Every finding on record at Vivo Healthcare Orange Park

Based on observations, interviews, facility document review, and the facility policy and procedure review, the facility failed to ensure that residents who needed respiratory care, were provided such care, consistent with professional standards of practice, for one (Resident #95) of four residents reviewed for respiratory care, in a total survey sample of 28 residents. Resident #95 did not receive oxygen at the flow rate ordered by his physician. The findings include: On 11/18/24 at 1:10 PM, Resident #95 was observed fully dressed, sitting in his wheelchair inside his doorway communicating with Maintenance Director A in Spanish. His room was approached and the resident's nasal cannula was observed on the floor next to his wheelchair. Maintenance Director A advised Licensed Practical Nurse (LPN) B that Resident #95's nasal cannula was on the floor. The Director of Nursing (DON) also advised LPN B that Resident #95 needed an oxygen tank for his wheelchair. The oxygen flow rate on the concentrator was set between 1.5 and 2.0 Liters per minute (L/min). (Photographic evidence obtained) On 11/19/24 at 8:34 AM, Resident #95 was not wearing his nasal cannula and the oxygen flow rate on his wheelchair oxygen tank was set at 2 L/min. (Photographic evidence obtained) A review of the resident's active Physician's Orders revealed the following: Oxygen at 3 L/min via nasal cannula, continuously every morning and at bedtime for oxygen management. (Dated 10/1/24) Change oxygen tubing weekly. Label each component with date and initials every night shift every Sunday for infection control. Change humidifier and label. (Dated 11/17/24). (Copy obtained) A review of the resident's medical record revealed an admitted [DATE] with a previous admission on 01/4/24. Resident #95's diagnoses included acute respiratory failure with hypoxia; shortness of breath, other pneumonia, unspecified organism, a need for assistance with personal care; adjustment disorder with anxiety; and anxiety disorder. A review of the resident's Quarterly Minimum Data Set (MDS) assessment, dated 10/4/24, revealed that the resident was independent with eating and required oxygen therapy. A review of the resident's active care plan revealed that focuses and goals included altered or potential for altered respiratory status related to shortness of breath. Interventions included to anticipate and meet the resident's needs and provide oxygen as ordered. On 11/20/24 at 4:25 PM, LPN C confirmed that Resident #95's oxygen flow rate order was for 3L/min. She stated the oxygen flow rate should be set at 3L/min. All staff provided ongoing monitoring of the resident's oxygen therapy. Nursing was responsible for assuring that the resident was receiving the correct oxygen flow rate per the physician's order. Correct oxygen flow rate settings were identified by checking the orders. Correct settings were communicated from one nurse to the next through nursing report sheets and reviewing the MAR. Resident #95 did not refuse oxygen therapy, though he would sometimes take the nasal cannula off. On 11/20/24 at 4:34 PM, the DON confirmed that correct oxygen flow rate settings were found in the resident's physician's orders. A review of the facility's policy and procedure titled Oxygen Administration (implemented on 03/2024), revealed: Oxygen is administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plans, and the resident's goals and preferences. Policy Explanation and Compliance Guidelines: 1. Oxygen is administered under orders of a physician, except in the case of an emergency. A review of the facility's policy and procedure titled Medication Administration (implemented on 03/24/23), revealed: Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. Policy Explanation and Compliance Guidelines: 14. Administer medication as ordered in accordance with manufacturer specifications. (copy obtained)

Based on observations, staff interview, and policy and procedure review, the facility failed to ensure food was prepared by methods that conserved nutritive value, flavor, and appearance. The facility failed to ensure food was served at a safe and appetizing temperature. Failure to provide palatable, attractive, and appetizing food in accordance with professional standards for food service, can decrease the amount of food all residents eat and drink. Residents at nutritional and hydration risk could be impacted as well as those recovering from illness or injury. The findings include: On 1/4/2023 at 11:11 am, a follow-up visit of the kitchen was conducted with Certified Dietary Manager (CDM) L. Observation of the tray line revealed potato salad covered with aluminum foil sitting in an ice bath on a separate cart next to the tray line. The potato salad, temped at 44 F, was pulled from the line and transferred to an ice bowl that was pulled from the freezer to help reduce the temperature to 41 F or less. After several minutes with no change in temperature, the potato salad was pulled from the menu. The CDM reported the potato salad was purchased ready-made from [provider] and was kept in the refrigerator. She stated the potato salad was placed on the tray line in an ice bath (on a separate cart next to the line) at the appropriate temperature. When asked what the appropriate serving temperature for the potato salad was, she stated, Between 35 F and 41 F, usually cold items are plated in individual bowls and placed in the refrigerator before serving to maintain temperatures. The CDM stated she was busy and did not have opportunity to plate potato salad individually. On 1/4/2023 at 4:12 pm, a follow-up observation was conducted in the kitchen. A test tray was requested for the 400-hallway area. The tray line began at 5:15 pm, and all menu item temperatures were above the appropriate holding temperature. The tray line ended at 6:30 pm. The surveyor arrived at the 400-hallway area at 6:34 pm and observed three staff assisting with passing trays. The CDM pulled the test tray last from the cart and temped each menu item at 6:47 pm: meat loaf with gravy: 135 F, mash potatoes: 142 F, broccoli: 135 F, dinner roll: room temperature, and strawberries with cream topping: 49 F. The plate holding the food items was chipped near the area close to the dinner roll. (Photographic evidence obtained) Broccoli stems were very soft with mushy florets and the strawberries with cream topping temped above 49 F. (Photographic evidence obtained) The broccoli nutritive value and appearance was not in accordance with resident preferences and the strawberries with cream topping was not at a preferable temperature for cold foods. On 1/6/2023 at 2:35 pm, Cook K confirmed receiving dietary training. She stated the CDM verbally provided updates and in-service training was held monthly, sometimes weekly. On 1/6/2023 at 2:46 pm, CDM L confirmed she received dietary training through culinary school and CDM training. During the second kitchen tour on 1/4/2023, CDM L confirmed dietary training was provided to staff monthly, upon hire, and when problems were identified. Training topics included sanitation, food preparation, substitutions, cleaning, and reading tickets. A review of the Resident Council Minutes, dated 7/6/22, revealed complaints that breakfast was cold and chicken and dumplings were of poor quality on 7/5/2022. A review of Resident Council Minutes, dated 9/14/22, revealed the oatmeal was too thick and fried eggs were runny on 9/14/22. A Grievance/Concern form, dated 9/14/2022, revealed that oatmeal was too thick and fried eggs were too runny on 9/14/22. A review of the Resident Council Minutes, dated 12/14/22, revealed that peanut butter sandwiches were too dry. A Grievance/Concern form, dated 12/14/2022, revealed most meals were served cold in the hallways and in the dining room (carts sitting too long before being served on the 300-400 hallway). A review of the facility's Preventing Foodborne Illness-Food Handling Policy and Procedure (dated July 2014), revealed: Food will be stored, prepared, handled, and served so that the risk of foodborne illness is minimized. This facility recognizes that the critical factors implicated in foodborne illness are . 1b. Inadequate cooking and improper holding temperatures. 2. With these factors as the primary focus of preventative measures, this facility strives to minimize the risk of foodborne illness to our residents. (Copy obtained) A review of the facility's Resident Nutrition Services Policy and Procedure (dated July 2017), revealed: Nursing personnel or feeding assistants will inspect food trays as they are delivered to ensure that the correct meal has been delivered, that the food appears palatable and attractive, and it is served at a safe and appetizing temperature. (Copy obtained)

Based on the kitchen food service observations, staff interviews, facility document review, and facility policy and procedure review, the facility failed to follow proper sanitation and food handling practices to prevent the outbreak of foodborne illness with the potential to affect all the residents who consumed foods in the facility. The facility failed to ensure that the dietary staff was trained and knowledgeable about the proper procedures for food storage and proper sanitation practices in the kitchen. Specific instruction on food handling and sanitation is important in health care settings serving nursing home residents. Unsafe food handling practices represent a potential source of pathogen exposure. The findings include: An initial tour of the kitchen was conducted with Certified Dietary Manager (CDM) L on 01/03/2023 at 9:55 a.m. During the tour, the bread cart next to the food prep area had four open bundles of bread with no date marking identified. Opened Thick and Easy food and beverage thickener was observed in the dry storage room on the bottom. These observations were made again on 01/04/2023 at 11:22 a.m. and again at 1:24 p.m. (Photographic evidence obtained) On 1/6/2023 at 2:22 p.m., Dietary Aide J stated CDM L and the Cook were responsible for dry storage. CDM L updated and checked off at delivery. It was a team effort; all staff would help put food away. When asked what happened to open food packages, Dietary Aide J stated they were sealed and dated. When asked what happened when bread was used from the rack, she stated staff should open and use what was needed, then seal the package and date it. When ask again, so open bread has to be dated? Dietary Aide J stated, Yes, to inform staff the day the bread was opened. Open bread must be discarded in three days. She confirmed that she received dietary training when hired at the facility and also received monthly refresher trainings in areas of the drink station, dating food, sanitation, and cleanliness. On 1/6/2023 at 2:35 p.m., Cook K reported that Dietary Aides were usually responsible for receiving the dry storage. All staff help each other. When asked to explain what happened when bread was used from the rack, she stated it could be used for pureed meals, and left-over bread was wrapped and dated. When asked again, what happens to open food packages, she confirmed that bread must be sealed and dated. Cook K confirmed that she received dietary training. She stated CDM L verbally provided updates. In-service training was provided monthly, and sometimes weekly. On 1/6/2023 at 2:46 p.m., CDM L reported she received, reviewed, and checked off food deliverys to ensure the facility received what was ordered. All staff assisted with putting food away in dry storage. The CDM completes inventory and cooks ensue when food is pulled that dates are in order. Bread is delivered frozen. Bread is pulled 2-3 days at a time. Open bread is dated and discarded after three days. If found open, the CDM will discard. Open food is securely closed and dated. CDM L confirmed she received dietary training through culinary school and CDM training. During the second kitchen tour on 1/4/2023, CDM L confirmed dietary training was provided to staff monthly, upon hire, and when problems were identified. Training topics included sanitation, food preparation, substitutions, cleaning, and reading tickets. On 1/6/2023 at 3:30 p.m., the facility's Food Storage, Safety and Sanitation Policy was requested from administration. Administation provided the policy for Preventing Foodborne Illness - Food Handling Policy, staing the facility did not have a food storage policy. .

Based on kitchen food service observations, staff interviews, facility document review, and facility policy and procedure review, the facility failed to maintain the kitchen freezer in a safe operating condition with the potential to place the health of all the residents who consumed foods in the facility at risk. The facility failed to ensure that the dietary staff was trained and knowledgeable about the proper procedures for maintaining essential equipment in the kitchen. Specific instruction on kitchen equipment is important in health care settings serving nursing home residents. Freezer units in disrepair may no longer be capable of properly cooling or holding time/temperature control for safety foods at safe temperatures. The findings include: An initial tour of the kitchen was conducted with Certified Dietary Manager (CDM) L on 01/3/2022 at 9:55 a.m. During the tour, observations of the walk-in freezer identified condensation buildup on and around the door area, to include shelves on the right side of freezer door and plastic freezer shields. (Photographic evidence obtained) Internal temperatures ranged from -6 F to -8 F. A second observation of the walk-in freezer identified condensation buildup in the same area, on and around door area, to include shelves on the right side of freezer door and plastic freezer shields. (Photographic evidence obtained) CDM L stated she reported the condensation buildup in the freezer to the maintenance department last week. It needs a new seal on the door; staff have to ensure the door is closed tight. No maintenance log was found in the kitchen. CDM L stated, Maintenance will have a log. CDM L confirmed that when equipment was broken, it was immediately reported to maintenance. She had never reported in the TELS system that was used to track maintenance jobs. On 01/05/23 at 2:58 PM, an interview in the dining room with the Maintenance Director, revealed he arrived at the facility this week to fill in. The facility's maintenance director was currently out of the facility at the time of the survey. When asked how maintenance was informed of equipment failures within the facility, he stated verbal requests could be made and/or work orders were submitted in TELS (electronic system). When asked whether he was familiar with the condensation buildup in the Dietary freezer, he confirmed he was not familiar with any freezer issues or condensation buildup, and he did not have access to the TELS system at the facility. The Maintenance Director had not been notified of any equipment issues within the Dietary Department since arriving at the facility this week. When asked what the process was for addressing equipment failures, he stated, To try to repair or fix the issue. If maintenance cannot repair or fix the issue, contact [outside service] to submit a work request. Any staff can call maintenance directly or submit a work order in the TELS system. He stated he would inspect the edge of the freezer door and seal, and replace it if needed. If he could not replace it, a work request would be submitted for repair. On 1/6/2023 at 2:22 PM, Dietary Aide J confirmed that Dietary equipment failures were reported to the CDM. If the CDM was not available, equipment failures were reported to the cook. She stated she did not believe there was a maintenance logbook in Dietary; she had never filled out a request. Dietary Aide J confirmed that she received Dietary training when hired at the facility, as well as monthly refresher trainings in areas of the drink station, dating food, sanitation, and cleanliness. On 1/6/2023 at 2:35 PM, Cook K confirmed that Dietary equipment failures were reported to the CDM. She documented on paper or a report sheet, and gave it to the CDM. Cook K confirmed receiving dietary training. She stated the CDM verbally provided updates. In-service training was conducted monthly, and sometimes weekly. On 1/6/2023 at 2:46 PM, CDM L stated that staff reported equipment failures to her, and she would report them to Maintenance. She stated the Dietary Department did not have a maintenance logbook. I will report directly to maintenance. CDM L confirmed she received Dietary training through culinary school and CDM training. During the second kitchen tour on 1/4/2023, CDM L confirmed that Dietary training was provided to staff monthly, upon hire, and when problems were identified. Training topics included sanitation, food preparation, substitutions, cleaning, reading tickets. A review of the facility's Maintenance Request forms (dated 12/23/2022 to 1/5/2023), revealed no work order submitted from Dietary for freezer repair. (Copy obtained) A review of the facility's policy and procedure entitled Hazardous Areas, Devices and Equipment (dated July 2017), revealed: All hazardous area devices and equipment in the facility will be identified and addressed appropriately to ensure resident safety and mitigate accident hazards to the extent possible. (Copy obtained) Reference: United States Food and Drug Administration Food Code 2017. 4.501.11. Good Repair and Proper Adjustment. Page 504. https://www.fda.gov (Accessed 0n 01/09/2023): Proper maintenance of equipment to manufacturer specifications helps ensure that it will continue to operate as designed.

Based on observations, staff interviews, record review, and facility policy and procedure review, the facility failed to implement a culturally competent, person-centered care plan for the use of assistive devices and a translation/interpreter service for communication, and the correct contact information for the contracted translator services for one (Resident #41) of three residents whose primary language was not English, from a total sample of 33 residents. The staff did not have a way to communicate with Resident #41 except to have her point at things. They relied on her family and staff who spoke her language (if they were available or on duty). The staff was unable to consistently communicate effectively with Resident #41 in a language she understood. Failure to develop and implement the care plan can result in negative health outcomes for the residents. The findings include: On 01/03/2023 at 11:10 AM, Resident #41 was observed lying in bed watching television. When she was greeted, she began to speak in French Creole. She did not speak any English. There were no communication devices in her room. There was no information posted regarding a translation line for staff to call to have an interpreter assist with obtaining vital information from the resident. During an interview with Certified Nursing Assistant (CNA) M on 01/03/2023 at 11:18 AM, she confirmed that there were no communication devices in Resident #41's room. She stated the staff told Resident #41 to point to what she wanted. She stated she did not speak French Creole and was unaware of whether there was a staff member who did. She did not work with Resident #41 often, but she knew she had family and they visited on New Year's day. During an interview with Occupational Therapist (OT) O on 01/04/2023 at 4:26 PM, she stated she did not work with Resident #41, however, she was familiar with her. She stated Resident #41 spoke French Creole. She confirmed that she herself did not speak French Creole, but there were several staff members who did. She named a night shift nurse that spoke French Creole and worked with the resident. She stated there were several CNAs who spoke French Creole. She was not sure about the translator service phone line. She had never used it and did not know where the information could be located. During an interview with Licensed Practical Nurse (LPN) N on 01/04/2023 at 5:20 PM, she stated this was the third time she had worked this hallway since it had become the COVID-19 unit, and she had only worked with Resident #41 during those three shifts. She was asked how she communicated with the resident. She stated she did not speak French Creole. She stated there was a telephone number they could call for translator services. She was not sure where the number was located, but she thought it was at the nurses' station. She did not have the number on the medication cart. She confirmed that there was no communication board/device for the resident in her room, and that the resident pointed to the things she wanted. She used the example that if the resident had pain, she would point to where she had the pain. She did not know the word for pain in the language of French Creole. She confirmed that she did not know the resident well enough to determine if she understood English. During an interview with LPN/Unit Manager (UM) P of the COVID-19 unit on 01/04/2023 at 5:25 PM, she stated she did not know the translator service telephone number, but she would get it. She walked down the hall to the Director of Nursing's (DON's) office. She returned a few minutes later with the DON, who provided a piece of 8 x 11.5 inch paper with the contracted translator services name and telephone number printed on it. It was handed back to her, and she was asked to make sure LPN N had the information in case of an emergency. She agreed. The Regional Nurse Consultant (RNC) then took the paper and made several copies. She began to provide an in-service for the staff present, and she gave a copy to the UM. The DON stated she would post the information on the wall in the resident's room, then took the paper to LPN N. During an interview with LPN Q on 01/05/2023 at 9:18 AM, he confirmed that he was assigned to Resident #41 and had already passed her medications to her. He was familiar with some of the residents because they came to this unit from the long-term care unit on the other side of the building. He had only worked on this newly established COVID-19 unit today. He knew of the translation service phone number and pointed to it on the wall. He stated he had never used it. He was Spanish-speaking himself. He did not know how to speak French Creole, but he did not think he would need to use the translation line to speak with Resident #41. He stated that Spanish and French are similar and, for example, the word for pain was very similar. He did not have the translation telephone line on the medication cart. He stated he had administered the resident's medications already this morning with no problem. He confirmed that there were no communication devices in her room. He then moved the cart down the hallway away from the nurses' station. The RNC walked down the hall, handed LPN Q the phone number for the translation line, and told him to keep it on the cart and use it when he needed to obtain information from the resident. On 01/05/2023 at 11:23AM, an interview was attempted with Resident #41. She was lying in her bed on her right side. Her eyes were closed, and she appeared to be asleep. She did not wake up or respond when her name was called. An attempt was made to reach the translation service provider via telephone using the number posted in the resident's room. The automated system asked for a location number that was not on the signage posted in the resident's room. An identification number was on the form along with a Branch number. A representative came on the line after several attempts to input the information on the form. The representative requested the location number. After giving the information on the form to the representative, the line was disconnected by the service provider. During an interview with the Assistant Director of Nursing (ADON) on 01/05/23 at 11:40 AM, she was asked for the location number for the translation services. The sign with the telephone number was no longer posted at the nurses' station. She went to her office and stated she had taken the sign down from the nurses' station to make copies. She did not know that the location number was not on the form, only the Branch number. She went to find the DON. The DON arrived on the unit, and when asked for the location number, she went to Social Services Director's (SSD's) office and asked the SSD if she knew the location number for the translation service. The SSD pointed to the sign for the contracted translation service posted on her bulletin board. The Branch number was crossed off and a different number had been handwritten on it. She stated that number was the correct number. The DON took the information and stated she would verify whether the information was correct, then make a new sign for the staff. During an interview with the RNC and Registered Nurse (RN) S on 01/05/23 at 12:00 PM, the RNC stated she did not know why the translation line was not working, but they were working on it. She had placed communication forms in the resident's room this morning. During an interview with the Administrator on 01/05/23 at 12:28 PM, she stated the facility had contracted with the translation services provider in September 2022 when the facility was purchased. She had called the new translation services provider number today and could not get through. She was not sure why, and stated the company was located in another country and may not be available right now. She stated, They may be asleep. She stated she did not know how long it had been that the translation services provider number did not work. She stated she was going to conduct an in-service for the staff to use an internet application in the meantime until they could get the service provider to fix the problem. She produced emails to show her attempts. (Copies obtained) At 12:51 PM, the Administrator produced copies of all correspondence with the translation service provider, and stated she set up a temporary work around with the other service provider available on the internet. She had tried it, knew it worked, and they would have the staff use it, if necessary, until they could get the contracted provider to fix the problem. She confirmed that there were no other residents in the building that spoke French Creole, and she was not sure, but thought there might be a couple who spoke Spanish. She stated they would post the temporary provider information for the staff at the nurses' station and in Resident #41's room. During an interview with the RNC on 01/05/2023 at 4:39 PM, she produced documentation to indicate the telephone number for the translation service was now operational. She stated the problem had been fixed. A new sign with the correct information was posted on the wall of the nurses' station. During an interview with LPN T on 01/06/2023 at 12:43 PM, he stated he was assigned to Resident #41, and that today was his first day working the COVID-19 hallway. He had just started working at this facility and was unfamiliar with Resident #41. He did not know she only spoke French Creole. He administered her medications today. He stated he did not think he would need to have a translator, and if he needed information, he would call the family. Resident #41 was observed on 01/06/2023 at 2:10 PM. She was lying in bed looking at her television. An attempt was made to interview the resident using the new translation telephone line obtained from the sign at the nurses' station. Resident #41 made good eye contact but would not respond to the interpreter or this surveyor. The telephone number for the translation line was not posted in the resident's room. (Photographic evidence obtained) During an interview with the DON on 01/06/2023 at 2:20 PM, she was informed that the new telephone number for the translation/interpreter line was not posted in the resident's room. She appeared surprised and said Oh no, I'll fix that. It probably didn't get replaced because it has changed so much recently. A review of the clinical record for Resident #41 revealed that on the Minimum Data Set (MDS) assessment, dated 12/16/2022, the resident was initially admitted to the facility on [DATE]. Her diagnoses included cerebral infarction due to thrombosis of the right, middle cerebral artery, pain, and hemiparesis following cerebral infarction affecting left non-dominant side. Her hearing was documented as adequate, and her vision was moderately impaired. She was sometimes understood, and sometimes understood others. She did not exhibit inattention, disorganized thinking, or an altered level of consciousness. A Brief Interview for Mental Status (BIMS) score could not be determined. She was rarely/never understood. She required extensive assistance of one to two persons for her Activities of Daily Living (ADLs), and she was totally dependent for transfers and bathing. She did not walk during the assessment period. The section for preferred language was left blank. She was assessed as not needing or wanting an interpreter to communicate with a doctor or health care staff. The assessment was documented as having been completed with the assistance of the resident's family. (Copy obtained) A review of the January 2023 Physician's Order Sheets for Resident #41 revealed no orders for the use of a communication device or translation service. (Copy obtained). A review of the current, electronic Care Plan on 01/04/2023, revealed no care plan for the use of a communication device. The phone numbers for the translation service were not the same as the numbers posted at the nurses' station during this survey. The Focus read: [Resident #41] has difficulty communicating related to a decline in cognitive status, language barrier, as patient only speaks Creole. Patient can sometimes understand others and can sometimes make self-understood with Creole-speaking translator. Initiated on 06/03/2021. Last update on 01/07/2022. The Goals read: Will have needs met through normal daily routine without having to express them. Needs will be met with comfort and dignity. Speak in a manner that can be understood. The interventions included: Gain individual's attention before beginning to converse. Initiated 06/14/2018. Speaks only Creole. Initiated 06/23/2021. Utilize French/Creole interpreter hotline as needed [Telephone number]. Initiated 11/03/2021. (This telephone number was for the previous, contracted provider service used prior to this facility being purchased in September 2022.) Utilize French/Creole interpreter hotline as needed [Telephone number] [Branch number]. Initiated 05/25/2021. Revised 08/05/2021. (This telephone number was for the previous, contracted provider service.) Utilize interpreter/Creole-speaking staff to translate as needed. Initiated on 06/14/2018. Last revised 05/25/2021. When talking to patient, use gestures and simple sentences while maintaining eye contact. Initiated 06/06/2018. Revised 05/25/2021. (Photographic evidence obtained) A review of the facility's policy and procedure entitled Translation and/or Interpretation of Facility Services (Version 1.2 (H5MAPL0897, revised March 2012) revealed: This facility's language access program will ensure that individuals with limited English proficiency (LEP) shall have meaningful access to information and services provided by the facility. 11. Competent oral translation of vital information that is not available in written translation, and non-vital information shall be provided in a timely manner and at no cost to the resident through the following means (as available to the facility): a. A staff member who is trained and competent in the skill of interpreting, b. A staff interpreter who is trained and competent in the skill of interpreting, c. Contracted interpreter service, d. Voluntary community interpreters who are trained and competent in the skill of interpreting, and e. Telephone interpretation service. (Copy obtained) .

Based on observations, staff interviews, record review, and facility policy and procedure review, the facility failed to provide necessary care and services to ensure a resident's ability to communicate, by failing to provide assistive devices for communication and correct contact information for the contracted translator services for one (Resident #41) of three residents whose primary language was not English, from a total sample of 33 residents. The staff did not have a way to communicate with Resident #41 except to have her point at things. They relied on her family and staff who spoke her language if they were available or on duty. The staff was unable to consistently communicate effectively with Resident #41 in a language she understood. Inability to make her needs known due to a language barrier may result in isolation, depression and unmet needs. The findings include: On 01/03/2023 at 11:10 AM, Resident #41 was observed lying in bed watching television. When she was greeted, she began to speak in French Creole. She did not speak English. There were no communication devices in her room. There was no information posted regarding a translation line for staff to call to have an interpreter assist with obtaining vital information from the resident. During an interview with Certified Nursing Assistant (CNA) M on 01/03/2023 at 11:18 AM, she confirmed that there were no communication devices in Resident #41's room. She stated the staff told Resident #41 to point to what she wanted. She stated she did not speak French Creole and was unaware of whether there was a staff member who did. She did not work with Resident #41 often, but she knew she did have family and they visited on New Year's day. During an interview with Occupational Therapist (OT) O on 01/04/23 at 4:26 PM, she stated she did not work with Resident #41, however, she was familiar with her. She stated Resident #41 spoke French Creole. She confirmed that she herself did not speak French Creole, but there were several staff members who did. She named a night shift nurse that spoke French Creole and worked with the resident. She stated there were several CNAs who spoke French Creole. She was not sure about the translator service phone line. She had never used it and did not know where the information could be located. During an interview with Licensed Practical Nurse (LPN) N on 01/04/2023 at 5:20 PM, she stated this was the third time she had worked this hallway since it became the COVID-19 unit. She had only worked with Resident #41 during those three shifts. She was asked how she communicated with the resident. She stated she did not speak French Creole. There was a telephone number they could call for translator services. She was not sure where the number was located, but she thought it was at the nurses' station. She did not have the number on the medication cart. She confirmed that there was no communication board/device for the resident in her room, and that the resident pointed to the things she wanted. She used the example that if the resident had pain, she would point to where she had the pain. She did not know the word for pain in the language of French Creole. She confirmed that she did not know the resident well enough to determine whether she understood English. During an interview with Employee LPN/Unit Manager (UM) P of the COVID-19 unit on 01/04/2023 at 5:25 PM, she stated she did not know the translator service telephone number, but she would get it. She walked down the hall to the Director of Nursing's (DON's) office and returned a few minutes later with the DON, who provided a piece of 8 x 11.5 inch paper with the contracted translator services name and telephone number printed on it. It was handed back to her, and she was asked to make sure LPN N had the information in case of an emergency. She agreed. The Regional Nurse Consultant (RNC) then took the paper and made several copies. She began to provide an in-service for the staff present and gave a copy to the UM. The DON stated she would post the information on the wall in the resident's room and then took the paper to LPN N. During an interview with Employee LPN Q on 01/05/2023 at 9:18 AM, he confirmed that he was assigned to Resident #41 and had already administered her medications. He was familiar with some of the residents, because they came to this unit from the long-term care unit on the other side of the building. He had only worked on this newly established COVID-19 unit today. He knew of the translation service phone number and pointed to it on the wall. He stated he had never used it. He was Spanish-speaking, himself, but did not know how to speak French Creole. He did not think he would need to use the translation line to speak with Resident #41. He stated that Spanish and French were similar and, for example, the word for pain was very similar. He did not have the translation telephone line on the medication cart. He stated he had administered the resident's medications already this morning with no problem. He confirmed that there were no communication devices in her room. He then moved the cart down the hallway away from the nurses' station. The RNC walked down the hall and handed LPN Q the phone number for the translation line, and told him to keep it on the cart and use it when he needed to obtain information from the resident. Resident #41 was observed on 01/05/2023 at 11:23AM, and an interview was attempted. She was lying in her bed on her right side. Her eyes were closed, and she appeared to be asleep. She did not wake up or respond when her name was called. An attempt was made to reach the translation service provider via telephone at the number posted in the resident's room. The automated system asked for a location number that was not on the signage posted in the resident's room. An identification number was on the form along with a Branch number. A representative came on the line after several attempts to input the information on the form. The representative requested the location number. After giving the information on the form to the representative, the line was disconnected by the service provider. During an interview with the Assistant Director of Nursing (ADON) on 01/05/23 at 11:40 AM, she was asked for the location number for the translation services. The sign with the telephone number was no longer posted at the nurses' station. She went to her office and stated that she had taken the sign down from the nurses' station to make copies. She did not know that the location number was not on the form, only the Branch number. She went to find the DON. The DON arrived on the unit, and when asked for the location number, she went to Social Services Director's (SSD's) office and asked the SSD if she knew the location number for the translation service. The SSD pointed to the sign for the contracted translation service posted on her bulletin board. The Branch number was crossed off and a different number had been handwritten on it. She stated that number was the correct number. The DON took the information and stated she would verify whether the information was correct and make a new sign for the staff. During an interview with the RNC and Registered Nurse (RN) S on 01/05/23 at 12:00 PM, the RNC stated she did not know why the translation line was not working, but they were working on it. She had placed communication forms in the resident's room this morning. During an interview with the Administrator on 01/05/23 at 12:28 PM, she stated the facility had contracted with the translation services provider in September 2022 when the facility was purchased, but when she called the new translation services provider number today, she could not get through. She was not sure why and stated that the company was located in another country and may not be available right now. She stated, They may be asleep. She stated she did not know how long it had been that the translation services provider number did not work. She stated she was going to conduct an in-service for the staff to use an internet application in the meantime until they could get the service provider to fix the problem. She produced emails to show her attempts. (Copies obtained) At 12:51 PM, the Administrator produced copies of all correspondence with the translation service provider, and stated she set up a temporary work around with the other service provider available on the internet. She had tried it, knew it worked, and they would have the staff use it, if necessary, until they could get the contracted provider to fix the problem. She confirmed that there were no other residents in the building that spoke French Creole, and she was not sure, but thought there might be a couple who spoke Spanish. She stated they would post the temporary provider information for the staff at the nurses' station and in Resident #41's room. During an interview with the RNC on 01/05/2023 at 4:39 PM, she produced documentation to indicate the telephone number for the translation service was now operational. She stated the problem had been fixed. A new sign with the correct information was posted on the wall of the nurses' station. During an interview with LPN T on 01/06/2023 at 12:43 PM, he stated he was assigned to Resident #41, and today was his first day working the COVID-19 hallway. He had just started working at this facility and was unfamiliar with Resident #41. He did not know she only spoke French Creole. He administered her medications today and stated he did not think he would need to have a translator. If he needed information, he would call the family. Resident #41 was observed on 01/06/2023 at 2:10 PM. She was lying in bed looking at her television. An interview was attempted using the new translation telephone line obtained from the sign at the nurses' station. Resident #41 made good eye contact, but would not respond to the interpreter or this surveyor. The telephone number for the translation line was not posted in the resident's room. (Photographic evidence obtained) During an interview with the DON on 01/06/2023 at 2:20 PM, she was informed that the new telephone number for the translation/interpreter line was not posted in the resident's room. She appeared surprised and said Oh no, I'll fix that. It probably didn't get replaced because it has changed so much recently. A review of the clinical record for Resident #41 revealed that on the Minimum Data Set (MDS) assessment, dated 12/16/2022, the resident was initially admitted to the facility on [DATE]. Her diagnoses included cerebral infarction due to thrombosis of the right, middle cerebral artery, pain, and hemiparesis following cerebral infarction affecting left non-dominant side. Her hearing was documented as adequate, and her vision was moderately impaired. She was sometimes understood, and sometimes understood others. She did not exhibit inattention, disorganized thinking or an altered level of consciousness. A Brief Interview for Mental Status (BIMS) score could not be determined. She was rarely/never understood. The section for preferred language was left blank. She was assessed as not needing or wanting an interpreter to communicate with a doctor or health care staff. The assessment was documented as having been completed with the assistance of the resident's family. (Copy obtained) A review of the January 2023 Physician's Order Sheets for Resident #41 revealed no orders for the use of a communication device or translation service. (Copy obtained). A review of the current, electronic Care Plan on 01/04/2023, revealed no care plan for the use of a communication device. The phone numbers for the translation service were not the same as the numbers posted at the nurses' station during this survey. The Focus read: [Resident #41] has difficulty communicating related to a decline in cognitive status, language barrier, as patient only speaks Creole. Patient can sometimes understand others and can sometimes make self understood with Creole-speaking translator. Initiated on 06/03/2021. Last update on 01/07/2022. The Goals read: Will have needs met through normal daily routine without having to express them. Needs will be met with comfort and dignity. Speak in a manner that can be understood. The interventions included: Gain individual's attention before beginning to converse. Initiated 06/14/2018. Speaks only Creole. Initiated 06/23/2021. Utilize French/Creole interpreter hotline as needed [Telephone number]. Initiated 11/03/2021. (This telephone number was for the previous, contracted provider service used prior to this facility being purchased in September 2022.) Utilize French/Creole interpreter hotline as needed [Telephone number] [Branch number]. Initiated 05/25/2021. Revised 08/05/2021. (This telephone number was for the previous, contracted provider service.) Utilize interpreter/Creole-speaking staff to translate as needed. Initiated on 06/14/2018. Last revised 05/25/2021 When talking to patient, use gestures and simple sentences while maintaining eye contact. Initiated 06/06/2018. Revised 05/25/2021. (Photographic evidence obtained) A review of the facility's policy and procedure entitled Translation and/or Interpretation of Facility Services (Version 1.2 (H5MAPL0897, revised March 2012) revealed: This facility's language access program will ensure that individuals with limited English proficiency (LEP) shall have meaningful access to information and services provided by the facility. 11. Competent oral translation of vital information that is not available in written translation, and non-vital information shall be provided in a timely manner and at no cost to the resident through the following means (as available to the facility): a. A staff member who is trained and competent in the skill of interpreting, b. A staff interpreter who is trained and competent in the skill of interpreting, c. Contracted interpreter service, d. Voluntary community interpreters who are trained and competent in the skill of interpreting, and e. Telephone interpretation service. (Copy obtained)

Based on observations, staff and resident interviews, medical record review, and facility policy review, the facility failed to ensure that two (Residents #85 and #69) of a sample of 33 residents who were unable to carry out Activities of Daily Living (ADLs), received the necessary services to maintain grooming and personal hygiene for fingernail care and trimming. The findings include: On 01/03/23 at 4:00 pm, Resident #85 was observed sitting up in bed, awake, with the company of two visitors. The visitors identified themselves as the resident's son and daughter-in-law. The family members verbally encouraged the resident to speak up if she had anything to say. Resident #85 presented extremely elongated fingernails on both hands. She stated she had asked staff to trim them several times, but no one had trimmed them. (Photographic evidence obtained) The resident's daughter-in-law proceeded to trim the resident's nails during visit, stating, If no one else is going to do it, then I will. On 01/03/23 at 4:05 pm, Resident #69 was observed lying in bed, awake. The resident showed her fingernails which were unusually elongated (right hand was observed to have thumb and index finger at normal length. The resident stated, Those two have just broke on their own. The middle, ring, and pinky fingernails were observed to be elongated and curled under. The left hand was observed to have all five fingers elongated and curled under. (Photographic evidence obtained) The resident was asked if she preferred her nails at that length. She replied, No, they hurt and dig into my hand. Both hands were observed to be contracted, with nails pressing against the palms. The resident was asked if she had asked staff to trim her nails. She stated, Yes, I've asked and asked, and they just ignore it. My mom and my daughter are both scared to cut them because they are so long. On 01/05/23 at 1:45 pm, Resident #69 was observed lying bed; her mother was visiting. Her mother voiced concerns regarding the resident's elongated fingernails. Resident #69's fingernails were observed to be as long as they were during the 1/3/23 observation. Her mother stated, I'm afraid to cut them, I don't want to hurt her. She's asked the staff many times to just cut them, but no one ever comes back to cut them. A medical record review for Resident #85 revealed diagnoses including cerebral arteritis, cerebral infarction, type two diabetes, muscle weakness, and the need for assistance with personal care. A review of the Minimum Data Set (MDS) assessment, Section G, conducted on 11/14/22, revealed that Resident #85 required extensive assistance and the assist of one person for personal hygiene. A review of the same MDS, Section E, revealed the resident had not had any instances of refusal of care. A review of the person-centered care plan for Resident #85, dated 5/23/22 and revised on 6/13/22, revealed a focus area which read: The resident has an ADL self care performance deficit. The related goal (revised 11/15/22) read: The resident will improve current level of function in at least one ADL by next review date. The interventionsincluded: Bathing: check nail length and trim on bath day and as needed. Report any changes to the nurse. Bathing: the resident requires staff participation with bathing. Assist with personal hygiene. A medical record review for Resident #69 revealed diagnoses including spina bifida and functional quadriplegia. A review of the MDS assessment, Section G, conducted on 10/25/22, revealed that Resident #69 was totally dependent and required the assistance of two people for personal hygiene. A review of the same MDS, Section E, revealed that the resident had not had any instances of refusal of care. A review of the person-centered care plan for Resident #69, dated 4/28/21 and revised on 6/18/21, revealed a focus area which read: ADL self care deficit as evidenced by requiring assistance related to physical limitations, spina bifida, weakness, and other medical comorbidities. The related goal (revised 10/27/22) read: Will receive assistance necessary to meet ADL needs (last revision 10/27/22) The interventions included: Assist with daily hygiene, grooming, dressing, oral care, and eating as needed. On 01/05/23 at 4:33 pm, in an interview with Certified Nursing Assistant (CNA) A, he was asked if he was caring for Residents #85 and #69 today. He said yes. He was asked who trimmed and cleaned the residents' fingernails. He replied, That is not my job. I let the nurse know on shower day if a resident needs their nails trimmed. On 01/05/23 at 4:40 pm, in an interview with Licensed Practical Nurse (LPN) B, she was asked who cleaned and trimmed the residents' fingernails. She stated, The podiatrist will trim the toenails, and the CNAs will clean and trim the fingernails. She was asked if she ever checked residents' fingernails. She stated no. She was asked if she had seen Resident #69's fingernails. She stated, No, I haven't. She was asked if the assigned nurses looked at residents' fingernails. She stated, Yes, they would during the weekly skin assessment completed by nursing. On 01/06/23 at 10:02 am, in an interview with CNA C, she was asked who cleaned and trimmed the residents' fingernails. She stated, I don't cut them. I'll let the unit manager know if they need to be trimmed. I know the CNAs can't cut the diabetic fingernails, but I don't know if we can cut any fingernails, so I just let the unit manager know if anyone's fingernails need to be trimmed. On 01/06/23 at 10:10 am, in an interview with LPN D, she was asked who cleaned and trimmed the residents' fingernails. She stated, I'm not sure. I think the podiatrist does that. She was asked who cleaned and trimmed the diabetic residents' fingernails. She replied, I don't think we're allowed to. I think the podiatrist does that too. On 01/06/23 at 10:20 am, in an interview with the Director of Nursing (DON), she was asked who cleaned and trimmed the residents' fingernails. She stated, Generally, the CNAs will do that as part of the ADLs. If a resident is very contracted and they are uncomfortable with the task, they would let the nurse know so the nurse can clean and trim the fingernails. If it's a diabetic resident, then the nurse will trim the nails, not the CNA. She was asked how the nurse was made aware of whether a resident needed their nails trimmed by the nurse. She stated, The CNA would be observing the fingernails on their shower day and reporting to the nurse if they need to be trimmed, if they are diabetic or uncomfortable with contractures of the hands. A review of the facility's policy titled: Care of Fingernails/Toenails (revised 10/2010) revealed: Purpose: The purposes of this procedure are to clean the nail bed, to keep the nails trimmed, and to prevent infections. General Guidelines: 1. Nail care includes daily cleaning and regular trimming. 2. Proper nail care can aid in the prevention of skin problems around the nail bed. Reporting: 1. Notify the supervisor if the resident refuses the care.

Based on resident, family, and staff interviews, and medical record review, the facility failed to ensure that one (Resident #85) of a sample of 33 residents, received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. The findings include: On 1/3/23 at 4:00 pm, Resident #85 was observed sitting up in her bed, awake. She stated she had asked to have appointments for a rheumatologist. She stated there had been no follow up and no appointments made that she was aware of. A medical record review revealed an order written on 8/24/22 which read: Schedule an appointment with rheumatology for consult. No evidence of this appointment being made or having taken place was found in the medical record. On 01/05/23 at 2:24 pm, Resident #85 was observed sitting up in her wheelchair with her son and daughter-in-law visiting. The resident was asked if she had a rheumatology consult since she was admitted to the facility in May 2022. She stated, No, no one has ever gotten back to me about that. I know I need the consult because of the Prednisone I take. I'm taking that for the vasculitis that caused my stroke. Further review of the resident's medical record revealed an admitted [DATE] with diagnoses including cerebral arteritis and cerebral infarction. Further review of the physician's orders revealed: 5/22/22: Prednisone 20 mg (milligrams): three tablets by mouth daily for inflammation (d/c 9/26/22) (discontinued 9/26/22) 8/24/22: Schedule an appointment with rheumatology for consult 9/27/22: Prednisone 20 mg: two tablets by mouth daily for inflammation A review of Pharmacy Medication Review/Recommendations for Resident #85 and dated 8/15/22, revealed: Resident has an order for Prednisone 60 mg daily for inflammation with no stop date. Recommendation: Please provide a stop date for high-dose steroid treatment or describe why continued use is clinically indicated. Physician response: Other: Pt (patient) needs rheumatology consult (signed 8/24/22 by the physician). A review of the neurology consult visit, dated 9/20/22, revealed: Plan: Continue with current medication regimen, in particular continue Prednisone as stated in previous [hospital name] discharge, 60 mg daily, until rheum appt. established. Rheum appointment pending. On 01/05/23 at 4:20 pm, in an interview with LPN B, she was asked whether Resident #85 had any outside physicians appointments scheduled. She stated, I'm not sure. [Receptionist E] schedules those and then we get the appointment 1-2 days prior, so we know who is going out and when, so they can be gotten up and ready on time for transportation. [Receptionist E] also schedules the transportation. On 01/06/23 at 8:16 am, in an interview with Receptionist E, she was asked how appointments for outside physicians referrals she made. She stated, They come to me from the nurses and/or the social worker. Sometimes the appointments are already made by the family, or they are admitted with follow-up appointments, so I'll just schedule transportation for the appointments that are already made. She was asked if she had a doctor's appointment referral made/pending for a rheumatologist for Resident #85. She stated, No requests have been made for that. Let me double check that. No, I haven't received any requests for a rheumatology appointment to be made for her. On 01/06/23 at 9:05 am, in an interview with Social Services Worker G, she was asked how outside doctors' consults were arranged for residents. She stated, If they need to go out, they have appointments from the house doctor request, so we'll make the appointments after the nurse gives us the order, and we'll arrange transportation. Sometimes the new patients will come in with appointments. Sometimes when we check their insurance, we have to make new appointments with doctors who accept their insurance. She was asked if she could provide information about a rheumatology consult for Resident #85. She stated, I'll be scheduling that. I've called two doctors who were recommended by her neurologist. One doesn't take her insurance. I'm waiting to hear back from the second one; they are waiting for the referral from her neurologist. She needs the rheumatology appointment before she sees neurology again in March. I didn't know about that appointment until the son let me know yesterday, and that's when I started working on it. She was asked if she was aware of an order for a rheumatology consult which was ordered on 8/24/22. She replied, No, I wasn't aware of that consult request. I just heard about it yesterday from her son. On 01/06/23 at 9:31am, in an interview with Registered Nurse (RN) F, she was asked if she could confirm through medical record review, that Resident #85 had not had a rheumatology appointment scheduled since her admission to the facility. She stated, Yes, as far as I know, there has not been a rheumatology appointment scheduled.

Based on observation, interview, and record review, the facility failed to ensure that one (Resident #50) of 16 residents receiving respiratory treatments, from a total sample of 33 residents, received the correct number of liters of oxygen as ordered by the physician. The findings include: On 01/04/2023 at 10:53 am, Resident #50 was observed lying in bed with her eyes closed wearing a nasal cannula. Resident #50's oxygen concentrator, located at bedside, was set at 3.0 Liters per minute (L/min) with no date to identify a change of tubing. (Photographic evidence obtained) A review of Resident #50's physician's order, dated 01/03/2023, revealed she was to receive oxygen at 2 L/min via nasal cannula every shift for oxygen management to keep her oxygen level >93%. On 01/05/2023 at 10:46 am, a second observation of Resident #50's oxygen concentrator, revealed it was set at 3.0 L/min with no date to identify a change of tubing. (Photographic evidence obtained) A medical record review revealed the resident was admitted on [DATE]. Her diagnoses included acute respiratory failure, unspecified whether with hypoxia or hypercapnia; morbid (severe) obesity due to excess calories; cognitive/communication deficit; dementia in other diseases classified elsewhere, psychotic disturbance, mood disturbance, and anxiety. A review of the resident's January 2022 Medication Administration Record (MAR), revealed: Oxygen at 2 L/min via nasal cannula every shift for oxygen management to keep oxygen level >93% with nursing initials indicating the oxygen was provided per the order and oxygen saturation ranging 95-96%. A review of the quarterly minimum data set (MDS) assessment, dated 12/5/2022, revealed that Resident #50 had a Brief Interview for Mental Status (BIMS) score of 6 out of a possible 15 points, indicating severe cognitive impairment. The assessment also documented that she was receiving oxygen therapy. A review of Resident #50's care plan, dated 12/16/2022, revealed she had altered respiratory status/difficulty breathing relating to oxygen utilization usage of a continuous positive airway pressure (CPAP) and recent history of shortness of breath. Interventions included: Administer medications/puffers as ordered. Monitor for effectiveness and side effects, change tubing weekly. On 01/05/23 at 2:41pm, and in the presence of Licensed Practical Nurse (LPN) H, Resident #50's oxygen concentrator was set to administer oxygen at 3.0 L/min. (Photographic evidence obtained) LPN H confirmed that Resident #50's physician's order was for a flow rate of 2 L/min, and due to the undated oxygen tubing, the nurse could not verify that it had been changed weekly as ordered. The resident's oxygen saturation ranges between 95 and 96 percent and she has no distress. LPN H reported that nursing was responsible for on-going monitoring of oxygen therapy, ensuring the resident was provided the correct oxygen flow rate per physician's order, as well as weekly oxygen tube changes. The correct oxygen settings were communicated from one nurse to another during change of shift report. On 01/06/22 at 9:15am, the DON confirmed that the correct oxygen settings were identified in the MAR, nursing was responsible for providing on-going monitoring of oxygen therapy and tube changes. A CNA cannot change settings. It is the nurses' responsibility to ensure that oxygen therapy is provided as ordered. A review of the facility's policy and procedure entitled Oxygen Administration (dated October 2010), revealed that preparation included: Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration.

Based on observation and interview, the facility failed to perform hand hygiene during medication administration for one (Resident #37) of three residents observed during medication administration. This practice has the potential to affect more than a limited number of residents. Facility census: 93 The findings include: During an observation of medication administration on 01/05/23 at 9:30 AM, Licensed Practical Nurse (LPN) H was observed preparing and administering medication for Resident #37. LPN H failed to perform hand hygiene prior to preparing the medication, and failed to perform hand hygiene after administering the medications to the resident. On 01/05/23 at 9:45 AM, an interview was conducted with LPN H. He confirmed that hand hygiene was required prior to and after each resident medication administration. He confirmed that he failed to perform hand hygiene during medication administration. He stated he forgot. A review of the facility's policy titled, Handwashing/Hand Hygiene, with a revised date of 12/2009, revealed on page one, number two, All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. A review of the facility's policy titled, Administering Medications, with a revised date of 12/2012, revealed on page two, number 22, Staff shall follow established facility infection control procedures (e.g., handwashing, antiseptic technique, gloves, isolation precautions, etc.) for the administration of medications.

Based on record review, interviews and facility policy and procedure review, the facility failed to ensure the physician reviewed the resident's total program of care, including medications and treatments, by failing to ensure proper administration and laboratory monitoring of [MEDICATION(S)] (antibiotic) for one (Resident #1) of two sampled residents reviewed for [MEDICATION(S)] administration. The findings include: A review of Resident #1's hospital medication list (at discharge) dated 1/18/22 indicated she was to continue [MEDICATION(S)] inject 1250 milligrams (mg) into the vein every 24 hours for 30 days. The discharge instructions read, You will be scheduled for a follow up appointment in the infectious disease office prior to stopping your IV antibiotics. If you have any questions regarding your appointment or your antibiotic medications, please call the Infectious Disease Clinical-number provided. (Copy obtained) A review of Resident #1's clinical record revealed she was admitted from the hospital to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . She was readmitted from the hospital on 2/21/22, with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . (Copy obtained) Further review of Resident #1's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The end date was listed as 1/21/22. (Copy obtained) A review of the progress note dated 1/19/22 at 8:10 AM by Medical Staff 1, ARNP for Resident #1, indicated the following: Resident was admitted with [CONDITION(S)], with plan to continue [MEDICATION(S)] and [MEDICATION(S)] until 2/17/2022. Consultation for infectious disease and pharmacy to dose [MEDICATION(S)]. A review of the progress note dated 1/23/22 at 9:13 PM by Medical Staff 2, MD for Resident #1, indicated the following: Resident admitted with [CONDITION(S)] L4-L5. Continue [MEDICATION(S)] and [MEDICATION(S)] until 2/17/22. Consult Infectious Disease (ID). Pharmacy to dose [MEDICATION(S)]. Labs reviewed by Medical Staff 2, MD. A review of the progress note dated 1/24/22 by Medical Staff 1, ARNP indicated an assessment and plan as 1. Acute embolism and [CONDITION(S)] of deep veins of right upper extremity. 2 [CONDITION(S)] L4-L5 continued [MEDICATION(S)] and [MEDICATION(S)] until 2/17/22. Consult infectious disease. Pharmacy to dose [MEDICATION(S)]. A review of the January 2022 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Start date documented as 1/19/2022. The medication was documented as administered on 1/20, 1/21, 1/22, 1/23, 1/24, 1/25, 1/26 and 1/27/22. A review of the laboratory reports related to Resident #1's [MEDICATION(S)] dosing revealed the following: Report was collected on 1/20/2022 at 5:00 AM, received on 1/20/2022 at 3:19 PM and reported on 1/20/2022 at 5:15 PM. Ordered by Medical Staff 2, MD. The regional consultant nurse provided that on 2/24/2022 at 2:37 PM and signed the lab report for Resident #1 indicated no other labs were available for Resident #1 while on [MEDICATION(S)]. The copy of labs data collected on 1/20/2022 at 5:00 AM provided a Magnesium/CBC with differential, CMP comp metabolic. The lab was electronically signed reviewed by Medical Staff 1, ARNP on 01/21/2022 at 5:21 PM. The BUN was elevated at 30 (H) milligrams/deciliter (mg/dl)-reference range was 7-25 mg/dl. Resident #1's Creatinine was elevated at 1.31 (mg/dl) (H)-reference range was 0.60-1.30 mg/dl. No Trough ordered and no order identified to hold [MEDICATION(S)] or get more labs identified. A review of documentation provided dated 2/16/2022 at 11:22 AM by the Regional Nurse Consultant documented, Resident #1 received [MEDICATION(S)] for X 7 days from 1/20 to 1/27/2022 without any [MEDICATION(S)] levels drawn. Resident went to the emergency room for a Deep Vein [CONDITION(S)] (DVT). The emergency room doctor called and wanted to know levels for Resident #1. During the review, Physician did not order levels and nursing did not ask for levels. Pharmacy sent [MEDICATION(S)] without any levels drawn. Further record review revealed Resident #1 was transferred to the hospital as ordered on 1/27/22 for bilateral upper extremity [CONDITION(S)], weakness, jerking movement, positive left foot DVT and MRI of lumbar region. A review of the acute care hospital progress notes documented an admission to the acute care hospital on 1/27/2022. History of present illness indicated due to patient's mentation; a majority of history was gathered from her son. Family visits noted increased confusion for the last two days when they visited. Initial laboratory results indicated a BUN 33 mg/dl (reference range 9-23 mg/dl), Creatinine of 2.87 mg/dl (reference range of 0.55 - 1.02 mg/dl). The documented assessment and plan indicated acute toxic metabolic [CONDITION(S)], complicated urinary tract infection, and acute kidney injury among 6 diagnoses. An interview was conducted with Employee B, Licensed Practical Nurse (LPN) on 2/24/22 at 1:12 PM. She acknowledged her understanding of [MEDICATION(S)] trough levels. She was asked if she had looked for a [MEDICATION(S)] level when she administered [MEDICATION(S)] to Resident #1. She replied, Not that I can recall. On 2/24/22 at 1:27 PM, an interview was conducted with Employee A, LPN who was familiar with Resident #1. She was asked if there were any requirement to check the trough blood level for Resident #1. She stated there was no requirement to check trough from her understanding at that time. She said that Pharmacy doses [MEDICATION(S)] and based on the pharmacy report, they would either give or hold the [MEDICATION(S)]. Since she received the [MEDICATION(S)], she thought the pharmacy had the lab and it was okay to give. Employee A, LPN confirmed that she never looked at any labs for Resident #1 prior to giving her the [MEDICATION(S)]. An interview was conducted with Pharmacy 2, Pharmacist on 2/24/2022 at 2:23 PM. She confirmed that on 1/22/22 the pharmacist (Pharmacy 3, Pharmacist) sent the [MEDICATION(S)] but was supposed to request lab reports but never did. The Pharmacy 2, Pharmacist stated she was out at the time so did not know why the protocol was not followed. An interview was conducted with the Pharmacy 1, Pharmacist on 2/24/22 at 3:03 PM. She indicated that the pharmacy was going to have to do a Root Cause Analysis (RCA) and look into the situation with Resident #1. Pharmacist 1 could not say where the process was at the time of the interview. A telephone interview was conducted with the Medical Director (MD) on 2/24/2022 at 3:38 PM. The MD confirmed that the problem with Resident #1's [MEDICATION(S)] administration was that the facility was supposed to get a baseline lab. The physician, nursing and the pharmacy are supposed to work together and are all a part of what happened to Resident #1. The MD confirmed that there was no formalized discipline at the time for the Physician or ARNP. The MD stated that he and the Regional Nurse Consultant had discussions about Resident #1 and getting the correct labs for Residents on [MEDICATION(S)]. A review of the facility's policy and procedure for Medication Monitoring and Documentation, with effective date of 7/1/15, read: The purpose of this policy is to provide guidelines for documentation and communication of resident information regarding intravenous therapy (IV). Procedure: 1. Upon receipt of a new order for IV therapy, the Technician or Pharmacist shall collect all the necessary information needed to complete an IV Medication Profile. Information to be included on an IV Medication Profile includes, but is not limited to: f. Recent pertinent laboratory results. 2. (b.) Information that may be included in a Pharmacy Care Plan includes but is not limited to: Desired outcomes or goals, clinician interventions, monitoring guidelines, dates and Pharmacist's initials. Pharmacy Care Plan for [MEDICATION(S)] included potential problem as Nephrotoxicity, desired outcome documented was avoid Nephrotoxicity and monitoring and clinical intervention included Monitor BUN (Blood Urea Nitrogen), serum Creatinine and trough concentration weekly or more frequently as necessary. (Copy obtained) A review of the facility's policy and procedure for Laboratory Monitoring of IV Medications, with effective date of 4/17, read: Laboratory tests require an order from a Physician or Pharmacist. Contact laboratory for specific criteria on how to draw sample. General Guidelines: 1. Therapeutic medication monitoring is done so that effective therapeutic levels of a medication can be determined, and to prevent toxicity. 2. The Physician or Pharmacist will determine frequency of laboratory testing. 3. (a) Trough concentration is the lowest level of a medication in plasma. This level is drawn BEFORE the next dose. Time of draw can range from 30-minutes to immediately before the next dose. PEAK concentration is the highest level of a medication in the plasma. 4. Notify Physician and/or Pharmacist of levels when results are received. 5. Obtain orders for medication dosage adjustments as necessary. 7. Indicated Laboratory tests commonly recommended for particular IV antibiotics: [MEDICATION(S)] included BUN, CBC with differential, Peak and Trough levels and serum Creatinine. (Copy obtained)

Based on record review, interviews and facility policy and procedure review, the facility failed to provide pharmaceutical services accurately in dispensing antibiotics, which included a review of blood levels to provide for the safe administration of [MEDICATION(S)] (antibiotic) for one (Resident #1) of two residents reviewed for [MEDICATION(S)] administration. The findings include: A review of Resident #1's hospital medication list (at discharge) dated 1/18/22 indicated she was to continue [MEDICATION(S)] inject 1250 milligrams (mg) into the vein every 24 hours for 30 days. The discharge instructions read, You will be scheduled for a follow up appointment in the infectious disease office prior to stopping your IV antibiotics. If you have any questions regarding your appointment or your antibiotic medications, please call the Infectious Disease Clinical-number provided. (Copy obtained) A review of Resident #1's clinical record revealed she was admitted from the hospital to the facility on [DATE] with diagnoses including discitis, [CONDITION(S)] of vertebra, and type 2 diabetes mellitus. She was readmitted from the hospital on 2/21/22, with a diagnosis of acute kidney failure. A review of her physician's order with start date of 1/19/22, revealed [MEDICATION(S)] HCI solution 1250 mg/250 mg intravenously every 24 hours for L4, L5 [CONDITION(S)] for 30 days. (Copy obtained) Further review of Resident #1's physician's order dated 1/19/22 indicated complete blood count (CBC), magnesium (Mag) level, c-reative protein test (CRP) in this AM 1/20/2022 one time only for diagnostics for two days. The end date was listed as 1/21/22. (Copy obtained) A review of the progress note dated 1/19/22 at 8:10 AM by Medical Staff 1, ARNP for Resident #1, indicated the following: Resident was admitted with [CONDITION(S)], with plan to continue [MEDICATION(S)] and [MEDICATION(S)] until 2/17/2022. Consultation for infectious disease and pharmacy to dose [MEDICATION(S)]. A review of the progress note dated 1/23/22 at 9:13 PM by Medical Staff 2, MD for Resident #1, indicated the following: Resident admitted with [CONDITION(S)] L4-L5. Continue [MEDICATION(S)] and [MEDICATION(S)] until 2/17/22. Consult Infectious Disease (ID). Pharmacy to dose [MEDICATION(S)]. Labs reviewed by Medical Staff 2, MD. A review of the progress note dated 1/24/22 by Medical Staff 1, ARNP indicated an assessment and plan as 1. Acute embolism and [CONDITION(S)] of deep veins of right upper extremity. 2 [CONDITION(S)] L4-L5 continued [MEDICATION(S)] and [MEDICATION(S)] until 2/17/22. Consult infectious disease. Pharmacy to dose [MEDICATION(S)]. A review of the January 2022 Medication Administration Record (MAR) for Resident #1 revealed the following: [MEDICATION(S)] HCL solution 1250 milligrams (mg)/250 milliliters (ml) use 1250 mg intravenously every 24 hours for L4, L5 [CONDITION(S)] for 30 days. Start date documented as 1/19/2022. The medication was documented as administered on 1/20, 1/21, 1/22, 1/23, 1/24, 1/25, 1/26 and 1/27/22. A review of the laboratory reports related to Resident #1's [MEDICATION(S)] dosing revealed the following: Report was collected on 1/20/2022 at 5:00 AM, received on 1/20/2022 at 3:19 PM and reported on 1/20/2022 at 5:15 PM. Ordered by Medical Staff 2, MD. The regional consultant nurse provided that on 2/24/2022 at 2:37 PM and signed the lab report for Resident #1 indicated no other labs were available for Resident #1 while on [MEDICATION(S)]. The copy of labs data collected on 1/20/2022 at 5:00 AM provided a Magnesium/CBC with differential, CMP comp metabolic. The lab was electronically signed reviewed by Medical Staff 1, ARNP on 01/21/2022 at 5:21 PM. The BUN was elevated at 30 (H) milligrams/deciliter (mg/dl)-reference range was 7-25 mg/dl. Resident #1's Creatinine was elevated at 1.31 (mg/dl) (H)-reference range was 0.60-1.30 mg/dl. No Trough ordered and no order identified to hold [MEDICATION(S)] or get more labs identified. A review of documentation provided dated 2/16/2022 at 11:22 AM by the Regional Nurse Consultant documented, Resident #1 received [MEDICATION(S)] for X 7 days from 1/20 to 1/27/2022 without any [MEDICATION(S)] levels drawn. Resident went to the emergency room for a Deep Vein [CONDITION(S)] (DVT). The emergency room doctor called and wanted to know levels for Resident #1. During the review, Physician did not order levels and nursing did not ask for levels. Pharmacy sent [MEDICATION(S)] without any levels drawn. Further record review revealed Resident #1 was transferred to the hospital as ordered on 1/27/22 for bilateral upper extremity [CONDITION(S)], weakness, jerking movement, positive left foot DVT and MRI of lumbar region. A review of the acute care hospital progress notes documented an admission to the acute care hospital on 1/27/2022. History of present illness indicated due to patient's mentation; a majority of history was gathered from her son. Family visits noted increased confusion for the last two days when they visited. Initial laboratory results indicated a BUN 33 mg/dl (reference range 9-23 mg/dl), Creatinine of 2.87 mg/dl (reference range of 0.55 - 1.02 mg/dl). The documented assessment and plan indicated acute toxic metabolic [CONDITION(S)], complicated urinary tract infection, and acute kidney injury among 6 diagnoses. An interview was conducted with Employee B, Licensed Practical Nurse (LPN) on 2/24/22 at 1:12 PM. She acknowledged her understanding of [MEDICATION(S)] trough levels. She was asked if she had looked for a [MEDICATION(S)] level when she administered [MEDICATION(S)] to Resident #1. She replied, Not that I can recall. On 2/24/22 at 1:27 PM, an interview was conducted with Employee A, LPN who was familiar with Resident #1. She was asked if there were any requirement to check the trough blood level for Resident #1. She stated there was no requirement to check trough from her understanding at that time. She said that Pharmacy doses [MEDICATION(S)] and based on the pharmacy report, they would either give or hold the [MEDICATION(S)]. Since she received the [MEDICATION(S)], she thought the pharmacy had the lab and it was okay to give. Employee A, LPN confirmed that she never looked at any labs for Resident #1 prior to giving her the [MEDICATION(S)]. An interview was conducted with Pharmacy 2, Pharmacist on 2/24/2022 at 2:23 PM. She confirmed that on 1/22/22 the pharmacist (Pharmacy 3, Pharmacist) sent the [MEDICATION(S)] but was supposed to request lab reports but never did. The Pharmacy 2, Pharmacist stated she was out at the time so did not know why the protocol was not followed. An interview was conducted with the Pharmacy 1, Pharmacist on 2/24/22 at 3:03 PM. She indicated that the pharmacy was going to have to do a Root Cause Analysis (RCA) and look into the situation with Resident #1. Pharmacist 1 could not say where the process was at the time of the interview. A telephone interview was conducted with the Medical Director (MD) on 2/24/2022 at 3:38 PM. The MD confirmed that the problem with Resident #1's [MEDICATION(S)] administration was that the facility was supposed to get a baseline lab. The physician, nursing and the pharmacy are supposed to work together and are all a part of what happened to Resident #1. The MD confirmed that there was no formalized discipline at the time for the Physician or ARNP. The MD stated that he and the Regional Nurse Consultant had discussions about Resident #1 and getting the correct labs for Residents on [MEDICATION(S)]. A review of the facility's policy and procedure for Medication Monitoring and Documentation, with effective date of 7/1/15, read: The purpose of this policy is to provide guidelines for documentation and communication of resident information regarding intravenous therapy (IV). Procedure: 1. Upon receipt of a new order for IV therapy, the Technician or Pharmacist shall collect all the necessary information needed to complete an IV Medication Profile. Information to be included on an IV Medication Profile includes, but is not limited to: f. Recent pertinent laboratory results. 2. (b.) Information that may be included in a Pharmacy Care Plan includes but is not limited to: Desired outcomes or goals, clinician interventions, monitoring guidelines, dates and Pharmacist's initials. Pharmacy Care Plan for [MEDICATION(S)] included potential problem as Nephrotoxicity, desired outcome documented was avoid Nephrotoxicity and monitoring and clinical intervention included Monitor BUN (Blood Urea Nitrogen), serum Creatinine and trough concentration weekly or more frequently as necessary. (Copy obtained) A review of the facility's policy and procedure for Laboratory Monitoring of IV Medications, with effective date of 4/17, read: Laboratory tests require an order from a Physician or Pharmacist. Contact laboratory for specific criteria on how to draw sample. General Guidelines: 1. Therapeutic medication monitoring is done so that effective therapeutic levels of a medication can be determined, and to prevent toxicity. 2. The Physician or Pharmacist will determine frequency of laboratory testing. 3. (a) Trough concentration is the lowest level of a medication in plasma. This level is drawn BEFORE the next dose. Time of draw can range from 30-minutes to immediately before the next dose. PEAK concentration is the highest level of a medication in the plasma. 4. Notify Physician and/or Pharmacist of levels when results are received. 5. Obtain orders for medication dosage adjustments as necessary. 7. Indicated Laboratory tests commonly recommended for particular IV antibiotics: [MEDICATION(S)] included BUN, CBC with differential, Peak and Trough levels and serum Creatinine. (Copy obtained) .

Based on observations, resident/staff interviews, clinical record review, and facility policy and procedure review, the facility failed to ensure that a resident with a pressure ulcer, received necessary care and services, consistent with professional standards of practice, to promote healing and prevent worsening of the pressure ulcer for one (Resident #75) of four residents reviewed for pressure ulcer development, from a total of 35 residents in the sample. The facility failed to reposition the resident to reduce the pressure on her coccyx/sacral area, and failed to provide the resident with a pressure-reducing mattress when the wound was discovered on 05/12/2021. This contributed to worsening of the pressure area from a Stage II to an unstageable wound. The findings include: Resident #75 was observed on 05/24/2021 at 9:30 AM, 10:22 AM, 12:40 PM, 1:45 PM and 2:50 PM. Each time she was in her room, lying in bed on her back. She was on a standard mattress. Resident #75 was observed on 05/25/2021 at 10:05 AM lying in bed on her back. She was awake and alert. She was pleasant and moderately confused when asked to put on her call light. She did not know how to use it. She did not know what a call light was. After an explanation and demonstration, she continued to say she did not know how to use it. She stated she could not turn herself in the bed; she needed staff to help her. She could not confirm that staff were repositioning her. She was not aware that she had a wound on her coccyx/sacral area. She was lying on a standard mattress. Resident #75 was observed on 05/25/2021 at 12:20 PM, lying in bed on her back. She was on a standard mattress. On 05/25/2021 at 11:20 AM, an interview was conducted with the Unit Manager (UM)/Registered Nurse (RN) for the short-term rehabilitation side of facility. She stated she was also the wound care nurse for assessments. She rounded with the Advanced Registered Nurse Practitioner (ARNP) for wounds on Wednesdays and took photographs and measurements of each wound. She produced a photograph of the wound she took two weeks ago. No slough/eschar was observed. She stated it was a Stage II. She stated she had not seen it for two weeks, and she was going to look at it today. She had been informed by the floor nurses that it was healing. Resident #75 was observed on 05/25/2021 at 12:20 PM, lying in bed on her back. She was on a standard mattress. Resident #75 was observed on 05/26/2021 at 8:50 AM, seated in her wheelchair in the common area of the 200 hall. At 11:50 AM, she was observed sitting in her wheelchair in the same position in the common area of the 200 hall. Resident #75 was observed on 05/26/2021 at 1:35 PM, 2:45 PM and 4:37 PM. Each time, she was in her room lying in bed on her back. She was on a standard mattress. Her heels were resting directly on the mattress. Wound care was observed on 05/26/2021 at 12:10 PM. The wound depth could not be measured due to slough covering the wound bed. (Photographic evidence obtained) During a telephone interview with the facility's wound care ARNP on 05/26/2021 at 12:37 PM, she stated the wound had been a Stage II, however, it was now a Stage III. The wound depth had increased. Although the margins are smaller, pressure has made it go deeper and it has progressed to a Stage III. During an interview with Employee B, Certified Nursing Assistant (CNA), on 05/26/2021 at 12:45 PM, she stated Resident #75 did not have an air mattress. She repositioned her every two hours and put a pillow between her legs. During an interview with the Unit Manager (UM) on 05/26/2021 at 2:22 PM, she stated there was no policy and procedure for repositioning. The expectation is every two hours. It is a nursing standard of practice. Resident #75 was observed on 05/27/2021 at 9:50 AM and at 12:05 PM. Each time, she was lying in bed on her back. She was on a standard mattress. Her heels were resting directly on the mattress. During an interview with Resident #75's Hospice nurse on 05/27/2021 at 1:40 PM, she stated she was not aware that the resident had a pressure ulcer. When she was informed that the resident's wound was first identified on 05/12/2021, she stated she was not aware that new orders had been written for wound care and an air mattress. Hospice CNAs were bathing Resident #75, but they had not informed her of the wound. She stated the Hospice Provider could get the resident an air mattress. Resident #75 was observed on 05/27/2021 at 3:40 PM, lying in bed on her back with a pillow between her knees. She was lying on a standard mattress, and this was the first observation of a pillow being used between her knees. Her heels were resting on the mattress. Resident #75 was observed on 05/27/2021 at 4:05 PM, lying in bed on her back. She was on a standard mattress. Her heels were resting on the mattress. During an interview with the Administrator and the Unit Manager (UM) on 05/26/2021 at 2:45 PM, the UM stated the facility did not have a policy instructing staff to reposition a resident every two hours. The Administrator stated the understanding for the CNAs was that they reposition the resident as needed. Neither the Administrator nor the UM could explain what that meant for Resident #75 whose pressure ulcer had worsened. The Administrator was asked to clarify what as needed meant, however no explanation was provided. A review of Resident #75's clinical record revealed she was admitted on [DATE]. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . (Copy obtained) A review of the Minimum Data Set (MDS) assessment, dated 05/08/2021, revealed the resident was assessed as requiring extensive physical assistance of one-person for bed mobility, transfers, dressing, eating, grooming and toileting. She was totally dependent on the physical assistance of one person for bathing. Her Brief Interview for Mental Status (BIMS) score was documented as a 99, indicating that the resident was unable to answer four or more questions, or she gave a nonsensical response. Per the MDS assessment, a subsequent interview with facility staff about the resident's cognition indicated she had both short- and long-term memory impairment, and daily decision-making was moderately impaired - decisions poor; cues/supervision required. (Copy obtained) A review of the care plan dated 05/20/2021 revealed: Pressure ulcer to sacrum. Goal: Will heal within the limits of the disease process. Interventions: Administer treatment per physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Notify physician as needed. A review of the care plan dated 05/03/2021 revealed: Hospice/Palliative care need due to terminal illness-[CONDITION(S)] and [CONDITION(S)] following cerebral infarction affecting left non-dominant side. Goal: Will be comfortable. Interventions: Assist to reposition, report skin breakdown. A review of the care plan dated 05/01/2021 revealed: At risk for alteration in skin integrity related to left-sided weakness, impaired mobility. Goal: Decrease/minimize skin breakdown risks. Interventions: Observe skin condition with ADL care daily; report abnormalities, provide preventative skin care routinely and as needed. A review of a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Every day shift and as needed. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Air mattress/turn per facility policy/float heels. Registered Dietician consult for pressure ulcer. (Photographic evidence obtained) A review of the Skin and Wound Evaluation, dated 05/12/2021, revealed: Pressure ulcer. In-house acquired. New. Stage 2. 100% granulation of wound bed. No slough. (Copy obtained) A review of the Skin and Wound Evaluation, dated 05/26/2021, revealed: Presents today with stage 3 pressure ulcer to the coccyx. Wound edge macerated and viable. 15a Stage: 7. Unstageable: obscured full-thickness skin and tissue loss due to slough. In-house acquired. Length: 0.8 cm, width: 0.5 cm., depth was not applicable. 20% granulation of wound bed. Slough 80% of wound bed. (Copy obtained) A review of the ARNP's progress note, dated 05/26/2021 at 5:02 PM, revealed: Addendum Note. This is an unstageable pressure ulcer to the coccyx, not a Stage 3. (Photographic evidence obtained) A review of the May 2021 CNA repositioning documentation in the electronic medical record, revealed the staff documented they repositioned the resident on the following dates and times: 05/01/2021 Documented 22:59 05/02/2021 Documented 00:24 , 10:04, 17:44 05/03/2021 Documented 00:30, 10:57 and 16:15 05/04/2021 Documented 04:44 and 08:48 05/05/2021 Documented 01:10 and 11:32 05/06/2021 Documented 01:03, 09:45, 17:33 and 23:48 05/07/2021 Documented 10:47 and 16:14 05/08/2021 Documented 02:38, 11:30, 19:06 and 22:21 05/09/2021 Documented 01:50, 12:56, 16:59 05/10/2021 Documented 00:02 and 13:46 05/11/2021 Documented 00:07, 11:00 and 19:37 05/12/2021 Documented 00:31, 11:51, 18:34 05/13/2021 Documented 23:36, 11:43 05/14/2021 Documented 01:19, 10:20, 17:15 05/15/2021 Documented 00:16, 17:36 05/16/2021 Documented 00:59, 16:27 05/17/2021 Documented 01:36, 11:09 05/18/2021 Documented 01:20 and 11:08 05/19/2021 Documented 01:10, 14:59 and 16:49 05/20/2021 Documented 00:26 and 18:38 05/21/2021 Documented 01:54, 12:27 and 16:17 05/22/2021 Documented 01:45, 09:16, 16:31 and 22:50 05/23/2021 Documented 02:11, 09:44, 18:23 05/24/2021 Documented 22:57 05/25/2021 Documented 00:21, 12:17, 18:34 and 23:38 (Copy obtained) A review of the facility's policy and procedure entitled Skin Practice Guide revealed: The purpose of the guide is to describe the process/steps for identification of patients at risk for the development of pressure ulcers, identify prevention techniques and interventions to assist with the management of pressure ulcers and skin alterations. There are additional contributing factors which impact an individual's risk for development of and healing potential of any skin alteration including pressure resulting from immobility. Prevention Interventions: Reposition frequently in bed and chair. Select appropriate support surfaces. Pressure points: Identification of risk factors and potential pressure points for a particular patient is important in developing a skin prevention care plan. Pressure points are areas of risk for skin breakdown. Patient position can assist with reducing the risk for breakdown. Supine Position: Dorsal [MEDICATION(S)] area and sacrum. Wheelchair position: Sacrum. Pressure ulcer prevention pathway. Care plan for actual skin problems. Mobility, activity, or sensory perception. Bed support surface: turn/reposition schedule, pressure redistribution-bed/chair. Daily body audits. Phase 3: Implement. Skin Evaluations: Patients at risk for skin breakdown have a head-to-toe skin evaluation weekly by a licensed nurse. Patients with pressure ulcers have a head-to-toe skin evaluation completed daily by the licensed nurse to identify additional skin changes. Positioning, mobility, restraints: Body positioning provides for pressure redistribution and can decrease pressure, friction, and shear. The use of support surfaces and positioning devices can provide for additional pressure redistribution. Examples of possible interventions include: minimize direct pressure over vulnerable areas and actual pressure ulcers. Reposition frequently; use friction reducing devices for assistance. (Copy obtained) Reference: Support surfaces are an important element in pressure injury prevention and treatment because they can prevent damaging tissue deformation and provide an environment that enhances perfusion of at risk or injured tissue. Support surfaces alone neither prevent nor heal pressure injuries, but support surfaces play a significant role in an individualized comprehensive management plan for pressure injury prevention and treatment. Pressure injury risk factors vary from person to person. Choosing a support surface for an individual should take into account their specific needs. Individuals should not lie on a pressure injury. Implementation Considerations: Continue to reposition individuals placed on a pressure redistribution support surface. Repositioning and mobilizing individuals is an important component in the prevention of pressure injuries. Extended periods of lying or sitting on a particular part of the body and failure to redistribute the pressure of the body surface can result in sustained deformation of soft tissues and ultimately, tissue damage. Prevention and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . European Pressure Ulcer Advisory Panel, National Pressure Injury Advisory Panel and Pan Pacific Pressure Injury Alliance. Prevention and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Emily Haesler (Ed.). EPUAP/NPIAP/PPPIA: 2019

Based on record reviews and interview, the facility failed to monitor targeted behaviors for residents who were receiving [CONDITION(S)] medications, and/or failed to monitor for drug-related side effects for four (Residents #25, #72, #330 and #381) of five residents reviewed for the use of [CONDITION(S)] medications, from a total of 35 residents in the sample. The findings include: 1. A review of Resident #25's medical record revealed an admitted [DATE]. Her primary medical diagnosis was [CONDITION(S)]. Her cognition was intact, and she required total assistance from staff with activities of daily living (ADLs). A review of Resident #25's physician's orders revealed: An order dated 3/13/21 for [MEDICATION(S)] (an antidepressant) 100 mg (milligrams) via g-tube (feeding tube) two times daily for depression. Monitoring of potential side effects related to the use of [MEDICATION(S)] did not commence until 5/24/21. A second order, dated 3/13/21, for [MEDICATION(S)] (an antidepressant) 50 mg via g-tube at bedtime for depression. Monitoring of potential side effects related to the use of [MEDICATION(S)] did not commence until 5/24/21. 2. A review of Resident #72's medical record revealed an admitted [DATE]. Her primary medical diagnosis was an open wound of the right leg. Her cognition was intact, and she required limited assistance with ADLs. A review of Resident #72's physician's orders revealed: An order for [MEDICATION(S)] (an antidepressant) 15 mg by mouth at bedtime for depression, dated 5/1/21. An order dated 5/24/21 directed staff to monitor for side effects related to the use of [MEDICATION(S)]. There was no evidence of monitoring for targeted behaviors related to the medication. An order for [MEDICATION(S)] (an antidepressant) 100 mg by mouth once a day for depression, dated 5/1/21. An order dated 5/24/21, directed staff to monitor for side effects related to the use of [MEDICATION(S)]. There was no evidence of monitoring for targeted behaviors related to the medication. An order for [MEDICATION(S)] (an anti-anxiety agent) 1.0 mg by mouth two times daily for anxiety, dated 5/5/21. An order dated 5/24/21 directed staff to monitor for side effects related to the use of [MEDICATION(S)]. There was no evidence of monitoring for targeted behaviors related to the medication. 3. A review of Resident #330's medical record revealed an admitted [DATE]. Her cognition was intact, and she required limited to extensive assistance with ADLs. A review of Resident #330's physician's orders revealed: An order dated 5/19/21 for [MEDICATION(S)] 150 mg, give one tablet by mouth two times daily for depression. Monitoring of side effects for this medication did not commence until 5/24/21. 4. A review of Resident #381's medical record revealed an admitted [DATE]. His diagnoses included dementia in other diseases classified elsewhere without behavioral disturbance, [CONDITION(S)] (GERD), and major depressive disorder. A review of Resident #381's physician's orders revealed: [MEDICATION(S)] tablet (an antidepressant) 15 mg, 1 tablet by mouth at bedtime, start date 5/12/21. [MEDICATION(S)] (hydrochloride) tablet 5 mg, 1 tablet by mouth every 8 hours for anxiety/depression, start date 5/19/21. The order to monitor for side effects related to use of [CONDITION(S)] medications ([MEDICATION(S)]) every shift for side effects of [CONDITION(S)] medications, had a start date of 5/24/21. The order to monitor for side effects related to use of [CONDITION(S)] medications ([MEDICATION(S)]) every shift for side effects of [CONDITION(S)] medications, had a start date of 5/24/21. (Photographic evidence obtained) A review of Resident # 381's May 2021 Medication Administration Record (MAR) revealed the facility had no documentation in place to monitor for side effects related to use of [MEDICATION(S)] and [MEDICATION(S)] ([CONDITION(S)] medications) from 5/12/21 through 5/23/21. An interview was conducted with the Director of Nursing (DON) on 5/27/21 at 4:29 PM. After reviewing Resident #381's May 2021 MAR, the DON confirmed that monitoring for side effects related to use of [CONDITION(S)] medications did not start until 5/24/2021. She also acknowledged that the facility should have started monitoring for side effect the same day the resident received his [CONDITION(S)] medications.

Based on observations, clinical record review, resident and staff interviews and facility policy and procedure review, the facility failed to provide reasonable accommodation of individual needs by ensuring one (Resident #11) of 35 sampled residents from a total of 84 residents had access to his call light at all times. The findings include: During a 05/24/2021 interview with Resident #11 at 11:45 AM, he stated he had concerns about pain (sciatica), and he had to ask for pain medication when he needed it. His call light was observed on the floor behind his bed. (Photographic evidence obtained) When asked if he could reach his call light, he stated, It's always like that. (on the floor) They put it in the drawer too. He confirmed that the staff moved his call light out of his reach and sometimes put it in the drawer of his nightstand. He confirmed he was not able to roll over in bed by himself and reach the call light when it was not clipped to the bed within his reach. He also confirmed that when he could reach the call light, he was able to use it to summon the staff. A review of the resident's Minimum Data Set (MDS) assessment, completed on 02/20/2021, documented his Brief Interview for Mental Status (BIMS) score as 11 out of a possible 15 points, indicating moderate cognitive impairment. He exhibited some forgetfulness during the BIMS. He required extensive physical assistance of two persons for bed mobility, transfers, dressing, personal hygiene and toilet use. He did not walk during the assessment period. He was incontinent of bowel and bladder. Pain medications were documented as PRN. (The resident requests them when needed; they are not provided routinely.) Presence of occasional pain was documented. (Copy obtained) A review of the care plan, dated 02/20/2021, revealed focus areas for Fall Risk and Assistance with Daily Activities/Self-Care Deficit. Interventions included: Keep call light within reach. (Copy obtained) On 05/24/2021 at 2:55 PM, Resident #11's call light was observed hanging down to the floor from the wall behind his bed. On 05/26/2021 at 4:05 PM, Resident #11's call light was observed clipped to his bed sheet at the upper end of the mattress. (Photographic evidence obtained) The resident did not know where it was, and when informed, he stated he could not reach it. He attempted to grab hold of it, but could not reach it. On 05/27/2021 at 3:27 PM, Resident #11's call light was observed clipped to his bed sheet at the upper end of the mattress. The resident did not know where it was, and when informed, he stated he could not reach it. During a 05/27/2021 interview with Employee A, Certified Nursing Assistant (CNA), at 3:35 PM, she was shown the call light and was asked if the resident was able to reach it. She stated, Oh, I forgot to put it back. I just changed him. I just forgot to put it back. Resident #11 stated, See what I mean? They do it all the time. They come in and take it away from me. The CNA did not respond to the resident's statement. A review of the facility's policy and procedure entitled Call Lights, revealed: Purpose: To use a light and/or sound system to alert staff to patient needs/requests. Procedure: 6. Always position call light conveniently for use and within reach. 8. Check call lights daily when providing care to ensure that cord length is appropriate and that light is in working order.

Based on observations, interviews and record reviews, the facility failed to provide services which met professional standards of quality for during medication administration. Professional standards of quality means that care and services are provided according to accepted standards of clinical practice. The findings include: On 5/25/21 at 9:30 AM, an observation of medication administration was conducted for Resident #75 with Employee E, Licensed Practical Nurse (LPN). The nurse unlocked the medication cart and removed two Styrofoam cups from the top drawer. Resident #75's first name was written on one cup. Resident #76's first name was written on the second cup. Each cup contained medications. The nurse was unable to recall the contents of either cup when asked. The nurse was asked to dispose of the cups and prepare new medications for one resident at a time. The nurse noted that Resident #75 had an order to receive [MEDICATION(S)] (a diuretic) 40 milligrams (mg) and explained that it was not available. She was asked about the facility's process for medications that were unavailable. She explained that the facility did have an emergency drug supply, but she wasn't sure whether the [MEDICATION(S)] was available in the supply. She continued preparing medications and did not attempt to check the emergency drug kit for [MEDICATION(S)]. On 5/25/21 at 9:35 AM, an observation of medication administration was conducted for Resident #67 with Employee E, LPN. The nurse unlocked the cart and removed a plastic 30 ml (milliliter) medication cup from the top drawer of the cart with Resident #67's last name written on it. The cup contained medications. The nurse was unable to recall the contents of the cup. The nurse was asked whether pre-pouring and storage of medications was an appropriate practice in the facility. She stated, I label everything. I don't see why it matters. The nurse was asked to dispose of the pre-poured medications and prepare new ones for administration to the resident. On 5/25/21 at 9:38 AM, an observation of medication administration was conducted for Resident #17 with Employee E, LPN. The nurse noted an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated, This one has been on order for over two weeks. The nurse then noted an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The nurse stated, This one has been on order from the pharmacy since 4/28/21. When asked whether she had been obtaining these medications from another source, she stated, No. I just can't give them if they aren't here. The nurse further explained that she hadn't notified the physician but stated she had called the pharmacy a couple of times to remind them. When asked whether the nurse was going to check the emergency drug supply for the medications she stated, I could, but it's way over there. referencing the other nursing unit in the building. On 5/26/21 at 12:51 PM, an interview was conducted with the Director of Nursing (DON) concerning the facility's medication administration practices. Regarding medications that were unavailable for administration, the DON explained that the nurse should notify the pharmacy to reorder the medications. Additionally, the nurse should notify the physician to obtain a hold order and check the facility's emergency drug kit. The DON explained that the facility had initiated an audit of medications on 5/25/21 and had determined there were quite a few medications not available for administration. The DON produced three handwritten pages of medications from the audit conducted on the 300/400 hall and acknowledged that there was definitely a problem. The DON was asked to contact Resident #17's physician and ensure he/she was aware that the resident had missed his medications for the prevention of seizures and blood clots. The DON returned and explained that a [MEDICATION(S)] level had been ordered, and that the medications were being sent from the pharmacy as soon as possible. The DON also confirmed that medications should not be pre-poured and stored in the medication cart for later administration. A review of Mosby's Guide to Nursing Skills and Procedures, Ninth Edition, p.365 (Accessed on 5/27/21 at 3:30 PM), directs nurses not to leave medications unattended to ensure the correct medications are prepared for the correct patient.

Based on observations, clinical record review and resident/staff interviews, the facility failed to ensure one (Resident #75) of one resident sampled for mobility, from a total of 35 sampled residents, received appropriate treatment and services to prevent further worsening of a left hand contracture. The findings include: A review of Resident #75's clinical record revealed she was admitted on [DATE]. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . (Copy obtained) A review of the Minimum Data Set (MDS) assessment, dated 05/08/2021, revealed the resident was assessed as requiring extensive physical assistance of one-person for bed mobility, transfers, dressing, eating, grooming, and toileting. She was totally dependent on the physical assistance of one person for bathing. Her Brief Interview for Mental Status (BIMS) score was documented as a 99, indicating that the resident was unable to answer 4 or more questions, or she gave a nonsensical response. Per the MDS assessment, a subsequent interview with facility staff about the resident's cognition indicated she had both short- and long-term memory impairment, and daily decision-making was moderately impaired - decisions poor; cues/supervision required. Functional limitation in range of motion, to include the hand and wrist was marked as no impairment. (Copy obtained) A review of the care plan dated 05/01/2021 revealed: At risk for alteration in skin integrity relate to left sided weakness, impaired mobility. Goal: Decrease/minimize skin breakdown risks. Interventions: Observe skin condition with ADL care daily, report abnormalities, provide preventative skin care routinely and as needed. A review of the care plan dated 05/03/2021 revealed: Hospice/Palliative care needed due to terminal illness-[CONDITION(S)] and [CONDITION(S)] following cerebral infarction affecting left non-dominant side. Goal: Will be comfortable. Interventions: Assist to reposition, report skin breakdown. No focus areas or interventions specific to the resident's left hand contracture were located in the care plans. (Copies obtained) Resident #75 was observed on 05/24/2021 at 9:30 AM lying in bed. Her eyes were closed. Her left hand appeared to be contracted, and no splinting device was being used. Resident #75 was observed on 05/24/2021 at 10:22 AM lying in bed. Her eyes were closed. Her left hand appeared to be contracted, and no splinting device was being used. Resident #75 was observed on 05/24/2021 at 12:40 PM lying in bed. Her left hand appeared to be contracted, and no splinting device was being used. Resident #75 was observed on 05/24/2021 at 1:45 PM lying in bed. Her left hand appeared to be contracted, and no splinting device was being used. Resident #75 was observed on 05/24/2021 at 2:50 PM lying in bed. Her eyes were closed. Her left hand appeared to be contracted, and no splinting device was being used. Resident #75 was observed on 05/25/2021 at 10:05 AM lying in bed. She was awake and alert. She was pleasant and expressed gratitude for being checked on. She was moderately confused when asked to put on her call light. She did not know how to use her call light. She did not know what a call light was. After explanation and demonstration, she continued to say she did not know how to use it. She stated she could not turn herself in the bed; she needed the staff to help her. Her left hand appeared to be contracted, and no splinting device was being used. Resident #75 was observed on 05/25/2021 at 12:20 PM, lying in bed. Her left hand appeared to be contracted, and no splinting device was being used. Resident #75 was observed on 05/26/2021 at 11:50 AM, seated in her wheelchair in the common area of the 200 hallway. Her left hand appeared to be contracted, and no splinting device was being used. Resident #75 was observed on 05/26/2021 at 1:35 PM, lying in bed with her eyes closed. Her left hand appeared to be contracted, and no splinting device was being used. Resident #75 was observed on 05/26/2021 at 2:45 PM, lying in bed with her eyes open. Her left hand appeared to be contracted, and no splinting device was being used. Resident #75 was observed on 05/26/2021 at 4:37 PM, lying in bed with her eyes open. Her left hand appeared to be contracted, and no splinting device was being used. During an interview with Employee B, Certified Nursing Assistant (CNA), on 05/26/2021 at 12:45 PM, she confirmed that Resident #75 had no splinting device for her left hand. Resident #75 was observed on 05/27/2021 at 9:50 AM, lying in bed on her back. No splinting device was being used on her left hand. Resident #75 was observed on 05/27/2021 at 12:05 PM, lying in bed. No splinting device was being used on her left hand. During an interview with the MDS (Minimum Data Set) Coordinator on 05/26/2021 at 12:55 PM, she stated she was not aware that the MDS was coded inaccurately for Resident #75 regarding the impairment/contracture of her left upper extremity. During an interview with the MDS Coordinator on 05/27/2021 at 3:30 PM, she stated she had filed an amended assessment to correct the section that indicated no impairment in Resident #75's upper extremities. She stated the resident did have a contracture of the left hand. She did not think there was any splinting device being used, however. On 05/27/2021 at 10:00 AM, an interview was conducted with Employee N, Speech Therapist. She was asked whether Resident #75's left hand had been assessed for contracture and a splinting device. She stated she would check the resident's record. At 10:20 AM the same morning, Employee N stated there had been no assessment/evaluation/screening conducted of the resident's left hand for contracture or the need for a splinting device. On 05/27/2021 at 3:17 PM, Employee N stated the therapy department had now conducted an assessment of the resident's left hand, and they were going to recommend the use of a rolled washcloth and range of motion (ROM) exercises. Resident #75 was observed on 05/27/2021 at 3:40 PM, lying in bed. Her eyes were closed. No splinting device was being used on her left hand. Resident #75 was observed on 05/27/2021 at 4:05 PM, lying in bed with her eyes closed. No splinting device was being used on her left hand. A review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER]

Based on observations, interviews, and record reviews, the facility failed to provide adequate supervision and assistive devices to prevent accidents for one (Resident #20) of one resident reviewed for accidents, from a total of 35 residents in the sample. The findings include: A review of Resident #20's medical record revealed he was admitted to the facility on [DATE] with a primary diagnosis of [CONDITION(S)]. His secondary diagnoses included [CONDITION(S)] and arthritis. Resident #20 had a Brief Interview for Mental Status (BIMS) score of 13 out of a possible 15 points, indicating he was cognitively intact. He required extensive assistance from staff with activities of daily living (ADLs), including toileting. On 5/24/21 at 11:22 AM, Resident #20 was observed sitting up on the side of his bed. A large, crusted laceration was observed on the right side of his forehead. Resident #20 was yelling out repeatedly, Bathroom! The resident's room lights were off, and the window blinds were closed. He was asked whether he needed assistance to the restroom and he replied, yes. His call light was observed lying on the floor between his bedside table and the bed. Staff were immediately notified of the resident's request for assistance. Further review of Resident #20's medical record revealed he had sustained falls on 3/4/21, 4/13/21, 4/23/21, 4/28/21 and 5/17/21. Following the falls on 3/4/21 and 5/17/21, psychiatric consults were requested. A psychiatric evaluation dated 3/10/21, indicated the resident was complaining of poor sleep at night. It was recommended that a bedside commode be placed near the resident's bed. A second psychiatric evaluation dated 5/19/21, recommended to open the blinds in the room and have the resident sit by natural light to promote circadian rhythm. This evaluation further recommended staff to be sure the resident's room was bright during the day and to limit daytime sleeping. A review of the resident's comprehensive care plans revealed a focus area for falls. An intervention dated 4/28/21 directed staff to provide the resident with a bedside commode. (Photographic Evidence Obtained) On 5/24/21 at 12:00 PM, an interview was attempted with Resident #20. He was lying in his bed with his eyes closed. The room lights were off, the window blinds were closed, and no bedside commode was noted in the room. On 05/25/21 at 3:26 PM, an interview was attempted with Resident #20. He was lying in his bed with his eyes closed. The room lights were off, the window blinds were closed, and no bedside commode was noted in the room. On 5/27/21 at 3:54 PM, Resident #20 was observed lying in bed. He was awake and attempting to make a call using his telephone. The room was dark, the blinds were closed, and no bedside commode was noted in the room. The resident was asked whether he was able to see his phone well enough to dial a number. He replied, No I can't. The resident was then asked whether he would like the lights to turned on and/or the window blinds opened. He replied, Yes, that would be great! The resident's room lights were turned on and the window blinds were opened. The resident was then asked whether he used a bedside commode. He stated he was unsure. On 05/27/21 at 4:02 PM, an interview was conducted with the resident's assigned nurse. She explained that she was familiar with the resident and his fall history. She further explained that the resident did have a bedside commode in his room at one time, and that she was not sure what happened to it. She explained that the resident did use it and it had been missing for about two weeks. Regarding the lighting in the room, the nurse wasn't aware of any reason why the lights wouldn't be on, or the window blinds wouldn't be open.

Based on observations, interviews, and record reviews, the facility failed to provide routine drugs for two (Resident #17 and Resident #75) of seven residents reviewed for compliance with medication administration, from a total of 35 residents in the sample. The findings include: On 5/25/21 at 9:30 AM, an observation of medication administration was conducted for Resident #75 with Employee E, Licensed Practical Nurse (LPN). The nurse noted that the resident had an order to receive [MEDICATION(S)] (a diuretic) 40 milligrams (mg) and explained that it was not available. The nurse was asked about the facility's process when medications were unavailable. She explained that the facility did have an emergency drug supply, but that she wasn't sure if the [MEDICATION(S)] was available in the supply. She then continued preparing medications. On 5/25/21 at 9:38 AM, an observation of medication administration was conducted for Resident #17 with Employee E, LPN. The nurse noted an order for the resident to receive an [MEDICATION(S)] (blood thinner) 5.0 mg tablet. She stated, This one has been on order for over two weeks. The nurse then noted an order for the resident to receive [MEDICATION(S)] 100 mg capsules for a diagnosis of [CONDITION(S)]. The nurse stated, This one has been on order from the pharmacy since 4/28/21. When asked whether she had been obtaining these medications from another source, the nurse replied, No. I just can't give them if they aren't here. The nurse further explained that she hadn't notified the physician, but stated she had called the pharmacy a couple of times to remind them since 4/28/21. When asked whether the nurse was going to check the emergency drug supply for the medications she stated, I could but it's way over there. referencing the facility's other unit. The facility's policy titled, Medication Shortages/Unavailable Drugs was reviewed. The policy was last revised in 8/2018. The policy indicated that if a medication shortage was discovered, a licensed nurse should contact the pharmacy and determine the status of the order. Then, if the next available delivery caused the resident to miss a dose, the facility should obtain the medication from the emergency medical supply to administer the dose. A list of the emergency drug supply contents was requested. The printed contents indicated that the facility had a total of 12 [MEDICATION(S)] 100 mg capsules on hand and a total of 8 [MEDICATION(S)] 2.5 mg tablets on hand. On 5/26/21 at 12:51 PM, an interview was conducted with the Director of Nursing (DON) regarding the facility's medication administration practices. Regarding medications that were unavailable for administration, the DON explained that the nurse should notify the pharmacy to reorder the medication. Additionally, the nurse should notify the physician to obtain a hold order and check the facility's emergency drug kit (Omnicell). The DON explained that the facility had initiated an audit of medications on 5/25/21 and had determined there were quite a few medications not available for administration. The DON produced three handwritten pages of medications from the audit conducted on the 300/400 hall and acknowledged that there was definitely a problem. She also explained that she wasn't sure all staff knew how to reorder medications, and she planned to conduct education. The DON was asked to contact the physician for Resident #17 and ensure the physician was aware that the resident had missed his medications for the prevention of seizures and blood clots. The DON returned and explained that a [MEDICATION(S)] level had been ordered and that the medications were being sent from the pharmacy as soon as possible.

Based on observations and interviews, the facility failed to ensure medication error rates were not five percent or greater. There were 44 opportunities for error with a total of three errors, resulting in a medication error rate of 6.81% and involving two (Residents #75 and #17) of seven residents observed during medication administration. The findings include: On 5/25/21 at 9:30 AM, an observation of medication administration was conducted for Resident #75 with Employee E, Licensed Practical Nurse (LPN). The nurse noted that the resident had an order to receive [MEDICATION(S)] (a diuretic) 40 milligrams (mg) and explained that it was not available. The nurse was asked about the facility's process for medications that were unavailable. She explained that the facility did have an emergency drug supply, but she wasn't sure whether the [MEDICATION(S)] was available in the supply. She continued preparing medications and did not attempt to obtain [MEDICATION(S)] for the resident. On 5/25/21 at 9:38 AM, an observation of medication administration was conducted for Resident #17 with Employee E, LPN. The nurse noted an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated, This one has been on order for over two weeks. The nurse then noted an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The nurse stated, This one has been on order from the pharmacy since 4/28/21. When asked whether she had been obtaining these medications from another source, she stated, No. I just can't give them if they aren't here. The nurse further explained that she hadn't notified the physician but stated she had called the pharmacy a couple of times to remind them. When asked whether the nurse was going to check the emergency drug supply for the medications she stated, I could, but it's way over there. referencing the other nursing unit in the building. She made no attempt to obtain either medication from the emergency drug supply. On 5/26/21 at 12:51 PM an interview was conducted with the Director of Nursing (DON) regarding the facility's medication administration practices. Regarding medications that were unavailable for administration, the DON explained that the nurse should notify the pharmacy to reorder the medication. Additionally, the nurse should notify the physician to obtain a hold order and check the facility's emergency drug kit. The DON explained that the facility had initiated an audit of medications on 5/25/21 and had determined there were quite a few medications not available for administration.

Based on resident record review, and staff, Ombudsman, family and resident, the facility failed to notify in writing one resident (Resident #1) of the intent to transfer or discharge, provide at least 30 days notice of discharge, and provide information regarding the resident's right to appeal the discharge decision, out of a total of 1 resident reviewed for a facility-initiated discharge following transfer to a hospital. The findings include: In an interview with the Director of Nursing (DON) at 10:30 am on 7/25/19, she stated there had been one facility-initiated discharge since the last survey, a Baker Act involving Resident #1. A closed record review for Resident #1 found a Discharge Return Not Anticipated minimum data set (MDS) assessment with an assessment reference date (ARD) of 6/4/19. Resident #1 was admitted to the facility on [DATE] and had an unplanned discharge to an acute care hospital on [DATE]. The Admission MDS with an ARD of 5/10/19 assessed Resident #1 with a brief interview for mental status (BIMS) score of 13, indicating he was cognitively intact and able to make informed decisions about his daily activities. Resident #1 participated in the assessment and expected to remain in the facility for long term care. No active discharge planning was occurring. Resident #1 did not wish to talk to anyone about leaving the facility and returning to the community to receive services. A review of Resident #1's electronic nursing progress notes found the following: 5/4/19 - Resident #1 was being very abusive to CNAs, calling them (expletives) and saying he was going to throw stool in their faces. Resident was on a [DEVICE] (feeding tube) for supplemental nutrition, and received all of his medications through the tube. 5/17/19 - Resident #1 was using sexually provocative insults and refused his morning medications. 5/27/19 - Resident was very suspicious that people were ignoring him when providing care to the (resident in ) A bed. 6/3/19 - Staff went to Resident #1's room, he was refusing care and was verbally abusive, using foul language. Resident #1 told staff Hell no, leave me alone. 6/4/19 at 1:47pm - Resident #1 was noted to present with aggressive behavior towards staff. While two staff were attempting to perform ADL care, Resident #1 began swinging at the staff member. Prior to the staff being able to remove herself, he punched her twice in the chest and kicked her in the stomach. The Nurse Practitioner was notified, and orders were received for one on one monitoring, intramuscular (IM) [MEDICATION NAME] (anti-anxiety), and to call the sheriff for further behaviors. 6/4/19 at 2:23pm - Resident #1 was transferred to the hospital via 911 under a Baker Act related to his violent behavior. Review of an AHCA Nursing Home Transfer and Discharge Notice revealed Resident #1 was transferred to a local hospital. The date the notice was given was 6/4/19, with an effective date 6/4/19 - Baker Act. The reason for transfer or discharge was marked that the safety of other individuals in the facility was endangered. The explanation to support the action simply stated Baker Act: combative towards staff. The form was signed by the Nursing Home Administrator and the Physician/Designee on 6/4/19; however, the signature line for the resident or the resident representative was blank. There was no indication that Resident #1 had received the notice of immediate discharge, or a statement of his appeal rights, including the contact information for the local Office of Appeals or information on how to complete and submit the appeal hearing request. Photographic evidence was obtained. A telephone call was placed to the local Long Term Care Ombudsman's office (LTCO) on 7/25/19 at 11:38 am. The LTCO representative was able to contact Resident #1's family member via telephone on 6/18/19. The family member expressed no knowledge of Resident #1's right to appeal the discharge decision. The LTCO was able to provide the family member with a phone number to the Office of Appeals, 14 days after Resident #1's transfer to the hospital for psychiatric stabilization. A telephone interview was conducted with Resident #1's family member on 7/25/19 at 1:44 pm. The family member stated Resident #1 had been placed in a nursing home out of town. They were together at that moment. Explaining that Resident #1 could be very difficult to understand, Resident #1 granted permission for the phone to be placed on speaker, should interpretation from family be required. A telephone interview was conducted with Resident #1 at this time. He was able to clearly state he was discharged from the facility in (MONTH) or July. The family member added that the facility failed to provide any appeal information following discharge. An interview was conducted with the facility's Social Services Director (SSD) on 7/25/19 at 2:00 pm. She stated Resident #1 was discharged following punching and kicking a staff member. She explained that the due to the intensity of the act, the facility had to react. He was transferred to the closest Baker Act receiving facility and has been gone since. She confirmed she initiated the AHCA Transfer Discharge form, stating the (former) Administrator signed it. She stated generally she would send the form to a family member if the resident did not have the cognitive capability of signing the form, but there was no family member on file; only a friend with no address. The SSD confirmed Resident #1 was not provided with a 30-day notice of discharge, as required, and had not been provided with his appeal rights. An interview was conducted with the interim Administrator on 7/25/19 at 2:28 pm. She stated she had not been made aware of Resident #1's discharge until today. She reviewed the discharge notification and confirmed there was no indication Resident #1 was offered a 30 day notice, or of his right to appeal the decision, as required.

Based on resident record review, and staff, Ombudsman, family and resident interviews, the facility failed to permit one resident who was admitted for long-term care (Resident #1) to return to the facility following a hospital transfer, and failed to comply with requirements of §483.15 (c) as they pertain to discharge, out of a total of 1 sampled resident reviewed for facility-initiated discharge and emergency transfer. The findings include: In an interview with the Director of Nursing (DON) at 10:30 am on 7/25/19, she stated there had been one facility-initiated discharge since last survey, a Baker Act involving Resident #1. A closed record review for Resident #1 found a Discharge Return Not Anticipated Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 6/4/19. Resident #1 was admitted to the facility on [DATE] and had an unplanned discharge to an acute care hospital on [DATE]. The Admission MDS with an ARD of 5/10/19 assessed Resident #1 with a Brief Interview for Mental Status (BIMS) score of 13, indicating he was cognitively intact and able to make informed decisions about his daily activities. Resident #1 participated in the assessment and expected to remain in the facility for long term care. No active discharge planning was occurring . Resident #1 did not wish to talk to anyone about leaving the facility and returning to the community to receive services. A review of Resident #1's electronic nursing progress notes found the following: 5/4/19 -Resident #1 was being very abusive to CNAs, calling them (expletives) saying he was going to throw stool in their faces. Patient was on a [DEVICE] (feeding tube) for supplemental nutrition, and received all of his medications through the tube. 5/17/19 -Resident #1 was using sexually provocative insults and refused his morning medications. 5/27/19 -Resident was very suspicious that people were ignoring him when providing care to the (resident in ) A bed. 6/3/19 -Staff went to Resident #1's room, he was refusing care and was verbally abusive, using foul language. Resident #1 told staff, Hell no, leave me alone. 6/4/19 at 1:47pm - Resident #1 was noted to present with aggressive behavior towards staff. While two staff were attempting to perform ADL care, Resident #1 began swinging at the staff member. Prior to the staff being able to remove herself, he punched her twice in the chest and kicked her in the stomach. The Nurse Practitioner was notified, and orders were received for one on one monitoring, intramuscular (IM) [MEDICATION NAME] (anti-anxiety), and to call the sheriff for further behaviors. 6/4/19 at 2:23pm -Resident #1 was transferred to the hospital via 911 under a Baker Act related to his violent behavior. Review of an AHCA Nursing Home Transfer and Discharge Notice revealed Resident #1 was transferred to a local hospital. The date the notice was given was 6/4/19, with an effective date 6/4/19 - Baker Act. The reason for transfer or discharge was marked that the safety of other individuals in the facility was endangered. The explanation to support the action simply stated Baker Act: combative towards staff. The form was signed by the Nursing Home Administrator and the Physician/Designee on 6/4/19; however, the signature line for the resident or the resident representative was blank. There was no indication that Resident #1 had received the notice of immediate discharge, or a statement of his appeal rights, including the contact information for the local Office of Appeals or information on how to complete and submit the appeal hearing request. Photographic evidence was obtained. Further review of the resident's record found no documented evidence the facility followed up with the hospital after the Baker Act transfer to determine the resident's status [REDACTED].#1's successful return to his home (the facility). A telephone call was placed to the local Long Term Care Ombudsman's office (LTCO) on 7/25/19 at 11:38 am. A representative explained they received a telephone call from a Case Manager during Resident #1's hospitalization . The Case Manager stated Resident #1 was ready for discharge, but the facility refused to readmit him. The LTCO representative was able to contact Resident #1's family member via telephone on 6/18/19. The family member confirmed the facility's refusal to readmit, and expressed no knowledge of Resident #1's right to appeal the discharge decision. The LTCO was able to provide the family member with a phone number to the Office of Appeals, 14 days after Resident #1's transfer to the hospital for psychiatric stabilization. A telephone interview was conducted with Resident #1's family member on 7/25/19 at 1:44 pm. The family member stated Resident #1 had been placed in a nursing home out of town. They were together at that moment. Explaining that Resident #1 could be very difficult to understand, Resident #1 granted permission for the phone to be placed on speaker, should interpretation from family be required. A telephone interview was conducted with Resident #1 at this time. He was able to clearly state he was discharged from the facility in (MONTH) or July. When asked if he was permitted to return, he replied, No. He explained that decision made him feel not very good at all. The hospital Case Manager told him he was not permitted to return to the facility, and that they would now need to find another place for him to go. Resident #1 then said, They found this place and they put me here. He said he was not very happy at all and that he wanted to apologize for his behavior, but was not given that chance. I am sorry I caused so much trouble. The family member then intervened, confirming the facility refused to permit Resident #1 to return. As a result, Resident #1 was Upset. Very upset. He said Resident #1 had liked it there. The family member confirmed the facility provided no information regarding the resident's right to appeal the decision to discharge Resident #1. An interview was conducted with the facility's Social Services Director (SSD) on 7/25/19 at 2:00 pm. She stated Resident #1 was discharged following kicking and punching a staff member. She explained that the due to the intensity of the act, the facility had to react. They called the sheriff, and the physician decided to Baker Act him. He was transferred to the closest Baker Act receiving facility and has been gone since. She was not sure what happened to him next, but Resident #1 was not permitted to return to the facility. She confirmed she initiated the AHCA Transfer Discharge form, stating the (former) Administrator signed it. Generally she would send the form to a family member if the resident did not have the cognitive capability of signing the form, but there was no family member on file; only a friend with no address. The SSD confirmed Resident #1 was not provided with a 30 day notice of discharge, as required and had not been provided with his appeal rights or information. An interview was conducted with the interim Administrator on 7/25/19 at 2:28 pm. She stated she had not been made of Resident #1's discharge until today. She reviewed the discharge notification and confirmed there was no indication Resident #1 was offered a 30 day notice, or of his appeal rights to return, as required.

Based on record reviewss, facility policy review and staff interviews, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice, by failing to recognize, assess and promptly address changes in one resident's (#256) physical condition out of a total resident sample of 39. This resulted in a delay in treatment and hospitalization of the resident. Though the resident's diastolic blood pressure consistently dropped from 5/25/19 to 5/28/19, and the resident concurrently experienced an elevated temperature requiring medication, a poor appetite, lethargy, amber-colored urine, failure to void following removeal of a urinary catheter and diarrhea, there was no documentation to confirm that the resident's physician was notified until 5/28/19 at 7:00 AM. At that time, the physician was notified of the resident's inability to void, and a catheter was reinserted, however, there was no indication that the physician was made aware of any other symptoms/concerns. On 5/28/19 at 11:15 AM, the physician was notified of the resident's low blood pressure after nursing was prompted by the therapy department, and the resident was sent to the hospital emergently at 11:35 AM. The findings include: A review of the clinical record revealed that Resident #256 was an [AGE] year-old male who had a transmetatarsal amputation (TMA - left mid foot amputation) on 5/16/2019. He was subsequently admitted to the nursing home on 5/22/2019, with [DIAGNOSES REDACTED]. A review of Resident #256's blood pressure (B/P) records from 5/22/2019 through 5/28/2019, revealed the following: 5/22/19 at 11:58 PM - 149/65 5/23/19 at 9:44 PM - 147/61 5/24/19 at 2:58 AM - 138/69 5/24/19 at 7:38 AM - 159/78 5/24/19 at 12:24 PM - 153/98 5/24/19 at 10:58 PM - 160/52 5/25/19 at 10:58 AM - 132/81 5/26/19 at 8:18 AM - 154/65 5/26/19 at 4:54 PM - 153/61 5/27/19 at 8:34 AM - 162/48 5/27/19 at 3:30 PM - 106/47, and 5/28/19 at 11:26 AM - 91/36 (Copies obtained) A review of the nurses' notes from 5/26/19 at 1:10 AM through 5/28/19 at 11:15 AM, revealed the following: 5/26/19 at 3:32 PM - 154/65, no s/s discomfort or distress, P:77, O2: 96%, Temp: 98.6 5/27/19 at 6:24 PM - Temp: 102.4, Tylenol given per prn (as needed) order. 5/27/19 at 6:39 PM - Insulin held. Resident did not eat. 5/27/19 at 9:53 PM - Tylenol given per prn (as needed) order. Administration effective. Temp: 99.0 5/27/19 at 10:42 PM - Assumed care of patient at 3:00 PM. Patient sleeping and very lethargic. Patient vitals stable, except for a temp of 100.7. Medicated with Tylenol as per MAR (medication administration record). Patient temp came down. Patient had moderate amount of diarrhea. Incontinent care provided and bed bath. Patient was able to take medications crushed in applesauce and did eat about 25% of dinner. Foley taken out at approximately 7:30 PM. Urine was dark amber in color. Continue to monitor. 5/28/19 at 7:00 AM - RN prior shift refer pt (patient) no voiding all shift. Resident was noted as not having voided. A urinary catheter was reinserted, the physician was called, there were no new orders, and the nurse documented that she would continue to monitor. 5/28/19 at 11:15 AM - Therapy refers pt unresponsive, evaluated pt and observed hypoactive, he response to talk and touch but continue sleeping, BS: 102 mg/dL, BP: 91/38, transfer pt to bed and it is placed in position trendelenburg, after 5 min BP: continue same. Notify NP Dr. (nurse practitioner doctor) he place order for NS (normal saline) at 60 cc/hr (cubic centimeters per hour), hold [MEDICATION NAME] today, VS every 4 hrs (hours) x 3 days. Start IV (intravenous) fluid as ordered. 11:30 NP Dr. Dr. order transfer pt by emergency room by 911. call 911 11:35 Rescue start working with pt and transfer to (acute care hospital) (Copies obtained) A review of Resident #256's temperature records from 5/22/19 at 11:59 PM through 5/28/19 at 11:27 AM, revealed that on 5/27/19 at 3:30 PM, the resident's temperature was recorded at 101.6 degrees. (copy obtained) An observation was made of a nurse standing at the resident's room door on 5/28/19 at 11:31 AM, while paramedics were in the resident's room. When asked if she was the resident's nurse, she stated yes. When asked what had happened to the resident, she stated she did not know. At this time, the paramedic was overheard telling his colleague that Resident #256 had pinpoint pupils and was unresponsive. During an interview with Employee A, Registered Nurse/Unit Manager, on 05/30/19 at 11:17 AM concerning Resident #259, she was asked what would be considered a normal blood pressure. She stated 120/60 mmhg. She further stated that a diastolic reading below 60 mmhg would be considered a low reading, and that changes in a resident's condition should be communicated to the physician as soon as possible. During an interview with the Director of Nursing on 05/30/19 at 11:55 AM, she was asked to review Resident #256's blood pressure records. After her review, she stated that the nursing staff should have reassessed the resident at the time of the first abnormal reading, and should have contacted the physician at that time. A review of the facility's Change in Condition policy, dated 11/2016, revealed, According to the Medical Directors Association Clinical Practice guidelines for acute changes in condition in the long-term care setting --- immediate notification is recommended for any symptom, sign or apparent discomfort that is acute or sudden in onset, and a marked change in relation to usual symptoms. According to Mayo Clinic.org, in the section entitled Low Blood Pressure ([MEDICAL CONDITION]), it stated, A blood pressure reading lower than 90 millimeters of mercury (mmhg ) for the top number (systolic) or 60 mmhg for the bottom number (diastolic) is generally considered low blood pressure.