Every finding on record at Tyler's Retreat at Iron Bridge

Based on observation, staff interview, facility document review, and clinical record review, the facility staff failed to implement bed rail requirements for four of 36 residents in the survey sample, Residents #6, #100, #101, and #102. The findings include: 1. For Resident #6 (R6), the facility staff failed to assess the resident for risk of entrapment and failed to attempt appropriate alternatives prior to the resident's use of bed rails (grab bars).On 8/11/25 at 12:44 p.m., R6 was observed lying in bed with bilateral grab bars in the upright position.A review of R6's clinical record (including an enabler-restraint observation form dated 7/3/25) failed to reveal documentation that the facility staff assessed the resident for risk of entrapment or attempted appropriate alternatives.On 8/12/25 at 3:12 p.m., an interview was conducted with LPN (licensed practical nurse) #1. LPN #1 stated the facility staff does not assess residents for risk of entrapment or attempt alternative devices for residents who use grab bars.On 8/12/25 at 4:49 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing) were made aware of the above concern.The facility policy titled, Bed Rail Policy documented, 1. The facility will attempt to use appropriate alternatives prior to installing a side or bed rail. 2. If a bed or side rail or bar is used, the facility will: a. Evaluate the potential risks associated with the use of bed rails including the risk of entrapment, prior to bed rail installation. No further information was presented prior to exit.2. For Resident #100 (R100), the facility staff failed to assess the resident for risk of entrapment and failed to attempt appropriate alternatives prior to the resident's use of bed rails (grab bars).On 8/11/25 at 4:05 p.m., R100 was observed lying in bed with bilateral grab bars in the upright position.A review of R100's clinical record (including an enabler-restraint observation form dated 8/6/25) failed to reveal documentation that the facility staff assessed the resident for risk of entrapment or attempted appropriate alternatives.On 8/12/25 at 3:12 p.m., an interview was conducted with LPN (licensed practical nurse) #1. LPN #1 stated the facility staff does not assess residents for risk of entrapment or attempt alternative devices for residents who use grab bars.On 8/12/25 at 4:49 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing) were made aware of the above concern.No further information was presented prior to exit.3. For Resident #101 (R101), the facility staff failed to assess the resident for risk of entrapment and failed to attempt appropriate alternatives prior to the resident's use of bed rails (grab bars).On 8/11/25 at 1:34 p.m., R101 was observed lying in bed with bilateral grab bars in the upright position.A review of R101's clinical record (including an enabler-restraint observation form dated 8/8/25) failed to reveal documentation that the facility staff assessed the resident for risk of entrapment or attempted appropriate alternatives.On 8/12/25 at 3:12 p.m., an interview was conducted with LPN (licensed practical nurse) #1. LPN #1 stated the facility staff does not assess residents for risk of entrapment or attempt alternative devices for residents who use grab bars.On 8/12/25 at 4:49 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing) were made aware of the above concern.No further information was presented prior to exit.4. For Resident #102 (R102), the facility staff failed to assess the resident for risk of entrapment and failed to attempt appropriate alternatives prior to the resident's use of bed rails (grab bars).On 8/11/25 at 1:44 p.m., R102 was observed lying in bed with bilateral grab bars in the upright position.A review of R102's clinical record (including an enabler-restraint observation form dated 8/8/25) failed to reveal documentation that the facility staff assessed the resident for risk of entrapment or attempted appropriate alternatives.On 8/12/25 at 3:12 p.m., an interview was conducted with LPN (licensed practical nurse) #1. LPN #1 stated the facility staff does not assess residents for risk of entrapment or attempt alternative devices for residents who use grab bars.On 8/12/25 at 4:49 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing) were made aware of the above concern.No further information was presented prior to exit.

Based on staff interview, facility document review, and clinical record review, the facility staff failed to implement hospital transfer requirements for two of 36 residents in the survey sample, Residents #96 and #5.The findings include:1. For Resident #96 (R96), the facility staff failed to provide a bed hold notice when the resident transferred to the hospital on [DATE]. A review of R96's clinical record revealed a nurse's note dated 12/27/24 that documented, MD (Medical Doctor) made this nurse aware of need to send resident to ER for evaluation of right jaw swelling. Resident noted to have increased edema of right jaw and MD concerned re: cellulitis or an abscess . Further review of R96's clinical record failed to reveal the resident/resident representative was provided a written notice of the bed hold policy. On 8/12/25 at 3:12 p.m., an interview was conducted with LPN (licensed practical nurse) #1. LPN #1 stated a copy of the bed hold policy is supposed to go with the resident when a resident is sent to the hospital and the nurse should document a note this was done. On 8/12/25 at 4:49 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing) were made aware of the above concern. The facility policy titled, Resident Discharge/Transfer Letter Policy documented, G) The resident or responsible party will receive a bed hold notice along with the discharge/transfer letter, when applicable. No further information was presented prior to exit. 2. For R5, the facility staff failed to evidence that written notification was provided to R5’s responsible party in a practicable timeframe for a facility-initiated transfer on 03/03/2025 and on 03/25/2025. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 07/05/2025, R5 scored 15 out of 15 on the BIMS (brief interview for mental status), indicating the R5 was cognitively intact for making daily decisions. The facility’s nurse’s note dated 03/03/2025 at 1:34 p.m., for R5 documented in part, “Resident was received by writer with report of consistent pain to abdomen during the night and nausea (PRN (as needed) Tylenol) administered during 11-7 (11:00 p.m. to 7:00 a.m. shift)). Resident remains consistent with c/o (complaint of) pain during medication administration. Writer notified NP (nurse practitioner) and MD (medical doctor) of resident's discomfort and condition. MD in to assess resident with writer. Findings of tenderness to right abdomen w/o distention. Resident reported last BM (bowel movement) was 3/2/25. MD ordered for resident to be sent to EM (emergency room) for further evaluation. Writer contacted 911 for transport. EMT (emergency medical technician) arrived at facility at 1050am (10:50 a.m.) and transported resident safely from w/c (wheelchair) to stretcher by only contact assist (assistance) . The resident's needs cannot be meet [sic] at the facility at this time after several attempts to meet resident's needs. Resident was oriented and prepared for transfer.” The facility’s nurse’s note dated 03/25/25 documented in part, “Pt (patient) left via (by) EMS (emergency medical services) at 1155 (11:55 a.m.) for worsening right upper quadrant pain unrelieved by pain meds…” Review of the clinical record and the EHR (electronic health record) for R5 failed to evidence written notification of the discharge was provided to R5’s responsible party for the facility-initiated transfers on 03/03/2025 and on 03/25/2025. On 08/12/2025 at approximately 11:45 a.m., a request was made to ASM (administrative staff member) #1, administrator, for evidence that the facility provided R5’s responsible party written notification of R5’s transfers on 03/03/2025 and on 03/25/2025. On 08/12/2025 at approximately 1:00 p.m. OSM (other staff member) #5, social worker, provide the surveyor with copies of two “U. S. Postal Service Certified Mail Receipts” for the written notifications sent to R5’s responsible party for the transfers on 03/03/2025 and on 03/25/2025. Further review of the receipts revealed postage dates of 03/20/2025 and 04/01/2025 indicating that the notification letters were sent 17 and seven days following R5’s transfers on 03/03/2025 and on 03/25/2025. On 08/12/2025 at approximately 3:41 p.m. an interview was conducted with OSM #5. When asked if the written notifications to R5's responsible party were sent within a practical time frame she stated no. OSM #5 stated that an acceptable time frame to send the written notification to a responsible party would be within 24 hours on a weekday. She further stated if the resident was sent out on a Friday the written notification to the party responsible would be sent the following Monday. On 08/12/2025 at approximately 4:35 p.m. ASM #1, ASM #2, director of nursing, and RN (registered nurse) #1, assistant director of nursing, were made aware of the above findings. No further information was provided prior to exit.

Based on observation, resident interview, staff interview, facility document review, and clinical record review, the facility staff failed to provide respiratory care and services for two of 36 residents in the survey sample, Residents #100, and #102. The findings include: 1. For Resident #100 (R100), the facility staff failed to store a nebulizer (1) mask in a sanitary manner.R100's admission minimum data set assessment was not complete. An admission observation form dated 8/6/25 documented R100 was oriented, the resident's memory was intact, and the resident's thinking was clear and organized. A review of R100's physician's order revealed an order dated 8/8/25 for ipratropium-albuterol inhalation solution (2) for nebulization, 0.5mg (milligrams)-3mg (2.5mg base)/ 3ml (milliliters) every six hours times 72 hours for shortness of breath/wheezing.On 8/11/25 at 4:05 p.m., R100 was observed lying in bed. The resident's nebulizer mask was uncovered and was sitting against the nebulizer machine on top of the resident's nightstand. R100 stated she used the nebulizer mask and staff had not provided anything to cover the mask.On 8/12/25 at 3:12 p.m., an interview was conducted with LPN (licensed practical nurse) #1. LPN #1 stated a nebulizer mask should be stored in a plastic bag for infection control purposes.On 8/12/25 at 4:49 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing) were made aware of the above concern.The facility policy titled, Nebulizer Administration Policy documented, 11. Empty nebulizer cup, rinse with sterile water/sterile saline and air dry. Wipe mask with alcohol wipe and store them in a plastic bag. No further information was presented prior to exit.References:(1) A nebulizer is a small machine that turns liquid medicine into a mist that can be easily inhaled. This information was obtained from the website: https://medlineplus.gov/ency/patientinstructions/000006.htm(2) Ipratropium-albuterol inhalation solution is used to relax muscle in the airways and enables better breathing. This information was obtained from the website: https://medlineplus.gov/ency/patientinstructions/000006.htm2. For Resident #102 (R102), the facility staff failed to obtain a physician's order for the use of an incentive spirometer and failed to store the incentive spirometer in a sanitary manner. R102's admission minimum data set assessment was not complete. An admission observation form dated 8/8/25 documented R102 was oriented, the resident's memory was intact, and the resident's thinking was clear and organized. A review of R102's clinical record failed to reveal a physician's order for an incentive spirometer.On 8/11/25 at 1:44 p.m., R102 was observed lying in bed. An incentive spirometer was observed sitting on the resident's overbed table, with the mouthpiece uncovered. R102 stated she used the incentive spirometer and staff had not provided a cover for the mouthpiece.On 8/12/25 at 3:12 p.m., an interview was conducted with LPN (licensed practical nurse) #1. LPN #1 stated a physician's order should be obtained for an incentive spirometer because the use of the device was a treatment. LPN #1 stated an incentive spirometer should be stored in a plastic bag for infection control purposes.On 8/12/25 at 4:49 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing) were made aware of the above concern.The facility policy titled, Incentive Spirometry Policy documented, Licensed clinicians with demonstrated competence may provide incentive spirometry education and therapy as ordered by a provider. EQUIPMENT: 3. Plastic bag for storage. No further information was presented prior to exit.Reference:(1) Your health care provider may recommend that you use an incentive spirometer after surgery or when you have a lung illness, such as pneumonia. The spirometer is a device used to help you keep your lungs healthy. Using the incentive spirometer helps you take slow deep breaths. This information was obtained from the website: https://medlineplus.gov/ency/patientinstructions/000451.htm

Based on staff interview, clinical record review, and facility document review, it was determined that the facility staff failed to implement a pain management program consistent with professional standards of practice for one of 36 residents in the survey sample, Resident #63. The findings include:On the most recent MDS (minimum data set), a significant change assessment with an ARD (assessment reference date) of 5/2/2025, the resident scored two out of 15 on the BIMS (brief interview for mental status) assessment, indicating they were severely impaired for making daily decisions. It further documented R63 receiving as needed pain medications and not having pain in the past five days.The physician orders for R63 documented in part, Morphine concentrate (1) 100mg(milligram)/5ml(milliliter) (20mg/ml); 0.25ml oral every 4 hours PRN (as needed) pain/SOB (shortness of breath). Before: Pain; Non-Pharm Intervent(s). Start date: 08/27/2024. The orders also documented, Acetaminophen [OTC] (over the counter) (2) tablet extended release 650mg; two tablets oral every 4 hours PRN. Give two tablets by mouth every four hours as needed for pain. Do not exceed 3 grams in 24 hours. Offer non-pharmacological interventions prior to administration. Start Date: 04/29/2024. The physician orders failed to evidence pain level parameters for staff to follow for administration of the medications listed above.Review of the eMAR (electronic medication administration record) for R63 dated 6/1/2025-6/30/2025 documented the Acetaminophen administered once for a pain level of four and the Morphine administered eight times for pain levels between five and seven.Review of the eMAR for R63 dated 7/1/2025-7/31/2025 documented the Acetaminophen administered once for a pain level of five and the Morphine administered once for a pain level of six.Review of the eMAR for R63 dated 8/1/2025-8/30/2025 failed to evidence administration of doses the Acetaminophen or the Morphine.The comprehensive care plan for R63 documented in part, Problem Start Date: 06/19/2024. Category: Pain. Potential for pain related to ischemic cardiomyopathy, reflux, contracture of both pinky fingers, and hiatal hernia - c/o (complaints of) tooth pain; noted caries/chipped teeth/hx of infection. Edited: 05/15/2025 .On 8/12/2025 at 3:05 p.m., an interview was conducted with RN (registered nurse) #3 who stated that R63's pain was assessed using facial expressions, grimacing and behaviors. She stated that there were times when R63 could verbalize pain but not always and staff went by the actions of the resident when administering the as needed pain medications. RN #3 stated that the Morphine and Acetaminophen orders should have pain level parameters in place for staff to use as guidance for administration because they did not want to overmedicate the resident.On 8/12/2025 at 4:08 p.m., an interview was conducted with ASM (administrative staff member) #2, the director of nursing who stated that when a resident had multiple pain medications ordered the staff should perform a pain assessment and administer the milder pain medication for mild to moderate pain. She stated that when a resident was cognitively impaired, they went by behaviors and facial expressions to evaluate pain, and she would expect the medication orders to have pain level parameters for staff to use to guide them when to administer each medication. The facility policy Pain Management Policy revised 1/8/2025 documented in part, .If non-pharmacological intervention[s] fail[s] then when multiple PRN medications are available with corresponding intensity ratings, the resident will be administered the medication ordered for the corresponding pain rating within the PRN order .According to Fundamentals of Nursing, eighth edition, 2013, [NAME] & [NAME] page 977 documented in part, .Pain therapy requires an individualized approach, perhaps more so than any other patient problem. The nurse, patient, and frequently the family are partners in pain management. Nurses administer and monitor interventions ordered by health care providers for pain relief in addition to complimentary pain-relief measures. Usually, you try the least invasive or safest therapy first along with previously used successful patient remedies. If there is a question about a medical therapy, consult with the health care provider.On 8/12/2025 at 4:35 p.m., ASM #1, the administrator and ASM #2, the director of nursing were made aware of the concern.No further information was provided prior to exit.Reference:(1) Morphine immediate-release tablets and oral solution are used to relieve severe, acute pain (pain that begins suddenly, has a specific cause, and is expected to go away when the cause of the pain is healed) and chronic pain in people who are expected to need an opioid pain medication and who cannot be treated with other pain medications. Morphine extended-release tablets and capsules are used to relieve severe and persistent pain in people who are expected to need an opioid pain medication around the clock and who cannot be treated with other pain medications. Morphine extended-release tablets and capsules should not be used to treat pain that can be controlled by medication that is taken as needed. Morphine is in a class of medications called opiate (narcotic) analgesics. It works by changing the way the brain and nervous system respond to pain . This information was obtained from the website: Morphine: MedlinePlus Drug Information (2) Acetaminophen is used to relieve mild to moderate pain from headaches, muscle aches, menstrual periods, colds and sore throats, toothaches, backaches, reactions to vaccinations (shots), and to reduce fever. Acetaminophen may also be used to relieve the pain of osteoarthritis (arthritis caused by the breakdown of the lining of the joints). Acetaminophen is in a class of medications called analgesics (pain relievers) and antipyretics (fever reducers). It works by changing the way the body senses pain and by cooling the body . This information was obtained from the website: Acetaminophen: MedlinePlus Drug Information

Based on staff interview, facility document review, and clinical record review, it was determined the facility staff failed to notify the physician of a change in condition for one of 11 residents in the survey sample, Resident #1. The findings include: For Resident #1 (R1), the facility staff failed to notify the physician of a change in condition reported by physical therapy to the nurse. R1 was admitted to the facility with diagnoses with diagnoses that included but were not limited to diarrhea, unspecified and aftercare following joint replacement surgery. A physical therapy note dated 5/13/2024 documented in part, .Patient supine in bed upon arrival, reports that she is thirsty but cannot seem to take a sip of water and states she is spilling it on herself, nursing notified with BP (blood pressure) assessed 100/60, patient requested therapist to return later to complete session after therapist provided positioning with pillows in the bed with max A (maximal assistance). Call button in hand . A physician progress note dated 5/13/2024 documented in part, .Chief Complaint/Reason for this Visit: follow-up on the followings: patient reporting multiple issues and concerns health related: #1 diarrhea, persistent, watery, no hematochezia (1), no fever. I am not getting Imodium because nurses told me I can only have once a day. #2 persistent decreased oral intake. Decreased water intake. My mouth is dry. #3 GERD (gastroesophageal reflux disease). Currently taking omeprazole 40mg daily. Pepcid discontinued. Patient stated it is helping. #4 and my appetite is not good. #5 Rehabilitation team reported blood pressure lying in bed is 100/60. #6 Feeling weak and dry mouth . Assessment and Plan: 1. dehydration/dry mucous membrane/poor skin turgor: patient currently not on any diuretics. Clinically dehydrated. Associated hypotension. Patient is given education regarding her current condition and the need for hydration. Starting patient on normal saline 125cc per hour x 3L (liters) . 2. diarrhea, etiology unknown, recent use of antibiotics due to UTI (urinary tract infection): rule of C. difficile (2) associated diarrhea. Stool sample was sent this morning .Start patient on empirical oral vancomycin 250mg 4 times a day for 10 days. Start probiotics as well. Encourage fluids . A physical therapy note dated 5/13/2024 documented in part, .Patient supine in bed upon arrival, initially stating she is weak and cannot get up, requested not to stand up today .BP assessed 88.76, PTA (physical therapy assistant) collaborated with nursing RE: low blood pressure, patient's dry mouth and generalized weakness, therapist encouraged fluids during session, call button in hand upon departure of therapist . Review of the nursing notes and skilled nursing observations failed to evidence documentation on 5/13/2024. A nursing note dated 5/14/2024 documented, Resident noted with acute distress, unable to convey her needs to staff, which is not her baseline. Daughter at bedside, MD (medical doctor) notified of chance [sic]. The medical record failed to evidence documentation of an assessment of R1 after the physical therapy observations on 5/13/2024 or notification of the physician of the change in blood pressure. On 6/11/2024 at 2:54 p.m., an interview was conducted with LPN (licensed practical nurse) #2. LPN #2 stated that R1 had a history of c-dificile infection prior to admission and started having diarrhea off and on not long after admission. She stated that she had started the clysis infusion on 5/13/2024 because they were dehydrated and normally would have documented that in the progress notes. She stated that she did not recall therapy reporting any change in R1's blood pressure to them on 5/13/2024. She stated that residents were assessed every shift by the nurses and notes were documented in the medical record. On 6/11/2024 at 2:54 p.m., an interview was conducted with LPN #3. LPN #3 stated that she did not recall any staff reporting any change in R1's blood pressure to them on 5/13/2024. She stated that she remembered the physician seeing R1 that day and ordering the fluids and antibiotic. She stated that she assessed residents vital signs, oxygen levels and lung sounds every shift for changes. On 6/12/2024 at 10:55 a.m., an interview was conducted with OSM (other staff member) #3, physical therapy assistant. OSM #3 stated that they worked with R1 during their stay at the facility. OSM #3 stated that they saw R1 on 5/13/2024 twice. She stated that when she first saw R1 on 5/13/2024 the resident was unable to drink out of the straw and was spilling water on themselves and requested that they come back later to attempt therapy. She stated that she reported R1's condition to the nurse and the unit manager at that time. She stated that the second visit she made to R1 on 5/13/2024 she had again collaborated with the nursing staff regarding R1's condition and low blood pressure. She stated that R1 had started having diarrhea right after admission and had progressively gotten weaker and weaker but had significantly declined over the weekend from the Friday to Monday when she saw her again and she had been a loud whistle when reporting her decline to the nursing staff. On 6/12/2024 at 11:04 a.m., an interview was conducted with ASM (administrative staff member) #4, medical doctor. ASM #4 stated that they cared for R1 when they were at the facility. He stated that it was a struggle to get R1 to drink fluids. He stated that he saw R1 on 5/10/2024 and encouraged her to increase the fluid intake at that time and was disappointed when he saw them on Monday 5/13/2024. He stated that when he saw R1 on 5/13/2024 it was in the morning and he spoke with the resident and the daughter regarding starting IV (intravenous) fluids and the Vancomycin. On 6/12/2024 at 1:50 p.m., an interview was conducted with ASM #2, interim director of nursing. ASM #2 stated that the expectation for nursing staff was to notify the physician if there was a change in the residents blood pressure reported to them especially when the resident was being treated for acute dehydration at the time. ASM #2 stated that they would expect to see documentation of assessing the resident and monitoring them for improvement or notification of the physician of a lack of response to the treatment provided. The facility policy, Resident Change in Condition Policy revised 2/9/2024, documented in part, The licensed nurse will recognize and intervene in the event of a change in resident condition. The Physician/Provider and the Family/Responsible Party will be notified as soon as the nurse has identified the change in condition and the resident is stable . The nurse will record the information related to the change in condition and subsequent events and notifications in the resident's health record . On 6/12/2024 at 2:55 p.m., ASM #1, the administrator, ASM #2, the interim director of nursing, ASM #3, the regional director of clinical services and ASM #6, the administrator of a sister facility were made aware of the findings. No further information was obtained prior to exit. Reference: (1) Rectal bleeding is when blood passes from the rectum or anus. Bleeding may be noted on the stool or be seen as blood on toilet paper or in the toilet. The blood may be bright red. The term hematochezia is used to describe this finding. This information was obtained from the website: https://medlineplus.gov/ency/article/007741.htm (2) C. diff bacteria are commonly found in the environment, but people usually only get C. diff infections when they are taking antibiotics. That's because antibiotics not only wipe out bad germs, but they also kill the good germs that protect your body against infections. The effect of antibiotics can last as long as several months. If you come in contact with C. diff germs during this time, you can get sick. You are more likely to get a C. diff infection if you take antibiotics for more than a week. This information was obtained from the website: https://vsearch.nlm.nih.gov/vivisimo/cgi-bin/query-meta?v%3Aproject=medlineplus&v%3Asources=medlineplus-bundle&query=c.+diff+infections

1B. For Resident #4 (R4), the facility staff failed to implement the comprehensive care plan to assist with ADL's to provide incontinence care. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 3/15/2024, the resident scored 5 out of 15 on the BIMS (brief interview for mental status) assessment, indicating the resident was severely impaired for making daily decisions. Section GG documented R4 having impairment on one side in the upper and lower extremity and being dependent for toileting. On 6/10/2024 at 1:18 p.m., an interview was conducted with R4's responsible party (RP). R4's RP voiced concerns regarding the resident being left soiled for extended periods of time and being found wet when they arrived to visit frequently. R4's RP stated that when they found R4 soiled they would usually have to go out to find someone to come in to clean them up. R4's RP stated that the facility refused to provided underpads for the residents and only put briefs on the residents and the urine would frequently soak through the brief onto the bed so they had purchased underpads specifically for R4's use which they took home to wash and return. R4's RP stated that they had discarded several of the underpads due to the urine being so saturated into the underpads that they were unable to get the smell out of them. R4's RP stated that these were normally the night shift underpads that were soaked with urine. The comprehensive care plan for R4 documented in part, Resident has ADL/self-care deficit related to CVA (cerebrovascular accident) with right hemiparesis, dysphagia, dysarthria, HTN (hypertension), DM (diabetes) w/PN (pneumonia), GERD (gastroesophageal reflux disease), BPH (benign prostatic hypertrophy), HLD (hyperlipidemia), a-fib (atrial fibrillation). Date Initiated: 06/22/2023. Under Interventions/Tasks it documented in part, *Assist with activities of daily living, dressing, grooming, toileting, feeding, oral care. 1-2 staff assist. Date Initiated: 06/22/2023 . Toileting with total assist of one. Date Initiated: 12/27/2023 . Review of the ADL (activities of daily living) documentation for 5/1/2024- 5/31/2024 and 6/1/2024-6/11/2024 failed to evidence incontinence care provided to R4 on the following dates. On day shift on 5/6/24, 5/7/24, 5/9/24, 5/10/24, 5/13/24, 5/14/24, 5/15/24, 5/16/24, 4/17/24, 5/20/24, 5/21/24, 5/23/24, 5/24/24, 5/27/24, 5/28/24, 5/29/24, 6/1/24, 6/2/14, 6/7/24, and 6/10/24. On evening shift on 5/6/24, 5/7/24, 5/10/24, 5/20/24, and 6/1/24. On night shift on 5/5/24, 5/6/24, 5/7/24, 5/8/24, 5/10/24, 5/13/24, 5/14/24, 5/15/24, 5/18/24, 5/26/24, 5/30/24, 6/3/24, 6/4/24 and 6/6/24. On 6/11/2024 at 4:30 p.m., a request was made to ASM (administrative staff member) #1, the administrator, for evidence of incontinence care provided to R4 on the dates and shifts listed above. On 6/12/2024 at 9:55 a.m., ASM #1 provided ADL documentation from R4's record and stated that was all they had to provide. The documentation provided failed to evidence incontinence care provided on the dates/shifts listed above. On 6/11/2024 at 6:38 a.m., an interview was conducted with CNA (certified nursing assistant) #2. CNA #2 stated that they normally cared for about 15-16 residents on the night shift and felt that they were able to get their work completed and care for the residents in a timely manner. CNA #2 stated that residents were rounded on every two hours for incontinence care during the night and turned and repositioned at that time. CNA #2 stated that incontinence care provided was evidenced by their documentation every shift in the computer. On 6/11/2024 at 7:05 a.m., an interview was conducted with CNA #4. CNA #4 stated that they cared for about 18 to 20 residents during their shift and felt that they were able to complete their work in a timely manner to meet the needs of the residents. CNA #4 stated that they rounded for incontinence care every two hours and as needed. CNA #4 stated that incontinence care was evidenced as done by the documentation in the computer completed every shift. On 6/12/2024 at 1:50 p.m., an interview was conducted with ASM #2, the interim director of nursing. ASM #2 stated that the purpose of the care plan was to help them care for the residents. ASM #2 stated that they put interventions in place to try to prevent things from happening or set goals for the resident and it was specific to the resident. She stated that the care plan should be implemented because that was the reason that it was put into place. On 6/12/2024 at 2:55 p.m., ASM #1, the administrator, ASM #2, the interim director of nursing, ASM #3, the regional director of clinical services and ASM #6, the administrator of a sister facility were made aware of the findings. No further information was provided prior to exit. 2. For Resident #11 (R11), the facility staff failed to trim their fingernails in a timely manner. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 4/17/2024, the resident scored 15 out of 15 on the BIMS (brief interview for mental status) assessment, indicating the resident was cognitively intact for making daily decisions. Section GG documented R11 requiring partial/moderate assistance with bathing and supervision or touching assistance with personal hygiene. On 6/11/2024 at 7:38 a.m., an interview was conducted with R11 in their room. R11 was observed sitting in a wheelchair beside their bed. R11 stated that their fingernails needed trimming down and they had been asking the nurses for a few weeks now but it had done it yet. R11's nails were observed to be clean, with the free edge on each finger extending approximately one-quarter inch from the nail bed. When asked who trimmed their nails normally, R11 stated that they were not able to trim them and the nurses had to do it for them due to the swelling and weakness in their hands. The comprehensive care plan for R11 documented in part, Resident has ADL(activities of daily living)/self-care deficit related to GERD (gastroesophageal reflux disease), HTN (hypertension), COPD (chronic obstructive pulmonary disease), CHF (congestive heart failure), depression, prostate CA (cancer), PN (pneumonia), cervical myopathy, hx (history) of spinal cord injury/quadriparesis. Date Initiated: 12/01/2023. Under Interventions/Tasks it documented in part, *Assist with activities of daily living, dressing, grooming, toileting, feeding, oral care. Date Initiated: 12/01/2023 . On 6/12/2024 at 1:34 p.m., an interview was conducted with CNA (certified nursing assistant) #1. CNA #1 stated that the CNA's were responsible for trimming the residents fingernails. She stated that they checked and trimmed the nails on the residents shower days and as needed. She stated that if a resident was unable to trim their nails themselves the CNA did it for them. On 6/12/2024 at 1:50 p.m., an interview was conducted with ASM (administrative staff member) #2, the interim director of nursing. ASM #2 stated that the purpose of the care plan was to help them care for the residents. ASM #2 stated that they put interventions in place to try to prevent things from happening or set goals for the resident and it was specific to the resident. She stated that the care plan should be implemented because that was the reason that it was put into place. ASM #2 stated that the CNA staff trimmed residents fingernails unless the resident was diabetic and then the nurses trimmed them after reviewing the residents history. She stated that she was not aware of any concerns regarding R11's fingernails needing trimming. ASM #2 observed R11's fingernails and stated that they needed to be trimmed. ASM #2 advised R11 that she would send someone down to trim their nails or she would come do them herself. On 6/12/2024 at 2:55 p.m., ASM #1, the administrator, ASM #2, the interim director of nursing, ASM #3, the regional director of clinical services and ASM #6, the administrator of a sister facility were made aware of the findings. Based on observations, staff interview, clinical record review, the facility staff failed to follow the comprehensive care plan for two of 11 residents in the survey sample, Resident #4 (R4) and R11. The findings include: 1a. For R4, facility staff failed to follow the comprehensive care plan for the placement of fall mats. R4 was admitted to the facility with a diagnosis that included but was not limited to hemiplegia (1) and hemiparesis (2). On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 03/15/2023, R4 scored 5 (five) out of 15 on the BIMS (brief interview for mental status), indicating R4 was severely impaired of cognition for making daily decisions. On 06/11/2024 at 1:35 p.m., an observation of R4 revealed he was laying on his bed in his room. Observation of the fall mats in the room revealed one fall mat was on the floor next to the left side of the bed and the other fall mat was folded in half, standing on edge at the foot of the bed. The comprehensive care plan for R4 dated 06/22/2023 documented in part, Focus. Resident is at risk for further falls related to CVA (cerebral vascular disease - stroke) with right hemiparesis . Date Initiated: 06/22/2023. Under Interventions/Tasks it documented in part, Floors mats on both sides of bed when in bed. Date Initiated: 10/06/2023. On 06/12/2024 at approximately 1:57 p.m., an interview was conducted with ASM (administrative staff member) #2, interim director of nursing regarding fall precautions for R4. ASM #2 stated that R4 should have fall mats on the floor, next to the bed every time. After reviewing the comprehensive care plan for R4 dated 06/22/2023y, ASM # 2 stated that R4 should have two fall mats on the floor when he is in bed, one on each side of the bed. When asked to describe the purpose of the care plan ASM #2 stated it can be a guide for taking care of the resident. After informed of the observation stated above, ASM #2 was asked if the care plan was followed for the use of fall mats, ASM #2 stated no. On 06/12/2024 at approximately 2;58 p.m., ASM #1, administrator, ASM #2, interim director of nursing, ASM #3, regional director of clinical services, and ASM #6, administrator for sister facility, were made aware of the above findings. No further information was provided prior to exit. References: (1) Also called: Palsy, Paraplegia, Quadriplegia. Paralysis is the loss of muscle function in part of your body. It can occur on one or both sides of your body. It can also occur in just one area, or it can be widespread. This information was obtained from the website: https://medlineplus.gov/paralysis.html. (2) Paralysis is the loss of muscle function in part of your body. This information was obtained from the website: https://medlineplus.gov/paralysis.html.

Based on staff interview, facility document review, and clinical record review, it was determined the facility staff failed to follow professional standards of quality for one of 11 residents in the survey sample, Resident #1. The findings include: For Resident #1 (R1), the facility staff failed to evidence insertion and monitoring of a hypodermoclysis (1) infusion on 5/13/24-5/14/24. R1 was admitted to the facility with diagnoses with diagnoses that included but were not limited to diarrhea, unspecified and aftercare following joint replacement surgery. A physician progress note dated 5/13/2024 documented in part, .Chief Complaint/Reason for this Visit: follow-up on the followings: patient reporting multiple issues and concerns health related: #1 diarrhea, persistent, watery, no hematochezia, no fever . #2 persistent decreased oral intake. Decreased water intake. My mouth is dry. #4 and my appetite is not good. #5 Rehabilitation team reported blood pressure lying in bed is 100/60. #6 Feeling weak and dry mouth . Assessment and Plan: 1. dehydration/dry mucous membrane/poor skin turgor: patient currently not on any diuretics. Clinically dehydrated. Associated hypotension. Patient is given education regarding her current condition and the need for hydration. Starting patient on normal saline 125cc per hour x 3L (liters) . 2. diarrhea, etiology unknown, recent use of antibiotics due to UTI (urinary tract infection): rule of C. difficile (2) associated diarrhea. Stool sample was sent this morning .Start patient on empirical oral vancomycin 250mg 4 times a day for 10 days. Start probiotics as well. Encourage fluids . The physician orders documented an order dated 5/13/2024 at 3:41 p.m. for Sodium Chloride 0.9% 1000ml via clysis (hypodermoclysis) at 60ml/hr x 3L and an order dated 5/13/2024 at 3:32 p.m. for Vancomycin 250mg four times a day to start on 5/14/2024 at 8:00 a.m. Both orders were entered by LPN (licensed practical nurse) #2. The eMAR (electronic medication administration record) for R1 dated 5/1/2024-5/31/2024 documented the resident starting the Vancomycin on 5/14/2024 at 8:00 a.m. and the Sodium Chloride 0.9% 1000ml via clysis at 60ml/hr on day shift starting on 5/13/2024. The eMAR failed to evidence documentation of insertion procedure, toleration of the procedure, failed IV (intravenous) attempts, time of procedure, time of start of fluids, or monitoring of the insertion site. Review of the nursing notes and skilled nursing observations failed to evidence documentation on 5/13/2024. The medical record failed to evidence documentation of insertion of the clysis insertion procedure, failed IV attempts, time of start of fluids, time of procedure or monitoring of the infusion site. On 6/11/2024 at 2:54 p.m., an interview was conducted with LPN (licensed practical nurse) #2. LPN #2 stated that R1 had a history of c-dificile infection prior to admission and started having diarrhea off and on not long after admission. She stated that she had started the clysis infusion on 5/13/2024 because they were dehydrated and normally would have documented that in the nursing notes. On 6/12/2024 at 10:45 a.m., an interview was conducted with LPN #1. LPN #1 stated that when clysis fluids were started on a resident the nurse documented in the nurses note the location of the clysis infusion, the type of fluids started, the rate and tolerance of the procedure. She stated that this was done to show that the physician's order was completed and because it had to be done. She stated that it evidenced the care that was provided to the resident. On 6/12/2024 at 1:50 p.m., an interview was conducted with ASM (administrative staff member) #2, interim director of nursing. ASM #2 stated that they would expect to see documentation of the insertion of the clysis infusion, location of the clysis infusion, and tolerance of the procedure in the nursing notes. She stated that she would also expect to see monitoring of the clysis site and tolerance of the fluids being administered documented in the medical record during the treatment period every shift. According to Fundamentals of Nursing Made Incredibly Easy [NAME] and [NAME], Philadelphia PA page 23: Nursing documentation is a highly significant issue since documentation is a fundamental feature of nursing care. Patient records are legally valid, and need to be accurate and comprehensive so that care can be communicated effectively to the health care team. Unless the content of documentation provides an accurate depiction of patient and family care, quality of care may not be possible. Many nurses do not realize that what they document or fail to record can produce an enormous effect on the care that is provided by other members of the health care team. The following quotation is found in [NAME] and Perry's Fundamentals of Nursing 6th edition (2005, p. 477): Documentation is anything written or printed that is relied on as record or proof for authorized persons. Documentation within a client medical record is a vital aspect of nursing practice. Nursing documentation must be accurate, comprehensive, and flexible enough to retrieve critical data, maintain continuity of care, track client outcomes, and reflect current standards of nursing practice. Information in the client record provides a detailed account of the level of quality of care delivered to the clients. On 6/12/2024 at 2:55 p.m., ASM #1, the administrator, ASM #2, the interim director of nursing, ASM #3, the regional director of clinical services and ASM #6, the administrator of a sister facility were made aware of the findings. No further information was obtained prior to exit. Reference: (1) How does hypodermoclysis work? A bag of fluid is connected to a long needle by a plastic tube. The needle is put under the skin and taped in place, usually on the chest, abdomen, or thighs. The fluid drips from the bag, through the tube and needle, and into the skin. The skin then absorbs the fluid into the body. This information was obtained from the website: https://familydoctor.org/artificial-hydration-and-nutrition/?adfree=true (2) C. diff bacteria are commonly found in the environment, but people usually only get C. diff infections when they are taking antibiotics. That's because antibiotics not only wipe out bad germs, but they also kill the good germs that protect your body against infections. The effect of antibiotics can last as long as several months. If you come in contact with C. diff germs during this time, you can get sick. You are more likely to get a C. diff infection if you take antibiotics for more than a week. This information was obtained from the website: https://vsearch.nlm.nih.gov/vivisimo/cgi-bin/query-meta?v%3Aproject=medlineplus&v%3Asources=medlineplus-bundle&query=c.+diff+infections

Based on observation, resident and/or representative interview, clinical record review, staff interview, and facility document review it was determined that the facility staff failed to provide ADL (activities of daily living) care to dependent residents for two of 11 residents in the survey sample, Resident #4 and Resident #11. The findings include: 1. For Resident #4 (R4), the facility staff failed to provide incontinence care. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 3/15/2024, the resident scored 5 out of 15 on the BIMS (brief interview for mental status) assessment, indicating the resident was severely impaired for making daily decisions. Section GG documented R4 having impairment on one side in the upper and lower extremity and being dependent for toileting. On 6/10/2024 at 1:18 p.m., an interview was conducted with R4's responsible party (RP). R4's RP voiced concerns regarding the resident being left soiled for extended periods of time and being found wet when they arrived to visit frequently. R4's RP stated that when they found R4 soiled they would usually have to go out to find someone to come in to clean them up. R4's RP stated that the facility refused to provided underpads for the residents and only put briefs on the residents and the urine would frequently soak through the brief onto the bed so they had purchased underpads specifically for R4's use which they took home to wash and return. R4's RP stated that they had discarded several of the underpads due to the urine being so saturated into the underpads that they were unable to get the smell out of them. R4's RP stated that these were normally the night shift underpads that were soaked with urine. Review of the ADL (activities of daily living) documentation for 5/1/2024- 5/31/2024 and 6/1/2024-6/11/2024 failed to evidence incontinence care provided to R4 on the following dates. On day shift on 5/6/24, 5/7/24, 5/9/24, 5/10/24, 5/13/24, 5/14/24, 5/15/24, 5/16/24, 4/17/24, 5/20/24, 5/21/24, 5/23/24, 5/24/24, 5/27/24, 5/28/24, 5/29/24, 6/1/24, 6/2/14, 6/7/24, and 6/10/24. On evening shift on 5/6/24, 5/7/24, 5/10/24, 5/20/24, and 6/1/24. On night shift on 5/5/24, 5/6/24, 5/7/24, 5/8/24, 5/10/24, 5/13/24, 5/14/24, 5/15/24, 5/18/24, 5/26/24, 5/30/24, 6/3/24, 6/4/24 and 6/6/24. The comprehensive care plan for R4 documented in part, Resident has ADL/self-care deficit related to CVA (cerebrovascular accident) with right hemiparesis, dysphagia, dysarthria, HTN (hypertension), DM (diabetes) w/PN (pneumonia), GERD (gastroesophageal reflux disease), BPH (benign prostatic hypertrophy), HLD (hyperlipidemia), a-fib (atrial fibrillation). Date Initiated: 06/22/2023. Under Interventions/Tasks it documented in part, *Assist with activities of daily living, dressing, grooming, toileting, feeding, oral care. 1-2 staff assist. Date Initiated: 06/22/2023 . Toileting with total assist of one. Date Initiated: 12/27/2023 . On 6/11/2024 at 4:30 p.m., a request was made to ASM (administrative staff member) #1, the administrator, for evidence of incontinence care provided to R4 on the dates and shifts listed above. On 6/12/2024 at 9:55 a.m., ASM #1 provided ADL documentation from R4's record and stated that was all they had to provide. The documentation provided failed to evidence incontinence care provided on the dates/shifts listed above. On 6/11/2024 at 6:38 a.m., an interview was conducted with CNA (certified nursing assistant) #2. CNA #2 stated that they normally cared for about 15-16 residents on the night shift and felt that they were able to get their work completed and care for the residents in a timely manner. CNA #2 stated that residents were rounded on every two hours for incontinence care during the night and turned and repositioned at that time. CNA #2 stated that incontinence care provided was evidenced by their documentation every shift in the computer. On 6/11/2024 at 7:05 a.m., an interview was conducted with CNA #4. CNA #4 stated that they cared for about 18 to 20 residents during their shift and felt that they were able to complete their work in a timely manner to meet the needs of the residents. CNA #4 stated that they rounded for incontinence care every two hours and as needed. CNA #4 stated that incontinence care was evidenced as done by the documentation in the computer completed every shift. The facility policy ADL Documentation Policy revised 8/12/2020 documented in part, Provision of ADL (activities of daily living) care will be documented each shift by staff providing the care. This shall include, but not be limited to, documentation of food intake, toileting, ambulation, bathing, dressing, and transferring. PROCEDURE: In facilities where an electronic health record (EHR) is utilized, ADLs will be documented with the Point of Care (POC) module of the record . On 6/12/2024 at 2:55 p.m., ASM #1, the administrator, ASM #2, the interim director of nursing, ASM #3, the regional director of clinical services and ASM #6, the administrator of a sister facility were made aware of the findings. No further information was provided prior to exit. 2. For Resident #11 (R11), the facility staff failed to trim their fingernails in a timely manner. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 4/17/2024, the resident scored 15 out of 15 on the BIMS (brief interview for mental status) assessment, indicating the resident was cognitively intact for making daily decisions. Section GG documented R11 requiring partial/moderate assistance with bathing and supervision or touching assistance with personal hygiene. On 6/11/2024 at 7:38 a.m., an interview was conducted with R11 in their room. R11 was observed sitting in a wheelchair beside their bed. R11 stated that their fingernails needed trimming down and they had been asking the nurses for a few weeks now but it had done it yet. R11's nails were observed to be clean, with the free edge on each finger extending approximately one-quarter inch from the nail bed. When asked who trimmed their nails normally, R11 stated that they were not able to trim them and the nurses had to do it for them due to the swelling and weakness in their hands. The comprehensive care plan for R11 documented in part, Resident has ADL(activities of daily living)/self-care deficit related to GERD (gastroesophageal reflux disease), HTN (hypertension), COPD (chronic obstructive pulmonary disease), CHF (congestive heart failure), depression, prostate CA (cancer), PN (pneumonia), cervical myopathy, hx (history) of spinal cord injury/quadriparesis. Date Initiated: 12/01/2023. Under Interventions/Tasks it documented in part, *Assist with activities of daily living, dressing, grooming, toileting, feeding, oral care. Date Initiated: 12/01/2023 . On 6/12/2024 at 1:34 p.m., an interview was conducted with CNA (certified nursing assistant) #1. CNA #1 stated that the CNA's were responsible for trimming the residents fingernails. She stated that they checked and trimmed the nails on the residents shower days and as needed. She stated that if a resident was unable to trim their nails themselves the CNA did it for them. On 6/12/2024 at 1:50 p.m., an interview was conducted with ASM (administrative staff member) #2, the interim director of nursing. ASM #2 stated that the CNA staff trimmed residents fingernails unless the resident was diabetic and then the nurses trimmed them after reviewing the residents history. She stated that she was not aware of any concerns regarding R11's fingernails needing trimming. ASM #2 observed R11's fingernails and stated that they needed to be trimmed. ASM #2 advised R11 that she would send someone down to trim their nails or she would come do them herself. The facility policy Morning Care/AM Care revised 11/08/2023 documented in part, Morning care will be offered each day to promote resident comfort, cleanliness, grooming, and general wellbeing. Residents who are capable of performing their own personal care are encouraged to do so but will be provided with setup assistance if needed. Showers and baths are scheduled two times weekly or more or less often according resident preference . 9. Provide fingernail care . On 6/12/2024 at 2:55 p.m., ASM #1, the administrator, ASM #2, the interim director of nursing, ASM #3, the regional director of clinical services and ASM #6, the administrator of a sister facility were made aware of the findings.

2. For Resident #1 (R1), the facility staff failed to assess and monitor for a further decline in condition. R1 was admitted to the facility with diagnoses with diagnoses that included but were not limited to diarrhea, unspecified and aftercare following joint replacement surgery. A physical therapy note dated 5/13/2024 documented in part, .Patient supine in bed upon arrival, reports that she is thirsty but cannot seem to take a sip of water and states she is spilling it on herself, nursing notified with BP (blood pressure) assessed 100/60, patient requested therapist to return later to complete session after therapist provided positioning with pillows in the bed with max A (maximal assistance). Call button in hand . A physician progress note dated 5/13/2024 documented in part, .Chief Complaint/Reason for this Visit: follow-up on the followings: patient reporting multiple issues and concerns health related: #1 diarrhea, persistent, watery, no hematochezia (1), no fever . #2 persistent decreased oral intake. Decreased water intake. My mouth is dry. #4 and my appetite is not good. #5 Rehabilitation team reported blood pressure lying in bed is 100/60. #6 Feeling weak and dry mouth . Assessment and Plan: 1. dehydration/dry mucous membrane/poor skin turgor: patient currently not on any diuretics. Clinically dehydrated. Associated hypotension. Patient is given education regarding her current condition and the need for hydration. Starting patient on normal saline 125cc per hour x 3L (liters) . 2. diarrhea, etiology unknown, recent use of antibiotics due to UTI (urinary tract infection): rule of C. difficile (2) associated diarrhea. Stool sample was sent this morning .Start patient on empirical oral vancomycin 250mg 4 times a day for 10 days. Start probiotics as well. Encourage fluids . A physical therapy note dated 5/13/2024 documented in part, .Patient supine in bed upon arrival, initially stating she is weak and cannot get up, requested not to stand up today .BP assessed 88.76, PTA (physical therapy assistant) collaborated with nursing RE: low blood pressure, patient's dry mouth and generalized weakness, therapist encouraged fluids during session, call button in hand upon departure of therapist . Review of the nursing notes and skilled nursing observations failed to evidence documentation of a nursing assessment completed on 5/13/2024. A note dated 5/14/2024 documented, Resident noted with acute distress, unable to convey her needs to staff, which is not her baseline. Daughter at bedside, MD (medical doctor) notified of chance [sic]. The physician orders documented an order dated 5/13/2024 at 3:41 p.m. for Sodium Chloride 0.9% 1000ml via clysis (3) at 60ml/hr x 3L and an order dated 5/13/2024 at 3:32 p.m. for Vancomycin 250mg four times a day to start on 5/14/2024 at 8:00 a.m. Both orders were entered by LPN (licensed practical nurse) #2. The eMAR (electronic medication administration record) for R1 dated 5/1/2024-5/31/2024 documented the resident starting the Vancomycin on 5/14/2024 at 8:00 a.m. and the Sodium Chloride 0.9% 1000ml via clysis at 60ml/hr on day shift starting on 5/13/2024. The eMAR failed to evidence documentation of insertion procedure, toleration of the procedure, failed IV (intravenous) attempts, time of procedure, time of start of fluids, or assessment and monitoring of the insertion site. The medical record failed to evidence documentation of an assessment of R1 after the physical therapy observations on 5/13/2024, or assessment and monitoring of the clysis insertion site. On 6/11/2024 at 2:54 p.m., an interview was conducted with LPN (licensed practical nurse) #2. LPN #2 stated that R1 had a history of c-difficile infection prior to admission and started having diarrhea off and on not long after admission. She stated that she had started the clysis infusion on 5/13/2024 because they were dehydrated and normally would have documented that in the progress notes. She stated that she did not recall therapy reporting any change in R1's blood pressure to them on 5/13/2024. She stated that residents were assessed every shift by the nurses and notes were documented in the medical record. On 6/11/2024 at 2:54 p.m., an interview was conducted with LPN #3. LPN #3 stated that she did not recall any staff reporting any change in R1's blood pressure to them on 5/13/2024. She stated that she assessed residents vital signs, oxygen levels and lung sounds every shift for changes. LPN #3 stated that R1 had a sudden change in condition on 5/14/2024 and they had notified the physician and nurse practitioner who had sent them out to the emergency room. She stated that she had worked with R1 over the weekend prior and R1 was alert and oriented and at their baseline and she thought the diarrhea had started the day before they went to the hospital. On 6/12/2024 at 10:55 a.m., an interview was conducted with OSM (other staff member) #3, physical therapy assistant. OSM #3 stated that they worked with R1 during their stay at the facility. OSM #3 stated that they saw R1 on 5/13/2024 twice. She stated that when she first saw R1 on 5/13/2024 the resident was unable to drink out of the straw and was spilling water on themselves and requested that they come back later to attempt therapy. She stated that she reported R1's condition to the nurse and the unit manager at that time. She stated that the second visit she made to R1 on 5/13/2024 she had again collaborated with the nursing staff regarding R1's condition and low blood pressure. She stated that R1 had started having diarrhea right after admission and had progressively gotten weaker and weaker but had significantly declined over the weekend from the Friday to Monday when she saw her again and she had been a loud whistle when reporting her decline to the nursing staff. On 6/12/2024 at 1:50 p.m., an interview was conducted with ASM (administrative staff member) #2, interim director of nursing. ASM #2 stated that they would expect nursing to monitor a resident receiving fluids for dehydration closely for improvement or lack of response to treatment and would expect documentation of assessments to be in the medical record each shift. On 6/12/2024 at 2:55 p.m., ASM #1, the administrator, ASM #2, the interim director of nursing, ASM #3, the regional director of clinical services and ASM #6, the administrator of a sister facility were made aware of the findings. No further information was obtained prior to exit. Reference: (1) Rectal bleeding is when blood passes from the rectum or anus. Bleeding may be noted on the stool or be seen as blood on toilet paper or in the toilet. The blood may be bright red. The term hematochezia is used to describe this finding. This information was obtained from the website: https://medlineplus.gov/ency/article/007741.htm (2) C. diff bacteria are commonly found in the environment, but people usually only get C. diff infections when they are taking antibiotics. That's because antibiotics not only wipe out bad germs, but they also kill the good germs that protect your body against infections. The effect of antibiotics can last as long as several months. If you come in contact with C. diff germs during this time, you can get sick. You are more likely to get a C. diff infection if you take antibiotics for more than a week. This information was obtained from the website: https://vsearch.nlm.nih.gov/vivisimo/cgi-bin/query-meta?v%3Aproject=medlineplus&v%3Asources=medlineplus-bundle&query=c.+diff+infections (3) How does hypodermoclysis work? A bag of fluid is connected to a long needle by a plastic tube. The needle is put under the skin and taped in place, usually on the chest, abdomen, or thighs. The fluid drips from the bag, through the tube and needle, and into the skin. The skin then absorbs the fluid into the body. This information was obtained from the website: https://familydoctor.org/artificial-hydration-and-nutrition/?adfree=true Based on clinical record review staff interview, and facility document review, it was determined that the facility staff failed to maintain the resident's highest level of well-being for 2 (two) of 11 residents in the survey sample, Resident #2 (R2) and R1. The findings include: 1. For R2, the facility staff failed to obtain physician orders for the treatment of a surgical wound in a timely manner. R2 was admitted to the facility with a diagnosis that included but was not limited to surgical aftercare following surgery on the digestive system. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 09/13/2023, R2 scored 8 (eight) out of 15 on the BIMS (brief interview for mental status), indicating R2 was moderately impaired of cognition for making daily decisions. The physician's order for R2 documented in part, Change dressing to abd (abdomen) daily on evening shift. Every evening shift for Wound care. Order Date: 06/13/2023 Start Date: 06/14/2023. The eTAR (electronic treatment administration record) dated June 2023 for R2 documented the physician's order for abdominal daily dressing changes as stated above. The eTAR also documented dressing changes were done on 06/14/2024, 06/15/2024, 06/16/2024, 06/17/2024 and on 06/18/2024. The nursing note for R2 dated 06/18/2023 documented in part, 1935 (7:35 p.m.) Type: Discharge Summary. Late Entry. Nursing Summary: Resident was admitted follow [sic] hospital stay, came back on dialysis, sent out to ER (emergency room) for chest pain and re-admitted to hospital. discharge date /time: 06/18/2023 10:00 AM (a.m.). The nursing note for R2 dated 06/20/2023 at 7:20 p.m., documented in part, Text: Resident Arrival Date and Time: 06/20/2023 at 7:20 p.m. Resident Admitting From: (Name of Hospital). Resident returned to the facility at 7:20 pm. Resident is alert and responsive no distress noted at this time. The facility's Weekly Wound Assessment dated 06/27/2023 for R2 documented in part, 1. Wound Type: surgical incision. 2. Wound Location: Abdomen. 3. Date wound identified: 06/20/2023. The physician's order for R2 documented in part, Cleanse with wound cleanser or NS normal saline), pat dry. -Apply hydrocortisone 1% cream to wound bed x7 days. (tx (treatment) for moist wound healing and/or autolytic debridement). -Cover with dry dressing. -Change dressing QD and as needed for saturation or soilage. Every day shift for Wound Care. Order Date 06/27/2023. Start Date: 06/28/2023. The facility's wound care note for R2 dated 06/26/2024 documented in part, Wound care to abdomen as follows: -Cleanse with wound cleanser or NS (normal saline), pat dry. -Apply alginate (2) to proximal (close to) and distal (away from) dehiscence (open wound) -Cover with foam dressing. As needed for saturation and soilage. The eTAR (electronic treatment administration record) dated June 2023 for R2 documented the physician's order for the use of wound cleanser or normal saline as stated above. Further review of the eTAR failed to evidence wound treatments were conducted from 08/21/2023 through 08/25/2023 for R2. Review of the facility's nursing notes dated 08/21/2023 through 08/25/2023 failed to document evidence that wound treatments were conducted for R2. Further review of the notes failed to evidence notification to the physician and responsible party of documentation to continue the wound treatment the lack of wound treatment for R2. Review of R2's ehr (electronic heal record) failed to evidence documentation of a physician's order for wound treatment from 08/21/2023 through 08/27/2023. Review of the nurse practitioner notes dated 06/23/2024, 06/25/2024 and 06/28/2024 failed to evidence documentation of R2's surgical wound and wound treatments. On 06/12/2024 at 1:34 p.m., an interview was conducted with ASM (administrative staff member) #2, interim director of nursing. When asked to describe the procedure to continue the treatments of a resident's surgical wound if it was interrupted by the resident's hospitalization ASM #2 stated she would notify the physician and family for the need of treatment orders, re-assess the wound and document the treatment and notification progress notes. When asked if timely continuation of R2's wound treatment was provided she stated no. When asked about effects of a delay in treatment of a wound ASM #2 stated it is a risk of infection or worsening of the wound. On 06/12/2024 at approximately 2;58 p.m., ASM #1, administrator, ASM #2, interim director of nursing, ASM #3, regional director of clinical services, and ASM #6, administrator for sister facility, were made aware of the above findings. No further information was provided prior to exit.

Based on clinical record review staff interview, and facility document review, it was determined that the physician failed to oversee the resident's plan of care for 3 (three) of 5 (five) days for Resident #2. The findings include: For R2, the physician to provide assessments and treatments for a surgical wound. R2 was admitted to the facility with a diagnosis that included but was not limited to surgical aftercare following surgery on the digestive system. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 09/13/2023, R2 scored 8 (eight) out of 15 on the BIMS (brief interview for mental status), indicating R2 was moderately impaired of cognition for making daily decisions. The physician's order for R2 documented in part, Change dressing to abd (abdomen) daily on evening shift. Every evening shift for Wound care. Order Date: 06/13/2023 Start Date: 06/14/2023. The eTAR (electronic treatment administration record) dated June 2023 for R2 documented the physician's order for abdominal daily dressing changes as stated above. The eTAR also documented dressing changes were done on 06/14/2024, 06/15/2024, 06/16/2024, 06/17/2024 and on 06/18/2024. The nursing note for R2 dated 06/18/2023 documented in part, 1935 (7:35 p.m.) Type: Discharge Summary. Late Entry. Nursing Summary: Resident was admitted follow [sic] hospital stay, came back on dialysis, sent out to ER (emergency room) for chest pain and re-admitted to hospital. discharge date /time: 06/18/2023 10:00 AM (a.m.). The nursing note for R2 dated 06/20/2023 at 7:20 p.m., documented in part, Text: Resident Arrival Date and Time: 06/20/2023 at 7:20 p.m. Resident Admitting From: (Name of Hospital). Resident returned to the facility at 7:20 pm. Resident is alert and responsive no distress noted at this time. The facility's Weekly Wound Assessment dated 06/27/2023 for R2 documented in part, 1. Wound Type: surgical incision. 2. Wound Location: Abdomen. 3. Date wound identified: 06/20/2023. The physician's order for R2 documented in part, Cleanse with wound cleanser or NS normal saline), pat dry. -Apply hydrocortisone 1% cream to wound bed x7 days. (tx (treatment) for moist wound healing and/or autolytic debridement). -Cover with dry dressing. -Change dressing QD and as needed for saturation or soilage. Every day shift for Wound Care. Order Date 06/27/2023. Start Date: 06/28/2023. The facility's wound care note for R2 dated 06/26/2024 documented in part, Wound care to abdomen as follows: -Cleanse with wound cleanser or NS (normal saline), pat dry. -Apply alginate (2) to proximal (close to) and distal (away from) dehiscence (open wound) -Cover with foam dressing. As needed for saturation and soilage. The eTAR (electronic treatment administration record) dated June 2023 for R2 documented the physician's order for the use of wound cleanser or normal saline as stated above. Further review of the eTAR failed to evidence wound treatments were conducted from 08/21/2023 through 08/25/2023 for R2. Review of the facility's nursing notes dated 08/21/2023 through 08/25/2023 failed to document evidence that wound treatments were conducted for R2. Further review of the notes failed to evidence notification to the physician and responsible party of documentation to continue the wound treatment the lack of wound treatment for R2. Review of R2's ehr (electronic heal record) failed to evidence documentation of a physician's order for wound treatment from 08/21/2023 through 08/27/2023. Review of the nurse practitioner notes dated 06/21/2024, 06/23/2023 and 06/25/2024 failed to evidence documentation of assessments and monitoring of R2's surgical wound. Review of the facility nurse's notes for R2 dated 06/20/2024 through 06/025/2024 failed to evidence documentation of treatment for R2's surgical wound. Review of R2's EHR (electronic heal record) failed to evidence documentation of physician's treatment order for R2's surgical wound from 08/21/2023 through 08/25/2023. On 06/12/2024 at 11:03 a.m., an interview was conducted with ASM (administrative staff member) #4, physician. When asked if he recalled R2 and his abdominal surgery ASM #4 stated that he did. When asked about monitoring of the surgical site/wound ASM #4 stated he would expect daily monitoring of the site for infection and ensure the dressing was intact. When asked about documentation of R2's surgical site/wound ASM #4 stated that the wound should be mentioned. After reviewing the nurse practitioner notes for R2 dated 06/21/2024, 06/23/2024 and 06/25/2024 ASM #4 stated that there was no documentation of the surgical site/wound that it was major surgery, and it should have been mentioned. On 06/12/2024 at approximately 11:30 a.m., a request was made to ASM #1, administrator, to speak with ASM #7, previous nurse practitioner. ASM #1 stated that ASM #7 no longer worked at the facility. On 06/12/2024 at 12:12 p.m., an interview was conducted with ASM (administrative staff member) #5, nurse practitioner. When asked if she would document about a resident's surgical wound and what would be included in that documentation ASM #5 stated yes and the note would include any abnormalities, such as redness, or drainage, if the wound was open or closed and the current treatment. When asked to describe the procedure she would follow if the treatment of a resident's surgical wound if it was interrupted by the resident's hospitalization ASM #5 stated she would check the previous orders, assess the wound refer the resident to the wound NP and continue care. After reviewing the nurse practitioner notes for R2 dated 06/21/2024, 06/23/2024 and 06/25/2024 ASM #4 stated that there was no documentation of the surgical site/wound. When asked why it was important to continue timely care of the surgical wound ASM #4 to prevent infections. On 06/12/2024 at 1:34 p.m., an interview was conducted with ASM (administrative staff member) #2, interim director of nursing. When asked to describe the procedure to continue the treatments of a resident's surgical wound if it was interrupted by the resident's hospitalization ASM #2 stated she would notify the physician and family for the need of treatment orders, re-assess the wound and document the treatment and notification progress notes. When asked if timely continuation of R2's wound treatment was provided she stated no. When asked about effects of a delay in treatment of a wound ASM #2 stated it is a risk of infection or worsening of the wound. On 06/12/2024 at approximately 2;58 p.m., ASM #1, administrator, ASM #2, interim director of nursing, ASM #3, regional director of clinical services, and ASM #6, administrator for sister facility, were made aware of the above findings. No further information was provided prior to exit.

Based on staff interview, clinical record review and facility document review, it was determined that the facility staff failed to follow the comprehensive care plan for one of four residents in the survey sample; Resident #3. The findings include: For Resident #3, the facility staff failed to obtain weights per the comprehensive care plan. Resident #3 was admitted to the facility on [DATE] and had the diagnoses of but not limited to protein-calorie malnutrition and nutritional/metabolic disease. The most recent MDS (Minimum Data Set) was a quarterly assessment with an ARD (Assessment Reference Date) of 7/26/23 and coded the resident as severely cognitively impaired in ability to make daily life decisions, scoring a 5 out of a possible 15 on the BIMS (Brief Interview for Mental Status). The resident was coded as requiring supervision for eating. The facility policy, Comprehensive Care Planning Policy was reviewed. This policy documented, .D. All staff must be familiar with each resident's Care Plan and all approaches must be implemented . A review of the comprehensive care plan revealed one dated 8/9/22 for Resident has increased malnutrition/dehydration risk related to: Moderate nutritional risk with altered nutrition related lab values and inability to manage self care. A therapeutic diet is provided. Interventions included one dated 8/9/22 for Monitor weight per protocol. The facility policy, Weights Policy was reviewed. This policy documented, Weights will be obtained routinely in order to monitor parameters of nutrition over time. Each individual's weight will be determined upon admission /readmission to the facility, weekly for the first four weeks after admission/readmission, and monthly or more often if risk is identified A review of the physician's orders revealed one dated 8/3/22 for Weight on admission and then weekly x 4 one time a day every Thu (Thursday) for monitor weight for 4 weeks. There were no further orders for weights once this order was completed. There were no current orders for weight monitoring at the time of the survey. A review of the weight log revealed that monthly weights were obtained from August 2022 through July 2023. On 7/4/23 the resident's weight was 132.0 pounds. There were no further weights until 10/2/23, at which time the resident was 122.0 pounds, a ten pound (7.6%) weight loss over approximately 90 days. A review of the progress notes revealed one by the dietician dated 10/3/23 that documented, Data : WEIGHT WARNING: Value: 122.0. Vital Date: 2023-10-02 -3.0% change from last weight [ 7.6%, 10.0 ]. -7.5% change [ 7.6%, 10.0 ]. Comments : Wts (weights), intakes variable 2/2 (secondary to) food preferences. Will add magic cup, discussed in IDT (interdisciplinary team) meeting. A review of the progress notes revealed one by the nurse practitioner dated 10/3/23 that documented, .Weight loss from 132 - 122 lbs (pounds) - consider restarting Mirtazapine (1) 7.5mg (milligrams) PO (by mouth) at bedtime for depression and weight loss. At risk for malnutrition BMI (body mass index) of 24.1 - continue nutritional and dietary support. Monitor oral intake and weight. continue multivitamins. RD (Registered Dietician) consult as needed. Treatment plan discussed with patient and assigned nurse. We'll continue to follow-up with patient on as needed basis. On 10/17/23 at 3:44 PM, an interview was conducted with ASM #2 (Administrative Staff Member) the Director of Nursing. She stated that Resident #3 often refuses to eat, and most of the time peanut butter and jelly sandwich is the only thing they can get her to eat. On 10/17/23 at 4:07 PM in a follow up interview ASM #2 stated that upon review, there were no weights for August and September 2023. She stated that it would appear that when the order for weights dated 8/3/22 (above) fell off, it did not roll over to obtaining weights monthly. She stated that there was a CNA (Certified Nursing Assistant) that normally obtained monthly weights and got them on all residents on the long term care unit, but that the resident was moved to another unit (on 7/26/23) and the other unit did not continue to obtain monthly weights since it wasn't on the orders. She stated there was no way to determine if the weight loss was gradual or sudden. Without monthly monitoring, there was a potential that interventions were delayed. On 10/17/23 at 4:21 PM, in a follow up interview with ASM #2, she stated that the care plan is the guideline for how to take care of the resident for following, tracking and documenting their care. When asked if the care plan was followed for Resident #3, she stated that it was not. No further information was provided by the end of the survey. Reference: 1. Mirtazapine is used to treat depression. Information obtained from https://medlineplus.gov/druginfo/meds/a697009.html

Based on staff interview, clinical record review and facility document review, it was determined that the facility staff failed to monitor a resident's weight to ensure nutritional status was maintained for one of four residents in the survey sample; Resident #3. The findings include: Resident #3 was admitted to the facility on [DATE] and had the diagnoses of but not limited to protein-calorie malnutrition and nutritional/metabolic disease. The most recent MDS (Minimum Data Set) was a quarterly assessment with an ARD (Assessment Reference Date) of 7/26/23 and coded the resident as severely cognitively impaired in ability to make daily life decisions, scoring a 5 out of a possible 15 on the BIMS (Brief Interview for Mental Status). The resident was coded as requiring supervision for eating. A review of the physician's orders revealed one dated 8/3/22 for Weight on admission and then weekly x 4 one time a day every Thu (Thursday) for monitor weight for 4 weeks. There were no further orders for weights once this order was completed. There were no current orders for weight monitoring at the time of the survey. A review of the weight log revealed that monthly weights were obtained from August 2022 through July 2023. On 7/4/23 the resident's weight was 132.0 pounds. There were no further weights until 10/2/23, at which time the resident was 122.0 pounds, a ten pound (7.6%) weight loss over approximately 90 days. A review of the progress notes revealed one by the dietician dated 10/3/23 that documented, Data : WEIGHT WARNING: Value: 122.0. Vital Date: 2023-10-02 -3.0% change from last weight [ 7.6%, 10.0 ]. -7.5% change [ 7.6%, 10.0 ]. Comments : Wts (weights), intakes variable 2/2 (secondary to) food preferences. Will add magic cup, discussed in IDT (interdisciplinary team) meeting. A review of the progress notes revealed one by the nurse practitioner dated 10/3/23 that documented, .Weight loss from 132 - 122 lbs (pounds) - consider restarting Mirtazapine (1) 7.5mg (milligrams) PO (by mouth) at bedtime for depression and weight loss. At risk for malnutrition BMI (body mass index) of 24.1 - continue nutritional and dietary support. Monitor oral intake and weight. continue multivitamins. RD (Registered Dietician) consult as needed. Treatment plan discussed with patient and assigned nurse. We'll continue to follow-up with patient on as needed basis. On 10/17/23 at 1:20 PM, Resident #3 was observed feeding herself without any issues identified. On 10/17/23 at 3:44 PM, an interview was conducted with ASM #2 (Administrative Staff Member) the Director of Nursing. She stated that Resident #3 often refuses to eat, and most of the time peanut butter and jelly sandwich is the only thing they can get her to eat. On 10/17/23 at 4:07 PM in a follow up interview ASM #2 stated that upon review, there were no weights for August and September 2023. She stated that it would appear that when the order for weights dated 8/3/22 (above) fell off, it did not roll over to obtaining weights monthly. She stated that there was a CNA (Certified Nursing Assistant) that normally obtained monthly weights and got them on all residents on the long term care unit, but that the resident was moved to another unit (on 7/26/23) and the other unit did not continue to obtain monthly weights since it wasn't on the orders. She stated there was no way to determine if the weight loss was gradual or sudden. Without monthly monitoring, there was a potential that interventions were delayed. A review of the comprehensive care plan revealed one dated 8/9/22 for Resident has increased malnutrition/dehydration risk related to: Moderate nutritional risk with altered nutrition related lab values and inability to manage self care. A therapeutic diet is provided. Interventions included one dated 8/9/22 for Monitor weight per protocol. The facility policy, Weights Policy was reviewed. This policy documented, Weights will be obtained routinely in order to monitor parameters of nutrition over time. Each individual's weight will be determined upon admission /readmission to the facility, weekly for the first four weeks after admission/readmission, and monthly or more often if risk is identified No further information was provided by the end of the survey. Reference: (1) Mirtazapine is used to treat depression. Information obtained from https://medlineplus.gov/druginfo/meds/a697009.html

Based on staff interview, clinical record review, and facility document review, it was determined that the facility staff failed to provide written notice of a hospital transfer to the Resident Representative and/or State Long Term Care Ombudsman office for four of 30 residents in the survey sample; Residents #1, #8, #35, and #72. The findings include: 1. For Resident #1, the facility staff failed to evidence a written notification of a hospital transfer was provided to the resident representative and to the State Long Term Care Ombudsman office for a hospital transfer on 10/19/22; and failed to evidence a written notification of a hospital transfer was provided to the resident representative for a hospital transfer on 12/8/22. A. A review of the clinical record was conducted for Resident #1. Resident #1 was transferred to the emergency roiagnom on [DATE] for further evaluation and treatment of anemia. The clinical record failed to reveal any evidence that a written notification of this hospital transfer was provided to the resident's legal representative and to the State Long Term Care Ombudsman office. Further review of the clinical record revealed Resident #1 was transferred to the emergency roiagnom on [DATE] for further evaluation and treatment for uncontrolled abdominal pain. The clinical record failed to reveal any evidence that a written notification of this hospital transfer was provided to the resident's legal representative. On 1/19/23 at 9:06 AM, an interview was conducted with ASM #2 (Administrative Staff Member) the Director of Nursing. She stated that the written notification to the resident's (legal representative / responsible party) was not something that the facility had been doing. On 1/19/23 at 9:27 AM, an interview was conducted with OSM #7 (Other Staff Member), the social worker. She stated that she did not have a written notice to the Ombudsman for 10/19/22, as it was overlooked but should have been done. A review of the facility policy Discharge Planning that was provided, was conducted. This policy did not include any direction for the regulatory requirement of notifying, in writing, the resident representative and State Long Term Care Ombudsman office of a hospital transfer. On 1/19/23 at approximately 10:30 AM, ASM #1 (the Administrator) and ASM #2 were made aware of the findings. No further information was provided by the end of the survey. 2. For Resident #8, the facility staff failed to evidence that a written notification of a hospital transfer was provided to the resident representative for a hospital transfer on 12/17/22. A review of the clinical record was conducted for Resident #8. Resident #8 was transferred to the emergency roiagnom on [DATE] for further evaluation and treatment for possible injury after a fall. Further review of the clinical record failed to reveal any evidence that a written notification of this hospital transfer was provided to the resident's legal representative. On 1/19/23 at 9:06 AM, an interview was conducted with ASM #2 (Administrative Staff Member) the Director of Nursing. She stated that the written notification to the resident's (legal representative / responsible party) was not something that the facility had been doing. A review of the facility policy Discharge Planning that was provided, was conducted. This policy did not include any direction for the regulatory requirement of notifying, in writing, the resident representative and State Long Term Care Ombudsman office of a hospital transfer. On 1/19/23 at approximately 10:30 AM, ASM #1 (the Administrator) and ASM #2 were made aware of the findings. No further information was provided by the end of the survey. 3. For Resident #35, the facility staff failed to evidence that a written notification of a hospital transfer was provided to the resident representative for a hospital transfer on 10/25/22. A review of the clinical record was conducted for Resident #8. Resident #8 was transferred to the emergency roiagnom on [DATE] for further evaluation and treatment for possible injury after a fall. Further review of the clinical record failed to reveal any evidence that a written notification of this hospital transfer was provided to the resident's legal representative. On 1/19/23 at 9:06 AM, an interview was conducted with ASM #2 (Administrative Staff Member) the Director of Nursing. She stated that the written notification to the resident's (legal representative / responsible party) was not something that the facility had been doing. A review of the facility policy Discharge Planning that was provided, was conducted. This policy did not include any direction for the regulatory requirement of notifying, in writing, the resident representative and State Long Term Care Ombudsman office of a hospital transfer. On 1/19/23 at approximately 10:30 AM, ASM #1 (the Administrator) and ASM #2 were made aware of the findings. No further information was provided by the end of the survey. 42106 4. For Resident #72 (R72), the facility staff failed to provide evidence that written notification of transfer was provided to the resident and/or the representative for a facility-initiated transfer on 11/3/2022. On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 11/2/2022, the resident scored 15 out of 15 on the BIMS (brief interview for mental status) assessment, indicating the resident was cognitively intact for making daily decisions. The progress notes for R72 documented in part, - 11/3/2022 10:54 (10:54 a.m.) Nursing note. Note Text: PT (patient) transported to [Name of hospital] by EMS (emergency medical services) @ 1048 (10:48 a.m.) . Further review of the clinical record failed to reveal evidence that written notification of transfer was provided to the resident and/or the representative for a facility-initiated transfer on 11/3/2022 On 1/19/2023 at 8:33 a.m., a request was made to ASM (administrative staff member) #1, the administrator for evidence of written notification of transfer was provided to R72 and/or the representative for a facility-initiated transfer on 11/3/2022. On 1/19/2023 at 9:25 a.m., ASM #3, the assistant director of nursing provided the progress note documented above dated 11/3/2022 10:54 a.m. and stated that was all they had. At that time an interview was conducted with ASM #3. ASM #3 stated that they did not have any documentation to show that written notification of transfer was provided to R72 and/or the representative for a facility-initiated transfer on 11/3/2022. ASM #3 stated that nursing had not been sending a written notice of discharge and they had begun discussing a new process to put into place. ASM #3 stated that no one in the facility had been providing a written notice of discharge to the resident or the representative, that it was only verbal notification. On 1/19/2023 at 9:58 a.m., ASM #1, the administrator, ASM #2, the director of nursing and ASM #3, the assistant director of nursing were made aware of the above finding. No further information was provided prior to exit.

Based on observation, staff interview, facility document review, clinical record review, and in the course of a complaint investigation, it was determined the facility staff failed to develop and/or implement a comprehensive care plan for five of 30 residents in the survey sample, Residents #123, #23, #1, #21 and #68. The findings include: 1. For R123, the facility staff failed to implement the comprehensive care plan for the administration of medications per the physician order. On the most recent MDS (minimum data set) assessment, a Medicare five-day assessment, with an assessment reference date of 9/8/2022, the resident scored a 7 on the BIMS (brief interview for mental status) score, indicating the resident was severely impaired for making daily decisions. In Section N - Medications the resident was coded as receiving antidepressants during the look back period. The comprehensive care plan dated 8/18/2022, documented in part, Resident has altered cardiac status. The Interventions documented in part, Administer medications as directed by the physician. The care plan further documented in part, Focus: Resident is on antianxiety therapy related to anxiety disorder. The Interventions documented in part, Administer antianxiety medications as prescribed by the physician. The care plan further documented in part, Resident has infection, liver abscess, PICC line. The Interventions documented in part, Administer antibiotics/anti-viral per physician order and monitor side effect. The physician orders dated 8/17/2022, documented the following: Lipitor (Atorvastatin) (used to treat high cholesterol) (1) 80 mg (milligrams); give 1 tablet by mouth at bedtime for cholesterol. Mirtazapine (Remeron) (used to treat depression) (2) 7.5 mg; give 1 tablet by mouth at bedtime for Adult Failure to Thrive. Sertraline HCL (hydrochloride) (used to treat depression and anxiety disorders) (3) Capsule 150 mg; give 1 capsule by mouth at bedtime related to anxiety disorder. Ceftriaxone Sodium Solution Reconstituted 2 GM (grams) (used to treat infections) (4), Use 2000 milligrams intravenously every 24 hours related to abscess of liver for 23 days. R123 was readmitted to the facility on [DATE]. The physician orders documented: Lipitor 80 mg; give 1 tablet by mouth at bedtime for cholesterol Sertraline HCL capsule 150 mg; give 1 capsule by mouth at bedtime related to anxiety disorder. Flagyl (metronidazole) Tablet 500 mg (used to treat infections) (5), Give 1 tablet my mouth every 8 hours related to abscess of liver for 23 days. The August 2022 MAR (medication administration record) documented the above orders. On 8/17/2022, the Lipitor, Mirtazapine and Sertraline were scheduled to be administered at 9:00 p.m. The nurse documented a 19 on the block where it is documented as administered. A 19 indicated, Other/See Nurses Notes. The August MAR also documented the above order for Ceftriaxone with a scheduled time of 24h. There was no scheduled time for the administration of the medication. On 8/17/2022, the nurse documented a 19 on the block where it is documented as administered. A 19 indicated, Other/See Nurses Notes. The EMAR (electronic medication administration record) note dated 8/17/2022 at 8:45 p.m. documented for all the Lipitor, Sertraline and Mirtazapine, Awaiting delivery. The EMAR note dated 8/17/2022, for the Ceftriaxone at 7:36 p.m. documented, Just admitted . The September 2022 MAR documented the above orders. The Lipitor and Sertraline were scheduled to be administered at 9:00 p.m. on 9/2/2022. The nurse documented a 19 on the block where it is documented as administered. A 19 indicated, Other/See Nurses Notes. The Flagyl was scheduled to be administered on 9/3/2022 at 12:00 a.m. The nurse documented a 19 on the block where it is documented as administered. The EMAR note dated 9/2/2022 at 8:28 p.m. documented for the Sertraline and Lipitor medications, On order. The EMAR note for the Flagyl, dated 9/3/2022 at 12:07 a.m. documented, Awaiting delivery. The on-site emergency pharmacy dispensing machine inventory list was reviewed. The following was documented as being in the pharmacy machine on site: Atorvastatin 40 mg tablets - PAR level is 10 tablets. Mirtazapine 7.5 mg tablets - PAR level is 10 tablets. Sertraline 100 mg tablets - PAR level is 10 tablets. Sertraline 50 mg tablets - PAR level is 10 tablets. Metronidazole 500 mg tablets - PAR level is 10 tablets. Ceftriaxone 1 GM vial 1 EA (each) - PAR level - 5. On 1/18/2023 at 2:51 p.m., an interview was conducted with LPN (licensed practical nurse) #3. LPN #3 stated the purpose of the care plan was to let staff know what was needed to care for the resident. LPN #3 stated that the care plan was there to help them take care of the residents and help to avoid any incidents. On 1/18/2023 at 3:47 p.m., an interview was conducted with RN (registered nurse) #3, unit manager. RN #3 stated that the purpose of the care plan was to plan the residents care and to have a document for staff to reference to help prevent incidents. RN #3 stated that they used the care plans to alert the staff to the resident's individualized needs. The facility policy, Comprehensive Care Planning Policy, documented in part, PROCEDURE: A) The facility must develop a comprehensive Person Centered Care Plan for each resident that includes measurable objectives and timetables to meet the resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessments .D) All staff must be familiar with each resident's Care Plan and all approaches must be implemented. ASM #1, the administrator, and ASM #2, the director of nursing, were made aware of the above on 1/19/2023 at 9:49 a.m. No further information was obtained prior to exit. (1) This information was obtained from the following website: https://medlineplus.gov/druginfo/meds/a600045.html (2) This information was obtained from the following website: https://medlineplus.gov/druginfo/meds/a697009.html (3) This information was obtained from the following website: https://medlineplus.gov/druginfo/meds/a697048.html (4) This information was obtained from the following website: https://medlineplus.gov/druginfo/meds/a685032.html (5) This information was obtained from the following website: https://medlineplus.gov/druginfo/meds/a689011.html. 42106 2. For Resident #23 (R23), the facility staff failed to implement the comprehensive care plan to A. provide pressure ulcer treatment as ordered and B. place a fall mat to the left side of the bed. On the most recent MDS (minimum data set) assessment, a quarterly assessment with an ARD (assessment reference date) of 12/15/2022, the resident scored 3 out of 15 on the BIMS (brief interview for mental status), indicating the resident was severely impaired for making daily decisions. The assessment documented R23 having one Stage 3 pressure injury and not having any falls since the prior assessment. A. The comprehensive care plan for R23 documented in part, Risk for impaired skin integrity r/t (related to) impaired mobility and peripheral neuropathy. Actual impaired skin integrity: Hx of Chronic rash under abd (abdominal) fold. 6/3/22 DTI (deep tissue injury) left heel (resolved 1/10/23) . Under Interventions/Tasks it documented in part, .Treatments per order. Date Initiated: 03/19/2015. The wound physician progress note dated 1/10/2023 for R23 documented in part, .Resolved stage 3 PI (pressure injury) at left heel -- contributing factors are poor mobility, poor intake, dementia, restless legs causing friction, fragile skin. Care for prevention x2/weeks (for two weeks) to left heel as follows: - Apply skin prep/barrier film to wound bed. - Provide this care daily . Review of the physician orders failed to evidence an order for the skin prep to the left heel as documented in the wound physician progress note on 1/10/2023. Review of the eTAR (electronic treatment administration record) dated 1/1/2023-1/31/2023 for R23 failed to evidence a treatment to the left heel after 1/11/2023. On 1/18/2023 at 3:47 p.m., an interview was conducted with RN (registered nurse) #3, unit manager. RN #3 stated that the purpose of the care plan was to plan the residents care and to have a document for staff to reference to help prevent incidents. RN #3 stated that they used the care plans to alert the staff to the resident's individualized needs. RN #3 reviewed the wound physician progress note dated 1/10/2023, R23's physician orders and eTAR and stated that there was no order put in for the skin prep. RN #3 stated that they must have missed the order and did not put it in. B. On 1/17/2023 at 11:49 a.m., an observation was made of R23 in bed in their room. No fall mat was observed to the left side of R23's bed. Additional observations on 1/17/2023 at 3:52 p.m. and 1/18/2023 at 8:48 a.m. revealed R23 in bed with no fall mat on the left side of the bed. The comprehensive care plan for R23 documented in part, Hx of actual falls- Risk for further falls related to weakness, visual/hearing impairment, and dementia. Date Initiated: 05/11/2016 . Under Interventions/Tasks it documented in part, .Fall mat on left side of bed when in bed. Date Initiated: 03/28/2022 . The physician orders for R23 documented in part, Fall mat on left side of resident bed when resident in bed every shift for for safety. Order Date: 03/27/2022. On 1/18/2023 at 2:51 p.m., an interview was conducted with LPN (licensed practical nurse) #3. LPN #3 stated that the purpose of the care plan was to let staff know what was needed to care for the resident. LPN #3 stated that the care plan was there to help them take care of the residents and help to avoid any incidents. LPN #3 stated that the care plan was updated when there were any incidents like a fall or any new interventions or orders put into place. LPN #3 stated that they were not implementing the care plan if they were not keeping the fall mat down when R23 was in bed. On 1/18/2023 at 4:33 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, ASM #3, the assistant director of nursing, ASM #4, the regional director of clinical services and ASM #5, the regional vice president of operations were made aware of the concern. No further information was provided prior to exit. 29125 3. For Resident #1, the facility staff failed to implement the comprehensive care plan for the administration of oxygen per the physician's order. A review of the clinical record revealed a physician's order dated 10/20/22 for Oxygen 3LPM (liters per minute) via nasal cannula every shift . On 1/17/23 at 12:00 PM and at 2:25 PM, observations of the resident revealed the oxygen rate on the oxygen concentrator flow meter was set at 1.5 liters as evidenced by the ball of the flow meter centered on the line between the 1 and 2 liter marks. A review of the comprehensive care plan revealed one dated 8/27/21 for Resident is receiving continuous oxygen therapy. This care plan included an intervention dated 8/27/21 for Administer oxygen as ordered. On 1/19/23 at 10:00 AM an interview was conducted with LPN #2 (Licensed Practical Nurse). She stated that when she checked, the oxygen was set at the correct rate. She stated that if it was not at 3 liters when it was observed, then the care plan was not being followed. She stated that for this resident, it is important the oxygen be at the right rate because the resident gets hypoxic. A review of the facility policy Comprehensive Care Planning Policy that was provided, was conducted. This policy documented, .D) All staff must be familiar with each resident's Care Plan and all approaches must be implemented On 1/19/23 at approximately 10:30 AM, ASM #1 (the Administrator) and ASM #2 (the Director of Nursing) were made aware of the findings. No further information was provided by the end of the survey 4. For Resident #21, the facility staff failed to implement the comprehensive care plan to ensure that bilateral fall mats were in place. A review of the comprehensive care plan revealed one dated 3/23/21 for Actual fall; Risk for further falls . This care plan included an intervention dated 7/19/21 for Fall mats on both sides of bed. A review of the clinical record revealed the January 2023 eTAR (electronic treatment administration record.) This document included an item dated 7/20/21 for Fall Matts [sic] to each side of the bed for safety while in bed every shift for preventative. This document identified Day Evening and Night as three opportunities each day for staff to sign off that placement of the fall mats had been verified. Staff had completed this sign off each day through 1/18/23. Observations of Resident #21 on 1/17/23 at 10:57 AM, 1/17/23 at 2:30 PM, 1/18/23 at 11:49 AM, 1/18/23 at 3:51 PM, and 1/19/23 at 8:38 AM, all revealed Resident #21 in the bed. There were no fall mats down and no evidence of fall mats anywhere in the room. On 1/19/23 at 10:00 AM an interview was conducted with LPN #2 (Licensed Practical Nurse). She stated that the fall mats should have been down. She stated that it was her fault because she had taken them up over the weekend to have them cleaned and never replaced them. When asked if the care plan was being followed, she stated it was not. A review of the facility policy Comprehensive Care Planning Policy that was provided, was conducted. This policy documented, .D) All staff must be familiar with each resident's Care Plan and all approaches must be implemented On 1/19/23 at approximately 10:30 AM, ASM #1 (the Administrator) and ASM #2 (the Director of Nursing) were made aware of the findings. No further information was provided by the end of the survey. 5. The facility failed to develop a complete comprehensive care plan for dialysis fistula functioning monitoring for Resident #68. Resident #68 was admitted to the facility on [DATE] with diagnosis that included but not limited to: end stage renal disease The most recent MDS (minimum data set) assessment, a Medicare five-day assessment, with an ARD (assessment reference date) of 1/3/23, coded Section O-special procedures/treatments coded the resident as dialysis yes. A review of the comprehensive care plan dated 12/29/22, revealed, FOCUS: Resident receives dialysis treatments 3 times weekly. ESRD (end stage renal disease). LUE (left upper extremity) fistula. INTERVENTIONS: Bleeding occurs from dialysis site, apply pressure. Call 911, if needed. Fluid restrictions as ordered. Meds as ordered. Monitor labs and report to physician any abnormalities. Monitor shunt/vascular catheter site for bleeding or signs /symptoms of infection. No labs/BP (blood pressure) in shunt arm. Assess/monitor dressing to shunt. Replace dressing if dressing should come off while not in dialysis. Assess/Monitor for signs /symptoms of bleeding due to anticoagulant therapy. Assist with transfer needs when going to dialysis. Maintain communication with dialysis staff and physician per routine. Dialysis per orders. Report any changes in condition to the nursing/physician. An interview was conducted on 1/17/23 at 2:15 PM with Resident #68. When asked whether staff monitor her fistula, Resident #68 stated, No, they do not monitor it here. They do at the dialysis center. An interview was conducted on 1/18/23 at 2:00 PM with LPN (licensed practical nurse) #2. When asked the purpose of the baseline care plan, LPN #2 stated, it is to initiate the plan of care for the resident based on their needs. When asked what should be included on the baseline care plan for a dialysis resident, LPN #2 stated, it should include monitoring their fistula for bleeding, bruit and thrill. If they are on a fluid restriction, monitoring the intake and to communicate with the dialysis center and physician if any changes occur. When asked if the care plan did not include monitoring the fistula for bruit and thrill, was it a complete care plan, LPN #2 stated it was not. On 1/18/23 at approximately 4:30 PM, ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, ASM #3, assistant director of nursing, ASM #4, the regional director of clinical services and ASM #5, the regional vice president for operations were made aware of the findings. No further information was provided prior to exit.

Based on clinical record review, staff interview and facility document review it was determined that the facility staff failed to provide one of 30 residents in the survey sample the opportunity to formulate an advance directive (1); Resident #11. The findings include: For Resident #11 (R11), the facility staff failed to fully review advance directives with the resident and/or the representative, and provide an opportunity to formulate an advanced directive. R11 was admitted to the facility on [DATE]. On the most recent MDS (minimum data set), an annual assessment with an ARD (assessment reference date) of 12/16/2022, the resident scored 13 out of 15 on the BIMS (brief interview for mental status) assessment, indicating the resident was cognitively intact for making daily decisions. Review of R11's clinical record failed to evidence documentation of advanced directive review. The progress notes documented periodic review of DNR (do not resuscitate) status. The comprehensive care plan for R11 documented in part, Resident/Responsible party has chosen DNR (do not resuscitate). Date Initiated: 02/16/2019 .Interventions/Tasks: .Review code status annually, quarterly and/or PRN (as needed) Date Initiated: 02/16/2019 . On 1/18/2023 at approximately 11:50 a.m., a request was made to ASM (administrative staff member) #1, the administrator, for evidence of review of advanced directive for R11. On 1/18/2023 at 12:49 p.m., an interview was conducted with OSM (other staff member) #3, social services. OSM #3 stated that they reviewed advance directives when they did the quarterly or annual assessments. OSM #3 stated that they interviewed the resident and discussed the code status and asked them if they wanted to change it. OSM #3 stated that as far as the bigger picture of advance directives they did not have those conversations. On 1/19/2023 at 8:00 a.m., ASM #1 provided a social service initial assessment dated [DATE] for R11. The assessment documented in part, .DNR . The section which documented, Advanced directives have been reviewed was observed to be blank. On 1/19/2023 at approximately 9:10 a.m., a follow up interview was conducted with OSM #3, social services. When asked about the assessment dated [DATE] for R11, OSM #3 stated that it evidenced that the DNR was reviewed. The facility policy, Advance Directives Protocol documented in part, .Advance directives will be reviewed at minimum annually according to MDS schedule .Different types of advance directives: Living will .Durable power of attorney .Code Status . On 1/18/2023 at 4:33 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, ASM #3, the assistant director of nursing, ASM #4, the regional director of clinical services and ASM #5, the regional vice president of operations were made aware of the concern. No further information was presented prior to exit. (1) Advance directive What kind of medical care would you want if you were too ill or hurt to express your wishes? Advance directives are legal documents that allow you to spell out your decisions about end-of-life care ahead of time. They give you a way to tell your wishes to family, friends, and health care professionals and to avoid confusion later on. A living will tells which treatments you want if you are dying or permanently unconscious. You can accept or refuse medical care. You might want to include instructions on: The use of dialysis and breathing machines. If you want to be resuscitated if your breathing or heartbeat stops. Tube feeding. Organ or tissue donation. A durable power of attorney for health care is a document that names your health care proxy. Your proxy is someone you trust to make health decisions for you if you are unable to do so. This information was obtained from the website: https://medlineplus.gov/advancedirectives.html

Based on staff interview, facility document review, clinical record review, and in the course of a complaint investigation, it was determined the facility staff failed to notify the physician when physician ordered medications were not administered for one of 30 residents in the survey sample, Resident #123 (R123). The findings include: The facility staff failed to notify the physician when antibiotics, antidepressants and medications for cholesterol were not administered per the physician order for R123. On the most recent MDS (minimum data set) assessment, a Medicare five-day assessment, with an assessment reference date of 9/8/2022, the resident scored a 7 on the BIMS (brief interview for mental status) score, indicating the resident was severely impaired for making daily decisions. In Section N - Medications the resident was coded as receiving antidepressants and antibiotics during the look back period. The physician orders dated 8/17/2022, documented the following: Lipitor (Atorvastatin) (used to treat high cholesterol) (1) 80 mg (milligrams); give 1 tablet by mouth at bedtime for cholesterol. Mirtazapine (Remeron) (used to treat depression) (2) 7.5 mg; give 1 tablet by mouth at bedtime for Adult Failure to Thrive. Sertraline HCL (hydrochloride) (used to treat depression and anxiety disorders) (3) Capsule 150 mg; give 1 capsule by mouth at bedtime related to anxiety disorder. Ceftriaxone Sodium Solution Reconstituted 2 GM (grams) (used to treat infections) (4), Use 2000 milligrams intravenously every 24 hours related to abscess of liver for 23 days. The August 2022 MAR (medication administration record) documented the above orders. On 8/17/2022, the Lipitor, Mirtazapine and Sertraline were scheduled to be administered at 9:00 p.m. The nurse documented a 19 on the block where it is documented as administered. A 19 indicated, Other/See Nurses Notes. The August MAR also documented the above order for Ceftriaxone with a scheduled time of 24h. There was no scheduled time for the administration of the medication. On 8/17/2022, the nurse documented a 19 on the block where it is documented as administered. A 19 indicated, Other/See Nurses Notes. The EMAR (electronic medication administration record) note dated 8/17/2022 at 8:45 p.m. documented for all the Lipitor, Sertraline and Mirtazapine, Awaiting delivery. The EMAR note dated 8/17/2022, for the Ceftriaxone at 7:36 p.m. documented, Just admitted . R123 was readmitted to the facility on [DATE]. The physician orders documented: Lipitor 80 mg; give 1 tablet by mouth at bedtime for cholesterol Sertraline HCL capsule 150 mg; give 1 capsule by mouth at bedtime related to anxiety disorder. Flagyl (metronidazole) Tablet 500 mg (used to treat infections) (5), Give 1 tablet my mouth every 8 hours related to abscess of liver for 23 days. The September 2022 MAR documented the above orders. The Lipitor and Sertraline were scheduled to be administered at 9:00 p.m. on 9/2/2022. The nurse documented a 19 on the block where it is documented as administered. A 19 indicated, Other/See Nurses Notes. The Flagyl was scheduled to be administered on 9/3/2022 at 12:00 a.m. The nurse documented a 19 on the block where it is documented as administered. The EMAR note dated 9/2/2022 at 8:28 p.m. documented for the Sertraline and Lipitor medications, On order. The EMAR note for the Flagyl, dated 9/3/2022 at 12:07 a.m. documented, Awaiting delivery. The comprehensive care plan dated 8/18/2022, documented in part, Resident has altered cardiac status. The Interventions documented in part, Administer medications as directed by the physician. The care plan further documented in part, Focus: Resident is on antianxiety therapy related to Anxiety disorder. The Interventions documented in part, Administer antianxiety medications as prescribed by the physician. The care plan further documented in part, Resident has infection, liver abscess, PICC line. The Interventions documented in part, Administer antibiotics/anti-viral per physician order and monitor side effect. The on-site emergency pharmacy dispensing machine inventory list was reviewed. The following was documented as being in the pharmacy machine on site: Atorvastatin 40 mg tablets - PAR level is 10 tablets. Mirtazapine 7.5 mg tablets - PAR level is 10 tablets. Sertraline 100 mg tablets - PAR level is 10 tablets. Sertraline 50 mg tablets - PAR level is 10 tablets. Metronidazole 500 mg tablets - PAR level is 10 tablets. Ceftriaxone 1 GM vial 1 EA (each) - PAR level - 5. An interview was conducted with LPN (licensed practical nurse) #4, the nurse that didn't give the above medications on 9/2/2022, on 1/19/2023 at 9:25 a.m. When asked the process when a new admission comes and it's time for the resident to receive their medications, LPN #4 stated you look at the computer, verify the medication, if you don't have the medication you go to the (name of pharmacy dispensing machine. LPN #4 stated if the medications are not in there, you call the doctor and follow their instructions and then notify the responsible party. When asked where the above actions are documented, LPN #4 stated it should be in a nurse's note in (name of computer program). The above medications were reviewed with LPN #4. When asked if these medications would be in the dispensing machine, LPN #4 stated, they are normal medications, they are in the machine. An interview was conducted with ASM (administrative staff member) #2, the director of nursing, on 1/19/2023 at 9:36 a.m. When asked the process for a new admission's medications, ASM #2 stated, if the medications have not been delivered by the pharmacy yet, the nurse is to go to the (name of pharmacy dispensing machine) and get which ones she can. If the medications are not in the (name of pharmacy dispensing machine) the nurse must call the physician and see what steps they want to take, hold till available or maybe give a substitute that is available, then the nurse calls the responsible party to inform them what actions they have taken. When asked where is all this documented, ASM #2 stated it should be in a nurse's note. A request for a policy for notifying the physician when medications were not available was requested on 1/19/2023 at approximately 10:15 a.m. The facility stated they had no policy on notifying the physician when medications were not available for administration. One of the responsibilities of the nurse administering medications is to check to ensure the medications are available for administration at the times ordered .verify the physician's order and check the drugs to be sure they are correct . if medications are not given for any reason the physician must be notified (6). ASM #1, the administrator, and ASM #2, were made aware of the above on 1/19/2023 at 9:49 a.m. No further information was obtained prior to exit. (1) This information was obtained from the following website: https://medlineplus.gov/druginfo/meds/a600045.html (2) This information was obtained from the following website: https://medlineplus.gov/druginfo/meds/a697009.html (3) This information was obtained from the following website: https://medlineplus.gov/druginfo/meds/a697048.html (4) This information was obtained from the following website: https://medlineplus.gov/druginfo/meds/a685032.html (5) This information was obtained from the following website: https://medlineplus.gov/druginfo/meds/a689011.html. (6) Lippincott Handbook of Nursing Procedures Bethlehem Pa 2008 page 569-570.

Based on staff interview, clinical record review, and facility document review, it was determined that the facility staff failed to evidence that all required documentation was provided to the receiving facility for hospital transfers for three of 30 residents in the survey sample; Residents #1, #8, and #72. The findings include: 1. For Resident #1, the facility staff failed to evidence that all, if any, required documentation was provided to the receiving facility upon a hospital transfer on 12/8/22. A review of the clinical record was conducted for Resident #1. Resident #1 was transferred to the emergency roiagnom on [DATE] for further evaluation and treatment for uncontrolled abdominal pain. Further review of the clinical record failed to reveal any evidence that the required documentation was provided to the receiving facility. On 1/19/23 at 9:36 AM an interview was conducted with ASM #2 (Administrative Staff Member) the Director of Nursing. She stated that there was no evidence of what documentation was sent. On 1/19/23 at 10:00 AM an interview was conducted with LPN #2 (Licensed Practical Nurse). She stated that upon a hospital transfer, the facility sends the change of condition note, the facesheet, the transfer form, the care plan, the medication list, a bed hold notice, the Do Not Resuscitate form (if applicable) and the current lab results. She stated that what was sent should be documented in the nurse's notes. She stated that a copy should be retained and left in the unit manager's box. A review of the facility policy Discharge Planning that was provided, was conducted. This policy documented, .6. Information to the Receiving Provider. Information provided to the receiving provider must include a minimum of the following: a. Contact information of the practitioner responsible for the care of the resident. b. Resident representative information including contact information. c. Advance Directive information. d. All special instructions or precautions for ongoing care, as appropriate. e. Comprehensive care plan goals. f. All other necessary information, including a copy of the residents discharge summary, as applicable, and any other documentation, as applicable, to ensure a safe and effective transition of care. On 1/19/23 at approximately 10:30 AM, ASM #1 (the Administrator) and ASM #2 were made aware of the findings. No further information was provided by the end of the survey. 2. For Resident #8, the facility staff failed to evidence that all, if any, required documentation was provided to the receiving facility upon a hospital transfer on 12/17/22. A review of the clinical record was conducted for Resident #8. Resident #8 was transferred to the emergency roiagnom on [DATE] for further evaluation and treatment for possible injury after a fall. Further review of the clinical record failed to reveal any evidence that the required documentation was provided to the receiving facility. On 1/19/23 at 9:36 AM an interview was conducted with ASM #2 (Administrative Staff Member) the Director of Nursing. She stated that there was no evidence of what documentation was sent. On 1/19/23 at 10:00 AM an interview was conducted with LPN #2 (Licensed Practical Nurse). She stated that upon a hospital transfer, the facility sends the change of condition note, the facesheet, the transfer form, the care plan, the medication list, a bed hold notice, the Do Not Resuscitate form (if applicable) and the current lab results. She stated that what was sent should be documented in the nurse's notes. She stated that a copy should be retained and left in the unit manager's box. A review of the facility policy Discharge Planning that was provided, was conducted. This policy documented, .6. Information to the Receiving Provider. Information provided to the receiving provider must include a minimum of the following: a. Contact information of the practitioner responsible for the care of the resident. b. Resident representative information including contact information. c. Advance Directive information. d. All special instructions or precautions for ongoing care, as appropriate. e. Comprehensive care plan goals. f. All other necessary information, including a copy of the residents discharge summary, as applicable, and any other documentation, as applicable, to ensure a safe and effective transition of care. On 1/19/23 at approximately 10:30 AM, ASM #1 (the Administrator) and ASM #2 were made aware of the findings. No further information was provided by the end of the survey. 42106 3. For Resident #72 (R72), the facility staff failed to provide evidence that comprehensive care plan goals and medication list were sent to the receiving hospital on 11/3/2022 for a facility-initiated transfer. On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 11/2/2022, the resident scored 15 out of 15 on the BIMS (brief interview for mental status) assessment, indicating the resident was cognitively intact for making daily decisions. The progress notes for R72 documented in part, - 11/3/2022 22:10 (10:10 p.m.) Note Text: Resident admitted to [Name of hospital]. - 11/3/2022 13:22 (1:22 p.m.) Physician/PA/NP (physician assistant/nurse practitioner) progress note .Sent to ER (emergency room ) for hypotension, chest pain and SOB (shortness of breath) . - 11/3/2022 10:54 (10:54 a.m.) Nursing note. Note Text: PT (patient) transported to [Name of hospital] by EMS (emergency medical services) @ 1048 (10:48 a.m.). Bed policy discussed, Bed hold refused. Husband took patient belongings. Further review of the clinical record failed to reveal evidence that the medication list or care plan goals were sent to the receiving facility. On 1/19/2023 at 8:33 a.m., a request was made to ASM (administrative staff member) #1, the administrator for evidence of documents sent to the receiving provider for the facility-initiated transfer on 11/3/2022 for R72. On 1/19/2023 at 9:25 a.m., ASM #3, the assistant director of nursing provided the progress note documented above dated 11/3/2022 10:54 a.m. and stated that was all they had. At that time an interview was conducted with ASM #3. ASM #3 stated that the process was for staff to complete a change in condition and transfer form and send those with the resident. ASM #3 stated that the staff were also supposed to write a progress note documenting when the resident left the facility, how they were transported, which hospital they went to, that a bed hold notice, facesheet, care plan, medication list and progress notes were sent with the resident. ASM #3 stated that they did not have any documentation to show that the care plan or medication list were sent with R72. On 1/19/2023 at 9:58 a.m., ASM #1, the administrator, ASM #2, the director of nursing and ASM #3, the assistant director of nursing were made aware of the above finding. No further information was provided prior to exit.

Based on staff interview, facility document review and clinical record review, it was determined the facility staff failed to review and revise the comprehensive care plan for one of 30 residents in the survey sample, Resident #10. The findings include: For Resident #10 (R10), the facility staff failed to review and revise the comprehensive care plan after a self-harm incident on 7/22/2022. On the most recent MDS (minimum data set) assessment, a quarterly assessment with an ARD (assessment reference date) of 12/23/2022, the resident scored 5 of 15 on the BIMS (brief interview for mental status) assessment, indicating the resident was severely impaired for making daily decisions. Section E documented no behaviors. The progress notes for R10 documented in part, - 7/22/2022 21:30 (9:30 p.m.) Nursing note. Note Text: While doing rounds CNA (certified nursing assistant) found patient in his room crying and making an apparent attempt to commit suicide. Patient had a small cutting tool resembling a pocket knife and had cut two superficial wounds into his left forearm. Patient was visibly upset, crying and shaking and yelling I just want to go! I just want to go! I'm going to kill myself! EMS (emergency medical services) was notified and patient assessed for other injuries. No other injuries noted; Vital signs stable. T (temperature) 97.3 P (pulse) 88 R (respirations) 22 BP (blood pressure) 164/70. After assessing resident, EMS left facility but police officers remained on scene. Officers then stated that they were waiting to hear back from [Name of county] Mental Health Crisis Center. After several minutes, police stated they spoke with the crisis center and were told that [R10] does not meet the criteria for removal from the facility. DON (director of nursing) and administrator immediately notified of situation and resident placed on 1:1 (one to one) observation to maintain safety. Son [Name of son] notified. ADON (assistant director of nursing) on site to follow up with crisis center for possible evaluation. - 7/22/2022 23:47 (11:47 p.m.) Nursing note. Note Text: ADON stated that there will not be any intervention from crisis center at his [sic] time. Resident will remain on 1:1 observation in order to maintain safety until further notice. Will continue to monitor. - 7/23/2022 05:59 (5:59 a.m.) Nursing note. Note Text: Resident rested well, no c/o (complaints of) voiced, continue on 1:1 supervision due to suicide attempt no problems noted will continue to monitor. - 7/23/2022 10:25 (10:25 a.m.) Nursing note. Note Text: Resident's son in to transport resident to hospital. Resident was on 1:1 until son arrived. - 7/29/2022 14:36 (2:36 p.m.) Physician/PA/NP (physician assistant/nurse practitioner) Progress note .readmitted on [DATE] after being sent out due to suicidal attempt where he cut his wrist. States he had romantic feelings toward a staff member and reportedly felt depressed after he was told the staff is married with children and has plans on moving to another state. He was sent to [Name of psychiatric hospital] for observation - medications adjusted and behavior improved and was sent back to to the facility . Review of the facility investigation dated 7/22/2022 documented a summary of the incident, staff statements, nursing notes, social services contact, the psychiatric evaluation dated 7/25/2022 and behavioral health assessments for R10 dated 8/11/2022, 8/25/2022 and 9/1/2022. The comprehensive care plan for R10 failed to evidence a review or revision related to the self-harm attempt on 7/22/2022. Review of the clinical record failed to evidence any self-harming behavior prior to 7/22/2022. On 1/18/2023 at 2:51 p.m., an interview was conducted with LPN (licensed practical nurse) #3. LPN #3 stated that the purpose of the care plan was to let staff know what was needed to care for the resident. LPN #3 stated that the care plan was there to help them take care of the residents and help to avoid any incidents. On 1/18/2023 at 3:47 p.m., an interview was conducted with RN (registered nurse) #3, unit manager. RN #3 stated that the purpose of the care plan was to plan the residents care and to have a document for staff to reference to help prevent incidents. RN #3 stated that they used the care plans to alert the staff to the resident's individualized needs. RN #3 stated reviewed R10's care plan and stated that they did not see any information regarding the self-harm attempt on 7/22/2022 and that the care plan should have been revised after the incident. On 1/18/2023 at 3:10 p.m., an interview was conducted with ASM (administrative staff member) #3, the assistant director of nursing. ASM #3 stated that they were the staff member on call on 7/22/2022 and they had come in when staff had called them. ASM #3 stated that they had checked R10's room to make sure there was nothing in the room that they could use to hurt themselves with. ASM #3 stated that R10 was already on 1:1 when they arrived and they had spoken with the police officers and the local mental health authority but they had advised that the resident could not be taken for evaluation. ASM #3 stated that they had made sure a staff member was with R10 the entire night and the son had come to take them for evaluation at the psychiatric hospital the next morning. ASM #3 stated that the onsite psychiatry services and social worker followed R10 closely. On 1/18/2023 at 4:09 p.m., an interview was conducted with OSM (other staff member) #3, social services. OSM #3 stated that they followed R10 closely. OSM #3 stated that when the incident happened on 7/22/2022 they focused on keeping the resident safe and getting them the help they needed and had forgotten to update the care plan when they came back from the hospital. OSM #3 stated that it needed to be done. The facility policy, Comprehensive Care Planning Policy revised 7/19/2019 documented in part, .Residents who have returned from the hospital in the past week. Their previous MDS and Care Plan must be reviewed and updated . On 1/18/2023 at 4:33 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, ASM #3, the assistant director of nursing, ASM #4, the regional director of clinical services and ASM #5, the regional vice president of operations were made aware of the concern. No further information was obtained prior to exit.

Based on staff interview, clinical record review, and in the course of a complaint investigation, it was determined the facility staff failed to follow professional standards of practice for medication administration. to clarify a physician order for one of 30 residents in the survey sample, Resident #123 (R123). The findings include: The facility staff failed to clarify a physician order for the administration time of an IV (intravenous) antibiotic for Resident #123 (R123). On the most recent MDS (minimum data set) assessment, a Medicare five-day assessment, with an assessment reference date of 9/8/2022, the resident scored a 7 on the BIMS (brief interview for mental status) score, indicating the resident was severely impaired for making daily decisions. In Section N - Medications the resident was coded as receiving antidepressants and antibiotics during the look back period. The physician order dated, 8/17/2022, documented, Ceftriaxone Sodium Solution Reconstituted 2 GM (grams) (used to treat infections) (1), Use 2000 milligrams intravenously every 24 hours related to abscess of liver for 23 days. The August 2022 MAR documented the above order with a scheduled time of 24h. There was no scheduled time for the administration of the medication. The comprehensive care plan dated 8/18/2022, documented in part, Resident has infection, liver abscess, PICC line. The Interventions documented in part, Administer antibiotics/anti-viral per physician order and monitor side effect. An interview was conducted with LPN (licensed practical nurse) #4, on 1/19/2023 at 9:25 a.m. When asked if a new admission arrives with an order for intravenous antibiotics, how does the order get onto the MAR, LPN #4 stated she would have looked on the paperwork from the hospital to see when it was last given and then assign that time on the MAR at the facility. The above MAR was reviewed with LPN #4. When asked if the order needed to be clarified, LPN #4 stated, yes. An interview was conducted with ASM (administrative staff member) #2, the director of nursing, on 1/19/2023 at 9:36 a.m. When asked the process for when a new admission comes with physician orders for IV antibiotics, ASM #2 stated if the medication is scheduled and it hasn't come in from the pharmacy, ASM #2 stated they check the (name of pharmacy dispensing machine). If it's not there you call the doctor and follow their instructions. When asked where this is documented, ASM #2 stated it should be in a nurse's note. The time documented on the MAR for the above medication was reviewed with ASM #2, ASM #2 stated there should be a time documented for the administration. When asked what time should be documented, ASM #2 stated, if it's given every 24 hours then our scheduled time is 9:00 a.m. but I would have checked when it was last given at the hospital prior to transfer and follow that time. Per Fundamentals of Nursing, Lippincott, Williams & Wilkins, Always clarify with the prescriber any medication order that is unclear or seems inappropriate. (2) ASM #1, the administrator, and ASM #2, were made aware of the above on 1/19/2023 at 9:49 a.m. No further information was obtained prior to exit. (1) This information was obtained from the following website: https://medlineplus.gov/druginfo/meds/a685032.html (2) Fundamentals of Nursing, Lippincott, Williams & Wilkins, page 553.

Based on staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to evidence a complete discharge summary for one of 30 residents in the survey sample, Resident #70. The findings include: For Resident #70 (R70), the facility staff failed to evidence a discharge summary that included a recapitulation of the resident's stay, a final summary of the resident's status at the time of discharge, reconciliation of all pre-discharge medications with the resident's post discharge medications, and a post discharge plan of care for the discharge on 10/27/2022. On the most recent MDS (minimum data set), a discharge assessment with an ARD (assessment reference date) of 10/27/2022, the resident was coded as being severely impaired for making daily decisions. The progress notes for R70 documented in part, 10/27/2022 11:31 (11:31 a.m.) Note Text: Resident discharged home left via transportation van with attendant. Resident took all her belongings with her at discharge. The comprehensive care plan for R70 documented in part, Canceled: Resident plans to return to the community. Date Initiated: 10/24/2022 .Interventions/Tasks: CANCELED: Provide resident/family with written instructions upon discharge. Date Initiated: 10/24/2022 .CANCELED: Upon discharge resident/family will receive written discharge instructions to enable a safe return to the community. Date Initiated: 10/24/2022 . Further review of the clinical record failed to evidence a discharge summary that included a recapitulation of the resident's stay, a final summary of the resident's status at the time of discharge, reconciliation of all pre-discharge medications with the resident's post discharge medications and a post discharge plan of care for the discharge on 10/27/2022. On 1/19/2023 at 8:33 a.m., a request was made to ASM (administrative staff member) #1, the administrator for evidence of discharge instructions provided to the resident and the discharge summary that included a recapitulation of the resident's stay for the discharge on 10/27/2022. On 1/19/2023 at 9:47 a.m., ASM #3, the assistant director of nursing stated that they did not have any evidence of discharge instructions or a recapitulation of the resident's stay for the discharge on 10/27/2022. At that time an interview was conducted with ASM #3. ASM #3 stated that the process was for the discharge nurse to educate the resident and/or the representative on the medications and discharge instructions using the discharge summary completed under assessments in the computer. ASM #3 stated that the nurse should document a progress note regarding who they educated and what they educated them on, when and how they went home and whether they had any questions or concerns about the discharge instructions. ASM #3 reviewed R70's clinical record and stated that there was no discharge assessment completed for them. The facility policy, Discharge planning policy revised 9/24/2020 documented in part, .4. Discharge Summary/Instructions. When a discharge is anticipated, [Facility] will develop a discharge summary/instructions that includes, but is not limited to, the following: a. Summary of Stay. A summary of the resident's stay that includes, but is not limited to, diagnoses, course of illness/treatment or therapy, and pertinent lab, radiology, and consultation results. b. Final Summary Available for Release. A final summary of the resident's status to include, the resident's needs, strengths, goals, life history and preferences (as identified in the MDS) at the time of the discharge that is available for release to authorized persons and agencies, with the consent of the resident or resident's representative. c. Medication Reconciliation. Reconciliation of all pre-discharge medications with the resident's postdischarge medications (both prescribed and over-the-counter). d. Post-Discharge Plan of Care. A post-discharge plan of care that is developed with the participation of the resident and, with the resident's consent, the resident representative(s), which will assist the resident to adjust to his or her new living environment. The post-discharge plan of care will indicate where the individual plans to reside, any arrangements that have been made for the resident's follow up care and any post-discharge medical and non-medical services. A copy of the post-discharge plan will be provided to the resident and, with the resident's consent, the resident representative(s), the receiving provider, if applicable, and a copy will be filed in the resident's medical record . On 1/19/2023 at 9:58 a.m., ASM #1, the administrator, ASM #2, the director of nursing and ASM #3, the assistant director of nursing were made aware of the above finding No further information was provided prior to exit.