Autumn Care Of Madison

Based on staff interview and clinical record review, it was determined the facility staff failed to notify the physician and the responsible party of changes in condition for one of four residents in the survey sample, Resident # 3.
The findings include:
For Resident #3, the facility staff failed to notify the responsible party of a bruise on 12/19/24 and a fall on 12/25/24.
The nurse's note dated 12/19/24 at 6:47 p.m. documented, Hospice CNA (certified nursing assistant) reported to this speaker that resident has bruising to R. (right) buttock. There is no documentation the physician or responsible party were notified of the bruise.
The nurse's note dated 12/25/24 at 6:47 p.m. documented, Resident had unwitnessed fall in bathroom located beside commode, resident was sitting upward, Resident (+) (positive for) PEERLA (pupils, equal, round, reactive to light and accommodation), upper and lower extremities move at previous levels, respirations even and resident abdomen soft and non-tender resident denies pain and discomfort. There is no documentation the physician or responsible party were notified of the fall.
On 2/5/25 at 1:46 p.m., An interview was conducted with RN (registered nurse) #,1 RN #1 stated When there is a fall, bruise or any change in condition, the nurse should notify the doctor, family and the director of nursing.
On 2/5/25 at 2:16 p.m., ASM (administrative staff member) #2, the director of nursing, stated, They did not have any documentation that the provider and/or responsible party was notified of the above.
The facility policy, Incident/Accident Policy documented in part, 5. The incident will be reported to the provider as soon as practicably possible .6. The incident will be reported to the resident's responsible party as soon as practicably possible, including any known injury and provider orders.
ASM #1, the administrator, ASM #2, and ASM #3, the regional director of operations.
No further information was provided prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and clinical record review, it was determined the facility staff failed to maintain a complete and accurate clinical record for one of four residents in the survey sample, Resident #1.
The findings include:
Resident #1 was admitted to the facility on [DATE]. The resident was transferred to the hospital on 6/29/24 and did not return to the facility after her stay in the hospital. Resident was transferred elsewhere.
Review of the clinical record revealed documented a physician note dated, 7/23/24, documented in part, Patient seen and evaluated for continuity of necessity of rehabilitation stay/skilled nursing/medication order review. Nurses' notes/vitals reviewed in PCC (initials of computer program), discussed patient status/progress with nursing staff.
A second physician note dated, 8/27/24, documented in part, Patient seen and evaluated for continuity of necessity of rehabilitation stay/skilled nursing/medication order review. Nurses' notes/vitals reviewed in PCC, discussed patient status/progress with nursing staff.
The physician was not available for interview at this time.
On 2/5/25 at 2:27 p.m., The above was shared with ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, and ASM #3, the regional director of operations ASM #3 stated, They have reached out to the physician regarding this.
No further information was provided prior to exit.

Based on resident interview, clinical record review, staff interview and facility document review, it was determined the facility staff failed to evidence consistent communication to the hemodialysis (1) center for one of 28 residents in the survey sample, Resident #35.
The findings include:
For Resident #35 (R35), the facility staff failed to evidence communication to the dialysis facility for nine of 32 dialysis appointments between 12/10/2022-2/23/2023. There was no evidence of dialysis communication from the facility to the dialysis center on 12/27/2022, 1/5/2023, 1/10/2023, 1/14/2023, 1/17/2023, 1/19/2023, 2/7/2023, 2/11/2023 and 2/16/2023.
On the most recent MDS (minimum data set) assessment, an admission assessment with an ARD (assessment reference date) of 12/17/2022 the resident scored 12 out of 15 on the BIMS (brief interview for mental status) assessment, indicating the resident was moderately impaired for making daily decisions. Section O documented R35 receiving dialysis services while a resident at the facility.
On 2/22/2023 at 9:22 a.m., an interview was conducted with R35. R35 stated that the staff send a communication book with them when they go to dialysis. R35 stated that the book was kept at the nurses station.
On 2/23/2023 at 8:07 a.m., a review of R35's dialysis communication book revealed printed facility dialysis communication forms dated 1/26/2023, 1/31/2023, 2/2/2023, 2/4/2023, 2/14/2023, 2/18/2023 and 2/23/2023.
Review of R35's clinical record failed to evidence dialysis communication for the dialysis appointments on 12/27/2022, 1/5/2023, 1/10/2023, 1/14/2023, 1/17/2023, 1/19/2023, 2/7/2023, 2/11/2023 and 2/16/2023.
The comprehensive care plan for R35 documented in part, DIALYSIS: ESRD (end stage renal disease). Resident receives dialysis treatments 3 times weekly. ESRD. Dialysis at [Name of dialysis center] on TU-TH-SA .Date Initiated: 12/12/2022 .
The physician orders for R35 documented in part, May attend dialysis at [Name of dialysis center] on
Tuesday/Thursday/Saturday. pick-up time 12:15pm for chair time 1:00pm [Name, address, phone number of dialysis center]. Order Date: 01/30/2023 .
On 2/23/2023 at approximately 8:30 a.m., a request was made to ASM (administrative staff member) #2, the director of nursing for evidence of dialysis communication from the facility for the dialysis appointments on 12/27/2022, 1/5/2023, 1/10/2023, 1/14/2023, 1/17/2023, 1/19/2023, 2/7/2023, 2/11/2023 and 2/16/2023 for R35.
On 2/23/2023 at 9:52 a.m., an interview was conducted with LPN (licensed practical nurse) #2. LPN #2 stated that they completed the dialysis communication forms in the electronic medical record prior to R35 leaving for dialysis with current vital signs and any pertinent information on it to send with the resident in the dialysis communication book. LPN #2 stated that after they completed the dialysis communication form they printed it out and placed it in the book so that it was ready when transport came to pick the resident up. LPN #2 stated that dialysis sent the book back with any communication to them each treatment.
On 2/23/2023 at 11:11 a.m., ASM #2 stated that they did not have any evidence of dialysis communication for R35 for 12/27/2022, 1/5/2023, 1/10/2023, 1/14/2023, 1/17/2023, 1/19/2023, 2/7/2023, 2/11/2023 and 2/16/2023 to provide.
The facility policy, Hemodialysis Care Policy effective 6/16/2017 with a revision date of 4/20/2022 documented in part, Policy: Licensed staff with demonstrated competence will care for residents who require hemodialysis (via onsite third-party providers or who travel to an outpatient setting). Communication between the dialysis provider and facility staff will occur before and after each hemodialysis treatment and as needed . The policy further documented, Pre-dialysis process: .Document assessment in the Dialysis Communication Tool. Assessment includes:
- Vital signs.
- Pre-treatment weight (unless performed at dialysis).
- Medications administered before treatment.
- Time of last meal.
- Fluid intake.
- Any additional alerts or information.
Print the Tool and send with resident to dialysis (if off-site) .
On 2/23/2023 at approximately 11:15 a.m., ASM #1, the administrator, ASM #2, the director of nursing and ASM #5, the regional director of clinical services were made aware of the findings.
No further information was provided prior to exit.
(1) hemodialysis
When your kidneys are healthy, they clean your blood. They also make hormones that keep your bones strong and your blood healthy. When your kidneys fail, you need treatment to replace the work your kidneys used to do. Unless you have a kidney transplant, you will need a treatment called dialysis. There are two main types of dialysis. Both types filter your blood to rid your body of harmful wastes, extra salt, and water.: Hemodialysis uses a machine. It is sometimes called an artificial kidney. You usually go to a special clinic for treatments several times a week. Peritoneal dialysis uses the lining of your abdomen, called the peritoneal membrane, to filter your blood. This information was obtained from the website: https://medlineplus.gov/dialysis.html

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 one of 28 residents in the survey sample, Resident # 49 (R49).
The findings include:
For (R49) the facility staff failed to attempt non-pharmacological interventions prior to the administration of a prn (as needed) pain medications, hydromorphone (1) and Tylenol (2) and failed to clarify the physician's orders for the use of the PRN pain medications.
(R49) was admitted to the facility with a diagnosis that included but was not limited to chronic pain.
On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 02/03/2023, (R49) scored 15 out of 15 on the BIMS (brief interview for mental status), indicating (R49) was cognitively intact for making daily decisions. Under J0600. Pain Intensity it documented, A. Numeric Rating Scale (00-10). (R49) was coded a 7 (seven).
The physician's order for (R49) documented in part, Hydromorphone HCl Tablet 2 MG (milligrams). Give 2 tablet by mouth every 6 hours as needed for chronic pain. Order Date: 09/16/202 and Tylenol Tablet 325 MG (Acetaminophen). Give 975 mg by mouth every 6 hours as needed for pain. Order date: 08/29/2022. Further review of the physician's orders failed to evidence pain level parameters for the administration of the above prn pain medications.
The eMAR (electronic medication administration record) for (R49) dated January 2023 documented the physician's orders as stated above. The eMAR revealed that (R49) received 2 mgs of hydromorphone on the following dates and times, with no evidence of non-pharmacological interventions being attempted: 01/03/2023 at 10:16 a.m., 01/04/2023 at 10:53 a.m., 01/06/2023 at 2:47 p.m., 01/07/2023 at 10:17 a.m., 01/11/2023 at 8:28 a.m. and at 3:54 p.m., 01/12/2023 at 9:03 a.m. and at 4:29 p.m., 01/13/2023 at 8:31 a.m. and at 3:54 p.m., 01/14/2023 at 12:53 p.m., 01/17/2023 at 7:39 a.m., 01/20/2023 at 11:37 a.m., 01/21/2023 at 4:51 p.m., 01/22/2023 at 9:05 a.m., 01/26/2023 at 8:00 a.m. and at 3:54 p.m., 01/27/2023 at 1:01 p.m. and at 7:07 p.m., and on 01/31/2023 at 12:32 p.m. Further review of the eMAR revealed that (R49) received 975 mg of Tylenol on the following dates and times, with no evidence of non-pharmacological interventions being attempted on: 01/11/2023 at 8:28 a.m., 01/13/2023 at 10:18 a.m., 01/14/2023 at 12:55 p.m., 01/21/2023 at 4:52 p.m., 01/22/2023 at 9:06 a.m., 01/24/2023 at 11:24 a.m., and on 01/26/2023 at 11:34 a.m.
The eMAR for (R49) dated February 2023 documented the physician's orders as stated above. The eMAR revealed that (R49) received 2 mgs of hydromorphone on the following dates and times, with no evidence of non-pharmacological interventions being attempted: 02/01/2023 at 7:38 a.m. and at 2:33 p.m., 02/10/2023 at 9:58 a.m. and at 4:32 p.m., and on 02/15/2023 at 2:09 p.m. Further review of the eMAR revealed that (R49) received 975 mg of Tylenol on the following dates and times, with no evidence of non-pharmacological interventions being attempted on: 02/08/2023 at 5:36 a.m. and on 02/15/2023 at 2:09 p.m.
On 02/21/23 at approximately 11:45 a.m., an interview was conducted with (R49). When asked if they have pain (R49) stated they have chronic pain. When asked when they receive as needed pain medication, if the staff try to alleviate their pain before administering their pain medication, (R49) stated no.
The comprehensive care plan for (R49) dated 08/16/2022 documented in part, The resident has pain r/t (related to) Neuropathy (3) and PVD (peripheral vascular disease) (4). Has hx (history) of chronic pain to lower back and legs. Date Initiated: 08/16/2022. Under Interventions it documented in part, Staff to offer/implement non-pharmacological interventions for pain relief .Date Initiated: 08/16/2022.
On 02/22/2023 at approximately 12:55 p.m., an interview was conducted with LPN (licensed practical nurse) #7. When asked to describe the procedure when administering as needed pain medication LPN #7 stated that the nurse assesses the resident's pain by obtaining the severity of the resident's pain on a scale of zero to ten, with ten being the worse pain, the location of the pain and the type of pain. LPN #7 stated that the nurse would start with non-pharmacological interventions such as repositioning and if that did not alleviate the resident's pain, they would administer the prescribe medication. When asked how often non-pharmacological interventions should be attempted, LPN #7 stated that it should be attempted each time before the as needed pain medication is administered. When asked to describe the procedure they follow when a resident is prescribed two prn pain medications without pain level parameters LPN #7 stated they would clarify the orders. After reviewing the physician's orders for the prn pain medications stated above, LPN #7 was asked how they determine which pain medication they administer when (R49) tells them they are in pain. LPN #7 stated that (R49) will tell them which pain medication the want.
On 02/22/2023 at approximately 1:15 p.m., an interview was conducted with ASM (administrative staff member #2, director of nursing. After reviewing the physician's orders for the prn pain medications stated above, ASM #2 was asked how they determine which pain medication they would administer when (R49) tells them they are in pain. ASM #2 stated that the physician's order should have been clarified. ASM #2 was asked to review the dates and times stated above on the eMARS to determine if there was documentation of non-pharmacological interventions attempted prior to the administration of (R49's) prn pain medications. At approximately 2:05 p.m., ASM #2 stated that there was no documentation of non-pharmacological interventions attempted for the dates and times stated above.
The facility's policy Pain Management Protocol documented in part, Non-pharmacological intervention[s] will be attempted prior to the administration of PRN pain medications. When it is determined the resident's pain will need pharmacological interventions: a. Documentation of administration of medications will be located in the electronic medication record (eMAR). b. The effectiveness of the medication(s) will be identified on the eMAR.
On 02/22/2023 at approximately 4:49 p.m., ASM #1, administrator, and ASM #2, director of nursing, ASM #3, assistant director of nursing, and ASM #4, business office manager/administrator in training, were made aware of the above findings.
No further information was provided prior to exit.
References:
(1) Used to relieve severe pain. This information was obtained from the website: Hydromorphone: MedlinePlus Drug Information.
(2) Used to relieve mild to moderate pain. This information was obtained from the website: https://medlineplus.gov/druginfo/meds/a681004.html.
(3) Nerve damage. This information was obtained from the website: https://www.google.com/#q=neuropathy+nih.
(4) Arteries can become thick and stiff, a problem called atherosclerosis. Blood clots can clog vessels and block blood flow to the heart or brain. Weakened blood vessels can burst, causing bleeding inside the body.) This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/vasculardiseases.html.

2. The facility staff failed to provide oxygen per the physician order for Resident #45 (R45).
On the most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 12/12/2022 the resident scored a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired for making daily decisions. In Section O - Special Treatments, Procedures and Programs, the resident was not coded as using oxygen.
The physician order dated 2/10/2022 read: Oxygen at 2 LPM for acute respiratory failure for 7 days.
Observation was made of R45 on 2/21/2023 at 1:30 p.m., 3:12 p.m. and 4:49 p.m., sitting in their bed with oxygen on via a nasal cannula. The oxygen concentrator was set at 3 LPM (liters per minute). On 2/21/2023 at 4:59 p.m. R45 was asked if they adjusted the oxygen rate on the concentrator, R45 stated, no, they can hardly reach where the machine is. Another observation was made on 2/22/2023 at 8:50 a.m. The resident was in bed with the oxygen on via the nasal cannula. The oxygen concentrator was set at 3 LPM.
On 2/22/2023 at 2:38 p.m. an observation of the concentrator was made with LPN (licensed practical nurse) #3. The oxygen concentrator was set at 2 LPM. LPN #3 stated she had adjusted it in the morning as it was set incorrectly at 3 LPM.
Review of the February MAR (medication administration record) and TAR (treatment administration record) failed to evidence documentation of the use of oxygen for February 21 - 22, 2023.
The comprehensive care plan dated 2/14/2023, documented in part, Focus: Resident has infection R/T (related to) pneumonia, oxygen use as directed. The Interventions documented in part, Oxygen as directed.
An interview was conducted with LPN #3 on 2/22/2023 at 3:30 p.m. When asked where she signed off the resident is using oxygen, LPN #3 stated, on the TAR or MAR. When asked if R45 has a current order for oxygen, LPN #3 proceeded to review the physician orders for R45 in the computer. After reviewing the orders, LPN #3 stated, She does not have a current order for oxygen at this time. When asked should there be an order, LPN #3 stated, yes.
The facility policy, Oxygen Administration Policy, documented in part, POLICY: Licensed clinicians with demonstrated competence will administer oxygen via the specified route as ordered by a provider. In an emergency, clinicians may administer oxygen and obtain a provider's order as soon as practicably possible after patient stabilization or transfer .PROCEDURE: 1. Verify provider order.
ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, ASM #4, the business office manager/administrator in training, and ASM # 5, the regional director of clinical services, were made aware of the above finding on 2/22/2023 at 4:55 p.m.
No further information was provided prior to exit
Based on observation, resident interview, clinical record review, staff interview and facility document review it was determined that the facility staff failed to provide respiratory care and services consistent with professional standards of practice for two of 28 residents, Resident #43 and Resident #45.
The findings include:
1. For Resident #43 (R43), the facility staff failed to properly store a BiPAP (1) mask in a sanitary manner when not in use.
On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 1/19/2023, the resident scored 11 out of 15 on the BIMS (brief interview for mental status) assessment, indicating the resident was moderately impaired for making daily decisions. Section I documented R43 having diagnoses including but not limited to Obstructive Sleep Apnea.
On 2/21/2023 at 12:29 p.m., an observation was made of R43 in their room. A BiPAP machine was observed on the nightstand to the right side of R43's bed. A mask with tubing was attached to the machine. The mask was observed to be uncovered and laying on the nightstand surface.
Additional observation of R43 on 2/21/2023 at 2:50 p.m. revealed the BiPAP mask uncovered on the nightstand surface. An interview was attempted with R43 however due to their cognitive status it was not completed. On 2/22/2023 at 9:29 a.m., the BiPAP mask was observed uncovered on the nightstand surface.
The comprehensive care plan for R43 documented in part, Respiratory Status: COPD (chronic obstructive pulmonary disease), OSA (obstructive sleep apnea). Resident has altered pulmonary status R/T (related to) COPD and Obstructive Sleep Apnea. Resident has use of BIPAP. Date Initiated: 10/13/2022 .
The physician orders for R43 documented in part, BIPAP q (every) HS (bedtime) .Order Date: 10/12/2022 .
The eMAR (electronic medication administration record) dated 2/1/2023-2/28/2023 for R43 documented the use of the BiPAP each night at 8:00 p.m. from 2/1/2023 through 2/21/2023 with the exception of 2/2/2023, 2/3/2023 and 2/8/2023 when R43 refused to wear the BiPAP.
On 2/22/2023 at 2:38 p.m., an interview was conducted with LPN (licensed practical nurse) #3. LPN #3 stated that BiPAP masks should be washed with soap and water and stored in a bag after they were dried to keep them clean. LPN #3 stated that the bags were changed every week. LPN #3 observed R43's BiPAP mask uncovered on the nightstand and stated that at times R43 refused to wear it but it should be covered to keep it clean.
The facility policy, BiPAP/CPAP Policy effective 1/24/2017 and revised 10/20/2021 documented in part, .Mask: wash mask with soap and water or CPAP masks after each use, let air dry. Once dry store mask in a plastic bag to keep it clean .
On 2/22/2023 at 4:47 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, ASM #3, the assistant director of nursing/infection preventionist, ASM #4, the business office manager/administrator in training and ASM #5, the regional director of clinical services were made aware of the concern.
No further information was provided prior to exit.
Reference:
(1) Bi-Pap
Positive airway pressure (PAP) treatment uses a machine to pump air under pressure into the airway of the lungs. This helps keep the windpipe open during sleep. The forced air delivered by CPAP (continuous positive airway pressure) prevents episodes of airway collapse that block the breathing in people with obstructive sleep apnea and other breathing problems Bilevel positive airway pressure (BiPAP or BIPAP) has a higher pressure when you breathe in and lower pressure when you breathe out. This information was obtained from the website: https://medlineplus.gov/ency/article/001916.htm

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, clinical record review, staff interview and facility document review it was determined that the facility staff failed to provide foot care for two of 28 residents, Resident #43 and Resident #7.
The findings include:
1. For Resident #43 (R43), the facility staff failed to provide foot care services.
On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 1/19/2023, the resident scored 11 out of 15 on the BIMS (brief interview for mental status) assessment, indicating the resident was moderately impaired for making daily decisions. Section G documented R43 requiring extensive assistance of one staff member for personal hygiene. Section I documented R43 having diagnoses including but not limited to Diabetes Mellitus (1).
On 2/21/2023 at 12:29 p.m., R43 was observed lying in bed asleep. R43's right foot was observed outside of the blanket uncovered. The toenail on the great toe was observed to be uneven with thick jagged edges which extended past the toe. The nails on the other toes were observed to be long but not jagged.
Additional observations of R43 on 2/21/2023 at 2:50 p.m. revealed to same observation of the right foot uncovered outside of the blanket. An interview was attempted with R43 however due to their cognitive status it was not completed.
On 2/22/2023 at 9:29 a.m., an observation was made of R43 in bed with both of R43's uncovered and visible. Observation of the left foot revealed the great toenail to be thick and long with jagged edges which extended past the toe. The nails on the other toes were observed to be long but not jagged.
The comprehensive care plan for R43 documented in part, ADL (activities of daily living) Functional Status: The resident has an ADL self care performance deficit r/t (related to) general weakness, morbid obesity, adult failure to thrive and neuropathy. Requires staff to assist with completing adl's daily. Date Initiated: 10/13/2022 .
On 2/22/2023 at 2:38 p.m., an interview was conducted with LPN (licensed practical nurse) #3. LPN #3 stated that the facility had a podiatrist that came in but they were not sure how often they came in the building or their schedule. LPN #3 stated that there was a podiatrist list kept at the nurses station and they could add residents to be seen as needed. LPN #3 stated that the CNA's (certified nursing assistants) could trim fingernails of residents unless they were diabetic and the nurses could trim the fingernails and toenails of all residents. LPN #3 stated that the nurses would trim or file the residents toenails and if they were too long, painful or too thick they would have the podiatrist see them because they did not have the proper equipment. LPN #3 observed R43's toenails and agreed that they were long and jagged and needed to be trimmed up.
On 2/22/2023 at 4:33 p.m., an interview was conducted with ASM (administrative staff member) #3, the assistant director of nursing, infection preventionist. ASM #3 stated that they were responsible for the podiatry schedule at the facility. ASM #3 stated that the podiatrist came to the facility every three months and more frequently if needed. ASM #3 stated that the nurses trimmed the toenails of diabetic residents. ASM #3 stated that the podiatrist preferred to have 10 to 15 residents to see when they came in the building but came in to see one resident if there was a need or a consult within 48-72 hours or they sent residents out to see a podiatrist.
On 2/22/2023 at 4:47 p.m., ASM #1, the administrator, ASM #2, the director of nursing, ASM #3, the assistant director of nursing/infection preventionist, ASM #4, the business office manager/administrator in training and ASM #5, the regional director of clinical services were made aware of the concern.
On 2/23/2023 at 11:10 a.m., ASM #5, the regional director of clinical services stated that the facility did not have a policy regarding foot care or podiatry services and that they followed [NAME] as their nursing standard of practice.
On 2/23/2023 at 11:41 a.m., ASM #5 provided the title page of Lippincott Manual of Nursing Practice, Eleventh Edition.
According to Lippincott Manual of Nursing Practice, 10th Edition, it documented in part, Diabetes Mellitus and Related Disorders .Foot Care Guidelines .6. Go to a podiatrist on a regular basis if corns, calluses, and ingrown toenails are present. 6.a. Trim toenails straight across to prevent ingrown toenails. b. File any rough corners with an emery board .
No further information was provided prior to exit.
(1) Diabetes Mellitus
Diabetes is a disease in which your blood glucose, or blood sugar, levels are too high. Glucose comes from the foods you eat. Insulin is a hormone that helps the glucose get into your cells to give them energy. With type 1 diabetes, your body does not make insulin. With type 2 diabetes, the more common type, your body does not make or use insulin well. Without enough insulin, the glucose stays in your blood. You can also have prediabetes. This means that your blood sugar is higher than normal but not high enough to be called diabetes. Having prediabetes puts you at a higher risk of getting type 2 diabetes. Over time, having too much glucose in your blood can cause serious problems. It can damage your eyes, kidneys, and nerves. Diabetes can also cause heart disease, stroke and even the need to remove a limb. This information was obtained from the website: https://medlineplus.gov/diabetes.html
2. For Resident #7 (R7), the facility staff failed to provide foot care services.
On the most recent MDS (minimum data set), a five day admission assessment with an ARD (assessment reference date) of 1/4/2023, the resident scored 12 out of 15 on the BIMS (brief interview for mental status) assessment, indicating the resident was moderately impaired for making daily decisions. Section G documented R7 requiring extensive assistance of one staff member for personal hygiene. R7 was not documented as being a diabetic.
On 2/21/2023 at 12:15 p.m., an interview was conducted with R7 in their room. R7 stated that they had a lot of pain in their left foot from their toenails. R7 stated that they had been having pain for a long time. R7 stated that a nurse had looked at their toenails and told them the doctor was going to trim them but no one had been in. R7 stated that the nursing staff had told them that they were not allowed to trim their toenails. R7 stated that the toenails were so long that it was hurting their feet and they could not wear their shoes because it hurt. R7 was observed wearing non-slip socks on their feet. R7 stated that they were unable to trim their toenails themselves and required someone to do this for them.
Additional observations of R7 on 2/21/2023 at 2:55 p.m. revealed R7 in the hallway in a wheelchair wearing non-slip socks.
The comprehensive care plan for R7 documented in part, ADL (activities of daily living) self care deficit: The resident has an ADL self care performance deficit r/t (related to) pain, BLE (bilateral lower extremity) edema (swelling), CHF (congestive heart failure), DJD/DDD (degenerative joint disease/degenerative disc disease), gen. (general) weakness. Date Initiated: 12/29/2022 .
The progress notes for R7 documented in part,
- 1/13/2023 10:38 (10:38 a.m.) Physician/PA (physician assistant)/NP (nurse practitioner) Progress note . History of Present Illness: Asked to see patient to evaluate pain. Nursing reports patient complaining of left great toe pain. Patient interviewed. Reports having difficulty with her toes and needing them trimmed. Patient also reports pain and discomfort to left great toe .Skin: Warm and dry, normal color for ethnicity. **Hypertrophic thick and discolored toenails noted .Assessment/Plan (reviewed w/ (with) patient): 1) Left great toe pain- Acute. Most likely related to hypertropic [sic] nails. Patient placed on Podiatry list. 2) Hypertropic [sic] toenails- Acute. Consult Podiatry to evaluate and treat .
On 2/22/2023 at 2:38 p.m., an interview was conducted with LPN (licensed practical nurse) #3. LPN #3 stated that the facility had a podiatrist that came in but they were not sure how often they came in the building or their schedule. LPN #3 stated that there was a podiatrist list kept at the nurses station and they could add residents to be seen as needed. LPN #3 stated that the CNA's (certified nursing assistants) could trim fingernails of residents unless they were diabetic and the nurses could trim the fingernails and toenails of all residents. LPN #3 stated that the nurses would trim or file the residents toenails and if they were too long, painful or too thick they would have the podiatrist see them because they did not have the proper equipment. An observation of R7's toenails was requested with LPN #3. Observation of R7's toenails revealed the left and right great toenails to be long, thick and curved over growing towards the second toe. The additional toenails were observed to be long, thick and curved downward under the toes. LPN #3 agreed that they were long, thick, curved into the toes next to them and needed to be trimmed. LPN #3 stated that if R7 had been complaining of pain from the toenails they should have seen the podiatrist at the facility or been sent out to see a podiatrist.
On 2/22/2023 at 4:33 p.m., an interview was conducted with ASM (administrative staff member) #3, the assistant director of nursing, infection preventionist. ASM #3 stated that they were responsible for the podiatry schedule at the facility. ASM #3 stated that the podiatrist came to the facility every three months and more frequently if needed. ASM #3 stated that the CNA's could trim toenails of non-diabetic residents however the nurses preferred to do them to assess each residents feet. ASM #3 stated that the podiatrist preferred to have 10 to 15 residents to see when they came in the building but came in to see one resident if there was a need or a consult within 48-72 hours or they sent residents out to see a podiatrist. ASM #3 stated that the nurses were responsible for arranging the appointments for residents to go to a podiatrist outside of the facility.
On 2/22/2023 at 4:47 p.m., ASM #1, the administrator, ASM #2, the director of nursing, ASM #3, the assistant director of nursing/infection preventionist, ASM #4, the business office manager/administrator in training and ASM #5, the regional director of clinical services were made aware of the concern.
No further information was provided prior to exit.

Based on staff interview, facility document review, and clinical record review, it was determined the facility staff failed to ensure a new heel wound was assessed accurately, and a treatment was obtained and implemented timely, for one of 28 residents in the survey sample, Resident #33 (R33).
The findings include:
For R33, the facility staff failed to obtain a physician's order for a treatment to an opened heel blister, and, the heel blister was not assessed and staged as a pressure injury per the National Pressure Injury Advisory Panel (NPIAP) guidelines.
On the most recent MDS (minimum data set) assessment, a quarterly/Medicare five-day assessment, with an assessment reference date of 1/2/2023, the resident scored an eight out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was moderately cognitively impaired for making daily decisions. In Section M - Skin Conditions, R33 was not coded as having any pressure ulcers.
The Weekly Wound Assessment dated 2/10/2023, documented in part, Wound type: other. Other wound type: open blister. Stage: N/A (not applicable). Wound location: right heel. Length: 5.0 cm (centimeters). Width: 6 cm. Depth: 0.2 cm. Location where wound was acquired: in house. Date wound identified: 2/10/2023. Wound status: New Wound. Treatment: area cleaned and dressing applied. Comments: Call placed to on call doctor, awaiting return call. The nurse who documented the wound was not available for interview.
Per the NPIAP: Stage 2 Pressure Injury: Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. These injuries
commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the
heel . (1)
The Wound Care Specialist Note dated, 2/14/2023, documented in part, Wound: Right heel (+) full-thickness wound that measures 5.0 x 6.0 x 0.2 cm. Wound base 40% purple/maroon tissue, 60% granular, (+) surface induration, edges adherent to the wound base, moderate non-odorous serous drainage, Peri wound without erythema, induration or signs of cellulitis. Patient does not demonstrate evidence of pain when area palpated .Wound care to right heel as follows: Cleanse with normal saline or wound cleanser, pat dry. Apply Alginate to wound bed. Cover with gauze and kerlix dressing. Change dressing every day and as needed for saturation or soilage.
Review of the physician orders failed to evidence documentation of the wound care specialist directions.
Review of the TAR (treatment administration record) for February, failed to evidence documentation of any dressing changes from 2/10/2023 through 2/14/2023 or 2/15/23 through 2/20/2023.
The physician order dated, 2/21/2023, documented, Cleanse right heel with wound cleanser and apply xeroform and dressing daily to open blister.
The comprehensive care plan dated, 9/13/2022, documented in part, Focus: Skin Integrity/Pressure Ulcer Development: The resident has potential for skin breakdown including pressure ulcer development r/t (related to) decrease in mobility. Resident refuses treatments at times. 2/20/2023 - Left heel wound (area is on his right heel). The Interventions dated 9/13/2022, documented in part, Administer treatments as ordered and monitor for effectiveness. Assess/document/report to MD (medical doctor) PRN (as needed) changes in skin status.
On 2/23/2023 at 9:15 a.m., ASM (administrative staff member) #2, the director of nursing, was asked if there was any documentation of any treatments between 2/10/2023 and 2/20/2023, ASM #2 stated there was no documentation of any wound treatment between 2/10/2023 and 2/20/2023. The Wound Care Specialist recommendations for wound care on 2/14/2023 was reviewed with ASM #2. ASM #2 stated the orders were never transferred over to the TAR.
On 2/23/2023 at 9:15 a.m., R33 was observed in bed with an air mattress in use on the bed. R33 was lifting both of his legs around in the bed. During the wound care observation at that time, the resident was able to lift his leg independently for the nurse to perform the dressing change. A dressing was observed on the heel prior to the dressing change.
An interview was conducted with LPN (licensed practical nurse) #5 on 2/23/2023 at 9:26 a.m. When asked the process for assessing and treating a new pressure wound, LPN #5 stated, the nurse should do a head-to-toe assessment, if any new areas are found, they complete the Weekly Wound Assessment form which documents the type of wound, location of wound, measurements and notification of the doctor and RP (responsible party), the new orders received from the doctor or nurse practitioner. When asked if there should be a treatment for an open blister, LPN #5 stated, yes. When asked what the process is for after the wound care specialist sees a resident with a pressure area, LPN #5 stated, typically the nurse practitioner will give a verbal order at the time she sees the resident. If she doesn't give a verbal order, her notes are faxed over to the facility in the evening after she was in the building. LPN #5 stated, typically the resident is reviewed the next day to ensure there are appropriate orders in place. The copy of the wound care specialist notes are printed and given to the nurse on the unit. The nurse is to transcribe the orders into the computer record. LPN #5 reviewed the February TAR. When asked if she saw any treatment documented between 2/10/2023 and 2/20/2023, LPN #5 stated, she didn't see anything
The facility policy, Skin and Wound Care Best Practices documented in part, Pressure Injury and Wound Treatment: steps initiated based on skin assessment findings: Pressure injuries and wounds will be treated with evidence-based interventions as ordered by the provider. See Wound Product Selection Guide for guidance on wound type/stage identification and suggested treatment approaches. Conduct comprehensive pain assessment for those with pressure injury. Communities may engage the services of a consulting wound care provider. Use of a consulting wound care provider for management of wounds is recommended for the following: A stage 3 or greater pressure injury, complicated vascular wounds, complicated diabetic wounds, wounds which are worsening, wounds which are not healing even with treatment changes, infected wounds, when assistance with correctly staging or categorizing a wound is needed.
ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, and ASM # 5, the regional director of clinical services, were made aware of the above finding on 2/23/2023 at 11:15 a.m.
No further information was provided prior to exit.
Reference obtained from:
(1) https://cdn.ymaws.com/npiap.com/resource/resmgr/online_store/npiap_pressure_injury_stages.pdf

Based on staff interview, facility document review and clinical record review, it was determined the facility staff failed follow the physician's order for obtaining daily weights for one of 28 residents in the survey sample, Resident #33.
The findings include:
For Resident #33 (R33), the facility staff failed to obtain daily weights twice in December 2022 and three times in January 2023.
On the most recent MDS (minimum data set) assessment, a quarterly/Medicare five day assessment, with an assessment reference date of 1/2/2023, the resident scored an eight out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was moderately cognitively impaired for making daily decisions. R33 has a diagnosis of congestive heart failure (CHF).
The physician order dated, 11/17/2022, documented, Daily Weight.
The December 2022 and January 2023, MAR (medication administration record) documented the above order for daily weights. The following dates were blank: 12/29/2022, 12/20/2022, 1/3/2023, 1/4/2023, 1/29/2023.
Review of the Weights tab in the electronic medical record failed to evidence documentation of weights obtained on the above dates.
The comprehensive care plan dated, 9/14/2022 and revised on 10/13/2022, documented in part, Focus: The resident has a potential nutritional problem r/t (related to) risk for malnutrition r/t depression, celiac disease, Vitamin deficiency, and duodenal ulcer. The Interventions documented in part, Weights per orders/routine/prn (as needed).
An interview was conducted with LPN (licensed practical nurse) #5 on 2/23/2023 at 9:26 a.m. When asked where daily weights are documented and why they are done, LPN #5 stated they are documented on the MAR and typically done for residents with CHF. When asked if there is a blank on the MAR for a day, what does that indicate, LPN #5 stated, if it's not documented it wasn't done.
The facility policy, Weights Policy documented in part, POLICY: Weights will be obtained routinely in order to monitor parameters of nutrition over time. Each individual's weight will be determined upon admission/readmission to the facility, weekly for the first four weeks after admission/readmission, and monthly or more often if risk is identified. Obtaining accurate weights is vital for the nutritional assessment of each resident and can be used as a basis for medical and nutritional intervention. Nursing is responsible for the determination of each individual's weight.
ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, and ASM # 5, the regional director of clinical services, were made aware of the above finding on 2/23/2023 at 11:15 a.m.
No further information was provided prior to exit.

Based on staff interview, clinical record review, and facility document review, it was determined that facility staff failed to revise the comprehensive care plan for one of 28 residents in the survey sample, Resident #49.
The findings include:
For Resident #49 (R49) the facility staff failed to update the comprehensive care plan for activities to include (R49's) preference of being outside when the weather is good.
(R49's) most recent comprehensive MDS (minimum data set), a significant change assessment with an ARD (assessment reference date) of 01/12/2023, coded (R49) as scoring a 15 on the brief interview for mental status (BIMS) of a score of 0-15, with 15 being cognitively intact for making daily decisions. Under F0500. Interview for Activity Preferences it coded (R49) as it being Very important to go outside to get fresh air when the weather is good.
The comprehensive care plan for (R49) dated 08/22/2022 documented in part, Focus: Activities: Resident prefers/enjoys the following activities: watching tv, spending time on social media and phone. Date Initiated: 08/22/2022. Under Interventions it documented, Engage resident in group activities Date Initiated: 08/22/2022. Monitor independent activities prn (as needed). Date Initiated: 08/22/2022.
On 02/23/2023 at approximately 8:45 a.m., an interview was conducted with LPN (licensed practical nurse) #6, MDS assistant coordinator. After reviewing section F0500 of (R49's) significant change MDS and their comprehensive care plan for activities, LPN #6 stated that (R49's) care plan was revised to include their activity preference of being outside when the weather is good. When asked to describe the procedure for ensuring the care plan reflects the resident's preferences for activities LPN #6 stated that they follow the RAI (resident assessment instrument) manual.
On 02/23/2023 at approximately 11:10 a.m., ASM #1, administrator, and ASM #2, director of nursing, and ASM #5, regional director of clinical services, were made aware of the above findings.
No further information was provided prior to exit

Based on resident interview, staff interview, facility policy review, and clinical record review, it was determined the facility staff failed to implement the comprehensive care plan for two of 28 residents in the survey sample, Residents
#33 and #49.
The findings include:
1. The facility staff failed to implement the care plan for obtaining weights per the physician orders for Resident #33 (R33).
On the most recent MDS (minimum data set) assessment, a quarterly/Medicare five-day assessment, with an assessment reference date of 1/2/2023, the resident scored an eight out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was moderately cognitively impaired for making daily decisions. R33 has a diagnosis of congestive heart failure (CHF).
The comprehensive care plan dated, 9/14/2022 and revised on 10/13/2022, documented in part, Focus: The resident has a potential nutritional problem r/t (related to) risk for malnutrition r/t depression, celiac disease, Vitamin deficiency, and duodenal ulcer. The Interventions documented in part, Weights per orders/routine/prn (as needed).
The physician order dated, 11/17/2022, documented, Daily Weight.
The December 2022 and January 2023, MAR (medication administration record) documented the above order for daily weights. The following dates were blank: 12/29/2022, 12/20/2022, 1/3/2023, 1/4/2023, 1/29/2023.
Review of the Weights tab in the electronic medical record failed to evidence documentation of weights obtained on the above dates.
An interview was conducted with LPN (licensed practical nurse) #3 on 2/22/2023 at 3:30 p.m. When asked the purpose of the care plan, LPN #3 stated, It is to make sure we are doing the right things for our folks. It should have new orders, falls, treatments, ADLs (activities of daily living), and code status. LPN #3 stated it is individualized [care plan] for each resident, as each resident is different in their care needs. When asked if it should be followed, LPN #3 stated, yes.
The facility policy, Comprehensive Care Planning Policy documented in part, POLICY: An interdisciplinary plan of care will be established for every resident and updated in accordance with state and federal regulatory requirements and on an as needed basis. In states where pre-admission screening applies, this will be coordinated with the facility assessment. Goals must be measurable and objective . D) All staff must be familiar with each resident's Care Plan and all approaches must be implemented.
ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, and ASM # 5, the regional director of clinical services, were made aware of the above finding on 2/23/2023 at 11:15 a.m.
No further information was provided prior to exit.
2. For Resident #49 (R49) the facility staff failed to implement the comprehensive care plan for the use of non-pharmacological interventions prior to the administration of a prn (as needed) pain medications,
(R49) was admitted to the facility with a diagnosis that included but was not limited to chronic pain.
On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 02/03/2023, (R49) scored 15 out of 15 on the BIMS (brief interview for mental status), indicating (R49) was cognitively intact for making daily decisions. Under J0600. Pain Intensity it documented, A. Numeric Rating Scale (00-10). (R49) was coded a 7 (seven).
The physician's order for (R49) documented in part, Hydromorphone HCl Tablet 2 (two) MG (milligrams). Give 2 tablet by mouth every 6 (six) hours as needed for chronic pain (1). Order Date: 09/16/202, and Tylenol Tablet 325 MG (Acetaminophen). Give 975 mg by mouth every 6 hours as needed for pain (2). Order date: 08/29/2022. Further review of the physician's orders failed to evidence pain level parameters for the administration of the above prn pain medications.
The comprehensive care plan for (R49) dated 08/16/2022 documented in part, The resident has pain r/t (related to) Neuropathy (3) and PVD (peripheral vascular disease) (4). Has hx (history) of chronic pain to lower back and legs. Date Initiated: 08/16/2022. Under Interventions it documented in part, Staff to offer/implement non-pharmacological interventions for pain relief .Date Initiated: 08/16/2022.
The eMAR (electronic medication administration record) for (R49) dated January 2023 documented the physician's orders as stated above. The eMAR revealed that (R49) received 2 mgs of hydromorphone on the following dates and times, with no evidence of non-pharmacological interventions being attempted: 01/03/2023 at 10:16 a.m., 01/04/2023 at 10:53 a.m., 01/06/2023 at 2:47 p.m., 01/07/2023 at 10:17 a.m., 01/11/2023 at 8:28 a.m. and at 3:54 p.m., 01/12/2023 at 9:03 a.m. and at 4:29 p.m., 01/13/2023 at 8:31 a.m. and at 3:54 p.m., 01/14/2023 at 12:53 p.m., 01/17/2023 at 7:39 a.m., 01/20/2023 at 11:37 a.m., 01/21/2023 at 4:51 p.m., 01/22/2023 at 9:05 a.m., 01/26/2023 at 8:00 a.m. and at 3:54 p.m., 01/27/2023 at 1:01 p.m. and at 7:07 p.m., and on 01/31/2023 at 12:32 p.m. Further review of the eMAR revealed that (R49) received 975 mg of Tylenol on the following dates and times, with no evidence of non-pharmacological interventions being attempted: 01/11/2023 at 8:28 a.m., 01/13/2023 at 10:18 a.m., 01/14/2023 at 12:55 p.m., 01/21/2023 at 4:52 p.m., 01/22/2023 at 9:06 a.m., 01/24/2023 at 11:24 a.m., and on 01/26/2023 at 11:34 a.m.
The eMAR for (R49) dated February 2023 documented the physician's orders as stated above. The eMAR revealed that (R49) received 2 mgs of hydromorphone on the following dates and times, with no evidence of non-pharmacological interventions being attempted: 02/01/2023 at 7:38 a.m. and at 2:33 p.m., 02/10/2023 at 9:58 a.m. and at 4:32 p.m., and on 02/15/2023 at 2:09 p.m. Further review of the eMAR revealed that (R49) received 975 mg of Tylenol on the following dates and times, with no evidence of non-pharmacological interventions being attempted: 02/08/2023 at 5:36 a.m. and on 02/15/2023 at 2:09 p.m.
On 02/21/23 at approximately 11:45 a.m., an interview was conducted with (R49). When if they have pain (R49) stated they have chronic pain. When asked if they receive as needed pain medication, does the staff try to alleviate their pain before administering their pain medication (R49) stated no.
On 02/22/2023 at approximately 1:15 p.m., an interview was conducted with ASM (administrative staff member) #2, director of nursing. ASM #2 was asked to review the dates and times stated above on the eMARS to determine if there was documentation of non-pharmacological interventions attempted prior to the administration of (R49's) prn pain medications. At approximately 2:05 p.m., ASM #2 stated that there was no documentation of non-pharmacological interventions attempted for the dates and times stated above.
On 02/23/2023 at approximately 8:55 a.m., an interview was conducted with ASM #2. After reviewing (R49's) comprehensive care plan as stated above, ASM #2 was asked if the care plan was being implemented if there was no evidence of non-pharmacological interventions attempted. ASM # 2 stated no.
The facility's policy Comprehensive Care Planning Policy documented in part, D) All staff must be familiar with each resident's Care Plan and all approaches must be implemented.
On 02/23/2023 at approximately 9:00 a.m., ASM #2, director of nursing, was made aware of the above findings.
No further information was provided prior to exit.
References:
(1) Used to relieve severe pain. This information was obtained from the website: Hydromorphone: MedlinePlus Drug Information.
(2) Used to relieve mild to moderate pain. This information was obtained from the website: https://medlineplus.gov/druginfo/meds/a681004.html.
(3) Nerve damage. This information was obtained from the website: https://www.google.com/#q=neuropathy+nih.
(4) Arteries can become thick and stiff, a problem called atherosclerosis. Blood clots can clog vessels and block blood flow to the heart or brain. Weakened blood vessels can burst, causing bleeding inside the body.) This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/vasculardiseases.html.

Based on staff interview, facility document review and clinical record review, the facility staff failed to notify a resident's responsible party of a change in condition for one of 28 residents in the survey sample, Resident #223.
The findings include:
For Resident #223 (R223), the facility staff failed to notify the resident's RP (responsible party) of a new physician's order for melatonin.
A review of R223's clinical record revealed a note signed by the nurse practitioner on 1/27/23 that documented, 4) Insomnia - Acute. New recommendations given . A physician's order dated 1/27/23 documented an order for melatonin 5 milligrams by mouth at bedtime for insomnia. Further review of R223's clinical record failed to reveal the resident's RP was made aware of the resident's insomnia and new medication order.
On 2/23/23 at 8:52 a.m., an interview was conducted with LPN (licensed practical nurse) #8. LPN #8 stated a resident's RP should be notified regarding any change in condition and new medication order. LPN #8 stated, You want the RP to know a change was made and this is a reason for what the doctor is doing.
On 2/23/23 at approximately 11:15 a.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing) were made aware of the above concern.
The facility policy titled, Resident Change in Condition Policy documented, 5. The Resident/Physician or Provider/Family/Responsible Party will be notified when there has been .e. A need to alter the resident's medical treatment, including a change in provider orders.

Based on staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to provide the required written documentation for a facility-initiated transfer, for one of 28 residents in the survey sample, Resident # 64 (R64).
The findings include:
For (R64), the facility staff failed to evidence that written notification was provided to (R64) and (R64's) responsible party for a facility-initiated transfer on 02/10/2023.
On the most recent MDS (minimum data set), an annual assessment with an ARD (assessment reference date) of 01/20/2023, (R64) scored three out of 15 on the BIMS (brief interview for mental status), indicating the resident was severely impaired of cognition for making daily decisions.
The facility's progress noted for (R64) dated 2/10/2023 at 7:35 a.m., documented in part, Situation: The Change In Condition/s reported on this CIC (change in condition) Evaluation are/were: Nausea/Vomiting . A. Recommendations: If resident has additional n/v (Nausea/Vomiting) please send to hospital for evaluation.
The facility's progress noted for (R64) dated 2/10/2023 at 10:05 a.m., documented. RT (Resident) sent to (Name of Hospital) at 0700 (7:00 a.m.) for vomiting and abnormal VS (vital signs).
Review of the clinical record and the EHR (electronic health record) for (R64) failed to evidence written notification of the discharge was provided to (R64) and (R64's) representative for the facility-initiated transfer on 02/10/2023.
On 02/22/2023 at approximately 3:58 p.m., an interview was conducted with OSM (other staff member) #1, director of social services. When asked about providing a written notification to the resident and the resident's RP regarding the transfer, OSM stated they mail a copy of the letter and scan it into the resident's electronic health record.
On 02/22/2023 at approximately 4:49 p.m., ASM (administrative staff member) #1, administrator, stated that they did not have evidence of providing written notification provided to (R64) and (R64's) responsible party for a facility-initiated transfer on 02/10/2023.
The facility's policy Resident Discharge / Transfer Letter Policy documented in part, E) Social Services or designee will assure the original discharge/transfer letter is given to resident or guardian/sponsor, id applicable. 1. Copies will be sent to Department of Health, Ombudsman Office, and filed in the business file and/or scanned into PCC (point click care - electronic health record) documents tab with administrator/designee signature, with certified receipt if applicable.
On 02/23/2023 at approximately 11:10 a.m., ASM #1, administrator, and ASM #2, director of nursing, and ASM #5, regional director of clinical services, were made aware of the above findings.
No further information was provided prior to exit

Based on clinical record review and staff interview it was determined that the facility staff failed to maintain an accurate MDS (minimum data set) assessment for one of 28 residents in the survey sample, Resident #38.
The findings include:
For Resident #38 (R38), the facility staff failed to code the quarterly MDS assessment with an ARD (assessment reference date) of 1/2/2023 for hospice services received during the assessment period.
Review of the clinical record for R38 revealed the most recent MDS assessment to be a quarterly MDS with an ARD of 1/2/2023. Section O of the assessment failed to document R38 receiving hospice services during the assessment period.
The physician orders for R38 documented in part, Admit to [Name of hospice] - Do Not Give Antibiotics, No Vital Signs or Weights, Do Not Send To ER (emergency room) or Hospital, Do Not Draw Blood, Collect Urine or XR (x-ray) Testing, Do Not Give Tube Feedings. Order Date: 06/28/2021.
The comprehensive care plan for R38 documented in part, HOSPICE SERVICES: Resident is on Hospice services, (Name of hospice) (phone number]) Date Initiated: 06/28/2021 .
On 2/22/2023 at 2:00 p.m., an interview was conducted with LPN (licensed practical nurse) #1, MDS coordinator. LPN #1 stated that they used the RAI (resident assessment instrument) manual as their guide when completing the MDS assessments. LPN #1 stated that R38 received hospice services and the MDS should be coded for the services. LPN #1 reviewed the quarterly MDS with the ARD of 1/2/2023 and stated that it was not coded for hospice and should have been and it would be corrected.
According to the RAI Manual, Version 1.16, dated October 2018, section O0100 documented in the steps for assessment, 1. Review the resident's medical record to determine whether or not the resident received or performed any of the treatments, procedures, or programs within the last 14 days .O0100K, Hospice Care, Code residents identified as being in a hospice program for terminally ill persons where an array of services is provided for the palliation and management of terminal illness and related conditions. The hospice must be licensed by the state as a hospice provider and/or certified under the Medicare program as a hospice provider .
On 2/22/2023 at 4:47 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, ASM #3, the assistant director of nursing/infection preventionist, ASM #4, the business office manager/administrator in training and ASM #5, the regional director of clinical services were made aware of the concern.
No further information was provided prior to exit.

Based on staff interview, facility document review and clinical record review, it was determined that the facility staff failed provide a bed hold policy notice to the resident or the resident's representative, for a facility-initiated transfer of one of 28 residents in the survey sample, Resident #64 (R64).
The findings include:
For (R64), the facility staff failed to evidence that a bed hold policy notice was provided to (R64) and (R64's) responsible party for a facility-initiated transfer on 02/10/2023.
On the most recent MDS (minimum data set), an annual assessment with an ARD (assessment reference date) of 01/20/2023, (R64) scored three out of 15 on the BIMS (brief interview for mental status), indicating the resident was severely impaired of cognition for making daily decisions.
The facility's progress noted for (R64) dated 2/10/2023 at 10:05 a.m., documented. RT (Resident) sent to (Name of Hospital) at 0700 (7:00 a.m.) for vomiting and abnormal VS (vital signs).
Review of the clinical record and the EHR (electronic health record) for (R64) failed to evidence a bed hold policy was provided to (R64) and (R64's) representative for the facility-initiated transfer on 02/10/2023.
On 02/22/2023 at approximately 3:58 p.m., an interview was conducted with OSM (other staff member) #1, director of social services. When asked about the procedure to provide a bed hold policy for a facility-initiated transfer, OSM #1 stated the hold policy is given to the resident when they to go to emergency room and then it is scanned into the resident's electronic health record.
On 02/22/2023 at approximately 4:49 p.m., ASM (administrative staff member) #1, administrator, stated that they did not have evidence of providing a bed hold policy to (R64) and (R64's) responsible party for a facility-initiated transfer on 02/10/2023.
The facility's policy Resident Discharge / Transfer Letter Policy documented in part, G) The resident or responsible party will receive a bed hold policy notice along with the discharge / transfer letter, when applicable. Bed hold notices can be found within PCC (point click care - electronic health record) under Document Manager .
On 02/23/2023 at approximately 11:10 a.m., ASM #1, administrator, and ASM #2, director of nursing, and ASM #5, regional director of clinical services, were made aware of the above findings.
No further information was provided prior to exit

Based on observation, staff interview, and clinical record review, it was determined the facility staff failed to maintain effective infection control for one of 28 residents in the survey sample, Resident #33.
The findings include:
For Resident #33 (R33), the facility staff failed to provide a treatment to a pressure ulcer in a manner to prevent infection.
The physician order dated, 2/21/2023, documented, Cleanse right heel with wound cleanser and apply xeroform and dressing daily to open blister.
On 2/23/2023 at 9:15 a.m., LPN (licensed practical nurse) #4 was observed providing a treatment to R33's right heel. LPN #4 was at the treatment cart where she got a 4x4 gauze packet, opened the packet by tearing it across one corner, used her hands to pull the gauze out of the packet and placed in on the outside of the packet. She proceeded to spray the gauze pad with wound cleanser. LPN #4 gathered the rest of her supplies; a xeroform dressing, a bordered gauze dressing, a 4x4 gauze pad, a red plastic bag, and a sterile field packet. LPN #4 entered the room. She placed the supplies on the overbed table that contained a container of thickened liquids on it. LPN #4 did not clean the table. LPN #4 then washed her hands, put on clean gloves, then proceeded to remove the current dressing from the right heel and placed it in the red bag. She then took the gauze pad, that had the wound cleanser on it and wiped the wound. She did not change gloves or perform hand hygiene between the dirty dressing and clean dressings. She then opened the clean 4x4 gauze pad by tearing it open, not using the edges to open it up. Dried the wound. Opened the xeroform dressing according to package directions, took a pair of scissors out of her pocket and proceeded to cut the xeroform dressing. She did not clean her scissors after removing them from her pocket. She placed the xeroform dressing on the wound. LPN #4 took the bordered dressing packet and tour it open and placed it on the resident's right heel. She took a marker out of her pocket which was the same pocket where the scissors were, and wrote the date and her initials on the dressing. LPN #4 removed her gloves, washed her hands and gathered the sterile field packet and returned to the treatment cart.
The above observations were reviewed with LPN #4, she concurred that she did not set up a clean field or used the sterile field packet, failed to change her gloves between taking the dressing off and putting on the new dressing, failed to clean her scissors, and failed to write the date and her initials prior to placing the dressing on the resident's heel.
A policy was requested for dressing application. The facility staff stated they did not have a policy; they follow standards of care.
Wound Care: Preventing Infection: Gather supplies (dressings, tape, scissors, sterile saline solution, cotton swabs, extra gauze and culture materials if indicated). Wash your hands thoroughly and don gloves. Ensure strict aseptic technique during dressing changes. Lippincott Manual of Nursing Practice, 11th Edition, Wolters and Kluwer, page 104.
ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, and ASM # 5, the regional director of clinical services, were made aware of the above finding on 2/23/2023 at 11:15 a.m.

Based on observation, staff interview, and facility document review it was determined facility staff failed to store food in the kitchen in accordance with professional standards for food service safety.
The facility failed to properly dispose of dry goods that were past their expiration date, dispose of milk past it expiration date and date/label refrigerated juice not stored in it's original container.
The findings include:
On 9/14/2021 at approximately 11:00 a.m., an observation of the facility's kitchen was conducted. Observation of the kitchen's dry storage area revealed an opened 24 ounce bag of french fried onions approximately three-quarters full with no open date on the package and a manufacturer's date on the package documenting Best used by 19:35 Jun (June) 24 2021. A second 24 ounce bag of french fried onions was observed on the shelf unopened with a manufacturer's date on the package documenting Best used by 19:33 Jun 24 2021.
Observations of the kitchen's walk in refrigerator revealed an approximately two quart sized clear plastic pitcher filled with a red liquid approximately 1/8 full. No label documenting what the pitcher contained or the date it was poured was observed. Further observation of the walk in refrigerator revealed 14 half-pint whole milk cartons with a manufacturer's date of sep (September) 12 observed in a crate with other half-pint milk cartons dated sep 20.
On 9/14/2021 at approximately 11:30 a.m., an interview was conducted with OSM (other staff member) #6, the dietary manager. OSM #6 stated that opened dry good stored in the dry storage area were dated with the opened date. OSM #6 stated that the french fried onions were out of date and should have been discarded. OSM #6 stated that the opened bag of french fried onions should have been dated when it was opened and thrown away when it expired. OSM #6 stated that the staff always checked the milk cartons when they retrieved them from the walk-in refrigerator before they were served but the 14 cartons of whole milk expired on 9/12/2021 and should not have been available for use in the refrigerator. OSM #6 stated that they received deliveries of milk every Monday and staff were supposed to go through the milk and discard any expired products. OSM #6 stated that it appeared someone had just placed the 14 milk cartons on top of the new ones in the milk crate. OSM #6 stated that the red liquid in the pitcher was V8 (tomato) juice and should have been labeled so they would know when it was poured and when to discard it. OSM #6 stated that the juice needed to be discarded.
On 9/15/2021 at approximately 5:15 p.m., a request was made to ASM (administrative staff member) #1, the administrator for the facility policy for storage of dry goods, discarding expired foods and storage of refrigerated foods in the facility.
The facility policy Storage of Dry Food Policy dated 6/21/2021 documented in part, Food and Nutrition Services will store dry goods in a manner which avoids contamination, optimizes food safety, and protects food quality .
The facility policy Storage of Refrigerated Food Policy dated 2/19/2019 documented in part, .Refrigerated items must have a label showing the name of the food and the date it should be consumed, or discarded . The policy further documented, Create a schedule to check food dates on a regular basis. If a food item has not been used by a specific date, throw it out, then clean and sanitize the container if it is a re-usable container.
On 9/15/2021 at approximately 5:20 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing and ASM #3, the regional director of clinical services were made aware of the findings.
No further information was provided prior to exit.

Based on observation, clinical record review, staff interviews and facility document review it was determined that the facility staff failed to ensure an injury of unknown origin was immediately reported to the administrator, State Agency and other officials for one of 34 residents in the survey sample, Resident #609.
The facility staff failed to immediately report an injury of unknown origin for Resident #609 that was first observed on 12/23/2020. The injury of unknown origin was not reported to the director of nursing until 12/24/2020 and the director of nursing failed to immediately report the injury to the administrator. Resident #609's injury of unknown origin was not reported to the administrator until 12/28/20 and to the appropriate agencies or the responsible party until 12/28/2020.
The findings include:
Resident #609 was admitted to the facility with diagnoses included but were not limited to osteoarthritis (1) and dementia without behavioral disturbance (2). Resident #609's most recent MDS (minimum data set), a significant change assessment with an ARD (assessment reference date) of 8/28/2021, documented Resident #609 as scoring a one on the brief interview for mental status (BIMS) of a score of 0 - 15, one - being severely impaired for making daily decisions. Section G documented Resident #609 requiring extensive assistance of one person for bed mobility and total assistance of two or more persons for transfers. Section J documented a fall in the last month prior to admission/entry or reentry.
The comprehensive care plan for Resident #609 documented in part, FALL RISK: Resident is at risk for falls characterized by history of falls, multiple risk factors related to: bladder incontinence, bowel incontinence, dementia, unaware of safety need, rolled out of right side of bed 3/4/21, 3/21/21- fall out of bed, 6/11/21-Fall w/ (with) laceration, 8/15/21-Fall/ sent to ER (emergency room) 8/17-with leg pain and bruising=admitted subdural hematoma (3), 9/2/21-Fall out of bed. Date Initiated: 08/25/2021 .
The progress notes for Resident #609 documented in part,
- 12/22/2020 17:38 (5:38 p.m.) Physician Progress note. Late Entry: Note Text: Patient was seen and examined today beside [Sic]. Necessity for Skilled Nursing home stay visit. Medications and allergies reviewed, continue as ordered. The current medical regimen and psycho-social regimen reviewed, assessed and evaluated. Continue plan of care discuss with staffs. Chart reviewed for continued appropriateness of meds/ (medications) dosages. Allergies reviewed. Diagnosis reviewed to correspond with meds. Discussed with nurse manager when changes needed. Currently doing well without acute medical concerns per nursing staff. Comfortable beside [Sic.] with no apparent clinical complaints .Skin: no rash, itching. HEENT (head, eyes, ears, nose, throat): no runny nose, nasal congestion or sore throat .
- 12/23/2020 08:00 (8:00 a.m.) Nursing note: Late Entry: Note Text: on 12/23/2020 before breakfast around 0800 hrs. The NP (nurse practitioner) noted a hematoma (4) in the residents forehead and asked for vitals I took them and handed them to her. Resident is usually out of bed by 0700 when our shift begins. I had not noticed this or been told about any injuries or accidents during my on shift report. Until the NP told me.
- 12/27/2020 06:51 (6:51 a.m.) Nursing note: Note Text: CNA (certified nursing assistant) called this nurse in residents room, This nurse noted old bruising around eyes and forehead, bruising yellow/green in color. Multiple areas about face. Resident does not know what happened and denies any pain at all. Oncoming Nurse made aware.
- 12/28/2020 18:55 (6:55 p.m.) Head to toe Eval. (evaluation) Late Entry: Overview: This note is a follow up to bruising to face .NP (nurse practitioner) and RP (responsible party) notified - Resident with continued bruising to forehead, nose, eyes, and cheeks. Bruising is fading down her face. No pain or tenderness.
- 12/28/2020 19:46 (7:46 p.m.) Family/Responsible Party Contact Note. Note Text: Notified daughter (emergency contact #1) about hematoma and bruising found on resident's face on 12/23/2020. No concerns were expressed at this time to me.
- 12/29/2020 10:59 (10:59 a.m.) Nursing note: Late Entry: Note Text: Resident discussed by IDT (interdisciplinary) this morning r/t (related to) hematoma and bruising to the face. Resident could have hit her head on her grab bars while in bed, or she may have hit her forehead on the footboard of her bed. She was previously observed sitting in her wheelchair with her head resting on the top of the footboard. IDT recommended that resident be reassessed for the use of grab bars, pad the top of her footboard, and place a concave mattress on her bed. She has no complaints of pain.
- 12/29/2020 15:04 (3:04 p.m.) Social Services note. Note Text: Writer visited resident today R/T recent incident. Resident displayed no ill effects from the incident. Resident was not fearful when writer visited. Resident noted to be at baseline as to talking to her baby doll while up in W/C (wheelchair) sitting near her door way.
- 1/1/2021 20:00 (8:00 p.m.) Head to Toe eval. Overview: This note is a follow up to bruising to face with unknown cause . no c/o pain from bruising to face
Review of the Facility Reported Incidents (FRI) provided upon survey entrance documented a FRI dated 12/28/2020 for Resident #609 which documented in part, Report Date: 12/28/2020, Incident Date: 12/23/2020. Resident Involved: [Resident #609], Injuries: No, Injury of unknown origin, on 12/23/2020 resident was seen by NP (nurse practitioner) before breakfast and she noted a large hematoma to the right side forehead. Resident has history of being combative with ADL (sanctities of daily living) care and is noted to lay on footboard of bed when in room. Resident has no complaints of pain and has severe dementia and unable to be interviewed. Staff are being interviewed and statements obtained. Investigation underway and final outcome to follow .If applicable, date notification provided to: Responsible party 12/28/2020, Physician 12/23/2020, APS (adult protective services) 12/28/2020 . Attached to the FRI document were 12 facsimile transmission reports starting on 12/28/2020 at 19:17 (7:17 p.m.) with a successful transmission of the FRI on 12/29/2020 at 12:50 (12:50 p.m.).
Included in the FRI folder for Resident #609 dated 12/28/2020 was an incident report dated 12/23/2020 0800 (8:00 a.m.) for Resident #609 which documented in part, Incident Description: 0800 NP saw resident on 12/23 and noted hematoma on right side of forehead and reported to the nurse at this time. This resident is unable to tell how hematoma occurred due to dementia, she does have history of thrashing around in bed when care provided. She also will lay her forehead on footboard when up in w/c and leans forward. 12/25/2020 skin assessment noted bruising around eyes and hematoma. Hematoma is resolving and the bruising is showing up around eyes. She was observed leaning head also on footboard, that is noted on the skin check. 12/27/2020 Nurse's note that indicates that bruising is resolving around the eyes and forehead. Denies any pain. Resident description: Resident unable to give description .Agencies/People Notified: Responsible party: [Name of RP] 12/28/2020 16:52 (4:52 p.m.), physician [Name of NP] 12/23/2020 08:01 (8:01 a.m.).
Included in the FRI folder for Resident #609 dated 12/28/2020 was a document titled Abatement Plan for Late Reporting on 12/28/2020. It documented in part, Problem: Incident reported to Admin (administrator) on 12/27 (12/27/2020). 0800 NP saw resident on 12/23 and noted hematoma on right side of forehead and reported to the nurse at this time. The nurse did not document in an incident report or in nurses notes on 12/23/2020. Late entry placed on 12/28/2020. The resident is unable to tell how hematoma occurred due to dementia, she does have history of thrashing around in bed when care provided. 12/24/2020 DON (director of nursing) was aware of bruise and began questioning staff. COVID (5) testing as well and had positive resident that needed to be moved and setting up unit. Follow through and reporting timely was not done .12/28/2020 No abuse indicated. No psychosocial harm noted, not fearful of staff when speaking to. FRI completed and sent to OLC (office of licensure and certification), Ombudsman, APS (adult protective services). RP notified. Gathering statements from staff that worked 12/22 and 12/23/2020. Statements from 11-7 (11:00 p.m.-7:00 a.m.) aide indicates that resident was combative with care on morning of 12/23/2020 and may have hit head on side rail at that time. The hematoma was noted by the NP on 12/23/2020 on AM (morning) rounds. 12/29/2020 Padded footboard as leans head on when up in w/c. 12/29/2020 Side rail asst. (assessment) redone to assess for need for SR (side rail) and side rails were removed. Believe hit head on footboard or rails, no abuse indicated. Interventions: 12/28/2020 FRI was done to all required agencies. RP notification. Care plan updated. Chart reviewed. Employee interviews performed. Resident is non-interviewable. Education to staff started for Abuse policy, documentation, and reporting. DON and ADMIN (administrator) education completed for timely reporting. RDCS (regional director of clinical services) and Administrator went and saw resident and resident was pleasantly confused and did not appear fearful at time of visit. No apparent psychosocial harm seen. She was holding doll baby and talking to us in non-coherent speech r/t her severe dementia. Looked at like residents. All residents with BIMS 9 and below that have side rails were reviewed and re-assessed for needs of side rails. If not needed, rails removed. 12/29/2020 Padded foot board as she leans forward in chair and lays head on edge of footboard. Side rails removed as re-assessed and found that resident does not need. She was given a concave mattress to help define the perimeters of the bed. Bed in low position for safety. Social services saw resident to ensure no psychosocial harm. Social services to see resident weekly for 4 weeks and document to ensure doing well. Education completed. Adhoc QAPI (quality assessment performance improvement) held. Audits: All incidents will be reviewed in AM clinical meeting 5 times a week for next 3 months to indicate if incident is reportable. Report as per the regulation and policy. The findings will be reported to monthly QAPI for the next 3 months. Administrator will be in charge of this audit tool in the AM meeting. Findings: The facility can substantiate that they failed to report this incident timely and that the injury remains unknown, but is believed not due to any type of abuse. The resident has history of combative behaviors with ADL: care. She has history of thrashing around in the bed when care provided and had 1/4 side rails that she could have hit on during care. 11-7 aide statement that says she was combative with car eon the AM on 12/23/2020. The are [sic] on right forehead was not noted until the AM by the NP on early AM rounds. Side rails have been removed for no further injury of this nature can occur and also padded the edge of the foot board as she also likes to lay head on edge of when up in wheelchair. Education has been provided to all nurses, Aides, DON, and Administrator on reporting and documentation.
An education sign-in sheet dated 12/28/2020 documented the director of nursing and administrator who were employed at the facility at that time being educated on timely reporting. It documented, Any incident of unknown origin has to be reported timely. Injury [within] 2 (hours) & if 0 (not) [within] 24 (hours) as soon as notification of an incident you have to report to RDCS (regional director of clinical services), FRI, Quick response . Included with the document was documentation of nursing staff inservice completed on 12/28/2021 at 10:30 a.m., 11:30 a.m., 2:00 p.m., 3:30 p.m., 12/29/2021 at 7:15 a.m., 1:00 p.m., 3:15 p.m., and 12/30/2021 at 8:00 a.m., 12:00 p.m., and 4:00 p.m. on Documentation requirements and reporting policy of Injury of unknown origin. Abuse/reporting policy.
The QAPI (quality assessment and performance improvement) action plan dated 12/29/2020 documented a meeting focusing on late reporting of an injury of unknown origin to the state and the RP (responsible party), the incident report not completed timely and late entry documentation in the nurse's notes. The QAPI action plan documented in part, staff education, correction action interventions specific to Resident #609, identification and assessment of similar residents with potential for injury of unknown origin and the facility plan to audit and monitor performance with an actual completion date of 12/29/2020 and onging audits for three months.
The staff sign-in sheets for the timely reporting, documentation of incidents, reporting and Abuse policy were reviewed and verified by multiple staff interviews. The other points of the plan of correction as described in this writing were verified with facility document review, observations, and clinical record reviews and staff interviews. No concerns were identified.
On 9/15/2021 at 3:45 p.m., an interview was conducted with ASM (administrative staff member) #1, the administrator. ASM #1 stated that the former administrator and former director of nursing were employed at the time of the injury of unknown origin FRI reported for Resident #609. ASM #1 stated that any injuries of unknown origin were investigated to determine a possible cause. ASM #1 stated that staff reported any injuries to them or the DON who investigated and reported them to the appropriate agencies. ASM #1 stated that immediately upon discovery the staff completed a full body assessment, vital signs, and neurological checks. ASM #1 stated that if the residents was interviewable they would ask them what happened and get statements. ASM #1 stated that in the case of Resident #609 they would not be able to say what happened and was not witnessed so they could only guess at the possible cause. ASM #1 stated that after speaking with any witnesses and getting a statement from the resident they would report the incident as an injury of unknown origin immediately to the appropriate agencies. ASM #1 stated that they had extending the QAPI for reviewing all incidents and accidents through January of 2022. ASM #1 stated that their understanding of why the FRI was sent in late to the state agency was that the DON did not report it to the administrator. ASM #1 stated that the FRI folder documented all nursing staff including CNA's (certified nursing staff) were educated on timely reporting, documentation and the abuse policy.
The facility policy Abuse, Neglect and Exploitation with a revision date of 7/14/2020 documented in part, It is the facility's policy to investigate all allegations, suspicions and incidents of abuse, neglect, involuntary seclusion, exploitation of residents, misappropriation of resident property and injuries of unknown source. Facility staff must immediately report all such allegations to the Administrator/Abuse coordinator. The Administrator/Abuse coordinator will immediately begin an investigation and notify the applicable local and state agencies in accordance with the procedures in this policy . It further documented, .Documentation in the nurses' notes should include the results of the resident's ROM (range of motion), body assessment, vital signs, the notification of the physician and the responsible party and treatment provided. Appropriate quality assurance documentation should be completed as well. Initial Reports. Timing. All allegations of Abuse, Neglect, Involuntary Seclusion, Injuries of Unknown Source, and Misappropriation of resident property must be reported immediately to the Administrator, Director of Nursing (DON) and to the applicable state agency .
On 9/15/2021 at approximately 5:20 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing and ASM #3, the regional director of clinical services were made aware of the concern.
PAST NONCOMPLIANCE
References:
1. Osteoarthritis-
Makes your bones weak and more likely to break. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/osteoporosis.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/000739.htm.
3. Subdural hematoma
A subdural hematoma is a collection of blood between the covering of the brain (dura) and the surface of the brain. This information was obtained from the website: https://medlineplus.gov/ency/article/000713.htm.
4. Hematoma
A bruise is an area of skin discoloration. A bruise occurs when small blood vessels break and leak their contents into the soft tissue beneath the skin. This information was obtained from the website: https://medlineplus.gov/ency/article/007213.htm.
5. COVID-19
COVID-19 is caused by a coronavirus called SARS-CoV-2. Coronaviruses are a large family of viruses that are common in people and may different species of animals, including camels, cattle, cats, and bats. Rarely, animal coronaviruses can infect people and then spread between people. This occurred with MERS-CoV and SARS-CoV, and now with the virus that causes COVID-19. The SARS-CoV-2 virus is a betacoronavirus, like MERS-CoV and SARS-CoV. All three of these viruses have their origins in bats. The sequences from U.S. patients are similar to the one that China initially posted, suggesting a likely single, recent emergence of this virus from an animal reservoir. However, the exact source of this virus is unknown. This information was obtained from the website: https://www.cdc.gov/coronavirus/2019-ncov/faq.html#How-COVID-19-Spreads.

Based on resident interview, staff interview and clinical record review it was determined that the facility staff failed to submit an accurate MDS (minimum data set) assessment for one of 34 residents in the survey sample, Resident #49.
Resident #49's quarterly MDS assessment with an ARD of 8/20/2021, in Section O failed to code Resident #49 as receiving oxygen during the assessment period.
The findings include:
Resident #49 was admitted to the facility with diagnoses that included but were not limited to congestive heart failure (1) and chronic obstructive pulmonary disease (2).
Resident #49's most recent MDS, a quarterly assessment with an ARD of 8/20/2021, coded Resident #49 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 O failed to coded Resident #49 receiving oxygen during the assessment period.
On 9/14/2021 at 2:08 p.m., an interview was conducted with Resident #49. Resident #49 was observed in bed wearing a nasal cannula attached to an oxygen concentrator. Resident #49 stated that they wore the oxygen all the time and needed it because they had lung problems.
Review of the clinical record revealed a physician's order dated 3/12/2021 which documented, O2 (oxygen) at @2 [sic] lpm (liters per minute) via NC (nasal cannula) every shift related to acute and chronic respiratory failure with hypoxia (3).
The eMAR (electronic medication administration record) for Resident #49 dated 8/1/2021-8/31/2021 and 9/1/2021-9/30/2021 documented O2 at 2 lpm received by nasal cannula every shift each day from 8/1/2021 through the current date.
The comprehensive care plan for Resident #49 dated 3/12/2021 documented in part, Oxygen use: Resident requires oxygen R/T (related to) COPD (chronic obstructive pulmonary disease) . Date Initiated: 03/12/2021; Revision on: 06/28/2021.
On 9/15/2021 at 11:51 a.m., an interview was conducted with LPN (licensed practical nurse) #2. LPN #2 stated that Resident #49 received oxygen by nasal cannula at all times and they documented this on the medication administration record.
On 9/16/2021 at 7:40 a.m., an interview was conducted with LPN #7, the MDS nurse. LPN #7 stated that they reviewed the resident's physician orders and clinical record when completing the MDS. LPN #7 stated that oxygen use was documented on the MDS assessment. When asked about Resident #49's quarterly MDS with the ARD of 8/20/2021 documenting oxygen use, LPN #7 stated that if Resident #49 was wearing the oxygen, had an order and it was documented on the administration record it should be documented on the MDS. LPN #7 stated that they were going to review the MDS to see if it was documented.
On 9/16/2021 at 8:05 a.m., LPN #7 reviewed Resident #49's quarterly MDS with the ARD of 8/20/2021 assessment and stated that oxygen was not documented and they would do a correction to add it. LPN #7 stated that they followed the RAI (resident assessment instrument) manual when completing the MDS assessments.
According to the RAI Manual, Version 1.16, dated October 2018, section O0100 documented in part, .Review the resident's medical record to determine whether or not the resident received or performed any of the treatments, procedures, or programs within the last 14 days .Check all treatments, procedures, and programs received or performed by the resident after admission/entry or reentry to the facility and within the 14-day look-back period .
On 9/16/2021 at approximately 8:40 a.m., ASM (administrative staff member) #1, the administrator was made aware of the findings.
No further information was provided prior to exit.
References:
1. Congestive heart failure: A condition in which the heart can't pump enough blood to meet the body's needs. Heart failure does not mean that your heart has stopped or is about to stop working. It means that your heart is not able to pump blood the way it should. It can affect one or both sides of the heart. This information was obtained from the website: https://medlineplus.gov/heartfailure.html
2. Chronic obstructive pulmonary disease (COPD): 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/copd.html.
3. Respiratory failure: When not enough oxygen passes from your lungs into your blood. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/respiratoryfailure.html.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, facility document review and clinical record review, it was determined that the facility staff failed to follow professional standards of practice for one of 34 residents in the survey sample, Resident #42.
The facility staff failed to clarify a physician's order to include the size of Resident #42's Foley urinary catheter (1).
The findings include:
Resident #42 was admitted to the facility on [DATE] and readmitted on [DATE]. Resident #42's diagnoses included but were not limited to chronic kidney disease, bladder disorder and muscle weakness. Resident #42's significant change in status minimum data set assessment with an assessment reference date of 8/19/21, coded the resident's cognition as moderately impaired. Section H coded Resident #42 as having a urinary catheter.
Review of Resident #42's clinical record revealed a physician's order dated 6/4/21 to change the resident's catheter as needed. Review of all physician's orders active as of 9/15/21 failed to reveal a physician's order for the size of the urinary catheter.
Resident #42's comprehensive care plan revised on 3/20/20 documented, Foley (size) 14F (French) 5cc (cubic centimeters) (balloon).
On 9/15/21 at 1:02 p.m., an interview was conducted with LPN (licensed practical nurse) #2. LPN #2 stated physician's orders for urinary catheters should contain the frequency the catheter should be changed and contain the size of the catheter. LPN #2 stated physician's orders for urinary catheters should contain the size because catheters come in all different sizes; someone may need a smaller catheter and someone may need a larger catheter.
On 9/15/21 at 2:03 p.m., another interview was conducted with LPN #2. LPN #2 reviewed Resident #42's physician's orders and stated there was no order for the size of Resident #42's urinary catheter. LPN #2 stated the physician's order for Resident #42's catheter needed to be clarified and the order needed to be put into the computer system.
On 9/15/21 at 5:27 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing) were made aware of the above concern.
On 9/16/21 at 7:39 a.m., an interview was conducted with LPN #7, the nurse who documented the catheter size on Resident #42's comprehensive care plan. LPN #7 stated Resident #42 went to the hospital to have his catheter replaced and she thought she obtained the size information from hospital documentation but would check. LPN #7 stated there should at least be a nurse's note but the physician's order for the catheter size should have been updated.
On 9/16/21 at approximately 7:50 a.m., LPN #7 stated she obtained the catheter size information from a nurse's note. The nurse's note dated 11/22/19 documented, Resident returned from (name of hospital) with 14fr (French) Foley intact draining yellow colored urine, no c/o (complaint of) pain or discomfort, no new orders.
The facility policy titled, Physician/Provider Orders documented, POLICY: The Charge Nurse shall transcribe and review all physician/provider orders .
The facility standard of practice LIPPINCOTT MANUAL OF NURSING PRACTICE 11th Edition, 2019 documented, 1. Integral to the practice of any profession is the inherent need to be responsible for actions taken and for omissions. 2. The professional nurse must be proactive and take all appropriate measures to ensure that professional practice is not lacking, remiss, or deficient in any area or way .e. Examine the quality (accuracy and completeness) of documentation.
No further information was presented prior to exit.
Reference:
(1) A urinary catheter is a tube placed in the body to drain and collect urine from the bladder. This information was obtained from the website: https://medlineplus.gov/ency/article/003981.htm

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, facility document review and clinical record review, it was determined that the facility staff failed to implement bed rail requirements for one of 34 residents in the survey sample, Resident #51.
The facility staff implemented bed rails for Resident #51 without a documented clinical need.
The findings include:
Resident #51 was admitted to the facility on [DATE]. Resident #51's diagnoses included but were not limited to muscle weakness, high blood pressure and malnutrition. Resident #51's significant change in status minimum data set assessment with an assessment reference date of 8/27/21, coded the resident's cognition as severely impaired. Section G coded Resident #51 as totally dependent on two or more staff with bed mobility.
On 9/14/21 at 1:49 p.m. and 9/15/21 at 8:21 a.m., Resident #51 was observed lying on her back in bed with bilateral one forth bed rails in the upright position.
Review of Resident #51's clinical record revealed a bed rail assessment dated [DATE], signed by LPN (licensed practical nurse) #2 that documented, 1. Medical need(s) for the side rail (bed rail) being considered: N/A (not applicable). 2. Resident's benefits from the use of side rail: N/A. 3. Alternatives attempted that failed to meet resident's need/alternatives considered but not attempted because they were considered inappropriate/ or refused by resident/resident representative, prior to the use of side rails: N/A .
Resident #51's comprehensive care plan dated 8/28/20 failed to document information regarding bed rails.
Review of Resident #51's physician's orders active as of 9/15/21 failed to reveal a physician's order for bed rails.
On 9/15/21 at 2:03 p.m., an interview was conducted with LPN #2. LPN #2 reviewed Resident #51's bed rail assessment dated [DATE]. LPN #2 stated she documented, N/A for medical needs for the bed rails because there was no medical need and no physician's order. LPN #2 stated she documented, N/A for benefits for the use of bed rails because she did not think Resident #51 benefited from the use of bed rails. LPN #2 stated Resident #51 stays in one position and will hold the bed rail if asked but will not grab the bed rail for herself.
On 9/15/21 at 5:27 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing) were made aware of the above concern.
The facility policy titled, Bed Rail Policy documented, Policy: The use of bed rails will be limited to circumstances where they are used to treat a medical condition and enhance the resident's functional abilities.
No further information was presented prior to exit.

Based on staff interview and facility document review, it was determined that the facility staff failed to complete an annual CNA (certified nursing aide) performance review for one of five CNA record reviews.
The facility staff failed to complete an annual performance review for CNA #3.
The findings include:
CNA #3 was hired on 8/8/18. Review of CNA #3's record revealed the last performance review was completed on 10/1/19.
On 9/15/21 at 10:53 a.m., an interview was conducted with ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing). ASM #1 stated usually the director of nursing is responsible for completing CNA's annual performance reviews. ASM #2 stated she had only been employed at the facility for approximately three weeks and had not completed performance reviews. ASM #1 stated annual performance reviews should be completed based on a monthly report ran by human resources and CNA #3's annual performance review was missed. ASM #1 was made aware this was a concern.
On 9/15/21 at 1:00 p.m., ASM #1 stated the facility did not have a specific policy for annual performance reviews.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and clinical record review it was determined that the facility staff failed to accurately complete a MDS (minimum data set) resident assessment for one of 42 residents in the survey sample, Resident #77. The facility staff failed to accurately complete the quarterly MDS (minimum data set) regarding the use of psychotropic medications for Resident #77 with the ARD (assessment reference date) of 01/31/2020.
The findings include:
Resident #77 was admitted to the facility on [DATE] with a readmission on [DATE] with diagnoses that included but were not limited to anxiety disorder (1), schizoaffective disorder (2) and major depressive disorder (3).
Resident #77's most recent MDS, a quarterly assessment with an ARD of 01/31/2020, coded Resident #77 as scoring a 12 on the brief interview for mental status (BIMS) of a score of 0 - 12, 12 - being moderately impaired for making daily decisions.
Review of the clinical record revealed a list of Resident #77's MDS assessments. The list revealed that a quarterly MDS assessment was completed on 01/31/2020. Section N0410 Medications Received of the 1/31/2020 assessment documented Resident #77 as having received antipsychotic medication during the previous seven days of the assessment period. Further review of the MDS assessment in section N0450 Antipsychotic Medication Review documented no antipsychotics were received since admission, reentry or the prior assessment.
The physician order summary dated 2/13/20 documented Seroquel (4) tablet 100 mg (milligram), give 1 (one) tablet by mouth at bedtime related to schizoaffective disorder, unspecified; Order Date: 01/11/2020; Start Date: 01/12/2020.
Review of the January MAR (medication administration record) revealed the above physician order and documented the medication was administered as ordered.
The comprehensive care plan Antipsychotic med use: Schizoaffective Disorder, The resident uses antipsychotic medications r/t (related to) Schizoaffective Disorder, Date Initiated: 02/26/2019, Revision on: 07/22/2019 for Resident #77 documented in part, Administer medications as ordered. Monitor/document for side effects and effectiveness. Date Initiated: 02/26/2019.
On 2/13/20 at 9:45 a.m., an interview was conducted with LPN (licensed practical nurse) #5, MDS coordinator. When asked how the MDS is completed, LPN #5 stated that the RAI (resident assessment instrument) manual is used as their guide in completing the assessment. When asked about section N of the 1/31/2020 quarterly MDS assessment for Resident #77, LPN #5 stated that both questions regarding antipsychotics should have documented Resident #77 receiving antipsychotics. LPN #5 stated that Resident #77 had been on antipsychotics since her initial admission to the facility and the question that documented no antipsychotics received since admission or reentry was incorrect and would be corrected.
According to the RAI Manual, Version 1.16, dated October 2018, guidance for completion of Section N documented the following:
Steps for Assessment
1. Review the resident's medication administration records to determine if the resident received an antipsychotic medication since admission/entry or reentry or the prior OBRA assessment, whichever is more recent.
2. If the resident received an antipsychotic medication, review the medical record to determine if a gradual dose reduction has been attempted.
3. If a gradual dose reduction was not attempted, review the medical record to determine if there is physician documentation that the GDR is clinically contraindicated.
Coding Instructions for N0450A
- Code 0, no: if antipsychotics were not received: Skip N0450B, N0450C, N0450D and N0450E.
- Code 1, yes: if antipsychotics were received on a routine basis only: Continue to N0450B, Has a GDR been attempted?
- Code 2, yes: if antipsychotics were received on a PRN basis only: Continue to N0450B, Has a GDR been attempted?
- Code 3, yes: if antipsychotics were received on a routine and PRN basis: Continue to N0450B, Has a GDR been attempted?
On 2/13/20 at approximately 10:20 a.m., a request was made to ASM (administrative staff member) #2, the director of nursing for the facility policy on the completion of the MDS.
On 2/13/20 at approximately 11:15 a.m., ASM #1, the administrator stated that the facility did not have a policy for the completion of the MDS and that they use the RAI manual.
On 2/13/20 at approximately 12:30 p.m., ASM #1, the administrator was made aware of the findings.
No further information was provided prior to exit.
References:
1. Anxiety - is fear. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/anxiety.html#summary.
2. Schizoaffective disorder is a mental condition that causes both a loss of contact with reality [psychosis] and mood problems [depression or mania]. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/ency/article/000930.htm.
3. Major depressive disorder is a mood disorder. It occurs when feelings of sadness, loss, anger, or frustration get in the way of your life over a long period of time. It also changes how your body works. This information was obtained from the website: https://medlineplus.gov/ency/article/000945.htm.
4. Seroquel (quetiapine) is an antipsychotic medicine. It works by changing the actions of chemicals in the brain. Seroquel is used to treat schizophrenia in adults and children who are at least [AGE] years old. Seroquel is used to treat bipolar disorder (manic depression) in adults and children who are at least [AGE] years old. Seroquel is also used together with antidepressant medications to treat major depressive disorder in adults. Seroquel may also be used for purposes not listed in this medication guide. This information was obtained from the website: https://www.drugs.com/seroquel.html

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Resident # 73 was admitted to the facility with diagnoses that included but were not limited to high blood pressure and anxiety [1].
Resident # 73's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of [DATE], coded Resident # 73 as scoring a three on the brief interview for mental status (BIMS) of a score of 0 - 15, three - being severely impaired of cognition for making daily decisions.
Review of Resident # 73's clinical record failed to evidence an advance directive. Further review of the clinical record revealed a Care Plan Conference Summary dated [DATE]. The Care Plan Conference Summary documented in part, Topics Discussed: Adv. Dir. [Advance Directive/Code Status: Discussed with Res. Rep [Resident Representative]. Comments DNR [Do Not Resuscitate]. Further review of the Care Plan Conference Summary failed to evidence a review was conducted to provide Resident # 73 and/or Resident # 73's representative with the opportunity to develop an advance directive.
The comprehensive care plan for Resident # 73 with a revision date of [DATE] documented in part, Focus: Code Status: Resident/Responsible party has chosen DNR. Under Interventions it documented, Review code status annually, quarterly and/or PRN [as needed]. Revision on: [DATE].
On [DATE] at 3:20 p.m., an interview was conducted with OSM [other staff member] # 3, social services director. When asked about the facility process for advanced directives, OSM # 3 stated that on admission staff follow up with the family to see if the resident has an advanced directive and get a copy if they do. OSM # 3 stated that if the resident comes from the hospital they contact the hospital to obtain any advanced directive to have on file. OSM # 3 stated that the admissions director is the first point of contact for new admission and the social services department is the second. OSM # 3 stated that the welcome packed it given to new admissions by the admissions director which contains information on formulating advanced directives. OSM # 3 stated that an admission huddle is also performed prior to admission where advanced directives are discussed.
On [DATE] at 3:51 p.m., an interview was conducted with OSM # 4, the admission director. When asked about the facility process for advanced directives, OSM # 4 stated that residents are asked if they have an advanced directive and if the resident has one, a copy is obtained and placed in the chart. OSM # 4 stated that if the resident comes from home or the hospital a welcome packet is given to the resident which contains information on advance directives. OSM # 4 stated that a path meeting is conducted with the resident or the responsible party and an advance directive is offered during the meeting. When asked if it is documented that advance directives are offered on admission, OSM # 4 stated that if the resident elects to develop an advance directive on admission the document would be on the chart and if they do not elect to develop an advance directive on admission there is no documentation of it. OSM # 4 stated that after admission social services picks up the advance directive process for review and revision.
On [DATE] at 10:00a.m., a follow up interview was conducted with OSM #3. After OSM #3 reviewed Resident # 75's Care Plan Conference Summary they were asked if there was evidence that Resident # 73 and/or Resident # 73's representative was given the opportunity to develop an advance directive. OSM # 3 stated no.
On [DATE] at 1:20 p.m. ASM [administrative staff member] # 1, administrator, ASM # 2, director of nursing, and RN [registered nurse] # 1, assistant director of nursing were made aware of the above findings.
No further information was provided prior to exit.
References:
[1]Fear. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/anxiety.html#summary.
Based on resident interview, staff interview, facility document review, and clinical record review, it was determined the facility staff failed to implement the facility policies to meet the requirements for advanced directives for six of 42 residents in the survey sample, Residents #6, #54, #44, #73, #31 and #63. The facility staff failed failed to evidence periodic review of resident (or the resident's representative) decisions for advance directives, with the opportunity to develop an advance directive, for Resident #6, #54, #44, #73, #31, and #63.
The findings included:
1. Resident #6 was admitted to the facility on [DATE]. His diagnoses included muscle weakness, depression, and high cholesterol. Resident #6's most recent Minimum Data Set (MDS) Assessment was a Significant Change Assessment with an Assessment Reference Date (ARD) of [DATE]. The Brief Interview for Mental Status (BIMS) scored Resident #6 at a 10, indicating moderate impairment. Resident #6 was coded as requiring extensive assistance of 1 person for most Activities of Daily Living (ADLs).
A review of the facility policy on Advanced Directives revealed the following:
Upon admission and during Your Path Meetings, advanced directives will be discussed with resident and/or resident representative to determine if any advanced directives have been chosen. Advanced directives will be reviewed at minimum annually according to MDS schedule.
A review of the resident record failed to reveal documented evidence that facility staff had conducted reviews of Resident #6's wishes regarding advanced directives.
On [DATE], at approximately 5:00 p.m., the facility staff were asked to look for documentation of periodic reviews of the advanced directives and to provide this information.
On the morning of [DATE], at approximately 8:30 a.m., the facility staff provided documentation of My Path meetings for Resident #6. On the My Path meeting sheet the following was documented: DNR - Reviewed/Addressed. There was no documentation of Advanced Directives was made.
On [DATE] at 3:20 p.m., an interview was conducted with Other Staff Member (OSM) #3, the Social Services Director. OSM #3 was asked about the importance of reviewing the Advanced Directive. OSM #3 stated An advanced directive tells us if there is gonna be a DNR [do not resuscitate], whether there is gonna be CPR [cardiopulmonary resuscitation], it contains a few separate things. When asked if there was a difference between an Advanced Directive and a resident's Code Status, OSM #3 stated yes there is. When presented with the My Path meeting document for Resident #6, and asked if the line documented above was referring to an Advanced Directive or just Code Status. OSM #3 stated that it looked like a description of Code Status was written. OSM #3 was asked to locate any further documentation of a review of the Advanced Directives for Resident #6.
On [DATE] at 9:59 a.m., OSM #3 stated that no further documentation related to Advanced Directives was available for Resident #6.
Administrative Staff Member (ASM) #1, the facility Administration, and ASM #2, the Director of Nursing, were informed of the findings at the end of day meeting on [DATE]. No further information was provided.
2. Resident #28 was admitted to the facility on [DATE]. His diagnoses included muscle weakness and depression. Resident #28's most recent MDS Assessment was a Quarterly Assessment with an ARD of [DATE]. The BIMS scored Resident #28 at a 9, indicating moderate impairment. Resident #28 was coded as requiring extensive assistance of 1 person for most ADLs.
A review of the resident record failed to reveal documented evidence that facility staff had conducted reviews of Resident #28's wishes regarding advanced directives.
On [DATE], at approximately 5:00 p.m., the facility staff were asked to look for documentation of periodic reviews of the advanced directives and to provide this information.
On the morning of [DATE], at approximately 8:30 a.m., the facility staff provided documentation of My Path meetings for Resident #28. On the My Path meeting sheet the following was documented for Resident #28 on the line Adv. Dir/Code Status: Full Code - Addressed/Reviewed. No documentation of Advanced Directives was made.
On [DATE] at 9:59 a.m., OSM #3 stated that no further documentation related to Advanced Directives was available for Resident #28.
Administrative Staff Member (ASM) #1, the facility Administration, and ASM #2, the Director of Nursing, were informed of the findings at the end of day meeting on [DATE]. No further information was provided.
3. Resident #59 was admitted to the facility on [DATE]. Her diagnoses included pneumonia and depression. Resident #59's most recent MDS Assessment was a Quarterly Assessment with an ARD of [DATE]. The BIMS scored Resident #59 at a 7, indicating severe impairment. Resident #59 was coded as requiring extensive assistance of 1 person for ADLs.
A review of the resident record failed to reveal documented evidence that facility staff had conducted reviews of Resident #59's wishes regarding advanced directives.
On [DATE], at approximately 5:00 p.m., the facility staff were asked to look for documentation of periodic reviews of the advanced directives and to provide this information.
On the morning of [DATE], at approximately 8:30 a.m., the facility staff provided documentation of My Path meetings for Resident #59. On the My Path meeting sheet the following was documented for Resident #59 on the line Adv. Dir/Code Status: Full Code - Addressed/Reviewed. No documentation of Advanced Directives was made.
On [DATE] at 9:59a.m. OSM #3 stated that no further documentation related to Advanced Directives was available for Resident #59.
Administrative Staff Member (ASM) #1, the facility Administration, and ASM #2, the Director of Nursing, were informed of the findings at the end of day meeting on [DATE]. No further information was provided.
5. The facility staff failed to periodically review Resident #31's (or the resident's representative) decisions regarding advance directives.
Resident #31 was admitted to the facility on [DATE] with a readmission on [DATE]. Resident #31's diagnoses included but were not limited to major depressive disorder (1) and dementia (2).
Resident #31's most recent MDS (minimum data set), a significant change assessment with an ARD (assessment reference date) of [DATE], coded Resident #31 as scoring a 1 (one) on the staff assessment for mental status (BIMS) of a score of 0 - 15, 1- being severely impaired for making daily decisions.
Review of Resident #31's clinical record revealed a document Care Plan Conference Summary dated [DATE] which documented in part DNR (do not resuscitate) addressed-reviewed but failed to evidence documentation of periodic review of advance directives with Resident #31's representative.
The comprehensive care plan for Resident #31 documented Code Status: Resident/Responsible party has chosen Full Code. [DATE] Resident is DNR per order. 2/1020 [sic] Followed by [Name of Hospice] Date Initiated: [DATE]; Revision on [DATE]. Review code status annually, quarterly and/or PRN (as needed). The care plan failed to evidence documentation for periodic review of advance directives with Resident #31's representative.
On [DATE] at approximately 10:00 a.m., a request was made via written list to ASM (administrative staff member) #1, the administrator for evidence of offering advance directives on admission to the facility and evidence of periodic review of advance directives for Resident #31.
On [DATE] at approximately 1:45 p.m., ASM #1 provided the document Care Plan Conference Summary dated 12-18-19 which documented DNR addressed-reviewed and a copy of Durable Do Not Resuscitate Order dated 9-30-19 for Resident #31.
On [DATE] at 3:20 p.m., an interview was conducted with OSM (other staff member) #3, the social services director. When asked about the facility process for offering advance directives OSM #3 stated that on admission staff discuss with residents and family to see if the resident has an advance directive. OSM #3 stated that if the resident already has an advance directive they request a copy to have in the chart. OSM #3 stated that the admissions director is the first point of contact for new admissions to the facility and the social services department is the second contact. OSM #3 stated that the welcome packet given to new residents by the admissions director contains information on how to formulate an advance directive. OSM #3 stated that an admission huddle is also performed prior to admission where advance directives are discussed. When asked if advance directives are periodically reviewed with residents and/or resident representative, OSM #3 stated that it is discussed during the care plan conferences. When asked if it is documented that the advance directives are reviewed or offered, OSM #3 stated it would be documented on the Care Plan Conference Summary.
On [DATE] at 3:20 p.m., a request was made to OSM #3, the social services director for evidence that periodic review for advance directives were conducted for Resident #31.
On [DATE] at 3:51 p.m., an interview was conducted with OSM #4, the director of admissions. When asked about the facility process for advance directives, OSM #4 stated that residents are asked if they have an advance directive on admission so a copy can be obtained for the chart. OSM #4 stated that if the resident comes from home or the hospital a welcome packet is given to the resident which contains information on advance directives. OSM #4 stated that a Path (plan of care) meeting is conducted with the resident or the responsible party on admission and an advance directive is offered during the meeting. When asked if it is documented that advance directives are offered on admission, OSM #4 stated that if the resident elects to develop an advance directive on admission the document would be on the chart and if they do not elect to develop an advance directive on admission there is no documentation of it. OSM #4 stated that after admission social services picks up the advance directive process for review and revision.
On [DATE] at 10:00 a.m., OSM #3, the director of social services stated that she did not have any additional information regarding the periodic review of advance directives for Resident #31. OSM #3 reviewed the Care Plan Conference Summary dated 12-18-19 for Resident #31 and stated that code status was being discussed during the care plan meetings. OSM #3 stated that the facility had in-service training planned for the following week on advance directives review. OSM #3 stated that if the periodic review was not documented on the care plan conference summary she could not say that it was being done.
The facility policy, Advance Directives Protocol documented in part, Upon admission and during Your Path Meetings, advance directives will be discussed with resident and/or resident representative to determine if any advance directives have be [sic] chosen.
On [DATE] at approximately 12:30 p.m., ASM (administrative staff member) #1, the administrator was made aware of the findings.
No further information was provided prior to exit.
References:
1. Major depressive disorder
Major depression is a mood disorder. It occurs when feelings of sadness, loss, anger, or frustration get in the way of your life over a long period of time. It also changes how your body works. This information was obtained from the website: https://medlineplus.gov/ency/article/000945.htm.
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/000739.htm.
6. Resident #63 was admitted to the facility on [DATE] with a readmission on [DATE]. Resident #63's diagnoses included but were not limited to aphasia (1) and major depressive disorder (2). Resident #63's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of [DATE], coded Resident #63 as being severely impaired for making daily decisions.
Review of Resident #63's clinical record revealed a document Care Plan Conference Summary dated 11-13-19 which documented DNR (do not resuscitate) reviewed- addressed but failed to evidence documentation of review of advance directives.
The comprehensive care plan for Resident #63 documented Code Status: Resident/Responsible party has chosen DNR. [DATE] NP (nurse practitioner) met with RP (responsible party) who declines hospice services at present. Date Initiated: [DATE], Revision on: [DATE]. Review code status annually, quarterly and/or PRN (as needed). The care plan failed to evidence documentation for periodic review of advance directives with Resident #63's representative.
On [DATE] at approximately 10:00 a.m., a request was made via written list to ASM (administrative staff member) #1, the administrator for evidence of offering advance directives on admission to the facility and evidence of periodic review of advance directives for Resident #63.
On [DATE] at approximately 1:45 p.m., ASM #1 provided the document Care Plan Conference Summary dated 11-13-19 which documented DNR reviewed- addressed and a copy of Durable Do Not Resuscitate Order dated [DATE] for Resident #63.
On [DATE] at 3:20 p.m., a request was made to OSM #3, the social services director for evidence that periodic review for advance directives were conducted for Resident #63.
On [DATE] at 10:00 a.m., OSM #3, the director of social services stated that she did not have any additional information regarding the periodic review of advance directives for Resident #63. OSM #3 reviewed the Care Plan Conference Summary dated 11-13-19 for Resident #63 and stated that code status was being discussed during the care plan meetings. OSM #3 stated that the facility had in-service training planned for the following week on advance directives review. OSM #3 stated that if the periodic review was not documented on the care plan conference summary she could not say that it was being done.
On [DATE] at approximately 12:30 p.m., ASM (administrative staff member) #1, the administrator was made aware of the findings.
No further information was provided prior to exit.
References:
1. Aphasia
A disorder caused by damage to the parts of the brain that control language. It can make it hard for you to read, write, and say what you mean to say. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/aphasia.html
2. Major depressive disorder
Major depression is a mood disorder. It occurs when feelings of sadness, loss, anger, or frustration get in the way of your life over a long period of time. It also changes how your body works. This information was obtained from the website: https://medlineplus.gov/ency/article/000945.htm.
References:
[1]Fear. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/anxiety.html#summary.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, staff interview, clinical record review and facility document review, it was determined that facility staff failed to implement infection control practices to prevent the development and spread of infection for two of 42 residents in the survey sample, Resident #23 and Resident #42. Resident #73's incentive spirometer was observed stored in an unsanitary manner. The spirometer was observed uncovered on the residents over the bed table during separate observations. Resident #42's catheter bag was observed resting directly on the floor during separate observations.
The findings include:
1. Resident # 23 was admitted to the facility with diagnoses that included but were not limited to: pulmonary edema [2], chronic obstructive pulmonary disease [3].
Resident # 23's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 12/06/19, coded Resident # 23 as scoring a 15 on the staff assessment for mental status (BIMS) of a score of 0 - 15, 15- being cognitively intact for making daily decisions. Resident # 23 was coded as requiring supervision of one staff member for activities of daily living.
On 02/11/20 at 11:40 a.m., and at 1:00 p.m., and on 02/12/20 at 8:10 a.m., observations of Resident #23's room revealed an incentive spirometer on the over-the-bed table uncovered.
The Physician's Order Sheet for Resident # 23 dated 02/122020 failed to evidence the use of an incentive spirometer.
The comprehensive care plan for Resident # 23 with a revision date of 07/19/2019 failed to evidence documentation addressing the use of an incentive spirometer.
On 02/12/20 at 9:36 a.m., an interview with Resident # 23. When asked about the incentive spirometer Resident # 23 stated, I use it almost every day I have COPD [chronic obstructive pulmonary disease].
On 02/12/2020 at 12:55 p.m., an interview and observation was conducted with LPN [licensed practical nurse] # 3. When asked if a spirometer is a piece of respiratory equipment, LPN # 3 stated yes. When asked how it should be stored when not in use, LPN # 3 stated it should be in a bag and dated. At this time LPN # 3 was accompanied to Resident # 23's room. After observing the uncovered incentive spirometer on Resident # 23's over-the-bed table LPN # 3 stated that the incentive spirometer should have been placed in a bag. When asked why it was important to store the incentive spirometer in a bag, LPN # 3 stated that it could cause a respiratory infection if it was not stored in a bag.
On 02/13/20 at 10:27 a.m., an interview was conducted with ASM [administrative staff member] # 2, director of nursing. When asked what standard of practice the facility follows, ASM # 2 stated, We follow [NAME] and our policies and procedures.
Wash the mouthpiece in warm water and dry it. Avoid immersing the spirometer itself in water because water enhances bacterial growth and impairs the internal filter's effectiveness in preventing inhalation of extraneous material. Place the mouthpiece in a plastic storage bag between exercises, and label it and the spirometer, if applicable, with the patient's name to avoid inadvertent use by another patient. Keep the incentive spirometer within the patient's reach. [NAME]'s Nursing Procedures (6th Edition) 2013.
On 02/12/2020 at 6:00 p.m. ASM [administrative staff member] # 1, administrator, ASM # 2, director of nursing, ASM # 3, regional director of clinical services and RN [registered nurse] # 1, assistant director of nursing were made aware of the above findings.
No further information was provided prior to exit.
References:
(1) A device used to help you keep your lungs healthy after surgery or when you have a lung illness, such as pneumonia. Using the incentive spirometer teaches you how to take slow deep breaths. Deep breathing keeps your lungs well-inflated and healthy while you heal and helps prevent lung problems, like pneumonia. This information was obtained from the website: https://medlineplus.gov/ency/patientinstructions/000451.htm.
(2) An abnormal buildup of fluid in the lungs. This buildup of fluid leads to shortness of breath. This information was obtained from the website: https://medlineplus.gov/ency/article/000140.htm.
(3) 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/copd.html.
2. Resident # 75 was admitted to the facility with diagnoses that included but were not limited to: sacral [tail bone] pressure ulcer and obstructive uropathy [2].
Resident # 75's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 01/31/2020, coded Resident # 75 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. Resident # 75 was coded as requiring extensive assistance of one staff member for activities of daily living. Section H Bladder and Bowel coded Resident # 75 as having an indwelling catheter.
On 02/11/20 at 11:46 a.m., an observation of Resident # 75 revealed the resident in bed. Observation of the bed revealed a catheter collection bag hanging on the right side of the bed resting on the floor. Observation of the catheter collection bag revealed that it had a privacy flap covering the front of the collection bag. Further observation revealed a CNA [certified nursing assistant] # 1 entered Resident # 75's room during this observation per the request of Resident # 75. CNA # 1 came into the room and readjusted Resident # 75's sheet and blanket on both sides of the bed and did not reposition the catheter collection bag.
On 02/11/20 at 12:59 p.m., an observation of Resident # 75 revealed the resident lying in bed. Observation of the bed revealed a catheter collection bag hanging on the right side of the bed resting on the floor. Observation of the catheter collection bag revealed that it had a privacy flap covering the front of the collection
On 02/12/20 at 8:10 a.m., an observation Of Resident # 75 revealed the resident lying in bed. Observation of the bed revealed a catheter collection bag hanging on the right side of the bed resting on the floor.
The POS [physician's order sheet] for Resident # 75 dated 02/12/2020 documented in part, Foley catheter size 16 F [French] with a 30ml [milliliter] Balloon. Related to pressure ulcer. Order date: 08/09/2019.
The comprehensive care plan for Resident # 75 dated 05/10/2019 documented in part, Focus: Foley catheter: Obstructive uropathy. The resident has Indwelling Catheter (16F w [with]/30cc [cubic centimeter] balloon): R/T [related to] obstructive uropathy; hip and sacral pressure ulcers. Under Interventions it documented in part, Position catheter bag and tubing below the level of the bladder. Revision on: 05/10/2019.
On 02/12/20 at 12:44 p.m., an interview and observation of Resident # 75's catheter collection bag was conducted with CNA [certified nursing assistant] # 1. When asked to describe the position a catheter collection bag should be placed in, CNA # 1 stated that it should be positioned on side of bed, at the lower end of the bed, below the bladder, off the floor and covered. When asked why it was important to keep the catheter collection bag off the floor, CNA # 1 stated, Its unsanitary could cause an infection. After observing the position of Resident # 75's catheter collection bag, CNA # 1 stated that it was touching the floor and immediately raised the bed to keep the bag off the floor.
02/13/20 at 10:27 a.m., an interview was conducted with ASM [administrative staff member] # 2, director of nursing. When asked what standard of practice the facility follows, ASM # 2 stated, We follow [NAME] and our policies and procedures.
According to Fundamentals of Nursing [NAME] and [NAME] Eighth Edition 2006, [NAME] Company, page 757, titled Renal and Urinary Disorders, under the heading Management of a Patient with an Indwelling Catheter and Closed Drainage System the subheading: Maintaining a closed drainage system: 2. Maintain an unobstructed urine flow. b. Urine should not be allowed to collect in tubing because free flow of urine must be maintained to prevent urinary tract infection. Improper drainage occurs when the tubing is kinked or twisted, allowing pools of urine to collect in the tubing. c. Keep the bag off the floor to prevent bacterial contamination.
On 02/12/2020 at 6:00 p.m. ASM [administrative staff member] # 1, administrator, ASM # 2, director of nursing, ASM # 3, regional director of clinical services and RN [registered nurse] # 1, assistant director of nursing were made aware of the above findings.
No further information was provided prior to exit.
References:
[1] A condition in which the flow of urine is blocked. This causes the urine to back up and injure one or both kidneys. This information was obtained from the website: https://medlineplus.gov/ency/article/000507.htm.
[2] A condition in which the flow of urine is blocked. This causes the urine to back up and injure one or both kidneys. This information was obtained from the website: https://medlineplus.gov/ency/article/000507.htm.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and facility document review it was determined facility staff failed to store food in a sanitary manner and discard food past its expiration date in two of two facility nourishment rooms observed.
The findings include:
On 2/11/20 at 3:15 p.m., an observation was made of the South unit nourishment room was conducted with ASM (administrative staff member) #2, the director of nursing. Observation of the refrigerator revealed a white paper bag inside of the bottom drawer. There was no name or date observed to be on the bag. Upon inspection by ASM #2 it was determined that the bag contained a white Styrofoam bowl with potato written on the lid. The bowl was observed to not contain a date or name on it. Further observation of the drawer revealed a second white paper bag without a date or a name. Upon inspection by ASM #2 it was determined that the bag contained a white Styrofoam bowl with vegetable beef written on the lid. The bowl was observed to not contain a date or name on it. Three plastic deli bags without a date or name on the packaging were located in the drawer of the refrigerator underneath the white plastic bags. The plastic deli bags were observed to contain German bologna with a use by date of 1/26/20 on the package label, marble cheese with a use by date of 1/25/20 on the package label and liverwurst with a use by date of 1/26/20 on the package label.
When asked about the paper bags containing the Styrofoam bowls ASM #2 stated that it could not be determined who the food belonged to or when it was placed in the refrigerator because it did not have a date or a name on it. ASM #2 stated that the food should be discarded because it could not be determined how long it had been in the refrigerator. When asked about the plastic deli bags which contained the German bologna, marble cheese and liverwurst ASM #2 stated that it could not be determined who the food belonged to or when it was placed in the refrigerator because it did not have a date or name on it. ASM #2 stated that the deli bag contents were past their dates and should be discarded. When asked which staff is responsible for the nourishment room, ASM #2 stated that dietary staff stock the snacks and drinks in the refrigerators for all resident use and that the nursing staff handle any resident food that is brought into the facility. ASM #2 stated that the nursing staff are to label all outside food brought in with the resident name and the date that it is brought in. ASM #2 stated that the food is kept for three days. ASM #2 stated that the refrigerator is supposed to be checked by the nurses every night on the night shift and anything that is not dated or past its expiration date is disposed of. ASM #2 discarded the soups, bologna, liverwurst and marble cheese.
On 2/11/20 at 3:30 p.m., an observation of the North unit nourishment unit was conducted with ASM #2. Observation of the refrigerator revealed one 5.3 ounce container of orange cream yogurt with the date [DATE] (December 16, 2019) on the container, one 5.3 ounce container of strawberry yogurt with the date [DATE] (December 29, 2019) on the container, two 5.3 ounce containers of blueberry yogurt with the date [DATE] (January 5, 2020) and two 5.3 ounce containers of cherry yogurt with the date [DATE] (December 27, 2019) on the container. The containers were observed to contain a name of a resident of the facility.
When asked about the yogurt containers and the date on the containers ASM #2 stated that the date was the expiration date and that they all should have been discarded and the resident that they belonged to should have been notified that they were being discarded. ASM #2 discarded the yogurt containers. ASM #2 stated that the refrigerators should be checked by the nurses every night on the night shift and anything that is not dated or past its expiration date be disposed of.
The facility policy Food Brought in From Outside the Facility, Effective Date: November, 2016, Date Revised: February 25, 2019 documented in part, The container will be labeled with name of food item and Resident name, dated, and placed in an appropriate non-dietary refrigerator (floor/unit fridge, neighborhood fridge, activities fridge Food dated by facility staff will be discarded within seven days from the date mark, with the exception of condiments, see dietary department for clarification.
On 2/12/20 at approximately 5:45 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing and ASM #3, the regional director of clinical services were made aware of the findings.
No further information was provided prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview and facility document review it was determined that facility staff failed to ensure an expired three milliliter multi-dose vile of Humalog [1] was not available for use for one of 42 residents in the survey sample, Resident # 47.
The findings include:
Resident # 47 was admitted to the facility with diagnoses that included but were not limited to: diabetes mellitus without complications [2].
Resident # 47's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 01/04/2020, coded Resident # 47 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 N Medications coded Resident # 47 as 0 [zero] under N0300 Injections. Record the number of days that injections of any type were received during the last 7 [seven] days or since admission/entry or reentry if less than 7 days. If 0 ---skip to N0410 Medications Received. Under N0350 Insulin sections A. Insulin Injections. Record the number of days that injections of any type were received during the last 7 days or since admission/entry or reentry if less than 7 days; B. Orders for insulin. Record the number of days the physician (or authorized assistant or practitioner) changed the resident's insulin orders during the last 7 days or since admission/entry or reentry if less than 7 days.
On 02/18/19 at 10:55 a.m., an observation of the facility's medication cart for the 200 Hall was conducted with LPN [licensed nurse] # 2. Observation inside of the top left drawer revealed a multi-dose vile of Humalog insulin inside a plastic, orange pharmacy bottle. Further observation of the vile of insulin revealed it was opened. Observation of the outside of the pharmacy bottle revealed a label documenting Resident # 47's name. Further observation reveal another label that documented, Discard 28 days after opening. Date Open - 7/28/19. After observing the vile of insulin and the plastic pharmacy bottle the insulin was in LPN # 2 was asked to give an approximation of the amount of insulin that remained in the vile. LPN # 2 stated it was about half full. When asked when the insulin should be discarded, LPN #2 read the label on the outside of the pharmacy bottle and stated, 28 days after opening. LPN #2 was asked when the vile of Humalog insulin was opened. LPN # 2 read another label on the outside of the pharmacy bottle and stated, 7/28/19. LPN # 2 further stated that Resident # 47 was not currently taking insulin. When asked how staff ensure the medication cart does not contain expired medications, LPN # 2 stated, As soon as the medication is discontinued I remove it from the cart. I check the cart daily to make sure there is nothing old in it. When asked about the expired Humalog for Resident # 47 being available in the medication cart, LPN # 2 stated that they didn't know how it got into the medication cart.
The comprehensive care plan for Resident # 47 with a revision date of 10/01/2019 documented in part, Diabetic Needs: Resident is at risk for hypo/hyperglycemia [high and low blood sugar] episodes R/T [related to]: NIDDM [non-insulin-dependent diabetes mellitus]. Revision on: 10/01/2019. Under Interventions it documented in part, Diet as directed. Date Initiated: 10/01/2019.
Review of the EHR [electronic health record] for Resident # 47 revealed a Discontinue Order. The order documented, Humalog. Discontinue Date: 9/30/2019.
On 02/13/20 at 10:27 a.m., an interview was conducted with ASM [administrative staff member] # 2, director of nursing. When asked what standard the facility follows, ASM # 2 stated, We follow [NAME] and our policies and procedures.
The Name of Manufacturer's] Information Sheet for Humalog documented in part, 16.2 Storage and Handling. 3mL [three milliliter]. In-Use (Opened) Room Temperature (Below 86 F [degrees Fahrenheit] 28 days, refrigerated/room temperature.
The facility's policy Discontinued Medications documented in part, Policy: When a medication is discontinued, the medication will be sent back to pharmacy or destroyed. Procedure: Nurse discontinuing the medication will remove the medication from the cart.
On 02/12/2020 at 6:00 p.m. ASM [administrative staff member] # 1, administrator, ASM # 2, director of nursing, ASM # 3, regional director of clinical services and RN [registered nurse] # 1, assistant director of nursing were made aware of the above findings.
No further information was provided prior to exit.
References:
(1) A rapid acting human insulin analog indicated to improve glycemic control in adults and children with diabetes mellitus. This information was obtained from the website: https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=c8ecbd7a-0e22-4fc7-a503-faa58c1b6f3f.
[2] A chronic disease in which the body cannot regulate the amount of sugar in the blood. The goal of treatment at first is to lower your high blood glucose level. Long-term goals are to prevent complications. The most important way to treat and manage type 2 diabetes is by being active and eating healthy foods. This information was obtained from the website: https://medlineplus.gov/ency/article/000313.htm.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and clinical record review, it was determined that the facility staff failed to ensure a drug regimen free from unnecessary medication for one of 42 residents in the survey sample, Resident # 73. The facility staff failed to implement non-pharmacological interventions prior to the administration of the prn [as needed] pain medications Hydrocodone-Acetaminophen and Tylenol to Resident #73.
The findings include:
Resident # 73 was admitted to the facility with diagnoses that included but were not limited to high blood pressure and chronic pain. Resident # 73's most recent MDS (minimum data set), an quarterly assessment with an ARD (assessment reference date) of 01/30/2020, coded Resident # 73 as scoring a three on the brief interview for mental status (BIMS) of a score of 0 - 15, three - being severely impaired of cognition for making daily decisions. Section J Health Conditions coded Resident # 73 as having frequent pain with a pain level of seven on a scale of zero to ten with ten being the worse pain.
The comprehensive care plan for Resident # 73 dated 12/29/2019 documented in part, Focus: PAIN RISK: The resident has chronic pain r/t [related to] Diabetic neuropathy, low back pain as well as generalized pain. Date Initiated: 12/29/2019. Under Interventions it documented in part, Administer analgesia/medication per orders. Date Initiated: 12/29/2019
The POS [physician's order sheet] dated 11/2019 for Resident # 73 documented, Hydrocodone-Acetaminophen Tablet 5-325MG [milligrams]. Give 1 [one] tablet by mouth every 8 [eight] hours as needed for pain related to OTHER CHRONIC PAIN. Order Date: 11/12/2019.
Resident # 73's eMAR [electronic medication administration record] dated November 2019 documented the physician's order as above. The eMAR failed to evidence documentation of attempted non-pharmacological interventions. Further review of the eMAR revealed the administration of Hydrocodone-Acetaminophen on 11/28/2019 at 8:57 p.m. with a pain level of six.
The POS [physician's order sheet] dated 01/2020 for Resident # 73 documented, Tylenol Tablet (Acetaminophen). Give 1000 mg [milligram] by mouth every 12 hours as needed for pain. Order Date: 12/29/2019.
Resident # 73's eMAR [electronic medication administration record] dated January 2020 documented the above physician's order. The eMAR failed to evidence documentation of non-pharmacological interventions attempted. Further review of the eMAR revealed the administration of Tylenol on: 01/13/2020 at 5:31 a.m. with a pain level of five, and on 01/22/2020 at 5:47 a.m. with a pain level of two.
Resident # 73's eMAR [electronic medication administration record] dated February 2020 documented the above physician's order for Tylenol. The eMAR failed to evidence documentation of attempted non-pharmacological interventions. Further review of the eMAR revealed the administration of Tylenol on: 02/08/2020 at 3:56 a.m. with a pain level of three.
Review of the eMAR notes and nurse's notes dated 11/13/2019 through 02/12/2020 failed to evidence documentation of attempted non-pharmacological interventions prior to the administration of Resident # 73's prn pain medications on the dates cited above.
On 02/12/20 at 9:57 a.m., an interview was conducted with Resident # 73. When asked if the staff attempt to alleviate the pain before administering pain medication, Resident # 73 stated sometimes.
On 02/13/20 at 8:40 a.m., an interview was conducted with LPN [licensed practical nurse] # 2. LPN #2 was asked to describe the procedure staff follows when administering as needed pain medication to a resident. LPN # 2 stated ask the resident their pain level on a scale one to ten with one being minor pain and ten being unbearable, ask where the pain is and offer an intervention before giving the pain medication and if it doesn't work give the pain medication and follow up in about an hour. When asked where they document the interventions attempted prior to administering the pain medication, LPN # 2 stated that they document them on the eMAR notes. After reviewing the eMAR notes and nurse's notes for Resident # 73 for the above dates, LPN # 2 stated there was no documentation of non-pharmacological interventions being attempted. When asked about the lack of documentation of attempted non-pharmacological interventions, LPN # 2 stated, It's not documented can't say it's being done. When asked why it was important to attempt non-pharmacological interventions, LPN # 2 stated that it is possible that they are getting a pain medication they might not need.
On 02/13/20 at 10:27 a.m., an interview was conducted with ASM [administrative staff member] # 2, director of nursing. When asked what standard of practice the facility follows, ASM # 2 stated, We follow [NAME] and our policies and procedures.
The facility's policy Pain Management and Pain Protocol documented in part, 3. Non-pharmacological intervention will be attempted prior to the administration of PRN pain medications.
On 02/13/2020 at 3:30 p.m. ASM [administrative staff member] # 1, administrator, ASM # 2, director of nursing, and RN [registered nurse] # 1, assistant director of nursing were made aware of the above findings.
No further information was provided prior to exit.
References:
[1] Hydrocodone is available in combination with other ingredients, and different combination products are prescribed for different uses. Some hydrocodone combination products are used to relieve moderate-to-severe pain. This information was obtained from the website: https://medlineplus.gov/druginfo/meds/a601006.html.
[2] Acetaminophen is 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 osteoarthritis (arthritis caused by the breakdown of the lining of the joints). This information was obtained from the website: https://medlineplus.gov/druginfo/meds/a681004.html.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, staff interview, clinical record review, and facility document review, it was determined that facility staff failed to ensure respiratory care and services consistent with professional standards of practice for one of 42 residents in the survey sample, Residents # 23. The facility staff failed obtain a physician's order for Resident #23's use of an incentive spirometer and failed to store the resident's incentive spirometer in a sanitary manner.
The findings include:
Resident # 23 was admitted to the facility with diagnoses that included but were not limited to: pulmonary edema [2], chronic obstructive pulmonary disease [3]. Resident # 23's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 12/06/19, coded Resident # 23 as scoring a 15 on the staff assessment for mental status, of a score of 0 - 15, 15- being cognitively intact for making daily decisions. Resident # 23 was coded as requiring supervision of one staff member for activities of daily living.
On 02/11/20 at 11:40 a.m., and at 1:00 p.m., and on 02/12/20 at 8:10 a.m., observations of Resident #23's room revealed an incentive spirometer on the over-the-bed table uncovered.
The Physician's Order Sheet for Resident # 23 dated 02/122020 failed to evidence the use of an incentive spirometer.
The comprehensive care plan for Resident # 23 with a revision date of 07/19/2019 failed to evidence documentation addressing the use of an incentive spirometer.
On 02/12/20 at 9:36 a.m., an interview with Resident # 23. When asked about the incentive spirometer, Resident # 23 stated, I use it almost every day I have COPD [chronic obstructive pulmonary disease].
On 02/12/2020 at 12:55 p.m., an interview and observation was conducted with LPN [licensed practical nurse] # 3. When asked if a spirometer is a piece of respiratory equipment, LPN # 3 stated yes. When asked how it should be stored when not in use, LPN # 3 stated it should be in a bag and dated. At this time, LPN # 3 was accompanied to Resident # 23's room. After observing the incentive spirometer on Resident # 23's over-the-bed table, LPN # 3 stated that the incentive spirometer should have been placed in a bag.
On 02/13/2020 at 11:20 a.m., an interview and observation was conducted with LPN # 2. When asked about lack of a physician's order for Resident # 23's incentive spirometer, LPN # 2 stated they typically have a physician's order for the incentive spirometer. LPN # 2 further stated, Speech therapy will teach residents how to use them and recommend the use, we get the order for the use. If they come from the hospital with an incentive spirometer [sic] will call the physician to get the order. Usually do not use them long term, usually after surgery or for COPD. When asked about the physician's order for Resident # 23's incentive spirometer, LPN # 2 stated that Resident # 23 has an order for the incentive spirometer on 02/12/2020 after the surveyor observed it.
02/13/20 at 10:27 a.m., an interview was conducted with ASM [administrative staff member] # 2, director of nursing. When asked what standard of practice the facility follows, ASM # 2 stated, We follow [NAME] and our policies and procedures.
The facility's policy Incentive Spirometer Policy documented in part, Procedure: 1. Verify order via [by] order sheet, MAR [medication administration record] or TAR [treatment administration record].
Wash the mouthpiece in warm water and dry it. Avoid immersing the spirometer itself in water because water enhances bacterial growth and impairs the internal filter's effectiveness in preventing inhalation of extraneous material. Place the mouthpiece in a plastic storage bag between exercises, and label it and the spirometer, if applicable, with the patient's name to avoid inadvertent use by another patient. Keep the incentive spirometer within the patient's reach. [NAME]'s Nursing Procedures (6th Edition) 2013.
On 02/12/2020 at 6:00 p.m. ASM [administrative staff member] # 1, administrator, ASM # 2, director of nursing, ASM # 3, regional director of clinical services and RN [registered nurse] # 1, assistant director of nursing were made aware of the above findings.
No further information was provided prior to exit.
References:
(1) A device used to help you keep your lungs healthy after surgery or when you have a lung illness, such as pneumonia. Using the incentive spirometer teaches you how to take slow deep breaths. Deep breathing keeps your lungs well-inflated and healthy while you heal and helps prevent lung problems, like pneumonia. This information was obtained from the website: https://medlineplus.gov/ency/patientinstructions/000451.htm.
(2) An abnormal buildup of fluid in the lungs. This buildup of fluid leads to shortness of breath. This information was obtained from the website: https://medlineplus.gov/ency/article/000140.htm.
(3) 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/copd.html.
On 02/13/20 at 10:27 a.m., an interview was conducted with ASM [administrative staff member] # 2, director of nursing. When asked what standard of practice the facility follows, ASM # 2 stated, We follow [NAME] and our policies and procedures.
According to Fundamentals of Nursing [NAME] and [NAME] Eighth Edition 2006, [NAME] Company, page 757, titled Renal and Urinary Disorders, under the heading Management of a Patient with an Indwelling Catheter and Closed Drainage System the subheading: Maintaining a closed drainage system: 2. Maintain an unobstructed urine flow. b. Urine should not be allowed to collect in tubing because free flow of urine must be maintained to prevent urinary tract infection. Improper drainage occurs when the tubing is kinked or twisted, allowing pools of urine to collect in the tubing. c. Keep the bag off the floor to prevent bacterial contamination.
On 02/12/2020 at 6:00 p.m. ASM [administrative staff member] # 1, administrator, ASM # 2, director of nursing, ASM # 3, regional director of clinical services and RN [registered nurse] # 1, assistant director of nursing were made aware of the above findings.
No further information was provided prior to exit.
References:
[1] A condition in which the flow of urine is blocked. This causes the urine to back up and injure one or both kidneys. This information was obtained from the website: https://medlineplus.gov/ency/article/000507.htm.
[2] A condition in which the flow of urine is blocked. This causes the urine to back up and injure one or both kidneys. This information was obtained from the website: https://medlineplus.gov/ency/article/000507.htm.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and clinical record review, it was determined that facility staff failed to provide care and services for an indwelling catheter for one of 42 residents in the survey sample, Residents # 75.
The findings include:
Resident # 75 was admitted to the facility with diagnoses that included but were not limited to: sacral [tail bone] pressure ulcer and obstructive uropathy [2]. Resident # 75's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 01/31/2020, coded Resident # 75 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. Resident # 75 was coded as requiring extensive assistance of one staff member for activities of daily living. Section H Bladder and Bowel coded Resident # 75 as having an indwelling catheter.
On 02/11/20 at 11:46 a.m., an observation of Resident # 75 revealed the resident was in bed. Observation of the bed revealed a catheter collection bag hanging on the right side of the bed and resting dirctly on the floor. Further observation revealed a CNA [certified nursing assistant] # 1 entered Resident # 75's room during this observation per the request of Resident # 75. CNA # 1 came into the room and readjusted Resident # 75's sheet and blanket on both sides of the bed and did not reposition the catheter collection bag.
On 02/11/20 at 12:59 p.m., an observation Of Resident # 75 revealed the resident in bed. Observation of the bed revealed a catheter collection bag hanging on the right side of the bed resting on the floor.
On 02/12/20 at 8:10 a.m., an observation Of Resident # 75 revealed the resident in bed. Observation of the bed revealed a catheter collection bag hanging on the right side of the bed resting directly on the floor.
The POS [physician's order sheet] for Resident # 75 dated 02/12/2020 documented in part, Foley catheter size 16 F [French] with a 30ml [milliliter] Balloon. Related to pressure ulcer. Order date: 08/09/2019.
The comprehensive care plan for Resident # 75 dated 05/10/2019 documented in part, Focus: Foley catheter: Obstructive uropathy. The resident has Indwelling Catheter (16F w[with]/30cc [cubic centimeter] balloon): R/T [related to] obstructive uropathy; hip and sacral pressure ulcers. Under Interventions it documented in part, Position catheter bag and tubing below the level of the bladder. Revision on: 05/10/2019.
On 02/12/20 at 12:44 p.m., an interview and observation of Resident # 75's catheter collection bag was conducted with CNA [certified nursing assistant] # 1. When asked to describe the position a catheter collection bag should be placed in, CNA # 1 stated that it should be positioned on side of bed, at the lower end of the bed, below the bladder, off the floor and covered. After observing the position of Resident # 75's catheter collection bag CNA # 1 agreed that it was touching the floor and immediately raised the bed to keep the bag off the floor.
On 02/13/20 at 10:27 a.m., an interview was conducted with ASM [administrative staff member] # 2, director of nursing. When asked what standard of practice the facility follows, ASM # 2 stated, We follow [NAME] and our policies and procedures.
According to Fundamentals of Nursing [NAME] and [NAME] Eighth Edition 2006, [NAME] Company, page 757, titled Renal and Urinary Disorders, under the heading Management of a Patient with an Indwelling Catheter and Closed Drainage System the subheading: Maintaining a closed drainage system: 2. Maintain an unobstructed urine flow. b. Urine should not be allowed to collect in tubing because free flow of urine must be maintained to prevent urinary tract infection. Improper drainage occurs when the tubing is kinked or twisted, allowing pools of urine to collect in the tubing. c. Keep the bag off the floor to prevent bacterial contamination.
On 02/12/2020 at 6:00 p.m. ASM [administrative staff member] # 1, administrator, ASM # 2, director of nursing, ASM # 3, regional director of clinical services and RN [registered nurse] # 1, assistant director of nursing were made aware of the above findings.
No further information was provided prior to exit.
References:
[1] A condition in which the flow of urine is blocked. This causes the urine to back up and injure one or both kidneys. This information was obtained from the website: https://medlineplus.gov/ency/article/000507.htm.
[2] A condition in which the flow of urine is blocked. This causes the urine to back up and injure one or both kidneys. This information was obtained from the website: https://medlineplus.gov/ency/article/000507.htm.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, clinical record review, facility document review and in the course of a complaint investigation, it was determined that the facility staff failed to follow professional standards for two of 42 residents in the survey sample, Resident # 79, and Resident #50. The facility staff obtain a physician's order for the use of an [NAME] machine post Resident #79's total knee replacement, and failed to administer the prescribed dosage of the scheduled Calcium/Vitamin D during the medication administration observation for Resident #50 on 02/12/2020 at 8:00 a.m.
The findings include:
1. Resident # 79 was admitted with diagnoses that included but were not limited to: aftercare following joint replacement [knee] surgery, and muscle weakness. Resident # 79's admission MDS (minimum data set), could not be completed before they were discharged to another facility. The facility's nursing admission assessment for Resident # 79 documented in part, admission: [DATE]. 16:55 [4:55 p.m.]. Cognitive Status/Orientation: AO [alert and orientated]. ADL [activity of daily living]/Mobility: WC [wheelchair and bedside commode].
Review of Resident # 79's EHR [electronic health record] revealed a Discharge Summary from [Name of Hospital] for Resident # 79 dated 01/10/20. Under Discharge Summary it documented in part, 2. Status post total knee replacement. A&P [assessment and plan]. Weight bearing as tolerated. Skilled nursing facility placement for nursing/PT [physical therapy]/OT [occupational therapy]. [NAME] machine [1] was used postoperatively to prevent swelling, and given to the patient for use after discharge.
The POS [physician's order sheet] for resident # 79 dated 01/10/2020 through 01/14/2020 failed to evidence an order for the use of an [NAME] machine.
The comprehensive care plan for Resident # 79 dated 01/10/2020 failed to evidence the use of an [NAME] machine.
The facility's nursing Progress Notes for Resident # 79 dated 01/11/2020 at 13:24 [1:24 p.m.] documented in part, She has [NAME] machine on morning part of shift and off at this time. Author [Name of LPN (licensed practical nurse) # 10] - e-SIGNED [electronically signed].
The facility's nursing Progress Notes for Resident # 79 dated 01/11/2020 at 16:55 [4:55 p.m.] documented in part, Using [NAME] for cold therapy to L [left] knee & [and] also receiving reg [regular] sced [scheduled] pain med [medication].
On 02/13/2020 at approximately 12:33 p.m., a telephone interview was conducted with CNA (certified nursing assistant) # 10. When asked if they recalled Resident # 79, CNA #10 stated yes. When asked if Resident # 79 had an [NAME] machine CNA #10 stated yes. When asked if they set up the machine, CNA # 10 stated that she filled the machine with ice and water but did not put it on Resident # 79.
On 02/13/2020 at approximately 12:53 p.m., a telephone interview was conducted with RN (registered nurse) # 4. When asked if they recalled Resident # 79, RN #4 stated yes. When asked if Resident # 79 was using the [NAME] machine during their shift on 01/11/2020, RN # 4 stated yes. When asked about the [NAME] machine for Resident # 79, RN # 4 stated, She would have already had it on at the beginning of my shift. I kept it filled with ice. When asked if there was a physician's order for the use of the machine, RN # 4 stated that they were not aware that there was not an order. When asked to describe the procedure for the use of a treatment device, RN # 4 stated, To get the order to use the machine.
On 02/13/2020 at approximately 1:09 p.m., a telephone interview was conducted with LPN [licensed practical nurse] # 10. When asked if they recalled Resident # 79, LPN #10 stated yes. When asked about the [NAME] machine for Resident # 79, LPN # 10 stated, She would have already had it on at the time of my shift. When asked if there was a physician's order for the use of the machine, LPN # 10 stated that they thought there was an order. LPN # 10 further stated that Resident # 79 put the machine on and turned it on herself. When asked to describe the procedure for the use of a treatment device, LPN # 10 stated, There should be an order for any medication or treatment.
On 02/13/20 at 12:11 p.m., an interview was conducted with ASM [administrative staff member] # 2, director of nursing. When asked about a physician's order for Resident # 79's use of the [NAME] machine, ASM # 2 stated that there was no order for the [NAME] machine. After reviewing Resident # 79's nurse's progress notes dated 01/11/2020, ASM # 2 agreed that staff used the [NAME] machine for Resident #79 on 1/11/2020. ASM # 2 further stated that they should not have used the machine without the order. When asked to describe the procedure the staff should have followed, ASM # 2 stated, The nurse should have checked the hospital discharge instructions and called the physician to obtain an order.
RN # 5 was unable to be interviewed due to the fact that they were no longer employed with the facility at the time of the survey.
On 02/13/20 at 10:27 a.m., an interview was conducted with ASM [administrative staff member] # 2, director of nursing. When asked what standard of practice the facility follows, ASM # 2 stated, We follow [NAME] and our policies and procedures.
On 02/13/2020 at 1:20 p.m. ASM [administrative staff member] # 1, administrator, ASM # 2, director of nursing, and RN [registered nurse] # 1, assistant director of nursing were made aware of the above findings.
No further information was provided prior to exit.
References:
[1] [NAME] Cold Therapy System helps reduce pain and swelling while facilitating rehabilitation by providing up to seven hours of continuous cold therapy before needing to be refilled with ice. Wrap-on pad (sold separately) securely connects to unit. Semi-closed loop system helps maintain consistent and accurate temperature. Features two-position locking top, water tight seal and thermostat for easy temperature adjustments. This information obtain from the website: https://www.alimed.com/[NAME]-cold-therapy-system.html.
2. Resident #50 was admitted to the facility on [DATE]. Resident #50's diagnoses included but were not limited to atrial fibrillation (2), dementia (3) and chronic obstructive pulmonary disease (4). Resident #50's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 01/07/20, coded Resident #50 as scoring a 15 on the staff assessment for mental status (BIMS) of a score of 0 - 15, 15- being cognitively intact for making daily decisions.
On 2/12/20 at 8:00 a.m., an observation was made of medication administration to Resident #50 by RN (registered nurse) #2. RN #2 prepared the following medications for Resident #50:
-Acetaminophen 500 mg (milligram) one tablet (used to treat pain or fever)
-Potassium Chloride ER (extended release) 10 meq (milliequivalents) one tablet (mineral supplement)
-Calcium/Vitamin D 600mg/400 IU (international units) one tablet (mineral/vitamin supplement)
-Eliquis 2.5 mg one tablet (used to prevent blood clots)
-Donepezil 23 mg one tablet (used to treat dementia)
-Amlodipine 2.5 mg one tablet (used to treat high blood pressure)
-Amiodarone HCL (hydrochloride) 200 mg one tablet (used to treat abnormal heartbeats).
RN #2 then proceeded to administer the medications as prepared to Resident #50.
Review of Resident #50's clinical record revealed a physician's order which documented, Calcium-Vitamin D Tablet 600-125 mg-unit (Calcium Carbonate-Vitamin D) Give 1 (one) tablet by mouth three times a day for hypocalcemia (5); Order Date: 11/08/2019, Start Date: 11/08/2019.
Review of Resident #50's clinical record revealed an eMAR (electronic medication administration record) dated 2/1/2020 through 02/29/2020. The eMAR documented, Calcium-Vitamin D Tablet 600-125 mg-unit (Calcium Carbonate-Vitamin D) Give 1 (one) tablet by mouth three times a day for hypocalcemia; Start Date: 11/08/2019 1200 (12:00 p.m.) to be administered at 0800, 1200, and 1600 (8:00 a.m., 12:00 p.m. and 4:00 p.m.). The eMAR documented the Calcium-Vitamin D tablet 600-125 mg-unit medication administered on 2/12/20 at 8:00 a.m. by RN #2.
On 2/13/20 at 7:45 a.m., an interview was conducted with RN #2 regarding the medication administration observation on 2/12/20 at 8:00 a.m. When asked what is checked prior to medication administration, RN #2 stated that the rights are checked, right patient, right drug and right route. RN #2 stated the medications are checked with the eMAR. When asked about the Calcium-Vitamin D tablet administered to Resident #50 on 2/12/20 at 8:00 a.m., RN #2 stated that after administering the medication she noticed that the house stock medication contained the incorrect dosage of Vitamin D. RN #2 stated that she had already clarified the physician order with the prescribing physician and updated the order and notified Resident #50. RN #2 stated that she normally works the night shift and is not familiar with the daytime medications for Resident #50. RN #2 stated that the physician order for the Calcium-Vitamin D had been updated to reflect the current dosage to be administered.
On 2/13/20 at 10:27 a.m., an interview was conducted with ASM [administrative staff member] #2, the director of nursing. When asked what standard of practice the nursing staff follow ASM #2 stated, We follow [NAME] and our policies and procedures.
The facility policy General Dose Preparation and Medication Administration, Effective Date 12/01/07, Revision 05/01/10, 01/01/13 documented in part, Procedure .3.7 Facility staff should verify that the medication name and dose are correct and should inspect the medication for contamination, particulate matter, discoloration or defects .
According to [NAME], [NAME] & [NAME]. 5th edition, Philadelphia, PA. Page 568 documented, Procedure 29-1; Administering Oral Medications
Procedure:
1. Wash hands
2. Arrange MAR next to medication supply
3. Prepare medications for only one client at a time
4. Remove ordered medications from supply
5. Calculate correct drug dosage
6. Prepare selected medications
7. Take medication directly to client's room. Do not leave medication unattended.
On 2/13/20 at approximately 12:30 p.m., ASM (administrative staff member) # 1, the administrator was made aware of the findings.
No further information was provided prior to exit.
References:
1. Calcium/Vitamin D: Uses of Calcium and Vitamin D Capsules and Tablets: It is used to help growth and good health. It is used to prevent or treat soft, brittle bones (osteoporosis). It is used to treat or prevent low calcium levels. It may be given to you for other reasons. Talk with the doctor. This information was obtained from the website: https://www.drugs.com/cdi/calcium-and-vitamin-d-capsules-and-tablets.html
2. Atrial fibrillation is a problem with the speed or rhythm of the heartbeat. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/atrialfibrillation.html.
3. Dementia is 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/000739.htm.
4. Chronic obstructive pulmonary disease is a 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/copd.html.
5. Hypocalcemia is a deficiency of calcium in the bloodstream. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/ency/article/007229.htm.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, staff interview, clinical record review, and facility document review, it was determined that facility staff failed to review and revise the comprehensive care plan for one of 42 residents in the survey sample, Residents # 23. The facility staff failed to revise Resident #23's comprehensive care plan to include the use of a spirometer.
The findings include:
Resident # 23 was admitted to the facility with diagnoses that included but were not limited to: pulmonary edema [2], chronic obstructive pulmonary disease [3]. Resident # 23's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 12/06/19, coded Resident # 23 as scoring a 15 on the staff assessment for mental status (BIMS) of a score of 0 - 15, 15- being cognitively intact for making daily decisions. Resident # 23 was coded as requiring supervision of one staff member for activities of daily living.
On 02/11/20 at 11:40 a.m., 02/11/20 at 1:00 p.m., and 02/12/20 at 8:10 a.m., observations of Resident #23 room revealed an incentive spirometer on the over-the-bed table uncovered.
The Physician's Order Sheet for Resident # 23 dated 02/122020 failed to evidence an order for the use of an incentive spirometer.
The comprehensive care plan for Resident # 23 with a revision date of 07/19/2019 failed to evidence any documentation addressing the use of an incentive spirometer.
On 02/12/20 at 9:36 a.m., an interview with Resident # 23. When asked about the incentive spirometer Resident # 23 stated, I use it almost every day I have COPD [chronic obstructive pulmonary disease].
On 02/12/20 at 2:23 p.m., an interview was conducted with LPN [Licensed practical nurse] # 4 and LPN # 5, MDS coordinators. When asked to describe the procedure for updating a resident's care plan, LPN # 4 stated that they go through the physician's orders every day for new orders and update the care plan with the new orders and that it is also done quarterly. LPN # 4 further stated that any changes with a resident would require an update or revision of the care plan and anything communicated from nursing about a change for a resident would also trigger them to update the care plan. After reviewing the comprehensive care plan for Resident # 23 with a revision date of 07/19/2019, LPNs # 4 and # 5 were asked if the care plan was updated to reflect Resident # 23's use of an incentive spirometer. LPNs # 4 and 5 stated no, the incentive spirometer should be on the care plan.
On 02/13/20 at 10:27 a.m., an interview was conducted with ASM [administrative staff member] # 2, director of nursing. When asked what standard of practice followed by the facility, ASM # 2 stated, We follow [NAME] and our policies and procedures.
The facility's policy Comprehensive Care Planning documented in part, F. The Comprehensive Care Plan is reviewed and updated at least every 90 days by the interdisciplinary team.
According to Fundamentals of Nursing [NAME] and [NAME] 2007 pages 65-77 documented, A written care plan serves as a communication tool among health care team members that helps ensure continuity of care .The nursing care plan is a vital source of information about the patient's problems, needs, and goals. It contains detailed instructions for achieving the goals established for the patient and is used to direct care .expect to review, revise and update the care plan regularly, when there are changes in condition, treatments, and with new orders . (1)
(1) Fundamentals of Nursing [NAME] & [NAME] 2007 [NAME] Company Philadelphia pages 65-77.
On 02/12/2020 at 6:00 p.m. ASM [administrative staff member] # 1, administrator, ASM # 2, director of nursing, ASM # 3, regional director of clinical services and RN [registered nurse] # 1, assistant director of nursing were made aware of the above findings.
No further information was provided prior to exit.
References:
(1) A device used to help you keep your lungs healthy after surgery or when you have a lung illness, such as pneumonia. Using the incentive spirometer teaches you how to take slow deep breaths. Deep breathing keeps your lungs well-inflated and healthy while you heal and helps prevent lung problems, like pneumonia. This information was obtained from the website: https://medlineplus.gov/ency/patientinstructions/000451.htm.
(2) An abnormal buildup of fluid in the lungs. This buildup of fluid leads to shortness of breath. This information was obtained from the website: https://medlineplus.gov/ency/article/000140.htm.
(3) 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/copd.html.