the resident hollering for help and found the resident on the ground at the stairwell on the ground level landing. This report documented, Investigation revealed that the resident left the first floor unit and went out of the south stairwell exit door. He then got up from his wheelchair and by using the handrail, went down the steps. He got to the ground floor landing and slipped or fell .His wheelchair was found on the first floor landing .The resident's Wander guard bracelet activated the alarm system but the door did not lock upon activation .Nurse assigned to the resident stated that she had heard the alarm on the south stairwell door go off about 20 minutes before the incident. She checked the stairwell and did not find anything amiss .South door Wander guard system's automatic locking mechanism was not functioning properly . Resident #187's clinical record documented a physician's orders [REDACTED]. Resident #187's fall risk assessments completed in (MONTH) (YEAR) and (MONTH) (YEAR) documented the resident as a high risk for falls due to a history of falls, wandering, incontinence, unsteady gait, poor balance, health conditions and multiple medications. The clinical record documented a history of falls and recent confusion prior to the elopement incident on [DATE]. A nursing note on [DATE] documented the resident attempted to get up without assistance throughout the day and was found on [DATE] at 8:10 p.m. in the floor by his bed. A follow up note regarding this fall dated [DATE] documented, .Investigation completed. Resident is confused and got out of bed unassisted, stated, 'I was trying to leave,' falling to fall mat . Resident #187's plan of care (June (YEAR)) documented the resident was at risk of injury for bruises, skin tears, scratches due to anticoagulation therapy and previous back surgery. The only interventions listed for injury prevention were call bell within easy reach and adequate staffing to assist the resident out of bed. The care plan had no problem, goals and/or interventions regarding wandering, elopement prevention or use of the Wanderguard device. There were no revisions to the care plan following the fall on [DATE]. The nurse assigned to Resident #187 and the director of nursing employed at the time of the elopement/fall on [DATE] were not available for interview as they no longer worked at the facility. On [DATE] at 2:00 p.m., the administrator was interviewed about Resident #187's elopement and fall in the stairwell. The administrator stated the resident had a pressure seat alarm and Wanderguard as interventions prior to the elopement/fall on [DATE]. The administrator stated their investigation revealed the nurse caring for Resident #187 did not check the stairwell for the resident when the door alarm sounded. The administrator stated the resident's wheelchair was found at the top of the stairs. The administrator stated if the nurse checked or searched in the stairwell, she would have seen the wheelchair and known the resident was in the stairwell. The administrator stated the Wanderguard bracelet was supposed to activate the door alarm and the door lock to prevent the resident from going into the stairwell. The administrator stated the alarm sounded but the door did not lock. The administrator stated maintenance checked the door after the incident and found a defective part. The administrator stated the nurse caring for Resident #187 had no explanation of why she did not see the wheelchair at the top of the stairs or why she did not search or account for the resident in response to the alarm. The administrator stated the protocol for door and/or Wanderguard alarms was for staff members to immediately check and account for residents. On [DATE] at 5:10 p.m., the maintenance director was interviewed about the south hall door lock malfunction found when Resident #187 fell on [DATE]. The maintenance director stated the door was inspected after the incident and found with a power supply failure. The maintenance director stated the alarm sounded at the nursing station but the magnet door lock did not activate allowing the resident to get into the stairwell. The maintenance director stated prior to Resident #187's elopement/fall the door locks were checked for proper function every 6 months. The maintenance director stated the door locks were lasted checked on [DATE] prior to the fall. The facility's policy titled Resident Elopement (revised [DATE]) stated, The Hundley Center is equipped with security alarm and wander guard systems to alert the staff of unauthorized entry or exit through the doors and elevators . This policy included in procedures for elopement prevention, .Respond to audio alarms immediately. This is the responsibility of all staff. When responding to an alarm: the person closest to the alarm panel shall ascertain which door has been opened .find out who/what activated the alarm before turning it off .check the area around the activated door, including stairwell and the outside vicinity .nursing staff check the whereabouts of residents identified as 'wanderers' or 'elopement risks' to ensure they are accounted for . These findings were reviewed with the administrator and director of nursing during a meeting on [DATE] at 2:30 p.m. This was a complaint deficiency. 4. Resident #25 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The minimum data set ((MDS) dated [DATE] assessed Resident #25 with severely impaired cognitive skills. Resident #25's clinical record documented a post fall evaluation note dated [DATE] stating the resident fell from a reclining chair in his room. The record documented no further details about the fall or any description of events leading up to or surrounding the incident. The form listed the resident expressed no pain at the time of the fall and documented vital signs (temperature, blood pressure, respiratory rate, pulse rate). There was no mention of any injuries on the post fall note. The clinical record documented no assessment or indication for the resident's use of a reclining chair. The resident's plan of care (revised [DATE]) listed interventions for injury prevention as: note his positioning and location while out of bed in wheelchair, Morse fall risk standard precautions, sensory pad while in bed or chair, evaluate room for clutter, frequent rounds, call bell accessible, low bed, monitor more frequently, remove from harmful objects and monitor as needed while in wheelchair. The care plan made no mention of using a reclining chair with Resident #25. On [DATE] at 9:48 a.m., the licensed practical nurse (LPN #6) working on Resident #25's living unit was interviewed about the fall on [DATE]. LPN #6 stated the resident had [MEDICAL CONDITION] and tried to get up and reached out for things frequently from the wheelchair. LPN #6 stated when the resident was more alert he was usually seated in a standard wheelchair. LPN #6 stated when Resident #25 was more restless and fidgety they sometimes placed him in a reclining chair. LPN #6 stated she did not know why the resident was in the reclining chair on [DATE]. On [DATE] at 10:12 a.m., the registered nurse responsible for quality assurance (RN #1) was interviewed about Resident #25's fall from the reclining chair. RN #1 stated she reviewed and investigated all falls to ensure interventions were implemented. RN #1 stated when a resident fell , staff members were supposed to complete a fall report, get statements from any witnesses and perform neurological checks if needed. RN #1 stated her records indicated Resident #25 had previous falls on [DATE], [DATE] and [DATE]. RN #1 stated she had no report of the fall on [DATE] so she had not investigated or reviewed the circumstances surrounding the fall. RN #1 was asked for any assessments regarding Resident #25's use of a reclining chair. On [DATE] at 10:31 a.m., LPN #7 caring for Resident #25 was interviewed about use of the reclining chair. LPN #7 stated the resident was typically out of bed in a standard wheelchair. LPN #7 stated she was not aware of Resident #25 using a reclining chair. On [DATE] at 10:39 a.m., RN #1 stated the resident had no assessment for use of the reclining chair. When asked if the resident was injured from the [DATE] fall, RN #1 stated the resident got a scratch above his right eyebrow but no other injuries. These findings were reviewed with the administrator and director of nursing during a meeting on [DATE] at 2:30 p.m. 5. Resident #54 was admitted to the facility originally on [DATE], with [DIAGNOSES REDACTED]. The most current MDS (minimum data set) was an annual quarterly assessment dated [DATE]. Resident #54 was assessed with [REDACTED]. A family interview was conducted on [DATE] at 12:21 PM. During the interview Resident #54's son verbalized that Resident #54 had fallen multiple times and Resident #54 does not use the call bell and tries to get out of bed and out of the wheelchair. Resident #54's son verbalized that Resident #54 does were an alarm and has a fall mat, but felt that a shortage of staff was the main reason for the falls because the certified nursing assistants (CNA) have so much to do. On [DATE] 3:30 p.m. Resident #54 was observed within 10 feet of the nurses station by 2 surveyors. Three staff members were at the nurses station, but were unaware that Resident #54 was attempting to get out of the wheelchair. This observation continued for 15 minutes. No staff member attempted to assist Resident #54 until one staff member observed the surveyors and then started interacting with Resident #54, trying to get Resident #54 to scoot back in the wheelchair. Resident #54 did not want to slide back in the wheelchair after being asked, resulting in 2 CNA's physically moving Resident #54 back in the wheelchair. Review of Resident #54's care plan for fall interventions included: Bed alarm, Chair alarm frequent observations, low bed with mat, remind to use the call light. These interventions were all dated on [DATE]. The most recent updated intervention was dated [DATE] and included, keep in sight during risk hours. According to documentation, Resident #54 had fallen a total of 7 times between [DATE] and [DATE]. Review of Resident #54's post fall evaluation notes with a date range from [DATE] through [DATE] documented unwitnessed falls on [DATE], [DATE], [DATE], [DATE], [DATE], and 2 falls on [DATE]. On [DATE] at 08:51 AM registered nurse (RN #3), was interviewed regarding Resident #54's frequent falls. RN #3 verbalized that Resident #54 is continuously trying to get out of bed or out of the wheelchair, does not call for help and has had multiple falls. RN #3 verbalized that the facility has tried to put interventions into place, and felt the Resident # 54 would benefit from more supervision. RN #3 verbalized that the facility does not provided one on one monitoring and has asked the family if they could have a sitter to come into the facility to be able to monitor Resident #54 more closely. RN #3 verbalized that the family was unable to provide a sitter. On [DATE] 10:49 AM the director of nursing was Informed of the concerns regarding lack of supervision resulting in multiple falls. No other information was provided prior to exit conference on [DATE].

Based on staff interview and clinical record review, the facility staff failed to ensure effective pain management was provided, and failed to determine the cause of pain, for one of 23 residents in the survey sample: Resident # 5. Resident # 5 sustained a fall on 11/30/18. From 12/1/18 through 12/8/18, the facility staff failed to evaluate and manage a complaint of leg pain, not relieved by a current as needed order for Tylenol already in place for back pain. On 12/8/18 the resident was sent out for x-rays which determined a [MEDICAL CONDITION]. Findings include: Resident # 5 was admitted to the facility 8/24/17 with [DIAGNOSES REDACTED]. The most recent MDS (minimum data set) was a quarterly review dated 1/29/18 and had Resident # 5 assessed with [REDACTED]. The electronic medical record (EMR) was reviewed on 5/9/18 at 7:45 a.m. Nursing narrative notes were as follows: (It should be noted here there was no times given for the events; just a time stamp for when the documentation was entered in the computer system): 12/1/17: While receiving her nightly bath Res (resident) complained of pain in her right leg. CNA (certified nursing assistant) tried putting lotion on her feet, Res cried out in loud pain. Writer gave Res 650 mg of Tylenol. Res continued to complain of pain the rest of the night. 12/4/17: While res was receiving her bed (sic), she complained of pain in her left leg. CNA tried rubbing lotion on the same leg and the res cried out in pain. Writer gave res 650 mg of Tylenol, but res continued to complain of pain. Writer passed along information to dayshift on 12/5/17. 12/8/17: Resident complains by hollering out when any care is provided and staff touches left side of body. 12/8/17: Staff reports resident complains of pain to left hip, leg, arm and shoulder when giving care, ADL's (activities of daily living), applying lotions, turning and repositioning. Assessed resident: confusion related to dementia, left hip and leg pain when rolled side to side to change resident, complains of left shoulder pain, laying supine (on her back) holding onto arm .Informed unit manager to inform MD and request xrays be done . 12/8/17: New order to obtain xray of left hip and left shoulder due to extreme pain/ hollering out . 12/8/17: Informed MD of pain/hollering out, obtained new order for xrays, created orders, and put in transportation slip. Awaiting update from MD to see if they are to be sent via 911 today or wait until Monday since radiology doubts they can fit her in today. On 5/9/18 at 11:00 a.m. RN (registered nurse) # 1 was asked about the documentation of Resident # 5's pain, and what had happened. RN # 1 stated the resident had fallen on 11/30/17 out of her wheelchair, but did not appear at the time to have incurred any injury. This surveyor asked where the documentation about the fall was located in the nurses' notes. RN # 1 stated Well, we have been told not to document any notes in the computer as the new program is not set up for that type of documentation. We have forms that are checked off and entered; there are some notes but those are usually if there's a significant event .we do documentation by exception, so unless there's something out of the ordinary we are told not to make daily notes. RN # 1 was then asked about the notes entered about the resident's pain. RN # 1 was also asked for pain assessments done for Resident # 5 after the fall, and any other notes about the resident's pain that were done. A copy of of the care plan in place at the time of the fall was also requested. RN # 1 stated She really didn't complain of that much pain after she fell until much later . RN # 1 was referred to the above notes which were written the day after Resident # 5 fell , noting it was documented the resident was in pain. RN # 1 did not comment. RN # 1 stated she would get the pain assessments copied, and the care plan. On 5/9/18 at 2:45 p.m. RN # 1 provided a copy of pain assessments, notes, and the care plan in place at the time of the fall. The pain assessments were not complete. The care plan, dated as implemented 9/5/17 was reviewed. Under Problems was documented Risk for injury: bruises, skin tears, scratches, falls .related to dementia . Under Goals was documented No fall related injuries . Interventions included: If (name of resident) has a fall assess each shift for 72 hours for pain, injury . Per a fall incident report, the resident was noted to have fallen at 4:43 p.m. on 11/30/17. Pain assessment sheets revealed from 5:00 p.m. on 11/30/17 through 12/4/17 the resident was assessed as having pain; a pain scale of 0-10 was used, but no documentation was located noting the resident's pain level. The assessment form also included an area where the pain was to be described for onset, duration, region, quality, when occurs, what makes pain worse, what makes pain better and comments. All the area's were blank. There was one pain assessment dated [DATE] which was partially completed and documented the resident had pain in the leg which was brought on by movement. A Resident Pain Perception Note dated 12/8/17 documented Ability to rate pain: Making self understood: Usually understood. Pain interview to be conducted: Yes. Under Resident Pain Perception was documented: How often pain or hurting was present in past 5 days: Frequently .Verbal rating of pain over past 5 days: Very severe, horrible. An xray report from the hospital dated 12/8/17 documented Clinical History: Pain after fall. Findings: .Proximal left femur is suspicious for a minimally impacted subcapital fracture . The ER (emergency room ) physician notes attached to the xray report documented History of Present illness: Pt. unable to provide much history. Onset 5 days ago. The course/duration of symptoms is constant. Type of injuryfall. Location: left hip/shoulder. The character of symptoms is pain . Diagnosis: [REDACTED]. On 5/10/18 at 2:00 p.m. RN # 1 was asked about the documentation on the pain assessment sheets. RN # 1 stated Well, it's not filled out or documented, I can say that. The administrator, DON (director of nursing), and several nursing staff were made aware of the above findings during a meeting with facility staff 5/10/18 beginning at 2:30 p.m. It was discussed at that time of the potential for harm associated with the deficiency, and if there were any questions or additional information they could provide. The administrator stated No, I don't think so. No further information was provided prior to the exit conference.

Based on staff interview, family interview, clinical record review, facility document review, and in the course of a complaint investigation, the facility staff failed to prevent the development of pressure ulcers during the use of a long knee immobilizer device for two of 26 residents. (Residents #2 and #17) 1. The facility staff failed to perform skin assessments on Resident #2 while she was ordered to wear a long immobilizer brace due to a fracture. The lack of skin assessments and removal of the leg immobilizer caused the development of an avoidable pressure ulcer, found at an unstageable level resulting in harm. 2. The facility staff failed to perform skin assessments on Resident #17 while ordered to wear a long immobilizer brace due to an orthopaedic surgical procedure to the knee. The lack of skin assessments caused the development of an avoidable pressure ulcer, found as a deep tissue injury, which is between a stage IV and unstageable pressure ulcer level according to the facility's Pressure Ulcer Staging Guide during the 8/3/15 admission, resulting in harm . The findings included: 1. Resident #2 was admitted to the facility on [DATE], with the last readmitted being 10/9/15 with [DIAGNOSES REDACTED]. The current minimum data set (MDS), a quarterly with an assessment reference date (ARD) of 9/1/15 showed the resident with a brief interview for mental status (BIMS) showed the resident with a score of three out of 15, meaning the resident is severely cognitively impaired. The clinical record was reviewed on 10/20/15 through 10/22/15. The progress notes documented 7/17/15 14:00 (2:00 p.m.) - (Name) responsible party (RP) in and made aware of hard raised knot just below resident's knee noted last night during her bath. (Name) RP in room and observed area. 7/17/15 14:19 (2:19 p.m.) - (Name) NP (nurse practitioner) at (Name) attending physician's office made aware of hard raised knot noted just below left knee. Left leg is the leg that has recently been casted. RCA (restorative care aides) performs ROM (range of motion) to leg and ankle as ordered. No s/s (signs and symptoms) of pain noted when area touched and no redness or warmth noted. See order to xray left knee. 7/17/15 17:10 (5:10 p.m.) - (Name) NP at (Name) attending physician's office made aware of left knee xray results indicate focal fracture of cortex or erosion at the inferior aspect of tibial tuberosity. See order for Ortho consult. 7/17/15 17:25 (5:25 p.m.) - (Name) Orthopaedic physician (ortho) made aware of ortho consult re: left knee results. (Name) ortho reviewed xray and states that resident has a crack at left tibial tuberosity. See orders for left knee immobilizer to be worn at all times x (for) six weeks. Bedrest and Ortho will see resident on Monday. States to call over the weekend if resident has any problems. 8/18/15 15:45 (3:45 p.m.) - (Name) Ortho made aware of left lower leg brace rubbing resident's leg. Unstageable area noted to back of left lower leg. See orders to remove brace for skin care as needed and pad area with foam dsgs (dressings) and remove dsgs as needed for skin care. 8/18/15 15:48 (3:48 p.m.) - Information faxed to (name) attending physician's office re: 2.5x4.5x0.5 cm (centimeter) unstageable area with 80% black and 20% pink tissue noted to back lateral left lower lef located where metal piece in brace stops. [MEDICATION NAME] gel and foam dsg (dressing) applied by TX (treatment) nurse. 8/18/15 16:07 (4:07 p.m.) - (Name) daughter made aware of 2.5x4.5x0.5 cm unstageable area to back lateral side of left lower leg - located where metal piece of brace stops. Resident c/o (complaint of) pain when CNA (certified nurses assistant) was giving her a bath. (Name) Ortho made aware and gave orders to remove brace as needed for skin care and to pad areas with foam dsgs as needed. TX nurse in to assess area and [MEDICATION NAME] gel and foam dsg applied. Will have wound nurse assess in am. Information faxed to (name) attending physician's office. 8/19/15 08:00 (8:00 a.m.) - (Name) Ortho in to see resident. See new orders to d/c (discontinue) left knee immobilizer and daily dressing heel sore. 8/19/15 08:22 (8:22 a.m.) - (Name) NP (nurse practitioner) at (name) attending physician's office called back. See order for wound consult for unstageable area on left lateral lower leg. 8/19/15 13:48 (1:48 p.m.) late entry for 8/19/15 09:40 (9:40 a.m.) - CWOCN (certified wound nurse) in to assess wound on Lt. (left) lower inner leg per request of writer, small amt. of serosanguinous drainage, no odor, approx. 40% black, 30% yellow and 30% pink tissue, 3 cm x 4.5 cm with dry discolored skin lat. (lateral) wound, tx. of [MEDICATION NAME] gel, foam dsg and wrap. Prevalon booties recommended. Specialty mattress on bed. Brace off as ordered by (name) ortho. 8/18/15 15:00 (3:00 p.m.) - In to assess wound left inner foot area from immobilizer pressure this AM. Unstag (unstageable) ulcer present as described in notes per (name) treatment nurse from device. Immobilizer off and area has been assessed also by (name) ortho. Resident is not to have that partic immobilizer replaced. Area is moist and some drainage - will need tx to debride and begin healing. Reported by (name) nurse family is aware of breakdown and still wants immobilizer back in place. Will need a different type that will not touch this area for healing to take place. The facility's Comprehensive Wound Assessment Form documented 8/18/15 under comments device related brace and that the wound was found at an unstageable wound. The most recent comprehensive wound assessment form dated 10/13/15 documented the wound as a healing stage III. The Braden Scale assessments showed dates of 7/2/15, 9/26/15, 10/9/15, and 10/16/15. There was no Braden scale for the month of 8/15. The 7/2/15 Braden scale form showed the resident with a moderate risk of developing a pressure ulcer. On 10/21/15 at 10:55 a.m., the treatment nurse, licensed practical nurse (LPN) #5 was asked about skin checks when the brace was on. LPN #5 stated the order called for it (the brace) to not be removed. Sometimes ortho orders the braces like that, to not remove the splint. When asked how the unstageable was found, LPN #5 stated the CNA was giving her a bath and the resident complained of pain and it was discovered. When asked how staff would monitor the residents skin when they were any type of brace, LPN #5 stated they would look as far as they could see the skin under the brace without moving it. When asked if it is common to find a pressure ulcer at an unstageable level, LPN #5 stated it is rare to find them at that level. On 10/21/15 at 11:15 a.m., LPN #5 was asked whether this unstageable pressure ulcer would be considered avoidable or unavoidable. LPN #5 stated it was avoidable. This surveyor asked to see the wound during the next dressing change. LPN #5 stated that will be in the morning, I will get you before I get ready to start it. On 10/21/15 at 11:50 a.m., the complainant was asked the unstageable ulcer area. The complainant stated she was made aware of the wound when it was found and was told that there was another resident that had the same type of wound from the same type of leg brace around the same time. On 10/21/15 at 2:25 p.m., registered nurse (RN) # 3 was asked for the weekly skin assessments for Resident #2. RN #3 stated we don't do weekly skin assessments. When residents are admitted we do a Braden scale once a week for four weeks and then monthly, and a full assessment quarterly for the MDS. On 10/21/15 at 3:45 p.m., the director of nurses was asked about the order for the brace to be on at all times and how would staff determine any skin issues when the brace is not removed. The director of nurses stated I am with you on the skin I that too, why clarification was not gotten for skin care. The director of nurses was asked if this ulcer would be considered unavoidable or avoidable, to which she replied avoidable. Director of nurses was advised of concern of possible harm. On 10/21/15 at 5:20 p.m., the administrative team was made aware of the findings during a meeting with the survey team. The administrative team was made aware of concern for possible harm. On 10/22/15 at 8:00 a.m., LPN #5 was asked when she was going to change the dressing on Resident #2. LPN #5 advised this surveyor that the resident was sent to the hospital last night so she is not here for me to change the dressing. On 10/22/15 at 2:20 p.m., LPN #5 was asked how she determines what stage a pressure ulcer is found at. LPN #5 provided this surveyor with Pressure Ulcer staging guide she uses. The guide states that Unstageable - Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore stage cannot be determined. Stable (dry, adherent, intact without [DIAGNOSES REDACTED] or fluctuance) eschar on the heels serves as the body's natural (biological) cover and should be not be removed. When asked if anyone thought that when this pressure ulcer was found that there was another resident with the same type of brace on, on the same unit and that maybe someone should check to see if the other resident had any skin issues. LPN #5 stated that might have come up, but nothing happened from it. On 10/22/15 at 5:39 p.m., this surveyor asked for the facility's policy on skin assessments and pressure ulcer prevention. On 10/26/15 at 8:30 a.m., this surveyor was provided with the facility's policy with the subject skin integrity program. states under I. Purpose: A. To promote healing and/or prevent skin breakdown. II. Preparation: A. Braden Scale Skin Assessment must be completed on all residents within 24 hours of admission, then weekly x (times) 4 then monthly. Reassessment must be done monthly or as indicated. Braden scale to be done by LPN/RN. Nutritional assessment is done on admission and at plan of Care review. G. See Skin Care Protocol. (Attached). On 10/26/15 at 9:00 a.m., this surveyor asked for the Skin Care Protocol, which was not attached to the facility's policy. On 10/26/15 at 10:15 a.m., this surveyor was provided with the facility's Skin Care Protocol which showed the Criteria - If the patient/resident meets any of the following, implement wound care protocol in addition to routine nursing care. Total score is 16 or less on Braden scale; Pt (patient) has skin breakdown; Pt has a splint/device; Pt is incontinent. In the area of Prevention and treatment of [REDACTED]. Assess skin under any splint or traction at least every 8 hours and document changes. No other information was provided to this surveyor prior to the exit conference on 10/26/15. This is a complaint deficiency. 2. Resident #17 was admitted to the facility on [DATE]. A previous admission was on 8/3/15 with a discharge date of [DATE]. The resident's admission [DIAGNOSES REDACTED]. The current minimum data set (MDS), an admission with an assessment reference date (ARD) of 9/25/15 showed the resident with a brief interview for mental status (BIMS) score of 15 out of 15, meaning the resident was cognitively intact. On 10/21/15 at 2:25 p.m., licensed practical nurse (LPN) #5 was asked if there were any other residents that developed a pressure ulcer while wearing a knee immobilizer. LPN #5 provided this surveyor with the name of Resident #17 and stated it (the pressure ulcer) was found before she went home. She is back now and we are still treating it. The clinical record was reviewed on 10/22/15 and 10/23/15. The 8/3/15 admitting orders documented reinforce drsg (dressing) PRN (when needed) and call ortho, leave drsg intact, knee immobilizer for two weeks - call ortho for d/c (discontinue) orders. An 8/3/15 Braden scale documented the resident with a score of 14, which is a moderate risk of developing a pressure ulcer. An 8/7/15 Braden scale documented the resident with a score of 17, which is a mild risk of developing a pressure ulcer. A Comprehensive wound assessment form dated 8/3/15 documented the resident with a wound site on the left tibia that was a post operative wound. The progress notes documented 8/3/15 23:02 (11:02 p.m.) - Unable to check left leg knee dressing, pain noted when attempted to unwrap immobilizer, she said it hurts. 8/5/15 08:42 (8:42 a.m.) - (name) resident moaning and restless at this time in bed complaining of left knee pain. States it is 10/10 max pain and she states 'I don't know whats wrong with my knee, it hurts so bad (sic). 8/5/15 11:58 (11:58 a.m.) - (Name) PA (physician's assistant) from ortho in this am to see resident and checked left lower leg surgical site and said at this time no noted infection (sic). 8/6/15 03:56 (3:56 a.m.) - resident c/o back pain and was repositioned; dressing is dry and intact and brace in place to left leg (sic). 8/6/15 23:29 (11:29 p.m.) - resident given (pain med) po (by mouth) given 20:02 (8:02 p.m.) for complaints of sharp burning pain in left knee, med ineffective, immobilizer intact to left knee, dressing dry and intact, old spot of bloody drainage noted (sic). 8/7/15 09:28 (9:28 a.m.) - (Name) resident sitting upright in bed states her left leg has sharp shooting pain (sic). 8/9/15 16:26 (4:26 p.m.) - resident noted to have had a much painless day with the left knee and her ribs that she said bothered her on yesterday and last night with burning to left knee and discomfort, napped on and off and only took her scheduled meds, (vitals), turned and repositioned several times for comfort, immobilizer reinforced and dressing to left knee inplace with small amt (amount) of drainage to underside, c/o pain when leg were moved and washed by writer, no wgt (weight) bearing to left leg, remains in bed to rest today, needs made known, no swelling to left leg, feet, moves toes well, she did say her feet also hurt when washed, assisted with bedpan (sic). 8/10/15 16:05 (4:05 p.m.) - resident has ben up to the recliner chair, back to bed and back up to a chair and back to be all in 8 hrs (hours) and had pain to left leg the entire shift with pain meds, scheduled meds, and nerve pill given therapy in to see her and suggested my pt therapist to use the w/c (wheelchair) on for sitting and no lift on her at this time, md and ortho were notified of pain to the left leg, immobilizer to left leg readjusted several times for comfort, dressing in place, not tampered with, leg w/d (warm/dry) to touch, moves toes to left foot weel, no swelling noted. 8/10/15 1918 (7:18 p.m.) - Ortho and Dr's (name) office updated per phone on resident's continued complaints of pain, per ortho resident to have brace removed tonight, and dressing changed and they will be in to see her tomorrow. Says she feels no relief of burning sensation in thigh (sic). 8/11/15 16:37 (4:37 p.m.) late entry for 8/11/15 13:15 (1:15 p.m.) - Res noted to have 4.5 cm x 1.5 cm area with 3 small purplish red purplish tissue with redness periwound on back of left heel,[MEDICATION NAME] foam dsg applied. (name) ortho in for dressing change to LLE (left lower extremity), assessed back of lt. heel per request of writer and stated [MEDICATION NAME] dsg and Prevalon booties is okay to use to prevent further skin breakdown. 8/12/15 15:51 (3:51 p.m.) - three dti (deep tissue injury) areas noted to left lower heel, pressure from brace, apply dressing to left heel, (pressure noted from brace) (sic). On 10/22/15 at 10:30 a.m., this surveyor spoke with the resident. She stated she is doing okay, but would prefer that surveyor not watch the dressing change with staff. On 10/22/15 at 2:20 p.m., LPN #5 was asked how she was made aware of the pressure ulcer on Resident #17. LPN #17 stated I was called to the room by a staff member. Once I had it dressed, the ortho doctor came in and I showed him and received orders. When asked how she determines the stage of a pressure ulcer, LPN #5 provided this surveyor with the Pressure Ulcer Staging guide she uses. A Deep Tissue Injury is in between the stage IV pressure ulcer and the unstageable pressure ulcer and states Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer, or cooler as compared to adjacent tissue. Deep tissue injury may be difficult to detect in individuals with dark skin tones. Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar. Evolution may be rapid exposing additional layers of tissue even with optimal treatment. This surveyor asked if the pressure ulcer was avoidable or unavoidable, she stated avoidable. When asked if anyone thought that when this pressure ulcer was found that there was another resident with the same type of brace on, on the same unit and that maybe someone should check to see if the other resident had any skin issues. LPN #5 stated that might have come up, but nothing happened from it. On 10/22/15 at 5:39 p.m., the administrative team was made aware of the findings during a meeting with the survey team. This surveyor advised that this was possible harm. This surveyor asked for the facility's policy on skin assessments and pressure ulcer prevention. On 10/26/15 at 8:30 a.m., this surveyor was provided with the facility's policy with the subject skin integrity program. states under I. Purpose: A. To promote healing and/or prevent skin breakdown. II. Preparation: A. Braden Scale Skin Assessment must be completed on all residents within 24 hours of admission, then weekly x (times) 4 then monthly. Reassessment must be done monthly or as indicated. Braden scale to be done by LPN/RN. Nutritional assessment is done on admission and at plan of Care review. G. See Skin Care Protocol. (Attached). On 10/26/15 at 9:00 a.m., this surveyor asked for the Skin Care Protocol, which was not attached to the facility's policy. On 10/26/15 at 10:15 a.m., this surveyor was provided with the facility's Skin Care Protocol which showed the Criteria - If the patient/resident meets any of the following, implement wound care protocol in addition to routine nursing care. Total score is 16 or less on Braden scale; Pt (patient) has skin breakdown; Pt has a splint/device; Pt is incontinent. In the area of Prevention and treatment of [REDACTED]. Assess skin under any splint or traction at least every 8 hours and document changes. No other information was provided to this surveyor prior to the exit conference on 10/26/15.

Based on observation, resident interview, staff interview, facility document review and clinical record review, the facility staff failed to provide supervision and/or interventions to prevent accidents resulting significant injuries with harm for three of 26 residents in the survey sample (Residents #1, #10, #16) and failed to implement or initiate use of safety interventions for two of 26 residents in the sample (Residents #6 and #18). 1. Resident #1 fell from her bed while being turned during incontinence care by one aide when the resident required the assistance of two people for safe bed mobility. The resident experienced a painful fracture of her right great toe as a result of the fall, resulting in harm. There was no investigation of the resident's fall/fracture and no new safety interventions implemented regarding safety during incontinence care. The resident fell from her bed again eight days later when being turned in bed by one aide. 2. Resident #18, with severely impaired cognitive skills, was observed with the bed control cord hanging from her neck. There were no assessments or interventions implemented regarding the resident's safety in bed with accessible bed control or call bell cords. 3. Resident #10 fell and fractured her shoulder while attempting to go to the bathroom unassisted after her call bell went unanswered by facility staff resulting in harm. 4. Resident #6 had no sensor alarm in use as required in the plan of care. 5. A certified nurses' aide (CNA) continued to take Resident #16's blood pressure with an automatic machine after the resident expressed pain in his arm from the blood pressure cuff. The resident suffered a painful hematoma with bruising around his entire upper arm requiring medical treatment, resulting in harm. The findings include: 1. Resident #1 fell from her bed while being turned during incontinence care by one aide when the resident required the assistance of two people for safe bed mobility. The resident experienced a painful fracture of her right great toe as a result of the fall, resulting in harm. The resident fell from her bed again eight days later while care was provided by one aide. No interventions were implemented regarding the resident's safety during incontinence care following either fall. Resident #1 was admitted to the facility on [DATE] with a re-admission on 1/15/13. [DIAGNOSES REDACTED]. The minimum data set ((MDS) dated [DATE] assessed Resident #1 with severely impaired cognitive skills. This MDS assessed Resident #1 as weighing 191 pounds and to require the extensive assistance of two people for bed mobility and transfers. Resident #1 fell from the bed and fractured her toe on 4/25/15 when the certified nurses' aide (CNA) rolled her in bed while providing incontinence care. The resident fell from her bed again on 5/3/15 when a CNA was providing incontinence care. Resident #1's clinical record documented a nursing note dated 4/25/15 at 2:20 p.m. stating, While CNA .in changing resident this afternoon went to turn resident to change brief and resident proceeded to roll out of bed and unto (onto) floor, resident sitting on bottom end and holding on to bed rails, resident placed on to lift pad and lifted back into bed where care was given, Resident complaining of pain in right great toe which she can wiggle . The record documented the resident was diagnosed with [REDACTED]. The x-ray report dated 4/25/15 documented, Findings consistent with nondisplaced but mildly comminuted fractures involving the base and the proximal medial cortex of the proximal phalanx of right great toe. The Lippincott Manual of Nursing practice 10th Edition on page 1131 defines as comminuted fracture as a fracture in which bone has splintered into several fragments. (1) The resident's medication administration record (MAR) for April 2015 and May 2015 documented the resident was medicated for pain on four days following the fall. The resident was administered Tramadol for toe pain on 4/25/15, 4/27/15, 4/28/15 and 4/30/15. Nursing notes documented the following in the days following the resident's fall/fractured toe. 4/25/15 - .Tramadol 50 mg (milligrams) oral .c/o (complained of) right great toe pain . 4/26/15 - Resident complaining of being sore from yesterday's fall, right great toe noted swollen and bruised . 4/27/15 - .Received Ultram this am for pain, complaints of soreness in body from fall . 4/28/15 - .c/o right great toe pain with bruising and swelling noted, xray done that showed right great toe fracture and order to elevate right foot . Nursing notes documented the resident fell from the bed again while incontinence care was provided on 5/3/15. The note dated 5/3/15 documented, The resident was eased to the floor by the CNA; She had turned the resident to change her; and she slide (slid) to the floor; Assessed no injury noted. (sic) The clinical record documented the resident was assessed as a high risk for falls prior to the fall on 4/25/15. A fall risk evaluation was documented on 1/27/15, 4/14/15 and 4/25/15 listing the resident as a high fall risk due to cognitive impairment, vision problems, incontinence, poor mobility, lack of balance, medications and health conditions. The assessments listed Resident #1 with scores of 18, 20 and 20. The form documented, A resident who scores a 10 or higher is at risk. The resident's plan of care (revised 9/25/15) listed the resident was at risk of injury due to a history of falls, non-ambulatory status, poor balance, decreased mobility and total assistance required for transfers and toileting. Interventions for fall/injury prevention included fall malls at bedside, bean bags beside the bed, sensory pad to bed/chair, accessible call bell, low bed except during care, adequate staff for assistance out of bed and supervision for out of bed activity. The care plan listed the resident fell from bed on 4/25/15 and fractured her toe and fell from her bed on 5/3/15 but included no goals/interventions regarding assistance required during incontinence care or turning the resident in bed. The fall care plan interventions had not been updated since 7/14/14 when floor bean bags were added. The care plan was not updated after the fall/fracture on 4/25/15 or the fall on 5/3/15. The facility had no documented investigation of Resident #1's fall/fracture on 4/25/15 or the fall from bed on 5/3/15. On 10/21/15 at 9:25 a.m. CNA #5 caring for Resident #1 was interviewed about the resident's fall/fracture and assistance required. CNA #5 stated Resident #1 required the assistance of one person some days and on other days two people were required. CNA #5 stated the resident had little use of her legs and was unable to control the position of her legs/feet when turned. CNA #5 stated if the resident's legs got too far over it was difficult to keep her from sliding off the bed. CNA #5 stated some days the resident helped by holding the grab bar but on other days she was unable to assist with turning. CNA #5 stated the day the resident fell and fractured her toe (4/25/15) the aide caring for her was from another floor and not familiar with her. When asked how they know what assistance was required for residents, CNA #5 stated, We get report from the off going shift. On 10/21/15 at 12:10 p.m. the licensed practical nurse (LPN #10) caring for Resident #1 on 4/25/15 was interviewed about the fall/fracture. LPN #10 stated it was hard to control Resident #1's momentum when turning her in bed. LPN #10 stated, When you turn her (Resident #1) she will continue to roll. When asked about the fall/fracture on 4/25/15, LPN #10 stated, She (Resident #1) should have had two people. I was there that day. LPN #10 stated when the aide turned her in bed the momentum carried her off the bed. LPN #10 stated on 4/25/15 the CNA caring for Resident #1 was pulled from upstairs. LPN #10 stated, I don't think she (CNA from another floor) knew what she (Resident #1) required. When asked how the aide was supposed to know the assistance required to safely turn Resident #1, LPN #10 stated, I would be the one to tell her. LPN#10 stated, It was a lack of communication that day. On 10/21/15 at 12:20 p.m. the administrator was interviewed about any investigation regarding Resident #1's falls/fracture. The administrator stated she searched but did not have an investigation regarding Resident #1's fall/fracture on 4/25/15 or the fall on 5/3/15. On 10/21/15 at 2:50 p.m. LPN #12 responsible for care plans was interviewed about interventions for Resident #1's safety during incontinence care. LPN #12 stated Resident #1 should have two people when being turned in bed. LPN #12 stated some days the resident helped hold with the side rail but on other days she (Resident #1) was unable to assist. LPN #12 stated, On days she doesn't feel like it (holding on) she would need two people. LPN #12 stated the need for two people assisting with incontinence care was not on the care plan and may have been overlooked. On 10/21/15 at 3:45 p.m. the registered nurse unit manager (RN #3) was interviewed about Resident #1's fall/fracture. RN #3 stated Resident #1 sometimes would slide to the edge of bed during care and was dependent on staff for bed mobility. RN #3 stated Resident #1 sometimes needed two people and sometimes one person depending on the day. When RN #3 was told that LPN #10 stated the resident required two people on 4/25/15 because momentum carried her off the bed when turned, RN #3 stated, If that's what she (LPN #10) said I can't dispute that. RN #3 stated they had a huddle about Resident #1's fall/fracture but no new interventions were implemented regarding bed mobility safety. RN #3 stated they talked about some interventions for Resident #1 but nothing new was implemented. RN #3 stated they discussed with the family about moving the resident's bed against the wall but the resident and family did not want the bed moved. RN #3 stated the facility currently had no documented system for communication of resident requirements for the aides. RN #3 stated resident needs were communicated verbally to aides during shift report at shift changes. These findings were reviewed with the administrator and director of nursing during a review meeting on 10/21/15 at 5:15 p.m. When asked how the CNAs were expected to know the assistance required for residents the DON stated resident needs were communicated verbally at shift change. The DON stated CNAs also kept their own notebooks or note pads so they could write resident information down as needed. (1) Nettina, Sandra M. Lippincott Manual of Nursing Practice. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2014. 2. Resident #18, with severely impaired cognitive skills, was observed by a nurse with the bed control cord hanging from her neck. There was no assessment or any interventions implemented regarding the resident's safety in bed with accessible bed control or call bell cords. Resident #18 was admitted to the facility on [DATE] with a re-admission on 9/30/15. [DIAGNOSES REDACTED]. The minimum data set ((MDS) dated [DATE] assessed Resident #18 with severely impaired cognitive skills. On 10/22/15 at 7:50 a.m. Resident #18 was observed in bed. The resident was constantly tugging on her blanket with her right hand. The resident had the corded bed control in her left hand swinging it back and forth at her side. The resident also had a corded call bell at her side attached to her bed covers. Resident #18's clinical record documented a nursing note dated 8/12/15 stating, CP (care plan) problem #005 .Risk of injury .Writer walking pass (past) room saw resident had bed controller hang from the back of her neck. Redirected resident and educated on how that could easily choke her. Resident removed cord from neck and stated 'ok.' Will monitor. The clinical record made no further mention of the resident's safety regarding the bed control cord. The resident's care plan (revised 10/2/15) documented the resident was at risk injury due to her non-ambulatory status, dependence with transfers, bipolar diagnosis, impaired mobility, history of hallucinations, attempts to get on elevator to leave the unit and a history of looking for babies. The injury prevention care plan made no reference to the observation of the bed control cord hanging from the resident's neck. The care plan included no goals and/or interventions regarding the resident's safety with cords while in bed. On 10/22/15 at 11:35 a.m. the licensed practical nurse (LPN #2) caring for Resident #18 was interviewed about the observation made of the bed controller cord hanging from her neck. LPN #2 stated she was not aware of the note or that the resident had been observed with the cord hanging from her neck. LPN #2 stated Resident #18 constantly fiddled with things including her clothing, bed covers and bed control/call bell. On 10/22/15 at 11:45 a.m. the registered nurse unit manager (RN #4) was interviewed about the note of 8/12/15 of the resident with the cord hanging from her neck. RN #4 stated the resident pulled on her clothing and bedding constantly and pulls things around her. RN #4 stated the resident frequently put on multiple hats, blankets and liked to wrap things around her shoulders. Concerning the observation on 8/12/15, RN #4 stated she was made aware of the observation of the bed control cord hanging from the resident's neck in a morning meeting. RN #4 stated the resident had not been assessed for safety with cords in her bed and nothing had been added to the care plan. RN #4 stated, It (cord hanging from neck) was mentioned in report but she's not been care planned for that. When asked if educating the resident about cord safety was an effective intervention for Resident #18, RN #4 stated, No. RN #4 stated Resident #18 had significant cognitive impairment, poor safety awareness and was not able to understand safety risks. These findings were reviewed with the administrator and director of nursing during a review meeting on 10/22/15 at 5:40 p.m. 3. Resident #10 fell and fractured her shoulder while attempting to go to the bathroom unassisted after her call bell went unanswered by facility staff resulting in harm. Resident # 10 in the survey sample, a [AGE] year-old female, was admitted to the facility on [DATE], and most recently readmitted on [DATE] with [DIAGNOSES REDACTED]. Under Section G (Functional Status), the resident was assessed as needing extensive assistance with one person physical assist for transfer and toileting. According to the most recent Quarterly MDS with an ARD of 9/12/15, the resident was assessed under Section C (Cognitive Patterns) as being cognitively intact, with a Summary Score of 15 out of 15. Under Section G (Functional Status), the resident was assessed as needing limited assistance with one person physical assist for transfer. Review of the Interdisciplinary Progress (Nurses) Notes in Resident # 10's electronic medical record revealed the following entries: 4/13/15 - 3:21 a.m. Resident found in floor, lying face downward, resident had gotten up unassisted to use the bathroom, when she started to walk towards bathroom urinated on herself and floor and slipped in the liquid, resident rolled unto (sic) lift pad and hoyered lifted to bed, complaining of right shoulder pain Dr. (name), doctor on call according to call sheet called and order given to send resident to the ER for evaluation, daughter (name) called and updated and daughter (name) also returned call and notified, ER report given to (name), taken per stretcher to ER by (name) and (name) CNA's (Certified Nursing Assistants) fall huddle done, and resident had been instructed per CNA to call for assistance to go to toilet, however, CNA occupied at the time, VS (Vital Signs) 128/67 (Blood Pressure), 75 (pulse), 28 (respirations), 97.6 (temperature). 4/13/15 - 5:03 a.m. Report called from ER per (name) RN (Registered Nurse), at 4:50 a.m. resident ready to return to floor, humeral neck fracture .small abrasion noted to right forearm .Rt (right) arm in sling instructed no to use left arm to pull on right arm .resident returned to floor at 5:00 a.m. per stretcher At 9:25 a.m. on 10/22/15, Resident # 10 was interviewed regarding her fall on 4/13/15. At the time of the interview, the resident was in her room, lying in bed. Asked what happened, Resident # 10 said, I had to go to the bathroom. I called (rang the call bell) and nobody came. I couldn't wait, so I got my self up. When I got up I messed myself. I slipped in it and fell . When asked about treatment of [REDACTED].# 10 said, I've been lying in bed for three months now. My doctor said it may not help if they replace my shoulder. I just don't know what to do. During a meeting at 5:30 p.m. on 10/26/15, the administrative staff, including the Administrator and Director of Nursing, were advised the findings involving Resident # 10 had the potential to be placed at the harm level, and would be discussed at decision making. 4. The facility failed to ensure Resident # 6 had a sensor pad applied to the bed. Resident # 6 was admitted to the facility 2/11/13 with [DIAGNOSES REDACTED]. The most recent MDS (minimum data set) was a significant change assessment dated [DATE]. Resident # 6 had a total summary score of 04 out of 15, indicating severe cognitive impairment. The electronic medical record (EMR) was reviewed 10/20/15 beginning at 3:15 p.m. The current POS (physician order [REDACTED]. Check for placement Q (every) shift. Further review of the IPN's (interdisciplinary progress notes) revealed Resident # 6 had fallen five times since August 1st, 2015; falls had occurred on 8/7/15, 8/29/15, 10/9/15, 10/13/15, and 10/18/15. The IPN notes did not indicate the alarm sounding when Resident # 6 was found after a fall; one entry on 8/29/15 did note the alarm sounding. On 10/20/15 at 3:55 p.m. this surveyor went to Resident # 6's room. Resident # 6 was observed attempting to get out of bed. There was no alarm sounding, and this surveyor asked CNA (certified nursing assistant) # 1, who was coming down the hallway toward the resident's room, for assistance with Resident # 6. CAN # 1 and this surveyor entered the resident's room, and CNA # 1 helped Resident # 6 back in the bed without incident. This surveyor asked CNA # 1 about the sensory pad alarm on the bed. CNA # 1 looked on the bed under the resident and stated There's no alarm on his bed; is he supposed to have one? At that time a second CNA entered the room, and CNA # 1 asked if the resident was to have a sensor pad alarm. The second CNA stated she did not know, and looked in the seat of the wheelchair and stated Here it is. CNA # 1 then applied the sensor pad to the resident's bed. On 10/21/15 during a meeting with facility staff beginning at 5:15 p.m. the administrator and DON (director of nursing) were informed of the above observation. No further information was presented prior to the exit conference. 5. A certified nurses' aide (CNA) continued to take Resident #16's blood pressure with an automatic machine after the resident expressed pain in his arm from the blood pressure cuff. The resident suffered a painful hematoma with bruising around his entire upper arm requiring medical treatment, resulting in harm. Resident #16 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent MDS (minimum data set) was a quarterly assessment with an ARD (assessment reference date) of 08/28/2015. Resident #16 was assessed as moderately impaired in his cognitive skills with a total cognitive score of eight out of 15. On 10/21/2015 at approximately 7:50 a.m., during medication (med) pass observation, LPN #1 (licensed practical nurse) and this surveyor were standing outside of Resident #16's room. Resident #16 was sitting in a chair eating breakfast. Resident #16 stated to this surveyor, Look at this. Resident #16 pulled up the sleeve on his shirt to expose his right upper arm. A large bruise from just above his elbow to just below his shoulder area was noted. The bruise covered the entire circumference of this portion of the resident's arm. The bruise was dark purple, black, red in color, with some yellowing in the center. Resident #16 stated, Feel this. He pointed to an area on his right bicep. His arm was in a relaxed state at the time, no muscle flexion noted. The bicep area of his arm was palpated by this surveyor. The area was oval shaped, approximately the size of a large egg, hard and Resident #16 c/o (complained of) tenderness when palpated. Resident #16 stated, I took the last pill last night. I don't know what the plan is now. The doctor said if it wasn't any better after I finished my medicine I may have to have surgery. I don't know. LPN #1 was present during this entire conversation and observation. LPN #1 also examined and palpated Resident #16's right arm. Resident #16 was interviewed regarding how this bruise occurred. He stated, The nurse used that machine and it squeezed my arm. I told her it was too tight and she said, (it's okay, I know what I am doing). Resident #16 confirmed he was referring to the automatic blood pressure (b/p) machine. The resident was asked when he noticed the bruise and he stated, The next morning. LPN #1 and this surveyor immediately reviewed Resident #16's medical record together after the above observation. During the clinical record review the clinical coordinator on that unit, RN #4 approached the two of us. RN #4 was interviewed regarding Resident #16's bruise. RN #4 stated, Resident #16 c/o pain and bruising on his right arm after having his b/p taken. The bruise continued to get worse and he was sent to the ER (emergency room ) a couple of days later. He finished taking his Prednisone prescribed by the ER physician last night. RN #4 was asked if an investigation had been completed for this bruise. She stated, Just what is written in the notes and from the ER. On 10/22/2015 at approximately 8:00 a.m. Resident #16's clinical record was reviewed. The following IPN (interdisciplinary progress notes) were noted: 10/15/2015 08:29 PRN (as needed) Tylenol given .Reason: one tab for upper rt (right) arm pain of 5. 10/15/2015 20:17 (8:17 p.m.) Tylenol given .Reason: complains of right arm discomfort and requested tylenol he does not know why its bothering him (sic) 10/16/2015 21:09 (9:09 p.m.) Tylenol given .Reason: right arm discomfort only wanted one tablet (sic) 10/17/2015 00:11 (12:11 a.m.) This resident on evening shift 15:00 (3:00 p.m.) to 23:30 (11:30 p.m.), at change of shift the off going nurse and I looked at this residents right arm above the elbow was hurting him more than yesterday, when I looked at it yesterday there was no visible signs of bruising or edema, but when I saw it this shift, it was with edema and bruising purple in color and tender to touch, he also told us that his grip was impaired and had trouble opening the bathroom door or holding his utensils to eat. (sic) I call his doctors office but no answer so I called the on-call and Dr. (Name) was on call, he and I spoke at approximately 16:50 (4:50 p.m.) and told him what had occurred with this arm and I thought it needed to be looked at by someone else with more knowledge, and he gave an order to send him to the ER (sic) .the diagnosis/finding were hematoma and possible biceps tendon rupture, HTN (hypertension), and she wanted to know how it happen and how it could be ruptured, I repeated what I knew about have a lab drawn on 10-13-15 but knew nothing else, no falls which (Name) Resident #16 also said he had not fallen either .(sic). 10/17/2015 09:34 Tylenol given .Reason: Pain of 7 (10), Ice bag applied to upper Rt (right) arm. 10/17/2015 14:20 (2:20 p.m.) Bruise to right upper arm still present and swollen ice pack applied this morning per nursing staff and resident stated it did helped.Resident was given pain med earlier as well and was effective.Resident has been using arm today stated this morning could barely use it. Appears to be in n distress/discomfort since this morning.Will continue to monitor. (sic) 10/17/2015 15:36 (3:36 p.m.) Tylenol given .Reason: Rt arm pain of 9. 10/17/2015 22:54 (10:54 p.m.) Tylenol given .Reason: rigth arm hurting (sic) 10/18/2015 00:30 (12:30 a.m.) This resident right arm is showing increased bruising outside the marked area but the edema remains the same, I measured the arm yesterday and it was 28cm (centimeters) and the left was 25cm, tonight I measured it again and it was 28cm, he did complain of some discomfort and I gave him prn medication . (sic) 10/18/2015 10:36 Tylenol given .Reason: pain of 5 (10) 10/18/2015 14:49 (2:49 p.m.) Tylenol given .Reason: two tabs at noon, pain of 7, resolved to 5 10/19/2015 05:05 Tylenol given .Reason: c/o pain in rt arm 10/19/2015 08:13 right bicep has bruising noted dark purple and tender. bruising appears to be size of blood pressure cuff. Edges are straight and even rectangular shape on the mid bicep. Resident is concerned and believes it happened on Thursday night from evening Vital signs. RP (responsible party) notified of this mornings observation of bruise. (sic) 10/19/2015 19:15 (7:15 p.m.) Tylenol given .Reason: arm pain 10/21/2015 07:33 Message left for RP (Name) to notify her that DR (Name) (physician) office was notified of her concerns due to bruising and fear of muscle damage to bicep. Writer is waiting for Dr. response. 10/21/2015 08:06 Tylenol given .Reason: resident c/o pain in right arm 20% in pain. 3 10/21/2015 12:46 Tylenol given .Reason: resident c/o pain in right arm 20% in pain. 3 . 10/21/2015 16:06 (4:06 p.m.) (Name) with Physician (Name) office called and gave order for Ortho (Orthopaedic) consult for his right arm above the elbow where there is a hematoma . 10/21/2015 17:00 (5:00 p.m.) Tylenol given .Reason: right arm discomfort and requested one tablet. 10/21/2015 18:36 (6:36 p.m.) This resident still complaining of discomfort of the right bruising, given prn tylenol but only wanted one tablet, I measured it and it was 27.5 cm, turning yellow in the center of it and purpling is turning lighter as well, the raise are feels uneven texture of the skin . (sic) 10/22/2015 10:04 Made call to Ortho and left message on voice mail for consult for hematoma on right arm, waiting for response back. Call was made at 10:05AM (sic) The following documentation was located in the clinical record from Resident #16's ER visit on 10/16/15 at 1700 (5:00 p.m.). . Reason for Transfer / Actions Taken Prior to Transfer: R with a circle around it (right) arm new raised (edema) & (and) purple bruising & he c/o of grip is lesser .(sic) .Sites(s): Right arm above elbow Treatment: None, Alert, Oriented .c/o right arm has less grip & not able to turn door knob .Report given to: (Name) ER Nurse Date: 10-16-15 Time: 17:45 (5:45 p.m.) . Nurse's Notes .Arrival Date: 10/16/2015 Time: 17:58 (5:58 p.m.) .Chief Complaint: Arm Problem Diagnosis: [REDACTED].Presentation: 10/16 17:59 (5:59 p.m.) Presenting complaint: Patient states: Pt. states that after he had his blood pressure taken in his right arm two day s ago, his arm has been sore and red-. Care prior to arrival: None .Historical: .Home Meds: .4. Aspirin EC (enteric coated) PO (orally) 81 mg (milligrams) Daily (Last dose: 10/16/2015 09:00) .Assessment: 18:02 (6:02 p.m.) General: Appears comfortable. Pain: Complains of pain in right arm. Injury Description: Bruise sustained to right arm .19:15 (7:15 p.m.) General: .Pain: Pain currently is 4 out of 10 on a pain scale. Musculoskeletal: .hematoma noted to right upper arm . Physician Documentation .Arrival Date: 10/16/2015 Time: 17:58 .HPI: (History and Physical) 10/16 19:12 (7:12 p.m.) The patient or guardian complains of pain. The complaints affect the right bicep. Context: The problem was sustained at a nursing home or assisted living facility, resulted from unknown cause. Onset: The symptoms/episode began/occurred 2 day(s) ago, and became persistent. Modifying factors: the symptoms are aggravated by lifting weight. Associated signs and symptoms: Pertinent positives: ecchymosis .Historical: .Home Meds: .4. Aspirin EC PO 81 mg Daily (Last dose: 10/16/2015 09:00) .ROS: (Review of Systems) .Skin: Positive for ecchymosis, of the right bicep .Medications .Prescriptions: (for patients discharged from the Emergency Department): Prescription 1 prednisone 10 mg Oral tablet - take 1 tablet by ORAL route once daily; 5 tablet; 2 Tylenol 325 mg Oral Tablet - take 2 tablet by ORAL route every 6 hours As needed as needed; 60 bottle (sic) Discharge Instructions .Diagnosis: [REDACTED].Prescriptions prednisone Tylenol . (sic) Review of vital sign documentation for Resident #16 included B/P (blood pressure) readings on 10/12/2015 16:30 (4:30 p.m.) - 128/62 and 10/15/2015 17:00 (5:00 p.m.) - 150/88. No other B/P results were noted in the clinical record during this timeframe. At approximately 11:15 a.m. on 10/22/2015, during a meeting with the survey team, the Administrator and DON (director of nursing) were interviewed regarding Resident #16 and his arm bruise. The Administrator stated, We did go and talk to him after this incident. We meaning myself and (Name) DON. He told us it came from taking his blood pressure one time and it was too tight. I went back and looked to see if he had gotten his flu shot in that arm that could have caused the knot, but he had not. I also looked to see if he was on any blood thinners and he was not. I have a little thing written up where we talked to him that I will bring to you. On 10/22/2015 at approximately 3:30 p.m. an interview was conducted with Resident #16. Resident #16 was asked again about the bruise and knot on his right arm. He reiterated the same story as recorded above. At approximately 3:50 p.m., CNA #1 (certified nursing assistant) was interviewed regarding Resident #16 and the bruise on his right arm. CNA #1 stated, Resident showed me a small red spot about the size of an orange. I told the nurse (Name). She called the doctor and he went to the ER about one hour later.

Based on observation, clinical record review, staff interview, resident interview, and facility document review the facility staff failed to properly and promptly assess resident complaints of pain for one or 26 residents in the survey sample: Resident # 15, resulting in harm and also failed to follow physician orders [REDACTED].# 15, 12, 1, 18, 2, 25, and 19. 1A. Resident # 15's complaints of pain was not promptly and properly assessed to address a possible [MEDICAL CONDITION]. 1B. Resident # 15's insulin was not administered per physician orders. 2. Resident # 12 did not receive Keflex (an antibiotic) per physician order. 3. Resident # 1 did not have daily weights as ordered by the physician. 4. Resident # 18 did not receive Vitamin B-12 as ordered by the physician. 5. Resident # 2 did not have weekly weights as ordered by the physician. 6. Resident # 25 did not have an orthopedic consult in a timely manner as ordered. 7. Resident # 19 did not have intake and output monitored as ordered by the physician. Findings include: 1A. Resident # 15's complaint of right wrist pain was not promptly and properly assessed by the facility staff to address a possible [MEDICAL CONDITION] ulna. Resident # 15 was admitted to the facility 8/20/13 with a readmission date of [DATE]. [DIAGNOSES REDACTED]. The most recent MDS (minimum data set) was an annual review dated 7/28/15 and had Resident # 15 with moderate impairment in cognition with a total summary score of 10 out of 15. The electronic medical record (EMR) was reviewed 10/22/15 at 9:00 a.m. An IPN (interdisciplinary progress note) dated 4/5/15 documented .Tylenol 325 mg tab give two tablets oral as needed every four hours for pain. Reason: right wrist pain. (Previous IPN notes did not document complaints of wrist pain for Resident # 15.) Additional entries beginning with date 4/6/15 documented Resident's complaint of hitting right wrist on burgundy bed rail, area noted warm to the touch, no redness noted. 4/10/15 Tylenol 325 mg two tablets for complaints of right wrist pain. 4/10/15 Resident continues to complain of right wrist pain; Tylenol given . will not let writer touch it, only look at it. No redness noted, slightly swollen. 4/10/15 Information faxed to Dr's office re: right wrist pain, faintly reddened- resident hit wrist on handrail on wall beside bed recently. Nursing requests xray. 4/10/15 Message left for (name of office staff) to call for an update on resident (right wrist faintly reddened, complaint of pain- had hit it on handrail recently and MD office aware- nursing requests xray). There were no other entries in the IPN notes about the resident's wrist until 4/13/15 which documented Primary care nurse showed me x-ray report to right wrist which shows fracture right ulna, Further review of the IPN notes revealed the following: 4/13/15 primary care nurse updated the family about the x-ray. DON (director of nursing) aware. A message was left on voice mail at Dr. office about the report and request for possible ortho (sic) consult. 4/13/15 Two Tylenol 325 mg tablets administered for c/o (complaint of) right wrist pain. (Resident # 15's pain level was documented to be an 8 out of 10). 4/14/15 (name of doctor) made aware of Ortho consult due to fractured right wrist. 4/15/15 .new order for CT scan to right wrist due to pathological fracture obtained . 4/16/15 Results of CT scan sent to (name of doctor). Awaiting return phone call. The CT scan report, dated 4/15/15, documented Findings: plain radiographs of the right wrist obtained 4/11/15 were suggestive of fracture in the medial cortex and probably lateral cortex of ulnar styloid process in the distal end of the radius there is no evidence of fracture. Impression: In the ulnar styloid process there is no distinct fracture in the rest of the distal ulnar area there is no additional fracture or cystic change noted IPN notes continued to document: 4/17/15 Dr. orders a brace to be worn at all times except bathing for 3 weeks. Nursing staff and assistive personnel educated by Orthopedic staff how to apply brace correctly On 10/22/15 at 1:00 Resident # 15 was asked about the injury to her right wrist. Resident # 15 stated Oh, yes, I hit it on those rails right there (pointing to two burgundy handrails attached to the wall beside the bed) and it hurt something awful for a long time. They finally put a cast of some sort on it for a few weeks, but even after that it still hurt. It still bothers me a little bit, but not like it was. On 10/23/15 at 8:45 a.m. RN (registered nurse) # 3, who was the unit manager, was interviewed about the IPN notes and lapse of time for notification of the physician that the resident had made staff aware she hit her wrist, and her continued complaints of pain. RN # 3 stated There is a note on 4/6/15 that info was faxed to the Dr.; the note refers to the 'previous entry' which was the resident telling staff she hit her wrist. Sometimes it takes a while to get a response back. This surveyor noted the resident's complaints of pain after informing staff she had hit her wrist on the bedrail's continued for approximately 5 days before staff notified the physician, and an x-ray was not obtained until 4/11/15, 6 days after complaining of pain. RN # 3 did not respond when asked if there was no response in a timely manner from Dr's office, would she expect staff to call and ensure information was received. On 10/26/15 at 2:00 p.m. the resident's physician, who was the facility's medical director, was interviewed by phone. The physician was asked about the notification to his office via fax on 4/6/15. The physician stated I was actually off that day, but I have assistants who handle those types of things when I'm not in the office. I do not recall getting/being told of the resident's wrist pain, but the information could have gotten lost, or may not have been received; the type of information the facility staff fax over here is usually 'FYI' information, or labs .it's not usually things that need to be addressed immediately. I don't rely on faxes a lot for info; usually the staff will call for something like an injury. The administrator and DON (director of nursing) were informed of the above findings during a meeting with facility staff 10/26/15 beginning at 5:15 p.m. No further information was provided prior to the exit conference. 1B. Resident # 15's insulin was not administered per physician order. The electronic medical record (EMR) was reviewed 10/22/15 at 9:00 a.m. The current POS (physician order [REDACTED]. before meals and at bedtime per sliding scale At approximately 12:05 p.m. on 10/21/15, LPN (licensed practical nurse) #4 was observed getting on the elevator on the first floor. LPN #4 was pushing a medication cart. On top of the medication cart was an uncapped syringe. LPN #4 was asked where she was headed and stated, I am going to the dining room to give this insulin. At that time she picked the uncapped syringe up. Upon entering the dining room, Resident #15 was observed sitting at a table eating her lunch. LPN #4 entered the dining room, pushed her medication cart into an adjoining room and removed Resident #15 from her table. She took Resident #15 to the adjoining room and stated, I need to give you your insulin. LPN #4 was observed to administer 18 units of insulin into the abdomen of Resident #15 at 12:10 p.m. LPN #4 was asked when the insulin was due. She stated, 11:00 a.m. The order on the electronic MAR was observed by this surveyor and read .To be administered before meals . LPN #4 was asked why Resident #15 was just now getting her insulin. She stated, I just haven ' t had time to get it to her. A review of the eMAR (electronic medication administration record) revealed the insulin was signed out as given at 11:00 a.m. On 10/23/15 at 12:15 p.m. the assistant director (identified as Other Staff (OS) # 4) of the facility's IT department was interviewed. OS # 4 was asked how a medication could be documented out of the ordered timeframe. OS # 4 stated I think the parameters in the system are set to 'lock out' staff from being able to document medications after 2 hours past the ordered time; I will need to check on that. A while later, OS # 4 told the survey team There are no parameters set to prevent staff from documenting a medication, even if it's not given when due. They (staff) can document any time and the system will show medications were administered as ordered. The administrator and DON (director of nursing) were informed of the above findings during a meeting with facility staff 10/26/15 beginning at 5:15 p.m. No further information was provided prior to the exit conference. 2. Resident #12 did not receive physician prescribed Keflex as ordered. Findings were: Resident #12 was originally admitted to the facility on [DATE] and was most recently readmitted on [DATE]. Her [DIAGNOSES REDACTED]. The most recent MDS (minimum data set) was a quarterly assessment with an ARD (assessment reference date) of 08/28/2015. Resident #12 was assessed as having a cognitive summary score of 12, indicating moderate impairment with her cognitive status. The clinical record was reviewed on 10/21/2015. Observed in the interdisciplinary notes were the following entries: 08/20/2015 15:50 (3:30 p.m.) .see order for Keflex and consult surgeon or podiatrist for inflamed right great toe. 08/23/2015 16:01 (4:01 p.m.) LATE ENTRY FOR 8/22/2015 09:00 (9:00 A.M.) NO KEFLEX IN RESIDENT'S MEDICATION DRAWER OR MEDICATION CART. SHIFT SUPERVISOR WAS ABLE TO OBTAIN ONE DOSE FROM PHARMACY FOR 0900 MED PASS. 08/24/2015 12:35 (12:35 p.m.) Information faxed to (Dr's name) office .No redness noted to right great toe .Has not received Keflex as ordered-bottle missing and Pharmacy will not dispense another-does med need to be discontinued no inflammation present. 08/24/2015 14:28 (2:28 p.m.) (Name of person at Dr's office) called back. See order to d/c (discontinue) Keflex. The MAR (medication administration record) for August was reviewed. The following order was listed: 08/20/2015 Keflex 500 mg Cap ([MEDICATION NAME]) Oral twice daily at 09 and 21 (9:00 a.m. and 9:00 p.m.) 500 mg for Inflamed right great toe X (times) 7 days .Stop Date: 08/24/2015. The Keflex was signed off as given on 08/20/2015 at 9:00 p.m., 08/21/2015 9:00 a.m. and 9:00 p.m., 08/22/2015 9:00 a.m., 08/23/2015 9:00 p.m., 08/24/2015 9:00 a.m. Resident #12 received six doses of the 14 prescribed doses of Keflex. The DON (director of nursing) were notified of the missed doses of Keflex on 10/21/2015 during an end of the day meeting. On 10/22/2015 RN (registered nurse) #3 came tot the conference room to speak with this surveyor regarding the missed doses of Keflex for Resident #12. She stated, That happened over the weekend .they couldn't find the bottle. When I came in on Monday her toe wasn't inflamed and they had found the Keflex .I faxed the doctor because her toe looked better to see if we could discontinue it since she had missed the doses. He told us to discontinue it. RN #3 was asked why the pharmacy would not dispense additional Keflex when they were told the bottle was missing. She stated, I don't know. RN #3 was asked if the physician had been notified over the weekend that Resident #12 was not receiving her antibiotic. She stated, I don't think so. On 10/26/2015 at 2:30 p.m., the Director of Pharmacy came to the conference room to speak with this surveyor regarding Resident #12's Keflex. He stated, We sent 14 Keflex on 08/20 .they were in a medication bottle, labeled with the resident's name and the medication information .the med was misplaced in the med cart .the pharmacist was here on Saturday and gave them one dose and asked the staff to look for the bottle and call back the staff didn't call back .when the pharmacist called back the resident had missed two doses the medication was eventually found inside to the [MEDICATION NAME] bin in the medication drawer .it accidentally got put in there by one of the nurses .we never told them they couldn't have more Keflex, we asked them to look for it and call us back . The medication is also in the (Name of medication dispensing machine) .it was never not available to them. The Director of Pharmacy was asked if the staff was aware that the medication, Keflex was in the machine. He stated, Yes. No further information was obtained prior to the exit conference on 10/26/2015. 3. Resident #1's daily weights were not monitored as ordered by the physician. Resident #1 was admitted to the facility on [DATE] with a re-admission on 1/15/13. [DIAGNOSES REDACTED]. The minimum data set ((MDS) dated [DATE] assessed Resident #1 with severely impaired cognitive skills. Resident #1's clinical record documented a physician's orders [REDACTED]. The dietitian documented a note on 9/10/15 stating, Resident has had significant weight loss over 1 month (-5.5%) .Will continue to monitor po (oral) intake and weights on a weekly basis. The clinical record documented resident no weight for week ending 9/19/15. The first weekly weight listed was on 9/25/15. On 10/22/15 at 9:20 a.m. the registered nurse unit manager (RN #3) was interviewed about the missing weight for Resident #1. RN #3 stated Resident #1's weights for the first two weeks in September 2015 were missing and were not obtained. RN #3 stated the aides were supposed to obtain weights and record in the weight book kept on the unit. These findings were reviewed with the administrator and director of nursing during a review meeting on 10/22/15 at 5:40 p.m. 4. Resident #18's daily vitamin B12 was not administered as ordered by the physician. Nurses administered vitamin B12 orally to Resident #18 when the physician ordered the medication to be administered sublingually. Oral vitamin B12 supplied by the pharmacy in error was administered sublingually to Resident #18. Resident #18's clinical record documented a physician's orders [REDACTED]. The resident's October 2015 MAR listed the order as Vitamin B-12 23 mg (milligrams)-1000 mcg tab (Calcium/[MEDICATION NAME]) Sublingual in the morning at 09:00 (9:00 a.m.) . for supplement. Nurses documented on the MAR the supplement was administered orally or po (by mouth) on 10/2/15 through 10/5/15, 10/7/15 through 10/10/15 and on 10/12/15 through 10/15/15. The MAR listed the supplement was administered SL (sublingual) on 10/1/15, 10/6/15, 10/11/15 and on 10/16/15 through 10/22/15. On 10/22/15 at 3:30 p.m. the licensed practical nurse (LPN #1) that documented on four days she administered vitamin B12 orally to Resident #18 was interviewed. LPN #1 stated, She (Resident #18) takes it under her tongue (sublingual). When asked why she documented po if the tablets were administered under her tongue, LPN #1 stated, Because it was given by mouth. I never thought to put SL (sublingual) in there (MAR slot). When asked if she knew that sublingual and po (oral) were different routes of administration, LPN #1 stated, Yes. LPN #1 stated, She takes it by mouth so that's why I put po. On 10/22/15 at 3:50 p.m. the registered nurse unit manager (RN #4) was interviewed about Resident #18's vitamin B12 order and the multiple administration routes (sublingual and oral). Accompanied by RN #4, Resident #18's vitamin B12 supply in the medication cart was inspected. The resident's vitamin B12 supplied by the pharmacy was not sublingual but was labeled as oral medication. The vitamin B12 pharmacy label stated, 1 (One) tab by mouth daily. RN #4 reviewed the physician's orders [REDACTED]. RN #4 stated the vitamin B12 order must have been filled wrong by the pharmacy. RN #4 stated she was not aware of the discrepancy in vitamin B12 order or administration routes until questioned during the survey. On 10/22/15 at 4:00 p.m. the facility's director of pharmacy was interviewed by telephone concerning Resident #18's vitamin B12 order. After researching the pharmacy director stated the sublingual order was filled in error by the pharmacy with oral medication. The pharmacy director stated they did not routinely stock the sublingual form of vitamin B12 but the order should have been clarified prior to filling. The pharmacy director stated, We should have clarified it (ordered route) with the doctor but in this case that didn't happen. The pharmacy director stated sublingual tablets were designed to be dissolved under the tongue and oral (po) tablets were supposed to be swallowed. The facility's policy titled Preparing and Administering of Meds & Use of Drug Cart (revised 3/8/12) stated concerning medication administration, Remember the 5 R's - Right: Patient, Medication, Route, Dose, and Time .Before administering a drug, read the label three times: 1. When taking the container from the cart bin. 2. When preparing the dose. 3. When returning the drug to storage or discarding wrapper . Always make certain that you are giving the right doses of the right medication to the right resident at the right time by the right route .Keep accurate records of all medication doses administered .Sublingual and [MEDICATION NAME] routes of administration are used when rapid action is desired, or when drug is specifically designed to be easily absorbed into blood vessels under the tongue (sublingual route) .The tablets are completely soluble. These drugs cannot be given orally to obtain the same rapid effect . Routes of administration are not therapeutically interchangeable . The Drug Information Handbook for Nursing 13th Edition on page 280 describes vitamin B12 ([MEDICATION NAME]) as a water soluble vitamin used to the treatment of [REDACTED]. This reference states concerning routes of administration, Oral not recommended due to variable absorption . (1) These findings were reviewed with the administrator and director of nursing during a review meeting on 10/22/15 at 5:40 p.m. (1) Turkoski, Beatrice B., Brenda R. Lance and Elizabeth A. Tomsik. Drug Information Handbook for Nursing. Hudson, Ohio: Lexi-Comp, 2011. 5. The facility staff failed to obtain physician ordered weekly weights for Resident #2. Resident #2 was admitted to the facility on [DATE], with the last readmitted being 10/9/15 with [DIAGNOSES REDACTED]. The current minimum data set (MDS), a quarterly with an assessment reference date (ARD) of 9/1/15 showed the resident with a brief interview for mental status (BIMS) showed the resident with a score of three out of 15, meaning the resident is severely cognitively impaired. The clinical record was reviewed on 10/20/15 through 10/22/15. A 9/10/15 physician's orders [REDACTED]. The facility's documentation showed a weight done on 9/24/15. There was no documentation of any other weights done between the order date of 9/10/15 and 9/24/15. A readmission order dated 10/9/15 documented weight weekly x (times) 4 then monthly. The facility's documentation showed weights on 10/11/15 and 10/20/15. On 10/21/15 at 10:45 a.m., certified nurse assistant (CNA) #2 was asked about the resident's weekly weights. CNA #2 stated I do not normally have her, but as far as I know we are told in report who needs a weight done during our shift. I have not gotten any report that one was needed on her, but like I said I usually do not have her. When asked where the weight information would go if one was needed, CNA #2 stated I would give it to the nurse and they document it and I put it in care tracker. On 10/21/15 at 5:20 p.m., the administrative staff were made aware of the findings during a meeting with the survey team. No other information was provided to this surveyor prior to the exit conference on 10/26/15. 6. The facility staff failed to obtain a physician ordered orthopaedic consult for Resident #25. Resident #25 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent minimum data set (MDS), an annual with an assessment reference date (ARD) of 15 out of 15, meaning the resident is cognitively intact. The clinical record was reviewed 10/23/15 and 10/26/15. An orthopaedic consult dated 7/15/15 documented Findings: h/o (history of) trauma Left foot > (greater than) 1 month back, due to wheelchair, had pain, swelling. Seen in ER. x-ray ortho consult ordered but was not communicated till (attending physician) asked about it yesterday. I was called yesterday and ordered new x-ray. Now she has no foot pain. Diagnosis: [REDACTED]. The clinical record did not show documentation of an orthopaedic consult in June 2015, nor a nurse's note that an orthopaedic consult was requested by the attending physician. A nurse's note dated 6/12/15 documented Resident c/o (complaint of) left foot pain, observation revealed 0.5cm bruise under second joint of 2nd and 3rd toe. Resident stated another resident's chair hit her foot today during activity. MD (attending physician) and RP (responsible party) notitied. X-ray of Left foot ordered and place ice @ (at) 30 minute intervals as needed for pain. On 10/23/15 at 1:45 p.m., registered nurse (RN) #4 was asked about the resident's orthopaedic consult order for 6/12/15. RN #4 reviewed the clinical record and stated the only orthopaedic consult in here is the 7/15/15 consult. The facility investigation dated 7/17/15 documented Ortho consult ordered on [DATE]. The order to consult Ortho was not noted. On 7/15/15, attending physician notified that the consult ordered on [DATE] was not done. Ortho consult re-ordered and Ortho notified. On 10/26/15 at 2:00 p.m., the director of nurses was asked about the facility's findings regarding the orthopaedic consult for 6/17/15. The DON stated we determined it was requested but not noted anywhere. This surveyor asked to speak with the attending physician. On10/26/15 at 2:15 p.m., the attending physician was asked about the request for an orthopaedic consult on 6/17/15. The attending physician stated yes, that is something we would order to ensure that there were no other concerns not addressed. Yes I did request an orthopaedic consult then, but it was not done. On 10/26/15 at 5:40 p.m., the administrative team was made aware of the findings during a meeting with the survey team. No other information was provided to this surveyor prior to the exit conference on 10/26/15. 7. The facility staff failed to consistently document the intake and output of Resident # 19, who had a physician's orders [REDACTED]. Resident # 19 in the survey sample, an [AGE] year-old male, was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to an Admission Minimum Data Set (MDS), with an Assessment Reference Date of 8/18/15, the resident was assessed under Section C (Cognitive Patterns) as being cognitively intact, with a Summary Score of 13 out of 15. Resident # 19 had a physician's orders [REDACTED]. Review of the Medication Administration Record (MAR) and the Care Tracker I/O (Intake/Output) Chart Detail Report for the randomly selected two week period of 9/26 - 10/9/15 revealed the following: 9/28/15 - No intake recorded for the first and third shifts. 9/29/15 - No intake recorded for the first shift; no intake/output recorded for the second and third shifts. 9/30/15 - No intake recorded for the first shift. 10/1/15 - No intake recorded for the first and second shifts. 10/2/15 - No intake recorded for the first and third shifts. 10/3/15 - No intake recorded for the first shift; no output recorded for the second shift. 10/4/15 - No intake recorded for the first shift. 10/5/15 - No intake recorded for the first shift. 10/6/15 - No output recorded for the second shift. During a meeting with the administrative staff at 5:45 p.m. on 10/26/15, the Director of Nursing (DON) was asked why the Intake and Output documentation was maintained in two different locations. The DON said the CNA's (Certified Nursing Assistants) have access to, and document in Care Tracker, while the nurses document on the MAR. The DON went on to say that the Care Tracker I/O Chart Detail Report was the preferred place for documenting intake and output.