Wyandot County Skilled Nursing And Rehabilitation

Based on observation, staff interview, and review of the facility policy, the facility failed to ensure accuracy of insulin injection by priming the insulin pen prior to dialing up dose of insulin. This resulted in a significant medication error. This affected one resident (#01) of two reviewed for medications pass. The census was 64.
Findings include:
Review of the physician orders for Resident #01 revealed an order dated 05/16/24 for Novolog flexPen relion subcutaneous solution pen-injector 100 unit per milliter (ml) (Insulin Aspart) to inject as per sliding scale: if 0 to 150 to give 0 units; 151 to 200 to give 2 units; 201 to 250 to give 4 units; 251 to 300 to give 6 units; 301 to 350 to give 8 units; 351 to 400 to give 10 units; 401 to 500 to give 15 units, subcutaneously three times a day. An order for NovoLOG flexpen relion subcutaneous solution pen-injector 100 unit per ml (Insulin Aspart) to Inject 15 unit subcutaneously three times a day.
Observation of Licensed Practical Nurse (LPN) #132 revealed LPN #132 performed glucometer test for Resident #01, which was 158. The nurse then prepared the insulin injection. LPN #132 cleaned the Novolog flexpen with alcohol pad, then opened the needle and placed on flex pen. LPN #132 drew up 17 units of insulin. There was not a prime of two units into the needle. LPN #132 gave the resident the insulin in the left abdomen and held for the appropriate amount of time.
Interview with LPN #132 on 12/04/24 at 8:13 A.M. verified the flexpen was not primed prior to dialing up the 17 units.
Review of the policy dated 2021, Insulin Pen Policy, revealed it is the policy of this facility to use insulin pens in order to improve the accuracy of insulin dosing, provide increased resident comfort, and serve as a teaching aid to prepare residents for self-administration of insulin therapy upon discharge. To prime the the insulin pen, dial up two units by turning the dose selector clockwise, with the needle pointing up, push the plunger, and watch to see at least one drop of insulin appears on the tip of the needle. Then to set the insulin dose, turn the dose selector to ordered dose.

Based on observation, interview, and policy review, the facility failed to maintain the ventilation hood system in a sanitary condition. This had the potential to affect all residents in the facility. The facility census was 64.
Findings include:
Observation on 12/04/24 at 9:43 A.M. revealed the metal louvres in the hood system were covered in a thick coat of dust and debris. The hood system is directly above the flat top grill, burners, steamer, and convection oven.
Interview on 12/04/24 at 09:43 A.M. with Dietary Manager #119 confirmed the vents need to be cleaned.
Review of the undated, General Sanitation of Kitchen, policy revealed the hood system is not part of the daily cleaning schedule.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of medical record for Resident #20 revealed an admission date of 06/01/24. The resident was admitted with diagnoses including weakness, anemia, abnormal of gait and mobility, spinal stenosis, history of venous thrombosis and embolism.
Review of the DNR form dated 04/06/24 revealed the Power of Attorney (POA) signed for the resident's code status to be DNR- Comfort Care (CC).
Review of the face sheet for Resident #20 revealed a code status of DNR-CCA.
Review of the care conferences for 06/12/24 and 09/12/24 revealed the code status was DNR-CCA.
Interview with the DON on 12/05/24 2:00 PM. verified Resident #20's DNR form which was signed by the POA indicated the resident's code status to be DNR-CC, however PCC and care conferences both had the code status as DNR-CCA. The DON verified this was inaccurate information in both areas.
Based on medical record review, interviews, and policy review, the facility failed to ensure advanced directives were accurate. This affected two (Resident #18 and Resident #32) out of three residents reviewed for advanced directives. The census was 64.
Findings include:
1. Review of the medical record for Resident #18 revealed Resident #18 was admitted to the facility on [DATE] with diagnoses including acute respiratory failure with hypoxia, type two diabetes mellitus, and Alzheimer's disease.
Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #18 had a Brief Interview for Mental Status (BIMS) assessment score of 13, indicating intact cognitive function. Resident #18 was dependent for toileting hygiene, lower body dressing, putting on/taking off footwear, and personal hygiene.
Review of Resident #18's facesheet revealed the advance directive was listed as full code.
Review of Resident #18's care plan revealed Resident #18's code status was full code. The date initiated and date created for code status was 10/17/22.
Review of the multi-disciplinary care conference form dated 01/23/24 revealed Resident #18 was listed as Do No Resuscitate-Comfort Care Arrest (DNR-CCA).
Review of the multi-disciplinary care conference form dated 04/15/24 revealed Resident #18 was listed as DNR-CCA.
Review of the multi-disciplinary care conference form dated 07/19/24 revealed Resident #18 was listed as full code.
Review of the multi-disciplinary care conference form dated 10/11/24 revealed Resident #18 was listed as full code.
Review of Resident #18's hard medical chart revealed a DNR order form for Resident #18 signed by a physician on 01/18/24. Resident #18 was listed as DNR-CCA There was also a large green page in the front of the chart that said DNR-CC Arrest.
Interview on 12/04/24 at 10:43 A.M. with Licensed Practical Nurse (LPN) #132 confirmed Resident 18's advance directive was DNR-CCA. LPN #132 revealed Resident #18's advance directive was not updated in the Point Click Care (PCC) system.
Interview on 12/04/24 at 11:05 A.M. with the Director of Nursing (DON) revealed a staff member would look up a resident's advance directive in the hard chart and PCC. The DON confirmed that Resident #18's advance directive was incorrect in PCC and the advance directive should match in the hard chart, PCC, and care plan. The DON revealed Resident #18's code status was DNR-CCA.
Review of the, Advance Directive, policy dated 01/03/18 stated, DNR orders will be honored per established protocols and documented in the resident's care plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of medical record for Resident #20 revealed an admission date of 06/01/24. The resident was admitted with diagnoses including weakness, anemia, spinal stenosis, and history of venous thrombosis and embolism.
The MDS assessment dated [DATE] revealed Resident #20 had intact cognition. The resident was a substantial to maximal assist for mobility.
Review of the care plan revealed goals and interventions in place for anticoagulant therapy. Interventions included, observe and inform resident of signs or symptoms of bleeding tell him to inform staff of any such symptoms: black tarry stools, abnormal bleeding, administer coumadin as ordered, obtain labs and other diagnostic tests as ordered and report results, and notify physician as condition warrants.
A review of the progress notes dated 12/03/24 at 6:45 A.M. revealed a CNA came and got this nurse to check on the resident related to being unconscious on the toilet after being transferred to the toilet on the sit-to-stand. The resident's vital signs were a follows: blood pressure of 84 systolic 58 diastolic and the skin noted to be pale. When asked how he felt, the resident stated, I have had two migraines. When asked how he was feeling now, the resident stated sick. After finishing on the toilet, the resident was assisted back to bed and made comfortable, call light within reach. The note was absent of notification to the physician.
A progress note dated 12/03/24 at 10:46 A.M., revealed at 9:00 A.M. the resident was alert and able to eat this morning 100% and took all his fluids. The nurse had held morning blood pressure medications due to low blood pressure this morning and due to the resident passing out on toilet. The resident was in bed throughout the morning and slept after breakfast. At 10:15 A.M. the blood pressure was 81 systolic 50 diastolic, oxygen (02) saturation was 82 percent (%) on room air (RA), and the resident had a pale color. Applied O2 at two liters saturations up to 84 %. Increased to three liters saturation up to 89% and 90%. He was weak and does agree to go to hospital. Updated his daughter she also agreed to have him sent. The Certified Nurse Practitioner (CNP) aware of spell this morning and now low blood pressure and low O2 saturation. Note order to send to emergency room (ER) for evaluation. 911 called. At 10:40 A.M. squad arrived . At 10:45 A.M., the resident was transported out to ER. Report called to ER.
Review of the text message sent, which was given to the surveyor by the MDS Nurse #155, revealed the CNP was sent on 12/03/24 at 10:22 A.M. which included Resident #20 had another episode of passing out on toilet. The resident had a blood pressure of 85 systolic 58 diastolic and held morning blood pressure. The resident still week and blood pressure was now 81 systolic 50 diastolic shallow respirations O2 saturation 84%. Now up to 89%. The resident was alert and talking. Resident said he will go to hospital if needed. The resident is not getting enough fluids by mouth or food.
Interview with MDS Nurse #155 on 12/05/24 at 11:20 A.M. revealed the CNP was not notified of the change in condition with low blood pressure, unconsciousness, and blood pressure medication being held for Resident #20 at 6:00 A.M. until the 10:22 A.M. which at the time the CNP stated to send out to ER.
Based on medical record review, staff interview, and policy review, the facility failed to ensure the physician was notified when two residents (#07 and #20) experienced a change of condition. This affected two (#07 and #20) of 18 residents reviewed for changes in condition. The facility census was 64.
Findings include:
1. Review of the medical record of Resident #7 revealed an admission date of 03/30/21. Diagnoses include vascular dementia, glaucoma, and repeated falls.
Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #7 was cognitively impaired and required substantial/maximal assistance with transfers. The assessment further indicated one fall with minor injury.
Review of the progress note dated 07/20/24 at 8:44 A.M., documented by Licensed Practical Nurse (LPN) #132, revealed Certified Nurse Assistant (CNA) reported Resident #07 was not responding as per her norm during morning care. LPN #132 documented having assessed Resident #07 and noted audible wheezing. LPN #132 called to Resident #07 and received no response. Resident #07 responded with What when a sternal rub was performed. Resident #07 did not respond to requests of hand grasp or eye opening. Resident #07's pupils were round and sluggish to light. Blood pressure, oxygen saturation temperature, and pulse (vital signs) were all within normal limits. LPN #132 documented having called the responsible party and left a message, but not the physician.
Review of a second note at 12:04 P.M., documented by LPN #132, revealed Resident #07 was awake and responded Ok but could not form coherent sentences. Vital signs were within normal limits and Resident #07 refused lunch. LPN #132 documented the responsible party had not returned a phone call at that time. Still no documentation of physician notification.
Review of a third note at 7:34 P.M. documented by LPN #132 revealed Resident #07 was back to baseline, alert and speaking coherently.
Interview on 12/04/24 at 1:29 P.M. with LPN #132 revealed she was uncertain whether she had notified the doctor about the change of cognition for Resident #07.

Based on review of the medical record, staff interview, review of Centers for Disease Control and Prevention (CDC) guidelines, and policy review, the facility failed to ensure pneumococcal immunizations were offered to eligible residents. This affected one (#16) of five residents reviewed for pneumococcal immunizations. The census was 72.
Findings include
Review of the medical record for Resident #16 revealed an admission date of 12/19/23. Diagnoses included hypothyroidism, hyperlipidemia, osteoarthritis, and hypertensive heart disease with heart failure.
Review of the immunization record for Resident #16 revealed the resident received the pneumococcal polysaccharide vaccine (PPSV) 23 on 06/09/22. The resident had not been offered the updated pneumococcal conjugate vaccine (PCV) 15 or PCV20.
Review of CDC guidelines titled, Pneumococcal Vaccine Timing for Adults, revealed the resident was eligible to receive the updated pneumococcal conjugate vaccine (PCV) 15 or PCV20 one year after receiving the PPSV23.
Interview on 12/19/23 at 2:35 P.M., with Infection Preventionist (IP) #110 revealed Resident #16 was eligible for the PCV15 or PCV20 and the vaccine had not been offered to the resident.
Review of the policy titled, Pneumococcal Vaccine Series, dated 2023, revealed each resident would be offered a pneumococcal immunization unless it is medically contraindicated or the resident had already been immunized.

Based on observation, resident and staff interview, medical record review, and policy review, the facility failed to obtain physician orders for supplemental oxygen use. This affected one (#226) of three residents reviewed for oxygen use. The facility census was 72.
Findings include:
Review of Resident #226's medical record revealed an admission date of 12/14/23. Medical diagnoses included COPD, chronic systolic congestive heart failure, hypertensive heart disease, and a non-displaced intertrochanteric fracture of the right femur status post surgical repair.
Review of Resident #226's interdisciplinary progress notes revealed a note dated 12/17/23 at 11:33 A.M. which indicated Resident #226 was in bed with the head of the bed elevated. Resident #226's vital signs were obtained and noted her oxygen saturation level read 88% (low reading, normal value is greater than 90%). Resident #226 complained of it being hard to breathe and supplemental oxygen was applied per nasal cannula at a flow rate of one liter per minute.
Review of Resident #226's current physician's orders revealed no order for supplemental oxygen.
Observation on 12/18/23 at 11:19 A.M. revealed Resident #226 was seated up in her wheelchair and was awake and alert. Resident #226 was observed to have supplemental oxygen applied at a flow rate of 2 liters per minute delivered per nasal cannula.
An interview on 12/18/23 at 5:02 P.M. with RN UM #126 verified that Resident #226 did not have an order for oxygen as she was a recent admission and required oxygen use over the weekend.
A follow up interview on 12/21/23 at 8:50 A.M. with RN UM #126 verified Resident #226 still did not have an order for supplemental oxygen use and she would add an as needed order.
Review of the oxygen administration policy, dated 2020, revealed oxygen is administered under orders of a physician, except in cases of an emergency. In such cases oxygen is administered and orders for oxygen are obtained as soon as practicable when the situation is under control. The policy identified the resident's care plan shall identify the type of oxygen delivery system, when to administer (continuous or intermittent), equipment setting for prescribed flow rates, monitoring of oxygen orders, and monitoring for complications associated with the use of oxygen.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of medical records, review of facility SARS-CoV-2 (COVID-19) tracking documentation, review of Centers for Disease Control and Prevention (CDC) guidelines, staff interview, and policy review, the facility failed to timely identify and test residents and staff with signs or symptoms of COVID-19 or exposed to COVID-19. Additionally, the facility failed to ensure staff were appropriately wearing personal protective equipment. This had the potential to affect all 72 residents residing in the facility. The facility census was 72.
Findings include
1. Review of the medical record revealed Resident #33 had an admission date of 04/25/23. Diagnoses included hypertension, cerebrovascular disease and hyperlipidemia. Further review of the census data revealed the resident resided on C-Hall in the facility.
Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had impaired cognition. The resident required limited assistance of one staff for bed mobility, transfers, and ambulation and the extensive assistance of one staff for toileting.
Review of a nursing note dated 10/31/23 at 1:30 P.M. revealed the resident was sent to the hospital for critical laboratory values. Review of COVID-19 monitoring documentation revealed the resident tested positive for COVID-19 on 10/31/23 at the hospital. Further review of the COVID-19 monitoring documentation revealed only one other resident (Resident #33's roommate) was tested for COVID-19. No staff on C-hall were tested for COVID-19.
2. Review of the medical record for Resident #3 revealed an admission date of 05/02/23. Diagnoses included diabetes mellitus type tow, hypertension, chronic kidney disease and chronic diastolic heart failure.
Review of the quarterly MDS assessment dated [DATE] revealed the resident had impaired cognition. The resident required substantial or maximal assistance for bed mobility and partial or moderate assistance for transfers and ambulation.
Review of a nursing note dated 11/01/23 at 7:58 A.M. revealed Resident #3's roommate testing positive for COVID-19 in the hospital. Resident #3 was tested and was negative for COVID-19 on day one and day three after exposure. There was no documentation the resident was tested again on day five after exposure.
3. Review of the medical record for Resident #71 revealed an admission date of 10/20/23. Diagnoses included chronic kidney disease, sepsis, cachexia, hypertension, and anemia. Further review of the census data revealed Resident #71 resided on A-Hall and had no roommate.
Review of the admission MDS assessment dated [DATE] revealed the resident had impaired cognition. The resident required partial or moderate assistance for toileting hygiene, bed mobility, transfers, and ambulation.
Review of a progress note dated 11/02/23 at 11:47 A.M. revealed Resident #71 was sent to the emergency room for a low oxygen saturation level. The resident was admitted to the hospital and was positive for COVID-19.
Review of the COVID-19 monitoring documentation revealed no other residents or staff on A-Hall were tested for COVID-19 following Resident #71's positive COVID-19 test.
4. Review of the medical record for Resident #4 revealed an admission date of 08/04/23. Diagnoses included type two diabetes mellitus, hypertension, osteoarthritis and convulsions. Further review of the census data revealed the resident resided on B-Hall.
Review of the quarterly MDS assessment dated [DATE] revealed Resident #4 had intact cognition. The resident was dependent on staff for bed mobility, transfers, and toileting hygiene.
Review of a nursing note dated 12/03/23 at 9:14 A.M. revealed the resident was positive for COVID-19.
Review of the COVID-19 monitoring documentation revealed Resident #4's family member was positive for COVID-19. Further review of the documentation revealed Resident #4's roommate was tested for COVID-19 and was also positive. No other residents or staff on B-Hall were tested for COVID-19.
5. Review of the medical record for Resident #64 revealed an admission date of 10/31/23. Diagnoses included chronic pain syndrome, hypertension, and urinary retention. Further review of census data revealed the resident resided on A-Hall in a private room.
Review of the admission MDS assessment dated [DATE] revealed Resident #64 had intact cognition. The resident was dependent on staff for toileting hygiene, transfers, and ambulation. The resident required substantial or maximal assistance for bed mobility.
Review of a nursing note dated 12/06/23 at 3:23 P.M. revealed Resident #64 tested positive for COVID-19. Review of the COVID-19 monitoring documentation revealed no other residents or staff were tested.
6. Review of the medical record for Resident #66 revealed an admission date of 11/11/23. Diagnoses included acute respiratory failure, rhabdomyolysis, and hypothyroidism. Further review of the census data revealed the resident resided on A-Hall in a private room.
Review of the admission MDS assessment dated [DATE] revealed Resident #66 had impaired cognition. The resident required substantial or maximal assistance with toileting hygiene and bed mobility. The resident required partial moderate assistance with transfers and ambulation.
Review of a nursing note dated 12/11/23 at 7:38 A.M. revealed the resident had temperatures of 99.8 degrees Fahrenheit (F), 102.4 degrees F, and then 98.9 degrees F. Resident #66 also complained of a scratchy throat. The resident was administered the pain medication or fever reducing medication Tylenol. There was no documentation the physician was notified and there was no order for COVID-19 testing.
Review of a nursing note dated 12/12/23 at 10:54 A.M. revealed Resident #66 was positive for COVID-19. The physician was aware. No other residents or staff on A-hall were tested for COVID-19.
Review of the COVID-19 monitoring documentation revealed three employees working on B-Hall later tested positive for COVID-19 at local providers outside the facility. State Tested Nurse Aide (STNA) #191 developed signs and symptoms of COVID-19 on 12/04/23 and tested positive for COVID-19 on 12/05/23. STNA #191 last worked on 12/03/23 in B-Hall. STNA #181 developed signs and symptoms of COVID-19 on 12/05/23 and tested positive for COVID-19 on 12/05/23. STNA #181 last worked on 12/03/23 in B-Hall. STNA #280 developed signs and symptoms of COVID-19 on 12/07/23 and tested positive on 12/10/23. STNA #280 worked on B-Hall on 12/06/23 and C-Hall on 12/07/23 and 12/08/23. Licensed Practical Nurse (LPN) #107 developed signs and symptoms of COVID-19 on 12/01/23 and tested positive for COVID-19 on 12/04/23. LPN #107 worked on the A-Hall on 12/01/23 and C-hall on 12/03/23. Continued review of the COVID-19 monitoring documentation revealed no other residents or staff were tested for COVID-19.
Interviews on 12/19/23 beginning at 1:33 P.M. and on 12/20/23 beginning at 7:19 A.M., with Infection Preventionist (IP) #110 stated no resident testing was completed for residents exposed to staff who tested positive for COVID-19. IP #110 also revealed no staff testing was completed for staff exposed to other staff and residents positive for COVID-19. IP #110 revealed the staff she interviewed indicated they had spent less than 15 minutes with each resident at one time and therefore were not close contacts and testing was not required. IP #110 later revealed she was unaware a close contact was considered direct contact of more than 15 minutes during a 24-hour period and verified close contacts were not tested. IP #110 verified Resident #3 had exposure to his roommate who tested positive for COVID-19 and was not tested on day five after exposure per CDC guidelines. IP #100 revealed staff were not reporting when they had signs and symptoms of COVID-19. IP #110 verified STNA #181, STNA #191, LPN #108, and STNA #280 tested positive for COVID-19 had worked on all three halls in the facility.
Review of the policy titled, COVID-19 Testing, revealed employees would test for COVID-19, depending on current CMS (Centers for Medicare and Medicaid) guidelines. If an employee was symptomatic or exposed, they were responsible for testing prior to starting their next scheduled shift. The employee was responsible for locating the infection control manager or nurse to obtain a COVID-19 test, upon entering the facility. Residents may be tested for COVID-19, according to current CMS guidelines with a doctor's order. Residents would not be routinely tested unless symptomatic, leave regularly, or a positive COVID-19 staff, or resident was suspected/confirmed. A suspected or confirmed COVID-19 staff or resident may require all or specific staff and residents to test per CMS and CDC guidance.
Review of the CDC's Infection Control Guidance, updated 05/08/23, revealed anyone with even mild symptoms of COVID-19, regardless of vaccination status, should receive a viral test for SARS-CoV-2 as soon as possible. Asymptomatic patients with close contact with someone with SARS-CoV-2 should have a series of three viral tests for SARS-CoV-2 infections. Testing is recommended immediately and if negative again 48 hours after first negative test and if negative, again 48 hours after the second negative test. This would typically be at day one (1), day three (3) and day five (5).
Review of the CDC's guidance for Potential Exposure at Work, updated 09/23/22, revealed a close contact was an exposure of 15 minutes or more was considered prolonged. This could refer to a single 15-minute exposure to one infected individual or several briefer exposures to one or more infected individuals adding up to at least 15 minutes during a 24-hour period.
7. An observation and interview on 12/18/23 at 9:54 A.M. revealed signage outside of Resident #66's room to indicate he was on droplet and contact precautions. Unit Manager Registered Nurse (UM RN) #126 stated Resident #66 had contact and droplet isolation precaution in place related to active COVID-19 infection.
An observation on 12/18/23 at 11:22 A.M. revealed STNA #158 applied personal protective equipment (PPE) which included a gown, gloves, and eye protection. STNA #158 placed an N-95 respirator mask overtop of her surgical mask and entered Resident #66's room to deliver his lunch tray. Upon exiting the room, STNA #158 was observed to have taken off her N-95 respirator mask in the room. STNA #158 used the hand sanitizer outside of the room on the PPE cart and was not observed to change her surgical mask.
An interview on 12/18/23 at 11:31 A.M. with STNA #158 verified she did not change her surgical mask upon exiting Resident #66's isolation room. STNA #158 stated she did not know she was supposed to and stated she always wore an N-95 respirator mask overtop of a surgical mask when caring for COVID-19 patients. STNA #158 recalled having training on applying and PPE, but could not recall the specifics. She further stated she rarely worked on the hallway on which residents with COVID-19 usually reside.
8. Observation of STNA #115 on 12/19/23 at 9:10 A.M. revealed the staff was observed to put on gown, gloves, an N-95 face mask, and entered Resident #7's bedroom. Continued observation revealed the staff member exited the room with the PPE still on and carrying the finished breakfast meal tray. Resident #7's room was recessed approximately five feet from the main hallway and the meal tray cart was in the main hallway next to the recessed part of the hall. STNA #115 walked to the meal tray cart which was parked in the main hallway and placed the resident's meal tray on the cart with the other resident's meal trays. STNA #115 then returned to the resident's room, removed and discarded her gown and gloves, performed hand hygiene with alcohol-based hand rub, and exited the room wearing the N-95 mask. STNA #115 walked across the hall and down to the communal shower room and washed her hands with soap and water. STNA #115 then walked to the next room on the hallway, the soiled utility room, and discarded her N-95 face mask and put on a surgical mask.
Interview with STNA #115 on 12/19/23 at 9:13 A.M. confirmed she exited the resident's wearing her PPE and placed his breakfast tray on the meal tray cart that was in the hallway outside his room. STNA#115 confirmed she received training on how to put on and remove PPE at the facility, but did not remember when that occurred.
An interview on 12/21/23 at 2:48 P.M. with IP #110 verified staff members should not wear N95 face masks overtop of surgical masks, and masks should be changed when leaving isolation rooms. IP #110 additionally verified all staff, in all departments, should have on a surgical mask in resident care areas.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and policy review, the facility failed to ensure a valid level one Pre-admission Screen and Resident Review (PASRR) was completed timely under a hospital exemption. This affected one (#66) of one resident reviewed for PASRR. The facility census was 72.
Findings include:
Review of Resident #66's medical record revealed the resident was admitted to the facility on [DATE] from a hospital. Diagnoses included acute respiratory failure with hypoxia, weakness, hypothyroidism, and hyperlipidemia.
Review of Resident #66's PASRR records revealed a hospital exemption from preadmission screening notification dated 11/11/23.
Interview on 12/19/23 at 12:26 P.M. with the Administrator confirmed the hospital exemption was the only PASRR available for Resident #66.
Record review on 12/20/23 showed a PASRR available for Resident #66. The PASRR was dated on 12/19/23 and showed submitter information was Social Services Director #108.
Interview on 12/21/23 at 11:06 A.M. with Social Services Director #108 verified that Resident #66 PASRR was not completed within 30 days of his hospital exemption.
Review of the facility policy titled, Resident Assessment - Coordination with PASRR Program, dated 2023, revealed exemptions to the pre-admission screening program, dependent on State requirements, include those individuals who are readmitted directly from a hospital, and are admitted directly from a hospital, requires nursing facility services for the condition for which the individual received care in the hospital, and has been certified by the attending physician before admission that the individual is likely to require less than 30 days of nursing facility services. If a resident was not screened due to an exemption above and the resident remains in the facility longer than 30 days the facility must screen the individual using the State's Level I screening process and refer any resident who has or may have MD, ID or a related condition to the appropriate State-designated authority for Level II PASRR evaluation and determination.

Based on medical resident interview, staff interview, and policy review, the facility failed to ensure an accurate and thorough baseline care plan was completed. This affected one (#222) of one resident reviewed for dialysis. The facility census was 72.
Findings include:
Review of the medical record for Resident #222 revealed an admission date of 12/08/23. Medical diagnoses included stage five chronic kidney disease, anemia in chronic kidney disease, and dependence on renal dialysis.
Review of the Minimum Data Set (MDS) admission assessment, dated 12/12/23, revealed Resident #222 had moderately impaired cognition. Resident #222 was assessed to receive oxygen therapy on a continuous basis and required dialysis.
Review of the baseline care plan, dated 12/08/23, revealed Resident #222 required set up assistance with eating, and one person physical assistance with hygiene, toileting, dressing, and bathing. The section regarding medical conditions, including the question if Resident #222 required dialysis, was left blank. The baseline care plan stated to refer to the current physician's orders listed on the medication administration record (MAR) and treatment administration record (TAR). The baseline care plan summary revealed a brief narrative indicating Resident #222 required dialysis three times weekly. The baseline care plan narrative indicated Resident #222 had a fistula (vascular access through which hemodialysis is provided) to the right lower extremity (RLE). The diet order section on the baseline care plan was left blank, as were the sections asking for any dietary preferences or dietary risks.
An interview on 12/21/23 at 8:52 A.M. with Registered Nurse Unit Manager (RN UM) #126 verified the baseline care plan listed Resident #222's dialysis vascular access in the wrong extremity and did not have the information from physician orders including Resident #222's dietary order.
Review of the baseline care plan policy, dated 2023, revealed the facility will develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meets professional standards of quality care. The baseline care plan will include the minimum healthcare information necessary to properly care for a resident including, but not limited to dietary orders. Any special needs, such as for dialysis, shall be initiated and included in the baseline care plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, staff interview, and policy review, the facility failed to ensure the residents' care plans were updated timely. This affected two (#41 and #42) of 16 residents reviewed for care plans. The census was 72.
Findings include
1. Review of the medical record revealed Resident #41 had an admission date of 10/27/23. Diagnoses included atrial fibrillation, hypertension, venous insufficiency, hypothyroidism, chronic kidney disease stage three, hyperlipidemia, spinal stenosis, and heart failure.
Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #41 had intact cognition. The resident was frequently incontinent of urine and was dependent for toileting, hygiene, and transfers.
Review of a handwritten order dated 12/08/23 located in Resident #41's hard chart revealed to maintain urinary catheter until follow up in two to three weeks. Review of the physician orders in the electronic medical record revealed no orders regarding the urinary catheter.
Review of the resident's plan of care revealed the care plan had not been updated to include the use of the indwelling urinary catheter.
Interview on 12/19/23 at 1:04 P.M., the Director of Nursing (DON) verified Resident #41's plan of care had not been updated to include the use of an indwelling urinary catheter. The DON revealed the unit manager was responsible for ensuring the care plans were updated.
2. Review of the medical record for Resident #42 revealed an admission date of 10/19/21. Medical diagnoses included adult failure to thrive, depression, dementia, and senile degeneration of the brain. Resident #42 was admitted to hospice services at the facility on 11/27/23 with a primary diagnosis of adult failure to thrive.
Review of Resident #42's MDS assessment, dated 12/01/23, revealed Resident #42 to have moderately impaired cognition. Resident #42 was noted to have shortness of breath while lying flat. Resident #42 was coded as having received oxygen therapy while a resident.
Review of Resident #42's physician order, dated 11/26/23, revealed oxygen was ordered at two to five liters per minute as needed (PRN) to keep oxygen saturation levels greater than 90 percent (%).
Review of Resident #42's care plan revealed no indication or notation that he received supplemental oxygen while a resident of the facility.
An observation on 12/18/23 at 3:58 P.M. revealed Resident #42 seated up in recliner in his room and had supplemental oxygen applied per nasal cannula.
An interview on 12/20/23 at 8:59 A.M. with Registered Nurse Unit Manager (RN UM) #126 verified Resident #42's care plan contained no indication that supplemental oxygen was part of his care needs.
Review of the policy titled, Comprehensive Care Plans, dated 2023, revealed no guidelines for revising the plan of care when the resident had a change of condition.
Review of the oxygen administration policy, dated 2020, revealed oxygen is administered under orders of a physician, except in cases of an emergency. The policy identified the resident's care plan shall identify the type of oxygen delivery system, when to administer (continuous or intermittent), equipment setting for prescribed flow rates, monitoring of oxygen orders, and monitoring for complications associated with the use of oxygen.

Based on observation, staff interview, medical record review, and policy review, the facility failed to accurately assess a pressure ulcer as required. This affected one (#44) of two residents reviewed for wounds. The facility census was 72.
Findings include:
Review of the medical record for Resident #44 revealed an admission date of 11/13/23. Medical diagnoses included cerebral infarction with hemiplegia (paralysis) affecting the left non-dominant side, anemia, muscle weakness, and difficulty in walking.
Review of Resident #44's Minimum Data Set (MDS) assessment, dated 11/19/23, revealed the resident was assessed as cognitively intact. Resident #44 was identified to be at risk of developing pressure ulcers and injuries. Resident #44 was identified to have one stage two pressure ulcer (partial thickness skin loss with exposed dermis), and one stage three pressure ulcer (full thickness skin loss), both present upon admission to the facility.
Review of Resident #44's Braden scale for predicting pressure sore risk assessment, dated 11/13/23, revealed Resident #44 scored a nine, which indicated the resident was at very high risk for developing additional pressure ulcers.
Review of Resident #44's care plan, initiated 11/08/23, identified pressure ulcer development related to a history of ulcers, immobility, and a history of a cerebrovascular accident (stroke). Interventions included to administer treatments as ordered and monitor for effectiveness, treat pain as ordered, and provide weekly treatment documentation to include measurements of each area of skin breakdown's length, width, depth, type of tissue and exudate (drainage).
Review of Resident #44's physician's orders revealed orders dated 11/29/23 to apply calmoseptine cream to coccyx (sacral) wound and cover with a sacrum mepilex dressing twice daily and as needed, for Resident #44 to be up in her wheelchair for meals only, and to change position every two hours. Resident #44 was ordered to have a consultation with the facility wound nurse to monitor the coccyx wound. On 12/19/23, the order for the sacral wound was changed to a wet-to-dry dressing with normal saline to be changed once daily on night shift.
Review of Resident #44's sacral wound documentation revealed the facility staff classified the wound as moisture associated skin damage (MASD). The facility included pictures with their wound monitoring with monitoring occurring on 11/13/23, 11/29/23, and 12/18/23 with no measurements noted.
An observation and interview on 12/20/23 at 6:07 A.M. of Registered Nurse (RN) #112 revealed RN #112 provided wound care for Resident #44, while State Tested Nurse Aide #117 assisted with positioning. The observation revealed an open area to the bony aspect of Resident #44's sacrum approximately quarter-sized in length and width. RN #112 stated the wound was looking much improved as a few days prior the wound had slough (dead tissue) present in the wound. RN #112 verified the skin surrounding the open sacral wound did not blanche and verified this wound was a pressure ulcer with depth which required a wet-to-dry dressing. RN #112 completed the wet-to-dry dressing with normal saline as ordered, and RN #112 and STNA #117 assisted in repositioning Resident #44 for comfort.
A follow up interview on 12/20/23 at 6:25 A.M. with RN #112 revealed she was the facility wound nurse, but she had been filling in on the night shift performing other duties. RN #112 again verified Resident #44's sacral wound was a pressure ulcer, and was unsure if she was admitted to the facility with the pressure wound or if it developed in-house as Resident #44 had just transferred from a different unit.
An interview on 12/20/23 at 6:42 A.M. with the Director of Nursing (DON) verified RN #112 was the facility's wound nurse, but had been pulled to perform other duties on the night shift temporarily. The DON verified Resident #44 had a sacral pressure ulcer. During the interview, the DON reviewed the documented wound photos of Resident #44's sacral wound taken on 11/13/23, 11/29/23, and 12/18/23. The DON stated photos are what the facility used to measure wounds. The DON verified none of the three photos contained measurements which reflected depth to the wound, but depth was visible to the wound in the photographs. The DON additionally verified that Resident #44's sacral wound should not have been classified as MASD as that was incorrect. The DON verified there was 14 days between wound monitoring from 11/13/23 to 11/29/23 and 19 days between wound monitoring from 11/29/23 to 12/18/23. The DON stated the wound should have been monitored and measured on a weekly basis.
Review of the pressure injury prevention and management policy, revised May 2021, revealed licensed nurses will conduct a full body skin assessment on all residents upon admission/re-admission, weekly, and after any newly identified pressure injuries. Findings will be documented in the medical record. Assessments of pressure injuries will be performed by a licensed nurse and documented in the electronic medical record. The staging of pressure injuries will be clearly identified to ensure correct coding on the MDS. The RN Unit Manager, or designee, will review all relevant documentation regarding skin assessments, pressure injury risks, progression towards healing, and compliance at least weekly, and document a summary of findings in the medical record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, medical record review, review of hospital documentation, review of fall investigations, and policy review, the facility failed to ensure fall interventions were care planned and appropriately implemented to prevent falls. This resulted in actual harm for Resident #40 on 11/10/23 when she sustained a fall, was sent to the hospital, and was found to have a right non-displaced pubic superior fracture and left minimally displaced inferior pubic fracture (pelvic fractures). The fracture was deemed non-operable and Resident #40 was returned to the facility on [DATE]. This affected one (#40) of one resident reviewed for falls. The facility census was 72.
Findings include:
Review of the medical record for Resident #40 revealed an admission date of 09/07/21. Medical diagnoses included chronic pain, osteoarthritis, insomnia, and repeated falls.
Review of Resident #40's significant change in status Minimum Data Set (MDS) assessment, dated 11/22/23, revealed a Brief Interview for Mental Status (BIMS) score of 03, indicating the resident was assessed with severely impaired cognition. Resident #40 was not noted to have any behaviors or wandering. Resident #40 was noted to be in moderate pain and sustained one fall with no injury and one fall with major injury since the prior assessment.
Review of Resident #40's plan of care, initiated on 09/08/21 and revised on 11/28/23, revealed Resident #40 to be at risk for falls due to confusion, deconditioning, and not aware of safety needs. An intervention dated 09/12/22 revealed to ensure Resident #40 was wearing appropriate non-skid footwear when ambulating or mobilizing in wheelchair. Additional fall interventions were added to Resident #40's care plan on 11/16/23 following a fall with major injury on 11/10/23. The care plan indicated Resident #40 was sent to the emergency room for evaluation and treatment. There were no new interventions placed or added to the care plan upon the resident's return to the facility on [DATE]. On 11/15/23, following a fall dated 11/14/23, an approach was added to Resident #40's care plan for frequent checks and a bed alarm. On 11/28/23, following a fall dated 11/27/23, an approach was added to Resident #40's care plan to not leave Resident #40 unattended while toileting.
Review of the fall investigation report dated 11/10/23 at 6:29 A.M. revealed Resident #40 was observed on the floor next to her bed with her eyes open. Resident #40 indicated she was attempting to go to the bathroom and must have slipped or lost her balance. When staff assisted Resident #40 up off the floor, Resident #40 cried out in pain, grabbed her left leg, and staff returned her to a seated position. The provider was updated and gave an order to send Resident #40 to the hospital for evaluation and treatment. The investigation report identified predisposing situation factors to include Resident #40 ambulating without assistance and wearing improper footwear. There was no indication Resident #40 was wearing appropriate non-skid footwear or that staff had assisted with providing appropriate non-skid footwear. The fall investigation report identified an intervention for Resident #40 to use slipper socks at all times when transferring.
Review of the hospital after visit summary dated 11/10/23 revealed a computed tomography (CT) scan was performed at the hospital and revealed a right non-displaced pubic superior fracture and left minimally displaced inferior pubic fracture. The fall was deemed non-operable, and Resident #40 was returned to the facility on [DATE].
Review of Resident #40's physician's orders revealed an order dated 11/11/23 to check the chair and bed alarm to be sure it was on and working twice daily. Nurses were to document the alarm was on and in good working order at 8:00 A.M. and 8:00 P.M. beginning on 11/11/23.
Review of a fall investigation report dated 11/14/23 at 6:30 A.M. revealed Resident #40 was observed lying on the floor by day shift staff members entering the unit upon arrival for their shift. Resident #40 was confused and unaware of what had happened. Staff statements in the fall investigation report identified Resident #40's bed was in the low position, the call light was on the bed, and a bed alarm was on the bed but not sounding. Staff statements further revealed there were concerns about staff members turning the alarm to the off position. Resident #40 was found to be in continued pain related to the prior left pelvic injury but had no new injuries. The fall investigation report listed frequent checks and a pressure alarm as new interventions.
Review of a fall investigation report dated 11/27/23 at 5:03 P.M. revealed Resident #40 was observed lying on the floor on her back in front of the toilet. The fall was witnessed by a nurse aide when the nurse aide left Resident #40 behind a privacy curtain while using the toilet. Resident #40 sustained a skin tear to her left elbow during the fall. The fall investigation report listed staff to stay beside the resident during toileting for safety as a new intervention.
Observation of Resident #40 on 12/20/23 at 7:41 A.M. revealed her seated in a manual wheelchair being propelled down the hallway by a State Tested Nurse Aide (STNA) #121. On Resident #40's wheelchair was a cordless pressure alarm. Resident #40 was wearing non-skid shoes.
An interview on 12/20/23 at 7:48 A.M. with STNA #121 verified she just toileted Resident #40 and stayed at her side for safety. STNA #121 was familiar with Resident #40's fall interventions. When asked how often Resident #40 was checked and toileted, STNA #121 stated every two to three hours or as needed. STNA #121 verified Resident #40 was confused, rarely remembered to push her own call light, and would likely not think to apply her own footwear. STNA #121 stated changes are communicated verbally by the nurses when needed.
An interview on 12/20/23 at 09:40 A.M. with STNA #125 identified Resident #40 to be at risk for falls and had fall interventions which included a chair and bed alarm, a low bed, and non-skid footwear. When asked how often Resident #40 was checked and toileted, STNA #125 stated every few hours. STNA #125 stated nurses communicated changes, and they may also be in the electronic health record (EHR).
An interview on 12/20/23 at 11:07 A.M. with Licensed Practical Nurse (LPN) #119 identified Resident #40 to be cognitively impaired. LPN #119 stated Resident #40's alarm was cordless and sounded at the nurse's station. LPN #119 verified the control to turn the alarm on and off was at the nurse's station and intermittently there had been problems with staff turning off Resident #40's alarm. LPN #119 stated nurses communicate changes to things like interventions through verbal report and was not sure the STNAs had access to the care plan, but they did have access to the [NAME] within the HER which identified specifics about the resident's care. LPN #119 verified fall interventions of a pressure alarm to bed and chair, non-skid footwear, frequent checks, and not to leave the resident alone while toileting were not items included in Resident #40's [NAME].
An interview on 12/21/23 at 9:25 A.M. with Registered Nurse Unit Manager (RN UM) #126 discussed Resident #40's prior falls and subsequent interventions. RN UM #126 identified Resident #40 was severely cognitively impaired and verified she had a care planned intervention since 09/12/22 for non-skid footwear. RN UM #126 stated Resident #40 did not have the cognition to think to call for help in advance or apply her own shoes, and she should have had nonskid socks in place at night. RN UM #126 verified Resident #40 had the bed alarm ordered following the fall on 11/10/23, but it was not care planned or listed as an intervention until after the fall on 11/14/23. RN UM #126 was unable to identify or quantify how frequently Resident #40 should be checked or how that information was communicated to staff. RN UM #126 further verified that due to the frequent falls Resident #40 sustained, she should not have been left unattended in the bathroom, even for a moment. RN UM #126 was unsure if staff utilized the [NAME] function in the HER, but it should be updated and available as a reference. RN UM #126 verified no fall interventions were listed on the [NAME].
Review of the fall prevention program policy, revised 03/06/20, revealed each resident will receive care and services in accordance with the level of risk to minimize the likelihood of falls. Each resident should be provided with interventions that address unique risk factors which include medications, psychological, cognitive status, or a recent change in functional status. The policy further identified that interventions will be monitored for effectiveness and the plan of care will be revised as needed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, staff interview, and policy review, the facility failed to monitor and ensure catheter care was provided for a resident with an indwelling urinary catheter. This affected one (#41) of one resident review for an indwelling urinary catheter. The census was 72.
Findings include:
Review of the medical record revealed Resident #41 had an admission date of 10/27/23. Diagnoses included atrial fibrillation, hypertension, venous insufficiency, hypothyroidism, chronic kidney disease stage three, hyperlipidemia, spinal stenosis, and heart failure.
Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognition. The resident was frequently incontinent of urine. The resident was dependent for toileting hygiene and was dependent for transfers.
Review of a urology progress note dated 12/08/23 revealed the resident had urinary retention, hematuria, and a bladder stone. Resident #41 had a cystoscopy (a procedure to look inside the bladder) performed. The urologist ordered a urinary (Foley) catheter to remain in place until return for a follow up visit.
Review of a handwritten order dated 12/08/23 located in Resident #41's hard chart revealed to maintain urinary catheter until follow up. Review of the physician orders in the electronic medical record revealed no orders regarding the urinary catheter.
Observation on 12/18/23 at 1:18 P.M. revealed Resident #41 had a urinary catheter with a leg drainage bag.
Review of the treatment administration record (TAR) dated 12/08/23 through 12/18/23 revealed no documentation the Resident #41's catheter was monitored. Further review of the TAR revealed no documentation the resident received urinary catheter care each shift.
Interview on 12/19/23 at 1:04 P.M., the Director of Nursing (DON) revealed the order for the urinary catheter had not been entered into the electronic medical record. The DON revealed there was no documentation the nurses had monitored the catheter daily, and also no documentation Resident #41 was provided with catheter care.
Interview on 12/19/23 at 3:53 P.M., Registered Nurse (RN) #187 revealed the catheter was monitored and the nursing assistants were providing catheter care. RN #187 verified there was no documentation catheter care had been completed for the resident.
Review of the policy titled, Indwelling Catheter Use and Removal, dated 2023, revealed the facility would provide appropriate care for the catheter in accordance with current professional standards of practice and resident care policies and procedures including response of the resident during the use of the catheter and ongoing monitoring for changes in condition related to potential catheter-associated urinary tract infections, recognizing, report and addressing such changes.
Review of the policy titled, Catheter Care, dated 2023, revealed catheter care would be performed every shift and as needed by nursing personnel.

Based on observation, resident and staff interview, and medical record review, the facility failed to ensure resident who received dialysis were provided a diet as order and fluid restrictions were monitored as ordered. This affected one (#222) of one resident reviewed for dialysis. The facility census was 72.
Findings include:
Review of the medical record for Resident #222 revealed an admission date of 12/08/23. Medical diagnoses included stage five chronic kidney disease, anemia in chronic kidney disease, and dependence on renal dialysis.
Review of the Minimum Data Set (MDS) admission assessment, dated 12/12/23, revealed Resident #222 had moderately impaired cognition. Resident #222 was also identified to require dialysis.
Review of Resident #222's physician's orders revealed Resident #222 had an order dated 12/13/23 for a 40 ounce (1200 milliliters) fluid restriction daily. Additional review of the physician orders revealed Resident #222 had active orders dated 12/08/23 for a regular diet with regular texture and thin liquids, and on 12/11/23, both a no added salt (NAS) diet and a renal diet were ordered.
An observation on 12/19/23 at 8:10 A.M. with Resident #222 revealed he had just finished breakfast, and had an eight ounce (oz) cup of coffee (equivalent to 240 milliliters (ml) and a six oz cup of orange juice (180 ml) with his meal.
An interview conducted on 12/19/23 at 2:36 P.M. with Registered Dietician (RD) #301 identified she assessed Resident #222's nutritional needs on 12/13/23 on her first visit to the facility since Resident #222's admission. RD #301 identified Resident #222's diet order to be regular NAS, limit milk to four oz daily, and avoid high potassium and high sodium foods. RD #301 identified that was the facility's interpretation of a renal diet. Additionally, RD #301 recommended and the physician ordered a 40 oz (equivalent to 1200 ml) fluid restriction daily. RD #301 stated the total fluid restriction per day was the cumulative amount of fluid to be provided by both dietary and nursing. RD #301 believed the staff was following the ordered diet and fluid restriction.
An observation on 12/20/23 at 8:28 A.M. revealed Resident #222 was not in his room. His breakfast tray sat untouched on the overbed table in the room. There was a six oz cup of orange juice and an eight oz cup of coffee on the meal tray.
An interview on 12/20/23 at 10:13 A.M. with Licensed Practical Nurse (LPN) #186 revealed Resident #222 was out to dialysis treatments. LPN #186 stated the resident went out to dialysis very early in the morning, and did not receive breakfast until he returned around 11:00 A.M. LPN #186 stated she thought Resident #222 was on a fluid restriction, but there was no way to monitor his fluid intake. LPN #186 stated nurses initial the medication administration record (MAR) to indicate the resident was on a fluid restriction, but it had no numerical values of intakes. LPN #186 stated the STNAs record fluid intake but only specific to what the resident consumed during the meal. LPN #186 verified there was no way to total or reference the amount of fluid intake cumulatively provided by dietary and nursing.
A follow up observation on 12/20/23 at 11:00 A.M. revealed the breakfast tray in Resident #222's room remained untouched. The tray card was visible on the tray and stated Resident #222 was on a regular American Diabetics Association (ADA) #2 (diabetic) diet.
An interview on 12/20/23 at 1:13 P.M. with Dietary Manager (DM) #167 revealed she had been the dietary manager for approximately four years. The nurses are responsible for completing a diet slip and providing the slip to the kitchen. DM #167 verified she had Resident #222 listed as a Regular ADA #2 (diabetic) diet. DM #167 stated her process was to take the diet slips completed by the nursing staff and input it into her tray card program. DM #167 stated if there was an order for a fluid restriction, it would be added to and listed on the tray card. DM #167 verified she had no knowledge of Resident #222 having an ordered fluid restriction or being a hemodialysis patient. DM #167 verified she was the one responsible to complete a breakdown of the fluid restriction to indicate how much fluid will be administered per dietary, and how much fluid was left to be administered per nursing. DM #167 stated the dietician provides a list of what changes and recommendations that she made but she had not gotten through the stack of last week's changes. DM #167 verified that dialysis residents should not receive high potassium foods such as tomato juice or orange juice. DM #167 reviewed Resident #222's tray cards and verified that at each meal the kitchen had been sending Resident #22 six ounces of orange juice and a coffee cup for the staff to fill with eight ounces of coffee. DM #167 verified Resident #222 should not have received the orange juice. DM #167 additionally confirmed the kitchen provided 420 ml per meal for a total of 1260 ml per day, which was above Resident #222's ordered daily fluid restriction.
An observation and interview on 12/21/23 at 7:37 A.M. with Resident #222 revealed him eating breakfast. With his breakfast he was served an eight oz cup of coffee and a six oz cup of orange juice. His plate was clean and his liquids were almost gone. Resident #222 stated he enjoyed his breakfast and he got coffee and orange juice with each meal.
An interview on 12/21/23 at 8:10 A.M. with LPN #131 revealed dietary sometimes provided a sheet to indicate the breakdown of fluid restriction for dialysis residents, but they had not received one since Resident #222 was admitted to the facility. LPN #131 stated the nurse aides document fluids the resident drank during meals, but the nurses really do not look at those amounts or total them up to compare to the ordered fluid restriction. LPN #131 stated there really was no monitoring for accurate fluid intake for Resident #222's ordered fluid restriction.
An interview on 12/21/23 at 8:52 A.M. with Unit Manager (RN UM) #126 verified the physician ordered diet and fluid restriction should be consistent in both Resident #222's chart and the kitchen's system for tray cards. RN UM #126 verified there was no fluid restriction breakdown provided by dietary, nor were nurses recording and monitoring Resident #222's ordered fluid restriction. RN UM #126 additionally verified that Resident #222 should never have received high potassium drinks such as orange juice on a routine basis.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff and resident interview, and review of the facility policies, the facility failed to complete a thorough fall investigation for Resident #6 to prevent further accidents. This affected one (Resident #6) of two residents reviewed for falls. The facility census was 64.
Findings include:
Review of medical record for Resident #6 revealed the resident was admitted to the facility on [DATE]. Diagnoses included hydronephrosis, diabetes mellitus type two, malignant neoplasm of bone and articular cartilage, major depressive disorder, and acute kidney failure.
Review of the admission fall assessment completed 06/07/21, and subsequent fall assessments completed on 06/27/21, 08/16/21, and 09/07/21 revealed the resident was at moderate risk for falls.
Review of the admission Minimum Data Set (MDS) assessment, dated 06/07/21, revealed the resident was cognitively intact. She required extensive assistance with two- person assistance for bed mobility, transfers, toileting, and personal hygiene. She was extensive assistance with one person for dressing. She had falls prior to admission and within the last two to six months prior to admission with no fractures related to the falls.
Review of the care plan, dated 06/01/21, revealed the resident was a risk for falls related to deconditioning, history of falls at home, and weakness. On 6/27/21, she fell at bedside. There was no brakes used on the rollator and it moved away when attempting to sitting down. On 8/16/21, she fell from her recliner by sliding out of her chair while putting on her pants. Interventions included on 6/27/21 for the resident to call staff for any needs; she was re-educated on the importance of using her wheelchair and to always lock brakes and use all safety features to avoid injury. On 8/16/21, physical therapy was to complete and evaluation post fall; re-educated on the importance to call staff for all assistance needed to prevent future falls; anticipate and meet the resident's needs; be sure the resident's call light was within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance, ensure the resident was wearing appropriate footwear when ambulating or mobilizing in the wheelchair and follow facility fall protocol.
Review of the nursing notes revealed on 08/16/21 revealed the nurse was called to the resident's room. She was lying on her right side with legs bent at the knees and her right arm was under the resident, and her left arm was bent at the elbow and under her head. Resident stated she was getting her pants on and slid on her blanket. Resident reported she hit her head really hard and complained of head pain. Vital were taken, resident's son was notified, and a message was left. Transportation was called to have resident evaluated at emergency room. On 08/17/21 a new order for physical therapy to evaluate and treat. Physical therapy would see resident 12 times in four weeks. On 08/18/21, the resident was sitting up in her wheelchair alert and oriented times four. Bruising was periorbital bilateral eyes and forehead. The resident denies headache or any pain. Equal hand grasps and denies any dizziness. On 08/18/21, the resident placed ice on her forehead due to some swelling mainly over right eye. She denied pain. Resident had been up and about per her usual routine. On 08/19/21, the resident was resting quietly in her recliner. Facial bruising continues. She denies pain to the area.
Review of the fall investigation, dated 08/16/21, revealed an incident report was completed with a fall risk assessment and pain assessment. Interventions were not addressed in the fall investigation to know if the current care plan interventions were in place at the time of the resident's fall. Furthermore, no witness statements were completed, and neuro checks were missing.
Review of the hospital discharge, dated 08/16/21, revealed the resident receive a contusion of the forehead related to a fall and head injury.
Interview on observation on 09/07/21 at 12:30 P.M. with Resident #6 revealed she was sitting in her chair and slipped out of her chair and her head hit the bed. She went to the emergency room to be treated. Her face still had remnants of facial bruising under her eyes and around her jaw bones. She denied any pain.
Interview on 09/09/21 at 1:45 P.M. with the Director of Nursing verified the Incident Audit Report did not address current interventions and new interventions put into place after the fall on 08/16/21.
Interview on 09/09/21 at 2:21 P.M. with Registered Nurse (RN) #123 verified the fall investigation on 08/16/21 was not a complete and thorough fall investigation. She further verified the fall investigation did not discuss the current fall interventions or address potential new interventions to prevent further falls. RN #123 revealed when a fall occurs, the resident would be assessed, complete a post-fall assessment, notify the physician and family, review the resident's care plan and update as indicated, document all assessment and actions and obtain witness statements. RN #123 verified the neuro checks where not completed after Resident #6 returned from the hospital on [DATE], and no witness statements were obtained regarding the fall.
Review of the facility's policy titled Fall Prevention Program Policy revealed each resident will be assessed for the risks of falling and will receive care and services in accordance with the level of risk to minimize the likelihood for falls. When any resident experiences a fall, the facility will assess the resident, complete a post-fall assessment, complete an incident report, notify the physician and family, review the resident's care plan and update as indicated, document all assessments and actions, and obtain witness statements in the case of injury.
Review of the facility's policy titled Policy and Procedure for Neuro Checks revealed when a resident fall and sustains a suspected head injury or the fall was unwitnessed by staff, neuro checks will be done every 15 minutes for one hour, then every 30 minutes for one hour then, every hour for four hours then, every four hours for 24 hours.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the facility's policy, record review, and staff interview, the facility failed to provide a bed hold notice to a resident and/or the resident's family representative in a timely manner after discharge. This affected one (Resident #66) of three residents reviewed for discharges. The facility census was 64.
Findings include:
Record review for Resident #66 revealed the resident had been admitted to the facility on [DATE] and discharged to the hospital on [DATE]. Diagnoses for Resident #66 included cognitive loss, dementia, urinary incontinence, dehydration, falls, and a pressure ulcer. Review of the quarterly Minimum Data Set (MDS) assessment, dated 05/21/21, revealed the resident had impaired cognition.
Review of Resident #66's signed admission agreement, dated 04/07/21, revealed Resident #66's signed a statement regarding bed holds stating in the event of transfer the resident would like to reserve his room for possible transfer back to the facility.
Review of Resident #66's care plan, dated 04/2021, revealed a focus for the resident being a long term resident with no plans for discharge.
Review of Resident #66's progress notes, dated 06/13/21, revealed the resident a change in condition, decreased response, and the nurse was unable to obtain vital signs. Per the note, the resident was transferred to the hospital. The resident's wife was notified of the change of condition and a verbal consent was obtained to send the resident to the hospital. The note, dated 06/13/21 at 6:40 P.M., revealed the resident had been admitted to the hospital.
Further review of Resident #66's medical record revealed no notice of bed hold notification to the resident's family representative.
Interview on 09/08/21 at 3:45 P.M. with the Director of Nursing (DON) verified the facility had not provided Resident #66 or his family representative a bed hold notice after his transfer to the hospital on [DATE].
Review of the facility's policy titled 'Bed Hold Prior to Transfer', dated 11/2020, revealed despite payer source all residents will be provided a bed hold notice from the facility.