Every finding on record at Winchester Health & Rehabilitation

Based on staff interview, facility document review, and clinical record review, the facility staff failed to notify the physician of medications that were unavailable for administration for three of 17 residents in the survey sample, Residents #1, #3, and #12.The findings include:1. For Resident #1 (R1), the facility staff failed to notify the physician of medications unavailable for administration on 5/20/25. A review of R1's clinical record revealed the following progress note dated 9/20/25 at 4:00 p.m.: Resident arrived in a W/C (wheelchair) to floor Little before 1500 (3:00 p.m.). Pleasant and cooperate (sic) with staff.Resident alert and orient (sic) x 3.Resident receives Hemodialysis Tue (Tuesday), Thurs (Thursday), and Saturday. A review of R1's orders revealed, in part:Insulin Glargine 100 unit/ml (units per milliliter) Inject 15 units subcutaneously every night shift. Colesevelam (to treat high cholesterol) 625 mg (milligrams) Give 1 tablet by mouth two times a day. Coreg (to treat high blood pressure) 6.25 mg Give 1 tablet by mouth two times a day. Lyrica (to treat nerve pain) 25 mg Give 1 capsule by mouth two times a day. Midodrine (to treat low blood pressure) 5 mg Give 1 tablet by mouth two times a day. Senokot (laxative) 8.6 mg Give 2 tablets by mouth two times a day. Sevelamer Carbonate (to treat high phosphorus blood levels) 800 mg Give 2 tablets by mouth with meals. A review of R1's May 2025 MAR (medication administration record) revealed he did not receive insulin as ordered at night on 5/20/25. The insulin was documented as not given, new admit on order in the progress note. This review also revealed he did not receive the following medications in the evening on 5/20/25: Colesevelam, Coreg, Lyrica, Midodrine, Senokot, and Sevelamer. All of these medications were scheduled to be administered at 5:00 p.m. on 5/20/25. Further review of R1's clinical record failed to reveal evidence that the physician was notified of the resident not receiving these medications. On 9/9/25 at 9:23 a.m., ASM (administrative staff member) #3, the assistant director of nursing, was interviewed. She stated orders for new residents are placed in the electronic medical record and directly transmitted to the pharmacy. She stated the physician should be notified if a medication is unavailable for administration for any reason. She added that the physician should have the opportunity to order a different medication, or to say that it is okay for the resident to go without the medication for a certain amount of time. On 9/9/25 at 1:45 p.m., ASM #1, the administrator and ASM #2, the director of nursing, were informed of these concerns. A review of the facility policy, Change in a Resident's Condition, revealed, in part: The facility will promptly notify the resident, his or her physician/practitioner, and representative of changes in the resident's medical/mental condition and/or status No additional information was provided prior to exit. 2. For R11, facility staff failed to notify the physician that Clotrimazole (1) was not available for administration on 05/30/3035 and Aripiprazole (2) and Fluticasone-Salmeterol (3) were not available for administration on 05/31/2025. R11 was admitted to the facility with diagnoses that included but were not limited to bipolar disorder, pulmonary hypertension blood pressure in the lungs higher than normal, causing the heart to work harder) and muscle weakness. The physician's order for R11 documented in part:. Aripiprazole Oral Tablet 5 (five) MG (milligrams). Give 1 (one) tablet by mouth one time a day for bipolar disorder. Order Date: 5/30/2025. Fluticasone-Salmeterol 500-50 MCG/ACT (microgram/actuation) Aerosol Powder, breath activated. 1 (one) puff inhale orally one time a day related to TYPE 2 DIABETES MELLITUS WITH DIABETIC CHRONIC KIDNEY DISEASE. Order Date: 5/31/2025. Clotrimazole Mouth/Throat Troche (medicated lozenge)10 MG. Give 1 tablet by mouth five times a day for Candidiasis Fungal infection (yeast infection) of the Oropharynx (back of the throat). Order Date: 5/30/2025. The eMAR (electronic medication administration record) dated May 2025 for R11 documented the physician's orders as stated above. The eMAR coded a 9 (nine) on 05/30/2025 for Clotrimazole and a 9 on 05/31/2025 for Aripiprazole and Fluticasone-Salmeterol. The eMAR Chart Code documented in part, 9=Other / See progress Notes. The facility's nurse's note dated 05/30/2025 at 10:30 p.m. for R11 documented Clotrimazole Mouth/Throat Troche 10 MG. Give 1 tablet by mouth five times a day for Candidiasis Fungal infection of the Oropharynx. Medication on order unavailable in back stock. The facility's nurse's note dated 05/31/2025 for R11 documented, Fluticasone-Salmeterol 500-50 MCG/ACT Aerosol Powder, breath activated. 1 puff inhale orally one time a day related to TYPE 2 DIABETES MELLITUS WITH DIABETIC CHRONIC KIDNEY DISEASE . Pending delivery. The facility's nurse's note dated 05/31/2025 at 11:15 p.m. for R11 documented, Aripiprazole Oral Tablet 5 MG. Give 1 tablet by mouth one time a day for bipolar disorder. pending delivery. The facility's Omnicell (automated medication dispensing system) inventory list failed to evidence Clotrimazole 10 MG, Aripiprazole 5MG and Fluticasone-Salmeterol 500-50 MCG were available in the Omnicell system. The EHR (electronic health record) for R11 was reviewed. The EHR failed to evidence documentation that the physician was notified of Clotrimazole 10 MG, Aripiprazole 5MG and Fluticasone-Salmeterol 500-50 MCG was not available for administration to R11 on 05/30/2025 and 05/31/2025. On 9/9/25 at 9:23 a.m., ASM (administrative staff member) #3, the assistant director of nursing, was interviewed. She stated the physician should be notified if a medication is unavailable for administration. The physician should have the opportunity to order a different medication, or to say that it is okay for the resident to go without the medication for a certain amount of time. On 09/09/2025 at approximately 1:45 p.m. ASM (administrative staff member) #1, administrator, ASM #2, director of nursing, ASM #3, assistant director of nursing and ASM #6, regional director of clinical services, were made aware of the above findings. No further information was provided prior to exit. References: (1) Used to treat fungal skin infection. This information was obtained from the website: hhtps://medlineplus.gov/druginfo/meds/a618059.html. (2) Used to treat schizophrenia (a mental illness that affects how a person thinks, feels and behaves) bipolar disorder (a disease that causes depression, mania, and other abnormal moods). This information was obtained from the website: hhtps://medlineplus.gov/druginfo/meds/a603012.html. (3) Used to treat difficulty breathing, wheezing, shortness of breath, coughing, and chest tightness caused by asthma. This information was obtained from the website: hhtps://medlineplus.gov/druginfo/meds/a699063.html. 3. For Resident #12 (R12), the facility staff failed to notify the physician that Gabapentin was not administrered as ordered on 8/29/25, 8/30/25 and 8/31/25. The physician orders for R12 documented in part, Gabapentin Oral Tablet 800 MG (Gabapentin) Give 1 tablet by mouth every 8 hours for neuropathy. Order Date: 08/29/2025. Start Date: 08/29/2025. Review of the eMAR (electronic medication record) for R12 failed to evidence administration of the Gabapentin 800mg on 8/29/25 at 10:00 p.m., 8/30/25 at 6:00 a.m., 2:00 p.m., and 10:00 p.m. and 8/31/25 at 6:00 a.m. and 2:00 p.m. Review of the eMAR progress notes documented the medication being on order from the pharmacy. The progress notes failed to evidence notification of the physician or nurse practitioner of the medication not administered. On 9/9/2025 at 9:23 a.m., an interview was conducted with ASM (administrative staff member) #3, the assistant director of nursing who stated that orders for new residents were placed in the electronic medical record and directly transmitted to the pharmacy. She stated that the pharmacy delivered them as soon as possible and also added, We can also have them stat delivered. ASM #3 explained the facility has an Omnicell system that contains many standard medications, but not all and the nurse should check the Omnicell before determining that a medication was unavailable. She stated if there was a medication ordered that the facility was not able to obtain, the facility staff would ask the family members to bring in the medication from home and the physician should be notified if a medication was unavailable for administration. ASM #3 stated that the physician should have the opportunity to order a different medication, or to say that it was okay for the resident to go without the medication for a certain amount of time. On 9/9/2025 at 1:44 p.m., ASM #1, the administrator, ASM #2, the director of nursing and ASM #3, the assistant director of nursing were made aware of the findings. No further information was provided prior to exit.

Based on clinical record review, staff interview and facility document review, facility staff failed to provide medications as ordered for four of 17 residents in the survey sample, Residents #3 (R3), R11, R1 and R12. The findings include:1. For R3, facility staff failed to administer Panoxyl (1) according to the physician's orders. On the most recent MDS (minimum data set), an annual assessment with an ARD (assessment reference date) of 08/07/2024, R3 scored 15 out of 15 on the BIMS (brief interview for mental status), indicating the resident was cognitively intact for making daily decisions. The physician's order for R3 documented in part, Panoxyl External Liquid (Benzoyl Peroxide) Apply to body topically one time a day for acne. Order date: 9/20/2024. Discontinue Date: 11/05/0224. The eMAR (electronic medication administration record) dated September 2024 for R3 documented the physician's orders as stated above. The eMAR further documented R3 received Panoxyl two of ten opportunities. The eMAR (electronic medication administration record) dated October 2024 for R3 documented the physician's orders as stated above. The eMAR further documented R3 received Panoxyl 11 of 30 opportunities. The nurse's note dated 09/21/2024 for R3 documented Panoxyl External Liquid. Apply to body topically one time a day for acne. Pending. The nurse's note dated 09/22/2024 for R3 documented Panoxyl External Liquid Apply to body topically one time a day for acne. The nurse's note dated 09/23/2024 for R3 documented Panoxyl External Liquid. Apply to body topically one time a day for acne. np/pharmacy notified. The nurse's note dated 09/25/2024 for R3 documented Panoxyl External Liquid Apply to body topically one time a day for acne. Will give as scheduled when arrives. Resident aware. pharmacy notified. The nurse's note dated 09/26/2024 for R3 documented Panoxyl External Liquid. Apply to body topically one time a day for acne. Awaiting pharmacy delivery. MD and RP notified. The nurse's note dated 09/27/2024 for R3 documented Panoxyl External Liquid. Apply to body topically one time a day for acne. np/pharmacy notified. The nurse's note dated 09/28/2024 for R3 documented Panoxyl External Liquid. Apply to body topically one time a day for acne. np/pharmacy notified. The nurse's note dated 09/30/2024 at 10:24 a.m. for R3 documented. Called pharmacy at (Phone Number), spoke with (Name of Pharmacy Technician) pharm tech, regarding Panoxyl liquid soap. stated that an OTC (over the counter) authorization form needs to be sent for medication d/t due to) it's not covered by insurance and that facility will be billed. will inform NP. The nurse's note dated 09/30/2024 at 10:53 a.m. for R3 documented Weekly skin observation completed. Other skin concerns: Rash to upper body sides of trunk and back (acne vulgaris current treatment). The nurse's note dated 10/02/2024 for R3 documented, Panoxyl External Liquid. Apply to body topically (on the skin) one time a day for acne np (nurse practitioner)/pharmacy notified. The nurse's note dated 10/03/2024 for R3 documented, Panoxyl External Liquid. Apply to body topically one time a day for acne. np/pharmacy notified. The nurse's note dated 10/08/2024 for R3 documented, Panoxyl External Liquid. Apply to body topically one time a day for acne. np/pharmacy notified. The nurse's note dated 10/11/2024 for R3 documented, Panoxyl External Liquid. Apply to body topically one time a day for acne. np/pharmacy notified. The nurse's note dated 10/12/2024 for R3 documented, Panoxyl External Liquid. Apply to body topically one time a day for acne. np/pharmacy notified. The nurse's note dated 10/13/2024 for R3 documented, Panoxyl External Liquid. Apply to body topically one time a day for acne. The nurse's note dated 10/14/2024 for R3 documented, Panoxyl External Liquid. Apply to body topically one time a day for acne. The nurse's note dated 10/15/2024 for R3 documented, Panoxyl External Liquid. Apply to body topically one time a day for acne. Ordered. The nurse's note dated 10/16/2024 for R3 documented, Panoxyl External Liquid. Apply to body topically one time a day for acne. dont have. The facility's Omnicell (automated medication dispensing system) inventory list failed to evidence Panoxyl was available in the Omnicell system. On 9/9/25 at 12:09 p.m., ASM #5, the facility pharmacist, was interviewed. He stated for all order submissions on weekdays the pharmacy has cutoff times of 11:00 a.m. and 11:00 p.m. Any medication order submitted to the pharmacy before 11:00 a.m. will be delivered on the standard pharmacy run, sometime between 5:00 p.m. and 8:00 p.m. that evening (depending on traffic and other external factors). Any medication order submitted between 11:00 am and 11:00 p.m. will be delivered sometime between 4:00 a.m. and 8:00 a.m. the following morning. He stated if a resident is a new admission and arrives at the facility after the 11:00 a.m. cutoff time, the facility should either use the Omnicell medication supply, or the facility can call the pharmacy and request a stat (urgent) delivery. On 9/9/25 at 9:23 a.m., ASM (administrative staff member) #3, the assistant director of nursing, was interviewed. She stated orders for new residents are placed in the electronic medical record and directly transmitted to the pharmacy. The pharmacy delivers them as soon as possible. She added: We can also have them stat delivered. She explained the facility has an Omnicell system that contains many standard medications, but not all. The nurse should check the Omnicell before determining that a medication is unavailable. She stated if there is a medication ordered that the facility is not able to obtain, the facility staff will ask the family members to bring in the medication from home. She stated the physician should be notified if a medication is unavailable for administration. The physician should have the opportunity to order a different medication, or to say that it is okay for the resident to go without the medication for a certain amount of time. The facility's policy Unavailable Medications documented, Policy. Medications used by residents in the nursing facility may be unavailable for dispensing from the pharmacy on occasion. This may be due to the pharmacy being temporarily out of stock of a particular product, a drug recall, or manufacturer's shortage of an ingredient, or may be a permanent situation due to the medication no longer being produced. The facility must make every effort to ensure that medications are available to meet the needs of each resident. Procedure. The pharmacy staff shall: 1. Notify nursing staff that the order product(s) is/are unavailable. 2. Notify nursing staff of when it is anticipated that the drug(s) will become available. 3. Suggest alternative, comparable drug(s) and dosage of drug(s) that is/are available. The nursing staff shall: 1. Notify the attending physician (or on-call physician when applicable) of the situation and explain the circumstances, expected availability, and alternative therapy(ies) available. If the facility nurse is unable to obtain a response from the attending physician or on-call physician, the nurse should notify the nursing supervisor and contact the Facility Medical Director for orders and/or direction. 2. Obtain a new order and cancel/discontinue the order for the non-available medication. 3. Notify the pharmacy of the replacement order. On 09/09/2025 at approximately 1:45 p.m. ASM (administrative staff member) #1, administrator, ASM #2, director of nursing, ASM #3, assistant director of nursing and ASM #6, regional director of clinical services, were made aware of the above findings. No further information was provided prior to exit. Reference: (1) Works by killing the bacteria that cause acne. The information was obtained from the website: https://medlineplus.gov/druginfo/meds/a603024.html. 2. For R11, facility staff failed to administer Clotrimazole (1) on 05/30/3035, Aripiprazole (2) and Fluticasone-Salmeterol (3) on 05/31/2025. R11 was admitted to the facility with diagnoses that included but were not limited to bipolar disorder, pulmonary hypertension blood pressure in the lungs higher than normal, causing the heart to work harder) and muscle weakness. The physician's order for R11 documented in part: Aripiprazole Oral Tablet 5 (five) MG (milligrams). Give 1 (one) tablet by mouth one time a day for bipolar disorder. Order Date: 5/30/2025. Fluticasone-Salmeterol 500-50 MCG/ACT (microgram/actuation) Aerosol Powder, breath activated. 1 (one) puff inhale orally one time a day related to TYPE 2 DIABETES MELLITUS WITH DIABETIC CHRONIC KIDNEY DISEASE. Order Date: 5/31/2025. Clotrimazole Mouth/Throat Troche (medicated lozenge)10 MG. Give 1 tablet by mouth five times a day for Candidiasis Fungal infection (yeast infection) of the Oropharynx (back of the throat). Order Date: 5/30/2025. The eMAR (electronic medication administration record) dated May 2025 for R11 documented the physician's orders as stated above. The eMAR coded a 9 (nine) on 05/30/2025 for Clotrimazole and a 9 on 05/31/2025 for Aripiprazole and Fluticasone-Salmeterol. The eMAR Chart Code documented in part, 9= Other / See progress Notes. The facility's nurse's note dated 05/30/2025 at 10:30 p.m. for R11 documented Clotrimazole Mouth/Throat Troche 10 MG. Give 1 tablet by mouth five times a day for Candidiasis Fungal infection of the Oropharynx. Medication on order unavailable in back stock. The facility's nurse's note dated 05/31/2025 for R11 documented, Fluticasone-Salmeterol 500-50 MCG/ACT Aerosol Powder, breath activated. 1 puff inhale orally one time a day related to TYPE 2 DIABETES MELLITUS WITH DIABETIC CHRONIC KIDNEY DISEASE . Pending delivery. The facility's nurse's note dated 05/31/2025 at 11:15 p.m. for R11 documented, Aripiprazole Oral Tablet 5 MG. Give 1 tablet by mouth one time a day for bipolar disorder. pending delivery. The facility's Omnicell (automated medication dispensing system) inventory list failed to evidence Clotrimazole 10 MG, Aripiprazole 5MG and Fluticasone-Salmeterol 500-50 MCG were available in the Omnicell system. The EHR (electronic health record) for R11 was reviewed. The EHR failed to evidence documentation that the physician was notified of Clotrimazole 10 MG, Aripiprazole 5MG and Fluticasone-Salmeterol 500-50 MCG was not available for administration to R11 on 05/30/2025 and 05/31/2025. On 09/09/2025 at approximately 1:45 p.m. ASM (administrative staff member) #1, administrator, ASM #2, director of nursing, ASM #3, assistant director of nursing and ASM #6, regional director of clinical services, were made aware of the above findings. No further information was provided prior to exit. References: (1) Used to treat fungal skin infection. This information was obtained from the website: hhtps://medlineplus.gov/druginfo/meds/a618059.html. (2) Used to treat schizophrenia (a mental illness that affects how a person thinks, feels and behaves) bipolar disorder (a disease that causes depression, mania, and other abnormal moods). This information was obtained from the website: hhtps://medlineplus.gov/druginfo/meds/a603012.html. (3) Used to treat difficulty breathing, wheezing, shortness of breath, coughing, and chest tightness caused by asthma. This information was obtained from the website: hhtps://medlineplus.gov/druginfo/meds/a699063.html. 3. For Resident #1 (R1), the facility pharmacy failed to provide medications for administration on 5/20/25. A review of R1's clinical record revealed the following progress note dated 9/20/25 at 4:00 p.m.: Resident arrived in a W/C (wheelchair) to floor Little before 1500 (3:00 p.m.). Pleasant and cooperate (sic) with staff.Resident alert and orient (sic) x 3.Resident receives Hemodialysis Tue (Tuesday), Thurs (Thursday), and Saturday. A review of R1's orders revealed, in part:Colesevelam (to treat high cholesterol) 625 mg (milligrams) Give 1 tablet by mouth two times a day. Lyrica (to treat nerve pain) 25 mg Give 1 capsule by mouth two times a day. Senokot (laxative) 8.6 mg Give 2 tablets by mouth two times a day. Sevelamer Carbonate (to treat high phosphorus blood levels) 800 mg Give 2 tablets by mouth with meals. A review of R1's May 2025 MAR (medication administration record) revealed he did not receive any of these medications as ordered at 5:00 p.m. on 5/20/25. Each of these medications was documented as not having yet been received from pharmacy at that time. On 9/9/25 at 9:23 a.m., ASM (administrative staff member) #3, the assistant director of nursing, was interviewed. She stated orders for new residents are placed in the electronic medical record and directly transmitted to the pharmacy. The pharmacy delivers them as soon as possible. She added: We can also have them stat delivered. She explained the facility has an Omnicell system that contains many standard medications, but not all. The nurse should check the Omnicell before determining that a medication is unavailable. She stated if there is a medication ordered that the facility is not able to obtain, the facility staff will ask the family members to bring in the medication from home. She stated the physician should be notified if a medication is unavailable for administration. The physician should have the opportunity to order a different medication, or to say that it is okay for the resident to go without the medication for a certain amount of time. On 9/9/25 at 12:09 p.m., ASM #5, the facility pharmacist, was interviewed. He stated for all order submissions on weekdays the pharmacy has cutoff times of 11:00 a.m. and 11:00 p.m. Any medication order submitted to the pharmacy before 11:00 a.m. will be delivered on the standard pharmacy run, sometime between 5:00 p.m. and 8:00 p.m. that evening (depending on traffic and other external factors). Any medication order submitted between 11:00 am and 11:00 p.m. will be delivered sometime between 4:00 a.m. and 8:00 a.m. the following morning. He stated if a resident is a new admission and arrives at the facility after the 11:00 a.m. cutoff time, the facility should either use the Omnicell medication supply, or the facility can call the pharmacy and request a stat (urgent) delivery. On 9/9/25 at 1:45 p.m., ASM #1, the administrator and ASM #2, the director of nursing, were informed of these concerns. No additional information was provided prior to exit. 4. For Resident #12 (R12), the facility staff failed to ensure Gabapentin (1) was available for administration as ordered. The physician orders for R12 documented in part, Gabapentin Oral Tablet 800 MG (Gabapentin) Give 1 tablet by mouth every 8 hours for neuropathy. Order Date: 08/29/2025. Start Date: 08/29/2025. Review of the eMAR (electronic medication record) for R12 failed to evidence administration of the Gabapentin 800mg on 8/29/25 at 10:00 p.m., 8/30/25 at 6:00 a.m., 2:00 p.m., and 10:00 p.m. and 8/31/25 at 6:00 a.m. and 2:00 p.m. Review of the eMAR progress notes documented the medication being on order from the pharmacy. On 9/9/2025 at 9:23 a.m., an interview was conducted with ASM (administrative staff member) #3, the assistant director of nursing who stated that orders for new residents were placed in the electronic medical record and directly transmitted to the pharmacy. She stated that the pharmacy delivered them as soon as possible and also added, We can also have them stat delivered. ASM #3 explained the facility has an Omnicell system that contains many standard medications, but not all and the nurse should check the Omnicell before determining that a medication was unavailable. She stated if there was a medication ordered that the facility was not able to obtain, the facility staff would ask the family members to bring in the medication from home and the physician should be notified if a medication was unavailable for administration. ASM #3 stated that the physician should have the opportunity to order a different medication, or to say that it was okay for the resident to go without the medication for a certain amount of time. Review of the facility Omnicell inventory list documented the following strengths of Gabapentin available. Gabapentin 100mg capsule with a par level of 10 and Gabapentin 300mg capsule with a par level of 10. On 9/9/25 at 12:09 p.m., an interview was conducted with ASM #5, the facility pharmacist. He stated for all order submissions on weekdays the pharmacy had cutoff times of 11:00 a.m. and 11:00 p.m. and any medication order submitted to the pharmacy before 11:00 a.m. will be delivered on the standard pharmacy run, sometime between 5:00 p.m. and 8:00 p.m. that evening (depending on traffic and other external factors). He stated that any medication order submitted between 11:00 am and 11:00 p.m. will be delivered sometime between 4:00 a.m. and 8:00 a.m. the following morning. ASM #5 stated if a resident was a new admission and arrived at the facility after the 11:00 a.m. cutoff time, the facility should either use the Omnicell medication supply, or the facility can call the pharmacy and request a stat (urgent) delivery. On 9/9/2025 at 1:48 p.m., ASM #3, the assistant director of nursing, stated that it was difficult for staff to use the Gabapentin in the Omnicell if it was not the exact dosage and they had to obtain a new written prescription for the dosage in the Omnicell if they wanted to use what was on hand. On 9/9/2025 at 1:44 p.m., ASM #1, the administrator, ASM #2, the director of nursing and ASM #3, the assistant director of nursing were made aware of the findings. No further information was provided prior to exit. Reference: (1) Gabapentin capsules, tablets, and oral solution are used along with other medications to help control certain types of seizures in people who have epilepsy. Gabapentin capsules, tablets, and oral solution are also used to relieve the pain of postherpetic neuralgia (PHN; the burning, stabbing pain or aches that may last for months or years after an attack of shingles). Gabapentin extended-release tablets (Horizant) are used to treat restless legs syndrome (RLS; a condition that causes discomfort in the legs and a strong urge to move the legs, especially at night and when sitting or lying down). Gabapentin is in a class of medications called anticonvulsants. Gabapentin treats seizures by decreasing abnormal excitement in the brain. Gabapentin relieves the pain of PHN by changing the way the body senses pain. It is not known exactly how gabapentin works to treat restless legs syndrome. This information was obtained from the website: https://medlineplus.gov/druginfo/meds/a694007.html

Based on observation, resident interview, staff interview, clinical record review and facility document review, it was determined that the facility staff failed to maintain a call bell in a position that was accessible to the resident for one of 17 residents in the survey sample, Resident #5.The findings include:For Resident #5 (R5), the facility staff failed to maintain the call bell in reach.On the most recent MDS (minimum data set), an admission assessment, with an ARD (assessment reference date) of 8/24/25, the resident was assessed as being cognitively intact for making daily decisions. R5 was assessed as not having any limitations in range of motion to the upper extremities, dependent on staff for toileting hygiene and requiring substantial to maximal assistance for transfers.On 9/8/2025 at 12:05 p.m., an observation was made of R5 in their room. R5 was observed lying in bed with the call bell observed on the right upper bed rail wrapped around the lower portion of the rail. When asked if they were able to reach their call bell, R5 attempted to locate the call bell and stated that he did not know where it was and could not find it. R5 stated that he did use the call bell to get staff when he needed care and they normally responded in a timely manner.Additional observations of R5's call bell were made on 9/8/2025 at 1:49 p.m. and 2:37 p.m. The call bell was located on the right upper bed rail wrapped around the lower portion of the rail.On 9/9/2025 at 12:36 p.m., an interview was conducted with CNA (certified nursing assistant) #1 who stated that call bells should be placed in reach of all residents. She stated that this was so the resident could call if they needed something. CNA #1 stated that they checked the call bell placement every time they went into the room prior to leaving and when they walked past the rooms. The facility policy, Answering the Call Light revised 8/2020, documented in part, .When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident.On 9/9/2025 at 1:44 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing and ASM #3, the assistant director of nursing were made aware of the findings.No further information was provided prior to exit.

Based on clinical record review, staff interview and facility document review, facility staff failed to provide care and services to promote the resident's highest level of wellbeing for two of 17 residents in the survey sample, Residents #3 (R3) and R1. The findings include:1. For R3, facility staff failed to assess and monitor a skin rash. On the most recent MDS (minimum data set), an annual assessment with an ARD (assessment reference date) of 08/07/2024, R3 scored 15 out of 15 on the BIMS (brief interview for mental status), indicating the resident was cognitively intact for making daily decisions. The physician's order for R3 documented in part, Panoxyl (1) External Liquid (Benzoyl Peroxide) Apply to body topically one time a day for acne. Order date: 9/20/2024. Discontinue Date: 11/05/0224. The eMAR (electronic medication administration record) for R3 dated September 2024 documented the physician's order as stated above. The facility's weekly skin observation sheet for R3 dated 09/16/2024, 09/23/2024, 10/07/2024, 10/16/2024, 10/23/2024 and on 11/01/2024 failed to evidence documentation of acne or a rash. On 09/09/2025 at approximately 12:43 p.m. an interview was conducted with LPN (licensed practical nurse) #3. When asked about documenting a resident's abnormal skin condition such as a rash she stated that the condition should be documented on the skin observation sheet as long as the condition persists. When asked if the resident was being assessed and monitored when the skin observation sheets failed to consistently document the resident's skin rash she stated no. The facility's policy Change in a Resident's Condition documented in part, 7. The nurse / designee will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status. On 09/09/2025 at approximately 1:45 p.m. ASM (administrative staff member) #1, administrator, ASM #2, director of nursing, ASM #3, assistant director of nursing and ASM #6, regional director of clinical services, were made aware of the above findings. No further information was provided prior to exit. Complaint deficiency Reference: (1) Works by killing the bacteria that cause acne. The information was obtained from the website: https://medlineplus.gov/druginfo/meds/a603024.html. 2. For Resident #1 (R1), the facility staff failed to administer medications as ordered by the physician on 5/20/25. R1 was admitted to the facility on [DATE] and was discharged [DATE]. A review of R1's admission assessment dated [DATE] revealed R1 was oriented to person, place, and time; and was able to make his own decisions. A review of R1's cognitive assessment dated [DATE] revealed he had no cognitive impairment. A review of R1's clinical record revealed the following progress note dated 9/20/25 at 4:00 p.m.: Resident arrived in a W/C (wheelchair) to floor Little before 1500 (3:00 p.m.). Pleasant and cooperate (sic) with staff.Resident alert and orient (sic) x 3.Resident receives Hemodialysis Tue (Tuesday), Thurs (Thursday), and Saturday. A review of R1's orders revealed, in part:Insulin Glargine 100 unit/ml (units per milliliter) Inject 15 units subcutaneously every night shift. Coreg (to treat high blood pressure) 6.25 mg Give 1 tablet by mouth two times a day. Midodrine (to treat low blood pressure) 5 mg Give 1 tablet by mouth two times a day. A review of R1's May 2025 MAR (medication administration record) revealed he did not receive insulin as ordered at night on 5/20/25. The insulin was documented as not given, new admit on order in the progress note. This review also revealed he did not receive Coreg or Midodrine medications in the evening on 5/20/25. A review of the facility's Omnicell list (list of standard medications available at all times for residents) revealed the following medications were available for administration on 5/20/25 at 5:00 p.m.: Insulin Glargine 100 units/ml, Coreg 3.125 mg tablets, and Midodrine 5 mg. On 9/9/25 at 9:23 a.m., ASM (administrative staff member) #3, the assistant director of nursing, was interviewed. She stated orders for new residents are placed in the electronic medical record and directly transmitted to the pharmacy. The pharmacy delivers them as soon as possible. She added: We can also have them stat delivered. She explained the facility has an Omnicell system that contains many standard medications, but not all. The nurse should check the Omnicell before determining that a medication is unavailable. She stated if there is a medication ordered that the facility is not able to obtain, the facility staff will ask the family members to bring in the medication from home. She stated the physician should be notified if a medication is unavailable for administration. The physician should have the opportunity to order a different medication, or to say that it is okay for the resident to go without the medication for a certain amount of time. On 9/9/25 at 1:45 p.m., ASM #1, the administrator and ASM #2, the director of nursing, were informed of these concerns. No additional information was provided prior to exit.

Based on staff interview, facility document review and clinical record review, the facility staff failed to provide ADL (activities of daily living) care for two of 32 residents in the survey sample, Residents #263 and #262. The findings include: 1.a. For Resident #263 (R263), the facility staff failed to assist the resident with bathing/showers on multiple dates May 2022 through July 2022. R263's comprehensive care plan dated 10/28/21 documented, (R263) has an ADL self-care performance deficit r/t (related to) Activity Intolerance, Fatigue, Impaired balance, Limited Mobility, Musculoskeletal impairment and Chronic pain. Resident requires extensive to total care of 1-2 staff for the completion of ADL care . R263's quarterly MDS (minimum data set) assessment with an ARD (assessment reference date) of 5/30/22, coded the resident as being totally dependent on one staff with bathing. A review of R263's activities of daily living records for May 2022 through July 2022 revealed a section for staff to document bathing and showers. Further review of R263's clinical record, including ADL records and nurses' notes for May 2022 through July 2022, failed to reveal documentation that the resident was assisted with bathing and/or showers from 5/18/22 until 5/24/22 (five days), 5/31/22 until 6/7/22 (six days) and 6/11/22 until 7/11/22 (29 days). On 4/11/23 at 3:12 p.m., an interview was conducted with LPN (licensed practical nurse) #2. LPN #2 stated residents are provided showers two days each week and when requested. LPN #2 stated showers are evidenced by documentation in the computer (ADL records) and documentation on shower sheets, but the shower sheets were just implemented a month ago. On 4/11/23 at 4:04 p.m., an interview was conducted with CNA (certified nursing assistant) #1. CNA #1 stated residents are provided showers or a complete bed bath, per their preference, twice a week. CNA #1 stated that on the other five days, residents are provided partial bed baths. CNA #1 stated that CNAs should document any time that any type of bathing is provided. On 4/11/23 at 5:18 p.m., ASM (administrative staff member) #1, the administrator, and ASM #2, the director of nursing, were made aware of the above concern. The facility policy titled, Activities of Daily Living (ADLs) documented, 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); i. Each resident shall receive tub or shower baths as often as needed, but not less than twice weekly or as required by state law. Residents preference and/or whose medical conditions prohibit tub or shower baths shall have a sponge bath daily. ii. Residents will be assisted with dressing and grooming as appropriate and resident choice will be respected. iii. Residents shall be assisted with oral care as needed. b. Mobility (transfer and ambulation, including walking); i. Residents will be assisted with transfer and mobility as ordered by the physician/practitioner and/or as instructed in the resident's care plan. c. Elimination (toileting); i. Residents shall be assisted with toileting as needed. ii. Residents who are incontinent of bladder or bowel, will be provided care in a timely manner. d. Dining (meals and snacks); and i. Residents who require assistance with eating or drinking will be provided assistance as instructed in the resident's care plan. 1.b. For Resident #263 (R263), the facility staff failed to assist the resident with transfers out of bed on multiple dates May 2022 through July 2022. R263's comprehensive care plan dated 10/28/21 documented, (R263) has an ADL self-care performance deficit r/t (related to) Activity Intolerance, Fatigue, Impaired balance, Limited Mobility, Musculoskeletal impairment and Chronic pain. Resident requires extensive to total care of 1-2 staff for the completion of ADL care . R263's quarterly MDS (minimum data set) assessment with an ARD (assessment reference date) of 5/30/22, coded the resident as requiring extensive assistance of two or more staff with transfers. A review of R263's activities of daily living records for May 2022 through July 2022 revealed a section for staff to document transfers. Further review of R263's clinical record (including ADL records and nurses' notes for May 2022 through July 2022) failed to reveal documentation that the resident was assisted with transfers on 5/1/22, 5/4/22, 5/5/22, 5/17/22, 6/13/22, 6/24/22, 6/28/22, 6/30/22, 7/1/22, 7/2/22, 7/3/22, 7/4/22, 7/8/22, 7/9/22 and 7/10/22. On 4/11/23 at 3:12 p.m., an interview was conducted with LPN (licensed practical nurse) #2. LPN #2 stated staff should offer residents assistance with getting out of bed every day. On 4/11/23 at 4:04 p.m., an interview was conducted with CNA (certified nursing assistant) #1. CNA #1 stated, I offer multiple (transfers) throughout the day, every day, to prevent bed sores and stuff. If we transfer at all, it should be documented. On 4/11/23 at 5:18 p.m., ASM (administrative staff member) #1, the administrator, and ASM #2, the director of nursing, were made aware of the above concern. 1.c. For Resident #263 (R263), the facility staff failed to provide eating assistance on multiple dates May 2022 through July 2022. R263's comprehensive care plan dated 10/28/21 documented, (R262) has an ADL self-care performance deficit r/t (related to) Activity Intolerance, Fatigue, Impaired balance, Limited Mobility, Musculoskeletal impairment and Chronic pain. Resident requires extensive to total care of 1-2 staff for the completion of ADL care . R263's quarterly MDS (minimum data set) assessment with an ARD (assessment reference date) of 5/30/22, coded the resident as requiring extensive assistance of one staff with eating. A review of R263's activities of daily living records for May 2022 through July 2022 revealed a section for staff to document eating assistance. Further review of R263's clinical record (including ADL records and nurses' notes for May 2022 through July 2022) failed to reveal documentation that the resident was assisted with eating on 5/4/22, 5/5/22, 5/13/22, 5/14/22, 5/17/22, 5/19/22, 5/20/22, 5/28/22, 5/29/22, 5/30/22, 6/1/22, 6/2/22, 6/3/22, 6/4/22, 6/5/22, 6/8/22, 6/10/22, 6/12/22, 6/13/22, 6/14/22, 6/15/22, 6/16/22, 6/17/22, 6/18/22, 6/21/22, 6/22/22, 6/23/22, 6/24/22, 6/25/22, 6/26/22, 6/30/22, 7/1/22, 7/2/22, 7/3/22, 7/4/22, 7/5/22, 7/7/22, 7/8/22, 7/9/22, 7/10/22, 7/14/22, and 7/16/22. On 4/11/23 at 3:12 p.m., an interview was conducted with LPN (licensed practical nurse) #2. LPN #2 stated that most of the time, nurses recognize when a resident needs to be fed and tells the CNAs (certified nursing assistants) to feed the resident. LPN #2 stated feeding assistance has to be documented in the ADL records. On 4/11/23 at 4:04 p.m., an interview was conducted with CNA #1. CNA #1 stated that normally the speech therapist or a report from the hospital makes them aware of residents who need assistance with eating. CNA #1 stated that she makes the nurse aware and assists residents if she sees that they are having an issue with eating. CNA #1 stated she at least sits with residents and supervises them to see if they require assistance and she documents the assistance provided. On 4/11/23 at 5:18 p.m., ASM (administrative staff member) #1, the administrator, and ASM #2, the director of nursing, were made aware of the above concern. 42106 2. For Resident #262 (R262), the facility staff failed to provide incontinence care. The comprehensive MDS (minimum data set) had not been completed for R262 due to the short time the resident was in the facility. The admission nursing assessment for R262 dated 12/27/2021 documented the resident as being alert and oriented to person, place and time. The assessment further documented R262 being moderately short of breath, requiring continuous oxygen, occasionally incontinent of bowel and frequently incontinent of urine. The assessment documented R262 using pads and/or briefs. The ADL (activities of daily living) Toilet use, B&B (bowel and bladder) Bowel and B&B Bladder documentation dated 12/1/2021-12/31/2021 for R262 documented incontinence care provided on 12/28/2021 on the 7:00 a.m. to 3:00 p.m. shift requiring extensive assistance of one staff member. The ADL Toilet use documentation failed to evidence incontinence care provided on 12/27/2021 evening (3:00 p.m. to 11:00 p.m.) shift and night (11:00 p.m. to 7:00 a.m.) shift. It further failed to evidence incontinence care was provided on 12/28/2021 on the evening and night shift. The documentation areas for 12/27/2021 and 12/28/2021 evening and night shifts were observed to be blank. On 4/11/2023 at 3:25 p.m., an interview was conducted with LPN (licensed practical nurse) #2. LPN #2 stated that ADL's were documented in the computer. LPN #2 stated that blanks meant that they did not do anything. LPN #2 stated that they could not prove that anything was done. On 4/11/2023 at 4:04 p.m., an interview was conducted with CNA (certified nursing assistant) #1. CNA #1 stated that incontinence care was provided every two hours. CNA #1 stated that incontinence care was documented on the computer in the ADL's every shift to evidence that it was completed. On 4/12/2023 at 10:37 a.m., an interview was conducted with CNA #2. CNA #2 stated that incontinence care was provided every two hours. CNA #2 stated that they documented incontinence care in the electronic medical record under the ADL-Toilet use and B&B elimination areas. CNA #2 stated that they documented incontinence care every eight hours for each shift. CNA #2 reviewed the ADL-Toilet use and B&B elimination summary for R262 dated 12/1/2021-12/31/2021 and stated that the aide did not document that any care was provided. CNA #2 stated that there was no evidence that incontinence care was provided to R262 except for 12/28/2021 on the day shift. The facility policy Incontinence dated November 2017 documented in part, Based on the resident ' s comprehensive assessment, all residents that are incontinent will receive appropriate treatment and services . On 4/12/2023 at approximately 1:29 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing and ASM #4, the regional nurse consultant were made aware of the concern. No further information was provided prior to exit.

Based on staff interview and clinical record review, it was determined the facility staff failed to administer treatments to a pressure injury for one of 32 residents in the survey sample, Resident #14. The findings include: A. For Resident #14 (R14), the facility staff failed to evidence the administration of a wound vacuum for a sacral pressure injury. A pressure injury is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbidities and condition of the soft tissue. (1) On the most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date (ARD) of 12/28/2022, the resident scored a 14 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired for making daily decisions. On the MDS, closest to the time of the pressure injury, with an ARD of 5/31/2022, R14 was coded in Section M - Skin Conditions, as having a stage four pressure injury. Stage 4 Pressure Injury: Full-thickness skin and tissue loss Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible. Epibole (rolled edges), undermining and/or tunneling often occur. Depth varies by anatomical location. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. (1) The physician order dated, 2/28/2022, documented, Wound Vac (vacuum) with black sponge to be changed M-W-F (Monday - Wednesday - Friday) every day shift every [NAME], Wed, Fri to wound. The May 2022 TAR (treatment administration record) documented the above order. On the following dates the wound vac dressing was not documented as being done, the boxes were blank: 5/11/2022, 5/13/2022, 5/16/2022, 5/18/2022, 5/20/2022, 5/23/2022, 5/25/2022, 5/27/2022, and 5/30/2022. The June 2022 TAR documented the above order. There were blanks on the TAR for 6/10/2022. The July 2022 TAR documented the above order. There were blanks on the TAR for 7/1/2022, 7/9/2022, and 7/13/2022. The comprehensive care plan dated, 2/23/2022, documented in part, Focus: The resident has pressure injury to sacral area or potential for pressure injury development. Resident has a pressure area to sacral area. The Interventions documented in part, Administer treatments as ordered and monitor for effectiveness. Resident has a wound vac. Change dressing to pressure area M-W-F and as necessary. Wound vac has pre-programmed settings. Check for functioning as needed. An interview was conducted with LPN (licensed practical nurse) #2 on 4/11/2023 at 3:14 p.m. When asked what blanks on the TAR indicated, LPN #2 stated, It means they didn't do it. You can't prove you did it. The nurse might have forgotten to sign it off but you can't really prove that it was done. ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, and ASM #4, the regional nurse consultant, were made aware of the above concern on 4/11/2023 at 5:07 p.m. No further information was obtained prior to exit. (1) This information was obtained from the following website: https://cdn.ymaws.com/npuap.site-ym.com/resource/resmgr/npuap_pressure_injury_stages.pdf B. For Resident #14, the facility staff failed to administer a physician ordered treatment to a sacral pressure injury. The physician order dated, 8/19/2022, documented, Wound Care: Sacrum - Cleanse with normal saline, pat dry, apply skin prep to peri wound, place AquaCel AG on wound, secure with silicone super absorbent sacral dressing once daily and PRN (as needed) when soiled or dislodged every night shift for wound care. The September TAR documented the above order. On the following dates the treatment was not documented as being done, the boxes were blank: 9/5/2022, 9/8/2022, 9/9/2022, 9/16/2022, and 9/23/2022. The physician order dated, 9/23/2022, documented, Wound Care: Sacrum - Cleanse with normal saline, pat dry, apply skin prep to peri wound, place collagen particles on wound, secure with foam dressing once daily and PRN when soiled or dislodged, every night shift for wound care. The September TAR documented the above order. On the following dates the treatment was not documented as being done, the boxes were blank: 9/23/2022, 9/24/2022, 9/25/2022, 9/29/2022, and 9/30/2022. An interview was conducted with LPN (licensed practical nurse) #2 on 4/11/2023 at 3:14 p.m. When asked what blanks on the TAR indicated, LPN #2 stated, It means they didn't do it. You can't prove you did it. The nurse might have forgotten to sign it off, but you can't really prove that it was done. ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, and ASM #4, the regional nurse consultant, were made aware of the above concern on 4/11/2023 at 5:07 p.m. No further information was obtained prior to exit.

Based on staff interview and clinical record review, it was determined the facility staff failed to provide colostomy care for two of 32 residents in the survey sample, Residents #110 and #310. The findings include: Colostomy is a surgical procedure that brings one end of the large intestine out through an opening (stoma) made in the abdominal wall. Stools moving through the intestine drain through the stoma into a bag attached to the skin of the abdomen. (1) 1. For Resident #110, the facility staff failed to evidence that colostomy care was completed. On the most recent MDS (minimum data set) assessment, an admission assessment, the resident scored a 12 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was moderately impaired for making daily decisions. In Section H - Bladder and Bowel, the resident was coded as having an ostomy. The physician order dated, 6/3/2022, documented, Ostomy: Colostomy Care every shift and as needed, every 12 hours for Ostomy. The TAR (treatment administration record) for June 2022 documented the above order. Of the 48 opportunities for completing the colostomy care, 11 were blank. A blank on the TAR indicates the treatment was documented as performed. The TAR for July and August did not have the order for colostomy care. The nurse's notes were reviewed. The nurses documented in their notes, Bowel has ostomy noted. There was no documentation from June through August of any care provided for the colostomy. The comprehensive care plan dated, 6/16/2022, documented in part, Focus: Resident has a colostomy. The Interventions documented, Administer care as ordered. An interview was conducted with LPN (licensed practical nurse) #2 on 4/11/2023 at 3:14 p.m. When asked what blanks on the TAR indicated, LPN #2 stated, It means they didn't do it. You can't prove you did it. The nurse might have forgotten to sign it off but you can't really prove that it was done. An interview was conducted with ASM (administrative staff member) #2, the director of nursing, on 4/12/2023 at 11:09 a.m. When asked what colostomy care consists of, ASM #2 stated, the wafer has to be removed, the area cleaned with soap and water, the skin should be inspected for breakdown and redness, then dry the area thoroughly, apply ostomy paste to make a seal, apply the wafer and make sure you have a good seal. When asked how often this is to be done, ASM #2 stated the ostomy should be checked every 24 hours. When asked where it is documented, ASM #2 stated on the TAR. A policy on colostomy care was requested, however none was provided. ASM #1, the administrator, ASM #2, and ASM #4, the regional nurse consultant, were made aware of the above concerns on 4/12/2023 at 1:31 p.m. No further information was provided prior to exit. 29125 2. Resident #310's colostomy bag was not changed between 2/25/22 and 3/5/22, for a period of 9 days. A review of the clinical record revealed that there were no orders on frequency to change the ostomy bag until 3/4/22. The order documented, change colostomy every 3 days and included a start date of 3/5/22. A review of the Treatment Administration Record (TAR) revealed the bag was changed on 3/5/22. The next scheduled change was for 3/8/22. This was not done. A review of the nurse's notes revealed one dated 3/8/22 that documented, Resident wanted to wait till [they] had [their] shower to change [their] colostomy bag/appliance. Will pass on to the next shift to change colostomy. There was no evidence it was done. A nurse's note dated 3/6/22 documented, Resident C/O (complained of) pain to stoma site. Area is red, irritated, with slight inflammation. No S/S (signs/symptoms) of infection noted but resident has required several bag changes in the past few days from picking at wafer. Education and reminders given to not pick at the wafer . A nurse's note dated 3/7/22 documented, .resident has required several bag changes in the past few days from picking at wafer. Education and reminders given to not pick at the wafer. On 4/12/23 at 1:00 PM, an interview was conducted with ASM #3 (Administrative Staff Member) the Nurse Practitioner. She stated that, Every 3 days is not the protocol for colostomy bag changes. Every 7 days or when it leaks. When asked about an order for when to change a colostomy bag, she stated, To be clear for the facility there should be an order on the frequency but the frequency is variable depending on doctor and patient. If they have a good seal, every 7 days. As long as they have a good seal and no breakdown. I say that but a lot of times it doesn't last that long. The seal breaks, etc., It is good if it makes it 3 to 4 days. I don't like to make it (the order) for 3 days because it can be worn longer. Depends on the resident activity level as well. The max time would be 7 days. When asked if there is not an order at the time of admission on the frequency, should the facility call the physician to clarify an order for frequency, she stated that she would expect nurses to clarify at the time of admission an order for frequency. There was no evidence of bag changes before the above order and nurse's notes. From admission on 2/25/22 to the first bag change on 3/5/22 was a period of 9 days without an ostomy bag change. This exceeded the nurse practitioner's statement that it should be changed at least every 7 days. A policy regarding ostomy care and services was requested, however none was provided. On 4/12/23 at approximately 1:30 PM at the end-of-day meeting, ASM #1 (Administrative Staff Member) the Administrator, and ASM #2 were made aware of the findings. No further information was provided by the end of the survey. Reference: Colostomy (1) https://medlineplus.gov/ency/article/002942.htm

Based on staff interview and clinical record review it was determined that the facility staff failed ensure the required documentation and information was provided to the receiving provider, upon facility-initiated transfers for five of 35 residents in the survey sample. Residents #39, #18, #26, #13 and #32. The facility staff failed to evidence what if any required documentation was provided to the receiving facility for a facility-initiated transfers of Resident #39 on 8/2/2021, and Resident #18 on 6/18/2021. The staff failed to evidence the comprehensive care plan goals were provided to the receiving facility for a facility-initiated transfers of Resident #26 on 7/22/21, Resident #13 on 5/10/2021 and 5/26/2021, and Resident #32 on 7/14/21. The findings include: 1. Resident #39 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #39's most recent MDS (minimum data set) assessment, a quarterly assessment with an ARD (assessment reference date) of 8/11/2021, coded Resident #39 as scoring a 10 on the brief interview for mental status (BIMS) of a score of 0 - 15, 10 - being moderately impaired for making daily decisions. The progress notes for Resident #39 documented in part, 8/2/2021 09:12 (9:12 a.m.) Nursing progress note. NP (nurse practitioner) requests to send patient to [Name of hospital] ER (emergency room ) for AMS (altered mental status), dusky color, facial swelling, and cough. Chest xray obtained yesterday showed CHF ([CONDITION(S)]). Patient stated he was feeling too bad to go to [CONDITION(S)] today. BS (blood sugar) checked 152. Pt (patient) refused to eat breakfast. VS (vital signs) 119/79 (blood pressure), 97.8 (temperature), 92 (pulse), 93% RA (oxygen saturation on room air), 24 (respirations). Patient currently on [MEDICATION(S)] (antibiotic) for cough. Family notified. The clinical record failed to evidence documentation of information provided to the hospital on 8/2/2021. On 9/8/2021 at approximately 2:27 p.m., an interview was conducted with LPN (licensed practical nurse) #1. LPN #1 stated that when a resident was sent to the hospital they completed a transfer form, a SBAR (situation, background, assessment, response), contact the family, set up transport or called 911. LPN #1 stated that they sent the residents orders, a face sheet, the transfer form and the care plan if it coordinated with why they were going to the hospital. LPN #1 stated that they did not always send the care plan with the resident unless it applied to the reason they were being sent. LPN #1 stated that they documented this information in a progress note to evidence what was sent. LPN #1 stated that if there was no progress note or transfer form they could not evidence what information was provided to the receiving facility. LPN #1 stated that they had sent Resident #39 out to the emergency roiagnom on [DATE] and thought they had completed a transfer form, SBAR and documented what was sent to the hospital but did not see it in the medical record. On 9/9/2021 at approximately 10:30 a.m., a request was made to ASM #1 for the facility policy for transfers and discharges. On 9/9/2021 at 3:48 p.m., ASM #1 provided via email, Transfer/Discharge Notification & Right to Appeal dated 3/26/2018, which documented in part, .Information provided to the receiving provider must include but is not limited to: Contact information of the practitioner responsible for care of the resident; Resident representative information including contact information; Advance Directives; Special care instructions or precautions for ongoing care as indicated; Comprehensive care plan goals; All other necessary information, including copies of the resident's discharge summary and other documentation, as applicable to ensure safe and effective transition of care . On 9/8/2021 at approximately 5:02 p.m., ASM #1, the administrator, ASM #2, the director of nursing and ASM #3, the regional nurse was made aware of the findings. No further information was provided prior to exit. References: 1. Pneumonia: An infection in one or both of the lungs. Many germs, such as bacteria, viruses, and fungi, can cause pneumonia. You can also get pneumonia by inhaling a liquid or chemical. This information was obtained from the website: <https://medlineplus.gov/pneumonia.html> 2. End-stage kidney disease: The last stage of chronic kidney disease. This is when your kidneys can no longer support your body's needs. This information was obtained from the website: https://medlineplus.gov/ency/article/ 0.htm. 2. Resident #18 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #18's most recent MDS (minimum data set) assessment, a significant change assessment with an ARD (assessment reference date) of 7/9/2021, coded Resident #18 as scoring a 13 on the brief interview for mental status (BIMS) of a score of 0 - 15, 13 - being cognitively intact for making daily decisions. The progress notes for Resident #18 documented in part, 6/18/2021 12:47 (12:47 p.m.) Nursing progress note. [Name of nurse practitioner] in to see resident with new orders to draw Amylase and Lipase (laboratory test) on next day lab [laboratory] r/t (related to) jaundice (3). RP (responsible party) aware. The Change in Condition (SBAR) (situation, background, assessment, response) for Resident #18 dated 6/18/2021 documented in part, .critical total bilirubin of 13.1; Primary Care Clinician Notified: [Name of nurse practitioner], Date/Time notified: 06/18/2021 18:00 (6:00 p.m.); Recommendations of Primary Clinician: Send to ER (emergency room ) . The physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The clinical record for Resident #18, failed to evidence documentation of what if any information that was provided to the hospital on 6/18/2021. On 9/8/2021 at approximately 2:27 p.m., an interview was conducted with LPN (licensed practical nurse) #1. LPN #1 stated that when a resident was sent to the hospital they completed a transfer form, a SBAR (situation, background, assessment, response), contacted the family, set up transport or called 911. LPN #1 stated that they sent the residents orders, a face sheet, the transfer form and the care plan if it coordinated with why they were going to the hospital. LPN #1 stated that they did not always send the care plan with the resident unless it applied to the reason they were being sent. LPN #1 stated that they documented this information in a progress note to evidence what was sent. LPN #1 stated that if there was no progress note or transfer form they could not evidence what information was provided to the receiving facility. On 9/8/2021 at approximately 5:02 p.m., ASM #1, the administrator, ASM #2, the director of nursing and ASM #3, the regional nurse was made aware of the findings. No further information was provided prior to exit. References: 1. Chronic obstructive pulmonary disease ([CONDITION(S)]): Disease that makes it difficult to breath that can lead to shortness of breath. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/[CONDITION(S)].html. 2. Dysphagia: A swallowing disorder. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/swallowingdisorders.html. 3. Jaundice: causes your skin and the whites of your eyes to turn yellow. Too much bilirubin causes jaundice. Bilirubin is a yellow chemical in hemoglobin, the substance that carries oxygen in your red blood cells. As red blood cells break down, your body builds new cells to replace them. The old ones are processed by the liver. If the liver cannot handle the blood cells as they break down, bilirubin builds up in the body and your skin may look yellow. This information was obtained from the website: https://vsearch.nlm.nih.gov/vivisimo/cgi-bin/query-meta?v%3Aproject=medlineplus&v%3Asources=medlineplus-bundle&query=jaundice&_ga=2XXX 444XXX 8920XXX - XXX 3. Resident #26 was admitted to the facility on [DATE] with a recent readmission of 12/14/2020 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The most recent MDS (minimum data set) assessment, a significant change assessment, with an assessment reference date of 8/4/2021, coded Resident #26 as scoring a 6 on the BIMS (brief interview for mental status) score, indicating the resident was severely impaired to make daily cognitive decisions In Section O - Special Treatments, Procedures and Programs, the resident was coded as receiving hospice care while a resident at the facility. The nurse's note dated 7/22/2021 at 2:52 p.m. documented in part, Upon starting my shift, it was reported to this nurse that resident was unresponsive and had been since about noon. It was reported also that resident had been running a fever of over 101 and that on call DR (doctor) and family had been notified. Dr . orders for 1 L (liter) of fluid to be run via IV (intravenously) and STAT (immediately) labs (laboratory tests) were drawn by day nurse .Lab results later arrived and . was notified. WBC (white blood cell) count very high and NP suggested calling the family to see if they wanted comfort care or for resident to be sent to the ER (emergency room ). Family notified and requested resident to be sent to the ER for treatment. 911 called and took resident to the ER around 2230 (10:30 p.m.). Review of the clinical record failed to evidence a transfer form or documentation that the comprehensive care plan goals were sent with the resident and provided to the receiving hospital on 7/22/21. On 9/8/2021 at approximately 2:27 p.m., an interview was conducted with LPN (licensed practical nurse) # 1. LPN #1 stated that residents transferred to the hospital were sent with the physician orders, a face sheet, a transfer form and the care plan if it applied to the transfer. LPN #1 stated that they did not always send the care plan with the resident unless it applied to the reason they were being sent. LPN #1 stated that they documented this information in a progress note to evidence what was sent. LPN # 1 stated that if there was no progress note or transfer form they could not evidence what information was provided to the receiving facility. ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, and ASM #3, the regional nurse, were made aware of the above finding on 9/9/2021 at 11:14 a.m. No further information was provided prior to exit. References: (1) Stroke: abnormal condition in which hemorrhage or blockage of the blood vessels of the brain leads to oxygen lack and resulting symptoms - sudden loss of ability to move a body part [as an arm or parts of the face], or to speak, paralysis weakness or if severe, death. Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and Chapman, page 114. (2) Dysphagia: a condition in which swallowing is difficult or painful due to obstruction of the esophagus or muscular abnormalities of the esophagus or pharynx. Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and Chapman, page 178. (3) This information was obtained from the following website: https://vsearch.nlm.nih.gov/vivisimo/cgi-bin/query-meta?v%3Aproject=medlineplus&v%3Asources=medlineplus-bundle&query=[CONDITION(S)]&_ga=2XXX 3059XXX 2701XXX - XXX 4. Resident #13 was admitted to the facility on [DATE] with a readmission on 6/1/2021, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 6/30/2021 coded the resident as scoring a 15 on the BIMS (brief interview for mental status) score, indicating the resident is capable of making daily cognitive decisions. The resident was coded as requiring extensive assistance of one or more staff members for most of her activities of daily living. Review of the clinical record revealed the following: A Transfer Form dated 5/10/2021, which documented, reason for transfer, Unable to move from the neck down and stating she cannot see. A Transfer Form dated 5/26/2021, which documented, reason for transfer, Severe RLQ (right lower quadrant) pain. Further review of the clinical record failed to evidence any nurse's notes addressing the transfers of Resident #13 5/10/2021 and 5/26/2021, as documented above. Further review of the clinical record failed to evidence documentation that the comprehensive care plan goals were sent to the hospital with the resident upon transfer on 5/10/2021 and 5/26/2021. On 9/8/2021 at approximately 2:27 p.m., an interview was conducted with LPN (licensed practical nurse) # 1. LPN #1 stated that residents transferred to the hospital were sent with the physician orders, a face sheet, a transfer form and the care plan if it applied to the transfer. LPN #1 stated that they did not always send the care plan with the resident unless it applied to the reason they were being sent. LPN #1 stated that they documented this information in a progress note to evidence what was sent. LPN # 1 stated that if there was no progress note or transfer form they could not evidence what information was provided to the receiving facility. ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, and ASM #3, the regional nurse, were made aware of the above finding on 9/9/2021 at 11:14 a.m. No further information was provided prior to exit. (1) Dementia: a progressive state of mental decline, especially memory function and judgement, often accompanied by disorientation. Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and Chapman, page 124. 5. Resident # 32 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident # 32's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 08/04/2021, coded Resident # 32 as scoring a seven [7] on the brief interview for mental status (BIMS) of a score of 0 - 15, seven - being severely impaired of cognition for making daily decisions. The nurse's note for Resident # 32 dated 07/14/2021 at 4:34 p.m., documented, Nurse received X-ray results which showed displaced right clavicle fracture. Np [nurse practitioner] notified with orders to send to ER [emergency room ] for further eval [evaluation]. RP [responsible party] made aware. Review of the EHR [electronic health record] and the paper clinical record for Resident # 32 failed to evidence that the comprehensive care plan goals were sent to the receiving facility at the time of Resident # 32's resident-initiated transfer on 07/14/2021. On 9/8/2021 at approximately 2:27 p.m., an interview was conducted with LPN (licensed practical nurse) # 1. LPN # 1 stated that residents transferred to the hospital were sent with the physician orders, a face sheet, a transfer form and the care plan if it applied to the transfer. LPN # 1 stated that they did not always send the care plan with the resident unless it applied to the reason they were being sent. LPN # 1 stated that they documented this information in a progress note to evidence what was sent. LPN # 1 stated that if there was no progress note or transfer form they could not evidence what information was provided to the receiving facility. On 09/09/2021 at 11:30 a.m., ASM [administrative staff member] # 1, administrator, ASM # 2, director of nursing, and ASM # 3, regional nurse, were made aware of the above findings. No further information was provided prior to exit.

Based on observations, staff interview, facility document review and clinical record review, it was determined that the facility staff failed to develop and/or implement the comprehensive care plan for 10 of 35 residents in the survey sample, Resident's # 3, # 16, # 32, # 36, #26, # 44, #40, # 30, # 15 and # 25. The findings include: 1. The facility staff failed to develop a comprehensive care plan to address Resident # 3's pain. Resident # 3 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident # 3's most recent MDS (minimum data set) assessment, an admission assessment with an ARD (assessment reference date) of 06/10/2021, coded Resident # 3 as scoring a 15 on the brief interview for mental status (BIMS) of a score of 0 - 15, 15 - being cognitively intact for making daily decisions. Section J0300, J0400 and J0600 Pain Assessment Interview coded Resident # 3 as having frequent pain at a level of 4 [four] on a pain scale of zero to ten, with ten being the worse pain. The physician's order for Resident # 3 documented in part, [MEDICATION(S)] [1] [Oxycodone-Acetaminophen] 5-325MG [milligram]. Give 1 [one] tablet by mouth every 12 hours as needed for pain. Order Date: 7/12/2021. Acetaminophen [2] Tablet 325MG. Give 2 tablet by mouth every 4 [four] hours as needed for pain. Order Date: 6/4/2021. Review of the comprehensive care plan dated 06/09/2021 for Resident # 3 failed to evidence a care plan to address pain. On 09/08/2021 at 3:58 p.m., an interview was conducted with LPN #5 (Licensed Practical Nurse), the MDS nurse. LPN #5 stated that the purpose of the care plan was to direct resident care and set goals for resident care. When asked about a care plan to address Resident # 3's assessed pain, and prescribed pain medications, LPN #5 stated that the resident should have had a care plan developed by now. She stated that it [comprehensive care plan] could be an issue if someone who did not know the resident was assigned to care for the resident and there was no care plan to direct the resident's care. She stated that she was the only MDS nurse and was trying to do all the MDS work by herself and was behind on getting things done. When asked if there was any policy or procedure she follows regarding developing care plans she stated that she was sure there was one somewhere. She did not identify the RAI manual. On 09/09/2021 at 11:30 a.m., ASM [administrative staff member] # 1, administrator, ASM # 2, director of nursing, and ASM # 3, regional nurse, were made aware of the above findings. No further information was provided prior to exit. References: [1] Oxycodone [[MEDICATION(S)]] is used to relieve moderate to severe pain. This information was obtained from the website: https://medlineplus.gov/druginfo/meds/a 2.html. [2] Used to relieve mild to moderate pain from headaches, muscle aches, menstrual periods, colds and sore throats, toothaches, backaches, and reactions to vaccinations (shots), and to reduce fever. Acetaminophen may also be used to relieve the pain of [CONDITION(S)] (arthritis caused by the breakdown of the lining of the joints). This information was obtained from the website: https: https://medlineplus.gov/druginfo/meds/a 4.html. 2. The facility staff failed to implement the comprehensive care plan for the use of non-pharmacological interventions prior to the administration of as needed [prn] pain medication to Resident #16. Resident # 16 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident # 16's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 06/30/2021, coded Resident # 16 as scoring a 14 on the brief interview for mental status (BIMS) of a score of 0 - 15, 14 - being cognitively intact for making daily decisions. Section J0300, J0400 and J0600 Pain Assessment Interview coded Resident # 16 as having frequent moderate pain. The physician's order for Resident # 16 documented in part, [MEDICATION(S)] [2] [Oxycodone-Acetaminophen] 5-325MG [milligram]. Give 5 [five] mg by mouth every 8 [eight] hours as needed for pain. Order Date: 2/12/2020. Resident # 16's eMAR [electronic medication administration record] dated August 2021 documented the above physician's order. The eMAR failed to evidence documentation of non-pharmacological interventions attempted prior to the administration of [MEDICATION(S)] to Resident #16 on: 08/02/2021 at 8:29 a.m., with pain level of six, on 08/11/2021 at 10:30 a.m. with pain level of ten, on 08/14/2021 at 7:45 p.m. with pain level of seven, on 08/16/2021 at 9:03 a.m. with pain level of five, and on 08/31/2021 at 12:07 a.m. with pain level of seven. Further review of the August eMAR failed to evidence the location of Resident # 16's pain on: 08/02/2021 at 8:29 a.m., with pain level of six, 08/14/2021 at 7:45 p.m. with pain level of seven, 08/18/2021 with pain level of seven, and on 08/31/2021 at 12:07 a.m. with pain level of seven. Resident # 16's eMAR [electronic medication administration record] dated September 2021 documented the above physician's order for [MEDICATION(S)]. The eMAR failed to evidence documentation of non-pharmacological interventions attempted prior to the administration of [MEDICATION(S)] on: 09/01/2021 at 8:54 a.m. with pain level of five and on 09/02/2021 at 8:48 p.m. with pain level of nine. The comprehensive care plan for Resident # 16 with a revision date of 01/18/2021 documented in part, Focus: [Resident # 16] has potential for pain r/t Chronic Physical Disability, GERD, [CONDITION(S)], [CONDITION(S)], Gout. Revision on 01/18/2021. Under Interventions it documented in part, Use non pharmacological interventions per protocol. Date Initiated: 03/05/2020. On 09/07/2021 at approximately 3:25 p.m., an interview was conducted with Resident # 16. When asked if the nurse's attempt non-pharmacological interventions before administering the as needed pain medications, Resident # 16 stated, Sometimes. On 09/09/2021 at approximately 9:05 a.m., an interview was conducted with LPN [licensed practical nurse] # 4. After reviewing the eMARs for the dates and times listed above and Resident # 16's comprehensive care plan, LPN # 4 was asked if the care plan was being implemented for the use of non-pharmacological interventions before administering the prn pain medications. LPN # 4 stated no. When asked to describe the purpose of the care plan, LPN # 4 stated, So we know how to care for their individual needs. On 09/09/2021 at 11:30 a.m., ASM [administrative staff member] # 1, administrator, ASM # 2, director of nursing, and ASM # 3, regional nurse, were made aware of the above findings. No further information was provided prior to exit. References: [1] A narrowing of the spinal column that causes pressure on the spinal cord, or narrowing of the openings (called neural foramina) where spinal nerves leave the spinal column. This information was obtained from the website: https://medlineplus.gov/ency/article/ 1.htm. [2] Oxycodone [[MEDICATION(S)]] is used to relieve moderate to severe pain. This information was obtained from the website: https://medlineplus.gov/druginfo/meds/a 2.html. 3. The facility staff failed to implement the comprehensive care plan for the use of fall mats for Resident #32. Resident # 32 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident # 32's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 08/04/2021, coded Resident # 32 as scoring a seven [7] on the brief interview for mental status (BIMS) of a score of 0 - 15, seven - being severely impaired of cognition for making daily decisions. On 09/07/2021 at 5:00 p.m., an observation of Resident # 32's room revealed Resident # 32 lying in bed. Further observation failed to evidence fall mats on the floor on the right or left side of the bed. On 09/08/2021 at 2:25 a.m., an observation of Resident # 32's room revealed Resident # 32 lying in bed. Further observation failed to evidence fall mats on the floor on the right or left side of the bed. On 09/08/2021 at 2:25 p.m., an observation of Resident # 32's room revealed Resident # 32 lying in bed. Further observation failed to evidence fall mats on the floor on the right or left side of the bed. On 09/09/2021 at 8:20 a.m., an observation of Resident # 32's room revealed Resident # 32 lying in bed. Further observation failed to evidence fall mats on the floor on the right or left side of the bed. The comprehensive care plan for Resident # 32 dated 05/28/2021 documented in part, Focus: [Resident # 32] has had an actual fall with major injury r/t [related to] poor communication/comprehension, unsteady gait, weakness and debility. Under Interventions it documented in part, Bilateral floor mats at bedside. Date Initiated: 05/28/2021. On 09/09/2021 at 8:05 a.m., an interview and observation of Resident #32 was conducted with LPN [licensed practical nurse] # 3. LPN #3 observed Resident # 32 in bed without fall mats on the left or right side of the bed. After reviewing Resident # 32's comprehensive care plan, LPN # 3 stated that there were no fall mats alongside Resident # 32's bed. When asked if the care plan was being implemented, LPN # 3 stated no. On 09/09/2021 at 11:30 a.m., ASM [administrative staff member] # 1, administrator, ASM # 2, director of nursing, and ASM # 3, regional nurse, were made aware of the above findings. No further information was provided prior to exit. 4. The facility staff failed to develop a comprehensive care plan to address Resident # 36's use of oxygen. Resident # 36 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident # 36's most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 08/17/2021, coded Resident # 36 as scoring a 15 on the brief interview for mental status (BIMS) of a score of 0 - 15, 15 - being cognitively intact for making daily decisions. Section O Special Treatments, Procedures and Programs coded Resident # 36 as receiving oxygen therapy. On 09/07/2021 at 2:44 p.m., an observation of Resident # 36 revealed they were receiving oxygen by nasal cannula connected to an oxygen concentrator. Observation of the oxygen concentrator flow meter revealed the oxygen flow rate at two liters per minute. On 09/08/2021 at 9:15 a.m., an observation of Resident # 36 revealed they were receiving oxygen by nasal cannula connected to an oxygen concentrator. Observation of the oxygen concentrator flow meter revealed the oxygen flow rate at two liters per minute. The physician's order for Resident # 36 dated 08/24/2021 documented, Respiratory: Oxygen - Continuous 2L NC [two liters per minute nasal cannula]. Order Date: 08/24/2021. Review of the comprehensive care plan for Resident # 36 dated 09/07/2021 failed to evidence a care plan to address Resident # 36's use of oxygen. On 09/08/2021 at 3:58 p.m., an interview was conducted with LPN #5 (Licensed Practical Nurse), the MDS nurse. She stated that the purpose of the care plan was to direct resident care and set goals for resident care. When asked about Resident # 36's care plan for oxygen, LPN #5 stated that the resident should have had a care plan developed by now. She stated that it could be an issue if someone who did not know the resident was assigned to care for the resident and there was no care plan to direct the resident's care. She stated that she was the only MDS nurse and was trying to do all the MDS work by herself and was behind on getting things done. On 09/09/2021 at 11:30 a.m., ASM [administrative staff member] # 1, administrator, ASM # 2, director of nursing, and ASM # 3, regional nurse, were made aware of the above findings. No further information was provided prior to exit. References: [1] Disease that makes it difficult to breath that can lead to shortness of breath. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/[CONDITION(S)].html. 5. The facility staff failed to develop a care plan to address the needs of a resident receiving hospice care for Resident #26. Resident #26 was admitted to the facility on [DATE] with a recent readmission of 12/14/2020 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The most recent MDS (minimum data set) assessment, a significant change assessment, with an assessment reference date of 8/4/2021, coded the resident as scoring a 6 on the BIMS (brief interview for mental status) score, indicating the resident was severely impaired to make daily cognitive decisions. The resident was coded as being dependent upon one or more staff members for most of her activities of daily living. In Section O - Special Treatments, Procedures and Programs, the resident was coded as receiving hospice care while a resident at the facility. The physician order dated 7/26/2021, documented, Resident to be under the care of (Name of Hospice Company). The comprehensive care plan, dated 4/30/2020, failed to evidence a care plan to address hospice care for Resident #26. An interview was conducted with ASM (administrative staff member) #2, the director of nursing, on 9/9/2021 at 8:48 a.m. When asked the purpose of the care plan, ASM #2 stated it's to direct the staff to provide the care for each resident. When asked if a resident receiving hospice care, should have a care plan to address the hospice services and care, ASM #2 stated, yes, it should be care planned. ASM (administrative staff member) #1, the administrator; ASM #2 the director of nursing and ASM #3, the regional nurse, were made aware of the above concerns on 9/8/2021 at 5:10 p.m. No further information was provided prior to exit. References: (1) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and Chapman, page 114. (2) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and Chapman, page 178. (3) This information was obtained from the following website: https://vsearch.nlm.nih.gov/vivisimo/cgi-bin/query-meta?v%3Aproject=medlineplus&v%3Asources=medlineplus-bundle&query=[CONDITION(S)]&_ga=2XXX 3059XXX 2701XXX - XXX 6. The facility staff failed to develop a care plan to address Resident #44's physician ordered fluid restriction. Resident #44 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . (3). The most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 8/15/2021, coded the resident as scoring an 8 on the BIMS (brief interview for mental status) score, indicating the resident was moderately impaired to make daily cognitive decisions. The resident was coded as requiring extensive assistance of one or more staff members for most of her activities of daily living except eating which she was coded as independent after set up assistance was provided. The physician order dated, 4/8/2021, documented in part, 1500 ml (milliliters) fluid restriction 260 ml per meal and 240 ml every shift for CHF. The comprehensive care plan dated, 7/18/2021, documented in part, Focus: (Resident #44) has congestive heart failure. The Interventions documented in part, Monitor/document/report PRN (as needed) any s/sx (signs and symptoms) of Congestive Heart Failure, dependent [CONDITION(S)] of legs and feet, periorbital [CONDITION(S)], SOB (shortness of breath) upon exertion, cool skin, dry cough, distended neck veins, weakness, weight gain unrelated to intake, crackles and wheezes upon auscultation of the lungs, orthopnea, weakness and/or fatigue, increased heart rate ([CONDITION(S)]) lethargy and disorientation. The care plan further documented, dated, 2/3/2021, Focus: The resident has potential for fluid deficit r/t (related to) diuretic use. The Interventions documented in part, Monitor and document intake and output as per facility policy. The care plan did not address the need for Resident #44 to be on a fluid restriction. An interview was conducted with ASM (administrative staff member) #2, the director of nursing, on 9/9/2021 at 8:48 a.m. When asked if a physician prescribes a fluid restriction for a resident should that be addressed on the care plan, ASM #2 stated, Absolutely. The facility policy, Fluid Restrictions documented in part, The Care Planning Team will discuss the restriction, and they will be included in the Care Plan. ASM #1, the administrator, ASM #2 and ASM #3, the regional nurse, were made aware of the above concern on 9/8/2021 at 5:10 p.m. No further information was provided prior to exit. References: (1) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and Chapman, page 138. (2) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and Chapman, page 124. (3) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and Chapman, page 124. 7. The facility staff failed to implement Resident #40's care plan for care of a pressure injury. Resident #40 was admitted to the facility on [DATE] with a recent readmission on 12/15/2020, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] .)(1), diabetes, [CONDITION(S)] (chronic obstructive pulmonary disease - general term for chronic, nonreversible lung disease that is usually a combination of [CONDITION(S)] and chronic [CONDITION(S)]) (2), [CONDITION(S)] (any of a group of mental disorders characterized by gross distortions of reality, withdrawal of thought, language, perception and emotional response) (3), and high blood pressure. The most recent MDS (minimum data set), a quarterly assessment, with an assessment reference date of 8/11/2021 coded the resident as scoring a 14 on the BIMS (brief interview for mental status) score, indicating she was capable of making daily cognitive decisions. Resident #40 was coded as requiring extensive assistance of one or more staff members for all of her activities of daily living except eating in which she was coded as independent after set up assistance was provided. In Section M - Skin Conditions, Resident #40 was coded as having a Stage III pressure injury. [A pressure injury is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbidities and condition of the soft tissue. Stage III - Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury.] (4). The comprehensive care plan dated 12/10/2018, documented in part, Focus: (Resident #40) has potential for impairment to skin integrity r/t (related to) fragile skin, incontinence, infection, diabetes, impaired mobility. The Interventions documented in part, Monitor/document location, size and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . to MD (medical doctor). The nurse's note dated, 1/2/2021 at 12:10 p.m. documented, New order for tx (treatment) to coccyx pressure injury noted possible stage 2. The Change in Condition form dated 1/2/2021 documented a check mark next to, Pressure ulcer/Pressure injury. Further review of the form failed to evidence documentation of measurements of the pressure injury area or any description of the area. Further review of the clinical record failed to evidence documented measurements of the wound on or around 1/2/2021. The first documented measurements of the wound was on 2/1/2021 on the Weekly Wound Report: Pressure Injury. The form documented the resident's name, visualized stage - 3, Measurements - 2x1x0.2 (2 centimeters [cm] in length, by 1 cm in width by 0.5 cm in depth), Location - sacrum. An interview was conducted with LPN (licensed practical nurse) #6 on 9/8/2021 at 3:28 p.m. LPN #6 is the nurse who wrote the note of 1/2/2021. When asked if she was trained in wound care, LPN #6 stated she is trained in the basic dressing changes. When asked if she can stage a pressure injury, LPN #6 stated, Technically no, I need more training. LPN #6 was asked to explain what actions she took on 1/2/2021. LPN #6 stated when she found the area, she notified the doctor and management. She stated she told the ADON (assistant director of nursing). [ADON no longer employed at facility]. LPN #6 stated she implemented the new orders from the physician. When asked if she measured the wound, LPN #6 stated she did not. When asked if she should have measured the wound, LPN #6 stated, she should have measured the wound. When asked if the care plan was implemented if it documents to monitor/document location, size and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . ASM #1, the administrator, ASM #2, the director of nursing, and ASM #3, the regional nurse, were made aware of the above findings on 6/9/2021 at 11:14 a.m. No further information was provided prior to exit. References: (1) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and Chapman, page 124. (2) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and Chapman, page 124. (3) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and Chapman, page 522. (4) This information was obtained from the following website: http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-injury-stages/ 8. The facility staff failed to develop a comprehensive care plan for Resident #30. Resident #30 was admitted to the facility on [DATE] and had the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission MDS (Minimum Data Set) assessment with an ARD (Assessment Reference Date) of 8/5/21 coded the resident as cognitively intact in ability to make daily life decisions. Resident #30 was coded as requiring extensive care for bathing; limited assistance for transfers, toileting and hygiene; supervision for bed mobility; independent for eating; and as continent of bowel and bladder. This MDS assessment was coded in Section VO200C2 Signature of Person Completing Care Plan Decision and Date Signed of Section V - Care Area Assessment (CAA) Summary, was dated 8/12/21. A review of the RAI manual (Resident Assessment Instrument) dated October 2019 documented on page 2-16 the following in the table: Care Plan Completion Date (Item V0200C2) No Later Than, CAA(s) Completion Date + [plus] 7 calendar days. This indicates that the comprehensive care plan should have been completed by 8/19/21. A review of the care plan revealed that a comprehensive care plan was never completed as of 9/8/21. The only care plan areas that were developed for the resident were Activities (dated 8/6/21), Urinary tract infection (dated 8/5/21), and Mood (dated 8/16/21). Section V of the MDS documented the following areas as triggered to be care planned: Visual Function, ADL (activities of daily living) Functional/Rehabilitation Potential, Urinary Incontinence and Indwelling Catheter, Psychosocial Well-Being, Activities, Falls, Nutritional Status, Dehydration/Fluid Maintenance, Dental Care, Pressure Ulcer, Pain. None of the above areas other than Activities had been care planned. On 9/8/21 at 3:58 PM an interview was conducted with LPN #5 (Licensed Practical Nurse), the MDS nurse. She stated that the purpose of the care plan was to direct resident care and set goals for resident care. She stated that Resident #30 should have had a comprehensive care plan developed by now. She stated that it could be an issue if someone who did not know the resident was assigned to care for the resident and there was no care plan to direct the resident's care. LPN #5 stated that she was the only MDS nurse and was trying to do all the MDS work by herself and was behind on getting things done. When asked if there was any policy or procedure she follows regarding developing care plans, LPN #5 stated that she was sure there was one somewhere. She did not identify the RAI manual. A review of the facility policy Plans of Care documented, An individualized person-centered plan of care will be established by the interdisciplinary team (IDT) with the resident and/or resident representative(s) to the extent practicable and updated in accordance with state and federal regulatory requirements Develop and implement an Individualized Person-Centered comprehensive plan of care by the Interdisciplinary Team that includes but is not limited to - the attending physician, a registered nurse with responsibility for the resident, a nurse aide with responsibility for the resident, a member of food and nutrition services staff, and other appropriate staff or professionals in disciplines as determined by the resident's needs or as requested by the resident, and, to the extent practicable, the participation of the resident and the resident's representative(s) within seven (7) days after completion of the comprehensive assessment (MDS). On 9/8/21 at approximately 5:00 PM at the end-of-day meeting, ASM #1 (Administrative Staff Member) the Administrator, ASM #2 the Director of Nursing (DON) and ASM #3 the regional nurse, were made aware of the findings. ASM #1 stated that there had been a lot of staffing changes and the MDS nurse had been pulled to work on the unit for a period of time. No further information was provided by the end of the survey. No further information was provided by the end of the survey. 9. The staff failed to implement Resident #15's comprehensive care plan to apply Resident #15's physician ordered resting left hand splint on 9/7/21 and 9/8/21. Resident #15 was admitted to the facility on [DATE], and most recently readmitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On the most recent MDS (minimum data set), an annual assessment with an ARD (assessment reference date) of 7/6/21, Resident #15 was coded as severely cognitively impaired for making daily decisions, having scored eight out of 15 on the BIMS (brief interview for mental status). She was coded as requiring extensive assistance of staff for all activities of daily living. She was coded as having functional limitations for range of motion on both left and right upper extremities. On the following dates and times, Resident #15 was observed sitting in a wheelchair in her room. During all observations she was not wearing a hand splint on her left hand: 9/7/21 at 12:36 p.m. and 1:59 p.m.; 9/8/21 at 8:46 a.m. and 10:42 a.m. A review of Resident #15's comprehensive care plan, dated 11/12/18, updated on 5/5/21, revealed, in part: [Resident #15] has an ADL (activities of daily living) self-care performance deficit requiring extensive assist r/t Activity Intolerance, [CONDITION(S)], Fatigue, Limited Mobility .Hand splint as ordered. A review of Resident #15's clinical record revealed the following physician order dated 3/17/21: Pt (patient) to wear L (left) resting hand splint during the day, donned after breakfast and doffed before bed for pain management. Complete daily skin checks for s/s (signs/symptoms) skin breakdown. On 9/8/21 at 1:54 p.m., CNA (certified nursing assistant) #1 was interviewed. When asked how she knows what sorts of special devices a resident might need to wear, CAN #1 stated, It's usually on the chart. Or the nurse tells me. She stated she was not aware that Resident #15 needed a left hand splint. When asked if she can see a resident's care plan, CNA #1 stated she can only see what comes up on the tablet for her to chart. On 9/8/21 at 2:27 p.m., LPN (licensed practical nurse) #1 was interviewed. She stated the therapist usually informs the nursing staff of any devices needed to be worn by residents. She stated there is also usually an order. When asked if she was aware of any orders for Resident #15 for a left hand splint, LPN #1 stated she was not. When asked the purpose of a care plan, she stated the care plan is special for each resident. LPN #1 stated the care plan lets the staff know how to provide the right care for each person. When asked how she makes sure the care plan for each resident is being followed, LPN #1 stated, I know the residents well. I know how they like things. On 9/8/21 at 5:00 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, and ASM #3, the regional nurse, were informed of these concerns. No further information was provided prior to exit. REFERENCES: (1) [CONDITION(S)] is a group of disorders that affect a person's ability to move and to maintain balance and posture. This information is taken from the website https://medlineplus.gov/cerebralpalsy.html. (2) Psychotic disorders are severe mental disorders that cause abnormal thinking and perceptions. People with psychoses lose touch with reality. Two of the main symptoms are delusions and hallucinations. Delusions are false beliefs, such as thinking that someone is plotting against you or that the TV is sending you secret messages. Hallucinations are false perceptions, such as hearing, seeing, or feeling something that is not there. This information is taken from the website https://medlineplus.gov/psychoticdisorders.html. 10. The facility staff failed to develop a comprehensive care plan for Resident #25, who was admitted to the facility on [DATE]. Resident #25 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER]

Based on staff interview and facility document review, it was determined that the facility staff failed to have a complete infection control program as evidenced by missing infection control surveillance for April, May and June 2021. The findings include: On 09/09/2021 at approximately 10:00 a.m., a review of the facility's infection control surveillance for the past six months was conducted. Review of the surveillance records failed to evidence infection control surveillance for April, May and June 2021. On 09/09/2021 at approximately 10:33 a.m., an interview was conducted with ASM [administrative staff member] # 1, administrator. When asked about the missing surveillance ASM # 1 stated, We don't have a full six months of surveillance, we're unable to locate them. When asked who was responsible for infection control ASM # 1 stated that it was [ASM # 2], director of nursing who started at the facility on 09/02/2021. On 09/09/2021 at 12:58 p.m. an interview was conducted with ASM # 3, regional nurse. When asked to describe the procedure for maintaining the infection control surveillance ASM # 3 stated, They are all kept together for the year in a binder. When asked why it was important to maintain the surveillance records ASM # 3 stated, To track and trend infections and tract the use of antibiotics for overuse.' The facility's policy Surveillance for Infections documented in part, Policy Interpretation and Implementation. 1. The purpose of the surveillance of infections is to identify both individual cases and trends of epidemiologically significant organisms and Healthcare-Associated Infections, to guide appropriate interventions, and to prevent future infections. Under Gathering Surveillance Data it documented in part, 1. The Infection Preventionist or designated infection control personnel is responsible for gathering and interpreting surveillance data. The Infection Control Committee and/or QAPI [quality insurance performance improvement] Committee may be involved in interpretation of the data. Under Data Collection and Recording it documented in part, 4. For targeted surveillance using facility-created tools, follow these guidelines: a. DAILY (as indicated): Record detailed information about the resident and infection on an individual infection report form. b. MONTHLY: Collect information from individual resident infection reports and enter line listing of infections by resident for the entire month. c. MONTHLY: Summarize monthly data for each nursing unit by site and pathogen. d. MONTHLY/QUARTERLY: Identify predominant pathogens or sites of infection among residents in the facility or in particular units by recording month to month and observing trends. e. MONTHLY/QUARTERLY: Compare incidents of current infections to previous data to identify trends and patterns. Use average infection rate over a previous time period as a baseline. Compare subsequent rates to the average rate to identify possible increases in infection rates. No further information was provided prior to exit.

Based on resident interview, staff interview, clinical record review and facility document review, it was determined that the facility staff failed to implement a complete pain management program for three of 35 residents in the survey sample, Residents # 201, # 3, and # 16. The facility staff failed to assess and document the location of pain and failed to attempt and or provide non-pharmacological interventions prior to the administration of a prn [as needed] pain medications to Resident #201, #3 and Resident #16, on multiple occasions during August and September 2021. The findings include: 1. Resident # 201 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident # 201's most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 08/30/2021, coded Resident # 201 as scoring a 15 on the brief interview for mental status (BIMS) of a score of 0 - 15, 15 - being cognitively intact for making daily decisions. Section J0300, J0400 and J0600 Pain Assessment Interview coded Resident # 201 as having pain at a level of [seven] on a pain scale of zero to ten, with ten being the worse pain. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] *Controlled Drug* Give 2 tablet by mouth every 4 [four] hours as needed for Pain. Resident # 201's eMAR [electronic medication administration record] dated August 2021 documented the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of the August 2021 eMAR failed to evidence the location of Resident # 201's pain on 08/25/2021 at 8:25 p.m. with pain level of six, on 08/26/2021 at 12:35 a.m. with pain level of ten, on 08/28/2021 at 12:30 a.m., at 4:00 p.m. with pain level of eight, 08/29/2021 at 2:05 a.m. with pain level of six, on 08/30/2021 at 7:05 with pain level of eight, at 9:05 p.m. with pain level of six and on 08/31/2021 at 7:21 a.m. with pain level of seven and at 2:39 p.m. with pain level of seven. Resident # 201's eMAR [electronic medication administration record] dated September 2021 documented the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Further review of the September 2021 eMAR failed to evidence the location of Resident # 201's pain on: 09/01/2021 at 10:07 a.m. with pain level of seven, at 6:48 p.m. with pain level of seven at 11:50 p.m. with pain level of eight, on 09/02/2021 at 11:26 a.m. with pain level of seven, at 3:32 p.m. with pain level of six and at 8:08 p.m. with pain level of seven, on 09/04/2021 at 12:37 a.m. with pain level of seven, on 09/05/2021 at 7:07 a.m. with pain level of six, at 12:23 with pain level of seven, at 5:35 p.m. with pain level of six, at 11:53 p.m. with pain level of seven, on 09/06/2021 at 6:57 p.m. with pain level of seven, 09/07/2021 at 8:06 a.m. with pain level of seven and on 09/08/2021 at 2:10 a.m. with pain level of eight and at 7:16 a.m. with pain level of eight. Review of the facility's Progress Notes for Resident # 201 dated 08/24/2021 through 09/08/2021 failed to evidence documentation of non-pharmacological interventions prior to the administration of [MEDICATION(S)] and failed to document the location Of Resident # 201's pain as stated above. The comprehensive care plan for Resident # 201 dated 09/01/2021 documented in part, Focus [Resident # 201] has acute/chronic pain r/t Diabetic [CONDITION(S)], [CONDITION(S)], surgical wound, severe PAD, Date Initiated: 09/01/2021. Under Interventions: it documented, Monitor/document for side effects of pain medication. Date Initiated: 09/01/2021; Monitor/record/report to Nurse resident complaints of pain or requests for pain treatment. Date Initiated: 09/01/2021. On 09/07/2021 at approximately 3:00 p.m., an interview was conducted with Resident # 201. When asked if the nurse's attempt non-pharmacological interventions before administering the as needed pain medications Resident # 201 stated, No. On 9/7/2021 at 5:47 p.m., ASM [administrative staff member] #1, administrator, stated that the facility used their policies and procedures and Lippincott as their standard of practice. On 09/09/2021 at approximately 9:05 a.m., an interview was conducted with LPN [licensed practical nurse] # 4, regarding the procedure nursing staff follows when administering a prn pain medication. LPN #4 stated, the resident should be assessed for pain by determining a pain level on a scale of zero to 10, with ten being the worst pain, if the resident is able to communicate, determine the location of the resident's pain, try non-pharmacological strategies such as repositioning or relaxation to alleviate their pain. If it doesn't help check the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . When asked if the pain assessment including the location of the resident's pain and attempted non-pharmacological strategies are documented and where staff document this information, LPN # 4 stated that they are documented in the nurse's notes. LPN # 4 was then asked to review the eMAR and nurse's notes for the dates listed above for the administration of Resident # 201's prn [MEDICATION(S)]. LPN # 4 stated that there was no documented evidence of the location of Resident # 201's pain or the attempts of non-pharmacological strategies on the dates listed above. The facility's policy Pain Management Guideline documented in part, Treatment: Develop patient centered interventions (pharmacologic and non- pharmacologic) to manage pain. On 09/09/2021 at 11:30 a.m., ASM [administrative staff member] # 1, administrator, ASM # 2, director of nursing, and ASM # 3, regional nurse, were made aware of the above findings. No further information was provided prior to exit. References: [1] [MEDICATION(S)] [[MEDICATION(S)]] is an opioid pain medication. An opioid is sometimes called a narcotic. Acetaminophen is a less potent pain reliever that increases the effects of [MEDICATION(S)]. The combination of acetaminophen and [MEDICATION(S)] is used to relieve moderate to severe pain. This information was obtained from the website: https://www.rxlist.com/[MEDICATION(S)]-5-325-drug/patient-images-side-effects.htm. [2] The most common form of arthritis. It causes pain, swelling, and reduced motion in your joints. It can occur in any joint, but usually it affects your hands, knees, hips or spine. This information was obtained from the website: https://medlineplus.gov/[CONDITION(S)].html. 2. Resident # 3 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident # 3's most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 06/10/2021, coded Resident # 3 as scoring a 15 on the brief interview for mental status (BIMS) of a score of 0 - 15, 15 - being cognitively intact for making daily decisions. Section J0300, J0400 and J0600 Pain Assessment Interview coded Resident # 3 as having frequent pain at a level of 4 [four] on a pain scale of zero to ten, with ten being the worse pain. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] - [MEDICATION(S)] [Oxycodone-Acetaminophen] 5-325MG [milligram]. Give 1 [one] tablet by mouth every 12 hours as needed for pain. Order Date: 7/12/2021. - Acetaminophen Tablet 325MG. Give 2 tablet by mouth every 4 [four] hours as needed for pain. Order Date: 6/4/2021. Resident # 3's eMAR [electronic medication administration record] dated August 2021 documented the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The eMAR failed to evidence documentation of non-pharmacological interventions attempted or provided prior to the administration of [MEDICATION(S)] on: 08/01/2021 at 10:46 p.m. with pain level of eight, 08/04/2021 at 2:43 a.m. with pain level of eight and at 3:44 p.m. with pain level of five, 08 05/2021 at 8:20 a.m. with pain level of eight, 08/11/2021 at 11:03 a.m. with pain level of ten and at 11:59 p.m. with pain level of eight, 08/14/2021 at 12:04 a.m. with pain level of seven and at 5:40 p.m. with pain level of six, 08/16/2021 at 1:31 p.m. with pain level of three, 08/18/2021 at 12:22 a.m. with pain level of five, 08/23/2021 at 8:31 a.m. with pain level of four, 08/24/2021 at 8:54 a.m. with pain level of four and at 9:26 p.m. with pain level of two, 08/26/2021 at 12:30 a.m. with pain level of seven and at 2:16 with pain level of one, 08/28/2021 at 10:11 a.m. with pain level of eight, 08/30/2021 at 1:21 p.m. with pain level of one, 08/31/2021 at 2:26 a.m. with pain level of six and at 2:26 p.m. with pain level of ten. Further review of the August 2021 eMAR for the administration of [MEDICATION(S)], failed to evidence the location of Resident # 3's pain on: 08 05/2021 at 8:20 a.m. with pain level of eight, 08/11/2021 at 11:03 a.m. with pain level of ten and at 11:59 p.m. with pain level of eight, 08/14/2021 at 12:04 a.m. with pain level of seven and at 5:40 p.m. with pain level of six, 08/16/2021 at 1:31 p.m. with pain level of three, 826/2021 at 2:16 with pain level of one, 08/30/2021 at 1:21 p.m. with pain level of one, 08/31/2021 at 2:26 p.m. with pain level of ten. Resident # 3's eMAR [electronic medication administration record] dated August 2021 documented the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of the August 2021 eMAR for the administration of Acetaminophen, failed to evidence the location of Resident # 3's pain on: 08/14/2021 at 6:20 a.m. with pain level of six, 08/16/2021 at 8:53 a.m. with pain level of two. Resident # 3's eMAR [electronic medication administration record] dated September 2021 documented the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The eMAR failed to evidence documentation of non-pharmacological interventions attempted or provided prior to the administration of [MEDICATION(S)] on: 09/01/2021 at 9:17 p.m. with pain level of seven, 09/02/2021 at 5:26 with pain level of seven, 09/03/2021 at 2:41 p.m. with pain level of eight, 09/04/2021 at 3:46 a.m. with pain level of seven and at 5:19 p.m. with pain level of six, 09/05/2021 at 4:46 p.m. with pain level of seven, 09/07/2021 at 12:51 a.m. with pain level of six and at 12:22 p.m. with pain level of eight and on 09/08/2021 at 12:56 a.m. with pain level of eight. Further review of the August 2021 eMAR for the administration of [MEDICATION(S)], failed to evidence the location of Resident # 3's pain on: 09/02/2021 at 5:26 with pain level of seven, 09/04/2021 at 3:46 a.m. with pain level of seven and at 5:19 p.m. with pain level of six, 09/05/2021 at 4:46 p.m. with pain level of seven, 09/07/2021 at 12:51 a.m. with pain level of six and at 12:22 p.m. with pain level of eight. Resident # 3's eMAR [electronic medication administration record] dated September 2021 documented the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the facility's Progress Notes for Resident # 3 dated 08/01/2021 through 09/08/2021 failed to evidence documentation of non-pharmacological interventions attempted and or provided prior to the administration of [MEDICATION(S)] and acetaminophen and failed to document the location of Resident # 3's pain as stated above. On 09/07/2021 at approximately 2:26 p.m., an interview was conducted with Resident # 3. When asked if the nurse's attempt non-pharmacological interventions before administering the prn pain medications Resident # 3 stated, No. On 09/09/2021 at approximately 9:05 a.m., an interview was conducted with LPN [licensed practical nurse] # 4, regarding the procedure nursing staff follows when administering a prn pain medication. LPN #4 stated, the resident should be assessed for pain by determining a pain level on a scale of zero to 10, with ten being the worst pain, if the resident is able to communicate, determine the location of the resident's pain, try non-pharmacological strategies such as repositioning or relaxation to alleviate their pain. If it doesn't help check the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . When asked if the pain assessment including the location of the resident's pain and attempted non-pharmacological strategies and where staff document this information, LPN # 4 stated that they are documented in the nurse's notes. LPN #4 was then asked to review the eMAR and nurse's notes for the dates listed above for the administration of Resident # 3's prn [MEDICATION(S)] and acetaminophen. LPN # 4 stated that there was no documented evidence of the location of Resident # 3's pain or the attempts of non-pharmacological strategies on the dates listed above. On 09/09/2021 at 11:30 a.m., ASM [administrative staff member] # 1, administrator, ASM # 2, director of nursing, and ASM # 3, regional nurse, were made aware of the above findings. No further information was provided prior to exit. References: [1] Oxycodone [[MEDICATION(S)]] is used to relieve moderate to severe pain. This information was obtained from the website: https://medlineplus.gov/druginfo/meds/a 2.html. [2] Used to relieve mild to moderate pain from headaches, muscle aches, menstrual periods, colds and sore throats, toothaches, backaches, and reactions to vaccinations (shots), and to reduce fever. Acetaminophen may also be used to relieve the pain of [CONDITION(S)] (arthritis caused by the breakdown of the lining of the joints). This information was obtained from the website: https://medlineplus.gov/druginfo/meds/a 4.html. [3] A narrowing of the spinal column that causes pressure on the spinal cord, or narrowing of the openings (called neural foramina) where spinal nerves leave the spinal column. This information was obtained from the website: https://medlineplus.gov/ency/article/ 1.htm. 3. Resident # 16 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident # 16's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 06/30/2021, coded Resident # 16 as scoring a 14 on the brief interview for mental status (BIMS) of a score of 0 - 15, 14 - being cognitively intact for making daily decisions. Section J0300, J0400 and J0600 Pain Assessment Interview coded Resident # 16 as having frequent moderate pain. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Give 5 [five] mg by mouth every 8 [eight] hours as needed for pain. Order Date: 2/12/2020. Resident # 16's eMAR [electronic medication administration record] dated August 2021 documented the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of the August eMAR failed to evidence the location of Resident # 16's pain on: 08/02/2021 at 8:29 a.m., with pain level of six, 08/14/2021 at 7:45 p.m. with pain level of seven, 08/18/2021 with pain level of seven, and on 08/31/2021 at 12:07 a.m. with pain level of seven. Resident # 16's eMAR [electronic medication administration record] dated September 2021 documented the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The comprehensive care plan for Resident # 16 with a revision date of 01/18/2021 documented in part, Focus: [Resident # 16] has potential for pain r/t Chronic Physical Disability, GERD, [CONDITION(S)], [CONDITION(S)], Gout. Revision on 01/18/2021. Under Interventions it documented in part, Use non pharmacological interventions per protocol. Date Initiated: 03/05/2020 On 09/07/2021 at approximately 3:25 p.m., an interview was conducted with Resident # 16. When asked if the nurse's attempt non-pharmacological interventions before administering the prn pain medications Resident # 16 stated, Sometimes. On 9/7/2021 at 5:47 p.m., ASM [administrative staff member] #1, administrator, stated that the facility used their policies and procedures and Lippincott as their standard of practice. On 09/09/2021 at approximately 9:05 a.m., an interview was conducted with LPN [licensed practical nurse] # 4, regarding the procedure nursing staff follows when administering a prn pain medications. LPN #4 stated, the resident should be assessed for pain by determining a pain level on a scale of zero to 10, with ten being the worst pain, if the resident is able to communicate, determine the location of the resident's pain, try non-pharmacological strategies such as repositioning or relaxation to alleviate their pain. If it doesn't help check the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . When asked if the pain assessment including the location of the resident's pain and attempted non-pharmacological strategies are documented and where staff document this information, LPN # 4 stated that they are documented in the nurse's notes. LPN #4 was then asked to review the eMAR and nurse's notes for the date's list above for the administration of Resident # 16's prn [MEDICATION(S)]. LPN # 4 stated that there was no documented evidence of the location of Resident # 61's pain or the attempts of non-pharmacological strategies on the dates listed above. On 09/09/2021 at 11:30 a.m., ASM [administrative staff member] # 1, administrator, ASM # 2, director of nursing, and ASM # 3, regional nurse, were made aware of the above findings. No further information was provided prior to exit. References: [1] Oxycodone [[MEDICATION(S)]] is used to relieve moderate to severe pain. This information was obtained from the website: https://medlineplus.gov/druginfo/meds/a 2.html. [2] A narrowing of the spinal column that causes pressure on the spinal cord, or narrowing of the openings (called neural foramina) where spinal nerves leave the spinal column. This information was obtained from the website: https://medlineplus.gov/ency/article/ 1.htm.

Based on observation, staff interview, resident interview and facility document review it was determined that the facility staff failed to provide privacy for three of 35 residents in the survey sample, Resident #301, #33 and #47. Resident #301's urinary catheter bag was visible with urine in the bag from the hallway while the resident was in bed and was not covered with a privacy cover; Resident #33's protected health information was left open on the medication cart in the hallway and was visible to staff and or others passing by, during the medication administration observation; and facility staff failed to provide personal privacy for Resident #47 while she was receiving personal care on 9/7/21. The findings include: 1. On 9/7/2021 at approximately 12:47 p.m., an observation was made of Resident #301 in bed from the facility hallway. Resident #301 was observed lying in bed with a urinary catheter bag attached to the bedframe on the right side of the bed facing the hallway. Urine was observed in the catheter bag visible from the hallway. Additional observations on 9/7/2021 at 2:18 p.m., and 9/7/2021 at 4:33 p.m. revealed the urinary catheter bag hanging on the right side of the bed facing the hallway with urine visible in the bag from the hallway. On 9/8/2021 at 8:45 a.m., Resident #301 was observed in bed with a urinary catheter bag with a privacy cover hiding the contents of the bag from view. Resident #301 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #301's most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 9/2/2021, coded Resident #301 as scoring a 13 on the staff assessment for mental status (BIMS) of a score of 0 - 15, 13- being cognitively intact for making daily decisions. Section H documented Resident #301 having an indwelling catheter. On 9/7/2021 at 4:33 p.m., an interview was conducted with Resident #301. Resident #301 stated that they were at the facility for therapy and short-term. Resident #301 stated that the nursing staff handled the urinary catheter bag and emptied it when needed. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Order Date: 08/28/2021. The orders further documented, Foley and Suprapubic catheter care every shift. Order Date: 08/28/2021. The progress notes for Resident #301 documented in part, 8/27/2021 21:33 (9:33 p.m.) [Resident #301] was admitted on [DATE] .Catheter is indwelling supra-pubic . The baseline care plan for Resident #301 dated 8/27/2021 documented in part, Altered elimination .Catheter care per policy . On 9/8/2021 at approximately 1:54 p.m., an interview was conducted with CNA (certified nursing assistant) #1. CNA #1 stated that they placed urinary catheter bags on the bed frame and made sure the bag had a privacy cover on it. CNA #1 stated that some residents were admitted from the hospital with urinary catheter bags that did not have privacy covers on them and the nurses changed them after they were admitted to the ones with privacy covers. CNA #1 stated that they did this so everyone could not see the contents in the bag and that the urinary catheter bag with urine inside should not be visible from the hallway. On 9/8/2021 at approximately 2:27 p.m., an interview was conducted with LPN (licensed practical nurse) #1. LPN #1 stated that residents should have dignity bags for urinary catheters so that the contents could not be seen. LPN #1 stated that they should not be able to see the urine from the hallway. When asked about Resident #301's urinary catheter bag on 9/7/2021, LPN #1 stated that Resident #301 did not have a dignity bag but they had changed it to a dignity bag that morning so there would not be any further privacy concerns. On 9/9/2021 at approximately 10:30 a.m., a request was made to ASM #1 for the facility policy for care of urinary catheter bags and privacy. On 9/9/2021 at 3:48 p.m., ASM #1 provided via email, Catheter Care, Urinary dated 9/5/2017 which failed to evidence guidance on providing privacy for the urinary catheter bag contents. ASM #1 also provided the policy Notice of Privacy Practice dated 11/30/2014 which documented in part, .The facility is responsible to: Maintain the privacy of the resident health information . The facility policy Resident and Patient Rights dated 9/1/2017 documented in part, .It is the policy of The Company that all employees will conduct themselves in a professional manner at all times, respecting the rights of each resident or patient to privacy, personal care, self-respect and confidentiality . On 9/8/2021 at approximately 5:02 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing and ASM #3, the regional nurse were made aware of the findings. No further information was provided prior to exit. References: 1. Malignant neoplasm: refers to the presence of cancerous cells that have the ability to spread to other sites in the body (metastasize) or to invade nearby (locally) and destroy tissues. This information was obtained from the website: https://medlineplus.gov/ency/article/ 3.htm. 2. [CONDITION(S)]: is the loss of muscle function in part of your body. It happens when something goes wrong with the way messages pass between your brain and muscles. Paralysis can be complete or partial. It can occur on one or both sides of your body. It can also occur in just one area, or it can be widespread. Paralysis of the lower half of your body, including both legs, is called [CONDITION(S)]. This information was obtained from the website: https://medlineplus.gov/paralysis.html 3. Suprapubic catheter: A suprapubic catheter (tube) drains urine from your bladder. It is inserted into your bladder through a small hole in your belly. This information is taken from the website https://medlineplus.gov/ency/patientinstructions/ 5.htm. 2. On 9/7/2021 at approximately 4:55 p.m., an observation was made of LPN (licensed practical nurse) #3 administering medications at the facility. LPN #3 placed the medication cart in the hallway against the wall between the resident rooms. LPN #3 was observed preparing medications for administration to Resident #33. On 9/7/2021 at 5:07 p.m., LPN #3 entered Resident 33's room with the medications while leaving their laptop computer showing Resident #33's eMAR (electronic medication administration record) visible on the medication cart in the hallway. Another staff member was observed exiting Resident #33's room at that time, passing beside the medication cart. On 9/7/2021 at 5:11 p.m., LPN #3 exited Resident #33's room to obtain another medication and proceeded to enter the room with the eMAR still visible on the computer screen. On 9/7/2021 at 5:12 p.m., LPN #3 exited Resident #33's room and returned to the medication cart. Resident #33 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #33's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 8/6/2021, coded Resident #33 as scoring a 10 on the staff assessment for mental status (BIMS) of a score of 0 - 15, 10- being moderately impaired for making daily decisions. On 9/7/2021 at approximately 5:14 p.m., an interview was conducted with LPN #3. LPN #3 stated that they normally locked the computer screen on their computer before they left the cart to go into the residents room. LPN #3 stated that they had forgotten to lock the computer screen and left the eMAR in view by mistake. On 9/8/2021 at approximately 5:02 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing and ASM #3, the regional nurse were made aware of the findings. No further information was provided prior to exit. References: 1. [CONDITION(S)] ([CONDITION(S)]) Disease that makes it difficult to breath that can lead to shortness of breath. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/[CONDITION(S)].html. 2. Dementia A loss of brain function that occurs with certain diseases. It affects memory, thinking, language, judgment, and behavior. This information was obtained from the website: https://medlineplus.gov/ency/article/ 9.htm. 3. Resident #47 was admitted to the facility on [DATE], and most recently readmitted on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 8/16/21, Resident #47 was coded as requiring the extensive assistance of one staff member for toileting. On 9/7/21 at 2:32 p.m., Resident #47 was observed lying in her bed. The privacy curtain between her bed and the door was pulled 3/4 of the way down the bed. The other two privacy curtains were open, allowing Resident #47 to be observed by her roommate and the surveyor. Resident #47 was receiving assistance to pull up her underwear after using the bedpan, from OSM (other staff member) #2, an occupational therapy assistant. Two subsequent attempts to interview Resident #47 were unsuccessful. On 9/8/21 at 1:35 p.m., OSM #2 was interviewed. When asked if she remembered her work with Resident #47 the day before, she stated she did. OSM #2 stated she had transferred Resident #47 back to bed because the resident wanted to use the bedpan. When asked if she remembered who was able to see Resident #47 as she was toileting and re-dressing, OSM #2 stated, You walked into the room as I was getting her pants back on. She stated when she first began working with Resident #47 yesterday, the roommate was not in the room. She stated she did not realize the roommate had entered the room. OSM #2 stated for the resident's personal privacy, she should have made sure all three privacy curtains were pulled, completely keeping Resident #47 out of anyone's view. On 9/8/21 at 5:00 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, and ASM #3, the regional nurse, were informed of these concerns. No further information was provided prior to exit. REFERENCES: (1) End-stage kidney disease (ESKD) is the last stage of long-term (chronic) kidney disease. This is when your kidneys can no longer support your body's needs. End-stage kidney disease is also called end-stage renal disease ([CONDITION(S)]). This information is taken from the website https://medlineplus.gov/ency/article/ 0.htm. (2) [CONDITION(S)], or [CONDITION(S)], is a progressive disease that makes it hard to breathe. Progressive means the disease gets worse over time. [CONDITION(S)] can cause coughing that produces large amounts of a slimy substance called [MEDICATION(S)], wheezing, shortness of breath, chest tightness, and other symptoms. This information is taken from the website https://www.nhlbi.nih.gov/health-topics/[CONDITION(S)].

Based on observation, staff interview, clinical record review, and facility document review, it was determined that the facility staff failed to provide a clean and homelike environment for 2 of 35 residents in the survey sample; Residents #9 and #37. Resident #9's right and Resident #37's wheelchairs were not maintained in a condition of good repair. Resident #9's right wheelchair arm was observed with cracks in the vinyl material, and exposed foam in the cracks. The findings include: 1. Resident #9 was admitted to the facility on [DATE] and had the diagnoses of but not limited to [CONDITION(S)], chronic kidney disease, dysphagia, [CONDITION(S)], high blood pressure, depression, dementia, heart failure, and [CONDITION(S)]. The annual MDS (Minimum Data Set) assessment with an ARD (Assessment Reference Date) of 6/22/21 coded Resident #9 as cognitively impaired in ability to make daily life decisions. The resident was coded as requiring total care for bathing, hygiene and toileting; extensive assistance for dressing, transfers and bed mobility; as independent for eating; and as incontinent of bowel and bladder. On 09/07/21 5:22 PM during observations of Resident #9, the resident's right wheelchair arm was observed with cracks in the vinyl material, and exposed foam in the cracks. On 9/8/21 at 2:06 PM an interview was conducted with CNA #1 (Certified Nursing Assistant). She stated that when a resident's wheelchair is torn and requires maintenance, it should be written in the maintenance log at the nurse's station. A review of the maintenance log revealed that the last entry was dated 9/2/21 and there were no entries for Resident #9's torn wheelchair arm. On 9/8/21 at 4:18 PM an interview was conducted with OSM #4 (Other Staff Member) the Director of Maintenance. He stated that he was not aware of any issues with Resident #9's wheelchair arm rest and that it had not been documented in the log book. OSM #4 stated that the exposed foam absolutely cannot be cleaned and sanitized. A review of the facility policy Wheelchair Repairs - Non Electric Wheelchairs documented, Each resident requiring the use of a wheelchair will be provided the appropriate chair to maintain their highest level of functioning. All chairs will be maintained in safe operating condition. On 9/8/21 at approximately 5:00 PM at the end-of-day meeting, ASM #1 (Administrative Staff Member) the interim Administrator, ASM #2 the interim Director of Nursing (DON) and ASM #3 the regional nurse, were made aware of the findings. No further information was provided by the end of the survey. 2. Resident #37 was admitted to the facility on [DATE] with the diagnoses of but not limited to stroke, dysphagia, diabetes, chronic obstructive pulmonary disease, [CONDITION(S)], chronic kidney disease, heart attack, depression, peripheral vascular disease, pacemaker, [CONDITION(S)], [CONDITION(S)], and dementia. The quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 8/10/21 coded the resident as being cognitively impaired in ability to make daily life decisions. The resident was coded as requiring extensive assistance for bathing and dressing; limited assistance for transfers, bed mobility, toileting and hygiene; as independent for eating; and as continent of bowel and bladder. On 09/07/21 5:22 PM during observations of Resident #37, the resident's right wheelchair arm was observed with torn ripped vinyl, and exposed foam along the armrest. The top corners of the wheelchair backrest was also observed with torn vinyl and exposed foam. On 9/8/21 at 2:06 PM an interview was conducted with CNA #1 (Certified Nursing Assistant). She stated that when a resident's wheelchair is torn and requires maintenance, it should be written in the maintenance log at the nurse's station. A review of the maintenance log revealed that the last entry was dated 9/2/21 and there were no entries for Resident #9's torn wheelchair arm. On 9/8/21 at 4:18 PM an interview was conducted with OSM #4 (Other Staff Member) the Director of Maintenance. He stated that he was not aware of any current issues with Resident #37's wheelchair arm rest but that he has replaced it twice in the last 6 months, and most recently (approximately 3 weeks ago) repaired the breaks on Resident #37's wheelchair. OSM #4 stated that Resident #37 is hard on his wheelchair. He stated that the exposed foam absolutely cannot be cleaned and sanitized. On 9/8/21 at approximately 5:00 PM at the end-of-day meeting, ASM #1 (Administrative Staff Member) the interim Administrator, ASM #2 the interim Director of Nursing (DON) and ASM #3 the regional nurse, were made aware of the findings. No further information was provided by the end of the survey.

Based on staff interview and clinical record review, it was determined that the facility staff failed to ensure written notification was provided to the ombudsman, the resident and the resident's representative (RP) for a facility/resident-initiated transfer for one of 35 residents in the survey sample, Residents #32. The facility staff failed to evidence that the ombudsman was notified and Resident # 14 and resident's representative were provided written notification of a resident-initiated transfer on 07/14/2021 for Resident # 32. The findings included: Resident # 32 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident # 32's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 08/04/2021, coded Resident # 32 as scoring a seven [7] on the brief interview for mental status (BIMS) of a score of 0 - 15, seven - being severely impaired of cognition for making daily decisions. The nurse's note for Resident # 32 dated 07/14/2021 at 4:34 p.m., documented, Nurse received X-ray results which showed displaced right clavicle fracture. Np [nurse practitioner] notified with orders to send to ER [emergency room ] for further eval [evaluation]. RP [responsible party made aware. Review of the clinical record and the EHR (electronic health record) for Resident # 32 failed to evidence notification to the ombudsman and that a written notification was provided to the resident and resident's representative for Resident # 32's facility-initiated transfer on 07/14/2021. On 9/8/2021 at approximately 2:27 p.m., an interview was conducted with ASM [administrative staff member] # 1, the administrator. When asked about the documentation for the ombudsman notification and the written notification to Resident # 23 and Resident # 32's representative regarding the facility-initiated transfer on 07/14/2021, ASM # 1 stated that they were not completed because the staff knew the resident was being sent out and that they did not see a need for it. On 09/09/2021 at 11:30 a.m., ASM [administrative staff member] # 1, administrator, ASM # 2, director of nursing, and ASM # 3, regional nurse, were made aware of the above findings. No further information was provided prior to exit.

Based on resident interview, staff interview, facility document review, and clinical record review, it was determined that facility staff failed to provide a bed hold policy to the resident or the resident's representative upon a transfer to the hospital for one of 35 residents in the survey sample, Residents # 32. The facility staff failed to provide Resident #32 and or the resident's representative with a copy of the bed hold policy prior to and or at the time of transfer to the hospital on 07/14/2021. The findings included: Resident # 32 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident # 32's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 08/04/2021, coded Resident # 32 as scoring a seven [7] on the brief interview for mental status (BIMS) of a score of 0 - 15, seven - being severely impaired of cognition for making daily decisions. The nurse's note for Resident # 32 dated 07/14/2021 at 4:34 p.m., documented, Nurse received X-ray results which showed displaced right clavicle fracture. Np [nurse practitioner] notified with orders to send to ER [emergency room ] for further eval [evaluation]. RP [responsible party] made aware. Review of the clinical record and the EHR (electronic health record) for Resident # 32 failed to evidence documentation the a bed hold policy was provided to Resident # 32 or Resident # 32's responsible party in regard to the transfer to the hospital on 07/14/2021. On 9/8/2021 at approximately 2:27 p.m., an interview was conducted with ASM [administrative staff member] # 1, the administrator. When asked about documentation evidencing the bed hold policy was provided to Resident # 32 or Resident # 32's responsible party prior to and or at the time of transfer to the hospital on 07/14/2021, ASM # 1 stated that it wasn't [provided] because the staff knew the resident was being sent out and that they did not see a need for it. The facility's policy Bed Hold documented in part, At the time of transfer to the hospital or therapeutic leave, the center will provide a copy of notification of bed hold. On 09/09/2021 at 11:30 a.m., ASM [administrative staff member] # 1, administrator, ASM # 2, director of nursing, and ASM # 3, regional nurse, were made aware of the above findings. No further information was provided prior to exit.

Based on staff interview, clinical record review, and facility document review, it was determined that the facility staff failed to ensure an accurate MDS (minimum data set) assessment for two of 35 residents in the survey sample; Residents #37 and #52. 1. The 8/10/21 quarterly MDS assessment for Resident #37 was not completed accurately regarding the coding of Section J1800 falls. The clinical record documented Resident #37 was found on the floor by staff on 6/8/21, and Section J1800 of the 8/10/21, quarterly MDS assessment coded the resident as having 0 falls, since admission/entry or reentry or the prior assessment. 2. The facility staff failed to accurately code Resident # 52's discharge status to community on the discharge MDS (minimum data set) assessment with an ARD (assessment reference date) of 07/22/2021. Instead, the resident's discharge was coded as Acute hospital. The findings include: 1. Resident #37 was admitted to the facility on [DATE] with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 8/10/21 coded Resident #37 as cognitively impaired in ability to make daily life decisions. The resident was coded as requiring extensive assistance for bathing and dressing; limited assistance for transfers, bed mobility, toileting and hygiene; independent for eating; and as continent of bowel and bladder. A review of the clinical record revealed a Change in Condition assessment dated [DATE] that documented, Found sitting on floor in room between w/c (wheelchair) and bed. States he was trying to get into w/c. Pants noted soaked with urine .No injuries noted. VSS (vital signs stable). A review of the clinical record revealed a nurse's note dated 6/10/21 that documented, S/p (status post [MEDICAL RECORD OR PHYSICIAN ORDER] . Up to his wheelchair propel self up and down the hallways. Denied pain or discomfort. No concerns voiced this shift. Further review of the above quarterly MDS revealed that it was not accurately completed for Section J1800 Has the resident had any falls since admission/entry or reentry or the prior assessment . This question was coded as 0 (Code 0 for No and 1 for Yes). On 9/8/21 at 3:58 PM an interview was conducted with LPN #5 (Licensed Practical Nurse), the MDS nurse. She stated that it should be coded but was going to review it and see what happened with the coding. When asked if there was any policy or procedure she follows to complete the MDS, LPN #5 stated that she was sure there was one somewhere. She did not identify the RAI manual. A review of the facility policy MDS did not address the accuracy of an MDS. On 9/8/21 at approximately 5:00 PM at the end-of-day meeting, ASM #1 (Administrative Staff Member) the Administrator, ASM #2 the Director of Nursing (DON) and ASM #3 the regional nurse, were made aware of the findings. No further information was provided by the end of the survey. 2. Resident # 52 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident # 81's MDS (minimum data set) assessment, a discharge assessment with an ARD (assessment reference date) of 07/22/2021, coded Resident # 52 as 03 (three) - Acute hospital under section A2100 Discharge Status. The facility's Progress Notes dated 07/20/2021 documented in part, This SSD [social services department] spoke with resident about upcoming discharge. Resident states that she is ready to go home and feels that she and husband have developed a plan for safety when they discharge home. Resident will discharge home of 07/22/2021 with referral for home health to [Name of Home Health Agency]. On 09/08/2021 at 3:58 p.m., an interview was conducted with LPN #5 (Licensed Practical Nurse), the MDS nurse. She stated that it [A2100 Discharge Status on the MDS assessment] was coded in error. It should have been coded as a discharge to community. When asked if there was any policy or procedure she follows to complete the MDS assessments, LPN #5 stated that she was sure there was one somewhere. She did not identify the RAI manual. On 10/10/19 at approximately 4:10 p.m., ASM [administrative staff member] # 1, the administrator and ASM # 2, director of nursing and ASM # 3, regional nurse were made aware of the findings. No further information was provided prior to exit.

Based on observation, clinical record review, staff interview, and facility document review, it was determined that the facility staff failed to review and revise the comprehensive care plan for one of 35 residents in the survey sample; Resident #9. The facility staff failed to review and revise Resident #9's comprehensive care plan was to include and address the use of side rails. The findings include: Resident #9 was admitted to the facility on [DATE], with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The annual MDS (Minimum Data Set) assessment with an ARD (Assessment Reference Date) of 6/22/21 coded Resident #9 as cognitively impaired in ability to make daily life decisions. The resident was coded as requiring total care for bathing, hygiene and toileting; extensive assistance for dressing, transfers and bed mobility; independent for eating; and as incontinent of bowel and bladder. On 09/07/21 5:22 PM during observations of Resident #9, the resident was observed in bed eating her dinner meal, and the half-length upper side rails on Resident #9's bed were up. A review of the clinical record revealed a Side Rail Evaluation dated 7/7/21. This assessment documented, Resident use the rails for assist. Risk and benefit explained and measurements completed. A review of Resident #9's comprehensive care plan failed to reveal any evidence that the resident was care planned for the use of side rails. On 9/8/21 at 3:58 PM an interview was conducted with LPN #5 (Licensed Practical Nurse), the MDS nurse. She stated that the purpose of the care plan was to direct resident care and set goals for resident care. LPN #5 stated that the use of side rails should be care planned. She stated that any nurse or the DON (Director of Nursing) can review and revise a care plan. When asked if there was any policy or procedure she follows regarding reviewing and revising care plans she stated that she was sure there was one somewhere. She did not identify the RAI manual. A review of the facility policy Plans of Care documented, Review, update and/or revise the comprehensive plan of care based on changing goals, preferences and needs of the resident and in response to current interventions after the completion of each OBRA MDS assessment (except discharge assessments), and as needed. The interdisciplinary team shall ensure the plan of care addresses any resident needs and that the plan is oriented toward attaining or maintaining the highest practicable physical, mental and psychosocial well-being. On 9/8/21 at approximately 5:00 PM at the end-of-day meeting, ASM #1 (Administrative Staff Member) the interim Administrator, ASM #2 the interim Director of Nursing (DON) and ASM #3 the regional nurse, were made aware of the findings. No further information was provided by the end of the survey.

Based on staff interview, facility document review and clinical record review, it was determined that the facility staff failed to ensure professional standards for the administration of pain medications for one of 35 residents in the survey sample, Resident # 3. The facility staff failed to clarify physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The findings include: Resident # 3 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Resident # 3's most recent MDS (minimum data set), an admission assessment with an ARID (assessment reference date) of 06/10/2021, coded Resident # 3 as scoring a 15 on the brief interview for mental status (BIMS) of a score of 0 - 15, 15 - being cognitively intact for making daily decisions. Section J0300, J0400 and J0600 Pain Assessment Interview coded Resident # 3 as having frequent pain at a level of 4 [four] on a pain scale of zero to ten, with ten being the worse pain. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] · [MEDICATION(S)] [Oxycodone-Acetaminophen] 5-325MG [milligram]. Give 1 [one] tablet by mouth every 12 hours as needed for pain. Oder Date: 7/12/2021. · Acetaminophen Tablet 325MG. Give 2 tablet by mouth every 4 [four] hours as needed for pain. Oder Date: 6/4/2021. Resident # 3's ear [electronic medication administration record] dated August 2021 documented the above physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of the eMAR documented the administration of acetaminophen on 08/14/2021 at 6:20 a.m. with pain level of six, [MEDICATION(S)] on 08/14/2021 at 12:04 a.m. with pain level of seven and [MEDICATION(S)] at 5:40 p.m. with pain level of six, acetaminophen on 08/16/2021 at 8:53 a.m. with pain level of two and [MEDICATION(S)] at 1:30 p.m. for pain level of three, acetaminophen on 80/26/2021 at 10:36 a.m. with pain level of two and [MEDICATION(S)] at 12:30 a.m. with pain level of seven, and [MEDICATION(S)] at 9:16 p.m. with pain level of one. Resident # 3's eMAR [electronic medication administration record] dated September 2021 documented the above physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of the eMAR documented the administration of acetaminophen on 09/03/2021 at11:25 p.m. with pain level of seven and [MEDICATION(S)] at 2:41 p.m. with pain level of eight. On 09/09/2021 at 9:05 a.m., an interview was conducted with LPN [licensed practical nurse] # 4 regarding Resident # 3's prescribed as needed pain medication. LPN #4 reviewed the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . After completing the review, LPN # 4 was asked how staff determine which and when to administer each as needed pain medication to Resident # 3. LPN # 4 stated, [Resident # 3] requests which one she wants. When asked if this was the correct way to administer Resident # 3's as needed pain medications, LPN # 4 stated no. LPN # 4 stated, There are no parameters to tell me which pain medication to administer. When asked to describe the procedure that should be followed when they have two as needed pain medications without parameters LPN # 4 stated, Call the physician and get clarification. On 9/7/2021 at 5:47 p.m., ASM [administrative staff member] #1, administrator, stated that the facility used their policies and procedures and Lippincott as their standard of practice. According to Lippincott Manual of Nursing Practice, Eighth Edition: by Lippincott Williams & Wilkins, pg. 87 read: Nursing Alert: Unusual dosages or unfamiliar drugs should always be confirmed with the health care provider and pharmacist before administration. On pg. 15, the following is documented in part, Inappropriate Orders: 2. Although you cannot automatically follow an order you think is unsafe, you cannot just ignore a medical order, either. b. Call the attending physician, discuss your concerns with him, obtain appropriate .orders. c. Notify all involved medical and nursing personnel d. Document clearly. On 09/09/2021 at 11:30 a.m., ASM [administrative staff member] # 1, administrator, ASM # 2, director of nursing, and ASM # 3, regional nurse, were made aware of the above findings. No further information was provided prior to exit. References: [1] Oxycodone [[MEDICATION(S)]] is used to relieve moderate to severe pain. This information was obtained from the website: https://medlineplus.gov/druginfo/meds/a 2.html. [2] Used to relieve mild to moderate pain from headaches, muscle aches, menstrual periods, colds and sore throats, toothaches, backaches, and reactions to vaccinations (shots), and to reduce fever. Acetaminophen may also be used to relieve the pain of [CONDITION(S)] (arthritis caused by the breakdown of the lining of the joints). This information was obtained from the website: https: https://medlineplus.gov/druginfo/meds/a 4.html. [3] A narrowing of the spinal column that causes pressure on the spinal cord, or narrowing of the openings (called neural foramina) where spinal nerves leave the spinal column. This information was obtained from the website: https://medlineplus.gov/ency/article/ 1.

Based on observation, staff interview and facility document review, it was determined the facility staff failed to ensure physician ordered fluid restrictions were implemented and monitored per physicians orders for one of 35 residents in the survey sample, Resident # 44. The facility staff failed to ensure the amount of fluid Resident #44 received was monitored and within the physician prescribed fluid restriction amount of 1500 ml (milliliters). The findings include: Resident #44 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . (3). The most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 8/15/2021, coded the resident as scoring an 8 on the BIMS (brief interview for mental status) score, indicating Resident #44 was moderately impaired to moderately impaired to make daily cognitive decisions. The resident was coded as requiring extensive assistance of one or more staff members for most of her activities of daily living except eating, which she was independent after set up assistance was provided. The physician order dated, 4/8/2021, documented in part, 1500 ml (milliliters) fluid restriction 260 ml per meal and 240 ml every shift for CHF. Review of the meal tickets for 9/8/2021, one full day for Resident #44 was conducted. The meal ticket documented the three meals. For breakfast, the resident received 8 ounces (equals 237 ml) of whole milk. The lunch meal documented, 4 oz. (ounces) of water and 4 oz. of iced tea (237 ml). The dinner meal documented 4 oz. (ounces) of water and 4 oz. of iced tea (237 ml). Review of the POC (point of care) documentation, recorded by the staff after meal intake, for August 2021 and September 2021, revealed no documentation of fluid intake for Resident #44. The Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no total of liquids consumed for the day documented. On 8/15/2021 and 8/28/2021 for the day shift, a N/A (not applicable) was documented. On 8/18/2021 the total documented as consumed was 1640 ml. On 8/20/21 the total documented as consumed was 1700 ml. On 8/25/2021 the total documented as consumed was 2980 ml. The totals for the rest of the days in August 2021, documented 240 ml to 1240 ml. The MAR for September 2021 was reviewed. The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . On 9/6/2021 for the night shift N/A was documented. The totals for the day documented 480 ml to 1240 ml. The nurse's note dated, 8/26/2021 at 1:06 p.m. documented in part, Resident with new order for chest x-ray for increased sob (shortness of breath) two views. [MEDICATION(S)] (4), changed to two times a day. The comprehensive care plan dated, 7/18/2021, documented in part, Focus: (Resident #44) has [CONDITION(S)]. The Interventions documented in part, Monitor/document/report PRN (as needed) any s/sx (signs and symptoms) of [CONDITION(S)], dependent [CONDITION(S)] of legs and feet, periorbital [CONDITION(S)], SOB (shortness of breath) upon exertion, cool skin, dry cough, distended neck veins, weakness, weight gain unrelated to intake, crackles and wheezes upon auscultation of the lungs, orthopnea, weakness and/or fatigue, increased heart rate ([CONDITION(S)]) lethargy and disorientation. The care plan further documented, dated, 2/3/2021, Focus: The resident has potential for fluid deficit r/t (related to) diuretic use. The Interventions documented in part, Monitor and document intake and output as per facility policy. An interview was conducted with LPN (licensed practical nurse) #1, on 9/8/2021 at 2:27 p.m. When asked how staff know how much fluid to give a resident on physician ordered fluid restrictions, LPN #1 stated the amount comes with the physician order. When asked where the total amount of fluids given for the day is documented, LPN #1 stated it's on the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . When asked who monitors the fluid restriction, LPN #1 stated it (MAR or TAR) should have a place to put it in each shift. The CNA (certified nursing assistant) document fluids given. When a resident is on a fluid restriction, you normally know how much they had. The CNAs are with them more that we are. When asked why it is important to know the total amount of fluids given at the end of each day, LPN #1 stated it's to see if they went over their fluid restriction. When asked whose responsibility is it to monitor a fluid restriction, LPN #1 stated each nurse each shift should monitor it. They (the resident) has a specific number per shift they are allow, if they go over it they could go over it for the whole day. An interview was conducted with ASM (administrative staff member) #2, the director of nursing, on 9/9/2021 at 8:48 a.m. When asked who is responsible for monitoring that a resident is maintaining their fluid restriction, ASM #2 stated it should be on the intake record. Would expect the nurse to record all the resident receives on their shift. It's up to the nurse to coordinate with the aide to document what intake the resident has had for their shift. Someone should be monitoring it. ASM #2 was informed of the above concern and shown the above documents. The facility policy, Fluid Restrictions documented in part, Policy: Residents receive adequate fluid intake within the limitations determined by the attending physician. Procedure: A written order will be obtained from the attending physician. The resident will have fluid restrictions calculated so that he/she can have intake on each shift based on resident preferences. In calculating intake per shift, keep in mind fluid required for resident to take medications and desired at mealtimes. Caregivers will be notified on limitations. Dietary will be notified that resident is on restricted fluids and fluids on the resident's tray will be calculated according to overall restrictions. The dietician will determine d the amount of fluid to be given with each meal. The amount of fluid per meal is translated into allowed beverages and entered on the tray cared for reach meal. The Care Planning Team will discuss the restrictions, and they will be included in the Care Plan. The dietician documents the allowed fluids in the medication record and provides a written breakdown of fluids to the nursing staff. Resident education will be provided on established limits and importance of adherence to the restrictions. The Attending physician will be notified of resident non-compliance. ASM #1, the administrator, ASM #2, and ASM #3, the regional nurse, were made aware of the above findings on 9/9/2021 at 11:14 a.m. No further information was obtained prior to exit. References: (1) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and Chapman, page 138. (2) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and Chapman, page 124. (3) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and Chapman, page 124. (4) This information was obtained from the following website: https://vsearch.nlm.nih.gov/vivisimo/cgi-bin/query-meta?v%3Aproject=medlineplus&v%3Asources=medlineplus-bundle&query=[MEDICATION(S)]&_ga=2XXX 4112XXX XXX - XXX .

Based on observation, staff interview, facility document review and clinical record review, it was determined the facility staff failed to provide care and services consistent with professional standards of practice, to promote healing of a pressure injury for one of 35 residents in the survey sample, Resident #40. The facility staff failed to conduct a thorough initial assessment to include measurements of Resident #40's pressure injury upon discovery on 1/2/21, and failed to ensure ongoing assessments including measurements and staging until 2/1/2021. The findings include: Resident #40 was admitted to the facility on [DATE] with a recent readmission on 12/15/2020, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] .)(1), diabetes, [CONDITION(S)] ([CONDITION(S)] - general term for chronic, nonreversible lung disease that is usually a combination of [CONDITION(S)] and chronic [CONDITION(S)]) (2), [CONDITION(S)] (any of a group of mental disorders characterized by gross distortions of reality, withdrawal of thought, language, perception and emotional response) (3), and high blood pressure. The most recent MDS (minimum data set), a quarterly assessment, with an assessment reference date of 8/11/2021 coded the resident as scoring a 14 on the BIMS (brief interview for mental status) score, indicating she was capable of making daily cognitive decisions. The resident was coded as requiring extensive assistance of one or more staff members for all of her activities of daily living except eating in which she was independent after set up assistance was provided. In Section M - Skin Conditions, the resident was coded as having a Stage III pressure injury. (A pressure injury is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbidities and condition of the soft tissue. Stage III - Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury.)(4). A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the December 2020 TAR (treatment administration record) for Resident #40 documented the physician ordered Greers [NAME] was administered every day in December after the medication was ordered. The last Braden Scale (a scale to determine the likeness of developing a pressure injury) was dated 12/22/2020. The Braden Scale documented the resident was at low risk for developing a pressure injury. The Weekly Skin Integrity Review dated 12/24/2020 documented in part, Skin intact. A nurse's note dated, 1/2/2021 at 12:10 p.m. documented, New order for tx (treatment) to coccyx pressure injury noted possible stage 2. The Change in Condition form dated 1/2/2021 documented a check mark next to, Pressure ulcer/Pressure injury. Further review of the form failed to evidence documentation of the measurements of the area or any description of the area. A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the January 2021, TAR for Resident #40 documented the physician ordered [MEDICATION(S)] Paste was applied as ordered the entire month. Further review of the clinical record failed to evidence documentation of measurements of the wound on or around 1/2/2021. The first documentation of the wound was on 2/1/2021 on the Weekly Wound Report: Pressure Injury. The form documented the resident's name, visualized stage - 3, Measurements - 2x1x0.2 (2 centimeters [cm] in length, by 1 cm in width by 0.5 cm in depth), Location - sacrum. The nurse's notes dated 1/6/2021 at 9:36 p.m. documented in part, CNA (certified nursing assistant) reported to this nurse that she went in to resident's room to offer pericare since resident had not rung bell all shift to have brief changed (per resident's usual routine) and resident refused to allow CNA to check her brief or do pericare. Resident insisted she was dry and accused CNA of 'caller her a liar. The nurse's note dated 1/7/2021 at 12:09 p.m. documented, Pt (patient) is refusing to be changed at this time. The nurse's note dated 1/10/2021 at 2:48 p.m. documented, Pt refused CNAs to change her, pt states she is dry. The nurse's note dated 1/14/2021 at 12:59 p.m. documented, Patient refused shower and lunch, unable to redirect the pt. Educated pt. on importance of eating and taking a shower. Pt continues to refuse. The nurse's note dated 1/21/2021 at 11:33 a.m. documented, Pt refusing to have CNA change her at this time. Pt will not allow even be checked and stated to this write, 'I done (sic) even feel let I know if I'm wet. The comprehensive care plan dated 12/10/2018, documented in part, Focus: (Resident #40) has potential for impairment to skin integrity r/t (related to) fragile skin, incontinence, infection, diabetes, impaired mobility. The Interventions documented in part, Monitor/document location, size and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . to MD (medical doctor). The care plan, dated 2/3/2021, documented in part, (Resident #40) has a pressure injury on sacrum r/t hx (history of) ulcers, immobility, B&B (bowel and bladder) incontinence, refusal to be turned and repositioned, declining to get OOB (out of bed). The Interventions documented in part, Assess/record/ monitor wound healing per protocol. Resident refused to have air mattress placed on bed. On 9/7/2021 at 5:47 p.m., ASM [administrative staff member] #1, administrator, stated that the facility used their policies and procedures and Lippincott as their standard of practice. An interview was conducted with ASM (administrative staff member) #2, the director of nursing, on 9/8/2021 at 1:37 p.m. The above documents were reviewed with ASM #2. When asked at what stage was the wound found at, ASM #2 stated it was found as a stage III on wound documents of 2/1/2021. When asked if a nurse finds something, such as a possible stage II pressure injury what is the process, ASM #2 stated the nurse should do a skin assessment, measure the wound, stage the wound or have someone look at it if they are not proficient in it, assess the wound is it a pressure injury or excoriation. They need to find out what it is and notify the doctor to get treatment orders. Observation was made of the wound on 9/8/2021 at 11:31 a.m. accompanied by LPN (licensed practical nurse) #4. The wound was cleansed with wound cleanser. LPN #4 measured the wound. The length was 3.5 cm (centimeters), the width was 2.0 cm, and the depth was 1.0 cm. LPN #4 stated the wound had 100% granulation tissue. An interview was conducted with LPN (licensed practical nurse) #6 on 9/8/2021 at 3:28 p.m. LPN #6 is the nurse who wrote the note of 1/2/2021. When asked if she was trained in wound care, LPN #6 stated she is trained in the basic dressing changes. When asked if she can stage a pressure injury, LPN #6 stated, Technically no, I need more training. LPN #6 was asked to explain what actions she took on 1/2/2021. LPN #6 stated when she found the area, she notified the doctor and management. She stated she had told the ADON (assistant director of nursing). [ADON no longer employed at facility]. LPN #6 stated she implemented the new orders from the physician. When asked if she measured the wound, LPN #6 stated she did not. When asked if she should have measured the wound, LPN #6 stated, she should have measured the wound. The facility policy, Pressure Injury Record documented, Policy: To document the presence of skin impairment/new skin impairment related to pressure when first observed and weekly thereafter until the site is resolved. One site will be recorded per page. Procedure: 1. Residents will have a Pressure Injury Record completed for each skin impairment that is related to pressure. 2. Mark the pressure area on the body description identifying the site. 3. Enter the date. 4. Enter the stage of the pressure injury. 5. Enter the size of the pressure in [NAME] - length x width x depth in centimeters. 6. Enter tissue type and color. 7. Enter the wound edges and drainage. 8. Enter the peri-wound information. 9. Licensed nurse to sigh the appropriate area. The Pressure Ulcer Treatment Quick Reference Guide by NPUAP states on page 8 concerning pressure ulcer assessment, Assess and accurately document physical characteristics such as location, Category/Stage, size, tissue type (s), wound bed and periwound condition, wound edges, [MEDICATION(S)] tracts, undermining, tunneling, exudate, necrotic tissue, odor, presence/absence of granulation tissue, and epithelialization. Page 10 of this reference states, Re-evaluate the pressure ulcer, the plan of care, and the individual if the pressure ulcer does not show progress toward healing within 2 weeks (or as expected given the individual's overall condition and ability to heal) . This information was obtained from: National Pressure Ulcer Advisory Panel and European Pressure Ulcer Advisory Panel. Pressure Ulcer Prevention and Treatment: Clinical Practice Guideline. Washington, DC: National Pressure Ulcer Advisory Panel, Second edition published 2014. ASM #1, the administrator, ASM #2, the director of nursing, and ASM #3, the regional nurse, were made aware of the above findings on 6/9/2021 at 11:14 a.m. No further information was provided prior to exit. References: (1) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and Chapman, page 124. (2) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and Chapman, page 124. (3) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and Chapman, page 522. (4) This information was obtained from the following website: http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-injury-stages/