Every finding on record at Waterview Health & Rehab Center

Based on staff interview, clinical record review and facility documentation review, the facility staff failed to provide care and services to prevent the development of a pressure ulcer at an advanced stage for one Resident (Resident #413) in a survey sample of 64 Residents, resulting in harm for Resident #413. The facility self-identified this deficient practice prior to the survey, resulting in past non-compliance being achieved on 7/26/23. The findings included: For Resident #413, the facility staff failed to identify a pressure ulcer until it was at an advanced stage and then failed to initiate an appropriate treatment, this constituted harm. On 8/22/23-8/23/23, a closed record review was conducted of Resident #413's chart. This review revealed the following: A progress note dated 5/21/23, read, Skin note: assessed resident sacrum a few days prior and no areas was open. Resident did have redness area to bottom initiated zinc and dressing to buttock. Was notified by cna area that was not seen before is open. Wound evaluations dated 5/23/23, indicated Resident #413 was noted to have an unstageable sacral pressure ulcer to her right buttocks with 95% slough, that measured 8x7x0 centimeters (cm), and the wound bed was noted to have devitalized tissue. A second wound was noted on the left buttocks that was noted to be a stage III, with 70% slough that measured 2x2x.01cm. Treatment orders were obtained and initiated that day, which consisted of Cleanse Lt [left] and Rt [right] Buttock with 1/4 strength Dakin's solution. Apply Santyl nickel thick directly to wound bed. Apply calcium alginate and cover w/ border foam gauze dressing, one time a day. On the evening of 8/23/23, prior to the survey team sharing the concern noted above, the facility's Director of Nursing (DON) presented the survey team with a binder that contained information where they had self-identified the deficient practice with Resident #413 and implemented a plan of correction. The survey team requested a copy. Review of the facility's submitted documentation with regards to the self-identification of the deficient practice, they conducted staff interviews. Through this process it was noted that Resident #413 had a red area to her buttocks identified 5/19/23. Treatment orders were not obtained at that time and the family was not made aware. On 5/21/23, the area was identified by a CNA to be bleeding, the nurse was made aware and implemented zinc and a dressing, which the facility determined to not be an appropriate treatment. On 5/26/23, the facility conducted a skin sweep on the unit and conducted head to toe skin evaluations on each Resident, to identify if anyone else had been affected by the deficient practice. The facility then reviewed the treatment orders for all pressure ulcers. All the nursing staff were re-educated on wound prevention and change in condition. The facility then conducted weekly skin observations for 8 weeks to monitor compliance. The facility indicated their date of compliance was 7/26/23. The survey team reviewed all the credible evidence submitted and had no further concerns identified during the survey with regards to the prevention, identification of, or treatment of pressure ulcers. The facility achieved compliance for this deficient practice on 7/26/23.

Based on interview, clinical record, and facility documentation the facility staff failed to ensure residents are free from neglect and misappropriation of property for 21 Residents (#'s 42, 92, 23, 6, 363, 87, 52, 9, 38, 14, 97, 64, 7, 67, 78, 69, 56, 31, 364, 72, 88, 82 and 78), in a survey sample of 62 Residents. The findings included: For Resident #'s 42, 92, 23, 6, 363, 87, 52, 9, 38, 14, 97, 64, 7, 67, 78, 69, 56, 31, 364, 72, 88, 82 and 78, the facility staff failed to ensure the appropriate handling of medications to prevent misappropriation of Residents property. On 8/24/23 at 9:00 AM an interview was conducted with the DON (Director of Nursing) who stated that on 6/7/23, LPN N did not administer medications as she should have and there were controlled substances not accounted for. The proper authorities were notified, the OLC (Office of Licensure and Certification), DHP (Dept. of Health Professions), the Ombudsman, the Police, the pharmacy, physicians, and the Responsible Parties were all notified. LPN N refused to give a statement to the facility, however, she did speak with the police officers. The DON stated that LPN N said that she was resigning effective immediately. The DON stated that after the first incident of diversion of medication on 6/7/23, a second incident occurred on July 25th when the missing controlled substances involved 2 Residents (#'s 78 & 82) in that instance the Medication Cards for both Residents were taken. An investigation was conducted however, they were unable to determine when the cards were taken. There was a common nurse that worked with both Residents, and she was an agency nurse. The DON requested she not return to the facility. The facility self-identified the problem and put together a QAPI plan for both incidents they submitted for consideration for PNC (Past Non-Compliance). They are as follows: QAPI Plan of action for Misappropriation of Medication 6/7/23 1. All identified residents assessed to determine if any ill effects of medication/Tx omissions. 2. Reviewed administration record of MAR/TAR on individual nurses' assignment to identify affected residents. 3.Facility staff re-educated on abuse policy/misappropriation, Licensed nurses educated on shift-to-shift narc count, signs and symptoms of impairment, reporting suspicions of impairment, reporting controlled med discrepancies, misappropriation and abuse policy review, documentation of medications/Tx on MAR/TAR validating med/to documentation during shift change with off going nurse. 4.DON or designee will review 6 nurse shift assignments weekly to validate medications and Tx administer (sic) per order X 6 weeks. DON or designee will visually inspect controlled accountability records to controlled supply in med cart weekly to validate accountability X 6 weeks. 5. DOC (Date of Compliance) 8/1/23 QAPI Plan of action for Misappropriation of Medication 7/25/23 1. All identified residents assessed to determine if any ill effects of medication/Tx omissions. 2. Reviewed administration record of MAR/TAR on individual nurses' assignment to identify affected residents. 3.Review documentation of medications / TX's on the MAR's / TAR's, new log education, documenting of controls received and completed, new books on unit for controlled delivery manifest and completed control accountability records and misappropriation. 4. Facility SW will interview 3 residents per week to validate no concerns with medication administration for 6 weeks. DON /Designee will audit controlled accountability records to controlled supply in med cart weekly to validate accountability X 6 Weeks. The results of Audits will be reviewed in QAPI to determine if there is a need for further monitoring. 5. DOC (Date of Compliance) 8/15/23 While on the survey the survey team reviewed the Past Non-Compliance QAPI plan and the education provided, as well as the proof of in-service and training sheets. The new pharmacy count sheet was reviewed with the DON and the counting of controlled substances was observed utilizing the new pharmacy drug reconciliation forms. The staff correctly counted and used the pharmacy sheet for tracking the acquiring of medication from pharmacy, as well as the dispensing and completion of medication (when a Resident has completed the course of medication and the order is completed or when the medication is re-ordered, and the medication card is empty). On 8/25/23 the Administrator was made aware, and no further documentation was provided.

Based on observation, Resident interview, staff interview, clinical record review, and facility documentation review, the facility staff failed to provide assistance with activities of daily living (ADL) for Residents who were dependent upon facility staff for such care, affecting 3 Residents (Resident #10, #29, and #87) in a survey sample of 64 Residents. The findings included: 1. For Resident #10, the facility staff failed to provide needed assistance so that the Resident could be out of bed into her wheelchair, which resulted in her being served lunch in the bed and she did not eat the meal. On 8/24/23 at approximately 10 AM, Resident #10 was visited in her room by Surveyor C. Resident #10 stated that she was waiting to get up. On 08/24/23 at 11:20 AM, CNA M was observed in Resident #10's room. Resident #10 was dressed, and CNA M said she was getting her up. On 08/24/23 at 12:37 PM, Surveyor C observed that Resident #10's call light was on. The unit manager, LPN C was observed to respond to the call light and the Resident was heard to say, I want to get up. LPN C told the Resident meal trays were up [on the unit] and she would have to wait until after lunch. On 08/24/23 at 12:54 PM, Resident #10 was again asking to get up. An interview was conducted with CNA M who said, She [Resident #10] wants to get up but the lift wasn't working, by the time I found the one that was working, the meal trays were out on the floor. I'm going to get her up after lunch. On 8/24/23 at 1:40 PM, Resident #10 was observed to still be in bed with her meal tray in front of her and it was noted the Resident had not eaten. When asked, Resident #10 said, she was unable to eat, while the roommate is in the room defecating. It was noted that there was a strong odor of feces within the room. On 08/24/23 at 01:46 PM, an interview was conducted with LPN D. LPN D confirmed that they only have 1 mechanical lift on the unit, and they have about 11 or 12 Residents who require the lift for transfers. When asked if something was wrong with the lift, LPN D said, it stopped functioning properly. We tagged it out [took it out of service] and put it out back. LPN D then confirmed that there was only 1 functioning lift throughout the entire building, which would have to be shared between all 3 nursing units and across 2 levels. During the above conversation with LPN D, LPN C, the unit manager walked up. LPN C said she was unaware that it wasn't working. When LPN C was told Resident #10 wanted to get up and as a result had to eat in her room and had not eaten her lunch, LPN C said, I was in there at breakfast, and she told me when she wanted to get up. I then answered her call light and she said she wanted to get up but that was right when the trays were out, I told her after lunch they could get her up. Once she comes out, I can get her something else from the kitchen, they will make her something. LPN C was asked to explain what the meal trays being out had to do with a Resident being able to get out. LPN C explained that when the meal trays are on the unit, all the staff work on distributing meal trays, so they can get the trays out faster. On 8/24/23 at 2:20 PM, Several CNAs were observed at Resident #10's room with a lift but reported to Surveyor C that Resident #10 said, she had taken her shoes off and everything and said she isn't getting up now. Review of Resident #10's clinical record was conducted. The care plan identified a focus area that read, The resident has an ADL self-care performance deficit r/t [related to] hemiplegia. Interventions for this identified area, included but were not limited to, Eating: The resident at times has fluctuations in eating provide supervision and when needed physical assistance . Resident requires physical assistance with ADLS. Staff to provide physical assistance as needed . [Resident #10's name redacted] requires a full hoyer lift by 2 staff to move between surfaces as requested and as necessary . The facility policy titled, Activities of Daily Living (ADLs) was received and reviewed. Excerpts from this policy read, .4. Appropriate care and services will be provided for residents who are unable to carry out ADLS independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: a. Hygiene (bathing, dressing, grooming, and oral care) . b. Mobility (transfer and ambulation, including walking) . On 8/24/23, during an end of day meeting, the facility Administrator was made aware of the above findings. No further information was provided. 2. For Resident #29, the facility staff failed to provide assistance with showers/bathing so that the Resident would receive showers twice weekly. On 08/23/23 at 10:37 AM, during a Resident interview, Resident #29 verbalized frustration that she is only getting showers once a week. On 8/23/24-8/24/23, a clinical record review was conducted. This review revealed that according to the ADL sheet, Resident #29 had not received a shower from 7/25/23-8/24/23, only partial baths and bed baths were provided. The facility policy titled, Activities of Daily Living (ADLs) was received and reviewed. Excerpts from this policy read, .4. Appropriate care and services will be provided for residents who are unable to carry out ADLS independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: a. Hygiene (bathing, dressing, grooming, and oral care) . b. Mobility (transfer and ambulation, including walking) . On 8/25/23, the facility Administrator and Director of Nursing (DON) were made aware of the above findings. Following the end of day meeting, the DON provided Surveyor C with a report that indicated Resident #29 received showers on 8/16, 8/19, 8/20 and 8/25. However, according to the ADL sheet, a shower was noted but it was coded as 8/8, according to the legend the code 8/8 indicated Activity itself did not occur or family and/or non-facility staff provided care 100% of the time for that activity. No further information was provided. 37828 3. The facility staff failed to ensure Resident #87 received the necessary services to maintain good grooming and personal hygiene to include the removal of facial hair. Resident #87 Minimum Data Set (MDS - an assessment protocol), a quarterly with an Assessment Reference Date (ARD) of 06/26/23 coded Resident #87's Brief Interview for Mental Status (BIMS) score of 15 out of a possible score of 15 indicating no cognitive impairment. The MDS coded Resident #87 total dependent of two with bathing, extensive assistance of two with bed mobility, extensive assistance of one with transfer, dressing, toilet use and personal hygiene and supervision with eating for Activities of Daily Living (ADL) care. Resident #87's person-centered care plan with a revision date of 07/25/23 documented resident may have fluctuations in ADL's. The goal set for the resident by the staff was that the resident will maintain current level of function. The interventions/approaches the staff would use to accomplish this goal is that the resident requires physical assistance. During the initial tour on 08/22/23 at 2:34 p.m., Resident #87 was observed lying in bed with facial chin hair, approximately 1/4 inches long, gray, and black in color. The resident stated the facial chin hair is embarrassing and would remove it herself if someone would just give her a razor. She stated she had asked numerous times to be shaved but her request was never acted upon. The resident stated she would like to be shaved today if possible. On the same day at 3:45 p.m., Resident #87 was assessed by the Unit Manager (UM) with the surveyor present. Resident #87 informed the UM she had asked staff on several occasions to be shaved but the staff never shaved her. The UM stated Resident #87 need to be shaved and would make sure Resident #87 would be shaved right away. The UM stated all nursing staff are responsible for ensuring residents (male or females are shaved). She stated residents are to be shaved on their shower days and as needed. On 08/23/23 at 9:55 a.m., Resident #87 was observed lying in bed without facial hair to her chin. She stated she feels so much better while rubbing her chin. The Director of Nursing (DON) was interviewed on 08/25/23 at 4:45 p.m. She stated, first the staff must determine if Resident #87 wished to keep her facial hair or have her facial hair removed. She stated once her wish was determined, her wish must bed honored. A final meeting was held with the Administrator, Director of Nursing and Corporate on 08/25/23 at 6:00 p.m., who were informed of the above findings. An opportunity was offered to the facility's staff to present additional information, but no further information was provided. The facility's policy titled Activities of Daily Living (ADLs) noted to be without a created or revision date. It is the facility policy that residents will be provided with care, treatments, and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal hygiene, and oral hygiene. Specific procedures/guidance. 3. Each resident shall be given proper daily personal attention and care, including skin, nail, hair, and oral hygiene, in addition to any specific care ordered by the attending physician.

Based on resident and staff interviews, clinical record review and facility's documentation, the facility staff failed to ensure 2 of 64 residents (Resident #107 and #413) in the survey sample were free from the use of unnecessary medications. The findings included: 1. The facility staff failed to ensure Resident #107's antibiotic was discontinued on 07/26/23 as directed on the hospital discharge summary dated 07/18/23. Resident #107 received an extra 47 doses of the antibiotic (Cefadroxil). Resident #107 was admitted to the nursing facility on 07/18/23. Diagnosis for Resident #107 included but not limited to periprosthetic fracture around internal left hip and left ankle joint. The Minimum Data Set (MDS - an assessment protocol) an admission assessment with an Assessment Reference Date (ARD) of 07/22/23 coded Resident #107 with a 12 out of a possible score of 15 on the Brief Interview for Mental Status (BIMS), indicating moderate cognitive impairment. The MDS coded Resident #107 total dependence of one with bathing, extensive assistance of two with bed mobility, extensive assistance of one with dressing, limited assistance of one with transfer, toilet use and personal hygiene and supervision with one assist with eating for Activities of Daily Living (ADL) care. Resident #107's person-centered care plan created on 07/19/23 and revised on 07/27/23 identified the resident on antibiotic therapy related to post-op surgery. The goal set for the resident by the staff was that the resident will be free of any discomfort or adverse side effects of antibiotic therapy. Some of the interventions/approaches the staff would use to accomplish this goal is to administer antibiotic medications as ordered by the physician, monitor/document side effects of effectiveness every shift. An interview was conducted with Resident #107 on 08/22/23 at 12:11 p.m. He stated he is currently getting antibiotic on a routine basis but not sure how long he is scheduled to receive the antibiotic. A review of Resident #107's hospital discharge summary dated 07/18/23 revealed an order for Cefadroxil (antibiotic) 500 mg capsule - take 2 capsules daily for 7 days. The Physician Order Summary (POS) for August 2023 revealed an order starting on 07/19/23 for Cefadroxil 500 mg capsule - give one capsule twice a day for post-op prophylactic. The order also included clarification of a stop date by pharmacy. A review of Resident #107's Medication Administration Record (MAR) for July and August 2023 indicated Resident #107 received an extra 47 doses of the antibiotic Cefadroxil 500 mg. On 08/24/23 at 5:00 p.m., an interview was conducted with the Nurse Practitioner (NP.) She stated she was not aware Resident #107 was still on antibiotic therapy until she was informed by the DON on 08/23/23. She stated Resident #107's antibiotic should have been discontinued according to the resident's hospital discharge summary. An interview was conducted with the Director of Nursing (DON) on 08/25/23 at 5:00 p.m. After she reviewed Resident #107's hospital discharge orders, POS and MARs for July and August 2023, she stated Resident #107's antibiotic should have been discontinued after receiving the antibiotic for 7 days based on the resident's hospital discharge summary. A final meeting was held with the Administrator, Director of Nursing and Corporate on 08/25/23 at 6:00 p.m., who were informed of the above findings. An opportunity was offered to the facility's staff to present additional information, but no further information was provided. 41449 2. For Resident #413, the facility staff ordered and administered an antibiotic that was unnecessary, because the infection being treated was resistive to the antibiotic ordered. On 8/23/23-8/24/23, a closed clinical record review was conducted of Resident #413's medical chart. This review revealed the following: A urinalysis sample was obtained on 3/21/23, and the results were reported to the facility that evening which was indicative of a urinary tract infection. There were no notes proceeding this to indicate the Resident's symptoms. A progress note entered by the nurse practitioner on 3/22/23 at 7:14 PM, that read, .Patient seen today for UTI [urinary tract infection]. Per nursing staff, her yelling out has decreased. Patient is non-verbal but did not appear to be in distress. New order for Levaquin 500mg daily x 7 days, will continue to monitor. There were no notes proceeding this to indicate the Resident's symptoms. Review of the Medication Administration record (MAR) revealed Resident #413 received the Levaquin on 3/22/23 and 3/23/23. On 3/24/23, the order for Levaquin (antibiotic) was discontinued and a new order for Cipro Oral Tablet 500 MG (Ciprofloxacin HCl) Give 1 tablet by mouth two times a day for uti for 3 Days was entered. Resident #413 received the Cipro for one dose on 3/24/23, 2 doses on 3/25/23 and 3/26/23, and one dose on 3/27/23. Review of the Urine culture and sensitivity report that was received by the facility on 3/23/23 at 8:14 AM, revealed that the infection was resistive to Levofloxacin, also known as Levaquin and Ciprofloxacin, also known as Cipro. On 08/24/23 at 04:58 PM, an interview was conducted with Employee C, the nurse practitioner (NP) and ordering provider of the antibiotics noted above with regards to Resident #413. When asked about the order for Levaquin being changed to an alternate antibiotic that the infection was still resistive to, the NP said, It must have been a mistake, I wouldn't have had a reason to order an antibiotic it was resistive to, it didn't hurt her but didn't do any good. When asked about the unnecessary use of antibiotics and if that was upholding antibiotic stewardship, the NP said, absolutely not. We don't want people taking unnecessary antibiotics. Review of the facility's Antibiotic Stewardship Program was conducted. This policy defined antibiotic stewardship as refers to a set of commitments and actions designed to optimize the treatment of infections while reducing the adverse events associated with antibiotic. This can be accomplished through improving antibiotic prescribing, administration, and management practices thus reducing inappropriate use to ensure the residents receive the right antibiotic for the right indication, dose, and duration . On 8/24/23, during an end of day meeting, the facility Administrator and Director of Nursing were made aware of the above findings. No further information was provided.

Based on observation, interview, record review, and policy review, the facility failed to ensure palatable food was served to six (of 104 residents Resident (R) 61, R36, R69, R35, R7, R87). Specifically, the food did not look appetizing and lacked flavor, the variety of menu offerings was limited, and an established recipe was not being followed correctly. This failure contributed to residents' ongoing reluctance to consume their meals, an overall dissatisfaction with their dining experience and the deviation from established recipes left residents' health and well-being at risk. Findings include: Review of the undated paper Food and nutrition services policy revealed, Each resident is provided with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident . Food and nutrition services staff will inspect food trays to ensure that the correct meal is provided to each resident, the food appears palatable and attractive, and it is served at a safe and appetizing temperature .lf an incorrect meal is provided to a resident, or a meal does not appear palatable, nursing staff will report it to the Food Service Manager so that a new food tray can be issued. 1. Interviews with residents during the survey process revealed the following complaints about food palatability: a. On 08/22/23 at 11:48 AM, R61 stated that the food is not good, they've gotten warmers for plates, but the food comes cold. She can't get corned beef hash or sausage links or omelets. They only serve bacon and sausage patties. Review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/24/23 in the Electronic Medical Record (EMR) under the MDS tab indicated R61 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating the resident was cognitively intact. b. On 08/22/23 at 12:25 PM, R36 stated The food is disgusting, there's never anything different. The quality is lacking. Review of the annual MDS with an ARD of 06/19/23 in the EMR under the MDS tab revealed a BIMS score of 13/15, indicating the resident was cognitively intact. c. On 08/22/23 at 12:32 PM R69 stated that the food is terrible, there's either too much seasoning or not enough. She further stated that she never eats breakfast because she does not like it. Review of the quarterly MDS with an ARD of 06/28/23 in the EMR under the MDS tab revealed was unimpaired in cognition with a BIMS score of 15 out of 15. d. On 08/22/23 at 2:21 PM R35 stated, The food is too salty, there are too many starches on the plate, there is too much sugar, and the chicken is dry as a bone. Review of the quarterly MDS with an ARD of 05/09/23 in the EMR under the MDS tab revealed was unimpaired in cognition with a BIMS score of 15 out of 15. 2. The paper Resident Council Minutes revealed the following comments from anonymous residents and some staff who attended the meetings: 08/03/22 - The food is not good, and it is always cold. The residents would also like a different cereal. 09/02/22 - An ongoing concern was food choices. The residents requested that they bring back the buffet because they were tired of the same stuff being served. The residents inquired about switching to a new food vendor. 06/07/23 - Residents complained about 1) not having hot coffee and 2) not being able to have coffee at any time of the day, not just breakfast. 3) food was being wasted because residents were not eating the current food choices, their choices needed to be revised. 4) They needed new hot plates because food was cold when received. 06/28/23 - Residents had general complaints about the food. 07/05/23 - Residents formed a food committee. 08/02/23 - Residents complained that were 1) no longer getting sodas and 2) now were getting less variety of snacks. 3. Observations revealed concerns with meal palatability, attractiveness/appearance of food, and accuracy of recipes: a. On 08/24/23 at 1:08 PM a test tray was done with the Food Service Director (FSD) (Employee H) and the Regional FSD (Employee L): Temperatures were taken on the Skilled nursing North unit. The FSD took the following temperatures of the test tray food items: turkey - 146 degrees Fahrenheit (F), noodles 153 degrees F, carrots - 144 degrees F and dinner roll - 125 degrees F. The FSD stated that the carrots were frozen, steamed and then placed on steamed table, the noodles were made onsite and then placed in the steam table, and the turkey came raw and was cooked down and then sliced and placed on the steam table. Prior to tasting, the FSD took a package of salt and pepper and sprinkled it all over the plate. The carrots were found to be mushy and bland and overall lacking in discernible carrot flavor, the noodles were overcooked and bland and had a waterlogged texture, the turkey tasted extremely salty, more like a processed meat product (as opposed to a fresh turkey). The meal also came with a pink powdered drink mix which the FSD indicated was like a Crystal Light meaning that it was sugar free. All the residents in the facility were now being offered this drink in place of soda, as they [sodas] were deemed empty calories by the FSD. The FSD stated it was possible that the wrong type of turkey had been sent by his vendor. When the FSD was asked about the meal he stated, It's not bad. The regional FSD (Employee L) declined to try the test tray citing a turkey allergy. b. On 08/24/23 at 5:48 PM a second test tray was conducted with survey team. A takeout box was brought to the conference room once the last resident meal had been delivered. The menu revealed that the dinner was a soft beef taco, chopped cilantro, Spanish rice, and buttered kernel corn. The taco meat appeared to be a broken-up hamburger (as opposed to browned ground meat) and was extremely bland. The recipe called for onion, chili powder, garlic powder, ground oregano and cayenne none of which was evident to the palate. The Spanish rice appeared as a clumpy mass and tasted overcooked, bland, and waterlogged and the texture fell apart in the mouth. The corn (which was from a can) was also overcooked, bland and waterlogged and the texture was devoid of the usual crispness of corn. c. Interviews with residents were conducted after the first test tray: On 08/24/23 at 1:52 PM R7 stated that the noodles had no flavor, and the turkey was salty. On 08/24/23 at 1:54 PM R87 stated that the turkey was too salty, the carrots tasted off and that she didn't eat the noodles because they don't have any flavor. 08/24/23 at 1:57 PM R61 stated she ordered a chef's salad instead of the meal. 4. During an interview with Registered Nurse (RN) B on 08/23/23 at 11:34 AM she stated that sodas were taken away because of cost but also management said that they were empty calories, it happened around two weeks ago. They do give out snacks to the residents: i.e. chips, crackers, peanut butter sandwich crackers. She stated that snacks are given out mid-morning when they pass the ice, around 11:00 AM. The residents are not allowed to go into the pantry on their own to get snacks. When it was pointed out that the residents were seen sitting in the dining room currently with no obvious snacks or snack wrappers, she stated that the aides were busy with resident care currently. She then started asking the residents in the dining room if they wanted snacks. During a follow up tour of the kitchen and interview with the FSD on 08/24/23 at 11:38 AM he stated that Initially there was a five-week menu, and they [the residents] went down to four weeks. They are in the process of making changes, the main dining room is scheduled to open this coming Monday. The buffet had a soft opening about a month ago but there hasn't been another buffet since and the Regional FSD stated that We do order sodas but once that level is gone, that's it. The amount we order is two sodas per person per day. He stated that a 24 can case of soda is $11.00. During an interview with the Administrator on 08/25/23 at 7:58 AM he stated that he has tried the food a few times and stated, it wasn't bad. He agreed that the soda was not good for the residents. He was surprised to hear that the residents were not told about the sodas ahead of time. He stated that he was sorry that we [the facility] dropped the ball on the food quality and offering. During a follow up visit to the kitchen on 08/25/23 at 9:48 AM the FSD confirmed that the turkey used for the turkey a la king was not the frozen, raw turkey breast with skin that the recipe called for but rather a pressed turkey was used instead. The FSD stated that he was trying different things in order to accommodate the residents and that he did in fact order a different item than what the recipe stated. Upon further investigation of the drink mix, it was revealed that it was not sugar free but per serving contained 120 calories and 31 grams (g) of carbohydrate (30g added sugars.) The FSD pointed to the box where it stated that he thought it was crystal light because the box stated that it was powdered crystals. During an interview with the Registered Dietitian (RD) on 08/25/23 at 1:31 PM it was revealed that the dietary department was on a strict food budget which only allowed the Food Service Director to make certain foods, etc. It's only what can fit into the budget. They [the residents] may not like the menu sometimes. The paucity of sodas was the FSD's domain, and she was not able to speak to that.

Based on observations, resident interviews, record review and facility policy review the facility failed to follow the prescribed diet and honor food preferences for two (Residents (R) 69 and 35) of two residents sampled for food preferences, out of a survey sample of 35 residents. Specifically, R69 was not aware of alternate food options and had not had her food preferences updated since admission and R35 was receiving food that did not meet her taste and nutrition preferences. The failure to accommodate the residents' dietary choices and preferences violates their right to person centered care, potentially resulting in a diminished quality of life and potential negative health consequences. Findings include: Review of the facility's undated policy titled, Resident's Right to Make Personal Dietary, Food and Meal Choices, revealed, The facility recognizes the resident's/resident representative's right to make personal dietary, food, and meal choices. The facility also promotes, with reasonable accommodation, the choice of alternate foods, and flexible mealtimes .The resident and/or resident representative will be involved in choices about food and dining such as food selection to help them maintain a sense of dignity, control, and autonomy. 1. Review of the R69's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/07/23, located in the EMR under the MDS tab, revealed R69 had a Brief Interview for Mental Status (BIMS] score of 15 out of 15 which indicated the resident was cognitively intact. Her preferences for customary routines revealed that it was very important for the resident to have snacks available between meals. Review of R69's Physician Orders, dated 05/22/23, located in the EMR under the Physician Orders tab revealed that the resident was on a No Added Salt diet, Regular texture, Regular/Thin consistency, cut meat per resident request. Review of R69's Nutrition Care Plan, dated 03/29/23, located in the EMR under the Care Plan tab, indicated R69 Is at nutritional risk due to cardiovascular disease and cancer. Receives a therapeutic diet which is appropriate (NAS). Interventions included: Honor resident's preferences and requests within diet order. Honor resident's right to refuse food or fluids, Offer alternative meals or substitutions if poor po[by mouth] is observed Review of R69's Dietary Profile, dated 05/17/23, located in the EMR under the Assessments tab, indicated R69 had no food preferences, allergies, intolerances, or dislikes. Review of R69's Kardex (a dietary profile card used in the kitchen on the tray line) revealed the resident had no likes or dislikes and no snacks requested. On 08/22/23 at 12:32 PM, R69 stated that the food was terrible and she stated that she never eats breakfast because she does not like it. On 08/23/23 at 9:04 AM, R69 was observed without her breakfast tray. She stated she sent it back. The breakfast meal that day was Sausage gravy, parsley sprig, biscuit and oatmeal She stated she was not offered any alternatives and generally does not eat breakfast. She recounted her dinner the previous evening which was described as burnt sausage, greens and carrots that she doesn't eat. She stated that she only eats corn and green beans as vegetables but always gets vegetables that she doesn't like. On 08/24/23 at 8:45 AM, R69 was observed without her breakfast tray, she stated she sent it back. The breakfast meal that day was, Scrambled egg, slivered green onions, wheat toast and oatmeal. She added that she is never offered any snacks and must procure her own. On 08/24/23 at 11:52 AM during an interview with the Food Service Director (FSD) it was revealed that the resident did not have any preferences noted on her Kardex. It was completely blank. He stated that he would follow up with R69. During a follow up interview on 08/25/23 at 12:50 PM, R69 she thought when she first came someone did ask her preferences, but she stated she never saw a dietitian. She reiterated that she only liked corn and green beans, she liked ground beef, spaghetti, and hamburgers. She didn't like breakfast food as the food arrived cold in the morning. She stated she ordered takeout food the night before though if she had known that fish nuggets were an alternate menu option she would have chosen them. She stated that nobody comes to ask her what she might want to eat and she was not able to go and look at the list of alternates, she also wasn't allowed to fill out a menu. She stated that broccoli is always soggy, she doesn't get salt but she gets pepper, she is not given enough butter, she only gets one packet. She never gets any soda. She can get someone to go get a Pepsi out of the vending machine and it is $2.00. She stated that the sodas that they used to get were one little perk that they took away, it was still nice to have them. She liked having the Shasta, it was a little perk to make the meal a little bit better. She only ever saw snacks a few times when she first got here. At 1:13 PM R69's lunch tray arrived. The peaches do not look fresh, I only received one sugar packet, one package of butter, there's squash on my tray but I don't like squash and I also don't eat the sweet potato fries. During a follow up interview with the FSD on 08/25/23 at 9:48 AM he stated that he had not yet visited R69 to discuss her food preferences. On 08/25/23 at 1:48 PM during an interview with the Registered Dietitian (RD) it was revealed that R69 told her that she wants her meat cut up and indicated that she doesn't like peas or okra. The RD stated that when she meets with the residents she talks to them about the alternate menu, though this is not documented anywhere. She stated that all she has to do is request a menu and someone would print one out and get one to her. 2. Review of R35's quarterly MDS with an ARD of 05/09/23 located in the EMR under the MDS tab revealed R35 was unimpaired in cognition with a BIMS score of 15/15. Her preferences for customary routines revealed that it was very important for the resident to have snacks available between meals. Review of R35's Physician Orders located in the EMR under the Physician Orders tab revealed that the resident was on a No Added Salt diet, Mechanical Soft texture, Regular/Thin consistency on 05/26/22. R35 also had an order for fortified foods to be served at all meals for added protein and calories for weight loss prevention. Review of R35's Nutrition Care Plan, initiated date 05/25/21 and located in the EMR under the Care Plan tab, indicated R35 is at nutritional risk due to cardiovascular disease. Receives a mechanically altered, therapeutic diet due to cardiovascular disease (NAS) and is mechanical soft due to dentures/chewing concerns. Diet is also therapeutic due to receiving Ensure and fortified foods added to promote weight gain plan. Is at risk for weight loss due to hx. of weight loss. Goals: Ms. [NAME] will maintain adequate nutritional status as evidenced by maintaining weight without significant loss with no s/sx of malnutrition through the next assessment review date. Interventions included: Honor dietary preferences and requests within diet order, offer meal alternative or substitutions if poor intake is observed. Review of R35's Dietary Profile dated 08/21/22, located in the EMR under the Assessments tab, indicated R35 had no food preferences, allergies, or intolerances. Dislikes were noted as no gravy, butter, syrup, oatmeal, sugar, salt and pepper R35's comments revealed She doesn't really care for the food because it is salty. Review of R35's Kardex revealed that the resident liked orange juice and one boiled egg with meal, and no oatmeal, for lunch and dinner the Kardex indicated No gravy, no sugar, no salt and no pepper. On 08/22/23 at 2:21 PM, R35 stated that her food was too salty, there were too many starches on the plate and too much sugar and the chicken was dry as a bone. On 08/23/23 at 9:00 AM, R35 sent her biscuit and meat back stating that it was too salty, she only had the milk, juice, and an egg. On 08/23/23 at 2:38 PM, R35 was seen after lunch. She reported that she received corn, but she didn't eat it, the hamburger steak had too much sauce on it, the rice pilaf was overcooked, so she only had a tablespoon, and the sherbet was too sweet. During a follow up interview with the FSD on 08/25/23 at 10:20 AM he stated that the Kardex system generally works to ensure residents get their food preferences but if they don't read the card while the tray line is going it is possible for errors to occur. During an interview on 08/25/23 at 1:51 PM with the RD she stated that R35 on a No Added Salt (NAS) diet and receives fortified foods like soup, oatmeal with powder and additional food items. She stated that she was very underweight when she came to the facility. She lost weight when she first came and then she lost some weight, but recently her weight has increased. When this writer brought it to her attention that one of the resident's issues was that there were too many carbohydrates on her tray, she stated she would take a look.

Based on Resident interviews, staff interviews, and facility documentation review, the facility staff failed to provide snacks to Residents affecting multiple Residents on 3 of 3 nursing units. The findings included: The facility staff stopped providing snacks between meals and at bedtime which affected multiple Residents residing on each of the nursing units. On 8/22/23 and 8/23/23, during Resident interviews conducted by the entire survey team, on both nursing units, multiple Residents verbalized concern and frustration that their snack and drinks were taken away. Multiple Residents stated they were told They were a luxury. On 8/23/23 at 2 PM, a Resident Council meeting was held with 13 Residents in attendance (Resident #7, #13, #23, #41, #44, #47, #53, #58, #61, #67, #84, #92, and Resident #98). The Residents unanimously verbalized concern that the snacks and drinks were taken away and they don't receive any between meal or at bedtime snacks. The group collectively gave permission for the minutes from prior Resident council meetings to be reviewed. On 8/23/23, Surveyor C observed the pantry on the first floor and observed there were no drinks, snacks, or any type of substance items for staff to be able to distribute to Residents who requested a snack. Review of the Resident Council meeting minutes revealed the following: During the August 2, 2023, meeting, it was noted that the report from dietary included . there will be no more soda and less variety of snacks. On 8/24/23, an interview was conducted with a staff member who requested to remain anonymous. The employee was asked about the availability of snacks. The employee said that there are no snacks. They said, we make sandwiches and bring items from home to give our Residents. On 8/24/23, during an end of day meeting, the facility Administrator was made aware of the above findings.

Based on interview and record review, it was determined the facility failed to implement a comprehensive antibiotic stewardship program. This failure had the possibility of negatively impacting all residents in the facility. In addition, the facility staff failed to follow their antibiotic stewardship program by ensuring the Resident did not receive antibiotics that were inappropriate for 2 (residents 107 and 413) of 64 sampled residents. Findings include: During an interview on 08/25/23 at 2:20 PM with the Director of Nursing (DON), the DON stated the Infection Control Preventionist (ICP) was on vacation this week. The DON said she had not reviewed the ICP's infection control binder prior to today. The DON stated they do have a monthly care meeting (Clinical Operations Meeting) where they review tracking and trending, where infections are located within the building and what has been done in relation to those infections. The DON was unable to provide any maps tracking the location/types of infections in the facility. The DON stated, recently, the majority of the infections in the facility had been urinary tract infections. The DON was unable to locate a line listing for every month during 2023. The DON stated a review of all infections are held at the monthly clinical operations review. The DON said the Medical Director was at the facility every Wednesday and the ICP would review any infection/antibiotic concerns with the Medical Director at that time. Review of the Clinical Operations Reports from January 2023 through June 2023 indicated a review of the type and number of infections occurring in the facility, but no review of the antibiotic prescribed/used to treat the infections. Review of the facility's undated policy, Antibiotic Stewardship Program, stated, Policy: This organization is committed to providing sufficient resources to establish and maintain systems and processes fa facility wide system to monitor the use of antibiotics through an interdisciplinary Antibiotic Stewardship Program. Improving the use of antibiotics in the nursing facility to protect residents and reduce the threat of antibiotic resistance is a priority. The goals for the program include: Ensuring that residents who require an antibiotic, are prescribed the appropriate antibiotic, reducing the risk of adverse events, including the development of antibiotic-resistant organisms, from unnecessary antibiotic utilizations, and adverse outcomes monthly and feedback will be provided to the QAPI committee regarding antibiotic stewardship practices .Specific Procedures/Guidance: 1. The facility will establish and maintain an interdisciplinary Antibiotic Stewardship Program that will at a minimum include participation by the medical director, prescribing physicians/non-physician practitioners, consulting pharmacist, administrator, nursing leadership and infection control preventionist. 2. The Antibiotic Stewardship team will meet monthly to review antimicrobial regimens .4. A standard of criteria for defining various infections, (i.e. McGeer's Criteria) will be adopted and utilized for classifying infections .5.When symptoms of infection are identified, the clinical team .will complete an evaluation of the resident and communicate findings to the resident's physician for orders related to diagnostic testing and/or treatment .6. The initial tracking/surveillance tool will be initiated by the infection control preventionist .and will be completed for each resident .7. Infection and antibiotic therapy usage will be maintained for each unit .monthly 12. A summary of the monthly tracking, analysis and actions taken will be communicated to the QAPI Committee for additional oversight .13. At least on an annual basis, the facility will obtain and review an antibiotic algorithm . 37828 2. The facility staff failed to ensure Resident #107 received the antibiotic (Cefadroxil) for the length of time as ordered by the physician. Resident #107 was admitted to the nursing facility on 07/18/23. Diagnosis for Resident #107 included but not limited to periprosthetic fracture around internal left hip and left ankle joint. A review of Resident #107's hospital discharge summary dated 07/18/23 revealed an order for Cefadroxil (antibiotic) 500 mg capsule - take 2 capsules daily for 7 days. The Physician Order Summary (POS) for August 2023 revealed an order starting on 07/19/23 for Cefadroxil 500 mg capsule - give one capsule twice a day for post-op prophylactic. The order also included clarification of a stop date by pharmacy. The antibiotic Cefadroxil was first administered to Resident #107 on 07/19/23 and was administered until 08/22/23. A review of Resident #107's Medication Administration Record (MAR) for July and August 2023 indicated Resident #107 received an extra 47 doses of the antibiotic Cefadroxil 500 mg. An interview was conducted with the Director of Nursing (DON) on 08/05/23. She stated the Antibiotic Stewardship Program is monitored by the Assistant Director of Nursing (ADON) who is also the Infection Preventions (IP). She stated the IP is currently not available at this time. She stated when the nurse transcribed the order indicating the antibiotic was being used prophylactic, the ADON/IP did not have a reason to review the hospital discharge summary. On the antibiotic order, the pharmacy also requested to clarify the stop date. She stated in order for the nurse to see the pharmacy request for the a stop date, they would have to click the + sign in the order but again, since the order read prophylactic, no one expanded the order. A final meeting was held with the Administrator, Director of Nursing and Corporate on 08/25/23 at 6:00 p.m., who were informed of the above findings. An opportunity was offered to the facility's staff to present additional information, but no further information was provided. 41449 3. For Resident #413, the facility staff failed to follow their antibiotic stewardship program by ensuring the Resident did not receive antibiotics that were inappropriate. On 8/23/23-8/24/23, a closed clinical record review was conducted of Resident #413's medical chart. This review revealed the following: A urinalysis sample was obtained on 3/21/23, and the results were reported to the facility that evening which was indicative of a urinary tract infection. There were no notes proceeding this to indicate the Resident's symptoms. A progress note entered by the nurse practitioner on 3/22/23 at 7:14 PM, that read, .Patient seen today for UTI [urinary tract infection]. Per nursing staff, her yelling out has decreased. Patient is non-verbal but did not appear to be in distress. New order for Levaquin 500mg daily x 7 days, will continue to monitor. There were no notes proceeding this to indicate the Resident's symptoms. Review of the Medication Administration record (MAR) revealed Resident #413 received the Levaquin on 3/22/23 and 3/23/23. On 3/24/23, the order for Levaquin (antibiotic) was discontinued and a new order for Cipro Oral Tablet 500 MG (Ciprofloxacin HCl) Give 1 tablet by mouth two times a day for uti for 3 Days was entered. Resident #413 received the Cipro for one dose on 3/24/23, 2 doses on 3/25/23 and 3/26/23, and one dose on 3/27/23. Review of the Urine culture and sensitivity report that was received by the facility on 3/23/23 at 8:14 AM, revealed that the infection was resistive to Levofloxacin, also known as Levaquin and Ciprofloxacin, also known as Cipro. On 08/24/23 at 04:58 PM, an interview was conducted with Employee C, the nurse practitioner (NP) and ordering provider of the antibiotics noted above with regards to Resident #413. When asked about the order for Levaquin being changed to an alternate antibiotic that the infection was still resistive to, the NP said, It must have been a mistake, I wouldn't have had a reason to order an antibiotic it was resistive to, it didn't hurt her but didn't do any good. When asked about the unnecessary use of antibiotics and if that was upholding antibiotic stewardship, the NP said, absolutely not. We don't want people taking unnecessary antibiotics. Review of the facility's Antibiotic Stewardship Program was conducted. This policy defined antibiotic stewardship as refers to a set of commitments and actions designed to optimize the treatment of infections while reducing the adverse events associated with antibiotic. This can be accomplished through improving antibiotic prescribing, administration, and management practices thus reducing inappropriate use to ensure the residents receive the right antibiotic for the right indication, dose, and duration . On 8/24/23, during an end of day meeting, the facility Administrator and Director of Nursing were made aware of the above findings. No further information was provided.

Based on Resident interview and staff interview the facility staff failed to uphold Resident Rights regarding the right to receive mail and receive mail unopened affecting 14 Residents (Resident #7, #13, #23, #41, #44, #47, #53, #58, #61, #67, #82, #84, #92, and Resident #98) in a survey sample of 64 Residents. The findings included: 1. During a Resident Council meeting, 13 Residents (Resident #7, #13, #23, #41, #44, #47, #53, #58, #61, #67, #84, #92, and Resident #98), stated they do not receive mail on the weekends. On 8/23/23 at 2PM, a Resident Council meeting was held with 13 Residents. During the meeting all the Residents stated they did not receive any mail on Saturdays, only Monday through Friday. On 8/25/23 at 1:23 PM, an interview was conducted with Employee N, the receptionist. Employee N was asked about the distribution and delivery of mail on weekends. Employee N said, The receptionists that work the weekends do not do the mail, they sit it on a desk back there [pointing to the Administrative offices]. On 8/25/23 at approximately 1:40 PM, an interview was conducted with Employee F, the activities director. Employee F said she gets the mail out of her mailbox and writes down the Resident's names who receive mail and delivers it. When asked about weekends, Employee F said, I'm not here on weekends, I just do it Monday through Friday. On 8/25/23, the facility Administrator was asked to provide any facility policies with regards to the distribution of mail and reported they had no such policy. He was made aware of the above findings. No further information was provided. 2. For Resident #82, the facility staff opened his personal mail and packages prior to the Resident receiving it. On 08/22/23 at 03:06 PM, during an interview with Resident #82, he verbalized he was not happy that the facility opens his packages and mail before he receives them. On 8/25/23 at 1:23 PM, an interview was conducted with Employee N, the receptionist. Employee N was asked about Resident #82's receipt of packages. Employee N reported that Resident #82 receives a lot of packages, I let the activities director give him his. On 8/25/23 at approximately 1:40 PM, an interview was conducted with Employee F, the activities director. Employee F was asked about Resident #82's mail and packages. Employee F said, I deliver his mail and some packages I open because in the past he ordered a lot of sharp objects he couldn't have. When asked what time of items he received, Employee F said, like knives and medicines, I gave it to the nurse, and we put it in a box so his brother can pick it up. Employee F confirmed that Resident #82 had mentioned it to me once before, when asked if she was aware that Resident #82 did not want his mail opened prior to him receiving it. On 8/25/23 at approximately 2 PM, an interview was conducted with the facility Administrator. The Administrator stated he was not aware of Resident #82's packages being opened or the history of him ordering items that he wasn't permitted to have. No further information was provided.

Based on Resident interview, staff interview, facility documentation review, the facility staff failed to respond to Resident Council grievances These grievance included A) laundry not being returned timely B) items being lost, C) food not being good, D) lack of showers, E) cleanliness of the facility, and F) lack of cleaning in their rooms. The findings included: The Resident Council President gave permission on 8/22/23 for surveyors to review the Resident Council minutes prior to a meeting with the Council, planned for 8/23/23. Resident Council minutes were reviewed. The minutes revealed ongoing concerns and complaints regarding laundry not being returned timely and items being lost, food not being good, lack of showers, and cleanliness of the facility and lack of cleaning in their rooms. These concerns persisted over the course of the year, and during the survey. On 8/23/23 at 2:00 P.M., a surveyor met with 13 members of the Resident Council. The Council stated that a lot of people no longer attend the council meetings because it is a waste of time, and nothing is going to be done. The Residents verbalized that the same issues and complaints remain with no resolution. This is borne out by the repetition of the same grievances across multiple months of council minutes that were reviewed by surveyors. Throughout the survey, conducted from 8/22/23 through 8/25/23, other residents expressed the same concerns about the same issues. During the survey, Resident #26 called a surveyor to his room and said he had to purchase a broom to clean his room himself, because they don't clean. Resident #26 had swept his side of the room and there was a significant pile of dirt and debris noted. Throughout the survey, multiple Residents were observed to have bags of soiled clothing in their rooms. Resident #32 was asked about the multiple bags, and he stated, They are my clothes, you hate to send them down because you never get them back. Observations on all 4 days of the survey revealed that the dining room was not being used for meals, only activities. Interviews with facility staff revealed that the dining room has been closed for over a year. Throughout the survey an abundance of Residents had concerns with regards to the meals not being good. On 8/25/23, the facility Administrator was made aware of the concern that Resident Council expresses the same concerns for months with no resolution. No additional information was received.

Based on observation, Resident Interview, Facility staff interview and record review, the facility staff failed to revise 1 of 64 sampled residents care plan. The findings include: For Resident #87, the person-centered care plan failed to include the use of ace wrap dressings. Resident #87 Minimum Data Set (MDS - an assessment protocol), a quarterly with an Assessment Reference Date (ARD) of 06/26/23 coded Resident #87's Brief Interview for Mental Status (BIMS) score of 15 out of a possible score of 15 indicating no cognitive impairment. The MDS coded Resident #87 total dependent of two with bathing, extensive assistance of two with bed mobility, extensive assistance of one with transfer, dressing, toilet use and personal hygiene and supervision with eating for Activities of Daily Living (ADL) care. Resident #87's person-centered care plan with a revision date of 05/11/23 documented resident with impaired circulation related to lymphedema. The goal set for the resident by the staff was that the resident will be free from signs/symptoms of complications of poor circulation through the next review period dated 09/20/23. The interventions/approaches the staff would use to accomplish this goal is to keep legs elevated when resting. A review of Resident #87's Treatment Administration Record (TAR) for August 2023 revealed an order to apply ace wraps to bilateral lower extremities every other day as tolerated for edema starting on 07/22/23. The ace wraps are to be applied in the morning and remove at bedtime (night). During the initial tour on 08/22/23 at 2:37 p.m., Resident #87 was observed lying in bed. She stated she had a diagnosis of lymphedema (swelling in the arms or legs) and the nurse's had not wrapped her legs for several days. She stated she hope her legs are without any open areas or blisters. The resident removed the covers from her lower extremities. Both lower extremities had edema and were noted to be without ace wraps. An interview was conducted with the Director of Nursing (DON) on 08/25/23 at 4:50 p.m. She stated according to the physicians order, the ace wraps are used for edema. She stated MDS usually updates the care plans but any of the nursing staff can also update resident care plan. She stated Resident #87 has a diagnosis of lymphedema and the care plan should have included ace wraps, provide labs as ordered, and monitor for skin impairment. A final meeting was held with the Administrator, Director of Nursing and Corporate on 08/25/23 at 6:00 p.m., who were informed of the above findings. An opportunity was offered to the facility's staff to present additional information, but no further information was provided.

Based on facility staff interviews, clinical record review and facility documentation review, the facility staff failed to incorporate the recommendations from a level II PASARR (preadmission screening and resident review) into the Resident's assessment and care planning for one Resident (Resident #10) in a survey sample of 64 Residents. The findings included: For Resident #10, who had a level II PASARR, the facility staff were unaware until requested by the survey team, that the Resident had a level II screening and failed to incorporate the recommendations into the Resident's assessment and care planning. On 8/22/23-8/23/23, a clinical record review was conducted of Resident #10's electronic health record. Surveyor C was unable to find a PASARR. The care plan did not address a PASARR or any recommendations. On 8/24/23, the facility Administration was asked to provide the PASARR for Resident #10. On 08/24/23 at 02:19 PM, the Director of Nursing (DON) provided Surveyor C with a copy of the Level I PASARR for Resident #10. The level 1 PASARR indicated a level II was needed. On the afternoon of 8/24/23, an interview was conducted with Employee D, the Social Services Director (SSD). The SSD said, In going through I was able to find her level 1, I realized they checked yes she needed a level II. I found out a level 2 was done in 2018 by the hospital, but since I was here, I didn't know she had a level II [PASARR]. I called [the company that conducts level II PASARR's] and they were never notified where she went so it hasn't been updated. The SSD further confirmed that the Level II PASARR was in a soft file in the office and not part of the clinical chart and therefore, Resident #10's assessment and care plan had not incorporated the recommendations within the level II. Review of the facility policy titled, Virginia Long-Term Services and Supports (LTSS) Screening, Preadmission Screening and Resident Review (PASRR) Policy was conducted. Excerpts from this policy read as follows: .LTSS. 1. Pursuant to 32.1-330 of the Code of Virginia, individuals shall be screened prior to admission to a NF [nursing facility] if they are already Medicaid members or are financially eligible by way of application as verified by the ePAS system . 2. The LTSS Screening is reviewed ensure that applicable NF admission criteria have been met, documented, and submitted unless the individual meets any of the special circumstances set out in 12VAC30-60-302 E [sic] .PASRR 6. The facility will act upon all recommendations resulting from PASSR evaluations. The resident-centered, interdisciplinary care plan for a resident who has had a Level II evaluation will be developed . On 8/24/23, during an end of day meeting, the facility Administrator was made aware of the above findings. No further information was provided.

Based on staff interviews, record review, and review of the Resident Assessment Instrument (RAI) Manual, the facility failed to provide an accurate resident assessment two residents (Resident (R) 92 and 98) out of a total sample of 64 residents. Findings include: Review of R92's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) 04/06/23 located in the EMR under the MDS tab showed he was coded as independent with bed mobility, transfer, eating, and toileting. Review of R92's quarterly MDS, with an ARD of 05/09/23 showed he was coded as requiring the extensive assistance of one person for bed mobility, transfer, and toileting; and he required supervision and oversight, and meal set up by staff. His Brief Mental Status Interview (BIMS) revealed a score of eight out of 15 indicating he was cognitively impaired. During an observation on 08/22/23 at 12:15 PM, R92 was observed sitting in a chair, rising without assistant devices, ambulating independently, closing the room door to enable him to open the bathroom door to discuss the floor. In an interview on 08/24/23 at 2:34 PM, the MDS Coordinator (MDSC) stated she had reviewed everything and confirmed R92 did not require extensive assistance as indicated on the quarterly MDS with an ARD of 05/09/23 and the MDS was incorrect. The MDSC clarified, the Certified Nursing Assistant's (CNA's) documentation was incorrect, and it was not caught prior to 05/09/23 MDS submission. During an interview on 08/24/23 at 6:27 PM, the Director of Nursing (DON) stated the facility did not have a policy regarding MDS accuracy, they use the (RAI) Manual. At 6:31 PM, the DON stated the MDSC should review the documentation and observations; and do their own assessment. The DON stated an expectation the MDS is coded accurately. Review of the October 2019 RAI Manual showed on page G-1: Section G: Functional Status Intent: Items in this section assess the need for assistance with activities of daily living (ADLs), altered gait and balance, and decreased range of motion. In addition, on admission, resident and staff opinions regarding functional rehabilitation potential are noted. On Page G-3: Steps for Assessment 1. Review the documentation in the medical record for the 7-day look-back period. 2. Talk with direct care staff from each shift that has cared for the resident to learn what the resident does for himself during each episode of each ADL activity definition as well as the type and level of staff assistance provided. Remind staff that the focus is on the 7-day lookback period only. 3. When reviewing records, interviewing staff, and observing the resident, be specific in evaluating each component as listed in the ADL activity definition. For example, when evaluating Bed Mobility, observe what the resident is able to do without assistance, and then determine the level of assistance the resident requires from staff for moving to and from a lying position, for turning the resident from side to side, and/or for positioning the resident in bed. To clarify your own understanding and observations about a resident's performance of an ADL activity (bed mobility, locomotion, transfer, etc.), ask probing questions, beginning with the general and proceeding to the more specific. 40026 2. For Resident #98 the facility failed to accurately assess Resident #98 in the MDS (Minimum Data Set) with an ARD (assessment reference date of 8/2/23. On 8/23/98 at approximately 9:58 AM Resident #98 was observed sitting in his wheelchair watching the TV. Resident #98 was asked about his mobility, and he stated I cannot feel my legs other than the spasms I get from my back to my legs and then from the legs down with the neuropathy pain too. When asked if he could safely transfer on and off the toilet he stated, I manage ok, some days I need more. When asked if he could walk unassisted, he stated that he could not. The Resident stated that anything involving the legs down he needed assistance with. When asked does he get the assistance he needs when he requests it, he stated that he needs help with shower because if he bends over to wash his feet, he will fall out of the shower chair. A review of the MDS dated [DATE] Section G-0110 ADL (Activities of Daily Living) Assistance: B. Transfer- Resident 98 was coded as 0 (0 is Independent) and 0 (No set up or physical help from staff. C. Walk in Room - Resident 98 was coded as 0 (0 is Independent) and 0 (No set up or physical help from staff D. Walk in corridor- Resident 98 was coded as 0 (0 is Independent) and 0 (No set up or Physical help from staff E. Locomotion on unit - Resident 98 was coded as 0 (0 is Independent) and 0 (No set up or physical help from staff [this is correct as resident can self-propel on and off unit] F. Locomotion on unit -Resident 98 was coded as 0 (0 is Independent) and 0 (No set up or physical help from staff [this is correct as resident can self-propel on and off unit] G. Dressing - Resident 98 was coded as 0 (0 is Independent) and 0 (No set up or physical help from staff H. Eating - Resident 98 was coded as 0 (0 is Independent) and 0 (No set up or physical help from staff) I Toilet use Resident 98 was coded as 0 (0 is Independent) and 0 (No set up or physical help from staff) J Personal Hygiene - Resident 98 was coded as 0 (0 is Independent) and 0 (No set up or physical help from staff) Section G 0120 - Bathing Resident 98 was coded as 0 (0 is Independent) and 0 (No set up or physical help from staff) G0300 - Balance During Transfers and Walking A. Moving from seated to standing position - Resident #98 was coded as 0. Steady at all times. B. Walking with assistive device - Resident #98 was coded as 0. Steady at all times. C. Turning around and facing the opposite direction while standing - Resident #98 was coded as 0. Steady at all times. D. Moving on and off the toilet - Resident #98 was coded as 0. Steady at all times. E. Surface to surface transfer (between the bed and chair or wheelchair) Resident #98 was coded as 0. Steady at all times. G0400 Functional Limitations in Range of Motion A. Upper extremities Resident #98 was coded as 0 No impairment. B. Lower extremities Resident #98 was coded as 0. Steady at all times. G0600- mobility devices A. [NAME] or crutch - NO B. [NAME] - NO C. Wheelchair - Yes. On 8/23/23 at approximately 12:30 PM an interview was conducted with CNA H who was asked if Resident #98 requires assistance with ADL care CNA H stated that Resident #98 does need assistance with dressing and getting on and off the toilet as well as showering and Hygiene. CNA H stated that, Resident #98 does as much as possible on their own and we help when he calls for us. On 8/24/23 an interview was conducted with RN B who was shown the MDS G section and asked if that accurately reflects the condition of Resident #98 and she stated that it did not. When asked if this assessment would be considered inaccurate, RN B stated that it would. On 8/25/23 during the end of day meeting the Administrator was made aware of the concerns and no further information was provided.

Based on observation, Resident interview, staff interview and facility documentation review, the facility staff failed to maintain a homelike environment for one Resident (Resident #32) in a survey sample of 64 Residents. The finding included: For Resident #32, the facility staff failed to provide a homelike environment as evidenced by multiple ceiling tiles in his room were discolored and one in the bathroom was off the track, and appeared as though it may fall. On 8/22/23, in the late morning, during a Resident interview, Resident #32 told the surveyor to look at the ceiling tiles. He pointed out how multiple tiles were stained and said they had been like that for several weeks. Resident #32 said, I've told them for 3 weeks, but it goes in one ear and out the other. The resident then asked the surveyor to look in the bathroom. A ceiling tile in the bathroom was noted to be off the track and appeared as though it could fall. Resident #32 said, It's going to fall, I've told them, they do nothing. On 8/22/23, before going to lunch, Surveyor C shared the above findings with the facility Administrator. On 8/22/23 at 4PM, an observation was made of Resident #32's room with no changed noted, the ceiling tiles had not been changed. On 8/23/23, observations were made throughout the day, with the last observation being at 5 PM, and the ceiling tiles had not been replaced. On 8/23/23, during the end of day meeting, the facility Administrator was again made aware of the above findings. On 8/24/23 at 8:47 AM, Resident #32 was visited in his room and reported they replaced them at 6:30 this morning. No further information was provided.

Based on record review, interview and facility policy review, the facility failed to ensure one of seven residents (Resident (R) 91) reviewed for Preadmission Screening and Resident Review (PASARR) had a Level One PASARR completed prior to admission. This failure had the potential for R91 to not receive services necessary for mental health and psychosocial well-being. Findings include: Review of R91's hard (paper) chart and EMR record (tabs labeled Assessments, Progress Notes, and Misc [Miscellaneous]) showed no PASARR screening documentation. On 08/23/23 at 5:30 PM, the Director of Nursing (DON) was asked to provide R91's PASARR documentation. During an interview on 08/24/23 at 1:24 PM, the DON stated R91 did not have a PASARR. When asked to clarify if that was a PASARR level I or level II, the DON responded, There is no PASARR period. In an interview on 08/24/23 at 2:00 PM, the Social Services Director (SSD) also confirmed R91 did not have a PASARR. In a follow-up interview on 08/24/23 at 3:15 PM, the DON was asked if it was her expectation that all residents have a PASARR prior to admission and responded, That's my understanding. During an interview on 08/25/23 at 8:18 AM, the Administrator confirmed an expectation that all residents need a [PASARR] screening before admission. Review of the undated facility policy titled Virginia Long-Term Services and Supports (LTSS) Screening, Preadmission Screening and Resident Review (PASRR) Policy, read in pertinent part, Policy: The organization observes preadmission screening requirements to ensure that: 1) Prior to an individual's admission, The Social Worker, Admissions Coordinator, or designee will review the completed screening forms via e-PAS and obtain a copy for placement in the electronic medical record i) Nursing Facilities shall not accept paper screening forms as proof that admission criteria have been met and documented 2) Because the Virginia PASRR screening is coupled with the LTSS Screening for Virginia's Medicaid program, the screening team responsible for conducting the PASRR screening prior to admission is determined by who is required to complete the LTSS Screening a) Prior to Admission (hospital- inpatient, community- residing in community/assisted living) i) Already Medicaid members ii) Financially eligible by way of application as verified by the ePAS system b) Nursing Facility i) Medicare ii) Private Pay .

Based on observation, staff interview and record review, the facility staff failed to follow physician orders for the application of ace wraps to the bilateral lower extremities. The findings include Resident #87 was originally admitted to the nursing facility on 01/24/23. Diagnosis for Resident #87 included but not limited to lymphedema. Resident #87 Minimum Data Set (MDS - an assessment protocol), a quarterly with an Assessment Reference Date (ARD) of 06/26/23 coded Resident #87's Brief Interview for Mental Status (BIMS) score of 15 out of a possible score of 15 indicating no cognitive impairment. The MDS coded Resident #87 total dependent of two with bathing, extensive assistance of two with bed mobility, extensive assistance of one with transfer, dressing, toilet use and personal hygiene and supervision with eating for Activities of Daily Living (ADL) care. Resident #87's person-centered care plan with a revision date of 05/11/23 documented resident with impaired circulation related to lymphedema. The goal set for the resident by the staff was that the resident will be free from signs/symptoms of complications of poor circulation through the next review period dated 09/20/23. The interventions/approaches the staff would use to accomplish this goal is to keep legs elevated when resting. A review of Resident #87's Treatment Administration Record (TAR) for August 2023 revealed an order to apply ace wraps to bilateral lower extremities every other day as tolerated for edema starting on 07/22/23. The ace wraps are to be applied in the morning and remove at bedtime (night). During the initial tour on 08/22/23 at 2:37 p.m., Resident #87 was observed lying in bed. She stated she had a diagnosis of Lymphedema and the nurse's had not wrapped her legs for several days. She stated she hope her legs were without any open areas or blisters. The resident removed the covers from her lower extremities. Both lower extremities noted to be without ace wraps with edema present, but without any open areas or blisters. On 08/23/23 at 10:40 a.m., Resident #87 observed without ace wraps to her bilateral lower extremities. On the same day at 4:14 p.m., Resident #87 stated the nurse never applied the ace wraps to her lower extremities. The resident denied pain to her extremities. The resident removed the covers from her lower extremities and the ace wraps were not present. A review of Resident #87's TAR revealed the ace wraps were to be applied on 08/23/23 at 8:00 a.m., and to be removed at bedtime. On 08/24/23 at 2:45 p.m., an interview was conducted with License Practical Nurse, LPN-K. She stated she was assigned to Resident #87 on 08/23/23 (7-3 shift). She stated she did not apply Resident #87's ace wraps to her bilateral lower extremities. She stated she went to the room to apply the resident's ace wraps to her lower extremities, but she was not in the room, and she forgot to go back. An interview was conducted with the Director of Nursing (DON) on 08/25/23 at 4:50 p.m. She stated the nurses are to apply Resident #87's ace wraps as ordered by the physician. A final meeting was held with the Administrator, Director of Nursing and Corporate on 08/25/23 at 6:00 p.m., who were informed of the above findings. An opportunity was offered to the facility's staff to present additional information, but no further information was provided.

Based on staff interviews, facility document review, and clinical record review, the facility staff failed to afford a Resident the ability to make decisions in concerning their care for 1 of 64 residents (Resident #87), in the survey sample. The findings included: The facility staff failed to transfer Resident #87 to an acute care setting even after a significant change had been observed. Resident #87's Responsible Representative (RR) called non-emergent transportation who transported the resident to the local hospital on 02/02/23. Resident #87 was transferred to another acute care setting on 02/03/23. Resident #87 was readmitted to the nursing facility on 02/08/23. Resident #87 was originally admitted to the nursing facility on 01/24/23. Diagnosis for Resident #87 include but are not limited to rectal prolapse, Atrial Fibrillation (A-Fib), and lymphedema. Resident #87 Minimum Data Set (MDS - an assessment protocol), a quarterly with an Assessment Reference Date (ARD) of 06/26/23 coded Resident #87's Brief Interview for Mental Status (BIMS) score of 15 out of a possible score of 15 indicating no cognitive impairment. The MDS coded Resident #87 total dependent of two with bathing, extensive assistance of two with bed mobility, extensive assistance of one with transfer, dressing, toilet use and personal hygiene and supervision with eating for Activities of Daily Living (ADL) care. On 08/24/23 at 11:00 a.m., an interview was conducted with Resident #87's representative. She stated she received a call from (a family friend) on 02/02/23, who informed her that Resident #87 was not responding. She said Resident #87 was unable to open her eyes, lift her head off the pillow, eat, or acknowledged that she was in the room. She stated she contacted Resident #87's nurse, License Practical Nurse (LPN) - L., requesting for Resident #87 to be transferred to the hospital for evaluation. She stated the LPN said Resident #87's vital signs were within normal limits and did not appear to be in distress. She stated there was no reason to notify the physician or send the resident to the hospital. She said the nurse told her she could call 911 but she was not going to. The RR stated she called non-emergent transportation who arrived at the facility (time uncertain) and transferred Resident #87 to the local emergency room (ER). She stated Resident #87 was transferred to another hospital on 02/03/23 where she stayed for an extra 5 days. An interview was conducted with Visitor #2 on 08/24/23 at 4:49 p.m. She stated she came to visit Resident #87 on 02/02/23 around 5:00 p.m. She stated Resident #87 was not herself. She was not able to lift her head off the bed, speak or eat her dinner. She stated she had to put her ear to the resident's mouth when she spoke but was unable to understand what she was saying. She stated Resident #87's words were mumbled. She stated she spoke with Certified Nursing Assistant (CNA)-C who agreed Resident #87 had a change in condition. She stated she spoke with License Practical Nurse LPN-L who stated she saw no reason to send Resident #87 to the hospital because her vital signs were okay. The complainant stated she contacted Resident #87's representative (RR) and informed of the changes she witnessed in Resident #87. She stated RR called transportation to have Resident #87 taken to the hospital. She stated, Emergency Medical Transport (EMT) arrived at the facility, who asked Resident #87 if she wanted to go to the hospital, she replied, Yes. She stated Resident #87 was transferred to (name of hospital) and admitted . On 08/24/23 at 2:51 p.m., an interview was conducted with Certified Nursing Assistant (CNA) -C. She stated on 02/02/23, Resident #87 was not her normal self. She stated Resident #87 usually feeds herself but, on that day, she was very confused and unable to feed herself. She said Resident #87 was not aware her food was in front of her. When Resident #87 spoke, her words were mumbled. Resident #87 had a visitor who was very concerned of the changes seen in Resident #87. She stated she obtained vital signs and gave them to LPN-L. She stated there was an obvious decline in Resident #87. A phone interview was conducted with LPN-L on 08/24/23 at 11:24 a.m. She stated she remembered Resident #87 as a patient but really did not recall what occurred on 02/02/23 (3-11 shift). The surveyor read the nurses note to the LPN that she wrote on 02/02/23 at 9:29 p.m. She stated based on the nurses note, the resident's vital signs were stable so there was no reason to send Resident #87 to the hospital. She stated she did receive a phone call from Resident #87 RR requesting for Resident #87 to be transferred to the hospital. She stated she informed the RR that Resident #87 was not in distress, her vitals were stable and saw no reason to send the resident to the hospital. She stated she informed the RR that she would not be calling 911 but she could not stop her from calling 911. She stated the resident's representative called non-emergent transportation who arrived at the facility who transferred Resident #87 to the local hospital and admitted . A review of Resident #87's clinical record revealed a nurses' note written on 02/02/23, by LPN-L. The note documented the following: on 02/02/23, Resident #87's visitor informed LPN-L that Resident #87 was non-responsive and in distress. A head-to-assessment was completed, and the resident was without signs/symptoms (s/s) of distress. Resident #87 did however, verbalized she felt under the weather and Tramadol (pain medication) was administered. The resident's vital signs were (BP) 124/64, (P) 82, (R) 17, (T) 98.9 and oxygen saturation at 98% on room air. A COVID-19 test was performed with negative results. A phone call was received from Resident #87's RR who requested for Resident #87 to be transferred to the ER for evaluation. It was documented that the resident and the resident's visitor were both educated it was not necessary to send Resident #87 to ER for evaluation due to the results of the assessment. The note revealed LPN-L stated she would not call 911 but informed the RR she could call, which she did. Resident #87 was transferred to hospital and admitted . Resident #87 was transferred to the hospital on 02/02/23, then transferred to another acute care facility on 02/03/23. The hospital record from 02/02/23 was requested but not received. However, a review of the second hospital record from 02/03/23-02/08/23 revealed the following: Resident #87 had complained of having nausea/vomiting and dizziness prior to being transferred to the first hospital on 02/02/23. Resident underwent a perineal proctectomy and levatorplasty for a rectal prolapse on 01/09/23. She had been having liquid stool draining without continence since admitted to the nursing facility on 01/24/23. At the ER she had a low-grade fever (not documented), white blood count (12k) normal range (4,500-11,000), hypochloremia - low chloride (83) normal range (less than 95), hyponatremia - low sodium (128) normal range (135-145) and hypokalemia - low potassium (2.5) normal range (3.5-5.0). During the hospital stay, Resident #87 received intravenous (IV) antibiotic (Zosyn), IV dextrose 5% and sodium chloride 0.9% with KCL (potassium) 20 mEq/L. There was a concern for perirectal abscess and rectovaginal fistula but the findings were not transferred from the ER and was not accessible. The Zosyn (IV abx) was used for possible perirectal abscess. An interview was conducted with Director of Nursing (DON) on 08/25/23 at 5:00 p.m. She stated when Resident #87's visitor voiced concerns to the nurse that she observed a deterioration in Resident #87, the nurse should have completed an assessment, notified the physician right away with the findings. She stated if the resident's representative requested for Resident #87 to be transferred to the hospital via 911, the nurse should have called 911. The DON stated, The family should never be told they can call 911 in order to have their loved one transferred to the hospital. A final meeting was held with the Administrator, Director of Nursing and Corporate on 08/25/23 at 6:00 p.m., who were informed of the above findings. An opportunity was offered to the facility's staff to present additional information, but no further information was provided.

Based on interview, clinical record review and facility documentation the facility staff failed to promote and facilitate resident self-determination through support of Resident's choice, for 1 Resident in a survey sample of 64 Residents. The findings included: For Resident #98 the facility staff failed to schedule the appointments that the Resident had ordered by his physician. On 8/23/23 at approximately 9:58am, an interview was conducted with Resident #98. Resident #98 stated he needs psych services but has not had them since arrival at facility. He stated that his physician had written an order for him to be seen by a back specialist he had been to in the past when he had back issue. He stated the facility was supposed to be making an appointment with the specialist and he has not received a date and time of appointment yet either. A review of the clinical record revealed that the physician wrote the following orders that read: 7/31/23 - Refer to [facility name redacted] clinic for neuropathy and back pain. 8/10/23 - Refer to [psych services name redacted] On the afternoon of 8/24/23 an interview was conducted with LPN C, and she was asked what the process is when a physician writes an order for psych services. She stated that they have an appointment book the nurses make the appointments and put them on the calendar or in the book. When asked if Resident #98 had any scheduled appointments, LPN C stated that he did not. When asked if Resident #98 had an order for a consult with the back specialist written on 7/31/23, LPN C stated that he did. When asked if Resident #98 had an order to see psych services written on 8/10/23, LPN C stated that he did. When asked if there was any reason the orders were not carried out, LPN C stated that she did not know. On 8/25/23 during the end of day meeting, the Administrator was made aware of the concerns and no further information was provided.

Based on staff interviews, clinical record review and facility documentation review, the facility staff failed to ensure 1 of 64 residents (Resident #87) had an accurate medical record for an advanced directive. The finding included: Resident #87 Minimum Data Set (MDS - an assessment protocol), a quarterly with an Assessment Reference Date (ARD) of [DATE] coded Resident #87's Brief Interview for Mental Status (BIMS) score of 15 out of a possible score of 15 indicating no cognitive impairment. Resident #87's person-centered comprehensive care plan revised on [DATE] documented the resident is a Full Code. The goal set for the resident by the staff was that the resident's code status will be honored through the next review date of [DATE]. The interventions/approaches the staff would use to accomplish this goal is for the resident's code status to be reviewed and updated as needed. A review of Resident #87's Physician Order Sheet (POS) for [DATE] revealed the following order: Cardiopulmonary resuscitation (CPR) starting on [DATE]. On [DATE] at 11:00 a.m., a phone interview was conducted with Resident #87's Responsible Representative (RR.) She stated Resident #87's should be a do-not-resuscitate (DNR) but the facility still has Resident #87 as a full code. An interview was conducted with the Social Worker (SW) on [DATE] at 1:37 p.m. She stated Resident #87 is a DNR and her code status should have been switched from being a full code to DNR in PointClickCare (PCC.) On the same day at 2:14 p.m., an interview was conducted with the Director of Social Services. She provided a copy of a DNR form that was signed and dated by Resident #87 on [DATE]. She said Resident #87 is a DNR and not a full code. She stated the DNR form was in a soft file in her office. She stated once the DNR form was signed by Resident #87 on [DATE], the document should had been scanned in the resident's record and the DNR form given to nursing to adjust her order in PCC. The Director of Nursing (DON) was interviewed on [DATE] at 4:47 p.m. She stated as soon as the DNR form was signed by Resident #87, her code status should have been changed immediately in PCC from being a full code to DNR. A final meeting was held with the Administrator, Director of Nursing and Corporate on [DATE] at 6:00 p.m., who were informed of the above findings. An opportunity was offered to the facility's staff to present additional information, but no further information was provided. The facility's policy titled Advance Directives noted to be without a created or revision date. It is the facility policy that Advance directives will be respected in accordance with state law and facility policy. Specific procedures/guidance. 7. Information about whether or not the resident has executed an advance directive shall be displayed prominently in the medical record. 15. In accordance with current OBRA definitions and guidelines governing advance directives, our facility has defined advanced directives as preference regarding treatment options and include, but are not limited to: E. Do Not Resuscitate indicates that, in case of respiratory or cardiac failure, the resident, legal guardian health care proxy, or representative (sponsor) has directed that no cardiopulmonary resuscitation (CPR) or other life-sustaining treatments or methods are to be used.

Based on Resident interview, facility staff interview, clinical record review and facility documentation review, the facility staff failed to ensure that Residents were free from accident hazards, affecting one Resident (Resident #29) in a survey sample of 64 Residents. The findings included: For Resident #29, who went to an off-site dialysis clinic three days per week, the Resident was unable to gain entry to the facility for extended periods of time upon her return, resulting in her being left to sit outside, alone and at times in the dark. On 08/23/23 at 10:39 AM, during an interview with Resident #29, the Resident verbalized that frequently she waits 30 minutes or more when she arrives back at the facility at night because the facility staff won't answer the phone or doorbell. Resident #29 reported it is usually around 8:30-9 PM or later when she returns from dialysis, three days a week. The Resident said, she uses her cell phone and will call the facility before they ever arrive back at the facility, but facility staff do not answer the phone. Then, once she arrives, she and/or the transportation driver will ring the doorbell multiple times and wait over 30 minutes for facility staff to respond to let her into the facility. The Resident also confirmed that there are times when the transport driver is unable to wait with her, leaving her unattended and unmonitored to wait to get into the facility. During the above interview, Resident #29 said she has asked for a badge that would open the doors, but she was told it was a safety and security concern and they could not issue her a badge. On 8/23/23, observations revealed a sign on the front door of the facility that indicated the doors were locked at 8 PM and to gain entry the doorbell had to be used. On the evening of 8/23/23, Surveyors B and C returned to the facility at 8 PM, to observe what happened when Resident #29 returned from dialysis. The facility administration was still at the facility and was noted to be responding to the doorbell when visitors would press it to gain entry. However, Resident #29 did not return during the observations. During the observation, it was noted that a raccoon was at the front door around 8:40 PM, which startled 2 employees who were leaving the facility. The 2 employees exited the facility and ran to the parking lot, Surveyors B and C talked with them and they confirmed it was a raccoon. On 8/24/23, during the morning, Resident #29 was interviewed. Resident #29 reported she did not return on 8/23/23, until 9:45 PM. On 8/24/23, the receptionist, Employee N, was interviewed. The receptionist confirmed that the front doors are locked at 8 PM, nightly and to gain access a person would have to ring the doorbell. On 8/24/23 at 1:30 PM, during an interview with the Administrator and Director of Nursing, they were asked how someone gains entry into the facility in the evenings. Both said, After hours they have to press the door bell and wait for staff to answer. On 8/24/23 at approximately 2 PM, Surveyor B conducted an interview with an emergency medical staff (EMS) who worked for the rescue squad. During this interview, the EMS personnel stated they had responded to a call one evening and were unable to gain access to the facility. The EMS said, The dispatcher was calling the facility, but no one would answer the phone and they were ringing the doorbell with no response, for well over 15 minutes. The EMS went on to say that once entry was made, facility staff were observed at the nursing station not responding to the phone that was ringing and the call bell was engaged for the Resident they were responding to and staff were not responding to the call light. On 8/24/23, during an end of day meeting, the facility Administrator was made aware of the above concern with Resident #29 having to wait outside for extended periods of time. On 8/25/23, Surveyors C observed the facility Administrator ringing the doorbell, it was noted that the doorbell could be heard at the nursing station on the first floor. During this process, the unit manager, LPN C stated, If the nurse is down the hall passing medications it may take them a while to get to it [to respond to the person requesting entry]. On 8/25/23, in the afternoon, Employee M, the Regional Facility Maintenance Director, reported to the survey team that they had made badges- like employee's wear, that will be provided to dialysis Residents so they can gain entry into the facility upon their return. When asked why this had not been considered previously, Employee M stated that he didn't think the facility staff were aware that this was an option, and they could make badges of this nature. No further information was provided.

Based on record review, a complaint investigation and resident and staff interviews the facility staff failed to provide a two person assist during transfer for one resident (Resident #2) in the survey sample of 22 residents which resulted in a fall with a fracture. The findings included: 1. Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An annual Minimum Data Set ((MDS) dated [DATE] assessed Resident #2 in the area of Cognitive Patterns (Brief Interview for Mental Status) BIMS with a score of 13 out of 15 indicating no cognitive impairment. In the area of Activities of Daily Living (ADL) this resident was coded in the area of Transfer Limited assist of Self - Performance, Provide two person physical assist. In the area of balance during Transitions and walking this resident was coded as a (2) Not steady, only able to stabilize with staff assistance when moving from seated to standing position and surface to surface transfers (transfer between bed and chair or wheelchair). This resident was not coded for walking, turning around or moving on and off toilet (8). A Falls Risk Evaluation dated 2/21/17 indicated: Resident #2 was assessed as being a high risk for falls with a score of 10. The range indicated a score of 10 or above represents high risk for falls. A Care Plan dated 9/20/16 through 3/28/17 indicated: Problem- Resident has been assessed as having no or limited potential for change in ADL performance and requires extensive to total assistance with ADL's. Goal- Resident will not experience adverse outcomes from requiring extensive assistance with or being dependent in ADL's. Interventions- Transfer resident with mechanical lift and assist of 2 staff; as needed if resident is unable to use slide board. Resident has risk for falls and/or history of falls related to unsteady gait, Loss of balance, poor sitting balance/poor trunk control, Requires staff assistance for transfers. Goals- Resident will not experience fall- Interventions - keep bed in lowest position for safe transfer, keep bed wheels locked, Provide assistive mobility devices as recommended by therapy; report unsafe use to therapy. A Physical Therapy Care Plan dated 2/20/17 indicated: Problems- 1. Fall risk 2. Generalized weakness 3. Dependent for transfers. Goals- 1. Complete transfers using sit to stand lift for all functional transfers. Completed stand pivot transfers with CGA (contact guard assist)/minimal assist bed to w/c (wheelchair). 3. Pt (patient) will ambulate 3-5 feet with FWW (front wheeled walker) and CGA. Transfer training: sit to stand x 3 with maximal assist of 2 with verbal cues for hand placement, forward flexed posture, technique throughout. On first 2 attempts pt (patient) was very resistive and felt as though she was unable to stand and would push back in order to try and sit down. On third attempt, pt was able to stand fully upright for 20 seconds with increased encouragement and minimal assist to maintain balance throughout. Pt has not made progress towards goals to this point as pt still requires maximal assist from 2 people for transfers. An event report dated 3/9/17 indicated: The time to be 11:15 A.M., Fall during transfer, Fall Event Details- Assisted resident to ground/floor by employee, witness by staff, Assistive device - wheelchair, transferring to or from bed, chair etc. Person affected- Resident #2. Brief Factual Description of Events- Resident being transferred from bed to w/c legs buckled and she went down on her knees. Impact from fall- Injury related to fall - (NO INJURY is documented). Resident Interview: Resident did not know she was going to fall. Notification- Director of Nursing (DON) and family. A clinical note dated 3/9/17 at 4:21 PM indicated: (name of Resident #2) fell during transfer from bed to wheelchair, put back in bed VIA lift. Resident complained right leg/knee pain. Resident grimacing saying my leg hurts. right leg noted to have toes pointing out and shorter appearance compared to left leg. Resident assessed NP (Nurse Practitioner) in building with the order to send to ED (Emergency Department) for eval. 911 called and resident transported VIA stretcher to hospital. X-ray from the ED (emergency department) shows right femur spiral fracture. The DON provided the following Plan of Correction: The Incident Report indicated: Incident:- On 3/9/17 resident was being assisted from bed to shower chair via sit to stand lift. Aide reports that right leg buckled and patient went to her knees. Resident received a right femoral fracture. Resident History: Resident is a [AGE] year old female with a [DIAGNOSES REDACTED]. She has a history of prior ankle fracture and osteoporosis compression fractures. Resident is alert, oriented to self and place. Pleasantly confused at times. On resident's last MDS dated [DATE], it notes that residents BIMS was 13. That resident requires extensive assist with bed mobility and dressing /grooming. Resident required limited assist with transfers and mobility and was independent with eating. Resident has been receiving Vit D for some time now for Vit D deficiency. Investigation: Investigation conducted utilizing staff and resident interviews, and medical records review. The aide transferring resident reports she utilized the sit to stand mechanical lift during transfer. She reports prior to lifting the resident that she validated pt was secure on sling. She reports she validated feet properly placed on foot support and that hands were holding hand grip. She reports sling was in place around upper back. Aide reports as she started to raise lift, she saw resident's right leg buckle and the resident lost balance and went to her knees on the lift stand foot support. Aide reports an attempt to physically support resident during this time to prevent a traumatic fall. The aide called for help and pt was assisted back into the bed in a Hoyer like lift. Resident was sent to hospital for medical work up due to suspected fracture. RN (Registered Nurse) Unit Manager assessed pt. Resident was also assessed in center by an NP (Nurse Practitioner) that was in the center at time of event. Resident could not recall or express what had occurred. Findings: The sit to stand lift has been utilized at PACE and Nursing Home for transfers. Per the manufactures guidelines, resident must be able to bear weight on lower extremities and be able to hold onto the hand supports. The resident profile indicated resident was a mechanical lift for transfers. The maintenance director indicates lift in proper working condition. Actions and On-Going Interventions: 1. residents who utilize the sit to stand mechanical lift are at risk to be affected. 2. Residents who utilize the sit to stand mechanical lift were re-evaluated to determine if they meet the patient guidelines the manufactures suggest use for. The plan of care was adjusted as needed as well as resident profiles. 3. Staff were re-educated on transfers status. mechanical lifts (both sit to stand and Hoyer type), and resident profiles. Maintenance Director inspected lifts. Noted to be in proper working condition. Transfer observations initiated X 6 weeks. A(NAME) date 3/22/17 No other falls with injuries have occurred. A manufactory guideline for the use of the sit to stand indicated: in Section C- fig-13 (3). patients who have suffered a stroke who can only hold with one hand, or patients who cannot hold on at all, may still be lifted by the SARA but it will be necessary for the operator or a second nurse to support the patient's arm/arms down in front of the body during the lift. A facility policy for Transfer Using the Mechanical Lift indicated: Policy- mechanical lifts will be utilized by nursing staff to transfer residents who cannot help themselves, resident who fall, and residents who need repositioning that requires a mechanical lift. The number of staff assisting with transfer using the mechanical lift is dependent on: manufacturer guidelines- facility must review guidelines prior to use. Conditions that may require more than one person to assist during transfer and will be addressed in the resident care Plan (i.e. bariatric need, uncontrollable body movements, etc.). A written statement from the Unit Manager (Undated) indicated: On 3/9/17 about 11:25 A.M., staff nurse reports to me that resident had fallen during a transfer. Nurse had assessed the resident and requested I go in and assess the resident. On entering the room, the resident was lying on her back in her bed. resident was moaning occasionally and saying her leg hurts. Asked resident if she could tell me what happened she replied she could not. I asked her if she had fallen she stated she didn't know. I asked her where her pain was and she said her leg. I asked her if she was hurting anywhere else and she denied any other pain. Visual assessment done, nurses note in vision. A Nurses Note from the Unit Manager dated 3/9/17 at (2:06 P.M.) indicated: Resident fall during transfer from bed to wheel chair put back in bed VIA lift. Resident c/o (complained) right leg/knee pain. Resident grimacing saying my leg hurts. Right leg noted to have toes pointing out and shorter appearance compared to left leg. Resident assess by NP in building with the order to send to ED for eval. 911 called and resident transported VIA stretcher to hospital for eval. Out of building at 12:15, daughter aware of above and will meet at the ED. Provider was notified of fall prior to being seen by facility provider and an x-ray was ordered for the right leg D/T (due to) the appearance of the leg and the residents pain this writer requested the in facility provider assess d/t this writer's concern for time frame for portable x-ray. NP assessed and gave order to send to ED for eval. During an interview on 8/3/17 at (9:00 A.M.) with the Unit Manager she stated, I was not in the room when Resident #2 fell . I did not witness the type of lift used to transfer her. I was called to Resident #2's room to assess her for a fall. This was five minutes after her fall. When I first saw her she was already in bed. I assessed her and called for the Nurse Practitioner to come and assess her also. During an interview on 8/3/17 at 11:07 A.M. with Certified Nursing Assistant (CNA) #1, she stated, This was not my first time using the sit to stand lift. I all ways used it by self. I was only taught to use one to for the sit to stand lift. I had her positioned in the right way. I was getting her up to take a shower. Her leg slipped as I was lifting her up, her leg buckled. I assisted down to the floor. I called for help. Another CNA came and we used a total lift and placed her back in bed. A written statement from CNA #1 dated 3/9/17 indicated: It was (name of Resident #2's) shower day. I was preparing her for the bathroom. I put her on the sit to stand that she always use and I make sure that she was secure on the the sit to stand. Her hands, legs and body was secure rightly (sic) before I started lifting her up. I have (sic) not lifted her up far before she slid on her knee and I immediately called for help to get her up back in her bed. She complain of her legs and she was taken to the hospital. During an interview on 8/4/17 with the DON she stated, the facility followed the sit to stand manufactory guideline in their care plan to assist with the number of staff needed for transferring a resident. When shown the Care Plan for Resident #2, the DON stated the facility did not have manufactory guidelines included in the care plan. A Nurse Practitioner note dated 3/9/17 at 12:54 P.M. indicated: Asked by Nurse Manager to see Resident #2 after what sounds like a fall. Resident #2 is not one of my usual patients so my familiarity with her is limited. She is seen resting in bed on her back. She is awake, alert and interactive with me. her speech is clear. She does seem to have some memory/cognitive impairment-she cannot tell me what happened. Limited ROS (review of systems) was completed. She is positive for pain both hips, she denies chest pain, shortness of breath and difficulty breathing. Physical exam reveals that her right lower extremity is externally rotated and is shorter than her left. She has significant pain to palpation in that right hip. She exhibits facial grimaces with passive range of motion to both lower extremities; right greater than left. Vital signs at the time of my visit: 96.7 - 79-22-183/79 She was sent to the emergency room status [REDACTED]. Visit Diagnoses: [REDACTED]. A Fall Prevention and Management Policy: Purpose- To promote safety by identifying residents at risk of falls by use of falls risk predictors, including resident history, diagnosis. ambulatory status. gait/balance, mental status, medication regimen, elimination status. vision status, and systolic B/P (blood pressure). Using an interdisciplinary approach to fall management and prevention. Procedure: (C) The initial fall risk care plan is established at time of admission based on the resident's risk factors. A score of 10 or above on the Falls risk Assessment indicated high risk for falls. II. -B Care of Resident following a Fall 4. Do not move the patient until potential injures are identified and safety assured. The facility staff failed to provide Resident #2 with a two person assist to prevent a fall with injury and assess resident prior to moving. Complaint Deficiency

Based on observations clinical record reviews, staff interviews, and facility documentation, the facility staff failed to thoroughly assess, identify, treat and provide pressure relief devices for 2 of 24 residents in the survey sample, Residents #8 and #19. 1). During an observed assessment, the facility staff failed to identify the presence of an unstageable pressure ulcer on the right outer 5th toe that was determined to be eroded to the tendon and required surgical debridement, specialized grafting and antibiotic treatment for [REDACTED]. 2). During an observed assessment, the facility staff failed to identify deep tissue injury with a dark center on the right heel, as well as provide physician ordered treatment and the correct pressure relieving devices to the right heel for Resident #19. The findings include: 1. Resident #8 was originally admitted to the nursing facility on 1/10/15 with [DIAGNOSES REDACTED]. He was recently readmitted to the nursing facility on 8/30/11 with an additional [DIAGNOSES REDACTED]. Hospice was initiated on 5/25/12 for general debility. The most recent Minimum Data Set (MDS) assessment was a quarterly dated 3/13/12 and coded the resident with long and short term memory problems and severely impaired in the skills needed for daily decision making. Resident #8 was assessed to require extensive assistance of two staff for bed mobility, transfers, dressing, toilet use and personal hygiene. He was assessed totally dependent on staff for bathing. The resident was coded at risk for developing pressure ulcers, had no current unhealed pressure ulcers, but had one healed Stage II pressure ulcer noted on the prior assessment. The presented care plan dated 1/12/12 identified the resident is at risk for/has impaired skin integrity as evidenced by pressure ulcers and/or skin tears. Related risks/conditions included impaired mobility, need to extensive assistance or dependent in bed mobility and/or transfers, arterial or [MEDICAL CONDITION]. The goal of the staff was the resident would not develop pressure ulcers. Some of the interventions to accomplish this goal included report changes in foot color, temperature, pain, change in sensation, drainage or symptoms of infection, ensure appropriate fitting shoes, float heels, weekly skin or body audits and investigate new findings. The physician's orders dated 9/22/11 indicated the resident's right foot needed to be assessed once a day for pressure areas. According to the Treatment Administration Record (TAR) this assessment was scheduled to be performed on the 7/3 shift. The following observations were made of the resident's right lower leg/foot: On 6/5/12 at approximately 8:00 pm, Resident #8 was observed in bed. He had a left above the knee amputation (aka). He had a white sock on his right foot. Yellow colored drainage approximatley the size of a quarter was observed on the outer aspects of his right foot nearest the 5th toe. The TAR indicated an assessment was made of the resident right foot on 6/5/12 and indicated no areas found. There was no documentation on the body assessment form located on the reverse side of the TAR, nor in the nurse's notes indicating skin integrity issues. On 6/6/12 at 10:00 am, Certified Nurisng Assistants (CNA) #1 and #2 assisted Resident #8 via mechanical lift into the wheelchair. CNA #1 stated she had just completed the resident's bath. The sock on the resident's right foot exhibited the same amount of yellow colored drainage. The CNA placed a diabetic boot on the right foot. On 6/6/12 at approximately 1:30 pm, the resident was placed to bed via mechanical lift by CNAs #1, #2 and #3. CNA #1 removed the resident's boot and right sock and performed an assessment of the right foot. She separated all toes, looked underneath the foot and on the sides of the foot and stated there were no new areas on the foot, but the resident had a healed place on the right toe. It was stated by all three CNA's if anything was noted on the resident's skin, it would be reported to the licensed nurse. This writer observed a dark place on the outer 5th toe surrounded by yellow moist looking skin. The dark area was lifted and a separation observed between the center dark spot and yellow areas. The drainage on the sock was approximately the size of a 50 cent piece. She proceeded to place the same sock back on the resident's foot. On 6/6/12 at approximately 4:30 pm, the TAR was reviewed as signed off by the 7/3 LPN with no documentation regarding any skin problems on the TAR or in the nurse's notes. On 6/7/12 at 9:30 am, Resident #8 was observed in bed. CNA #5 was finishing Activities of Daily Living (ADL) morning care and stated she was getting ready to place the resident in the wheelchair. She stated the resident's skin was intact to include the right foot. A clean sock was in place on the resident's right foot, as well as the boot. On 6/7/12 at 10:15 am, the assigned 7/3 LPN #3 stated the resident had no pressure areas. The TAR was reviewed and was signed off by this LPN with no documentation regarding any skin problems on the TAR or in the nurse's notes. On 6/8/12 at 9:30 am, the North Wing Unit Manager stated the resident had no pressure areas. This writer shared the observations of the right 5th toe to the attention of the Unit Manager, the Assistant Director of Nursing (ADON) and Manager of Clinical Services. The Unit Manager stated, "That has been identified and brought to the attention of the Podiatrist." The ADON could not find any evidence the right 5th toe/lateral foot area had been addressed by nursing or the Podiatrist. On 6/8/12 at 9:40 am, LPN #3 was was to perform a skin assessment of the resident's right foot. The Manager of Clinical Services was present during this observation of the assessment. LPN #3 removed the white sock, where a small amount of yellow drainage was observed on the sock that covered the outer part of the 5th toe. She examined the entire foot and stated his skin was good and the touched the right great toe at the same time commenting there had been "an old place that healed here." The LPN replaced the sock and walked out of the room. The Manager of Clinical Services stated, "I see the place you were referring to. There is an obvious open area there that needs treatment." The area was immediately re-assessed by the Unit Manager as two new areas: 1) Lateral foot below 5th toe as a new unstageable pressure area with peri-wound edges lifted and not intact and large amounts of yellow exudate (drainage). An ulcer is considered unstageable when eschar or necrotic tissue covers the area preventing adequate staging. 2) Right fifth toe deep tissue injury (DTI) intact wound bed and edges. Deep tissue injury is a purple or maroon area of discolored intact skin due to damage of underlying soft tissue damage. The Physician was made aware on 6/8/12 at 10:30 am with new orders to cover the area with foam protection and schedule appointment with the Podiatrist for assessment at 12:45 pm. Resident #8 was evaluated in the Podiatrist office and according to his signed SOAP (subjective/objective/assessment/plan) note dated 6/8/12 at 1:15 pm, he made the following evaluation of the right foot: Two out of 4 DP pulses present, as well as 2/4 PT pulses present. Skin well hydrated. One out of 7 [MEDICAL CONDITION] of ankle and leg. Ulcer of right foot 5th toe dorsal aspects with erosion (disintergration) noted to the 4th Extensor Digitorium Longus (EDL) tendon of the 5th toe. Lesion is 1.2 centimeter (cm) by (x) 1.1 cm x 6 millimeters (mm). Wound is through the skin subcutaneous tissue to the tendon. It was documented the lesion was probably caused by pressure followed by poor circulation. Surgical debridement was performed to the area followed by an Acell (dermal skin cells) graft to the right foot covered with a sterile dressing. The nurse's notes dated 6/8/12 (no time) indicated a nurse accompanied the resident to the aforementioned podiatist appointment. She documented in the nurse's notes orders from the Podiatrist were to keep the dressing intact with stretch stocking and do not remove. Patient to receive wound care at the Poditrist office weekly. An antibiotic was ordered for wound infection starting on 6/10/12 every other day for 10 days and discontinuation of the diabetic shoe. Resident #8 was observed on 6/8/12 at apporixmately 4:00 pm in the wheel chair. The dressing and stocking covered the right foot. The right great toe and second toe was visible through the stocking. The resident was not wearing the diabetic shoe. A return call from the Podiatrist on 6/11/12 at 5:05 pm re-affirmed the finding in the SOAP note dated 6/8/12. He stated the area was pressure related and the tendon was visibly exposed. He said Acell, a polymicrobial peptide, was one of the only grafts that could cover tendon. He stated once tendon or bone was exposed normal tissue would not regenerate, thus the graft was indicated. According to the Podiatrist, he surgically debrided (removal of devitalized/necrotic tissue and foreign matter from a wound to improve or facilitate the healing process) the ulcer and deposited the Acell in hopes that the area would regenerate tissue and heal in the presence of infection. He stated because of his peripheral compromise, he did not want to have to resort to "using the knife" and losing a toe because he may not heal from any amputation. The Podisatrist stated the ongoing goal was to "keep his leg". On 6/9/12 at 3:20 pm, an interview was conducted with the Director of Nursing (DON) and the Assistant Director of Nursing (ADON). They stated many of the nursing staff have been sent to training and training had taken place in the facility on Skin assessment, identification of the pressure ulcers, Pressure ulcer prevention and treatment. They stated it was their expectation, since the CNA's bath and dress the resident, they report any skin integrity problems to the nurse. They also said it was their expectation that when the licensed nurse signs off on the TAR, she has actually performed a complete head to toe assessment herself. They were aware Resident #8 had physician orders, transcribed to the TAR, for daily foot assessments. They stated it was not a policy, but full body assessments were to be done by the licensed nurse weekly on all residents. The DON stated she has been in the facility nearly a year and has tried to put some things in place, but it was still a work in progress. They stated if any skin problems are identified, it should be assessed and the physician called for treatment options and/or further evaluation. 2. Resident #19, an [AGE] year old female, was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #19's most recent MDS (minimum data set) a quarterly with an ARD (assessment reference date) of 5/29/12 assessed the resident as having severely impaired cognition. Resident #19 was totally dependent on staff for bed mobility, transfers, dressing, eating, and personal hygiene, and required extensive assistance for toileting. Resident #19 was assessed as having a risk for the development of pressure ulcers. There were no pressure sores assessed during this ARD period. Resident #19 was assessed as having a pressure reducing device for the bed, nutrition or hydration interventions to manage skin problems, and having an application of ointments/medications other than to feet. Resident # 19's most recent care plan with recent review dates of 6/5/12 and 12/27/11 included that a pressure ulcer will not develop as a goal. General treatment and prevention interventions on care plan included: educate resident of importance of turning and pressure relief, report and investigate changes in skin condition (i.e. redness, bruising, changes in color, etc.), educate resident/family on risks, prevention and treatments, pressure reduction/relieving device to chair and bed, and weekly skin or body audits; investigate new findings. Interventions on the care plan included to float heels by using soft boots and to apply protective barrier as needed (i.e. cream, ointment, occlusive dressing, padding, etc.). Resident #19's most recent Braden Risk Assessment Scale dated April 2012 was scored at 11 with a high risk range being 10-12. The weekly skin assessment sheet for Resident #19 dated 6/5/12 noted no injuries, no abnormalities, and no breakdown. The Physician's orders dated for the month of May (5/1/2012-5/31/2012) included the order: Right foot: Apply Skin Prep once a day. The TAR (treatment administration record) dated for the month of May 2012 included the treatment for [REDACTED]. The Physician's orders dated for the month of June (6/1/2012-6/30/2012) did not include an order for [REDACTED]. On 6/9/12 at 2:30 P.M. surveyor #1 and #2 observed the right and left heels of Resident #19. Certified nurse aide (CNA) #4 was present and the resident was sitting in the gerichair with blue pressure relieving boots on both feet. CNA #4 indicated she had Resident #19 on Monday, Tuesday, Wednesday, and Saturday, had bathed her within that timeframe and did not notice any skin issues. The CNA stated, "These aren't the boots she usually has on, she usually has on the yellow boots but I had to send them down to be washed." CNA #4 was asked to look at and show the resident's heels to the surveyors. CNA #4 took off resident's boots and socks. She proceeded to look at resident's heels and she stated "I do not see anything." Surveyor #1 and #2 then looked at the resident's heels and noted a dark purple round area to left heel approximately the size of a fifty cent piece. The right heel was assessed as having a round purple area with a deeper purple area noted in the middle approximately the size of a fifty cent piece. At 2:40 P.M., surveyor #1 and #2 asked the Unit Manager #2 if the resident had any pressure areas. She stated, "We had a problem with the left heel but that area healed and she does not have any new areas." At 2:50 P.M., surveyor #1 and #2 went back up to the resident's room and upon entrance observed Unit Manager #2 assessing the heels of Resident #19. During the Unit Managers assessment, she concentrated on the resident's left heel and assessed the right heel and indicated Resident #19 did not have any pressure areas. At approximately 3:30 P.M. surveyors asked the DON (Director of Nursing) and the ADON (Assistant Director of Nursing) to assess the heels of Resident #19. At 3:40 P.M., the DON stated the resident is "very high risk for pressure areas and she does have a spot on both heels and there is a darker area in the pressure area of the right heel." She stated "Those aren't the right boots, she's supposed to wear the yellow boots." The ADON stated "We got her a new pair of boots, I don't know the name of the other boots she had on but these are the right ones. The CNA told me she sent the boots down to be washed 2-3 days ago. You can't dry them in the dryer they have to air dry." She indicated Resident #19 is supposed to wear the yellow boot ( Heelift Suspension Boot) which floats the heel. She stated, "We will give the resident new boots to put on." At 4:30 P.M., the DON indicated the nursing staff had recent inservices on pressure areas. Surveyor #1 asked what do you expect staff to do when a new pressure area is noted. The ADON stated "Report it, I expect them to report it, report it to Caretracker and report it to the nurse." The ADON provided the weekly pressure ulcer progress sheet which showed a deep tissue injury to the right heel (3.5 cm. x 3.5 c.m.) and a deep tissue injury to the left heel (2.5 cm x 2.5 cm) both identified as acquired on 6/9/12. The ADON provided new physician orders for the treatment of [REDACTED]. COMPLAINT DEFICIENCY

Based on staff interview, clinical record review, and review of facility documents, the facility staff failed to ensure the physician's order [REDACTED].#10, #5 and #14) in the survey sample. The findings include: 1. Facility staff failed to follow the attending physician's orders [REDACTED]. Resident #22 was a [AGE] year old resident who was admitted to the facility on [DATE] with a readmission date of [DATE]. [DIAGNOSES REDACTED]. The [DATE] Quarterly Minimum Data Set (MDS), on Resident #22's clinical record indicated Resident #22 had modified independence for daily decision making, required extensive assistance for bed mobility. Resident #22 required extensive assistance with all activities of daily living (ADL's). A review of the physician's orders [REDACTED]. The POS was recertified at the start of each month by the attending physician. A review of the Facility Reported Incident (FRI) reported to the State agency dated [DATE] and a final investigative report forwarded to the Sate agency dated [DATE] evidenced two (2) Licensed Practical Nurses (LPN's) failed to activate the "Full Code" status and initiate CPR for Resident #22 when notified of being and found to be unresponsive without pulse and respirations. A review of the Employment Statement of Incident dated [DATE] at 7:30 AM by Certified Nursing Assistance (CNA #3) evidenced that after taking her assignments and making rounds, upon passing Resident #22's room, she noticed the resident appeared to have been vomiting. Upon closer examination the resident appeared to be in a deep sleep and did not response to touch and the verbal calling of the residents name. CNA #3 immediately reported her findings to the 7AM to 3PM Licensed Practical Nurse (LPN #1) who responded quickly and after checking the resident stated "this is not from my shift", let me get the 11PM to 7PM shift nurse, and when the Licensed Practical Nurse (LPN #2) responded to the room, she stated "this is not from my shift either". Either LPN activated the "Full Code" status. CNA #3 then left the room. CNA #3 was not available for a interview during the survey period. A review of the final investigative report evidenced, LPN #1 left the room at 7:32 AM, went to the nurse's station and notified the Assistant Director of nursing (ADON), and the Registered Nurse (RN) Unit Manager (RN #1) by telephone of Resident #22's status, after which LPN #1 and LPN #2 discussed "whose responsibility it was to attend to the resident". A review of the final investigative report evidenced that after being notified, RN #1 responded to the Resident #22's room to find the resident unresponsive with no pulse and/or respirations. RN #1 reported the resident was cold and stiff with emesis coming from the mouth. RN #1 activated the "Full Code status and immediately initiated CPR. RN #1 reported CPR had not been initiated prior to her arriving to the room. RN #1 asked when was the resident found and how long had he been down, but neither LPN #1 whom first responded and found the resident or LPN #2 whom called for assistance were in the room nor did they come to the room during the "code" (emergency responsive to an unresponsive resident). The code was staff by nurses from another floor and the supervisory and administrative nursing staff. A review of the nursing unit's security camera video on [DATE] evidenced and confirmed ? CNA #3 entering Resident #22's room at 7:31 AM, and then exiting at 7:31.45 AM ? Returning with LPN #1 at 7:32.14 AM, whom exited the room at 7:32.26 AM, and the "Full Code" was not activated ? LPN #1 and LPN #2 entering and exiting the room at 7:32.57 AM, and the "Full Code" was not activated ? RN #1 arriving at 7:34.48 AM, activated the "Full Code" status. ? Other nursing staff with emergency equipment arriving at 7:35 AM. ? ADON arrived to room at 7:36 AM. The Emergency Medical Team (EMT), arrived at 8AM and transported Resident #22 to the local hospital emergency room at 8:10AM. LPN #1 only went to the room after being directed to by RN#1 to give the EMT's the resident's medical history. LPN #2 left the floor. The attending physician and the responsible party was notified by the nursing staff. The local hospital emergency room reported Resident #22 expired as a result of a [MEDICAL CONDITION] infarction (MI). (Death of a segment of heart muscle causing "[MEDICAL CONDITION]"). A total of four (4) minutes passed before the "Full Code status was activated and CPR was initiated for Resident #22 being found already unresponsive by CNA #3. "Brain death and permanent death start to occur in just 4 to 6 minutes after someone experiences [MEDICAL CONDITION]. [MEDICAL CONDITION] can be reversed if it's treated within a few minutes with an electric shock to the heart to restore a normal heartbeat. This process is called defibrillation. A victim's chances of survival are reduced by 7 to 10 percent with every minute that passes without CPR and defibrillation. Few attempts at resuscitation succeed after 10 minutes." "[MEDICAL CONDITION]", American Heart Association, webite address: http://www.americanheart.org/presenter.jhtml?identifier=4481 The ADON stated during an interview on [DATE] at 10:00AM, when she arrived to the code for Resident #22, she found LPN #1 and LPN #2 arguing over whose responsibility it was to respond and cover Resident #22. The ADON stated she intervened immediately and advise them to act professionally. The ADON advised the Administrator who immediately started an investigation and reported the results via FRI to the appropriate State Agencies and the Department of Adult Protective Services (APS). A review of the facilities policy on abuse revised [DATE] under the neglect section states staff is the successful key to prevention and immediate appropriate response to incidents wherein residents are at risk of harm and/or decreased function. During an interview with the Administrator, Director of Nursing (DON), ADON, and the Corporate RN on [DATE] at 2:13 PM, the Administrator stated, LPN #1 and LPN #2 identified in the facility investigation, failed to immediately initiate CPR upon notification and responding to Resident #22 had been terminated and reported to the Board of Health Professions for the appropriate action to be taken. The ADON stated the facilities policy is that CPR be started on all residents unless they are designated a Do Not Resuscitate (DNR). During the interview with the Administrator he stated as soon as the was incident was resolved, the facility took administrative action, completed an investigation and then reported the FRI to the appropriate State agencies. 2. Facility failed to apply Resident #10's TED Stocking (Support Hose), consistency as indicated by the attending physician order. Resident #10 was an [AGE] year old admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the most recent Quarterly Minimum Data Set (MDS), dated ,[DATE], evidenced that the resident was modified independence in the area of decision making for cognitive skills, required one person assist with ambulation, and required extensive assistance with activities of daily living including eating, bathing and dressing. On [DATE] upon admission the attending physician wrote an order that stated: "TED Stocking (Support Hose) on AM and off PM. On [DATE] at 9:00 AM, 10:20 AM, and 11:10 AM during observations of the resident it was noted that the resident was sitting the wheel chair in the resident day room, and did not have the support hose in place. Staff was in and out of the day room attending and checking with resident #10. On [DATE] at 9:00 AM, and 10:00 AM during observations of the resident it was noted that the resident was sitting the wheel chair in the resident day room, and did not have the support hose in place. Staff was noted taking too and giving Resident #10 fluids. On [DATE] at 12:15 Noon during continued observations of the residents it was noted that resident was sitting in the dining area in the wheel chair and did not have the support hose in place. A review of the treatment administration record (TAR) documented placement of the Support hose on the resident as ordered by the attending physician on [DATE], [DATE] and [DATE]. On [DATE] at 2:15 PM AM during an interview with the Unit Manager Registered Nurse (RN #1, she stated that Certified Nursing Assistance (CNA #2), assigned to Resident #10 was new and in orientation and probably did not know about the physician order [REDACTED]. On [DATE] at 2:45 PM, during an interview with the Director of Nursing (DON), and Assistance Director of Nursing (ADON), the ADON stated that they would look into the matter and make sure the order was followed as written by the attending physician. 3. Facility staff failed to obtain daily blood pressures as ordered by the physician. Resident #5 was a [AGE] year old re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the most recent quarterly Minimum Data Set ((MDS) dated [DATE] evidenced Resident #5 was able to answer 5 of 15 questions on the Brief Interview for Mental Status. The resident was coded as needing supervision with the assistance of one staff for ADLs (Activities of Daily Living). Review of the Physician order [REDACTED].> (greater than) 170 and /or Dyastolic (sic) B/P > 90". Review of the clinical record for Resident #5 evidenced blood pressures were not obtained on [DATE], [DATE], [DATE], [DATE], and [DATE]. During an interview on [DATE] at 10:45AM, the corporate nurse stated there was no additional information that the blood pressures had been obtained. 4. Facility staff failed to provide 8 ounces of water with medication as ordered by the physician. Resident #14 was a [AGE] year old admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the most recent quarterly Minimum Data Set ((MDS) dated [DATE] evidenced Resident #5 was able to answer 14 of 15 questions on the Brief Interview for Mental Status. The resident was coded as needing extensive assistance for ADLs (Activities of Daily Living). During observation of the medication administration for Resident #14 on [DATE], LPN (Licensed Practical Nurse) #4 put 17 grams of [MEDICATION NAME] (a laxative for constipation relief) in a 7 ounce cup and added approximately 4 ounces of water. The LPN then added 30 ml (milliliters) or approximately one ounce of Prostat (a thick liquid protein supplement). The 7 ounce cup was not filled to the top and the one ounce of thick liquid displaced the water in the cup making the cup appear to contain 5 to 6 ounces of water when administered to the resident. Review of the physician order [REDACTED]. During an interview on [DATE] at 10:45AM, the ADON (Assistant Director of Nursing) stated nurses had been made aware of the cup size and that 8 ounce cups had been ordered for medication administration.