Arbor Grace Guest Care Center

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for 1 of 2 residents (Resident #4) reviewed for appropriate treatment and services to prevent urinary tract infections (an infection in any part of the urinary system, the kidneys, bladder, or urethra (is a hollow tube that lets urine leave your body)).
The facility failed to ensure Resident #4's indwelling suprapubic catheter (drains urine from your bladder into a bag outside your body) had a catheter securement device to anchor the catheter to her leg.
This failure could place residents at risk for urinary tract infections.
Findings included:
Record review of Resident #4's face sheet, dated 04/01/25, indicated she was a [AGE] year-old female, admitted to the facility on [DATE]. Her diagnoses included retention of urine (a condition where a person is unable to completely empty their bladder), and Alzheimer's disease (a progressive neurodegenerative disorder that primarily affects memory, thinking, and behavior, and is the most common cause of dementia in older adults).
Record review of Resident #4's quarterly MDS assessment, dated 01/25/25, indicated she had a BIMS score of 11, which indicated moderate cognitive impairment. The MDS assessment further indicated she had an indwelling catheter and an ostomy (a surgically created opening, or stoma, in the abdominal wall that allows waste (stool or urine) to exit the body when the normal digestive or urinary pathways are damaged or removed).
Record review of Resident #4's Order Summary Report, dated 04/01/25, indicated she had an order for Suprapubic catheter privacy bag and securement device. Ensure placement every shift. The start date was 02/04/25.
Record review of Resident #4's undated care plan, included a focus of [Resident #4] has the potential for complications with UTI related t osupra-pubic catheter secondary to retention of urine, dysfunction of bladder, and overactive bladder. The focus was initiated on 06/12/2019 and last revised on 12/05/20. Interventions included monitor placement of catheter leg strap every shift, initiated on 04/24/24.
During an observation on 04/01/25 at 9:56 AM, LVN C provided catheter care to Resident #4. Resident #4 had a suprapubic catheter. Prior to the care Resident #4 did not have a catheter securement device in place.
During an interview on 04/01/25 at 10:00AM. LVN C said Resident #4 should always have a catheter securement device in place. She said she was not sure why the resident did not have a catheter securement device in place.
During an interview on 04/01/25 at 10:43AM, LVN C said Resident #4 was supposed to have a catheter securement device in place. She said it was important to have a catheter securement device in place because it avoids the catheter pulling and helps keep it in place. She said the nurse was responsible for ensuring the device was in place. She said it was the responsibility of the nurse to check for the device each shift.
During an interview on 04/02/25 at 12:15 PM, ADON A said she expected Resident #4 to have a catheter anchor in place. She said it was important to keep the anchor in place so the catheter did not pull out. She said the risk to the resident was that without the catheter, it could pull and cause pain, an injury, or even an infection.
During an interview on 04/02/25 at 12:26 PM, the DON said Resident #4 should have had a catheter securement device in place. She said the nurse should verify the anchor was in place each shift. She said it was important for the anchor to be in place to prevent the catheter from being pulled out. She said the risk was infection and pain.
During an interview on 04/02/25 at 12:37 PM, the Administrator said she expected the resident to have a catheter securement device in place. She said the catheter could have been pulled out. She said the risk to the resident was pain and a possible infection.
Record review of the facility's undated policy, Catheter Care, Urinary, stated:
.Ensure that the catheter remains secured with a securement device to reduce friction and movement at the insertion site .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure each resident received adequate supervision to prevent accidents for 1 of 20 residents (Resident #48) reviewed for adequate supervision.
The facility failed to keep prohibited items, isopropyl rubbing alcohol, out of Resident #48's room.
This failure could place residents at risk for injury, harm, and impairment or death.
Findings included:
Record review of Resident #48's admission Record indicated she was a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included Amyotrophic Lateral Sclerosis (progressive and fatal neurodegenerative disease that affects the motor neurons in the brain and spinal cord), Chronic Obtrusive Pulmonary Disease (a group of lung diseases that cause progressive airflow obstruction and breathing difficulties), Type 2 Diabetes (a chronic condition where the body does not use insulin effectively or does not produce enough insulin to regulate blood sugar levels).
Record review of Resident #48's MDS dated [DATE] revealed that the resident's BIMS score was a 10 indicating mild cognitive impairment. The MDS also revealed, Resident #48, required maximal assistance for all ADLs.
Record review of Resident #48's Care Plan revealed a problem initiation on 10/21/2022 for a Moderately impaired vision - not able to read large or small print but can identify objects: nuclear cataracts, cortical senile cataract, myopia with astigmatism and presbyopia of both eyes (you have a combination of age-related vision changes, including clouding of the lens, nearsightedness, blurry vision at all distances, and difficulty focusing on near objects).
During an observation and interview on 3/31/25 at 9:26 a.m., Resident #48 had a bottle of isopropyl alcohol on his bedside table. He said that he has always had that bottle on his bedside table and uses it to clean up.
During an observation on 4/1/25 at 3:04 p.m. Resident #48 had a bottle of isopropyl rubbing alcohol on his bedside table.
During an interview on 4/1/25 at 3:08 p.m. LVN C said residents were not allowed to have any over the counter medications or rubbing alcohol in their rooms . She said there was a risk that a resident could swallow the rubbing alcohol. She said that they would need to call poison control if a resident swallowed rubbing alcohol.
During an interview on 4/2/25 at 12:25 p.m., the Director of Nurses said that residents were not allowed to have prohibited medications or medical products in their rooms. She said that rubbing alcohol was a prohibited item and residents could not keep that unsecured in their rooms. She said there was a risk that a resident could drink the alcohol and call poison control. She said it was the responsibility of all staff to ensure prohibited items are not in resident rooms.
During an interview on 4/2/25 at 12:28 p.m., the Administrator said that residents were not allowed to have prohibited medical related items in their rooms. She said that rubbing alcohol was a prohibited item and residents could not keep it unsecured in their rooms. She said there was a risk that a resident could be harmed She said it was the responsibility of all staff.
Record review of a facility policy dated 2001 entitled Hazardous Areas, Devices and Equipment, All hazardous areas, devices and equipment in the facility will be identified and addressed appropriately to ensure resident safety and mitigate accident hazards to the extent possible As part of the facility's overall safety and accident prevention program, hazardous areas and objects in the resident environment will be identified and addressed by the safety committee A hazard is defined as anything in the environment that has the potential to cause injury or illness. Examples of environmental hazards include, but are not limited to the following: Access to toxic chemicals

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment, and to help prevent the development and transmission of communicable diseases and infections for 4 of 18 residents reviewed for infection control practices (Resident #'s 56, 4, 7, 28).
1.The facility failed to ensure the treatment nurse changed her gloves and performed hand hygiene appropriately while providing wound care to Resident #56.
2. The facility failed to ensure LVN C donned a gown before performing catheter care on Resident #4.
3.The facility failed to ensure LVN F donned a gown when she gave Peg-tube medications to Resident #7. Resident #7 was on enhancement barrier precautions.
4. The facility failed to ensure CNA E changed her gloves or sanitize her hands after performing incontinent care and applying clean brief for Resident #28. She touched a clean brief with her dirty gloves.
These failures could place residents at risk of exposure to communicable diseases, cross-contamination, and infections.
Findings included:
1.Record review of the undated admission Record indicated Resident #56 was a [AGE] year-old male that admitted [DATE].
Record review of the physician's orders dated 4/1/25 indicated Resident #56 had diagnoses that included: unspecified severe protein-calorie malnutrition (a person consumes inadequate amounts of protein and calories for an extendedperiodextended period , leading to significant health problems), type 2 Diabetes Mellitus with hyperglycemia (the body does not produce enough insulin or does not use insulin effectively, leading to high blood sugar levels), heart failure (the heart does not pump as much blood as it should), and anxiety (intense, excessive, and persistent worry and fear about everyday situations.) The physician's orders indicated:
3/10/25, Wound care: Sacrum: Stage 4 pressure wound, cleanse with normal saline or wound cleanser, pat dry. Apply collagen sheet to fit wound bed, followed by dry dressing. Apply barrier cream containing zinc ointment to peri-wound (area of skin surrounding a wound) tissue.
Record review of the admission MDS dated [DATE] indicated Resident #56 had clear speech, understood others and was understood by others. The MDS indicated he had a BIMS of 11 indicating moderate cognitive impairment and admitted with a stage 4 pressure ulcer (a pressure injury that extends through all layers of the skin and into underlying tissues, such as muscle, tendons, or bone.)
Record review of the care plan dated 2/19/25 indicated Resident #56 had a pressure ulcer. The goal was he would have no evidence of further skin breakdown/irritation and current wounds would heal without signs or symptoms of infection .
During an observation on 4/01/25 at 9:42 AM, the treatment nurse performed wound care on Resident #56. She did not change her gloves when performing wound care. With her dirty gloves she touched the collagen sheet placed on the wound and the outer dry dressing. She touched his clean brief, his blanket, and his comforter with the same gloves . She removed her gloves and without washing or sanitizing her hands adjusted the bed with the bed control.
During an interview on 4/1/25 at 9:50 AM, the treatment nurse said she was supposed to change her gloves after cleaning Resident #56's wound, a dirty procedure, and before going to the clean procedure. She said she was trained to change her gloves to prevent the risk of infection. She said failing to change her gloves or wash/sanitize her hands was an infection risk to the resident and to anyone else that touched the items she had touched with her dirty gloves.
Record review of a Competency Assessment, Dressings, Dry/Clean dated 9/30/24 indicated the treatment nurse was proficient in wound care.
During an interview on 4/01/25 at 4:01 PM, ADON B said when doing wound care, staff should change gloves after a dirty procedure and before going to a clean procedure. She said there should be 3 glove changes during wound care. She said not changing gloves and cleaning hands could cause an infection control issue/risk for staff and residents.
During an interview on 4/01/25 at 4:06 PM, ADON A said it would be an infection control risk for staff and for residents if a staff did not change gloves after performing a dirty procedure and before going to a clean procedure during wound care. She said staff were taught to change their gloves after a dirty procedure to prevent infection transmission to staff and residents.
During an interview on 4/2/25 at 11:50 AM, the DON said when performing wound care the treatment nurse or staff should change their gloves after performing a dirty procedure and before going to a clean one to prevent infection to residents and staff. She said touching the bed control with hands that were not sanitized or washed was also an infection control issue.
During an interview on 4/02/25 at 12:09 PM, the ADM said she expected staff to change their gloves after a dirty procedure and before going to a clean procedure to prevent infection. She said during wound care gloves should be changed several times. She said not changing gloves and washing hands could possibly cause an infection control issue to residents and staff. The ADM said staff have been trained to change their gloves when going from a dirty procedure to a clean one.
2. Record review of Resident #4's face sheet, dated 04/01/25, indicated she was a [AGE] year-old female, admitted to the facility on [DATE]. Her diagnoses included retention of urine (a condition where a person is unable to completely empty their bladder), and Alzheimer's disease (a progressive neurodegenerative disorder that primarily affects memory, thinking, and behavior, and is the most common cause of dementia in older adults).
Record review of Resident #4's quarterly MDS assessment, dated 01/25/25, indicated she had a BIMS score of 11, which indicated moderate cognitive impairment. The MDS assessment further indicated she had an indwelling catheter.
Record review of Resident #4's Order Summary Report, dated 04/01/25, indicated she had an order for Enhanced Barrier Precautions. The start date was 04/17/24.
Record review of Resident #4's undated care plan, included a focus of [Resident #4] has the potential for complications with UTI related to supra-pubic catheter secondary to retention of urine, dysfunction of bladder, and overactive bladder. The focus was initiated on 06/12/2019 and last revised on 12/05/20. Interventions included enhanced barrier precautions, initiated on 04/18/24.
During an observation on 04/01/25 at 9:56 AM, LVN C provided catheter care to Resident #4. There was a EBP sign on the Resident's door. LVN C did not don (put on) a gown before providing catheter care to Resident #4. Resident #4 had a suprapubic catheter.
During an interview on 04/01/25 at 10:14AM, LVN C said she should have worn a gown while providing care to Resident #4. She said it was important to follow EBP to protect residents from infection.
During an interview on 04/02/25 at 12:15 PM, ADON A said LVN C should have worn a gown when providing catheter care. She said it was important to protect the resident from infection. She said it is easier for the resident with a catheter to catch an infection.
During an interview on 04/02/25 at 12:26 PM, the DON said she expected LVN C to wear a gown while providing care to Resident #4. She said he risk to the resident was possible infection. She said a resident with medical devices can catch an infection easier.
During an interview on 04/02/25 at 12:37 PM, the Administrator said she expected LVN C to wear a gown while providing care to Resident #4. She said the risk was a potential infection.
3.Record review of Resident #7's face sheet, dated 4/1/25, indicated a [AGE] year-old female who initially admitted to the facility on [DATE] with diagnoses which included muscle weakness, unspecified dementia (a group of thinking and social symptoms that interferes with daily functioning), cerebrovascular disease (a medical emergency that encompasses a range of conditions affecting the brain's blood vessels and blood flow) and aphasia following unspecified cerebrovascular disease (a language disorder that affects a person's ability to communicate).
Record review of Resident #7's quarterly MDS assessment, dated 2/4/25, indicated she was rarely able to make herself understood and rarely understood others. No BIMS score was conducted for Resident #7. Resident #7 required dependent assistance with ADL's. Resident #7 was always incontinent of bladder and bowel.
Record review of Resident #7's care plan dated 2/21/25 indicated resident required enhancement barrier precautions related to indwelling catheter, feeding tube, and wound. Resident #7's interventions required staff to correctly put on gown and gloves and gown and gloves are used during high-contact sessions.
During observation on 04/01/2025 at 7:34 A.M., LVN F checked Resident #7's residual from peg-tube and did not apply PPE; the resident was on enhanced barrier precautions.
During observation on 04/01/2025 at 7:36 A.M., LVN F administered Resident #7's morning medication per peg-tube and did not apply PPE before giving medications; the resident was on enhanced barrier precautions.
During an interview on 04/01/25 at 9:03 A.M., LVN F said she knew she missed up during her med pass earlier. She said Resident #7 was on enhanced barrier precautions and she forgot to apply her PPE, because she was nervous. She said staff were supposed to wear PPE for enhanced barrier precautions for residents with feeding tubes, catheters, and wounds. She said staff wear the PPE for infection control. She said if PPE was not applied during contact care staff could transfer germs and it was a risk for infections for the residents.
4.Record review of Resident #28's face sheet, dated 4/2/25, indicated an [AGE] year-old female who initially admitted to the facility on [DATE] with diagnoses which included muscle weakness, unspecified dementia (a group of thinking and social symptoms that interferes with daily functioning) and chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe).
Record review of Resident #28's quarterly MDS assessment, dated 1/17/25, indicated she was able to make herself understood and understood others. Resident #28 had a BIMS score of 10, which indicated her cognition was moderately impaired. Resident #28 required moderate assistance with toileting hygiene and showers. Resident #28 was frequently incontinent of bladder and always incontinent of bowel.
Record review of Resident #28's care plan dated 8/28/23 indicated resident have a potential for impaired skin integrity related to decreased mobility, incontinence, low albumin level and low protein intake. Intervention was to keep resident clean, dry and sheets wrinkle free.
Record review of CNA D's: Clinical Proficiency-Incontinence Care sheet dated 2/17/25 indicated CNA D had met the requirements. The competency was signed by evaluator, LVN/ADON A.
Record review of CNA E's: Clinical Proficiency-Incontinence Care sheet dated 2/17/25 indicated CNA E had met the requirements. The competency was signed by evaluator, RN/ADON B.
During an observation on 04/01/25 at 9:47 A.M., CNA D and CNA E performed incontinent care on Resident #28. While the CNA's performed incontinent care; CNA E performed incontinent care on Resident #28 but did not remove her dirty gloves before applying a clean brief.
During an interview on 04/01/25 at 12:03 P.M., CNA E said she was very nervous with surveyor watching her and she had someone helping her, but she was use to performing the incontinent care alone. She said she did not change her gloves before applying the clean brief and she felt like she did not clean Resident #28 good enough during the care. She said after performing the incontinent care she should have removed her dirty gloves, sanitized her hands and applied clean gloves before applying the clean brief. She said not changing gloves after incontinent care could put the resident at risk for infection.
During an interview on 04/01/2025 at 3:24 P.M., CNA D said she saw when CNA E messed up during incontinent care with Resident #28. She said the proper way to do peri care was to wash your hands and have 3 bags. She said two things were missed, she said CNA E did not put drape over the resident and did not change her gloves or sanitize her hands, before applying the clean brief on Resident #28. She said improper hand hygiene could cause infections or an UTI.
During an interview on 04/02/2025 at 9:04 A.M., CNA G said when she worked with residents on enhanced barrier precautions; she wore her PPE. She said wearing the PPE decreased the risk of any contact with infections for the staff and the residents. She said when performing incontinent care staff should sanitize their hands and apply clean gloves after performing incontinent care, before they move on to the next step. She said proper hand hygiene prevent cross contamination.
During an interview on 04/02/2025 at 9:14 A.M., CNA H said if staff does not wear the correct PPE they could possibly contract what the resident has or the staff could transfer germs to the residents. She said after performing incontinent care staff should wash their hands and change gloves before a clean brief was applied. She said that would prevent cross contamination and infection.
During an interview on 04/02/2025 at 9:24 A.M., LVN I said she wear her PPE with resident that were on enhancement barrier precautions to prevent cross contamination. She said after performing incontinent care staff should perform hand hygiene and change gloves, before a clean brief is applied. She said proper hand hygiene prevents infection.
During an interview on 04/02/2025 at 9:41 A.M., LVN J said she wears PPE for resident on enhancement barrier precautions for protection, because the residents have some kind of open area. She said not wearing the PPE could spread bacteria for the resident and herself. She said wearing the PPE was for infection control. She said during incontinent care anytime going from dirty back to clean staff should remove dirty gloves, sanitize or wash their hands and then apply clean gloves before a clean brief was applied.
During an interview on 04/02/2025 at 11:35 A.M., LVN/ADON A said the facility always encourage the staff to wear PPE for enhancement barrier precaution residents. She said the precautions are in place to prevent cross contamination. She said after peri care the aides should be sanitizing or washing and changing their gloves. She said anytime staff touched something clean they should have clean gloves on. She said improper hand hygiene could put the resident at risk for infections.
During an interview on 04/02/2025 at 12:05 P.M., the DON said she expected the staff to gown up and use gloves when doing any physical activities with residents that were on enhancement barrier precautions. She said not wearing the appropriate PPE could put the residents at risk for infections. She said she excepted the staff to perform proper hand hygiene while performing care. She said CNA E should have removed her dirty gloves and performed hand hygiene before applying a clean brief. She said improper hand could cause infections with the resident.
During an interview on 04/02/2025 at 12:43 P.M., the ADM said she expected the staff to wear PPE with residents that were on enhancement barrier precautions. She said if staff do not wear the proper PPE that could make the residents acceptable to infections. She said she excepted the staff to perform proper hand hygiene while performing care. She said CNA E should have removed her dirty gloves and performed hand hygiene before applying a clean brief. She said improper hand could cause infections with the resident.
Record review of the facility's policy, Enhanced Barrier Precautions, dated August 2022, stated:
.Enhanced barrier precautions (EBPs) are utilized to prevent the spread of multi-dosing resistant organisms (MDROs) to residents .
.2. EBPs employ targeted gown and glove use during high contact resident care activities when contact precautions do not otherwise apply.
a. Gloves and gown are applied prior to performing the high contact resident care activity (as opposed to before entering the room) .
.3. Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include .
.g. device care or use (central line, urinary catheter, feeding tube, tracheostomy/ventilator, etc. ); .
Record review of the facility's policy, Perineal Care, dated February 2018, stated:
.The purpose of this procedure is to provide cleanliness and comfort to the resident, to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition .
.9. Discard disposable items into designated containers .
.10. Remove gloves and discard into designated container
.11. Wash and dry your hands thoroughly .
Record review of the facility's policy, Urinary Continence and Incontinence, dated August 2022, stated:
For a male resident with an indwelling catheter .
.1. The staff and practitioner will appropriately screen for, and manage, individuals with urinary incontinence .
.2. Management of incontinence will follow relevant clinical guidelines .
.3. The physician and staff will provide appropriate services and treatment to help residents restore or improve bladder function and prevent urinary tract infections to the extent possible .
Record review of the facility's policy, Dressing, Dry/Clean, dated September 2013, stated:
The purpose of this procedure is to provide guidelines for the application of dry, clean dressings .
Steps in the Procedure
.1. Clean bedside stand. Establish a clean field.
.2. Place the clean equipment on the clean field. Arrange the supplies so they can be easily reached.
.3. Tape a biohazard or plastic bag on the bedside stand or use a waste basket below clean field.
.4. Position resident and adjust clothing to provide access to affected area.
.5. Wash and dry your hands thoroughly.
.6. Put on clean gloves. Loosen tape and remove soiled dressing.
.7. Pull glove over dressing and discard into plastic or biohazard bag.
.8. Wash and dry your hands thoroughly.
.9. Open dry, clean dressing(s} by pulling corners of the exterior wrapping outward, touching only the exterior surface.
.10. Label tape or dressing with date, time and initials. Place on clean field.
.11. Using clean technique, open other products (i.e., prescribed dressing; dry, clean gauze).
.12. Wash and dry your hands thoroughly.
.13. Put on clean gloves.
.14. Assess the wound and surrounding skin for edema, redness, drainage, tissue healing progress and wound stage.
.15. Cleanse the wound with ordered cleanser. If using gauze, use clean gauze for each cleansing stroke. Clean
from the least contaminated area to the most contaminated area (usually, from the center outward).
.16. Use dry gauze to pat the wound dry.
.17. Apply the ordered dressing and secure with tape or bordered dressing per order. (Note: Use non- allergenic tape as indicated.) Label with date and initials to top of dressing.
.18. Discard disposable items into the designated container.
.19. Remove disposable gloves and discard into designated container. Wash and dry your hands thoroughly.
.20. Reposition the bed covers. Make the resident comfortable.
.21. Place the call light within easy reach of the resident.
.22. Clean the bedside stand.
.23. Wash and dry your hands thoroughly.
.24. If the resident desires, return the door and curtains to the open position and if visitors are waiting, tell them that they may now enter the room .
Record review of the facility's policy, Wound Care, dated October 2010, stated:
The purpose of this procedure is to provide guidelines for the care of wounds to promote healing .
.15. Remove the disposable cloth next to the resident and discard into the designated container .
.16. Discard disposable items into the designed container. Discard all soiled laundry, linen, towels, and wash cloths into the soiled laundry container. Remove disposable gloves and discard into designated container. Wash and dry your hands thoroughly .
Record review of the facility's policy, Infection Control Guidelines for All Nursing Procedures, dated August 2012, stated:
To provide guidelines infection control while caring for residents .
.2. Prevention of the transmission of multi-drug resistant organism .
.3. a. Before and after direct contact with residents .
.b. When hands are visibly dirty or soiled with blood or other body fluids .
.c. After contact with blood, body fluids, secretions, mucous membranes, or nonintact skin .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to ensure all drugs were stored and disposed of properly, for 1 of 6 residents (Resident #56) reviewed for medication storage.
1.The facility failed to ensure Resident #56's humlin 70/30 insulin was properly stored in the refrigerator.
2. The facility failed to ensure Resident #56's humlin 70/30 insulin with an expired date was disposed of.
This failure could place residents at risk of not receiving the therapeutic benefit of medications and adverse reactions to medications due to improper storage.
Findings included:
1.Record review of Resident #56's face sheet, dated 4/2/25, indicated a [AGE] year-old male who initially admitted to the facility on [DATE] with diagnoses which included type 2 diabetes mellitus with hyperglycemia( a condition where the body does not use insulin effectively, leading to high blood sugar levels), muscle weakness, unspecified severe protein calorie malnutrition (a condition where a person does not consume enough calories and protein to meet their nutritional needs) and chronic kidney disease (longstanding disease of the kidneys leading to renal failure).
Record review of Resident #56's quarterly MDS assessment, dated 2/27/25, indicated he was able to make himself understood and understood others. Resident #56 had a BIMS score of 11, which indicated her cognition was moderately impaired. Resident #56 required dependent assistance with ADL's . Resident #56 was always incontinent of bladder and bowel.
Record review of Resident #56's physician orders, dated 2/17/25, indicated humlin 70/30 subcutaneous suspension (70-30) 100unit/ milliliter (Insulin NPH Isophane and Reg (Human). Inject 5 units subcutaneously at bedtime for diabetes mellitus, hold for blood sugar less than 100.
Record review of Resident #56's care plan dated 3/14/25 indicated resident was at risk for frequent infections, pressure/venous/stasis ulcers, vision impairment, hyper/hypoglycemia, renal failure, cognitive/ physical impairment/ skin desensitized to pain or pressure, slow healing process related diagnosis of Diabetes Mellitus. Interventions were for staff to observe resident for signs of hyperglycemia (blood glucose >140mg/di; increase thirst, increase urination; increase appetite followed by lack of appetite; nausea, vomiting) and observe for signs of hypoglycemia (blood glucose<60mg/deciliter; sweating; cold; clammy skin; numbness of fingers, toes, mouth; rapid heartbeat; nervousness; tremors, faintness, dizziness).
During an observation on 4/2/25 at 9:30 A.M., with LVN K in back hall medication room. There were three bottles of humlin 70/30 insulin with Resident #56's information on it in a cabinet. Two of the bottles were not opened but one bottle had an expired date 1/21/25 on it which indicated been used.
During an interview on 4/2/25 at 10:02 A.M., LVN I said the insulin should have been stored in the refrigerator until it was opened. She said after an insulin was opened it was good for 20 days. She said she believed that the insulin found in the cabinet and not refrigerated came from Resident #56's home. She said the facility used the insulin until the resident's meds came from their pharmacy. She said the insulin should have been disposed of or sent back home with the family if the facility was not going to use it. She said since the insulin was improperly stored if it was used for Resident #56 it would not have been effective.
During an interview on 4/2/25 at 10:10 A.M., LVN K said insulin should be stored in the refrigerator if it had not been used. She said if insulin was not stored properly the effectiveness of the insulin would be at risk. She said the resident would not get the desired effect, which would be to decrease the blood sugar level.
During an interview on 4/2/25 at 11:35 A.M., LVN/ADON A said the insulin should have never been stored in the cabinets. She said unused insulin should be stored in the refrigerator. She said the nurses were responsible for the storage of the medications. She said improper storage of insulin would make the medication ineffective for the resident.
During an interview on 4/2/25 at 12:05 P.M., the DON said the insulin was a medication Resident #56 brought from home. She said the staff should have sent the medication back home with the family or destroyed it. She said an insulin improperly stored would not be effective for a resident. She said all unused insulin should be stored in the refrigerator until use. She said the facility has started an in-service over medication storage.
During an interview on 4/2/25 at 12:43 P.M., the ADM said she expected staff to properly store medications. She said the insulin should have been stored in the refrigerator or sent home with the family. She said improper storage of insulin would not be effective for the desired use of insulin.
Record review of the facility's policy, Medication Labeling and Storage, undated, stated:
The facility stores all medications and biologicals in locked compartments under proper temperatures, humidity, and light controls. Only authorized personnel have access to keys.
.3. If a medication has discontinued, outdated, or deteriorated medications or biologicals, the dispensing pharmacy is contacted for instructions regarding returning or destroying these items .
.6. Medications requiring refrigeration are stored in a refrigerator located in the medication room at the nurse's station or other secured location. Medications are stored separately from food and are labeled accordingly .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that residents who need respiratory care are provided with such care, consistent with professional standards of practices for 2 of 12 residents (Resident #35 and Resident #37) reviewed for respiratory care.
The facility failed to change the filters on oxygen concentrator machines that were in use for Resident #35 and Resident #37.
These failures could place residents at risk for of respiratory infections.
Findings included:
1.Record review of an undated face sheet revealed Resident #35 was an [AGE] year-old, female, and admitted on [DATE] with diagnoses including Autonomic Neuropathy (the damage to nerves that control your internal organs), Muscle Weakness (commonly due to lack of exercise, ageing, muscle injury or pregnancy), Anxiety Disorder (persistent and excessive worry that interferes with daily activities).
Record review of the MDS dated [DATE] revealed Resident #35 had a BIMS of 13, which indicated she was cognitively intact. MDS reflects Resident #35 received oxygen therapy. MDS reflected resident #35 required assistance with ADLs.
Record review of the Resident # 35's care plan dated 2/17/24 revealed Resident #35 was on oxygen therapy. Care plan revealed that Resident #35 will have no signs or symptoms of poor oxygen absorption.
During an observation and interview on 3/18/24 at 9:37 a.m., Resident # 35 said she used the oxygen concentrator every day. She said she did not know if the staff cleaned the machine or not. The concentrator was observed and the oxygen filter on Resident # 35's oxygen concentrator had a dirty filter. The filter had white and grey substances covering the filter.
During an observation on 3/20/24 at 9:15 a.m., Resident #35's air concentrator filter was dirty. The filter had unknown white and gray particles covering the air filter.
2. Record review of an undated face sheet revealed Resident #37 was an [AGE] year-old, female, and admitted on [DATE] with diagnoses including Chronic Obtrusive Pulmonary Disease (a common lung disease causing restricted airflow and breathing problems), Acute Respiratory Failure with Hypoxia (a condition where you don't have enough oxygen in the tissues in your body), Lack of Coordination (Impaired balance or coordination, can be due to damage to brain, nerves, or muscles).
Record review of the MDS dated [DATE] revealed Resident #37 had a BIMS of 11, which indicated she had mildly impaired cognition. MDS reflected Resident #37 received oxygen therapy. MDS reflected Resident #37 required assistance with ADLs.
Record review of the Resident # 37's care plan dated 1/24/24 revealed Resident #37 was on oxygen therapy related to Chronic Obtrusive Pulmonary Disease. The care plan revealed that Resident #37 will have no signs or symptoms of poor oxygen absorption.
During an observation and interview on 3/18/24 at 9:32 a.m., Resident #37 said she was not sure if anyone cleaned the air filter on the oxygen concentrator she used. She said she used the oxygen concentrator every day. It was observed that the oxygen concentrator machine had a dirty filter. The filter had unknown white and gray particles covering the air filter.
During an observation on 3/20/24 at 9:13 a.m., Resident #37's air concentrator filter was dirty. The filter had unknown white and gray particles covering the air filter.
During an interview on 03/20/24 at 9:20 a.m., the DON said nursing staff were responsible to ensure all oxygen tubing and filters were changed on the oxygen concentrators. She said there could be a risk for infection or the equipment malfunctioning when the oxygen concentrator did not have a clean filter.
During an interview on 3/20/24 at 1:08 p.m., the ADM said nursing staff were responsible to clean the filters on oxygen concentrators. He said he could not state the risks of oxygen concentrators with dirty filters as he was not a medical professional.
A record review of an oxygen concentrator policy was not completed as the facility was unable to provide a policy that addresses oxygen concentrators prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure that all alleged violations involving abuse, are reported to Texas Health and Human Services Commission immediately, but not later than 2 hours after forming the suspicion, if the events that cause the suspicion result in serious bodily injury, or not later than 24 hours if the events that cause the suspicion do not result in serious bodily injury for 1 of 5 (Resident #8) residents reviewed for abuse and neglect.
The facility did not report an allegation of abuse that occurred between 3/8/24-3/10/24 when Resident #8 reported to LVN A that CNA B had been rough while providing care and had caused a bruise on her right thigh.
This failure could place residents at risk of injuries, abuse, and/or neglect.
Findings included:
Record review of a facility face sheet dated 3/19/24 for Resident #8 indicated that she was a [AGE] year-old female that admitted to the facility on [DATE] with diagnosis of chronic obstructive pulmonary disease (causes airflow blockage and breathing related problems), schizophrenia (affects a person's ability to think, feel, and behave clearly), and muscle weakness.
Record review of a Quarterly MDS assessment dated [DATE] for Resident #8 indicated that he had a BIMS score of 11 indicating that she had a mildly impaired cognitive deficit.
Record review of a comprehensive care plan for Resident #8 revised on 11/14/23 indicated that she was PASRR positive due to a severe mental illness. Resident #8 refused all PASRR services and had signed refusal of PASRR MI specialized services form 1041.
During an interview on 3/18/24 at 10:42 AM, Resident #8 said on Thursday 3/14/24 or sometime last week (could not remember exact day) CNA B had come into her room to put on her nighttime brief, and CNA B jerked the right side of the brief up causing a tear in the skin at the crease of her thigh and groin area. Resident #8 said she yelled out that it hurt, and CNA B jerked up the right side of the brief again causing a bruise to her right upper thigh. Resident #8 said she reported the incident to LVN A the night it happened. Resident #8 said LVN A went and filled out a report about the incident and brought it back for her to sign. Resident #8 said after she signed the report LVN A told her she was going to place it under the door of Robbie (no known staff by that name). Resident #8 said after she reported the incident to LVN A she had not heard anything else about the incident.
During an interview by phone on 3/18/24 at 6:52 PM, LVN A said Resident #8 did report to her that CNA B had pulled Resident #8's brief up to rough while putting on her nighttime brief. LVN A said she told Resident #8 to talk to the Administrator. LVN A said she did not fill out any kind of report or have Resident #8 sign anything. LVN A said she did not report the incident to the Administrator or DON because Resident #8 said she was going to report the incident to administration on Monday. LVN A said she did not feel like CNA B had intentionally hurt Resident #8 and felt like Resident #8 had a personal issue with CNA B. LVN A said she did not remember what specific day the incident took place but thought it happened over the weekend of 3/8/24-3/10/24. LVN A said she had been trained on reporting abuse and neglect but did not think Resident #8 had been abused so she did not report it. LVN A said the facility policy was to report all allegations of abuse to the Administrator.
On 03/19/24 8:41 AM, Attempted phone interview with CNA B, she did not answer or return call by the time of exit.
During an interview on 3/19/24 at 9:30 AM Resident #8 said the Administrator had come to her room earlier that morning and talked to her regarding the incident with CNA B. Resident #8 said she did not get to tell the Administrator the whole story of what happened during the incident because the Administrator did all the talking and would not let her finish telling him what had happened.
During an observation and interview on 03/19/24 at 09:33 AM with the ADON C present observed Resident #8's groin area with red raw irritated with no obvious skin tear in the crease of the groin, no bruises observed to the right thigh area. Resident #8 said the bruises are healing up now because it happened last week. While skin was being observed Resident #8 told ADON C that CNA B had come in to put on her nighttime brief and jerked the right side of her brief up and caused a tear in the crease of her right leg. Resident #8 said she yelled out ouch that hurt and CNA B jerked the brief up again causing a bruise to her right leg.
During an interview on 3/19/24 at 9:37 AM, the ADON C said she worked at the facility for about 1 year. She said LVN A called her on 3/18/24 around 7:30pm after speaking to the surveyor and asked her if she was going to lose her job because she did not report that Resident #8 had said CNA B was being rough with her. The ADON C said she returned to the facility and the ADON C and LVN A went to Resident #8's room and Resident #8 described her interaction with CNA B as rough. Stating that CNA B pulled her brief up too tight causing bruising. The ADON C said Resident #8 also stated that she had told someone about the situation a week ago on a Monday. The ADON C said she felt like the incident was more of a personality conflict between Resident #8 and CNA B. The ADON C said CNA B normally dotes on Resident #8 and she thought CNA B told Resident #8 that she could be more independent and do some of her own tasks and it would make her stronger and Resident #8 got mad at CNA B for that. The ADON C said CNA B was on vacation out of state and had not spoken with her. The ADON C said she started staff education on: Skin Assessments/Reporting Skin Changes, Safe Handling, Skin Integrity on 3/18/24. The ADON C said she had not started abuse education training.
During an interview on 3/19/24 at 9:58 AM the Administrator said he was notified that a surveyor was asking questions about Resident #8 and a possible allegation of abuse at approximately 9:00pm on 3/18/24. He said he did not report the incident to HHSC because he did not feel like the incident was abuse. The Administrator said he and the SW spoke with Resident #8 and she told him CNA B was hateful and talking to her in a way she did not like and did not like CNA B's approach. The Administrator said Resident #8 told him CNA B put a brief on her and that she had a bruise on her leg but did not say what the bruise was from. He said he did not speak with LVN A that the complaint was originally reported to because the DON was handling the investigation on 3/18/24 due to him being in the ER with his 1 ½ year old child. He said he had not reported the incident as of 3/19/24 at 9:58am because Resident #8 did not make the allegation of abuse to him.
During an interview on 3/19/24 at 10:30 AM, the SW she said she went to speak with Resident #8 with the administrator the morning of 3/19/24. She said Resident #8 said CNA B has an attitude and said to her what do you want but did not say anything about the CNA B being physical. The SW said Resident #8 said CNA B told Resident #8 to not push her call light. The SW said Resident #8 did not mention anything about the brief or bruise. The SW said she had not received any complaints about CNA B before.
During an interview on 3/20/24 at 9:16 AM, the DON said she had worked at the facility for about 1 year. The DON said she received a text message from the ADON C and was notified of the alleged abuse by Resident #8 on 3/18/24 at 7:40pm and said she notified the administrator on 3/18/24 at 7:55pm. The DON said she was notified that Resident #8 complained to a the surveyor that CNA B was too rough putting a brief on her and had bruised her. The DON said the ADON C and LVN A did a skin assessment on 3/18/24 and did not find a bruise. She said the ADON C started in-servicing staff on Skin Assessments/Reporting Skin Changes, Safe Handling, Skin Integrity. The DON said she identified who the CNA was and made sure she was not working. The DON said the ADON C made sure Resident #8 was safe. The DON said she had not spoken with CNA B due to her being out of state on vacation. The DON said whether or not the abuse occurred, CNA B will not care for Resident #8 anymore. The DON said on 3/18/24 was the first time she had heard of the incident and LVN A had not reported the incident to her. The DON said that LVN A felt like Resident #8 was a constant complainer and took it as being another issue verses something she should report. The DON said the investigation was still pending and the SW had been doing safe surveys. The DON said her expectation was for staff to report all allegations of abuse to the administrator or if it was reported to a nurse manager, they would get that information to the administrator. The DON said the potential negative outcome for staff not reporting alleged abuse was the potential for further abuse to the resident.
On 03/20/24 11:28 AM Attempted phone interview with CNA B, she did not answer or return call by the time of exit.
During an interview on 3/20/24 at 1:08 PM the Administrator said his expectation was that staff were to report all allegations of abuse to him or their supervisor immediately. The Administrator said the resident could potentially continue to be subjected to abuse if staff did not follow the facility abuse policy.
Record Review of the ADON C statement dated 3/18/24. The statement revealed: On the evening of March 18, 2024, I returned to the facility after receiving a call from the charge nurse, LVN A, in regard to Resident #8. After arriving I had LVN A to go with me to resident room. I was able to visit with Resident #8 in regard to her concern with night CNA B. Resident #8 described her interaction with CNA B as Rough. Stating that CNA B pulled her brief up too tight causing bruising .
Record review of a facility incident log for March 2024 indicated that no incident report was filed for an incident regarding Resident #8.
Review of website for state complaints and incidents on 3/18/24 revealed there was no self-report to HHSC for incident on Resident #8 from facility.
Record review of in-service dated 1/2/24 titled Abuse/Neglect Reporting/Identifying revealed CNA had been educated prior to the incident.
Record review of in-service dated 2/29/24 titled Abuse/Neglect Reporting/Identifying revealed LVN had been educated prior to the incident.
Review of website for state complaints and incidents on 3/19/24 revealed the incident with Resident #8 had been reported to HHSC on 3/19/24 at 10:39am.
Record review of facility titled Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating with a revised date of September 2022 revealed: 1. If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. 2. The Administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies: a. The state licensing/certification agency responsible for surveying/licensing the facility;.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide the necessary services to maintain personal hygiene for 1 of 12 residents reviewed for ADLs (Residents #48.)
The facility did not clean or trim Resident #48's fingernails on 03/18/2023, 03/19/2024 and 03/20/2024.
This failure could place residents who required assistance from staff for ADLs at risk of not receiving care and services to meet their needs which could result in poor care, risk for skin breakdown, feelings of poor self-esteem, lack of dignity and health.
The findings included:
Review of Resident #48's electronic face sheet dated 09/22/22 revealed a [AGE] year old male who was admitted to the facility on [DATE] with diagnoses including Chronic Respiratory Failure (shortness of breath or feeling like you can't get enough air, extreme tiredness, an inability to exercise as you did before, and sleepiness), Muscle Weakness (commonly due to lack of exercise, ageing, muscle injury or pregnancy), Cardiac Pacemaker (a small, battery-powered device that prevents the heart from beating too slowly).
Record review of Resident #48's annual MDS dated [DATE] revealed a BIMS with a score of 09, which indicated Resident #48 had moderately impaired cognition. The MDS also revealed, Resident #48, required total assistance with ADLs.
Record review of Resident #48's care plan dated 1/24/24 revealed a problem initiated on 4/14/20. Resident #48 requires assistance with ADLs including personal hygiene. Care plan reflected that Resident # 48 will maintain a sense of dignity by being clean, odor free, and well groomed.
During an interview and observation on 3/18/24 at 9:51 a.m., Resident #48 said he wanted his fingernails cut. He said he did not know when his nails were cut last. He said he was unable to cut his own nails. He said a staff had cut them in the past. Resident #48's nails were long and there was a black unknown substance under his nails.
During an observation on 3/19/24 at 3:20 p.m., Resident #48 nails were long and there was a black unknown substance under his nails.
During an observation on 3/20/24 at 8:55 a.m., Resident #48 nails were long and there was a black unknown substance under his nails.
During an interview on 03/20/24 at 9:20 a.m., with the DON she said residents could be placed at risk for infection if their fingernails were not cut and maintained. She said that it was the responsibility of the CNAs to ensure that residents who were dependent for ADLs were cared for and their nails were kept cut and clean.
Review of the facility policy and procedure titles Activities of Daily Living (ADL), Supporting revised March 2018 revealed that Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs) .Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen (Main Kitchen), in that:
On 3/18/24 the facility failed to ensure food was discarded by the expiration date.
This deficient practice could place residents who ate food from the kitchen at risk for foodborne illness.
The findings included:
During an observation, in the dry storage area inside of the kitchen, on 03/18/2024 at 09:00 a.m., revealed one box of Swiss Miss hot chocolate mix containing twenty 0.73 ounce packets with expiration date of July 2023, three 13 ounces packets of Morrisons brown gravy mix with expiration date of 02/09/2024.
During an observation, of emergency food supply, on 03/18/2024 at 09:25 a.m., revealed six 8lb cans of Carriage House grape jelly with the expiration date of 06/22/2022, 2 cases of twenty-four 4 ounce cups of Sysco diced pears with the expiration date of 03/01/2024, one case of sixteen 14 ounce packets of Folgers coffee with the expiration date of 12/13/2023, 4 cases of ninety-six 1.25 ounce packs of Malt O'Meal raisin bran cereal with the expiration date of 11/11/2023, 2 cases of ninety-six 1.25 ounce packs of Malt O'Meal crispy rice cereal with the expiration date of 12/23/2023, 1 case of ninety-six 1.25 ounce packs of Malt O'Meal crispy corn flakes with the expiration date of 09/05/2023, 140 cups Snack Pack vanilla pudding 3.25 ounce cups with the expiration date of 12/11/2023.
During an observation and interview on 03/18/2024 at 09:25 a.m. the DM confirmed, by observations, that items in the dry storage area, and emergency food supply were not discarded by the expiration dates.
During an interview on 03/19/24 at 02:18 p.m., the DM said she had worked at the facility for about 28 years. She said it was her responsibility to check the expiration dates on all food in the kitchen. She said the last time she checked the food in the pantry in the kitchen was 3/19/24. She said she was supposed to check the food expiration dates on the day's groceries were delivered. She said she last checked the emergency food supply about 3-4 weeks ago but did not get to finish. She said consuming expired foods could put the residents at risk of food borne illnesses. She said the facility policy was all expired food was to be discarded by the expiration dates.
During an interview on 03/20/2024 at 03:00 p.m. the Administrator said he had worked at the facility for about 1 year. He said his expectations was for all expired food to be thrown away or sent back to the food company. The Administrator said, I've eaten expired food before, and it did not hurt me but maybe it could cause food borne illnesses.
Record review of facility policy titled Dry Storage and Supplies dated 2012, revealed All facility storage areas will be maintained in an orderly manner that preserves the condition of food and supplies. We will ensure storage areas are clean, organized, dry and protected from vermin, and insects. The facility policy did not address expiration dates.
Record review of the facility policy titled Use by Date Guide undated revealed: The following guide should be used to determine a use by date when labeling opened or unopened food that must be used within a certain timeframe. An exception to this would be if the manufacturer use by date comes before the date determined using the labeling guide.

Based on observation, interview and record review the facility failed to maintain all essential equipment in safe operating condition, for 1 of 1 stove in the kitchen reviewed for food service in that:
The facility did not ensure the gas stove was in working order. Three of six gas stove burners (front middle, right front, and right back) did not light automatically on 03/18/2024, when the knob was turned, the pilot light on the burners would not stay lit and both burners had carbon buildup.
This failure could place residents who eat out of the kitchen at risk for injury and under cooked food.
Findings included:
During an observation on 03/18/24 at 9:00 AM, the gas stove had six burners and three burners located in the front middle, right front, and right back had excess carbon buildup. The burners would not light automatically and the pilot light would not stay lit.
During an interview on 03/18/24 at 10:30 AM, the [NAME] stated she notified the Maintenance Director on 03/11/24 that the burners were not working. She said the Maintenance Director came and worked on the stove and the burners worked that day but the next day they were not working again. She said she notified the Maintenance Director again the next day and he came and tested the burners, but he had not been back since and burners continued to not work. She said the dietary manager was aware the burners did not work. She stated that the burners not working correctly could be a fire hazard.
During an interview on 03/19/24 at 10:28 AM the Maintenance Director said the ovens were deep cleaned this past weekend 3/15/24-3/17/24. He said he was called by the kitchen and told that a few of the stove burners were not working properly. He said he had checked on it first thing Monday morning 3/11/24 and noticed that the pilot light has a flame but took forever to light. He said the stove had a 1-year warranty, so he was working on getting someone to come out and repair the burners that are not working. He said even if it was not covered by warranty, he would still have the burners repaired . He said he was going to call and check on the status of the repair person coming out.
During an interview on 03/19/24 at 02:18 PM the DM stated that she and the other kitchen staff were responsible for maintaining the stove and keeping it clean. She stated if the burners were not working, or the carbon build up was excessive then she would tell the Maintenance Director. She stated she was aware of the burners not working and had notified the Maintenance Director. She said the Maintenance Director told her the burners may be stopped up. She said the Maintenance Director told her on 3/19/24 that he was going to call the manufacturer to check on the warranty. She stated if the stove was not working correctly, it could be a fire hazard.
During an interview on 03/20/24 at 3:00 PM the administrator stated it is news to me the stove in the kitchen was not in working order. The Administrator said that a deep clean was done on Friday 3/15/24 and no one mentioned to him there was a problem with the stove, or he would have taken care of it. The Administrator said the stove may still be under warranty. He said the Maintenance Director had asked him on 3/18/24 who the stove was purchased from. He said there was an open service call on the stove. The Administrator said the stove not working properly would not interfere with resident meals.
On 3/18/24 the Surveyor requested a facility policy regarding essential equipment, and none was provided by the time of exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan to meet each resident's medical, nursing, mental, and psychosocial needs for 1 of 5 resident's reviewed for care plans. (Resident #1)
The facility failed to ensure Resident #1's general surgeon (medical doctor) was informed of her care, as a follow-up appointment was missed and not rescheduled.
This failure could place residents at risk of not having individual needs met and cause residents not to receive needed services.
Findings included:
Record review of Resident #1's face sheet, printed on 02/29/24, indicated she was a [AGE] year old female, originally admitted to the facility on [DATE]. Her diagnoses included perforation of intestine (a hole in the intestine that can cause stool to leak into the abdomen), chronic kidney disease stage 4 (severe loss of kidney function), down syndrome (a genetic condition that causes mild to significant physical and developmental problems), and type 2 diabetes mellitus (a condition that happens because of a problem in the way the body regulates and uses sugar as a fuel).
Record review of Resident #1's admission MDS assessment, dated 01/09/24, indicated she had a BIMS score of 10, which indicated moderate cognitive impairment. She was usually able to make herself understood and usually able to understand others. She did not exhibit behaviors of rejection of care or wandering. She had a surgical wound that required surgical wound care.
Record review of Resident #1's care plan initiated on 01/23/24, and last revised on 02/28/24, indicated a focus of has alteration in skin integrity as evidenced by surgical wound to abdomen. The interventions included:
* Assess for possible reasons for skin concerns, report findings to MD
* Keep MD and RP informed of resident's progress
* Monitor area for increased breakdown, signs/symptoms of infection, report to MD
Record review of Resident #1's hospital after visit summary, dated 01/22/24, indicated she had a post-op appointment scheduled on January 25th, 2024 with the general surgeon that performed her abdominal surgery during the hospitalization.
Record review of Resident #1's hospital after visit summary, dated 01/30/24, indicated call [general surgeon], MD in 1 week(s). the summary further indicated Please notify [general surgeon] of any issues or concerns with the wound.
During an interview on 02/29/24 at 1:00PM, the DON said as far as she was aware Resident #1 did not go to a follow up appointment with her general surgeon. She said Resident #1 missed her 3 week follow-up appointment with the general surgeon because it was not on her hospital discharge orders from 01/30/24. She said since the appointment was not on her new discharge orders she did not expect for the resident to go to a follow-up with the abdominal surgery doctor. She said the wound care doctor was her first line for wounds and she would not expect to send Resident #1 to the general surgeon unless there was a significant issue. She said even though the surgical wound was open and being treated by the wound care doctor she did not reach out to the surgeon to notify him or schedule a follow up.
During an interview on 02/29/24 at 1:35PM, LVN C said she was responsible for scheduling residents' outside appointments. She said Resident #1 had a follow-up scheduled with the general surgery office for January 25th, 2024 and the resident did not go to that appointment because she returned to the hospital on that day. She said the resident's family called and cancelled the appointment because the resident was in the hospital. She said rescheduling the appointment was missed. She said she thought it was important for Resident #1 to make it to her surgical follow up appointments. She said by missing the appointments Resident #1's condition could have worsened and her overall status could have worsened.
During an interview on 02/29/24 at 1:44PM, Certified Medical Assistant D said she worked at the general surgeon's office. She said the office expects the patients to make it to their follow up appointments because the doctor likes to follow up on surgical wounds. She said she expected the facility to reach out and let them know of the reason for missing the appointment and then reschedule when possible.
During an interview on 02/29/24 at 2:00PM, the DON provided the hospital after visit summary dated 01/30/24. She said the after visit summary from 1/30/24 indicated call [general surgeon], MD in 1 week(s). She said those statements she sees as telling the facility to take care of the specific problem. She said sometimes the after visit summaries say call primary care doctor and they have a primary care doctor in house that they would use instead of an outside doctor. She said even though the discharge paperwork said contact the general surgery MD she expected her staff to not contact the surgeon because the wound care doctor was taking care of the wound. She said the facility did not have a policy that addresses the making of appointments and making sure that follow-up appointments are not missed. She said we are not regulated to have a policy on that so we do not have one.
During an interview on 02/29/24 at 2:18PM, Practice Manager E said she was the practice manager at the general surgeon's office. She said the general surgeon was unavailable for comment at that time. She said she expected the facility to keep a follow up appointments with the surgeon and reschedule if needed.
During an interview on 02/29/24 at 4:18PM, LVN F said he thought residents with follow up appointments should go to the appointment. He said if an appointment was missed then he would contact the surgeon's office and ask if they still want the resident to have the appointment or not. He said he would also contact the primary doctor and ensure everyone was on the same page.
During an interview on 02/29/24 at 4:20PM, ADON B said someone should have followed up with Resident #1's surgeon to see if he still wanted her to come to the appointment after her hospitalization. She said the risk to Resident #1 was an adverse situation such as an infected wound and prolonged healing.
During an interview on 02/29/24 at 4:24PM, ADON A said she expected someone to follow up with the surgeon after Resident #1 returned to the facility from her hospitalization to see if the surgeon still wanted the follow-up appointment or not. She said the admitting nurse was responsible for making the appointment. She said if the admitting nurse was unable to make the appointment, then the next day shift nurse was responsible for ensuring the appointment was made. She said the risk to the resident not having a follow up appointment with the surgeon was a possible wound infection.
During an interview on 02/29/24 at 4:29PM, the Administrator said he expected the staff to at least call the surgeon's office to see if they still wanted a follow-up appointment. He said the risk to the resident because she did not have a follow up appointment was a possible infection.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation interview and record review, the facility failed to ensure prompt efforts were made to resolve grievances for 1 of 4 residents reviewed for grievances. (Resident #1)
The facility Administrator and DON failed to document, resolve, and follow up on grievances related to quality of care on behalf of Resident #1 on 01/26/2024 and 02/09/2024.
These failures could place residents at risk for grievances not being addressed or resolved promptly.
Findings included:
Record review of Resident #1's face sheet dated 2/16/24 indicated Resident #1 was a [AGE] year-old female who admitted on [DATE] and readmitted to facility on 9/15/23 with diagnoses including, atherosclerotic heart disease of native coronary artery without angina pectoris (is caused by plaque buildup in the wall of the arteries that supply blood to the heart (called coronary arteries). Plaque is made up of cholesterol deposits. Plaque buildup causes the inside of the arteries to narrow over time. This process is called atherosclerosis), type 2 diabetes (a chronic condition that happens when you have persistently high blood sugar levels), dementia (a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), hallucinations (involve seeing, hearing, feeling, tasting, or smelling things that aren't really there), Parkinson's disease (A disorder of the central nervous system that affects movement, often including tremors), hypertension (also known as high blood pressure, is a long-term medical condition in which the blood pressure in the arteries is persistently elevated), and gastro-esophageal reflux disease (occurs when stomach acid repeatedly flows back into the tube connecting your mouth and stomach).
Record review of Resident #1's revised care plan dated 10/10/23 indicated the following: Focus - Self-Care deficit: bathing, dressing, feeding due to terminal illness. Goal - staff will anticipate all needs. Interventions - Evaluate Resident #1s ability to perform ADLs, maintain consistent schedule with daily routine, provide assistance with ADLs, and Provide meal support per Resident #1's need.
Record review of Resident #1's quarterly MDS assessment dated [DATE] indicated Resident #1 had difficulty communicating some words or finishing thoughts but was able if prompted or given time. Also, Resident #1 misses some part/intent of message but comprehends most conversation. She had a Brief Interview for Mental Status (BIMS) score of 6, which indicated severe cognitive impairment. Section GG: Resident #1 requires partial/moderate assistance with rolling left and right. Resident #1 was dependent, and helper did all of the effort for eating (assistance with utensils to bring food and/or liquid to the mouth and swallow food and/or liquid once the meal is placed before the resident). Section GG also indicated Resident #1 was dependent for most ADLs.
Record review of grievance/complaint report dated 12/11/23 indicated the following: Received by: The facility SW; Resident Representative - Relationship: Resident #1's family member; Grievance/complaint reported to: The facility SW; Describe grievance/complaint using factual terms: Staff at times not checking on Resident #1, not giving ice and water, not feeding Resident #1, not putting trapeze bar in her reach; Documentation of facility follow - up section: Individual(s) designated to take action on this concern; Date assigned; Time; Date to be resolved by; Was a group meeting held; Identify all individuals in attendance; Plan of care reviewed and updated date; questions were all BLANK and Not completed; What other action(s) were taken to resolve grievance/complaint (be specific)? Care plan scheduled for Friday 12/15/24 with department heads, Hospice, Ombudsman; and family rescheduled to 12/19/23 to accommodate all schedule. Resolution of Grievance/Complaint Section - Was grievance/complaint resolved: Yes, describe resolution; Care plan meeting held with family, ombudsman, and department leads on 12/19/23 to address issues/concerns. Report was signed at the bottom by both the Administrator and the SW and dated 12/19/23.
Record review care plan meeting typed notes dated 12/19/23, attached to Resident #1's family member grievance report date 12/11/23 revealed the following: .The ombudsman asked Resident #1's family what the facility could do to fix the issues. Resident #1 stated she had brought the concerns to SW and ADON. She stated that the concerns were addressed at the time but feels they are patched and not fixed for good. Resident #1's family member stated she wanted the problems fixed. The Administrator explained that those current concerns were discussed during department head meeting after it was brought to their attention and that he was personally going in to check in on Resident #1. Resident #1's family members stated they had brought their concerns to CNAs and the nurses and they in turn stated they have reported the concerns to administration. The Ombudsman explained to Resident #1's family members to contact the Administration immediately upon any concerns. The DON and the Administrator let Resident #1's family know their information was posted in the facility for contacting them and that they can do so at any time. Resident #1's family member stated she knew everyone was busy and she hated to bother them. The Administrator and DON both stated to call them at any time. The DON explained their goal was to better care for Resident #1 and to build on the communication between the family and administration. She also asked Resident #1's family member to let administration know immediately of concerns. Resident #1's family member stated she that meeting had helped open up that communication and she felt better about her concerns and that they would be addressed. Resident #1's family member stated she would contact administration on concerns from then on.
Record review of facility's grievance log revealed that grievances were not documented/filed on 01/26/2024 and 02/09/2024 on behalf of Resident #1.
Record review of text messages dated 1/16/24 between Resident #1's family member to the Administrator and the DON stated we have another incident of Resident #1 not being properly fed. Family member is sending photos of the unknown staff bringing Resident #1 her food that evening. Then of that unknown staff sitting down to feed Resident #1 and a third picture of same unknown staff getting up and walking out and leaving Resident #1 food plate sitting open. The unknown staff left and never came back to feed Resident #1. A nightshift CNA said there were three residents on the same hall who were not fed. Y'all need more help on that hall. There were too many residents needing hands on care for one person. Who is the unknown staff in the pictures? Lastly, family member will send a picture of how Resident #1 was whenever another family member got there. Family member sent a second text message that stated Things seems to be headed right back down the wrong path again. What actions will you take to correct these issues? The DON responded She is a new aid that just started this week. Today was her first day out of orientation. I will get with her tomorrow as she is already gone tonight. Thank you for letting us know.
Record review of text messages dated 2/09/24 between Resident #1's family member to the Administrator and the DON stated Question, what is the procedure for training these new aides for facility? Staff put Resident #1 in the recliner at 10am and no one had been in to put her back in her bed. Did not see an aide in Resident #1's room until 1pm for lunch. Charge nurse came in and sat up Resident #1 because she was slumped all the way over that evening, but no one had changed her pad since. That was part of the reason Resident #1 bottom kept getting open sores. A CNA came in and fed Resident #1 her dinner and came back to move Resident #1 back to bed whenever she finished feeding Resident #1. The night CNA needed help to tend to all the residents. Resident #1 had been in the same spot in her recliner since 10am, 9 hours. Unacceptable, Also the CNA who fed Resident #1 her lunch was talking on the phone to someone on her phone while feeding Resident #1. What happened to the no cell phone usage in residents' room? Things seemed to be headed backwards again. Resident #1 was completely soiled in poop, so much that it soiled the blanket she was sitting on in the chair. Completely unacceptable. The Administrator replied Unfortunately they could not be everywhere and see everything. Thank you for bringing it to their attention. All personnel go through the same orientation and appropriate on the job process. They will revisit and will keep working until they find the correct staff. The DON will follow up with her team. Resident #1's family member replied stating It was not about being everywhere, it was about the staff being trained appropriately and that you can trust that the CNAs were doing what they're supposed to. Again, this may come back to the chain of command, if the CNAs were not doing their jobs then someone should be checking on them throughout the day to make sure that the resident was not the one suffering. How would you like to sit in your own feces for no telling how long to the point that it bled through the blanket she was sitting on into the chair, that was a long time. Resident #1 has open sores on her bottom and the pad that was on her open sores was soiled all the way through to her skin. If anyone had taken the time to look, they would have seen she was soiled so badly you could tell from the front. The Administrator replied stating Thank you for bringing it to our attention. The DON will follow up with her team immediately.
Record review of handwritten note dated 02/14/2024 revealed Resident #1's family member visited Resident #1 and asked the Administrator what was being done to correct the problems from last week, and the Administrator replied the DON was working on that. Resident #1's family member asked what the DON was working on, and the Administrator just repeated that the DON was working on it.
During observation on 2/16/24 at 3:18 p.m., Resident #1 was lying in bed resting, she did not appear to be in pain at that time and was not able to answer questions asked.
During an interview on 2/16/24 at 5:245 p.m., and via phone on 3/1/24 at 11:15 a.m., Resident #1's family member said a lot had changed since the facility hired the new Administrator and DON for the worse nearly a year ago. Resident #1's family member said she had voiced several complaints to the CNAs, but nothing was getting better, so she complained to the SW who scheduled a care plan meeting with all the department heads back in December 2023. Resident #1's family member said during the December 2023 care plan meeting the ombudsman, the Administrator and the DON told her to start notifying the Administrator and/or the DON personally regarding any issues/concerns and they would address it. Resident #1's family member said back on 1/26/24 and on 2/9/24 she had group texted the Administrator and the DON regarding issues/concerns and as of 3/1/24 the Administrator nor the DON had gotten back to her regarding her complaints to let her know what had been done. Resident #1's family member said on 2/14/24 she tried asking the Administrator what was being done about her complaint she made via text message to him on 2/9/24 and the Administrator would say the same response the DON was handling it; she said she questioned what the DON was doing, and the Administrator repeated DON was working on it. Resident #1's family member said she would love to know from Administration what was going on and what was being done because she was still having issues, and she felt like the facility did not care because she was not getting any answers from anyone.
During an interview on 3/1/24 at 11:06 a.m., The Ombudsman said Resident #1's family has had numerous complaints about the care of Resident #1 that happened prior to the December 2023 big care plan meeting and was still going on. The Ombudsman said whenever Resident #1's family make a complaint, the first couple of days they attempted to improve care, but then thereafter it would go downhill. The Ombudsman said the Administrator mentioned that if Resident #1's family was not satisfied then they can move Resident #1.
During an interview on 2/23/24 at 2:58 p.m., The DON said they had a care plan meeting in December 2023 with Resident #1`s family regarding several issues and concerns the family had. The DON said they were able to address Resident #1's family concerns and since the meeting Resident #1's family have voiced issues to other staff about having issues with staff not feeding Resident #1 and not turning Resident #1 every two hours. The DON was asked if she addressed the issues or concerns the other staff had brought to her and she said she felt Resident #1's family did not like her and that was why she did not follow up with the family regarding any of the issues, and she did not know if the Administrator had followed up with the family regarding their concerns/issues.
During an interview on 2/23/24 at 3:23 p.m., The Social Worker said she was the grievance official who maintained the grievances. She said back on December 11, 2023 Resident #1's family member voiced several concerns to her and SW scheduled a care plan meeting for 12/13/24 to addressed the concerns with department heads and ombudsman. The SW said during the care plan meeting it was arranged/suggested for Resident #1's family to reach out directly to the DON and/or the Administrator moving forward with all concerns/issues. The SW said Resident #1's family had not come to her in 2024 regarding issues or concerns and she was not aware if Resident #1's family had reached out to the DON and/or the Administrator if they had then the DON nor the Administrator had told her.
During an interview on 2/23/24 at 4:20 p.m., The Administrator said back in December 2023 all the department heads, the ombudsman and Resident #1's family members had a care plan meeting regarding all the concerns the family was having, and they were able to address most of the issues. During the meeting the Administrator said he told the Resident 1's family to personally let him and/or the DON know of any issues or concerns going forward and they would address it. The Administrator said Resident #1's family member had texted him and the DON a few times regarding concerns. The Administrator read off his phone the text messages from February 9, 2024 from Resident #1's family member to him and the DON; when the Administrator was asked if he notified or followed up with Resident #1's family about the status or the outcome from the concerns that were texted to him and he said he did not follow up with Resident #1's family and said the DON pretty much addressed everything. The administrator was asked how the DON addressed the issues Resident #1's family texted to them, and he could not answer what the DON did, and stated that he was sure the DON did something but did not know nor did he ask the DON what she did. The Administrator said Resident #1's family would normally reach out to him on a Friday evening, and he had five children at home, so he was not also able to immediately get back with the family, but he personally did not follow up with Resident #1's family with the outcomes. The Administrator said on 2/14/24 Resident #1's family member stopped him in the hall and asked what happened to the staff she complained about on 2/9/24 via text message, and he said he told her that it was confidential and could not disclose to her what happened to the staff. The Administrator was asked what happened to the staff he was referring to and he did not answer the question. The Administrator said he felt Resident #1's family had unrealistic expectations and said he told Resident #1's family if they were unhappy or had so many issues, they could take Resident #1 somewhere else.
During an interview on 2/23/24 at 6:15 p.m., The DON said during the exit conference that she was not aware text messages needed to be followed up or was considered a complaint.
Record review of revised Grievance policy dated December 2004 revealed facility will assist residents, their representatives (sponsors), other interested family members, or resident advocates in filing grievances or complaints when such requests are made. Policy Interpretation and Implementation: 1) Any resident, his or her representative (sponsor), family member, or appointed advocate may file a grievance or complaint concerning treatment, medical care, behavior of other residents, staff members, theft of property, etc., without fear of threat or reprisal in any form. 2) Grievances and/or complaints may be submitted orally or in writing. Written complaints or grievances must be signed by the resident or the person filing the grievance or complaint on behalf of the resident. 3) The Social Worker has been delegated as the Grievance Official for the facility. Upon receipt of a written grievance and/or complaint, Designee will investigate the allegations and submit a written report of such findings to the QA committee. 4) The administrator will review the findings with the person investigating the complaint to determine what corrective actions, if any, need to be taken. 5) Should the resident not be satisfied with the result of the investigation, or the recommended actions, he or she may file a written complaint to the local ombudsman office or to the state survey and certification agency.
Record review of the Rights of the Elderly included in the facility's revised new admission packet dated February 2023 revealed An elderly individual has all the rights, benefits, responsibilities, and privileges granted by the constitution and laws of this State and the United States, except where lawfully restricted. The elderly individual has the right to be free of interference, coercion, discrimination, and reprisal in exercising these civil rights. An elderly individual has the right to be treated with dignity and respect for the personal integrity of the individual, without regard to race, religion, national origin, sex, age, disability, marital status, or source of payment. This means that the elderly individual: . An elderly individual may complain about the individual's care or treatment. The complaint may be made anonymously or communicated by a person designated by the elderly individual. The person providing service shall promptly respond to resolve the complaint. The person providing services may not discriminate or take other punitive action against an elderly individual who makes a complaint.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that a resident received care, consistent with professional standards of practice to prevent pressure ulcers for 1 of 2 residents reviewed for pressure ulcers. (Resident #1)
Resident #1 was noted with an area on her hip on [DATE]. However, skin assessment for the same date did not note the area.
Resident #1 had staff reported areas of concern on her right hip prior to being notified by the family on [DATE] that she has a pressure ulcer.
Resident #1 was identified by the family on [DATE] to have a stage 3 pressure ulcer to the right hip.
These failures could cause residents to develop pressure ulcers.
Findings included.
Record review of Resident #1's face sheet dated [DATE] indicated she was a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses were abnormal poster, high blood pressure, diabetes, and dementia without behavioral disturbances.
Record review of Resident#1's Annual MDS dated [DATE] indicated she had severely impaired cognition. She required extensive assistance with one person for bed mobility, transfer, locomotion off the unit. She was totally dependent for dressing, toilet use and personal hygiene, and required the assistance of one person.
Record review of Resident #1's care plan dated [DATE] indicated a Focus area of required assistant with ADLS and was at risk for deterioration in ADLS such as bed mobility, bathing, transfer, walking in room, walking in corridor, locomotion on the unit, locomotion off the unit, dressing, eating, toilet use, personal hygiene related to cognitive impairment. A Focused area initiated on [DATE] indicated Resident #1 was at risk for frequent infections, pressure/venous/status ulcers, vision impairment hyper/hypoglycemia, renal failure, cognitive/physical impairment/skin desensitized to pain and pressure, slow healing process related to a diagnosis of diabetes. Some of the interventions were monitor skin for changes; redness, circulatory problems, breakdown, and report to the MD/RP. (After area identified) A Focused area dated [DATE] indicated Resident #1 had alteration in skin integrity as evidenced by at risk for recurrence related to abrasions to the right hip due to constant scratching and picking at this are. Apply skin barrier cream to scabbed areas to the right hip and cover with border gauze daily. On [DATE] now Right thigh had a stage 3 measuring 0.8 x 0.5 x0.1 cm. some of the interventions were keep MD and RP informed of resident's progress, keep skin clean, dry and sheets wrinkle free, monitor area for increased breakdown, treatment as ordered if no improvement notify the MD.
Observation of a video on [DATE] at 2:11 p.m. Resident #1 had an area noted to her right hip, the area was red with about a dime sized raised area that was dark on top.
Record review of Resident #1's a Skin assessment dated [DATE] indicated no new skin areas and the comments indicated blanchable redness to the perineal, barrier cream used with brief changes to prevent break down.
Record review of Resident #1's Braden Scale for Predicting Pressure Sore Risk dated [DATE] indicated she was a low risk. The form indicated she had slightly limited sensory perception, she was rarely moist, chair fast, she had slightly limited mobility, her nutritional intake was adequate, and there was a potential problem for friction and shearing.
Record review of Resident #1's wound assessment dated [DATE] at 11:52 p.m. indicated a skin assessment was completed at this time. The skin is warm and dry; color is normal for race. There was redness noted to the right hip, barrier cream applied.
Observation of a video dated [DATE] at 11:15 a.m. showed Resident #1 in the bed, CNA E, an unidentified CNA, and a family member in the room. Resident #1 received incontinent care. During the care the family member asked if there was a wound on Resident #1's right hip. The aide said it was not a wound it was an area where a wound had healed.
Record review of Resident #1's wound assessment dated [DATE] at 9:58 p.m. indicated a skink assessment was completed at this time. The skin is warm and dry, color is normal for race. There was redness noted to the right hip, barrier cream applied.
Observation of a video dated [DATE] at 2:40 p.m. Resident #1 in bed on her left side with her right hip showing. A view of Resident #1's right lower thigh showed several deep cut-like areas that looked healed, but the skin was not closed. On her right hip was an old area that looked to have healed with discolored skin. There were two small areas that had scrabs and one of those areas was partially opened. There was one area to the lower hip that looked to be about the size of a dime, with the top layer of skin missing.
Record review of Resident #1's nurses notes dated [DATE] at 5:28 p.m. indicated red areas noted to the resident's right hip. Order to monitor and offload.
Record review of Resident #1's physician note dated [DATE] at 8:13 a.m. indicated the resident was seen today due to recent decline in her verbal communication and fluctuating glucose levels. She had a 10-pound weight gain. The patient had been primarily responding with Yeah,: indicated a decline in her verbal communications. Despite this her appetite remains fair, and she gained weight over the past year. She had episodes of recorded low glucose readings 74 on [DATE] and recent readings at heights of 456 and 496. He dementia symptoms appeared to be worsening. Family reported a possible wound. Spoke to the family member by phone and recommended considering hospice due to recent decline.
Review of Resident #1's nursing notes date[DATE] at 11:46 a.m. indicated the Treatment Nurse was notified of open areas to Resident #1's right hip. Upon assessment treatment nurse noted 3 areas to right hip (1) upper right hip scab noted, no drainage noted, surrounding skin intact, measured 0.5 x 0.5(2) Lateral right thigh, scab noted, no drainage noted, surrounding skin intact measured 1.) x 0.5 cm (3) Medial right thigh abrasion noted, no drainage, surrounding skin intact 1.5 x1.0cm. MD notified of areas and wound care doctor to see tomorrow when making rounds. Wound care orders received: Cleanse with Normal saline, pat dry, apply skin barrier cream and cover with border gauze. The treatment nurse noted the resident scratching at right hip during wound care.
Record Review of Resident #1's computerized physician order dated [DATE] indicated to monitor 3 areas to the right hip by offloading every day. An order dated [DATE] indicated apply skin barrier cream to scabbed areas to the right hip and cover with border gauze daily for wound healing and discontinued [DATE].
Record Review of Resident #1's Physician's Wound Summary report dated [DATE] indicated (site 1) Stage 3 pressure wound of the right hip full thickness, duration 1 day, size 0.8 x0.5cm x 0.1 cm. the surface area was 0.40 cm with light serous drainage and 50 percent slough, and 50 percent granulation tissue. (Site 2) non pressure wound of the right thigh partial thickness, the origin indicated trauma injury, duration 1 day, size of wound 1 x 0.5 dept was unmeasurable due to scab. (Site 3) non pressure wound of the right hip partial thickness. The origin indicated it was trauma, injury duration one day measured 0/4 x 0.4 cm, depth was unmeasurable due to scab.
Record review of Resident #1's nurses note dated [DATE] indicated an order was placed on Hospice services.
Record review of Resident #1's Record of Death dated [DATE] indicated the resident died on Hospice services with the family at the bedside.
During an interview on [DATE] at 11:11 a.m. LVN A said Resident #1 was full care when she transferred to his hall on or about [DATE]. He said at that time she did not eat much, required assistance with eating, and was placed on Hospice. He said Resident #1 had wound on the inside of the mouth and that was the only wound he was aware of.
During an interview on [DATE] at 11:24 a.m. LVN B said she worked with Resident #1 before got moved to the other hall. Resident #1 was a diabetic, blood sugar would fluctuate a lot. LVN B said Resident #1 had some breakdown on the right hip. She would lay on right side, would try to turn her but turn self to the right. LVN B said Resident #1 was declining. LVN B said she did not usually complete treatments they were completed by the wound care nurse.
During an interview on [DATE] at 11:34 a.m. CNA C said worked with Resident #1 sometimes. She said Resident#1 had something on her hip, but it covered when she saw it. CNA C said Resident #1 had a rash on her buttock and she out ointment on it.
During an interview on [DATE] at 12: 14 p.m. the Administrator said Resident #1's family had some care and concerns about that the resident had a big decline. He said the family notified staff on [DATE] Resident #1 had wounds on her hip. He said the facility had care planned Resident #1 for scratching and picking at her wounds. The Administrator said the family had concerned that she was lost weight because she felt the facility was not making sure she ate. We moved Resident #1 on [DATE]. He said the resident had a rapid decline and they had completed labs on her, her blood sugars were going up and up. He said when the labs were received, they were not good. The MD spoke to the family member on [DATE] regarding hospice care. He said the wound care physician looked at her wounds on [DATE] and said they were tiny. He said if the resident had anything on her hip on [DATE] the family would have notified them immediately.
During a telephone interview on [DATE] at 4:40 p.m. the Treatment Nurse/ LVN said the procedure was the nursing staff were supposed to notify treatment nurse and the physician if any new areas were identified. She said once she completed her assessment, she would notify physician and make the wound care physician aware to determine what the orders for wound care would be. The Treatment nurse said she had put treatments in place when notified on [DATE] of Resident #1's wounds. She conducted her skin assessment with the wound care doctor on [DATE].
During an interview on [DATE] at 4:59 p.m. the DON said they had conducted a skin assessment all residents in the building, and completed new skin assessments where necessary. She said they looked at changing their policy on how they conduced skin assessments. The nursing staff were doing the skin assessments weekly if the resident had no pressure areas.
During an interview on [DATE] at 12:58 p.m. the family member said they had a camera in Resident #1's room. They were reviewing the videos due to concerns with Resident #1's care. She said Resident #1 had an area on her right hip they saw on the camera on [DATE]. The family said another day CNA E told them Resident #1 had an old wound in a spot the family member asked about on the right hip. The family said no one ever told them Resident #1 had an area on her hip. The family member said on [DATE] the family identified a wound on Resident #1's right hip and notified the facility. The facility was not aware of the wound and had no treatments in place. Family member sent videos and pictures.
During a telephone interview on [DATE] at 3:15 p.m. CNA E said the family had asked her about an area on Resident #1's right hip and it was an old area that looked like it was going to reopen. CNA E said she had seen an area on Resident #1's right hip about a week before she was transferred on [DATE]. CNA E said she had reported the area to LVN B. She said the place was red, but it was not opened when she reported it the LVN B.
During an interview on [DATE] at 9:05 a.m. LVN B said CNA E had informed her of the wounds before the family identified the areas. She said she reported the concerns to the treatment nurse. LVN B said her observation of Resident #1's right hip had 3 small areas. She said there was no open wounds. LVN said she was not sure of what the date was, but she did not see the wound after it was opened. She said the area on her hip was about 3 x 2 cm about the size of a dime, but she did not measure it.
During an interview on [DATE] at 10:00 a.m. the DON said the Treatment Nurse did [NAME] assessment [DATE] that identified the area on the right hip as red. She said the area opened on [DATE] and they put treatments in place for the wound.
During an interview on [DATE] at 10:15 a.m. LVN F said she worked at the facility approximately 2 months. She said when Resident #1 came her hall on about [DATE]. She said when Resident #1 came she had an open wound that was about the size of a dime. She said Resident #1 had two scabbed areas. She said when she arrived on her hall she was not eating. The physician was in the facility on [DATE] and he spoke to the family on the phone about putting Resident #1 on hospice. She said the resident declined rapidly and died a few days after she was placed on hospice.
Record review of the facility Prevention of Pressure Injuries policy revised [DATE] indicated the purpose of the procedure was to provide information regarding identification of pressure injury risk factors and intervention for specific factors. Review the resident's care plan and identify risk factors as well as intervention designed to reduce or eliminate those considered modifiable. Assess the resident on admission, weekly and upon any change in condition, skin assessment should be comprehensive, during the skin assessment inspect presence of erythema, temperature of skin, soft tissue and edema, inspect the skin on a daily basis when performing or assisting with personal care or ADLs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure each resident was provided at least three meals daily for 1 of 5 residents reviewed for frequency of meals. (Resident #1)
The facility neglected to provide a resident with a breakfast tray on 10/23/23.
This negative finding could cause the resident to suffer physical harm and or emotional abuse.
Findings included:
Record review of Resident #1's face sheet dated 11/13/23 indicated she was a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses were abnormal poster, high blood pressure, diabetes, and dementia without behavioral disturbances.
Record review of Resident#1's Annual MDS dated [DATE] indicated she had severely impaired cognition. She required extensive assistance with one person for bed mobility, transfer, locomotion off the unit. She was totally dependent for dressing, toilet use and personal hygiene, and required the assistance of one person. The resident required extensive assistance with eating with one person assistance.
Record review of Resident #1's care plan dated 11/18/21 indicated a Focus area of required assistant with ADLS and at risk for deterioration in ADLS such as bed mobility, bathing, transfer, walking in room, walking in corridor, locomotion on the unit, locomotion off the unit, dressing, eating, toilet use, personal hygiene related to cognitive impairment. The resident would often lay her head down on the dining room table during activities and meal services. Some of the interventions were assist with ADLs as needed with the assistance of one staff member. The staff would feed the resident if she was unable to complete the meal with the assistance of one staff member. A Focused area dated 10/23/23 indicated Resident #1 was part of the red napkin program to alert staff that there was weight loss, and assistance was needed, and encouragement to eat. Some of the interventions where staff would assist and encourage the resident as needed. Staff would offer alternative foods if less than 25 percent was eaten. A Focused area was the resident would often lay her head down on the dining room table during activities and meal services. Some of the interventions were assist with ADLs as needed with the assistance of one staff member. The staff would feed the resident if she was unable to complete the meal with the assistance of one staff member. A Focused area noted as at risk for nutritional impairment related to below ideal body weight, currently receiving regular diet, mechanical soft texture, nectar thick liquids consistency. Self-care performance fluctuates related to diagnosis of dementia. Some of the interventions were assist with eating, staff to feed the resident if she was unable to feed herself. Ensure staff were aware of ADL functional level and report any increase or decline.
Observation of a video dated 10/28/23 and timed 7:30 a.m. LVN B was seen wheeling Resident #1 into the room. LVN B was heard to say your family member wanted you to eat in your room. LVN B told Resident #1 here are some crackers to eat until they bring your tray. The video showed Resident #1 eating the crackers. Observation of the video at 8:06 am., 8:41 a.m. , 9:00 a.m. and at 9:31 a.m. showed the Resident #1 sitting in the chair at the bedside table with her head down. The video showed at 10:00 a.m. Resident #1 wheeled herself away from the table towards the bed. During these observations there was no food tray noted.
Record review of Resident #1's ADL sheets dated 10/28/23 indicated for breakfast and 1 ( supervision oversight, encouragement or cueing) 1- setup help only. The ADL nutrition indicated Resident #1 ate 51 percent to 75 percent. The ADL documentation for that day was completed by CNA E.
During an interview on 11/13/23 at 11:11 a.m. LVN A said Resident #1 was full care when she transferred to his hall on or about 11/1/23. He said at that time she did not eat much, required assistance with eating, and was placed on Hospice.
During an interview on 11/13/23 at 11:24 a.m. LVN B said she worked with Resident #1 before was moved to the other hall. Resident #1 was a diabetic, blood sugar would fluctuate a lot. LVN B said Resident #1 would normally feed herself, but sometimes she required assistance.
During an interview on 11/13/23 at 11:34 a.m. CNA C said worked with Resident #1 said Resident #1 would eat by herself, however sometimes they would need to feed her a little more because she would not eat well on her own.
During an interview on 11/13/23 at 12: 14 p.m. the Administrator said Resident #1's family had some care and concerns about that the resident had a big decline. The Administrator said the family had concerned that she was lost weight because she felt the facility was not making sure she ate. The family member had seen her in the dining room with her [NAME] down and no tray was in front of her. They looked on the rack and saw her tray was on there and the family felt Resident #1 had lost weight. The Administrator said review of Resident #1's weight logs indicted she had gained 8. 2 pounds from April 2023 to October 24, 2023.
During an interview on 11/16/23 at 12:58 p.m. the complainant said they had a ring camera in Resident #1's room. She said they had concerns that on 10/23/23 someone was seen bringing Resident back to the room and telling Resident her breakfast tray would arrive soon at 7:30 a.m. they checked the camera every 30 minutes after that and at 10:00 a.m. Resident #1 did not have a breakfast tray at all that morning. The facility staff did not bring her a tray and never fed her breakfast that day.
During a telephone interview on 11/16/23 at 3:15 p.m. CNA E said she always made sure all my residents got a tray. She said Resident #1 did not require assistance with eating. CNA E said on the morning of 10/28/23 she was not sure if Resident #1 got her tray or not. CNA E said at that time she may have been reassigned and not working with Resident #1. She said she may have charted on the ADL sheet for someone else.
During an interview on 11/20/23 at 9:05 a.m. LVN B said she remembered the day she took Resident #1 back to her room and she gave her crackers. She said Resident #1 was in the dining room and she took her back to her room because the family member had said she wanted her to eat in her room. LVN B said she could not say for sure if Resident #1 got a tray that day or not. She said resident was a slow eater and would have likely not finished her tray in 30 minutes. She said she needed encouragement to eat and would often put her head down while eating. She said if you woke her up, she would eat her food fine, but she required some encouragement to eat.
Record review of the facility Abuse policy revised September 2022 indicated preventing resident neglect is a priority throughout all levels of the organizations. Neglect is defied as failure of the facility, it's employees or service providers to provide goods and services to a resident that are necessary to avoid physical pain, mental anguish, or emotional distress. Neglect occurs when the facility was aware of, or should have been aware of , goods or services a resident required but the facility failed to provide them, and this had a result or may have resulted in physical harm, pain, mental anguish, or emotional distress. Neglect included cases where the facility's indifference to or disregard for resident care, comfort or safety resulted in or could have resulted in physical harm, mental anguish, or emotional distress. Neglect may be a patter of failures or may be the result of one or more failures involving one resident and one staff.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure residents had the right to a dignified existence and were treated with respect and dignity that promoted or enhanced their quality of life for 1 of 5 residents reviewed for resident rights.(Resident #1)
Resident #1 was not assisted with her meal or allowed to finish eating. The staff took Resident #1's Breakfast tray on 10/23/23 while she was still chewing without asking if she was finished.
This negative finding caused resident to not have the right to a dignified existence.
Findings included:
Record review of Resident #1's face sheet dated 11/13/23 indicated she was a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses were abnormal poster, high blood pressure, diabetes, and dementia without behavioral disturbances.
Record review of Resident#1's Annual MDS dated [DATE] indicated she had severely impaired cognition. She required extensive assistance with one person for bed mobility, transfer, and locomotion off the unit. She was totally dependent for dressing, toilet use, and personal hygiene, and required the assistance of one person. The resident required extensive assistance with eating with one person assistance.
Record review of Resident #1's care plan dated 11/18/21 indicated a Focus area of required assistant with ADLS and was at risk for deterioration in ADLS such as bed mobility, bathing, transfer, walking in room, walking in corridor, locomotion on the unit, locomotion off the unit, dressing, eating, toilet use, personal hygiene related to cognitive impairment. The resident would often lay her head down on the dining room table during activities and meal services. Some of the interventions were to assist with ADLs as needed with the assistance of one staff member. The staff would feed the resident if she was unable to complete the meal with the assistance of one staff member. A Focused area dated 10/23/23 indicated Resident #1 was part of the red napkin program to alert staff there was weight loss, and assistance was needed, and encouragement to eat. Some of the interventions where staff would assist and encourage resident as needed. Staff would offer alternative foods if less than 25 percent was eaten.
Record review of Resident #1's weights indicated on 4/11/23 she weighed 130 pounds. Her last weight on 10/31/23 indicated she weighed 138.2 pounds.
Observation of a video dated 10/23/23 at 12:53 p.m. Resident#1 was sitting up in bed, with the bedside table over her lap and a tray of food sitting on the table. Resident #1was seen chewing. An unidentified aide came in the room and asked Resident #1 if she was finished eating. Resident #1 mumbled something, and the aide left. She did not ask her if she need assistance or encourage her to eat. Observation of the video at 12:58 p.m. Resident #1 was sitting in bed still chewing when CNA E came into the room. The CNA did not say a word, she picked up the plate cover from the foot of the bed, put the cover over the tray, and took the tray out of the room. Resident#1 did not say anything, she watched the aide leave the room, and leaned back in the bed.
Record review of Resident #1's ADL sheets dated 10/23/23 indicated for lunch and 1 ( supervision oversight, encouragement or cueing) 1- setup help only. The ADL nutrition indicated Resident #1 ate 51 percent to 75 percent. The ADL documentation for that day was completed by CNA E.
Record review of a family concern written by the administrator dated 10/26/23 indicated Resident #1's family member stated the other day she came into the dining room and Resident #1 had her head down on the table and no food was around. She asked the aide where the food was and was told Resident #1 had already eaten. The family member found the tray on the cart and noticed only a small amount was eaten. The family member asked Resident #1 if she was hungry and she said she was hungry. The family member said after the aide was questioned, she did feed Resident #1 and said Resident #1 ate every bite. The Administrator wrote, I did seek further clarification and possible different thought, that with the assistance of the family, could it have been possible the family brought some encouragement to finish the meal. The family had some concerns about weight loss and was informed according to the facility records the resident had gained about 8 pounds form April 2023 to October.
During an interview on 11/13/23 at 11:11 a.m. LVN A said Resident #1 required total care when she transferred to his hall on or about 11/1/23. He said at that time she did not eat much, required assistance with eating, and was placed on Hospice.
During an interview on 11/13/23 at 11:24 a.m. LVN B said she worked with Resident #1 before she was moved to the other hall. LVN B said Resident #1 would normally feed herself, but sometimes she required assistance.
During an interview on 11/13/23 at 11:34 a.m. CNA C said worked with NA C said Resident #1 would eat by herself, however sometimes they would need to feed her a little more because she would not eat well on her own.
During an interview on 11/13/23 at 12: 14 p.m. the Administrator said Resident #1's family had some care and concerns that Resident #1 had a big decline. The Administrator said the family had concerned that she was lost weight because she felt the facility was not making sure she ate. The family member had seen her in the dining room with her [NAME] down and no tray was in front of her. They looked on the rack and saw her tray was on there with only a little food missing, and the family felt Resident #1 had lost weight. The Administrator said review of Resident #1's weight logs indicted she had gained 8. 2 pounds from April 2023 to October 24, 2023.
During an interview on 11/13/23 at 12:33 p.m. the DON said Resident #1 was on the red napkin program. That program was to identify to staff that resident was identified as someone that was high risk for weight loss or needed extra encouragement to eat. The DON said those residents were brought to the dining room to eat and were always gotten up for their meals.
During an interview on 11/13/23 at 12:49 p.m. the ADON said the family member did mention some time ago Resident #1 did not get to eat. The ADON said it was a random thing not a current issue, she said it was in the past could not give a date. The ADON said a dietary review indicated Resident #1 was on red napkin program and had no significant weight loss. The ADON said Resident #1 ate in the dining room, but the family member requested she eat in her room so she could watch her eat on the camera.
During a telephone interview on 11/16/23 at 3:15 p.m. CNA E said she did not remember taking Resident #1's tray on 10/23/23. She said they pick up the trays around 1:00 p.m. and if she took the tray the resident hadthe tray a long time. She said Resident #1 did not require assistance with eating, and sometimes she did require encouragement. CNA E said if the ADL sheet said she filled it out she likely did. She said she would have been upset if someone took her food and she was not done eating. She also said if she had done so it was wrong.
During an interview on 11/20/23 at 9:05 a.m. LVN B said Resident #1 was a slow eater and would have likely not finished her tray in 30 minutes. She said she needed encouragement to eat and would often put her head down while eating. She said if you woke her up, she would eat her food fine, but she required some encouragement to eat.
Record review of the facility Resident Rights Guidelines for All Nursing Procedures dated October 2010. Indicated the purpose of the general guidelines was to provide resident rights while care for residents. Prior to having direct care responsibilities for resident's staff use have appropriate training on residents' rights including resident dignity and respect. Some of the general guidelines were to knock and gain permission before entering the resident room. Introduce self and ask permission before implementing the procedure.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure each resident had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences, except when to do so would endanger the health or safety of the resident or other residents for 3 of 20 residents (Residents #29, #35 and #36) reviewed for reasonable accommodations.
1. The facility failed to ensure Resident #29's call button was within reach while in bed and/or recliner.
2. The facility failed to ensure Resident #35's and Resident #36's call button was within reach while sitting in the recliner across the room.
These failures could place residents at risk for a delay in assistance and decreased quality of life, self-worth, and dignity.
Findings include:
1. Record review of Resident #29's electronic face sheet, dated 01/13/23, revealed a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included diabetes (a chronic (long-lasting) health condition that affects how your body turns food into energy), high blood pressure, syncope and collapse (another word for fainting or passing out), stroke (occurs when something blocks blood supply to part of the brain or when a blood vessel in the brain bursts) and dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities).
Record review of Resident #29's annual MDS assessment, dated 01/06/23, revealed under Section B, Hearing, Speech, and Vision, she was coded as 1 for usually understands and usually understood by others. Section C, Cognitive Patterns, under section C0500 Brief Interview for Mental Status, which indicated a score of 11, which indicated moderately impaired cognition. Section G, Function Status, under section B indicated she needed supervision with transfers and toileting.
Record review of Resident #29's comprehensive person-centered care plan, date initiated 02/16/21, and revised on 01/13/23 revealed a Focus indicted: Resident #29 required assist with ADLs and was at risk for deterioration in ADLs: (bed mobility,
bathing, transfer, walking in room, walking in corridor, locomotion on unit, locomotion off unit, dressing, eating, toilet use, personal hygiene) related to cognitive impairment. Intervention indicated: Encourage the resident to call for help before getting out of bed or chair, demonstrate the use of call light, always keep call light in reach, and visible. Inform resident of its location and use. Answer promptly.
During an observation and interview on 01/10/23 at 9:19 a.m., Resident #29 was sitting on the side of her bed with the call light clamped to the wall cord, not in reach. Resident #29 said she was on hall 400 but they moved her to hall 500 about a week ago. Resident #29 said she must get up and go fine help, when she needed to call for help. Resident #29 said in her old room she had a button to push for help, but she did not in this room but would like a call button.
During an observation on 01/10/23 at 5:20 p.m., Resident #29 sat in her recliner with call light remaining on wall, not in reach.
During an interview on 01/10/23 at 5:22 p.m., CNA Q observed Resident #29's call light on the wall. CNA Q said Resident #29 was in her right mind and if she said she did not know where her call light was, she did not. CNA Q placed the call light in reach of the resident. CNA Q said call lights should always be in reach so the residents could let the staff know if they needed anything. Failure to keep the call light in place could lead to a fall for Resident #29.
2. Record review of Resident #35's electronic face sheet, dated 01/13/23, revealed a [AGE] year old female who was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Metabolic encephalopathy (is a problem in the brain. It is caused by a chemical imbalance in the blood), diabetes, high blood pressure, Chronic obstructive pulmonary disease (COPD) (is a chronic inflammatory lung disease that causes obstructed airflow from the lungs), and dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities).
Record review of Resident #35's quarterly MDS assessment, with an ARD of 10/07/22, revealed under Section B, Hearing, Speech, and Vision, she was coded as 1 for usually understand and usually understood by others. Section C, Cognitive Patterns, under section C0500 Brief Interview for Mental Status, which indicated a score of 10, which indicated moderately impaired cognition. Section G, Function Status, under section G0110 indicated she needed supervision with bed mobility, transfers dressing, eating, personal hygiene and toileting.
Record review of Resident #35's comprehensive person-centered care plan dated initiated 03/30/18 and revised on 11/08/22. Focus indicted: Resident #35 had the potential for injury related to risk of falls . with diagnosis of high blood pressure and COPD. Intervention: Instruct/encourage Resident #35 to call for help before getting out of bed or chair, demonstrate the use of call light, always keep call light in reach, and visible. Keep resident informed of its location and use. Answer promptly.
During an observation on 01/09/23 at 9:23 a.m. revealed Resident #35 was sitting in the recliner with the call light on the bed, underneath clothing.
During an observation on 01/10/23 at 9:13 a.m. revealed Resident #35 was sitting up in her wheelchair and the call light on the bed and was not in reach.
During an observation and interview on 01/10/23 at 12:52 p.m., Resident #35's call light was on the bed and was not in reach. Resident #35 said if she needed anything while sitting in her chair or recliner, she would try her best to get up and alert staff. She said it would be good if she had the call light closer to her in case, she needed to push it.
During an observation and interview on 01/10/23 at 4:59 p.m., LVN K observed Resident #35 call light was not in reach when asked where her call light was. LVN K said the call light should be within reach so staff could meet the residents needs and prevent falls. LVN K had maintenance to add a longer call light, so it could reach Resident #35.
During an observation and interview on 01/11/23 at 5:43 p.m., Resident #35 was sitting in her recliner with the call light attached on recliner. Resident #35 said she was elated to have her call light on her recliner so she could reach it.
3. Record review of Resident #36's electronic face sheet, dated 01/13/23, revealed a [AGE] year old male resident who was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses which included Metabolic encephalopathy (is a problem in the brain. It is caused by a chemical imbalance in the blood), high blood pressure, pneumonia (an infection that inflames the air sacs in one or both lungs), depression (feeling of sadness) and dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities).
Record review of Resident #36's quarterly MDS assessment, dated 09/29/22, revealed under Section B, Hearing, Speech, and Vision, he was coded as 1 for usually understands and usually understood by others. Section C, Cognitive Patterns, under section C0500 Brief Interview for Mental Status, which indicated a score of 10, which indicated moderately impaired cognition. Section G, Function Status, under section B indicated he needed supervision with transfers and toileting.
Record review of Resident #36's comprehensive person-centered care plan, date initiated 08/03/16, and revised on 03/14/22 revealed. Focus indicted: Resident #36 was a high risk of falls related to gait/balance problem. Intervention: Be sure resident call light was within reach and encourage him to use it for assistance as needed.
During an observation on 01/10/23 at 9:33 a.m. revealed Resident #36 was sitting up in a recliner with the call light hanging on wall behind the bed. Resident #36 stated he yelled if he needed help. Resident #36 said he sometimes slept in his recliner, but mostly in bed and he could reach the call button while in bed.
During an observation and interview on 01/11/23 at 4:28 p.m., LVN L observed Resident #36's call light was not in reach when asked where his call light was. LVN L connected Resident # 36's call light to his recliner and said call lights should always be in reach to meet the needs of the resident's and to prevent injury.
During an interview on 01/17/23 at 2:06 p.m., the RNC said all residents should always have call lights in reach. The RNC said she expected the charge nurses to make rounds often to ensure call lights were in reach. The RNC said if call lights were not in reach residents' needs would not be meet and it placed them at greater risk of falling.
During an interview on 01/17/23 at 2:25 p.m., the ADON said she expected call lights to always be in reach of residents. The ADON said failure to keep call lights in reach could cause resident to fall, receive a bump, bruise or even a fracture.
During an interview on 01/17/23 at 5:00 p.m., the Interim Administrator said call lights should always be in reach. The Interim Administrator said administrated staff did rounds to ensure call lights were in reach.
Record review of the Call Light: Accessibility and Timely Response policy, revised October 2022, indicated, The purpose of this policy is to ensure the facility is adequately equipped with a call light at each residents' bedside, toilet, and bathing facility to allow residents to call for assistance. Call lights will directly relay to a staff member or a centralized location to ensure appropriate response. Staff will ensure the call light is within reach of resident and secure as needed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record review, the facility failed to ensure residents had the right to and the facility promoted and facilitated resident self-determination through support of resident choice for 1 of 16 residents (Residents #54) reviewed for residents' rights.
The facility failed to ensure Resident #54 was allowed to smoke during designated smoking times at the resident's request.
These deficient practices could place residents at risk of feeling controlled and not able to make requests or decisions about their own preferences.
Record review of Resident #54's face sheet, dated 1/13/23, revealed the resident, a [AGE] year old female, was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included: chronic obstructive pulmonary disease (a chronic inflammatory lung disease that causes obstructed airflow from the lungs), unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, or anxiety (a mental disorder in which a person loses the ability to think, remember, learn, make decisions, and solve problems), disorder of the arteries and arterioles (a buildup of fatty deposits in the arteries), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), anxiety disorder (a condition in which a person has excessive worry and feelings of fear, dread, and uneasiness), hallucinations (an experience involving the apparent perception of something not present), and dependence on supplemental oxygen.
Record review of Resident #54's Quarterly MDS assessment, dated 12/29/22, revealed the resident's BIMS score was 4, which indicated severe cognitive impairment. The resident required total dependence with locomotion off unit, extensive assistance with transfer, dressing, toilet use, and personal hygiene, and supervision for the tasks of locomotion on unit and eating.
Record review of pending orders from the electronic medical record for Resident #54 revealed there were 34 pending orders, dated 12/27/21, which included but not limited to, physician agrees to care plan, admit to skilled part A services, pain assessment before and after as needed medications, offer substitute if resident eats less than 50%, tuberculin purified protein derivative solution, hospice, may receive flu vaccine, may receive pneumonia, and Tuberculosis step screen on admission.
Record review of Resident #54's, undated, care plan, revealed Resident #54 had Nicotine addiction and was a smoker, has been assessed to be a supervised smoker, the resident will smoke traditional cigarettes, and the resident had decided she would try nicotine patches to aid in quitting, but have now decided I wan to
continue to smoke. Interventions for this focus were the facility would complete smoking assessment as per facility policy and ensure staff aware of my smoking desire, supervision requirements, and type of
smoking product(s) used.
During observation and interviewed on 1/10/23 at 11:47 AM with Resident #54, she was observed in her bed lying on her stomach. She said she asked a nurse to take her smoking during the 10:00 AM smoking slot but no one ever came. She said that she felt ignored and was upset by this. She was not able to state which nurse she asked.
During observation and interview on 1/11/23 at 02:34 PM with Resident #54, she was observed in observed in the area near the nurse's station. She said she was waiting to go for a smoke break and has had been waiting since 10:00 AM. She said she asked nursing staff and no one has taken her. She said she knew the smoking break times but she had preferred smoking time was at 10am daily. She only wanted to smoke once a day at that time. She said that 10am is a smoking break time. Resident #54 was unable to state exactly which nursing staff she asked.
During an interview on 01/17/23 at 12:51 PM, LVN O, she said Resident #54 was denied smoke breaks at least five days out of the week. She said her oxygen saturation would get low and staff would have to hurry back inside. She said Resident #54 was oxygen dependent and the oxygen could not go to the smoking area with her. She said Resident #54 had been denied for this reason. She said she does did not know what a smoking assessment, was so she did not know if Resident #54 has documentation in her electronic medical record to reflect a physician statement or orders to deny her right to smoke. She said Resident #54 was ordered nicotine patches, but she refused to wear them and requested to go for a smoke. LVN O said the risk to residents denied of their right was a loss of dignity and felt like they are were in a prison instead of their home.
During an interview on 01/17/23 at 1:36 PM, the RNC said she expected resident's right should always be respected. She said a resident had the right to smoke during the smoking schedule if they chose. She said the medical condition was not a factor unless otherwise noted by a physician. She said denial could make a resident feel like a child and not respected. She said it could affect their emotional well-being.
During an interview on 01/17/23 at 4:55 PM, the Interim Administrator said he expected the resident's rights to be respected in regard to smoking. He said even if the resident had a chronic lung condition, it was her right to smoke. He said no staff at the facility should have denied that request. He said this was demeaning and could cause the resident to feel a loss of dignity.
Record review of the undated facility smoking policy, revealed 18. Smoking assessment will be completed on admission, quarterly, and as needed only on residents who use tobacco and E-cigarette .
Record review of electronic medical records for Resident #54 had a smoking assessment completed on, 3/19/21, 6/18/21, 9/18/21, and 12/18/21 no others .smoking assessment dated [DATE], indicated that the resident is cognitive capable of making decision to smoke, the resident does not understand facility smoking policy due to diagnosis of dementia, resident has a history of smoking-related problems that would be hazardous to self or others because oxygen saturation while smoking. It further indicated the resident requires the supervision of a licensed nurse when smoking due to concerns with her oxygen saturation dropping, so the nurse can assist accordingly in such a situation.
Record review of the facility policy titled, Resident's Rights, indicated federal and state law guarantee certain basic rights to all residents of the facility. The rights include the resident's right to .self-determination .have the facility respond to his or her grievances

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to immediately inform the resident, consult with the resident's physician, and notify, consistent with his or her authority, the resident representative when there was a significant change in the resident's physical, mental, or psychosocial status for 2 of 20 residents (Residents #5 and #44) reviewed for notification of changes.
1. The facility failed to notify Resident #5's representative when she received 2 new pressure wounds.
2. The facility failed to notify Resident #44's representative and physician when they identified his PT/INR (A prothrombin time [PT] test measures how long it takes for a clot to form in a blood sample. An INR [international normalized ratio] is a type of calculation based on PT test results) level for Coumadin (is a blood-thinning medicine that's used to treat and prevent dangerous blood clots) labs were not drawn as ordered.
These failures could place residents at risk of their physician's or responsible parties not being aware of changes in the residents' conditions.
Findings include:
1. Record review of Resident #5's electronic face sheet, dated 01/13/23, revealed a [AGE] year old female who was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included multiple sclerosis (a chronic, typically progressive disease involving damage to the sheaths of nerve cells in the brain and spinal cord, whose symptoms may include numbness, impairment of speech and of muscular coordination, blurred vision, and severe fatigue), sepsis (a serious condition resulting from the presence of harmful microorganisms in the blood or other tissues and the body's response to their presence, potentially leading to the malfunctioning of various organs, shock, and death), anxiety (what we feel when we are worried, tense or afraid), high blood pressure, and Alzheimer's ( a type of dementia that affects memory, thinking and behavior).
Record review of Resident #5's quarterly MDS assessment, with an ARD of 10/26/22, revealed under Section B, Hearing, Speech, and Vision, was coded as a 0 indicating she understands and was understood by others. Section C, Cognitive Patterns, under section C0500 Brief Interview for Mental Status, which indicated a score of 14 for cognitive intact cognition. Section G, Function Status, under section B indicated she needed extensive assistance with bed mobility, personal hygiene, total assist with transfers, dressing, bathing, and supervision with eating. Section M, Skin Condition, under section M1200 she received pressure ulcer/injury care and application of nonsurgical dressing during the look back period.
Record review of Resident #5's comprehensive person-centered care plan, date initiated 12/27/17, and revised on 01/13/23 revealed the Focus indicted: Resident #5 was at risk for further skin breakdown, also had wound to right, distal, lateral calf lower leg and pressure area to right ischium related to immobility, incontinence, and disease process. Intervention indicated: Keep physician and RP informed of the resident's progress.
Record review of Resident #5's physician orders revealed, new treatment orders, placed on 01/05/23, to apply Skin Prep once daily to unstageable DTI (deep tissue injury) on outer aspect of right foot.
Record review of Residents #5's nurse notes dated on 1/12/23 at 9:30 a.m., did not indicate any notification to family on 01/05/23 when new wounds were identified, and orders given.
During a phone attempt on 01/12/23 at 9:27 a.m., to notify Resident #5's responsible party was attempted and was unsuccessful.
During an interview on 01/11/23 at 11:10 a.m., ADON G said the new unstageable DTI areas to left and right feet were identified with the wound care physician on 01/5/23 and she put them on the skin assessment but did not notify the family. ADON G said she should have notified the family of new pressure ulcers to keep them informed of resident's care.
During a phone interview on 01/12/23 at 9:50 a.m., revealed Resident #5's RP said he had not been notified of any new skin changes this month. He said he was not aware of any new skin issues.
2. Record review of Resident #44's electronic face sheet, dated 01/13/23, revealed a [AGE] year old male resident who was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included stroke(occurs when something blocks blood supply to part of the brain or when a blood vessel in the brain bursts), seizures (a sudden, uncontrolled electrical disturbance in the brain), aphasia (loss of ability to understand or express speech, caused by brain damage), and high blood pressure (elevated blood pressure).
Record review of Resident #44's quarterly MDS assessment, with an ARD of 12/15/22, revealed under Section B, Hearing, Speech, and Vision, he was coded as a 2 indicating he sometimes understands and sometimes was understood by others. Section C, Cognitive Patterns, under section C0500 Brief Interview for Mental Status, which indicated a score of 00 for severely impaired cognition. Section G, Function Status, under section B indicated he needed extensive help with bed mobility, transfers, eating and total help with dressing, toileting, personal hygiene, and bathing. Section N, Medications, under section N0410 indicated he received anticoagulant (Coumadin) for 7 days during the look back period.
Record review of Resident #44's comprehensive person-centered care plan, date initiated 01/13/21, and revised on 01/14/21 revealed the Focus indicted: Resident #44 had the potential for alteration in bleeding tendencies and increased bruising related to anticoagulants therapy of Coumadin. Interventions indicated: Administer medication as ordered, monitor for side effects and report ill findings to physicians.
Record review of Resident #44's physicians orders, dated 01/13/23, revealed Coumadin 7.5MG (milligram), give 1 orally in the evening related to stroke started 07/07/22.
Record review of Resident #44 labs revealed the last Coumadin level drawn was 07/13/22 but was ordered monthly.
Record review of Resident #44's nurses notes on 01/13/23 did not indicate any notification to the physician or resident representative that Coumadin level had not be drawn as ordered monthly when identified on 01/12/23.
During an interview on 01/12/23 at 5:38 p.m., LVN C said she was not aware Resident # 44 was not getting his Coumadin levels drawn monthly as ordered. LVN C said Resident #44 was on Coumadin and should be getting monthly Coumadin levels and failure to get labs could result in bleeding.
During a phone interview on 01/13/23 at 8:40 a.m., the Primary Doctor said he was not aware PT/INR levels had not been drawn since 07/13/22. The Primary Doctor said the facility should have drawn the PT/INR level as ordered and notified him of results. The Primary Doctor said failure to draw PT/INR levels could lead to Resident #44 bleeding and having another stroke.
During an interview on 01/17/23 at 2:40p.m., the RNC said the representative and physicians should be notified of all changes to resident's care. The RNC said the charge nurses are responsible to notify the representative and physician of any changes. The RNC said administrative nurses were to follow up on all labs and skin changes. The RNC said without labs been drawn as ordered, doctors would not know if the residents were within a therapeutic range; and without notification to the family, they would not know the resident had a change in care.
During an interview on 01/17/23 at 5:00 p.m., the Interim Administrator said he expected staff to notify representatives and physicians of any changes to the residents. The Interim Administrator said nursing staff were to follow up on notifications. The Interim Administrator said failure to notify could impede the resident's care.
Record review of the facility policy Notification of Changes, dated October 2022, indicated, The purpose of this policy is to ensure the facility promptly informed the resident, consults the resident physician; and notified, consistently with his or her authority, the resident's representative when there is a change requiring notification.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure personal privacy was provided for 1 of 24 residents reviewed for dignity. (Resident #51)
*The facility failed to ensure ADON A treated Resident #51 with dignity when she left the door open while providing wound care.
These deficient practices could place residents at risk of loss of dignity.
Findings included:
Record review of Resident #51's face sheet, dated 01/13/23, indicated a [AGE] year-old male who was admitted to the facility on [DATE] and readmitted [DATE] with diagnoses which included Left hip fracture, Chronic Obstructive Pulmonary Disease (COPD) (a chronic inflammatory lung disease that causes obstructed airflow from the lungs), high blood pressure, atrial fibrillation (abnormal heartbeat) and muscle weakness.
Record review of the MDS significant change of status assessment, dated 11/02/22, indicated in section B Resident #51 was usually understood and usually understood others. The BIMS (Brief Interview for Mental Status) was a 15, which indicated Resident #51 was cognitively intact. Section G indicated Resident #51 required supervision with bed mobility, transfers, eating, transfers, and personal hygiene and extensive assist with bathing.
During an observation on 01/12/23 at 11:55 a.m., ADON A was providing wound care on Resident #51 with the door open exposing his chest and abdominal area.
During an interview on 01/12/23 at 11:59 a.m., ADON A said she was supposed to close the door to provide privacy when providing care to Resident #51, but she did not. ADON A said she knew not closing the door while providing care was a privacy violation and could be a dignity issue for Resident #51.
During an interview on 01/12/23 at 12:10 p.m., Resident #51 said his back was located against the door, so he did not realize his door was open when the nurse did wound care on him. Resident #51 said he was not okay with anyone providing care to him with his door open.
During an interview on 01/17/23 at 2:06 p.m., the RNC said she expected all staff to provide privacy during care. The RNC said everyone was responsible to make sure the door was closed when care was provided. The RNC said failure to close the door when providing care could lead to embarrassment for the resident.
Record review of the facility's policy on promoting and maintaining resident dignity policy, dated 7/1/22 indicated, It is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment that maintains or enhances residence quality of life by recognizing each resident individuality. number one all staff members are involved in providing care to residents to promote and maintain residence dignity and respect residents' rights . #12 states maintain resident privacy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record review, the facility failed to ensure residents had the right to a clean, comfortable and homelike environment, which included but not limited to receiving treatment and supports for daily living safety, for 1 of 16 residents (Resident #5) reviewed for a homelike environment.
The facility failed to ensure Resident #5's in-room mini refrigerator was cleaned.
This deficient practice could place residents at risk of contaminated or expired food or drink products.
Findings include:
Record review of Resident #5's face sheet, dated 01/13/23, indicated, a 63- year- old female, who was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included: neuromuscular dysfunction of bladder (when a person lacks bladder control due to brain, spinal cord or nerve problems), hypokalemia (a lower than normal potassium level in your bloodstream), overactive bladder (when the muscles of the bladder start to contract on their own even when the volume of urine in your bladder is low), multiple sclerosis (a disorder of the central nervous system marked by weakness, numbness, a loss of muscle coordination, and problems with vision, speech, and bladder control), and generalized muscle weakness.
Record review Resident #5's annual MDS assessment, dated 10/26/22, revealed in in section B the resident was usually understood and usually understood others. The BIMS (Brief Interview for Mental Status) was a 14, which indicated Resident #5 was cognitive intact. Section G indicated Resident #5 required supervision with eating and locomotion on and off unit. Resident #5 required total dependence with transfer, dressing, and toilet use. Resident #5 required extensive assistance with bed mobility and personal hygiene.
Record review of Resident #5's comprehensive care plan, dated 01/13/23, indicated Resident #5 required assistance with ADLs and was at risk for deterioration in ADLs: (bed mobility, bathing, transfer, walking in room, walking in corridor, locomotion on unit, locomotion off unit, dressing, eating, toilet use, personal hygiene ). Interventions for this focus was tnstruct the to call for help before getting out of bed or chair, demonstrate the use of call light, keep call light in reach at all times, and visible. Inform the resident of its location and use and answer promptly.
During interview and observation with Resident #5 on 01/09/23 at 10:13 AM, she was observed sitting in wheelchair watching television. A walkthrough of the room was conducted and the minifridge was observed with mold (green and black hair like substance) on a clear container of a white milky substance, there were no dates or labels visibly seen. There was a brown and green substance in all four corners on the bottom of the refrigerator portion. There was a cloudy liquidly film over the bottom of the mini fridge. There were four containers of ensure that were not expired and red and orange Jell-O that had mold on them. Resident #5 said no family members visited or helped clean the mini fridge. She said no staff had come to clean the mini fridge for her. She said a nurse or CNA, she could recall, had given her a bottle of ensure from the refrigerator about one week ago. She said she had not asked that it be cleaned and did not know it needed to be cleaned.
During an interview on 01/14/23 at 11:12 AM, with Housekeeping Aid CC, she said she had not been told by her supervisor or the administrator that housekeeping staff is was responsible for cleaning the resident's in-room mini fridge. She said because of this, she would not know a cleaning schedule for cleaning the mini fridge. She said if a resident asked her to do it, she would. She said they only wiped down the outside but never opened them. She said she was not aware of any resident's mini fridges that needed cleaning . She said it was important to keep the mini fridge clean to prevent food from being expired and the residents could get sick.
During an interview on 01/14/23 at 11:47 AM, with the Housekeeping Director, she said her staff were responsible for wiping down the outside of the in-room mini fridges. She said the facility did not have a policy in place regarding who was responsible for the cleaning the inside of the resident's mini fridge. She said she believed it should be a housekeeping task. She said the risk to residents if their mini fridge was not clean was they could receive contaminated food and lead to foodborne illness.
During an interview on 01/14/2023 at 11:51 AM, with CNA P, she said nursing staff were not informed they needed to clean the dependent resident's mini fridge. She said she never cleaned one. She said she thought housekeeping would conduct this task and she saw housekeeping staff clean the outside of the mini fridges.
During interview on 01/15/2023 at 6:02 PM, with Administrator, she said there was no policy in place related to the cleaning of the residents' mini fridge. She said her expectation was anyone who said it needed to be cleaned to get it done. She said she would work with corporate to get a policy created. She said the risks to residents was if they received any items from an unclean mini fridge they could be exposed to bacteria, contaminated food and this could lead to foodborne illness.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that residents were free of significant medication errors for 1 of 6 residents reviewed for medication pass. (Resident #25)
LVN H failed to ensure Resident #25 received her Keppra (medication used for seizures) as ordered by the physician.
This failure could place the resident at risk of medical complications and not receiving the therapeutic effects of their medications.
Findings included:
Record review of a face sheet dated 01/13/23 indicated Resident #25 was a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of stroke, gastrostomy (tube inserted in stomach for nutrition and medications), seizures, and high blood pressure.
Record review of the most recent quarterly MDS dated [DATE] indicated Resident #25 was usually understood and usually understood others. The MDS revealed Resident#25 BIMS score was a two, indicating severe cognitive impairment. The MDS indicated Resident #25 required extensive assistance with bed mobility, transfers, and dressing. Resident #25 was totally dependent on locomotion, eating, toileting, and bathing. The MDS revealed under section I, Active Diagnoses, had seizure disorder or epilepsy checked.
Record review of the order summary report dated 01/13/23 indicated Resident #25 had an order for levetiracetam (Keppra) 100mg/ml solution give 5 milliliters via peg-tube four times a day for seizures with a start date of 02/18/2022.
Record review of the comprehensive care plan dated 06/06/21 with a revision date of 03/31/22 indicated Resident #25 was at risk for injury related to seizure disorder, receiving anti-convulsant medications, and was at risk for side effects from the medication which included adverse reactions and toxicity. The goal for Resident #25 was she would not exhibit signs and symptoms of side effects, adverse reactions, or toxicity to medications. The care plan intervention indicated to administer medications as ordered.
During an observation of medication administration on 1/10/23 at 09:18 AM, LVN H poured 10 milliliters of Keppra liquid in graduated medicine cup. LVN H administered the medication to Resident #25 via her gastrostomy tube (tube inserted in stomach for nutrition and medications).
During an interview on 01/13/23 at 8:53 AM, LVN H indicated she administered more than the prescribed dose of Keppra. LVN H, after reviewing Resident #25 physician orders, said she should have administered 5 milliliters of Keppra solution as ordered by the physician. LVN H said Resident #25 was at risk for having her Keppra level elevated due to receiving the double dose of medication .
During an interview on 01/13/23 at 2:17 PM, LVN H indicated the rights of medication administration included the right patient, right medication, right dosage, and right time.
During an interview on 01/17/23 at 1:57 PM, the RNC indicated she expected medications to be given as ordered by the physician. The RNC said by not following physician orders, the resident could be at risk for receiving the wrong dose.
During an interview on 01/17/23 at 5:00 PM, the Interim Administrator said he expected medications to be administered as ordered. The Interim Administrator said by not following the physicians orders the resident was at risk for adverse side effects. He said the DON and administrative nurses were responsible for ensuring the medications are administered as ordered.
Record review of the facility's policy titled Administering Medications revised in April 2019, indicated . medications are administered in accordance with prescriber orders, including any required time frame.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure residents had the right to be free from neglect for 8 of 20 residents (Residents #5, #120, #121, #44, #119, #32, #38 and #220) reviewed for neglect.
1. The facility failed to effectively monitor Residents #'s #32, #38, #119, and #220 weights, to prevent weight loss, and nutritional deficits. Failed to input weekly weight orders.
2. The facility failed to provide daily wound care to prevent the decline in wound conditions for Residents #'s #120 and #121. Resident #'s 120 and 121 both had Stage 4 sacral wounds decline resulting in hospitalizations for wound infections. Resident #121 died on [DATE] during his hospitalization.
3. The facility failed to implement dietary recommendations timely for Resident #121.
4. The facility failed to provide and maintain offloading devices for Residents #'s #120 and #121.
5. The facility failed to educate the nurses providing wound care.
6.Failed to input wound care orders in the computer system to be completed by the treatment nurses, nurses, or weekend nurses.
7. The facility failed to prevent Resident #5 from obtaining 2 new pressure injuries (DTIs) to both feet.
8. The facility failed to monitor and obtain Resident #44's anticoagulant laboratory results since 07/13/2022.
9. The facility failed to implement admission orders ensuring residents received the necessary care and services for: 22 of 80 residents with orders in the queue for implementation.
10. The facility failed to implement dietician recommendations timely for Resident #220.
11. The facility failed to implement heel protectors for Resident #5 while in bed according to the physician's orders.
12. The facility did not identify or document the onset or follow treatment orders for the left thumb of Resident #49 after a stage 2 pressure injury was identified by an outside agency.
13. The facility failed to draw routine hemoglobin A1C (HBA1C) (a blood test that shows what your average blood sugar (glucose) level was over the past two to three months) for Resident #35.
14. The facility failed to obtain Resident #34's Vancomycin (is used to treat infections caused by bacteria. It works by killing bacteria or preventing their growth) trough level (is drawn immediately before the next dose of the drug is administered because it is the lowest concentration in the patient's bloodstream) as ordered prior to administration of first dose of Vancomycin.
An Immediate Jeopardy (IJ) situation was identified on 01/13/2023 at 1:20 p.m. While the IJ was removed on 01/18/2022, the facility remained out of compliance at a scope of a pattern with the severity of actual harm that was not immediate jeopardy, with a scope identified as a pattern due to the facility's need to evaluate the effectiveness of the corrective systems.
These failures placed residents at risk for negative outcomes and including death.
Findings included:
Record review of the CMS 672, dated 01/09/2023, indicated in Section G, other. F140 1 resident with unplanned significant weight loss/gain.
1.) Record review of Resident #32's face sheet, dated 1/13/2023, indicated Resident #32 was a [AGE] year-old female who was admitted to the facility on [DATE] with the diagnosis diagnoses which included of stroke, pain, seizures, dysphagia (difficulty swallowing) and malnutrition (lack of nutrition).
Record review of Resident #32's consolidated physician's orders, dated 01/13/2023, indicated Resident #32 had a diet order of mechanical soft and nectar thickened fluids, dated 02/05/2022, and a magic cup with lunch and dinner, dated 09/06/2021.
Record review of Resident #32's computerized weights indicated her weight was 153.8 pounds on 12/09/2022 and 141.1 pounds on 01/06/2023.
Record review of a comprehensive care plan dated 04/08/2023 and revised on 05/03/2021 indicated Resident #32 required assistance with her ADLs including assistance with eating, with staff to feed Resident #32 if she was unable to complete the task. The care plan indicated Resident #32 was at risk for weight loss with the goal of maintaining her current level of weight through 02/16/2023. The interventions included monitor for signs of malnutrition, a weight every month, and report a loss or gain of more than 5%. The comprehensive care plan also indicated Resident #32 was receiving a therapeutic diet and was at risk for nutritional deficit. The goal was Resident #32 would consume adequate fluid and would consume 75% or more of the meals served with no associated weight loss through next review dated 04/08/2021. The interventions included administer snacks, and supplements as ordered, and provide a magic cup with lunch and dinner dated 07/07/2021.
Record review of an Annual MDS dated [DATE] indicated Resident #32 was sometimes understood and sometimes understands, and Resident #32's BIMs score was 00 indicating severe cognitive impairment. The MDS indicated Resident #2 required total assistance of one staff with meals. The MDS in Section K indicated Resident #32 did not have a swallow disorder or signs of a swallowing disorder. Section K also indicated Resident #32's height was 70 inches, and her weight was 147 lbs. with no weight loss or weight gain documented.
Record review of a weight record, dated 01/1 3/2023, indicated Resident #32's weight 180 days prior was 151.8 pounds, 90 days prior the weight was 152.8 pounds, and on 01/06/2023 Resident #32's weight was 141.1 pounds.
During observations on 01/10/2013 - through 01/11/2023 for Resident #32 revealed the following:
-On *01/10/23 at 12:55 p.m., there was no supplement with the Resident #32's lunch meal.
-On *01/10/2023 at 5:55 p.m., there was no magic cup with her Resident #32's evening tray.
- On *01/11/2023 at 12:25 p.m., there was no magic cup with her Resident #32's lunch tray.
-On *01/11/2023 at 6:00 p.m., there was no supplement with her Resident #32's evening tray.
Record review of the dietician reports revealed the following:
-On *10/22/2022, there was: no mention of recommendations for weekly weights for Resident #32.
-On *11/11/2022, there was: no mention of recommendations for weekly weights for Resident #32.
-On *11/30/2022, there was: no mention of recommendations for weekly weights for Resident #32.
-On *12/10/2022, there was: no mention of recommendations for weekly weights for Resident #32.
- On *12/18/2022, there was: no mention of recommendation for weekly weights for Resident #32.
On *01/08/2023 and 01/09/2023, there was: no mention of recommendations for weekly weights for, Resident #32.
2.) Record review of Resident #38's face sheet, dated 1/13/2023, indicated Resident #38 was an [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE] with the diagnosis diagnoses which included of stroke, diabetes (too much sugar in the blood), chronic kidney disease (longstanding disease of the kidney), and muscle weakness.
Record review of the consolidated physician orders, dated 1/13/23, indicated Resident #38 did not have a diet ordered. Resident #38 had orders in a que including which included the diet order waiting for processing.
Record review of Resident #38's comprehensive care plan, dated 11/29/2022, revealed there was no care plan addressing the risk of weight loss or actual weight loss.
Record review of the clinical records for Resident #38 indicated the Initial MDS was not completed.
Record review of Resident #38's computerized weights indicated on 11/18/2022 his weight was 225.0 pounds, and his weight was 190.8 pounds on 01/06/2023.
Record review of a dietician's consultant, dated 11/30/2022, indicated Resident #38 had no recommendations even though the weights indicated he had already lost 25 pounds.
Record review of a dietician's consultant report dated 12/10/2022 indicated Resident #38 was not evaluated.
Record review of a dietician's consultant report dated 12/18/2022 indicated Resident #38 was not evaluated.
Record review of a dietician's consultant report dated 01/08/2023 indicated Resident #38 was not evaluated.
Record review of a dietary profile dated 01/11/2023 indicated Resident #38 was receiving a regular diet with no dietary supplements.
3.) Record review of Resident #119's face sheet, dated 01/11/2023, indicated Resident #119 was an [AGE] year-old female who was admitted to the facility on [DATE] with the diagnoses of which included joint replacement surgery, muscle weakness, and high blood pressure.
Record review of the admission MDS, dated [DATE], indicated Resident #119 understood others and she was understood. The MDS indicated Resident #119 had problems with recall and her BIMs score was an 11, indicating which indicated she had moderate impairment with cognition. The MDS indicated Resident #119 required extensive assistance of one staff member with eating. The Section GG of the MDS indicated Resident #119 was independent eating with no assistance. The MDS indicated Resident #119's weight was 130 pounds in the section K0200. The MDS indicated Resident #119 had no weight loss or weight gain in the section of K0300.
Record review of a hospital medication consolidation record dated 12/19/2022, indicated on 12/14/2022 Resident #119's weight was 160 pounds, and her height was 62 inches.
Record review of a Dietary Profile dated 12/28/2022 indicated Resident #119 was receiving a regular diet and did not require any nutritional supplements.
Record review of Resident #119's weights indicated only one weight was obtained since admission on [DATE] of 130 pounds.
Record review of the Dietician Recommendation indicated on 01/08/2023 Resident #119 had no recommendations.
Record review of a Dietician Progress Note dated 01/08/2023 indicated Resident #119 was eating 50-75 % of meals, her weight was 130 pounds and stable. The note also indicated Resident #119 had no skin issues. The notes comments indicated the diet was regular diet with thin liquids, to maintain weight without significant change over the next three months and to continue current diet. The dietician note does not indicate there was a significant weight loss from the hospital weight of 160 pounds and the facility weight of 130 pounds.
Record review of the dietician reports revealed the following:
- On *01/08/2023 and 01/09/2023, there was: no mention of recommendations for weekly weights for Resident #'s #119.
Record review of the comprehensive care plan dated 01/10/2023 indicated Resident #119 was receiving a regular diet with the goal of her weight remaining stable through the next review. The interventions included allow choices in food items, and provide snacks or supplements as ordered.
During an observation on 01/10/2022 Resident #119 had consumed 50 % of her meal while in her bed.
Record review of the consolidated physician's orders dated 01/11/2022 indicated Resident #119's diet was a regular diet with thin liquids started 12/19/22.
During an interview with the DON on 01/11/2023 at 3:26 p.m., the DON said she inputs the resident's weights in the computer after their weight was obtained. The DON said the person obtaining the weights just logged the weight obtained. The DON said when she reviews reviewed the weights and, she stars starred them for a reweight to verify the changes. The DON said the hospital weights were often not correct therefore it was important to have a weight. The DON indicated all the systems were a process.
During an interview on 01/12/2023 at 2:24 p.m., the ADON A indicated there were no weekly standards of care meetings to review each resident with wounds, weight loss, labs, or accidents. ADON A said she had mentioned this to the management team but was not considered. ADON A said the standards of care meetings was a review of the resident to ensure all the care areas were met.
During an interview on 01/17/2023 at 1:36 p.m., LVN L indicated residents should be weighed on admission and monthly. LVN L indicated with not knowing the admission weight there could be a weight loss leading to skin problems, and even the loss of mobility.
During an interview on 01/17/2023 at 2:39 p.m., the Regional Nurse Consultant indicated she was unaware of weight loss issues. The Regional Nurse Consultant new admissions should have a weight once a week for 4 weeks or until stable. The corporate nurse indicated the admitting nurse was responsible for obtaining the admission weight. The Regional Nurse indicated there was not a reason for the admission or weekly weights not being obtained. The Regional Nurse Consultant said the DON was responsible for the weight management program.
During an interview on 01/17/2023 at 4:55 p.m., the Interim Administrator indicated the physician should be notified when the resident's weight falls fell in the parameter areas of 5% in one month, 7.5% in 3 months and 10% in 6 months either a loss or a gain. The Interim Administrator indicated health issues could arise when weights were not monitored. The Interim Administrator indicated the charge nurses, and DON were responsible for the monitoring of weights.
Record review of a Nutritional Management policy, dated 07/01/2022, indicated the facility provides care and services to each resident to ensure the residents maintains acceptable parameters of nutritional status in the context of his or her overall condition. 2. Identification/Assessment: a. Nursing staff shall obtain the resident's height and weight upon admission, and subsequently in accordance with facility policy. C. A comprehensive nutritional assessment will be completed by a dietician within 72 hours of admission, annually, and upon significant change in condition. Follow-up assessments will be completed as needed.
Record review of the facility's Weight Monitoring policy, dated 07/01/2022, indicated based on the resident's comprehensive assessment, the facility will ensure that all residents maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise. Compliance Guidelines: Weight can be a useful indicator of nutritional status. Significant unintended changes in weight (loss or gain) or insidious weight loss may indicate a nutritional problem. 5. A weight monitoring schedule will be developed upon admission for all residents: A. Weights should be recorded at the time obtained. B. newly admitted residents-monitor weight weekly for 4 weeks, Residents with weight loss -monitor weight weekly. 6. Weight analysis: The newly recorded resident weight should be compared to the previous recorded weight. A significant change in weight is defined as: a. 5% change in one month, b. 7.5% change in 3 months, c. 10% change in 6 months. Documentation: a. The physician should be informed of a significant change in weight and may order nutritional interventions.
4) Record review of Resident #121's face sheet, with the printed date of 1/13/2023, indicated Resident #121 was a [AGE] year-old male who admitted to the facility on [DATE] with the diagnoses of which included sepsis (severe complication of an infection) due to pneumonia, muscle weakness, acute kidney failure, high blood pressure, and malnutrition (lack of caloric needs).
Record review of Resident #121's The admission MDS revealed it was not completed.
Record review of a Resident #121's Baseline Care Plan, dated 12/14/2021, indicated Resident #121 required extensive assistance with his ADLs, he had a skin concern of a pressure ulcer to the sacrum, with the goals of the wound to show signs of healing with area decreasing in overall size. The interventions included to provide the wound care/preventative skin care, weekly skin checks, turn and reposition, and notify the physician of any changes in the wound or emerging wounds. The physician orders listed in Section M of the Baseline Care plan did not reveal a wound care order with the medication orders.
Record review of Resident #121's Admission-readmission Assessment, dated 12/14/2022, indicated Resident #121 was admitted to the facility on [DATE] from a hospital. The assessment indicated Resident #121 had a pressure injury to his vertebrae (upper-mid back) measuring 0.2 cm x 0.2 cm x undetermined depth, a coccyx pressure ulcer measuring 0.5 cm x 0.4 cm x undetermined, and a pressure ulcer to the left buttock measuring 0.5 cm x 0.5 cm x undetermined depth.
Record review of a Skin and Wound -total Body Skin Assessment, dated 12/14/2022 on admission, indicated Resident #121's skin turgor (skin elasticity) had poor elasticity, the skin color was normal, temperature was cool, the moisture was normal, the condition dry, and had 3 new wounds. The wounds were not specified in the assessment.
Record review of a Braden Scale for Prediction Pressure Sore Risk, dated 12/14/2022, indicated Resident #121 had no sensory perception impairment, he was occasionally moist, and he was chair fast with the ability to walk severely limited. The assessment indicated Resident #121 was slightly limited making frequent though slight changes in body or extremity positions independently, his nutrition was probably inadequate, and he required moderate to maximum assistance with moving. Resident #121's score was 15, indicating which indicated the resident was at risk for developing pressure sores.
Record review of a Daily Skilled Note, dated 12/18/2022, indicated Resident #121's indicated his skin was dry, he consumed 75% of meals, consumes consumed a regular diet with thin liquids. The note did not indicate there were no other skin problems. The skin condition section (6f) of the note failed to indicate pressure ulcers were present.
Record review of a Dietician Recommendation, dated 12/18/2022, indicated Resident #121 was recommended to have Pro stat 30 milliliters twice a day due to his albumin level (protein in the blood) was 2.8 with the normal range of 3.4 to 5.4.
Record review of a Daily Skilled Note, dated 12/19/2022, indicated Resident #121 had fair, dry and fragile skin. The note indicated Resident #121 fed himself and his intake was 75% or more each meal. The skin condition section of the note failed to indicate 6f. pressure ulcers were present.
Record review of a Skin assessment dated [DATE], indicted Resident #121's sacral wound measured 4.0 cm x 3.0 cm x 0.1 cm and was a stage 4 pressure ulcer. The skin assessment report indicated the wound was 100% slough (dead tissue) with a light serous drainage.
Record review of an Initial Wound Evaluation and Management Summary, dated 12/22/2022, indicated Resident #121 had a Stage 4 full thickness pressure wound to the sacrum measuring 4.0 cm x 3.0 cm x 0.1 cm. The wound was 100% slough (dead tissue) with a light serous drainage. The wound physician recommended leptospermum honey apply once daily for 30 days, cover with a gauze island with border dressing once daily. The Wound Evaluation indicated Resident #121 had a surgical excisional debridement procedure to remove necrotic tissue and establish margins of viable tissue. The additional note of the wound evaluation indicated post-debridement assess of the previously unstageable necrotic wound had been obscured by necrosis prior to this point. The wound now reveals itself to be a Stage 4 pressure injury. The Wound Evaluation's Treatment Plan indicated leptospermum honey would be applied once daily covered with a secondary dressing with a border. The recommendations included off-load the wound, limit sitting to 60 minutes, reposition according to facility protocol turn side to side and front to back in bed every 1-2 hours if able, a group 2 mattress, multivitamin daily, vitamin C 500 milligrams twice daily by mouth and zinc sulfate 220 mg once daily by mouth for 14 days.
Record review of the medication administration record, dated December 2022, failed to indicate the initial administration and ongoing administration of Vitamin C 500 mg twice daily by mouth or the zinc sulfate 220 mg once daily by mouth for 14 days. The medication administration record indicated the recommendations were started on 12/26/2022, 8 days after the recommendation was given by the dietician.
Record review of Resident #121's consolidated physician's orders dated 12/22/2022-01/31/2023, failed to indicate a low air loss mattress was ordered with appropriate setting to reflect his actual weight.
Record review of the Resident #121's December 2022 Treatment Administration Record indicated Resident #121 had no treatment to his sacral wound until after the wound care physician made his first visit on 12/29/2022. Resident #121's treatment record indicated there were no previous treatments to his sacral ulcer for 15 days.
Record review of a Skin Assessment, dated 12/29/2022, indicated Resident #121's sacral wound measured 3.5 cm x 3.0 cm x 0.1 cm and was considered a stage 4 pressure ulcer. The skin assessment indicated the wound had a light serous drainage and was 100% slough (dead tissue).
Record review of a January 2023 of a treatment administration record, indicated Resident #121's treatment to his sacral pressure ulcer was missed on 01/01/2023 and 01/07/2023.
During an interview on 01/11/2023 at 3:00 p.m., ADON A said she had sent Resident #121 to the emergency room related to increase pain to his sacral ulcer.
Record review of the Resident #121's progress note, dated 1/11/2023 at 3:34 p.m., indicated Resident #121 was sent to the local hospital for increased confusion, and increased pain.
Record review of Resident #121's comprehensive care plan did not reflect a potential impairment of the skin until 1/10/2023. The care plan indicated Resident #121 had the potential for impaired skin integrity related to decreased mobility, and low protein intake. The goal was to show no evidence of skin breakdown through the next review with the interventions of applying a barrier cream as needed, Braden risk assessment per facility protocol, encourage adequate nutrition and hydration, and keep Resident #121 clean, dry, and sheets wrinkle free, all dated 1/21/2022. The comprehensive care plan, dated 1/12/2023, indicated Resident #121 had a stage 4 pressure ulcer or the potential for pressure ulcer development related to impaired mobility. The goal was Resident #121's pressure ulcer would show signs of healing and remain free from infection. The interventions were to administer the treatment per the physician orders, do not massage over boney prominences, and use mild cleaners for peri-care. The other intervention, dated 01/12/2023, indicated Resident #121 required turning and repositioning every 2 hours, or more often as needed or requested.
Record review of the January 2023 medication administration record indicated Resident #121 had an order for that stated cleanse stage 4 to sacrum and apply leptospermum honey cover with a border gauze once daily. The treatment administration record indicated Resident #121 missed a treatment on January 1, 2023, and January 7, 2023.
Record review of a Weekly Wound Tracking Worksheet dated 01/02/2023 -01/06/2023, indicated Resident #121 had a Stage 4 pressure wound to his sacrum, with light serous drainage, measuring 4.0 cm x 3.0 cm x 0.1 cm, with the treatment was Medi-honey with a bordered dressing. The form indicated Resident #121 was on the corona virus unit during this assessment period.
Record review of the progress note, dated 1/11/2023 at 3:34 p.m., indicated Resident #121 was sent to the local hospital for increased confusion, and increased pain.
During an observation and interview on 01/09/2023 at 10:59 a.m., Resident #121 was sitting up in his wheelchair. Resident #121 said his wound on his bottom was hurting and he was administered a pain medication. Resident #121 said his wound care had not been completed. Resident #121's bed sheets had blood-tinged drainage on the sheets approximately where his bottom would have been.
During an interview on 1/10/2023 at 8:45 a.m., ADON A was asked to see the wound care for Residents #'s #120 and #121. ADON A said all treatments had been done for the day.
Record review of a Hospitalist admission Note, dated 01/11/2022, indicated Resident #121's diagnoses included Sepsis secondary to an unstageable sacral decubitus wound and acute on chronic kidney disease lll likely from the sepsis and congestive heart failure. The note indicated the Cat Scan (CT) of the abdomen/pelvis was positive for subcutaneous gas (gas gangrene a potentially deadly form of tissue death). The note indicated Resident #121 was placed on three broad spectrum antibiotics Vancomycin, cefepime, and clindamycin. The note indicated Resident #121 was referred to the general surgeon for wound debridement. The chief complaint was generalized body aches/pain and a worsening decubitus ulcer. The note indicated in the emergency room the sacral ulcer was foul-smelling. The note indicated he was in no acute distress at rest but does did have exquisite pain on any passive movement due to extensive sacra decubitus wound. The laboratory results listed on the admission note indicated Resident #121's white blood cell count was 16.9 (High) with normal range of 4,000 - 11,000/microliters indication of infection, (Albumin level) 1.8 (low) with normal range of 3.4 to 5.4 g/dl, and BUN (Blood urea nitrogen) was 52 (High) normal range 6 to 24 mg/dl indicating which included his kidneys were not functioning well.
Record review of a CT (cat scan) of the pelvis, dated 01/11/2023, indicated subcutaneous defect at the sacrum, with scattered subcutaneous gas about the sacrum at midline, as well as subcutaneous gas within the gluteal musculature bilaterally, left greater than right, with surrounding cellulitis. Findings were concerning for gas-forming infection as can could be seen in the setting of necrotizing fasciitis (flesh eating disease).
During a record review of the ER record dated 01/11/2023, a picture taken on arrival to the ER displayed a large sacral wound with base of wound covered with 80% in slough and eschar and the base of the spinal column was exposed.
During an observation and interview on 01/12/2023 at 11:30 a.m., Resident #121 was noted to be on the ER gurney at the local ER. Resident #121 stated he had been on the gurney for a day and was waiting a hospital bed because he was being admitted to the hospital for a wound infection. Resident #121 stated he had a large wound on his sacrum that was to the bone. Resident #121 stated it was painful and would not allow visualization of the wound. Resident #121 stated the pressure ulcer had gotten worse since he developed it because he was not being turned and he had gone multiple days with no treatment.
During an interview on 01/12/2023 at 12:30 p.m., the hospital SW stated the hospital was running test for sepsis and the resident was being admitted for a wound infection.
Record review of a Hospital History and Physical dated 01/22/2023 at 6:17 p.m., indicated Resident #121 was admitted to the hospital for severe sepsis (severe life-threatening complication of an infection secondary because of an infection to an unstageable pressure ulcer. The note indicated Resident #121 was started on two antibiotics for the pressure ulcer infection. The history and physical also indicated Resident #121 was in an acute on chronic kidney failure condition related to the sepsis. The history and physical note indicated in the emergency room, Resident #121's sacral pressure ulcer was foul smelling, extensive, and positive for gases (gas produced by dying tissue).
Record review of a Death Summary note, dated 01/22/2023, indicated Resident #121 was treated with pain medication and anxiety medication and died peacefully in the night. The note indicated Resident #121 had intractable pain and the family agreed to make him a do not resuscitate and placed him on palliative care with the intent of discharging to a nursing facility with hospice care.
5) Record review of a Resident #120's face sheet, dated 01/12/2023, indicated Resident #120 was a [AGE] year-old male who admitted to the facility on [DATE] with the diagnosis diagnoses which included of bacterial peritonitis (infection of the peritoneal cavity), severe sepsis with septic shock (a life-threatening complication of infection), and an unstageable pressure ulcer of the sacral region (low back).
Record review of Resident #120's admission assessment dated [DATE], indicated he had a sacral wound with no measurements included.
Record review of a Braden Scale for Predicting Pressure Sore Risk, dated 01/03/2023, indicated he was at risk for pressure injuries.
Record review of a Resident #120's Baseline Care Plan, dated 01/04/2023, indicated Resident #120 required extensive assistance of one staff for walking, toileting, locomotion, grooming, bathing, and set up help with eating. The care plan for bed mobility was left blank. The care plan indicated Resident #120 had a surgical wound, pressure ulcer, specify locations of treatment ordered (sacrum, upper back, and abdomen). The goal was the wounds would show signs of healing with area decreasing in overall size. The interventions included skin checks weekly, turn, and reposition frequently to decrease pressure, and wound vac.
Record review of the Resident #120's admission-readmission assessment, dated 01/03/2022, indicated Resident #120 had alterations in skin integrity. The assessment indicated he had a sacral pressure wound and an abdominal surgical incision. The assessment had no measurements of Resident #120's wounds.
Record review of the January 2023 EMR wound care entry for Resident #120's sacral wound indicated the wound care was not performed on 1/03/2023, 1/04/2023, 1/05/2023, 1/06/2023, and 1/08/2023.
Record review of Resident #120's skin assessment dated [DATE], indicated he had a stage 4 sacral pressure ulcer measuring 10cm x 10cm x 4cm.
Record review of a Resident #120's Dietician Progress Note and Recommendations, dated 01/08/2023, indicated Resident #120 was recommended to receive Juven (dietary supplement to enhance wound healing) twice daily.
Record review of Resident #120's EMR indicated the dietician recommendation of Juven 1 package twice daily was not implemented but another Arginaid (dietary supplement to enhance wound healing) one packet twice a day was ordered and implemented on 1/11/2023.
Record review of an Initial Wound Evaluation and Management Summary, dated 01/05/2022, indicated Resident #120 had a stage 4 pressure wound to the sacrum measuring 10 cm x 10 cm x 4 cm with 30% of the wound bed slough, 40% granulation tissue, and 30% muscle, facia, and/or bone. The wound care physician recommended off-loading of the wound, and to turn side to side every 1-2 hours, if able. The wound care note indicated the dressing treatment plan was Dakin's solution apply once daily, cover with abdominal pad. The wound care note indicated the wound care physician performed surgical removal of the devitalized tissue including slough, biofilm, and no-viable periosteum and bone were removed at a depth of 4 cm.
During an observation on 01/09/2023 at 11:09 a.m., Resident #120 was lying flat on his back on his bed, the wound vacuum was sitting in his wheelchair. Resident #120 said he had been at the facility for 5 days.
During an observation and interview on 1/09/2023 at 4:45 p.m., ADON A said Resident #120's wound vacuum will would not seal well due to the proximity to Resident #120's colostomy bag. ADON A indicated she would have to notify the physician for orders. Resident #120 was lying flat on his back. Resident #120's body reaches reached from side to side of the mattress.
During an observation on 1/10/2023 at 8:20 a.m., Resident #120 way lying in his bed on a standard hospital bed mattress. Resident #120 did not have a low air loss mattress. Resident #120's body reached the entire width of the bed. R[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to provide or obtain laboratory services to meet the needs of 3 of 20 residents reviewed for laboratory services. (Resident # 44, Resident #35, and Resident #34)
The facility failed to draw PT/INR (A prothrombin time (PT) test measures how long it takes for a clot to form in a blood sample. An INR (international normalized ratio) is a type of calculation based on PT test results) level for medication Coumadin (is a blood-thinning medicine that's used to treat and prevent dangerous blood clots) for Resident # 44 as ordered monthly for five months.
The facility failed to draw routine hemoglobin A1C (HBA1C) (a blood test that shows what your average blood sugar (glucose) level was over the past two to three months) for Resident #35.
The facility failed to obtain Resident #34's Vancomycin (is used to treat infections caused by bacteria. It works by killing bacteria or preventing their growth) trough level (is drawn immediately before the next dose of the drug is administered because it is the lowest concentration in the patient's bloodstream) as ordered prior to administration of first dose of Vancomycin.
These failures resulted in an identification of an Immediate Jeopardy (IJ) at 12:05 p.m. on 01/13/23. While the IJ was removed on 01/18/23, the facility remained out of compliance at the severity of no actual harm that is not immediate jeopardy with a scope identified as pattern due to the facility's need to evaluate the effectiveness of the corrective systems.
These failures could place residents at risk of not having their medications at a therapeutic level, delays in treatment, and/or deterioration in condition. Findings included:
1. Review of Resident #44's electronic face sheet dated 01/13/23 revealed he was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses of high blood pressure, seizures, stroke, and anemia (low blood).
Review of Resident #44's quarterly MDS assessment dated [DATE] revealed under Section B, Hearing, Speech, and Vision, he was coded as 2 for sometimes understands and sometimes understood by others. Section C, Cognitive Patterns, under section C0500 Brief Interview for Mental Status, which indicated a score of 99 for severely impaired cognition. Section G, Function Status under section B indicated he needed total assist with dressing, personal hygiene, and extensive assist with bed mobility, transfers, eating and toileting. Section N, Medication, under section N0410 indicated Resident #44 received 7 days of Coumadin during the look back period.
Review of Resident #44's physicians orders dated 1/13/22 revealed PT/INR to be drawn every 30 days for diagnosis of prostatic heart value (are designed to replicate the function of native valves by maintaining unidirectional blood flow).
Review of Resident #44's comprehensive person-centered care plan dated 01/13/21 when it was initiated, and it was revised on 01/14/21. Focus indicated: Resident #44 had the potential for alteration in bleeding tendencies and increased bruising related to anticoagulants therapy of Coumadin. Interventions indicated: Administer medication as ordered, monitor for side effects and report ill findings to physicians.
Review of Resident #44's labs did not reveal any PT/INR labs since 07/13/22 which was ordered monthly.
During an interview on 01/12/23 at 5:37 p.m., LVN C said Resident #44 was on Coumadin and should be getting monthly Coumadin levels and failure to get labs could result in bleeding.
During an interview on 01/12/23 at 5:46 p.m., LVN R said when charge nurses received new lab orders, they filled out a lab requisition and placed it in the lab book. LVN R said charge nurses then placed on the 24-hour report book to follow up on labs. LVN R said Resident #44 took Coumadin and thought he had a recent lab result. LVN R called the lab company to verify the last PT/INR and they confirmed his last results were PT-31.2 indicating high and INR-2.7 indicating high drawn on 07/13/22. LVN R said failure to do labs as ordered with Coumadin could cause Resident #44 to bleed out.
During an interview on 01/12/23 at 5:50 p.m., the DON said she was aware Resident #44 did not have his Coumadin level drawn monthly as ordered. The DON said Resident #44's last coumadin level was last drawn on 07/13/22. The DON said it took time to get things in order and she was still working on this process. The DON said she did not have a system in place to monitor labs at this time
During an interview on 01/12/23 at 6:10 p.m., the RNC said she was unaware Resident # 44 did not have a current PT/INR level but would make sure he got one done. The RNC said it is important to have the PT/INR drawn as ordered to ensure residents are in therapeutic levels and failure to do labs could cause bleeding.
During a phone interview on 01/13/23 at 8:40 a.m., the Primary doctor said he was not aware PT/INR levels had not been drawn since 07/13/22. The Primary doctor said the facility should have drawn the PT/INR level as ordered. The Primary doctor said failure to draw PT/INR levels could lead to Resident #44 bleeding and having another stroke.
Record review of Resident #44's progress note dated 01/13/2023 at 5:28 p.m., revealed PT/INR lab results received, PT 17.1, (normal range=9.0-12.2) and INR 1.4 (normal range 0.8-1.1). Physician made aware, new order to discontinue Coumadin 7.5mg and begin Coumadin 10 mg, give 1 tablet by mouth daily. Attempted to notify daughter to make aware of changes, call went unanswered. Resident #44 made aware of new change. Coumadin 10mg administered at this time, and new order to recheck PT/INR in one week.
2. Record review of a face sheet dated 01/17/23 indicated Resident #34 was a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of cellulitis (bacterial skin infection that causes redness, swelling, and pain to the affected area), Chronic obstructive pulmonary disease with acute exacerbation (group of lung diseases that cause airflow blockage and breathing related problems), acute systolic congestive heart failure (left ventricle of heart becomes weak), and weakness.
Record review of the quarterly MDS dated [DATE] indicated Resident #34 was usually understood and understood others. The MDS revealed Resident #34 had a BIMS score of 13 indicating intact cognition. The MDS indicated Resident #34 required extensive assistance with bed mobility, toileting, and personal hygiene. Resident #34 was totally dependent on dressing and bating. The MDS under section O, special treatments, procedures, and programs, had IV medications checked indicating Resident #34 had received IV medications within the last 14 days.
Record review of Resident #34's comprehensive care plan did not indicate Resident #34 was receiving IV antibiotics.
Record review of the order summary report dated 01/17/23 indicated Resident #34 had an order for Vancomycin HCL intravenous solution 750-0.9mg/150mls-% Use 150ml intravenously every 12 hours for cellulitis to right hand for 10 days with an order start date of 01/16/23.
Record review of the hospital patient discharge summary report dated 01/15/23 indicated new medications to start included Vancomycin HCL injection 750mg/sodium chloride 0.9% bag 250ml take IV piggyback every 12 hours. 250ml/hr. *Hold dose and DO NOT administer IF Trough is 20 or higher. Get trough level before 1st dose on 01/16/23.
Record review of the lab request form dated 01/16/23 indicated Vancomycin trough to be collected on 01/18/23.
During an interview on 01/17/23 at 09:45 AM, Resident #34 said he received his first dose of IV medication last night.
During an interview on 01/17/23 at 09:50 AM, LVN L said Resident #34 received his first dose of Vancomycin last night and was unsure if the vancomycin trough was obtained prior to Resident #34's first dose of vancomycin.
During an interview on 01/17/23 at 12:51 PM, ADON A said she did not see the order to obtain a trough level before the first dose of vancomycin for Resident #34 and it was not obtained. ADON A said by not obtaining the vancomycin trough level, Resident #34 could be at risk for receiving more than the therapeutic dose of vancomycin.
During an interview on 01/17/23 at 1:57 PM, the RNC said they should have obtained a vancomycin trough level prior administering the first dose of vancomycin. The RNC said by not obtaining the trough level as ordered the resident was a risk for receiving the wrong dose of vancomycin. The RNC said the nurse who hung the medication was responsible for ensuring Resident #34 had a vancomycin trough level prior to receiving his first dose of vancomycin.
During an interview on 01/17/23 at 5:00 PM, the Interim Administrator said he expected the nurses to follow the physician orders. The Interim Administrator said by not following the physicians' orders could cause the resident to have adverse effect.
Record review of the facility's policy titled Diagnostic Testing Services dated 07/01/22 indicated . this facility will provide the appropriate diagnostic services (laboratory and radiology) required maintain the overall health of its residents and in accordance with state and federal guidelines .
3. Record review of Resident #35's electronic face sheet, dated 01/13/23, revealed an [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Metabolic encephalopathy (is a problem in the brain. It is caused by a chemical imbalance in the blood), diabetes, high blood pressure, Chronic obstructive pulmonary disease (COPD) (is a chronic inflammatory lung disease that causes obstructed airflow from the lungs), and dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities).
Record review of Resident #35's quarterly MDS assessment, with an ARD of 10/07/22, revealed under Section B, Hearing, Speech, and Vision, she was coded as 1 for usually understand and usually understood by others. Section C, Cognitive Patterns, under section C0500 Brief Interview for Mental Status, which indicated a score of 10, which indicated moderately impaired cognition. Section G, Function Status, under section G0110 indicated she needed supervision with bed mobility, transfers dressing, eating, personal hygiene and toileting.
Review of Resident #35's physicians orders revealed, HGBA1C every 6 months in March and September.
Review of Resident #35's comprehensive person-centered care plan dated 03/30/18 when it was initiated, and it was revised on 11/08/22. Focus indicated: Resident #35 has the potential for complications related to diagnosis of Diabetes Melilites. Intervention: HBGA1c every 6 months, administer medication as ordered by physician and monitor for side effects.
During an interview on 01/12/23 at 5:46 p.m., LVN R said when charge nurses receive new lab orders, they fill out a lab requisition and place in lab book. LVN R said charge nurses then place on 24-hour report book to follow up on labs. LVN R verified order for Resident #35's HGBA1C to be drawn in March and September. LVN R said failure to do this lab as ordered could lead to Resident #35 not receiving correct dose of medication.
During an interview on 1/17/23 at 2:06 p.m., the RNC said all labs should be drawn as ordered. RNC said the charge nurses are responsible to ensure orders are received and lab requisitions are filled out completely. The RNC said administrative nurses was to follow up on all labs. The RNC said without labs been drawn as ordered, doctors would not know if the residents were within a therapeutic range.
During an interview on 01/17/23 at 2:25 p.m., ADON D said she expected the charge nurses to fill out the lab requisition and to make sure it was done. ADON D said she expected the charge nurses once lab received back to notify the physician because writing faxed on paper does not tell us anything. ADON D said the ADON's should be following up on labs. ADON D said Resident #44 could bleed out without propre dose of medication. ADON D said Resident #35's oral, or insulin medication could need readjustment but without proper lab they could not detect therapeutic levels and could lead to organ failure.
During an interview on 01/17/23 at 6:00 p.m., ADON D said Resident # 35 did not get her HGBAIC in September as ordered. ADON D said she was unaware why Resident #35 HGBA1C was not done. ADON D said with the new lab system, hopefully no more labs will be missed.
The Administrator was notified 01/13/22 at 1:20 p.m. that an Immediate Jeopardy (IJ) was identified due to the above failures. The IJ template was provided on 01/13/22 at 1:25 p.m. and a Plan of Removal (POR) was requested.
The following Plan of Removal submitted by the facility was accepted on 01/15/23 at 5:00 p.m. and included the following:
1.
Resident has received lab draw on 01/12/23.
2.
All resident on anticoagulant identified, only one identified. Identified by report and database confirming any resident on anticoagulant. Every monthly order in DCOL lab binder. Completed 01/13/23.
3.
MD notified of any residents without current PT/INR. Zero identify. Completed 1/13/23
4.
Order for new PT/INR to be immediately and lab notified. Completed 01/13/23
5.
Families made aware. Completed 01/13/23
6.
Orders for routine lab draws for anticoagulants current and corrected. DON insured lab and orders corrected. Completed 01/13/23.
7.
In-serviced all nursing staff of all residents on anticoagulants and routine lab orders. In-service completed by DON. In-service included anticoagulants and monitoring. In-service included how to run anticoagulant report from PCC. Completed 01/13/23
Monitoring:
Interviews on 01/17/23 from 5:00 p.m. until 5:48 p.m., the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the IJ by:
Interviews with 3-6am-6pm (LVN KK, LVN R and ADON G and 2-6pm-6am (LVN OO and LVN M) nurses who indicated they had received a written in-service regarding monitoring of labs. What blood thinners are such as medicines that prevent blood clots from forming. Residents who may needs blood thinners, with a certain heart or blood vessel diseases or an abnormal heart rhythm called atrial fibrillation. The different types of blood thinners which are anticoagulants, such as heparin or Coumadin, because they slow down your body's process of making clots and antiplatelets, such as aspirin and clopidogrel, which prevent blood cells called platelets from clumping together to form a clot. How to take blood thinners safely by getting labs to ensure you're taking enough medicine to prevent clots, but not so much that it causes bleeding; and the side effects of blood thinners was bleeding. All the nurses above stated they knew how to run a report to check to ensure any resident on Coumadin had an order for PT/INR.
Record review of an in-service training report dated 1/13/23 indicated anticoagulants and monitoring were the topic of the in-service. The training session included:
What are blood thinners?
Blood thinners are medicines that prevent blood clots from forming. They do not break up clots that you already have. But they can stop those clots from getting bigger. It's important to treat blood clots, because clots in your blood vessels and heart can cause heart attacks, strokes, and blockages.
Who needs blood thinners?
You may need a blood thinner if you have:
Certain heart or blood vessel diseases
An abnormal heart rhythm called atrial fibrillation
A heart valve replacement
A risk of blood clots after surgery
Congenital heart defects
What are the different types of blood thinners?
There are different types of blood thinners:
Anticoagulants, such as heparin or warfarin (also called Coumadin), slow down your body's process of making clots.
Antiplatelets, such as aspirin and clopidogrel, prevent blood cells called platelets from clumping together to form a clot. Antiplatelets are mainly taken by people who have had a heart attack or stroke.
How can I take blood thinners safely?
When you take a blood thinner, follow the directions carefully. Blood thinners may interact with certain foods, medicines, vitamins, and alcohol. Make sure that your health care provider knows all of the medicines and supplements you are using.
You may need regular blood tests to check how well your blood is clotting. It is important to make sure that you're taking enough medicine to prevent clots, but not so much that it causes bleeding.
What are the side effects of blood thinners?
Bleeding is the most common side effect of blood thinners. They can also cause an upset stomach, nausea, and diarrhea.
Other possible side effects can depend on which type of blood thinner that you are taking.
Call your provider if you have any sign of serious bleeding, such as:
Menstrual bleeding that is much heavier than normal
Red or brown urine
Bowel movements that are red or black
Bleeding from the gums or nose that does not stop quickly
Vomit that is brown or bright red
Coughing up something red
Severe pain, such as a headache or stomachache
Unusual bruising
A cut that does not stop bleeding
A serious fall or bump on the head
Dizziness or weakness
ANTICOAGULANT MONITORING
Keywords: Oral anticoagulant therapy
TYPES OF ANTICOAGULANT
APPROPRIATE TESTS
See also Thrombolytic therapy (Thrombolysis).
The type of tests and frequency of testing depends on the anticoagulant therapy and indication, as well as clinical history.
Heparin (standard, unfractionated)
Prior to commencing Full blood count (including platelet count), Coagulation profile (including APTT, INR, Prothrombin time). Platelet count is recommended on day 5 post commencement of therapy.
The method for monitoring continuous IV heparin infusion is usually APTT, however Activated clotting time (ACT) and Anti factor Xa are also used.
The level of anticoagulation may be monitored with the APTT and/or Anti factor Xa level, however monitoring(including the test and frequency) should be according to local guidelines. Prophylactic (low dose) heparin does not usually require monitoring.
In the event of bleeding on heparin, urgent APTT and Full blood count should be performed.
If progression of thrombosis, or thrombosis in other site(s) while patient on heparin, causes include:
Inadequate anticoagulation
Heparin-induced thrombocytopenia (HIT type II)
Antithrombin deficiency
APTT, Anti factor Xa
See also Heparin-induced thrombocytopenia investigation
Antithrombin - ideally should be deferred until heparin has been ceased (if not performed for some reason prior to heparin therapy), since heparin will reduce the measured level. Consultation with a haematologist is recommended to guide further testing and management. See also Thrombosis - venous. Low molecular weight heparin (LMWH) and heparinoids
Prior to commencing, Full blood count (including platelet count), Coagulation profile (including APTT, INR, Prothrombin time) and renal function should be performed. Platelet count is recommended on day 5 post commencement of therapy.
Monitoring of (full dose) low molecular weight heparin (LMWH) therapy is not generally required, except in renal failure, extremes of body weight, pregnancy or other situations where there is an increased risk of bleeding. LMWH should be used with care and monitoring in patients with any abnormality of renal function, particularly the elderly. Monitoring is with an Anti factor Xa level, but should be done in consultation with a haematologist and according to local guidelines.
Monitoring of routine LMWH prophylaxis is not cost effective, is not required to achieve clinical efficacy and is not indicated to predict risk of bleeding, which is minimal with prophylactic doses in patients with normal renal function.
Oral anticoagulants
Warfarin (Marevan/Coumadin)
Prothrombin time, INR
Increased frequency of testing may be required following change in dose, change in diet/oral intake, intercurrent illness and change in concomitant medications (including antibiotics).
For information on reversal of warfarin, see guidelines below.
New oral anticoagulants (NOACS)
NOAC do not require monitoring when used for thromboprophylaxis or therapeutic anticoagulation.
However, the anticoagulant effect should be measured if:
1. Clinically significant bleeding occurs
2. There is a change in clinical circumstances (eg, urgent surgery is required)
Routine coagulation studies may (but sometimes do not) provide information about the presence of anticoagulant effect (see below).
Specific assays for quantitation of drug levels may or may not be available depending on the drug and laboratory. Due to the short half-life of these drugs, information on the time of the last dose is important in interpreting the results.
Refer to coagulation laboratory.
Dabigatran
The Thrombin time (TT) is the most sensitive routine coagulation assay to detect the presence of dabigatran. A normal TT excludes the presence of dabigatran, however low drug levels may significantly prolong the TT, therefore the assay cannot be used to estimate plasma levels.
Some laboratories may perform a drug level assay (dilute thrombin clotting time assay).
Rivaroxaban
The Prothrombin time, INR (using a thromboplastin that is sensitive to rivaroxaban) is the most sensitive routine coagulation assay, however a normal PT does not exclude its presence. The APTT and PT cannot estimate the intensity of anticoagulant effect
Some laboratories may provide a drug specific anti-Xa for quantitative assessement of drug plasma levels. The clinical relevance of drug plasma levels is not known, and therefore should not be used to inform drug doses.
Apixaban
A normal PT and APTT does not exclude significant anticoagulant effect.
Drug specific anti-Xa assay may be used to estimate drug plasma levels, but this is not yet widely available. Please consult with laboratory.
References:
[NAME] DA et al; American College of Chest Physicians. Parenteral anticoagulants: Antithrombotic Therapy and Prevention of Thrombosis. 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 2012; 141 (2 Suppl): e24S-43S.
[NAME] H et al. An update of consensus guidelines for warfarin reversal. MJA 2013; 198: 198-199.
[NAME] H et al. New oral anticoagulants: a practical guide on prescription, laboratory testing and peri-procedural/bleeding management. IMJ 2014; 44: 525-536.
Record review of a written in-service dated 01/15/23 indicated licensed staff had been educated on labs.
The CEO and interim Administrator were informed the Immediate Jeopardy was removed on 01/18/23; however, the facility remained out of compliance at a severity level of no actual harm that is not immediate jeopardy and a scope of pattern due to the facility's need to evaluate the effectiveness of the corrective systems.
Record review of the original in-service conducted with all nursing staff addressed the policy for all residents with lab orders. The in-service included lab and diagnostic test result protocol. Monitoring to be completed by DON, and ADONs. In-service completed by the DON on 01/13/2023; verified by interview of in-serviced material.
After re-entering the facility on 2/8/23 at 9:05 a.m. additional information was gathered and included the following interviews and record reviews:
Record review of the laboratory process effective 01/18/23 indicated:
*admission orders were reviewed during next the clinical meeting.
*All orders were checked to ensure they were entered correctly. Any unclear orders were clarified.
*Any laboratory orders were verified of placement in the EMR to ensure laboratory requisitions were completed in the laboratory requisition book.
*Nursing to monitor laboratory results and review to ensure the MD was aware. Any new orders received would be implemented.
*Clinical meetings will occur twice a day to ensure communication was followed and any changes were updated.
*Initial requisition would indicate if a resident had recurring laboratory orders.
*During the daily clinical meeting, the PCC dashboard will be utilized to monitor for lab results, MD review, and followed for any order changes.
Interviews on 02/08/23 from 09:51 a.m. until 11:05 a.m., the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the IJ by:
Interview with 3- 6am-6pm (LVN B, LVN R and LVN Y) nurses who indicated the laboratory process included: when an order for a laboratory was obtained, the order was placed in the resident's electronic medical record, the laboratory requisition was filled out, placed in the laboratory book, and was written on the 24hr report. Residents with standing laboratory orders were indicated on the lab requisition form. The three LVNs said the ADONs review the lab book daily.
Interview with ADON A, ADON G, and RNC indicated they had placed a laboratory monitoring process on 1/18/23. New orders and admission orders were reviewed during the next clinical meeting. The laboratory process was:
-Laboratory orders received were ensured they were entered corrected in the EMR.
-The laboratory requisition was completed.
-The laboratory requisition was placed in the laboratory book.
The laboratory book was checked daily by the ADONs. Nursing would monitor for laboratory results, notify medical director, and implement any new orders received. If a laboratory result had not been received by 3:00 p.m., the ADON would then call the laboratory to check on the results.
Record review of 6 of 6 new admissions revealed if they had orders for laboratory services the laboratory levels were obtained according to orders.
Record review of 2 of 2 resident receiving vancomycin had their vancomycin troughs completed as ordered.
Record review of 4 of 4 residents reviewed for monthly laboratory orders were on the monthly laboratory log to be obtained.
Record review of Resident #34's vancomycin trough level, collected on 01/18/23, was 12.1. The medical director had reviewed and signed the laboratory results which included orders to discontinue the vancomycin due to the resident's refusal.
Record review of Resident #44's PT/INR results indicated his INR was 2.8. Resident #44 was to have his INR rechecked on 02/20/23. Resident #44 was on the scheduled monthly laboratory log.
The administrator was notified on 2/8/23 at 7:25 p.m. the immediacy remained in place until 1/18/23.

Based on interviews and record reviews, the facility failed to provide sufficient support personnel to carry out the functions of the food and nutrition services safely and effectively for 1 of 1 kitchen reviewed for dietary services.
The facility failed to ensure sufficient dietary staff was present for 3 of 7 days of meal service observed.
This failure could place residents at risks for not receiving meals at designated mealtimes.
Findings included:
Record review of a dietician cleanliness report dated 11/11/2022 indicated the following:
*Air conditioner vent (ceiling) needs cleaning
*Plate covers stacked wet
*Wipe down front of steam table
*Touch up paint to walls
*Outside door should be smooth and non-porous
*Drip tray empty but had a grease buildup in the corners -fire hazard
*Clean vent-a-hood filters
*Clean wall under dish machine area
*Clean garbage disposal
*Clean light cover and ceiling in dish room
*Pantry floor needs to be stripped and sealed
*Walk in cooler lean fan cover-condensation dripping on foods.
During initial tour on 01/09/2023 at 9:55 a.m., the following was observed:
*Stove top with chunks of burned food and black colored buildup
*Microwave oven with dried, brown colored food build up
*4-ounce glass bowls stacked facing upward under steam table with water and black mater floating in the bowls.
*Electrical outlet cover with sticky yellow colored greasy build up
*Wall behind steam table with splashes of food material
*Ceiling with dust like material above the dish machine
*Manuel can opener with black sticky build up to the piercing blade of the can opener.
*Dry food storage containers for beans, corn meal, flour, noodles covered with a sticky, and dusty film
Record review of the dietary work schedule indicated:
*Monday 01/09/2023 there were 2 staff scheduled for the entire day of meal services.
*Tuesday 01/10/2023 there were 2 staff scheduled for the entire day of meal services.
*Wednesday 01/11/2023 there were 3 staff scheduled for the entire day of meal services.
Record review of the dietary work schedule dated 01/01/2023 - 01-21-2023 had 4 staff assignments including the dietary manger.
During an observation and interview on 01/09/2023 at 10:15 a.m., the cook indicated she and the dietary manager were the only staff in the kitchen today. The cook said the lack of helper staff was common on most days.
During an interview on 01/10/2023 at 12:30 p.m., the dietary manager said she had 3 employees for the kitchen. The dietary manger said when someone needs off or calls off there was no one to call so they will work with 2 staff. The dietary manager said the lack of staff had impacted the dietary department. The dietary manager said there was no time to deep clean the kitchen or order sufficient stocked foods for emergency use. The dietary manager said she does not have a cleaning schedule for deep cleaning . The dietary manager said she had no one applying for the any dietary positions.
During an interview on 01/17/2023, the Interim Administrator said he was unaware of staffing needs of the facility at present time but he had a plan to review staffing needs.

Based on observation and, interview, the facility failed to prepare puree food by methods that conserve nutritive value, flavor, and appearance for residents on a pureed diet for 1 of 5 residents reviewed for pureed diet. (Resident #57)
Cook AA failed to ensure the puree diets were prepared by methods of conserving nutritive value, and flavor when she used tap water to prepare the pureed green peas.
This failure could place residents on a pureed diet at risk of receiving an inadequate diet that could affect their health.
Findings included:
During an observation and interview on 01/09/2023 at 11:38 a.m., [NAME] AA used a metal measuring cup to scoop out green peas from a larger pan on the steam table. [NAME] AA began to puree the green peas, then walked over to the three-compartment sink faucet and obtained tap water. [NAME] AA then added the tap water to the green peas to achieve the texture desired. When asked why she added the tap water to the green peas she denied doing so. When asked again why she added tap water to the green peas she said, I should have used the juice off the peas for nutrition. [NAME] AA said she had not used the recipe for the pureed diet preparations.
During an interview on 01/13/2023 at 6:00 p.m., the dietary manager said the pureed foods should be thinned with the juice from the canned vegetable or a broth. The dietary manager said the food will lose its nutrition.
During an interview on 01/16/2023 at 10:45 a.m., the Administrator said she expected the pureed foods to be processed by using the juice from the foods or a broth. The Administrator said the dietary manager was responsible for ensuring foods prepared according to the recipe. A policy was requested but not provided.
The policy on nutritive value of foods was requested but not provided by the facility.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in the facility's only kitchen.
The facility failed to ensure the stove top was clean.
The facility failed to ensure the microwave was clean.
The facility failed to ensure the walls and ceilings were clean.
The facility failed to ensure the dry storage bins were clean.
The facility failed to ensure the can opener was clean.
The facility failed to ensure the serving bowls were clean.
The facility failed to ensure the electrical outlet was clean.
Findings included:
During initial tour of the kitchen on 01/09/2023 at 9:55 a.m., the following was observed:
*Stove top with chunks of burned food and black colored buildup
*Microwave oven with dried, brown colored food build up
*4-ounce glass bowls stacked facing upward under steam table with water and black mater floating in the bowls.
*Electrical outlets cover with sticky yellow colored greasy build up
*Wall behind steam table with splashes of food material
*Ceiling with dust like material above the dish machine
*Manuel can opener with black sticky build up to the piercing blade of the can opener.
*Dry food storage containers for beans, corn meal, flour, noodles covered with a sticky, and dusty film.
During an interview on 01/10/2023 at 12:30 p.m., the dietary manager said she had 3 employees for the kitchen. The dietary manager said the lack of staff had impacted the dietary department. The dietary manager said there was not time to deep clean the kitchen or order sufficient stocked foods for emergency use. The dietary manager said she does not have a cleaning schedule for deep cleaning.
During an interview on 01/16/2023 at 10:45 a.m., the Administrator indicated she was responsible for the oversight of the dietary department. The Administrator said she had not made sanitation rounds in the dietary department.
Record review of a Sanitation Inspection policy dated 07/01/2022 indicated it is the policy of this facility, as part of the department's sanitation program, to conduct inspections to ensure food service areas are clean, sanitary, and in compliance with applicable state and federal regulations. Policy Explanation and Compliance Guidelines: 1. All food service areas shall be kept clean, sanitary, free from litter, rubbish, and protected from rodents, roaches, flies, and other insects. 2. The department shall establish a sanitation program for food services based on applicable state and federal requirements. 3. The sanitation program will provide for inspections to be conducted of the food service areas. 6. The dietary manager shall develop and provide food service personnel with standard operation procedures for sanitation and daily.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2) Record review of a face sheet dated 01/13/23 indicated Resident #38 was an [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of stroke, type 2 diabetes (chronic condition that affects the way the body processes blood sugar), weakness, right sided weakness, and atrial fibrillation (irregular heartbeat).
Record review of the MDS assessment dated [DATE] indicated Resident #38's MDS had not been completed.
Record review of Resident #38's comprehensive care plan dated 12/02/22 and revised on 12/09/22 indicated Resident #38 had cognitive impairment due to memory problems.
During an observation and interview on 01/10/2022 at 11:05a.m-11:30a.m., Resident #38 had his feet off the bed and was expressing the desire to get up. CNA P donned her PPE including a pair of gloves at the door. CNA P assisted Resident #38's feet back up on the mattress. CNA P removed the linen off Resident #38. CNA P then opened Resident #38's brief. CNA P began cleaning Resident #38's peri area wiping several times with the same wipes. CNA P then asked Resident #38 to roll over. CNA P ran out of wipes, so she walked to the dresser and open the top drawer looking for more wipes, never removing her soiled gloves. CNA P then walked to the room door opened the door with the same soiled gloves on and told LVN L to bring more wipes. LVN L provided CNA P with more wipes. She touched the bag of wipes with her dirty gloves on to finish cleaning the bowel movement from Resident #38. CNA P then took the new brief and applied the brief. CNA P then removed her gloves. CNA P assisted Resident #38 to his wheelchair not using hand sanitizer or washing her hands. CNA P said she should have changed her gloves between clean and dirty, and she should have not wiped using the one wipe multiple times. LVN L said not changing your gloves, cleansing your hands, and using separate wipes could cause an infection.
During an interview on 01/17/2023 at 2:39 p.m., the Regional Corporate Nurse said she expected the CNAs to have had skills check off for incontinent care. The Regional Corporate Nurse said she would expect the CNAs to change gloves between clean and dirty. The Regional Corporate Nurse said not changing your gloves, washing hands, or using sanitizer causes a risk of infection. The Regional Corporate Nurse said the DON was responsible for ensuring check offs were completed.
During an interview on 01/17/2023 at 4:38 p.m., the Interim Administrator said he was not a nurse therefore he could not answer concerning the technique, but he said not completing incontinent care correctly could cause infections.
Record review of a Healthcare-Associated Infections, identifying policy dated September 2017 indicated:
The facility shall attempt to identify and distinguish healthcare-associated infections from those acquired in the
community.
Policy interpretation and Implementation
1. Healthcare-associated infections (HAIs) are those that are acquired during the delivery of healthcare across
settings, in contrast to those that were acquired prior to entering the healthcare setting but may persist after
admission to the facility.
2. The goals of determining healthcare-associated infections are:
a. to identify and correct breaches in infection control practices that may have contributed to the spread
of a healthcare-associated infection.
b. to prevent the further spread of infection (resident-to-resident, staff-to resident) through the initiation
of appropriate isolation precautions where warranted; and
c. to identify, treat and report epidemiologically important organisms (e.g., C. difficile, MDROs) that
have a high risk of transmission, severity of disease, and/or are difficult to treat.
3. Record review of Resident #5's electronic face sheet, dated 01/13/23, revealed a [AGE] year old female who was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included multiple sclerosis (a chronic, typically progressive disease involving damage to the sheaths of nerve cells in the brain and spinal cord, whose symptoms may include numbness, impairment of speech and of muscular coordination, blurred vision, and severe fatigue), sepsis (a serious condition resulting from the presence of harmful microorganisms in the blood or other tissues and the body's response to their presence, potentially leading to the malfunctioning of various organs, shock, and death), anxiety (what we feel when we are worried, tense or afraid), high blood pressure, and Alzheimer's ( a type of dementia that affects memory, thinking and behavior).
Record review of Resident #5's quarterly MDS assessment, with an ARD of 10/26/22, revealed under Section B, Hearing, Speech, and Vision, was coded as a 0 indicating she understands and was understood by others. Section C, Cognitive Patterns, under section C0500 Brief Interview for Mental Status, which indicated a score of 14 for cognitive intact cognition. Section G, Function Status, under section B indicated she needed extensive assistance with bed mobility, personal hygiene, total assist with transfers, dressing, bathing, and supervision with eating. Section M, Skin Condition, under section M1200 she received pressure ulcer/injury care and application of nonsurgical dressing during the look back period.
Review of Resident #5's comprehensive person-centered care plan dated 12/27/17 when it was initiated, and it was revised on 01/13/23. Focus indicted: Resident #5 was at risk for further skin breakdown, also has wound to right, distal, lateral calf lower leg and pressure area to right ischium related to immobility, incontinence, and disease process. Intervention indicated: Keep physician and RP informed of my progress.
During an observation and interview on 01/11/23 at 11:10 a.m., ADON G was performing wound care on Resident #5, when she went from cleaning wound to left ischium to applying clean dressing without changing gloves or washing her hands. ADON G cleaned right ischium and did not wash her hands or apply clean gloves before applying clean dressing. ADON G said she should have changed her gloves and washed her hands in between dirty to clean to prevent infection.
During an observation and interview on 01/10/23 at 5:22 p.m., CNA Q was observed going in and out of resident's rooms on hall six hundred wearing a surgical mask. CNA Q said she had on a surgical mask because they did not have any N95 mask when she entered the facility. CNA Q said she had been trained and had several infection related in-services on what to wear during an outbreak. CNA Q said she knew who to ask for one, but she did not. CNA Q said failure to wear proper mask could lead to the spread of Covid.
During an observation and interview on 01/13/23 at 3:57 p.m., CNA V observed assisting a resident at lunch with a surgical mask on and was currently weighing residents with a surgical mask on. CNA V said she had been in-serviced on the proper mask to wear but it was hard to breathe in them. CNA V reached over nurses' station and placed on a N95 mask. CNA V said failure to wear proper mask while providing care could cause the residents to become ill.
During an observation and interview on 01/15/23 at 6:18 p.m., observed CNA W picking up residents' trays on hall two hundred wearing no mask. CNA W said she knew she was supposed to have on a mask, but they did not have any N95 mask when she entered the facility. CNA W said she was aware of where she could get a mask but started working and forgot. CNA W said failure to place on proper mask could cause residents to become ill.
During an interview on 01/17/23 at 2:06 p.m., the RNC said she expected everyone to wear the mask, change gloves properly and wash hands properly while during wound care according to protocol. The RNC said administrated nurses are the overseers to make sure everyone was wearing the correct mask, doing proper glove changes, and hand washing. The RNC said failure to wear the proper mask or do good handwashing could lead to spreading diseases and infection.
During an interview on 01/17/23 at 2:25 p.m., ADON A said she expected everyone to wear the proper mask, change gloves and preform hand washing properly while doing treatments. ADON A said she was the facility's Infection Preventionist and had done several Covid related in-services. ADON A said everyone could look and see if staff had on the correct mask and if not correct them. ADON A said failure to have on the proper mask or do proper handwashing could lead to the spread of infection.
Record review of COVID-19 infection prevention and control measures policy dated September 2021. This facility follows infection prevention and control practices recommended by the Center for Disease Control and prevention to prevent the transmission of COVID-19 within the facility the measures include A) screening, B) distancing, C) facility wide testing, D) vaccination, E) standard precaution, F) transmission-based precautions, G) universal source control, H) appropriate use of PPE, and I) environmental cleaning and disinfecting. Outbreak Quick reference guide stated test our staff and residents regardless of vaccination status. You will continue this practice every three to seven days until you have no positive for 14 days. All staff not testing during scheduled days' time must stop at the screening station and test prior to entry into the facility. Convert all staff to N95 doing outbreak testing. Follow your specific policy and procedure for visitation but remember essential care visits are always allowed. Review refresh and educate on your COVID-19 policy and procedure and infection control (IE proper PPE usage hand washing and quarantine process).
Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections reviewed for 3 of 20 residents (Resident # 5, Resident #38 and Resident #272) and 6 of 6 staff reviewed for infection control.
The facility failed to ensure staff were wearing N95 masks during a Covid-19 outbreak per their facility response plan (CNA Q, CNA V, CNA W).
CNA P failed to wash her hands and to change her gloves during incontinent care for Resident #38.
The facility failed to ensure staff were washing hands in between glove changes for Resident #5.
LVN K failed to disinfect the insulin pen prior to use and the glucometer after the use with Resident #272.
These failures could place residents, and staff at risk of the spread of infections, including COVID-19.
Findings include:
1. Record review of a face sheet dated 01/11/23 indicated Resident #272 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of type 2 diabetes (a chronic condition that affects the way the body processes blood sugar glucose), heart failure (a chronic condition in which the heart does not pump as well as it should), and high blood pressure.
Record review of the annual MDS dated [DATE], indicated Resident #272 was understood and understood others. The MDS revealed Resident #272 had a BIMS score of 14 indicating intact cognition. The MDS indicated Resident #272 required extensive assistance with bed mobility, transfers, locomotion, toileting, and bathing. Resident #272 required supervision with dressing, eating and personal hygiene. The MDS under section N, medications, indicated Resident #272 received insulin injections seven times in the last seven days.
Record review of the order summary report dated 01/11/23, revealed Resident #272 had an order for Novolog Solution (insulin Aspart) inject 15 units subcutaneously (under the skin) before meals for hyperglycemia (high blood sugar) with an order date of 01/07/23.
Record review of the comprehensive care plan dated 01/10/23 with a revision date of 01/11/23 indicated Resident #272 had diabetes and received insulin injections with interventions to give diabetic medications as ordered.
During an observation and interview on 01/10/23 at 11:36 AM, LVN K donned gloves and obtained Resident #272's fingerstick blood sugar. After removing test strip from glucometer, LVN K placed glucometer on top of the nurse's cart and proceeded to obtain Resident #272's Novolog insulin pen. LVN K took off the cap of the insulin pen and applied the needle to it. LVN K did not sanitize the tip of the insulin pen prior to applying the needle. LVN K proceeded to administer the 15 units of Novolog insulin to Resident #272. After medication administration, LVN K removed gloves and performed hand hygiene. LVN K placed the used glucometer inside the nurse's cart without disinfecting it. LVN K said he should have cleaned the tip of the insulin pen prior to applying the needle and should have disinfected the glucometer after he used it on Resident #272. LVK K said by not disinfecting the glucometer and insulin pen, the resident could be at risk for infection.
During an interview on 01/17/23 at 12:51 PM, ADON A said she expected the glucometer to be cleaned before and after each use with a disinfecting wipe and allowed to dry. ADON A said she expected the tip of the insulin pen be cleaned with alcohol wipes prior to applying the needle. ADON A said by not properly disinfecting the insulin pen or glucometer the residents could be at risk for infection.
During an interview on 01/17/23 at 1:57 PM, the RNC said she expected the glucometer to be cleaned before and after each use. The RNC said she expected the insulin pen to be cleaned prior to accessing it. The RNC said by not properly disinfecting the glucometer and insulin pen the residents were at risk for cross contamination and infection.
During an interview on 01/17/23 at 5:00 PM, the Interim Administrator said he expected the glucometer and insulin pens to be disinfected. The Interim Administrator said by not properly cleaning the glucometer and insulin pen it placed the residents at risk for infection.
Record review of the facility's policy titled Insulin Pen dated 07/01/22, indicated .remove the pen cap from the insulin pen. Wipe the rubber seal with an alcohol pad. screw the pen needle onto the insulin pen
Record review of the facility's policy titled Obtaining a Fingerstick Glucose Level revised on 10/11, indicated Always ensure that the blood glucose meters intended for reuse are cleaned and disinfected between resident uses .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure the resident's medical record included documentation that indicates the resident either received the influenza and the pneumococcal immunizations or did not receive the immunizations due to medical contraindications or refusals for 4 of 20 residents reviewed for immunizations. (Resident #'s 32, 60, 119, and 120)
The facility failed to ensure Resident #32's medical record contained evidence of the pneumococcal immunization or declination.
The facility failed to ensure Resident #60's medical record contained evidence of the influenza and the pneumococcal immunization or declination.
The facility failed to ensure Resident #119's medical record contained evidence of the influenza and the pneumococcal immunization or declination.
The facility failed to ensure Resident #120's medical record contained evidence of the influenza and the pneumococcal immunization or declination.
These failures could place residents at risk for contracting a viral disease that could spread through the facility and cause respiratory complications, and potential adverse health outcomes.
Findings included:
1)Record review of a face sheet dated 1/13/2023 indicated Resident #32 was a [AGE] year-old female who admitted on [DATE] with the diagnosis of stroke, pain, seizures, dysphagia, and malnutrition.
Record review of an Annual MDS dated [DATE] indicated Resident #32 sometimes understands and was sometimes understood. Resident #32's MDS indicated she had the inability to recall. The MDS in Section O0300 indicated she was offered the pneumococcal vaccination and declined.
Record review of the comprehensive care plan dated 04/08/2021 and revised on 05/03/2021 indicated Resident #32 required assistance with her ADLs including bed mobility. The interventions included to have the assistance of one to two staff for bed mobility.
Record review of Resident #32's immunization report dated 01/13/2023 indicated she had not had the pneumococcal vaccination or declined the vaccination.
2) Record review of Resident #60's face sheet dated 01/13/2023 indicated he was an [AGE] year-old-male who admitted on [DATE] with the diagnoses of anemia, anxiety disorder, and Post-Traumatic Stress Disorder.
Record review of Resident #60's physician's orders dated 01/13/2023 indicated he had an order for the administration of the influenza vaccine to be administered annually and the pneumonia vaccine to be administered every 5 years dated 06/21/2022.
Record review of an Immunization Report for Resident #60 indicated there were no immunizations administered or declined for influenza or pneumonia.
3) Record review of a face sheet dated 01/11/2023 indicated Resident #119 was an [AGE] year-old female who admitted on [DATE] with the diagnosis of joint replacement surgery, fracture of the right femur, and presence of an artificial right hip joint.
Record review of an Immunization Report for Resident #119 indicated there were no immunizations administered or declined for influenza or pneumonia.
4) Record review of a face sheet dated 01/12/2023 indicated Resident #120 was a [AGE] year-old male who admitted on [DATE] with the diagnosis of bacterial peritonitis (infection of the peritoneal cavity), severe sepsis with septic shock (a life-threatening complication of infection), and an unstageable pressure ulcer of the sacral region (low back).
Record review of an Immunization Report for Resident #120 indicated there were no immunizations administered or declined for influenza or pneumonia.
Record review of the CMS-672 completed on 01/09/2023 indicated the census was 80. In section G F144 indicated 31 residents received the influenza immunization and F144 19 residents received the pneumococcal vaccine.
During an interview on 01/12/2023 at 2:24 p.m., the ADON A (Infection Preventionist) said she had been informing the DON the vaccination program was not in place. ADON A said she had informed the DON this was not in line with the infection control policy. ADON A said there were no systems in place, and she had voiced her concerns to the DON.
During an interview on 01/17/2023 at 2:39 p.m., the Regional Nurse Consultant said she could not answer why Resident #'s 32, 60, 119, and 120 were not provided the flu and/or the pneumonia vaccine upon admission. The Regional Nurse Consultant said this should be reviewed during the admission process and the admitting nurse was responsible. The Infection Preventionist was also responsible and the ADON would follow up to ensure the vaccinations were offered. The Regional Nurse Consultant said the residents could become ill with the flu or pneumonia virus when not vaccinated.
During an interview on 01/17/2023 at 4:55 p.m., the Interim Administrator said the vaccinations should be offered upon admission. The Interim Administrator said missing the vaccinations could cause health issues.
Record review of a Vaccination of Residents policy dated October 2019 indicated all residents will be offered vaccines that aid in preventing infectious diseases unless the vaccine is medically contraindicated, or the resident has already been vaccinated. 1. Prior to receiving vaccinations, the resident or legal representative will be provided information and education regarding the benefits and potential side effects of the vaccinations. 2. Provision of such education shall be documented in the resident's medical record. 3. All new residents shall be assessed for current vaccination status upon admission. 5. If vaccinations are refused, the refusal shall be documented in the resident's medical record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, included the appropriate accessory and cautionary instructions, and the expiration date when applicable for 2 of the 3 medication carts reviewed for medications storage. (Halls 5/3 nurse's cart and halls 1/2 nurse/medication cart)
1. The facility failed to ensure Resident #63's two Lantus pens and one Humalog pen were dated when opened on halls 5/3 nurse's cart.
2. the facility failed to ensure Resident # 53's Lantus vial was dated when opened on hall 5/3 nurse's cart.
3. The facility failed to remove Resident #46's expired tramadol from the halls 5/3 nurse's cart.
4. The facility failed to remove Resident #40's expired fluticasone nasal spray from halls 1/2 nurse/medication cart.
5. The facility failed to remove the expired hemorrhoidal ointment from the halls 1/2 nurse/medication cart.
These failures could place residents at risk for not receiving the therapeutic benefit of medications, adverse reactions to medications, or harm by indigestion.
Findings include:
1. Record review of Resident #63's face sheet, dated 01/22/23, indicated a [AGE] year old male who was admitted to the facility on [DATE] with diagnoses which included type 2 diabetes mellitus (chronic condition that affects the way the body processes blood sugar), chronic obstructive pulmonary disease (chronic inflammatory lung disease that causes obstructed airflow from the lungs), hypertension (force of the blood against the artery walls is too high), chronic systolic congestive heart failure (chronic condition in which the heart doesn't pump blood as well as it should).
Record review of Resident #63's admission MDS, dated [DATE], indicated he was understood and understood others. Resident #63 had a BIMS score of 12, which indicated he had mildly impaired cognition. Resident #63 required supervision with all ADLs. Section N0350, Insulin, indicated Resident #63 received insulin injections seven times during the last seven days.
Record review of Resident #63's order summary report, dated 01/11/23, indicated he had the following orders:
*Humalog solution 100 unit/ml (insulin lispro) inject 33 units subcutaneously before meals and at bedtime related to Type 2 diabetes mellitus with an order date of 01/06/23.
*Lantus Solostar solution pen-injector 100unit/ml (insulin gargline) inject 90 units subcutaneously two times a day for diabetes with an order date of 10/01/22.
During an observation on 01/10/23 at 2:48 PM, the halls 5/3 nurse's cart revealed Resident #63's two Lantus insulin pens and one Humalog pen were opened and did not have an opened date on them.
2. Record review of Resident #53's face sheet, dated 01/11/23, indicated a [AGE] year old female who was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included type 2 diabetes mellitus (chronic condition that affects the way the body processes blood sugar), weakness, hypertension (force of the blood against the artery walls is too high), depression (mood disorder that causes persistent feeling of sadness or loss of interest), and dementia (memory loss).
Record review of the Resident #53's annual MDS assessment, dated 11/1/22, indicated she was understood and understood others. Resident #53's had a BIMS score of 10 which indicated she had moderately impaired cognition. Resident #53 required limited assistance with bathing and supervision with all other ADLs. Section N0350, Insulin, indicated Resident #53 received insulin injections seven times during the last seven days.
Record review of Resident #53's order summary report, dated 01/11/23, indicated she had an order for Lantus solution 100 unit/ml (insulin glargine) inject 90 units subcutaneously at bedtime for diabetes with an order date of 09/11/22.
During an observation on 01/10/23 at 2:48 PM, halls 5/3 nurse's cart revealed Resident #53's Lantus vial was opened and did not have an opened date.
3. Record review of Resident #46's face sheet, dated 01/11/23, indicated an [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included dementia (memory loss), anxiety, depression (mood disorder that causes persistent feeling of sadness or loss of interest), and hypertension (force of the blood against the artery walls is too high).
Record review of Resident #46's quarterly MDS dated [DATE] indicated she was usually understood and usually understood others. Resident #46's BIMS score was a five, which indicated she had severe cognitive impairment. Resident #46 required extensive assistance with bed mobility, transfer, locomotion, toileting, and personal hygiene. Resident #46 was totally dependent on dressing and bathing. Section J0100, pain management, did not indicate resident received scheduled pain medication or as needed pain medication within the last 5 days. Section J0300, Pain presence, indicated Resident #46 did not have pain within the last 5 days. Section N0410, medications received, did not indicate Resident #46 received opioid medication within the last seven days.
Record review of Resident #46's order summary report dated 01/11/23 indicated an order for tramadol 50mg tablet give 50mg by mouth every six hours as needed for moderate-severe pain with an order date of 06/13/22.
During an observation and interview on 01/10/23 at 2:48 PM, halls 5/3 nurse's cart revealed Resident #46's expired tramadol with an expiration date of 10/26/22. LVN H said the insulin was not good after 30 days of being out of the refrigerator. LVN H said by not knowing when the insulin was opened, the medication could not be sufficient for the blood sugar. LVN H said it was nurses' responsibility to make sure the insulin was dated when opened and to check the cart for expired medications. LVN H said the carts should be checked daily.
4. Record review of Resident #40's face sheet dated 01/11/23 indicated an [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses which included unspecified protein calorie malnutrition (disorder caused by a lack of proper nutrition or an inability to absorb nutrients from food), weakness, anxiety, and hypertension (force of the blood against the artery walls is too high).
Record review of Resident #40's quarterly MDS dated [DATE] indicated she was understood and understood others. Resident #40 had a BIMS score of 12, which indicated, mildly impaired cognition. Resident #40 was totally dependent on bathing and required supervision for all other ADLs.
Record review of Resident #40's order summary report dated 01/11/23 indicated an order for Flonase suspension 50mcg/act (fluticasone propionate) two sprays in each nostril every 24 hours as needed for allergies with an order date of 11/23/21.
During an observation and interview on 01/10/23 at 3:10 PM, hall 1/2 nurse/medication cart revealed Resident #40's expired fluticasone nasal spray with the expiration date of 12/21/22 and an over-the-counter expired hemorrhoidal ointment with the expiration date of 08/21. LVN L said the cart should be checked at least monthly for expired medications. LVN L said the resident could be at risk for receiving an expired medication and it would not be effective. LVN L said expired medications are placed in the discontinued box in the medication room.
During an interview on 01/17/23 at 12:51 PM, ADON A said she expected the carts to be checked weekly for expired medications. ADON A said expired medications should be taken off the cart and placed in the discontinued bin in the medication room. ADON A said she expected the nurse to date the insulin when first opened because some insulins are only good for 28 days. ADON A said by dating the insulin they will know when it needed to be replaced. ADON A said the resident would be at risk for receiving an expired medication and not be effective.
During an interview on 01/17/23 at 1:57 PM, the RNC said she expected the expired medications to be pulled off the cart and destroyed. The RNC said the nurses were responsible of ensuring there were no expired medications on the cart by checking the medications during their medication pass. The RNC said she expected the nurse who first opens the insulin to date it when opened. The RNC said resident was at risk for receiving an insulin that was not effective.
During an interview on 01/17 at 5:00 PM, the Interim Administrator said he expected expired medications to be pulled from the carts. The Interim Administrator said the DON was responsible of making sure there were no expired medications on the carts. The Interim Administrator said he expected the insulin to be dated when first opened. The Interim Administrator said by having expired medications on the cart could place the resident at risk for receiving an expired medication resulting in ineffective results.
Record review of the facility's policy titled Medication Storage dated 12/01/22, indicated .unused medications: The pharmacy and all medication rooms are routinely inspected by the consultant pharmacist for discontinued, outdated, defective, or deteriorated medications, with worn, illegible or missing labels. These medications are destroyed win accordance with our Destruction of unused drugs policy .
Record review of the facility's policy titled Destruction of Unused Drugs dated 07/01/22, indicated .All Unused, contaminated, or expired prescription drugs shall be disposed of in accordance with state laws and regulations unused, unwanted, and non-returnable medications should be removed from their storage area and secured until destroyed .
Record review of the facility's policy titled Multi-dose Vials dated 09/01/22 indicated .multi-dose vials will be relabeled with a beyond use date, 28 days after vial is opened or punctured (unless otherwise specified by the manufacturer). Follow the manufacturer's label to verify the beyond use date as some multi-dose vials expire sooner than 28 days after opening unit manager will perform random checks of opened multi-dose vials for appropriate dating.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Record review of Resident #32's face sheet, dated [DATE], indicated a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses which included stroke (occurs when something blocks blood supply to part of the brain or when a blood vessel in the brain bursts), pain, seizures (a sudden, uncontrolled electrical disturbance in the brain), dysphagia (difficulty swallowing), and malnutrition (lack of proper nutrition).
Record review of the comprehensive care plan, dated [DATE] and revised on [DATE], indicated Resident #32 required assistance with her ADLs which included bed mobility. The interventions included to have the assistance of one to two staff for bed mobility.
Record review of a skin assessment, dated [DATE], indicated Resident #32 had no alterations in skin integrity.
Record review of an incident report, dated [DATE] at 6:31 a.m., indicated Resident #32 was found by a CNA BB to have a bruise to her right eye. The incident report indicated Resident #32 was unable to explain the incident.
Record review of a skin assessment, dated [DATE] at 6:44 p.m., indicated Resident #32 had a bruised right eye that appeared sometime during the night. The comments mentioned Resident #32 did not have a fall but possibly occurred during sleeping in bed.
During an observation on [DATE] at 12:55 p.m., Resident #32 was sitting in the dining room. Resident #32 was noted to have dark black discoloration to her right eye.
During an interview on [DATE] at 1:00 p.m., CNA BB revealed she was the nurse aide for Resident #32. CNA BB said she left at 6:00 p.m. last night and there was not any bruising to Resident #32's right eye. CNA BB said Resident #32 was not combative with care. CNA BB said she reported Resident #32's right eye bruising to the DON and the charge nurses when her shift started at 6am.
During an interview on [DATE] at 1:05 p.m., LVN H said when she arrived this morning CNA BB reported Resident # 32 right eye bruising. LVN H said the right eye bruising was reported around 6am to the DON, the family member, and the physician.
During an interview on [DATE] at 1:30 p.m., the Administrator said she had just become aware of Resident #32's black eye. The Administrator said neither the nurses nor the DON made her aware of Resident #32's black right eye. The Administrator said she was the abuse coordinator and an injury of unknown origin required reporting within two hours. The administrator said because she was unaware of black eyes until now she would report to HHSC.
Based on observation , interviews and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse or resulted in serious bodily injury, or not later than 24 hours if the events that caused the allegation did not involve abuse and did not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with state law through established procedures for 3 of 20 residents (Residents #32, #271, and #221) reviewed for abuse.
1. The facility did not thoroughly investigate or report to the state survey agency when Resident #221 reported allegations of abuse of being pulled out of bed by a staff member.
2. The facility failed to report Resident #271's allegation of neglect timely to HHS.
3. The facility failed to report Resident #32's black eye, an injury of unknown origin, timely to HHS.
This failure could place the residents at risk for further potential abuse due to unreported and uninvestigated allegations of abuse, and neglect.
Findings include:
1. Record review of Resident #221's face sheet, dated [DATE], revealed, a 61- year- old male who was admitted to the facility on [DATE] with diagnoses which included: malignant neoplasm of prostate (another term for a cancerous tumor), secondary malignant neoplasm of bone (cancer that has started in another part of the body and has spread (metastasized) to the bone via the bloodstream or lymph nodes), congestive heart failure (a condition in which the heart has trouble pumping blood through the body), atrial fibrillation (an irregular heartbeat that occurs when the electrical signals in the atria (the two upper chambers of the heart) fire rapidly at the same time), other anxiety disorders (a condition in which a person has excessive worry and feelings of fear, dread, and uneasiness), and other recurrent depressive disorders (a disorder characterized by repeated episodes of depression, the current episode being severe with psychotic symptoms and with no previous episodes of mania). Resident #221 was discharged to the hospital on [DATE] and expired at the hospital.
Record review of Resident #221's admissions MDS assessment, dated [DATE], revealed the resident's BIMS score was 13, which indicated cognition intact. The resident required extensive assistance (staff provide weight bearing support) with two persons physical assistance for bed mobility, and total dependence (full staff performance every time during entire 7-day period) with two persons physical assistance for transfers, dressing and toileting.
Record review of Resident #221's care plan, revised [DATE], revealed Resident #221 had ADL (activities of daily living) functional/rehabilitation potential with a self-care deficit, and an intervention that stated requires staff assistance times one for assist bars and times two to enable self-bed mobility. Resident #221 had a terminal prognosis of prostate cancer, and the intervention was to assess the resident's coping strategies and respect resident wishes, encourage support system of family and friends, and work cooperatively with the hospice team to ensure the resident's spiritual, emotional, intellectual, physical, and social needs were met.
Record review of facility grievance/complaint report, dated [DATE], taken by the Administrator from the Resident #221. Indicated Resident #221 stated staff member drug him off the bed. He stated he had no feeling from his nipple down. Follow up documentation stated the Administrator spoke with staff and determined who the staff member was. The Administrator noted the staff member would be removed from caring for the resident. The resolution stated, staff member moved to remove from care for Resident #221 .
During an interview on [DATE] at 1:11 PM, the Administrator said she had taken the report from Resident #221 back in 11/22 . The Administrator said she filled out a grievance report. The Administrator said Resident #221 told her that a nurse, name unknown, pulled him out of the bed by his feet onto the floor. The Administrator said she spoke with nursing staff and determined who the resident could have been talking about, but when she took the staff member into the room with Resident #221 to ask if this was her, Resident #221 stated no, it is not. The Administrator said she removed that staff member from working with Resident #221 for that shift. She stated she looked for the investigation report she completed but was unable to locate it. She said she would take the tag for not reporting this one. She said she did not report the incident to HHS but after it was reviewed by the survey team, she realized she should have done so. She said it was important to report all allegations of abuse or neglect to HHS to prevent any further potional abuse or neglect. She said the risks to residents for not reporting an allegation like this, was they could continue to be abused or neglected causing potential phsycal and emotional harm.
Record review of the Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating policy, dated [DATE], indicated:
All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state, and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported
1. If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source
is suspected, the suspicion must be reported immediately to the administrator and to other officials
according to state law.
2. The administrator or the individual making the allegation immediately reports his or her suspicion to the
following persons or agencies:
a. The state licensing/certification agency responsible for surveying/licensing the facility.
3. Immediately is defined as: .
a. within two hours of an allegation involving abuse or result in serious bodily injury; or
b. within 24 hours of an allegation that does not involve abuse or result in serious bodily injury .
3. Record review of Resident #271's face sheet, dated [DATE], indicated a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses which included right fibula fracture (break in bone that stabilizes and supports your ankle and lower leg muscle), right tibia (shin bone) fracture, anxiety, depression (mood disorder that causes persistent feeling of sadness or loss of interest), and dementia (memory loss).
Record review of Resident #271's admission MDS, dated [DATE], indicated Resident #271 was understood and understood others. Resident #271 had a BIMS score of 12, which indicated she had mildly impaired cognition. Resident #271 required extensive assistance with two-person assist for bed mobility, transfers, locomotion, dressing, eating, toileting, and personal hygiene. Resident #271 was totally dependent on bathing. Section E, Behavior, did not indicate Resident #271 had any behaviors.
Record review of the comprehensive care plan, dated [DATE], indicated Resident #271 had impaired cognition, was at risk for falls and required assistance with ADLs. The care plan did not have any goals or interventions in place.
Record review of the grievance/complaint report, dated [DATE], indicated Resident #271 asked to go to the restroom around 7:30 PM- 8:00 PM on [DATE]. Resident #271 told the Administrator, the aides helped her put her pajamas on, assisted her to bed, she then wet herself and several hours later they changed her. The report indicated action taken was the grievance report and education with the aide.
Record review of intake #400136 in salesforce indicated a neglect allegation was reported to the state agency on [DATE] at 07:12 AM.
During an interview on [DATE] at 05:21 PM, Resident #271 said on [DATE] around 07:30 PM, CNA Z came to answer the call light. Resident #271 said she asked CNA Z to assist her to the bathroom and CNA Z said No, there is no one here to help me get you up. Resident #271 said she had to urinate in her disposable brief. Resident #271 said by CNA Z not assisting her to the bathroom, it made her feel belittled. Resident #271 said she had not reported the incident to anyone in the facility.
During an interview on [DATE] at 12:48 PM, the Administrator said she spoke to Resident #271 on [DATE]. The Administrator said she filled out a grievance report. The Administrator said Resident #271 told her CNA Z did assist her in putting her pajamas on and did change her several hours later. The Administrator said she spoke with CNA Z, and CNA Z had reported to her that she did assist Resident #271 to the bathroom with the help of CNA W. The Administrator said Resident #271 did pressed her call light again that night while CNA W was on break and CNA Z did not take her to the restroom at that time because she didn't think to ask the nurse for help. The Administrator said she did not feel the incident required to be reported during her initial phase of investigation.
During an interview on [DATE] at 3:40 PM, the Administrator said a grievance was done on Resident #271's complaint. The Administrator said it was in her policy that it was at her discretion to report or not report to HHSC.
During an interview on [DATE] at 1:57 PM, the RNC said she expected an allegation of neglect be reported immediately to the abuse coordinator, nurse, and DON. The RNC said the incident should be thoroughly investigated and be reported the state agency within 24 hours.
Record review of the Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating policy, dated [DATE], indicated:
All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation
of resident property are reported to local, state, and federal agencies (as required by current regulations) and
thoroughly investigated by facility management. Findings of all investigations are documented and reported.
1. If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source
is suspected, the suspicion must be reported immediately to the administrator and to other officials
according to state law.
2. The administrator or the individual making the allegation immediately reports his or her suspicion to the
following persons or agencies:
a. The state licensing/certification agency responsible for surveying/licensing the facility.
.
a. within two hours of an allegation involving abuse or result in serious bodily injury; or
b. within 24 hours of an allegation that does not involve abuse or result in serious bodily injury.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Record review of a Resident #271's face sheet, dated 01/13/23, indicated a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses which included right fibula fracture (break in bone that stabilizes and supports your ankle and lower leg muscle), right tibia (shin bone) fracture, anxiety, depression (mood disorder that causes persistent feeling of sadness or loss of interest), and dementia (memory loss).
Record review of Resident #271's admission MDS, dated [DATE], indicated Resident #271 was understood and understood others. Resident #271 had a BIMS score of 12, which indicated she had mildly impaired cognition. Resident #271 required extensive assistance with two-person assist for bed mobility, transfers, locomotion, dressing, eating, toileting, and personal hygiene. Resident #271 was totally dependent on bathing.
Record review of the electronic physician orders indicated Resident #271 had 39 queued orders. The following orders showed queued status being incomplete with a queued date of 12/20/22:
-*ST (Speech Therapy) to evaluate and treat
*PT (Physical Therapy)/ST (Speech Therapy) and OT (Occupational Therapy) to evaluate and treat as indicated
*May receive the flu vaccine 0.5 milliliters intramuscular every year as available
*May receive pneumonia vaccine 0.5 milliters intramuscular every 5 years
*May use generic drug product unless otherwise specified by physician
-*Admit to Skilled Part A services for diagnosis of:
-*Admit to long-term care
-*I have reviewed and concur with the current IDT (Interdisciplinary Team) care plan
-*Family/RP (responsible party) aware of resident's medical conditions and current plan of care
-*Resident has been informed of diagnosis and medical condition unless contradicted
-*May alter medication by crushing, opening capsules, or administering and/or cocktail all together in food/liquid at one time per medical director order due to inability to take all crushed medications individually at every shift unable to tolerate process; becomes tired/full from taking multiple crushed medications individually
-* The resident is free from communicable diseases
-*Observation of pain-observe every shift. If pain present, complete pain progress note and treat trying non-pharmacologic interventions prior to medicating if appropriate. Document in the progress notes. Patient stated tolerable pain level: (specify)
-*Pressure relieving cushion to wheelchair/recliner/gerichair
-*I hereby certify that this resident requires nursing home care for 180 days
-*Vital Signs every month
-*Tuberculin solution 5 unit/0.1milliliter
-*Read Tuberculosis results
-*Codes for nonpharmaceutical interventions: 0=none, 1=rest, 2=massage, 3=positioning, 4=heat/warm, 5= Range of motion/mobility, 6= Topical cream/ointments, 7= relaxation techniques, 8= therapy, 9= diversion activities, 10=social interaction, 11= redirection, 12= medication type code for interventions used prior to giving as needed (pain/antianxiety, sedative/hypnotic, antipsychotic) medication.
-*Behavior/mood monitoring:0= none, 1= physical, 2= verbal, 3 = pacing/wandering, 4= disrobing, 5= hoarding items, 6= suspicious for distrustful of others/delusion, 7= Hallucinations, 8=refusal to cooperate in routine care, 9= inattentions (difficulty focusing, easily distracted) 10= taking belongings or food items from others 11= sadness/crying. Document intervention in the progress note for any code other than '0'
-*May go out on pass with meds
-*May use generic equivalent medication
-*I certify these orders are valid for 60 days unless otherwise stated
-*I hereby certify that this resident requires/continues to require nursing facility care for 180 days.
-*May crush meds or open capsules as needed unless contraindicated
-*Pneumonia vaccination unless contraindicated
-*May receive influenza vaccination annually
-*Offer substitute if resident east less than 50 percent
-*Tuberculosis 2 step screen on admission unless contraindicated
-*May have pressure reducing mattress
-*May attend activities of choice as tolerated
-*Family/Responsible party is aware of medical condition
-*Pain assessment every shift using PAINAD /Dementia scare 0-10
-*Admit to (facility) under the care of (Doctor)
-*Physician agrees with plan of care
*Pain assessment before and after as needed medications: utilize 0-10 PAINAD. Document pain scare results, vital signs, interventions, outcomes, in progress notes. Utilize the non-pharmacological pain treatment code: P-position, R- Relaxation, H-Heat, C-Cold, M Music, O-other
-*OT (Occupational Therapy) may evaluate and treat as indicated
-*ST (Speech Therapy) may evaluate and treat as indicated
-*Baseline temperature every shift x 3 than average *put average temperature under vital as the baseline temperature .
Resident #271 did not have a baseline care completed.
3. Record review of Resident #54's face sheet, dated 1/13/23, revealed the resident was a [AGE] year old female who was admitted to the facility on [DATE] (readmission [DATE]) with diagnoses which included: chronic obstructive pulmonary disease (a chronic inflammatory lung disease that causes obstructed airflow from the lungs), unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, or anxiety (a mental disorder in which a person loses the ability to think, remember, learn, make decisions, and solve problems), disorder of the arteries and arterioles (a buildup of fatty deposits in the arteries), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), anxiety disorder (a condition in which a person has excessive worry and feelings of fear, dread, and uneasiness), hallucinations (an experience involving the apparent perception of something not present), and dependence on supplemental oxygen.
Record review of Resident #54's annual Quarterly MDS assessment, dated 12/29/22, revealed the resident's BIMS score was 4, which indicated severe cognitive impairment. The resident required total dependence with locomotion off unit, extensive assistance with transfer, dressing, toilet use, and personal hygiene, and supervision for the tasks of locomotion on unit and eating.
Record review of pending orders from electronic medical record for Resident #54 revealed there were 34 pending orders, dated 12/27/21, which included but not limited to, physician agrees to care plan, admit to skilled part A services, pain assessment before and after as needed medications, offer substitute if resident eats less than 50%, tuberculin purified protein derivative solution, hospice, may receive flu vaccine, may receive pneumonia, and TB step screen on admission.
Record review of Resident #54's, undated, care plan, revealed Resident #54 had risk for alteration in comfort and pain. The interventions for this focus were administer pain medication as ordered by physician and assess effectiveness, comprehensive pain assessment upon admission, re-admission, and change of condition, and review pain medication use to determine if changes in treatment. Resident #54 had been placed on palliative plan for care with diagnosis of chronic pulmonary disease and Heart to Heart Hospice will provide services. The interventions for this focus are administer medications as prescribed by physician for pain, administer oxygen as prescribed by physician for anxiety, ensure resident is comfortable at all times, and notify hospice nurse if any decline in resident's condition.
During observation and interview on 1/9/23 at 09:44 AM with Resident #54, she said she required assistance from staff with most her tasks. She said she could not remember the last time she was seen by a physician at the facility. She said she received the care she was supposed to receive from what she was told. She was not able to discuss if she felt she missed any vital care areas or medical needs. Resident #54 said she has been at the facility to more than two years, she did not know which vaccinations she has received or not.
Record review of the facility's policy titled admission Notes dated 09/12, indicated .Preliminary resident information shall be documented upon a resident admission to the facility. 1. When a resident is admitted to the nursing unit, the admitting nurse must document the following information (as each may apply) in the nurse's notes, admission form, or other appropriate place, as designated by facility protocol: h. the time the physician's orders were received and verified
Record review of the facility's policy titled admission Assessment and Follow Up: role of the nurse dated 09/12, indicated . The purpose of this procedure is to gather information about the resident's .for the purpose of managing the resident 11. reconcile the list of medications from the medication history, admitting orders, the previous MAR (if available) and the discharge summary from the previous institution, according to established procedures .
Based on interview, and record review the facility failed to ensure residents had physician orders for the resident's immediate care for 4 or 20 residents (Residents #41, #54, #220 and #271) reviewed for admission orders.
The facility did not implement the physician orders in the que (pending) for (Residents #41, #54, #220 and #271).
This failure could place residents at risk for not receiving appropriate care and treatment services.
Findings include:
1. Record review of Resident #41's computerized clinical records, under the section of orders, revealed Resident #41 had 12 orders showing incomplete status since 10/14/2022. The orders included:
-*Admit to Long term care
-*I have reviewed and concur with the current IDT care plan
-*Family/RP aware of resident's medical conditions and current plan of care
-*Resident has been informed of DX and medical condition unless contraindicated
-*May alter medication by crushing, opening capsules, or administering and/or cocktail all together in food/liquid at one time per MD order due to inability to take all crushed medications individually at every shift unable to tolerate process; becomes tired/full of taking multiple crushed meds individually.
-*This resident is free from communicable diseases
-*Pressure relieving cushion to wheelchair/recliner/Geri chair
-*I hereby certify that this resident requires NH care for 180 days
-*Vital signs Q month
-*Tuberculin solution 5 unit/0.1milliliter
-*Read TB results
-*Behavior/Mood Monitoring 0=none, 1= physical, 2=Verbal, 3=Pacing, 4=Disrobing, 5=Hoarding of items, 6=Suspicious or distrustful of others/Delusions, 7=Hallucinations, 8=Refusal to cooperate in routine care, 9=Inattention (difficulty focusing, easily distracted) 10= Taking belongings or food items from others, 11= sadness/crying. Document intervention in PN for any code other than 0.
Record review of Resident #41's face sheet, dated 01/13/2023, indicated a [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE] with the diagnoses which included sepsis (severe blood infection), malnutrition (lack of sufficient nutrients in the body) , intellectual disabilities (below average intelligence), and high blood pressure (a condition in which the force of the blood against the artery wall is too high).
Resident #41 did not have a baseline care plan completed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Record review of Resident #271's face sheet, dated 01/13/23, indicated a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses which included right fibula fracture (break in bone that stabilizes and supports your ankle and lower leg muscle), right tibia (shin bone) fracture, anxiety, depression (mood disorder that causes persistent feeling of sadness or loss of interest), and dementia (memory loss).
Record review of the Resident #271's admission MDS, dated [DATE], indicated Resident #271 was understood and understood others. Resident #271 had a BIMS score of 12, which indicated she had mildly impaired cognition. Resident #271 required extensive assistance with bed mobility, transfers, locomotion, dressing, eating, toileting, and personal hygiene. Resident #271 was totally dependent on bathing. Section M, skin conditions, indicated the resident did not have surgical wounds checked.
Record review of the order summary report, dated 01/11/23, did not reveal an order for Resident #271's diet, code status or an order to monitor the staples to her right leg.
Record review of the admission baseline care plan for Resident #271, dated 01/11/23, revealed the only areas completed were the following sections: A 1. indicated resident required assistance with ADLS related to her fractures., 2a. Resident required extensive assistance with bed mobility and 2b. Resident required extensive assistance with transfers. All other sections on the baseline care plan were not completed.
During an observation and interview on 01/09/23, Resident #271 had staples noted to the right upper leg and right inner lower leg. Resident #271 said she admitted to the facility with the staples already in place.
During an interview on 01/17/23 at 12:51 PM, ADON A said she was the ADON assigned to Resident #220 and Resident #221 was responsible for completing the baseline care plan within 48 hours of admission. ADON A said the risks of not having the baseline care plan completed timely could impact the resident by not receiving the care they require.
During an interview on 01/17/23 at 1:57 PM, the RNC said she expected the baseline care plan be completed immediately upon admission. The RNC said administrative nurses were responsible for ensuring the baseline care plans were completed. The RNC said by not completing the baseline care plan timely the nurses and staff would not know how to care for the resident.
During an interview on 01/17/23 at 04:55 PM, the Interim Administrator said he expected the baseline care plan to be completed within 48 hours. The Interim Administrator said by not completing the baseline care plan timely they would not know how to care for the resident . The Interim Administrator said the DON and ADONs were for ensuring the baseline care plans were completed timely.
Record review of the facility policy titled Care Plans- Baseline, revised on March 2022, indicated .a baseline plan of care to meet the resident's immediate health and safety needs is developed for each resident within forty-eight (48) hours of admission .The baseline care plan includes instructions needed to provide effective, person centered care of the resident that meet professional standards of quality care and must include the minimum healthcare information necessary to properly care for the resident including but not limited to the following: initial goals based on admission orders and discussion with the resident/representative; physician orders; dietary orders; therapy services; social services, and PASARR recommendation, if applicable
Based on observation, interviews and record review, the facility failed to develop and implement a baseline care plan for each resident that included the instructions needed to provide effective and person-centered care of the resident that met professional standards of quality care for 2 of 16 resident reviewed (Resident #220 and #271) reviewed for baseline care plans.
1. The facility failed to ensure Resident #220 had a base line care plan completed timely.
2. The facility failed to ensure Resident #271's had a baseline care plan completed timely.
These deficient practices could place residents at risk of not receiving care or attention needed.
Findings include:
1. Record review of Resident #220's face sheet, dated 1/13/23, revealed the resident was a [AGE] year old male, who admitted to the facility on [DATE] with diagnoses which included: chronic obstructive pulmonary disease (a chronic inflammatory lung disease that causes obstructed airflow from the lungs), sepsis (the body's extreme response to an infection), Type 2 diabetes mellitus without complications (an impairment in the way the body regulates and uses sugar (glucose) as a fuel), peroration of intestine (a loss of continuity of the bowel wall), paroxysmal atrial fibrillation (terminates spontaneously or with intervention within seven days of onset), heart failure (a condition that develops when your heart doesn't pump enough blood for your body's needs), and acute cystitis without hematuria (a sudden inflammation of the urinary bladder).
Record review of Resident #220's Quarterly MDS assessment was not completed and was not due according to admit date .
Record review of Resident #220's medical record revealed it was missing a baseline care plan. No comprehensive care plan was due according to admit date .
During an interview on 01/17/23 at 12:51 PM, ADON A said the facility has two ADONs and they are each responsible for a certain number of residents. She said they are divided by odd and even room numbers and that was how they determined who was responsible for completing the baseline care plan for a particular resident. She said baseline care plans were to be completed within 48 hours of a resident's admission to the facility. ADON A said the risks of not having the baseline care plan completed timely could impact the resident by not receiving the care they require.
During an interview on 01/17/23 at 1:57 PM, the RNC said she expected the baseline care plan be completed immediately upon admission. The RNC said administrative nurses were responsible for ensuring the baseline care plans were completed. The RNC said by not completing the baseline care plan timely the nurses and staff will would not know how to care for the resident.
During an interview on 01/17/23 at 04:55 PM, the Interim Administrator said he expected the baseline care plan to be completed within 48 hours. The Interim Administrator said by not completing the baseline care plan timely they would not know how to care for the resident. He said the ultimate responsiblity to ensure a baseline care plan is completed was the DON but that tasks were assigned to the ADONs according to odd and even room numbers.
Record review of the facility policy titled Care Plans- Baseline, revised on March 2022, indicated .a baseline plan of care to meet the resident's immediate health and safety needs is developed for each resident within forty-eight (48) hours of admission .The baseline care plan includes instructions needed to provide effective, person centered care of the resident that meet professional standards of quality care and must include the minimum healthcare information necessary to properly care for the resident including but not limited to the following: initial goals based on admission orders and discussion with the resident/representative; physician orders; dietary orders; therapy services; social services, and PASARR recommendation, if applicable

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Record review of a face sheet dated 01/11/2023 indicated Resident #119 was an [AGE] year-old female who admitted on [DATE] with the diagnosis of joint replacement surgery, fracture of the right femur, and presence of an artificial right hip joint.
Record review of Resident #119's admission assessment dated [DATE] indicated Resident #119 had a right trochanteric (hip) surgical incision. The surgical wound was not measured nor was there documentation indicating how many staples were present.
Record review of a comprehensive care plan dated 01/10/2023 and revised on 01/11/2023 indicated Resident #119 had a hip fracture from a fall at her home. The goal was Resident #119 would return to the prior level of function with the interventions of monitor, document, and report to the physician hip fracture complications. The comprehensive care plan did not mention the right hip surgical incision.
During an observation and interview on 1/10/2023 Resident #119 said she was worried about her surgical incision to her hip having the staples remaining so long. Resident #119 said she was not sure when she will see the surgeon.
During an interview on 01/17/2023 at 2:39 p.m., the Regional Corporate Nurse indicated she would expect the comprehensive care plan to be current and reflect the resident's current status. The Regional Corporate Nurse indicated the MDS nurse was responsible for ensuring the care plan was accurate and current. The Regional Corporate Nurse said the resident's care was discussed in morning meeting, and the MDS reads the resident's notes to ensure the care plan was accurate. The Regional Nurse Coordinator said the care plan should reflect a picture of the care a resident requires.
During an interview on 01/17/2023 at 4:55 p.m., the Interim Administrator said the care plan should represent the care needs of the resident.
During an interview on 01/17/2023 at 5:00 p.m., the CEO said the care plan should read as though it was a picture of the resident. The CEO said the intradisciplinary team was responsible for the care plans. The CEO said the care plan reflects the care a resident needs.
3. Record review of Resident #49's electronic face sheet, dated 01/13/23, revealed a [AGE] year old female who was admitted to the facility on [DATE] with diagnoses which included Respiratory failure (a serious condition that makes it difficult to breathe on your own), gastrostomy status (an opening into the stomach from the abdominal wall, made surgically for the introduction of food), anxiety (what we feel when we are worried, tense or afraid), high blood pressure(elevated blood pressure), and stroke(occurs when something blocks blood supply to part of the brain or when a blood vessel in the brain bursts).
Record review of Resident #49's quarterly MDS assessment, dated 01/04/23, revealed under Section B, Hearing, Speech, and Vision, she was coded as a 3 indicated Resident #49 rarely understands and was rarely understood by others. Section C, Cognitive Patterns, under section C0700 indicated she has short term memory loss, C0800 indicated long term memory problems, and C0100 coded as a 3 indicating Resident #49 had severely impaired decision making. Section G, Function Status under section G0110 indicated she required total assist with bed mobility, personal hygiene, dressing, bathing, and eating.
Record review of Resident #49's care plan did not reveal anything related to a left thumb stage 2 pressure injury noted on 01/02/23.
Record review of Resident #49's nurses notes did not reveal any charting about a left thumb stage 2 pressure injury identified on 01/02/23 until 01/12/23.
Record review of Resident #49's physicians orders, dated 01/13/23, revealed an order dated 01/11/23 to clean area to left thumb with wound cleanser apply collagen and dry dressing. Change every day and as needed.
During an interview on 01/17/23 at 2:06 p.m., the RNC said care plans should be current of resident status. The RNC said if the care plan was not done, staff would not have a good picture of the resident's care. The RNC said the MDS nurse was responsible to update all care plans.
During an interview on 01/17/23 at 4:36 p.m., The MDS nurse said she did not update Resident #49's care plan because she did not receive any new order about the left thumb; she was unaware to update care plan. The MDS nurse said it is important to update care plans as soon as possible to reflex care of the resident.
During an interview on 01/17/23 at 5:00 p.m., the interim administrator said the MDS nurse was responsible to update the care plan. The interim administrator said the care plan should be representing the resident's whole picture of care.
Based on interviews and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes that met a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 4 of 16 resident reviewed (Residents #57, #119, #49, and #271) for care plans.
1. The facility failed to ensure the comprehensive care plan included goals and interventions for the care of Residents #271 and #57.
2. The facility failed to update Resident # 49's care plan for her left thumb stage 2 pressure injury.
3. The facility did not care plan Resident #119's surgical incision with 29 staples to her right hip.
These deficient practices could place residents at risk of not having their individualized needs met, a decline in their quality of care and life, risk for pressure wounds and unwanted pain.
Findings include:
1. Record review of Resident #271's face sheet, dated 01/13/23, indicated Resident #271 was a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses of right fibula fracture (break in bone that stabilizes and supports your ankle and lower leg muscle), right tibia (shin bone) fracture, anxiety, depression (mood disorder that causes persistent feeling of sadness or loss of interest), and dementia (memory loss).
Record review of Resident #271's admission MDS, dated [DATE], indicated Resident #271 was understood and understood others. Resident #271 had a BIMS score of 12, which indicated she had mildly impaired cognition. Resident #271 required extensive assistance with two-person assist for bed mobility, transfers, locomotion, dressing, eating, toileting, and personal hygiene. Resident #271 was totally dependent on bathing. Section J for, health conditions, indicated Resident #271 had occasional pain and had repair fractures of the pelvis, hip, leg, knee, or ankle checked. Section M, skin conditions, indicated Resident #271 was at risk for developing pressure ulcers or injuries and did not have surgical wounds checked. Section V, Care Area Assessment (CAA) Summary, had the following areas checked and should be care planned on the comprehensive care plan:
*Cognitive loss/dementia
* Communication
* ADL functional/rehabilitation potential
*Urinary incontinence
*Psychosocial well being
*Falls
*Nutritional status
*Dehydration/fluid maintenance
*Pressure ulcer
*Psychotropic drug use
*Pain
Record review of the comprehensive care plan, dated 01/10/23, revealed Resident #271 did not have goals or interventions for the following focused areas:
*Risk for circulatory impairment, chest pain, irregular pulse, impaired skin integrity
*Cognitive impairment
*Potential for injury
*Potential for spontaneous fractures related to diagnoses of osteoporosis (bones become weak and brittle)
*Risk for increased abdominal distress, weight loss, and gastrointestinal bleed related to GERD (chronic acid reflux)
* Diagnosis of Hyperlipidemia (excess fats in blood)/Hypercholesterolemia (elevated cholesterol)
*Risk for adverse consequences related to receiving psychotropic medications and multiple med use due to 9 plus or more medications
*Potential for impaired skin integrity
*Assistance with ADLS
2. Record review of Resident #57's face sheet, dated 01/13/23, indicated a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses which included stroke, chronic obstructive pulmonary disease (chronic inflammatory lung disease that causes obstructive airflow from the lungs), schizophrenia (serious mental disorder that affects how a person thinks, feels, and behaves), and high blood pressure.
Record review of the admission MDS, dated [DATE], indicated Resident #57 was sometimes understood and sometimes understood others. Section C, cognitive patterns, the BIMS could not be conducted due to Resident #58 was rarely or never understood. Resident #57 required extensive assistance with eating and was totally dependent on bed mobility, dressing, toileting, personal hygiene, and bathing. Section V, Care Area Assessment (CAA) summary, had the following areas checked and should be care planned on the comprehensive care plan:
*Delirium
*Cognitive Los/Dementia
*Communication
*Urinary Incontinence
*Psychosocial Well-Being
*Mood State
*Activities
*Falls
*Nutritional status
*Pressure Ulcer
*Psychotropic Drug Use
*Pain
Record review of the comprehensive care plan, dated 12/02/22, revealed Resident #57 did not have goals or interventions for the following focused areas:
*Potential for alternation in bleeding tendencies and increased bruising related to use of anticoagulant/antiplatelet therapy
*Potential for self-care deficit and decline in ADLs related to stroke
*Potential for dehydration
*Potential for injury related to falls
*Potential for impaired skin integrity related to decrease mobility, incontinence, low albumin level, and low protein intake
*Require assistance with ADLS
*Receiving therapeutic or altered consistency diet
During an interview on 01/17/23 at 12:51 PM, ADON A said the MDS Coordinator was responsible for completing the comprehensive assessment. ADON A said she expected each focus on the care plan to have goals and interventions in place. ADON A said by not having the goal or interventions in place could place the residents at risk for not having their needs met.
During an interview on 01/17/23 at 1:36 PM, the RNC said she expected the care plan to be current to the resident status. The RNC said by not having the goals or interventions they would not be able to provide the care needed to the resident. The RNC said the comprehensive care plan was the responsibility of the MDS Coordinator.
During an interview on 01/17/23 at 4:55 PM, the Interim Administrator said he expected the comprehensive care plan be completed and should represent the resident . The Interim Administrator said it was important for the care plan to be completed so staff would know the resident's care needs.
Record review of the facility's policy titled Care Plans, Comprehensive Person-Centered, revised on March 2022, indicated .the comprehensive, person-centered care plan is developed within seven days of the completion of the required MDS assessment (Admission, Annual, or Significant Change in status) and no more than 21 days after admission .the comprehensive, person-centered care plan includes measurable objectives and timeframes; includes the resident's stated goals upon admission and desired outcomes; reflects currently recognized standards of practice for problem areas and conditions .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2) Record review of a Resident #119's face sheet, dated 01/11/2023, indicated Resident #119 was an [AGE] year-old female who was admitted to the facility on [DATE] with the diagnoses of which included joint replacement surgery (hip surgery), muscle weakness, and high blood pressure.
Record review of the admission MDS, dated [DATE], indicated Resident #119 understood others and she was understood. The MDS indicated Resident #119 had problems with recall and her BIMs score was an 11, indicating which indicated she had moderate impairment with cognition. Section E0200 of the MDS indicated Resident #119 did not have any behaviors that interferes interfered with the resident care. Section E0800 of the MDS indicated there were days when Resident #119 rejected care. Section F0400 indicated having the resident had the ability to choose between a tub bath, shower, bed bath, or sponge bath was very important to Resident #119. Section G of the MDS indicated Resident #119 required extensive assistance of one staff with personal hygiene, and total assistance of one staff with bathing.
Record review of the, undated, shower schedule indicated Resident #119 was to have a shower on Tuesday, Thursdays, and Saturdays on the day shift.
Record review of [NAME] ADLs computerized flow sheet for the dates of 12/29/2022 - 01/10/2023 indicated Resident #119 had a shower on 12/30/2022 and on 01/09/2023. The flow sheet indicated a code of not applicable on the days of 01/02/2023, 01/04/2023, and 01/06/2023.
Record review of a skin assessment shower sheet, dated 12/22/2022, indicated Resident #119 was provided a bed bath.
During an observation interview on 01/10/2023 at 8:25 a.m., Resident #119 said she needed a shower. Resident #119 said she had not had one in a very long time but could not recall how long. Resident #119 said she was supposed to go to the doctor for her hip and wanted a shower. Resident #119 did not have an odor but her hair appeared unclean.
3) Record review of a Resident #60's face sheet, dated 01/13/2023, indicated Resident #60 was an [AGE] year-old -male who admitted to the facility on [DATE] with the diagnoses of which included sepsis (life-threatening complication of an infection), malnutrition (lack of caloric intake), post-traumatic-stress disorder (mental health disorder triggered by a terrifying event), and bladder cancer.
Record review of Resident #60's admission MDS revealed it was unable to be completed due to MDS not completed.
Record review of Resident #60's baseline care plan, dated 01/06/2023, indicated Resident #60 required total assistance of one staff with grooming, hygiene, and bathing.
Record review of the, undated, shower sheets indicated Resident #60 was not on any of the hall lists for a shower.
Record review of a computerized ADLs flow sheet dated 12/27/2022 - 01/08/2023, indicated Resident #60 was showered on 01/06/2023. Resident #60 was not showered from 12/27/2022- 01/05/2023 and then 01/07/2023 and 01/08/2023.
Record review of a Resident #60's skin assessment-shower/bath sheet, dated 12/29/2022, indicated no shower was given on 12/29/2022 due to Resident #60 moving to the COVID- 19 hall.
During an observation and interview on 01/09/2023 at 11:00 a.m., Resident #60 was resting in bed with his spouse family member at his bed side. Resident #60 had facial hair of 1 1/2 inches long. Resident #60 and his spousefamily member said he had never had a beard only a mustache. Resident #60 said he wished to have a shave. Resident #60 said he had not had a shower since he arrived at the facility. Resident #60 appeared to have unclean hair with white flakes.
4) Record review of Resident #121's face sheet with the printed date of 1/13/2023 indicated Resident #121 was a [AGE] year-old male who admitted on [DATE] with the diagnoses of Sepsis (life threatening complication of infection) due to pneumonia, muscle weakness, acute kidney failure, high blood pressure, and malnutrition (lack of caloric intake).
Record review of a Resident #121's care plan, dated 01/10/2023 and revised on 01/12/2023, indicated Resident #121 required assistance with his ADLs. The goal was Resident #121 would maintain a sense of dignity by being clean, dry, odor free, well-groomed and will have no measurable decline in ADL functional ability through the next review. The intervention for Resident #121 was assist with his ADLs.
Record review of an the, undated, shower list indicated Resident #121 was to have a shower on Tuesday-Thursday-Saturdays on the day shift.
Record review of a computerized bath sheet dated 12/29/2022 - 01/13/2023, indicated Resident #121 had one shower on 01/09/2023. The computerized shower sheet indicated Resident #121 did not have a shower provided on 12/29/2022 through 01/08/2023, and then 01/10/2023 through 01/13/2023.
During an observation and interview on 01/09/2023 at 10:59 a.m., Resident #121 had facial hair one inch long over much of his face. Resident #121 said he had never worn a beard and wanted to be shaved. Resident #121 said he felt unclean.
During an interview on 01/16/2023 at 10:03 a.m., CNA CC said has worked the day shift on all halls since October 2022. CNA CC said the shower list was how she knew to provide showers to residents. CNA CC said staffing issues caused baths and charting to go not completed. CNA CC said not having a shower could make a resident feel bad about themselves and may not want to interact with others.
During an interview on 01/16/2023 at 10:10 a.m., LVN L said she was responsible for the ADLs of the residents. LVN L said the CNAs used the shower list and provided showers accordingly. LVN L said around 4:00 p.m., she starts started collecting the shower sheets from the CNAs. LVN L said when a resident refusesrefused, she will would attempt to ask them to shower and document their refusals. LVN L said residents could feel embarrassed when they were not showered.
During an interview on 01/17/2023 at 1:24 p.m., CNA DD said she worked on the front halls 100 and 200. CNA D said she used the shower list to know who requires required showeringshowers. CNA D said she always provided her showers unless there was were no towels or wash clothes. CNA D said running very low or out of towels and wash clothes occurred often.
During an interview on 01/17/2023 at 1:28 p.m., LVN L said to her knowledge showers were provided. All though, LVN L said she did not round to ensure showers and shaving was were provided. LVN L indicated she was not ensuring bathing was completed.
During an interview on 01/17/2023 at 1:59 p.m., the Regional Corporate Nurse said she expected ADLs to be performed daily. The Regional Corporate Nurse said without having ADLs completed a resident could feel bad about themselves or have increased infections. The Regional Corporate Nurse said she expected administrative nurses to be responsible for ensuring residents received their ADLs. The Regional Corporate Nurse said the facility had implemented the Ambassador Rounds (department head rounds to ensure care and services were delivered) but she said those rounds would be re-implemented.
During an interview on 01/17/2023 at 4:55 p.m., the Interim Administrator said the CNAs provided the showers according to the shower lists. He said the DON was responsible for the oversight of the ADLs. The Interim Administrator said the lack of ADLs could affect the health and dignity of the residents.
Record review of an Activities of Daily Living (ADL), Supporting policy, dated March 2018, indicated the residents will be provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene. 2. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: hygiene (bathing, dressing, grooming, and oral care).
Based on observation, interviews and record review, the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 5 of 16 resident reviewed (Residents #219, #38, #119, #60, and #121) reviewed for ADL care.
1. The facility failed to ensure Resident #219 received grooming and hygiene according to schedule and desire.
2. The facility failed to ensure Resident #119 received showers as scheduled.
3. The facility failed to ensure Resident #60 was shaved and received showers as scheduled.
4. The facility failed to ensure Resident #121 was shaved and received showers as scheduled.
These deficient practices could place residents at risk of not receiving care or attention needed which could lead to unwanted skin irritation and feelings of embarrassment.
Findings include:
1.Record review of Resident #219's face sheet, dated 01/13/23, revealed was a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses which included: encounter for orthopedic aftercare, Type 2 diabetes mellitus without complications (an impairment in the way the body regulates and uses sugar [glucose] as a fuel), muscle weakness, nondisplaced intertrochanteric fracture of the left femur (extracapsular fractures of the proximal femur that occur between the greater and lesser trochanter), fracture of the upper ed of the left humerus (a break in the upper part of your humerus near your shoulder), Glaucoma (a condition in which there is a build-up of fluid in the eye, which presses on the retina and the optic nerve), transient cerebral ischemic attack (a temporary blockage of blood flow to the brain), legal blindness (occurs when a person has central visual acuity (vision that allows a person to see straight ahead of them) of 20/200 or less in his or her better eye with correction), and history of malignant neoplasm of the larynx (area of the throat that contains the vocal cords and is used for breathing, swallowing, and talking).
Record review of Resident #219's admission MDS assessment, dated 11/27/22, indicated Resident #219 was understood and understood others. It revealed the resident's BIMS score was 14, which indicated cognition was intact. The resident required extensive assistance with bed mobility, transfer, dressing, eating, toilet use, and personal hygiene. The resident required total dependence with locomotion on and off unit.
Record review of Resident #219's care plan, dated 1/13/23, revealed Resident #219 had ADL (activities of daily living) functional/rehabilitation potential with a self-care deficit, and an intervention that stated required staff assistance times one for assist bars and times two to enable self-bed mobility. Resident #219 required a lift for all transfers and toilet use requires one staff assistance. Resident #219 has the potential for dental problems and mouth pain with interventions to assist with teeth brushes. Resident #219 required assist with ADLs and at risks for deterioration in ADLs with interventions to assist with ADLs as needed, allow extra time to complete ADLs, encourage independence with praise, and instruct to resident to call before getting out of bed or chair.
During interview and observation on 01/09/23 at 9:27 AM, with Resident #219, he was observed sitting in his wheelchair watching television. He said he had his bed bath this morning. He observed with dandruff and flaky scalp with oily hair.
During interview and observation 01/10/23 at 11:17 AM, with Resident #219, he was observed in bed watching television. He said the white substance on his shirt was from his head. He said his scalp itched and he would like his hair shampooed. He said he asked yesterday during his bed bath, but the CNA did not get to it. He said he is new to the facility and does not know the names of staff yet. He said he did not feel strong enough for a shower so he gets cleaned up in bed. Resident #219 said this meant a bed bath. He was observed with dandruff and a flaky scalp with oily hair. He said it did not make him feel bad, he just did not feel clean with his hair like this.
During interview and observation on 01/11/23 at 2:53 PM with Resident #219, he was observed sitting in bed watching television. He said he had not had his bed bath today. He said he really wanted his hair shampooed. He was observed with dandruff and flaky scalp with oily hair.
Record review of undated shower list indicated Resident #219 was to have a shower on Tuesday-Thursday-Saturdays on the day shift. There were no shower sheets available for review for Resident #219 since admission.
During interview on 01/14/2023 at 11:51 AM, with CNA P, she said some aids on the opposite rotation will bath or shower the residents and not wash their hair or clean their nails. She said shower/bath schedules were odd room numbers on Monday, Wednesday, and Friday, and even room numbers were Tuesday, Thursday, and Saturday. She said there was not one particular shift that did the care. She said the morning shift started the showers/baths for the day and the evening shift completed those who are were not done. She said some residents may refuse in the morning shift, but evening shift should ask them at least one more time. She said the staff must complete shower sheets that indicated areas of the body that were cleaned and note any skin issues. She said the same sheet was also where they documented refusal.
During an interview on 01/16/2023 at 10:10 a.m., LVN L said she was responsible for the ADLs of the residents. LVN L said the CNAs used the shower list and provided showers accordingly. LVN L said around 4:00 p.m., she started collecting the shower sheets from the CNAs. LVN L said when a resident refused, she would attempt to ask them to shower and document their refusals. LVN L said residents could feel embarrassed when they were not showered.
During an interview on 01/17/2023 at 1:59 p.m., the Regional Corporate Nurse said she expected ADLs to be performed daily. The Regional Corporate Nurse said without having ADLs completed a resident could feel bad about themselves or have increased infections. The Regional Corporate Nurse said she expected administrative nurses to be responsible for ensuring residents received their ADLs.
During an interview on 01/17/2023 at 4:55 p.m., the Interim Administrator said the CNAs provided the showers according to shower lists. He said the DON was responsible for the oversight of the ADLs. The Interim Administrator said the lack of ADLs could affect the health and dignity of the residents. he Regional Corporate Nurse said the facility had implemented the Ambassador Rounds but she said those rounds would be re-implemented. She said Ambassador Rounds are rounds completed by different department heads with residents regarding thier care each morning.
Record review of an Activities of Daily Living (ADL), Supporting policy, dated March 2018, indicated the residents will be provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene. 2. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: hygiene (bathing, dressing, grooming, and oral care).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure based on the comprehensive assessment, residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan and the residents' choices for 1 of 20 residents (Resident #119) reviewed for quality of care.
The facility did not obtain orders to remove 29 staples from Resident #119's hip when she had missed appointments with the surgeon on 01/04/2022, and 01/11/2022 due to no facility transportation.
These deficient practices could affect place residents at the facility who required care and could result in risk of missed or inappropriate care.
Findings included:
Record review of a Resident #119's face sheet, dated 01/11/2023, indicated Resident #119 was an [AGE] year-old female who was admitted to the facility on [DATE] with the diagnosis diagnoses which included of joint replacement surgery, fracture of the right femur (broken leg), and presence of an artificial right hip joint (surgical hip replacement)
Record review of Resident #119's admission assessment, dated 12/19/2022, indicated Resident #119 had a right trochanteric (hip) surgical incision. The surgical wound was not measured nor was there documentation indicating which indicated how many staples were present.
Record review of an admission MDS, dated [DATE], indicated Resident #119 understands and was understood. The MDS indicated in Section I 3900 indicated the resident had a hip fracture. Section J of the MDS indicated a hip replacement. Section M1040 failed to indicate Resident #119 had a surgical wound.
Record review of hospital discharge orders for Resident #119 indicated she had a ground level fall and required a right hip replacement. The discharge orders indicated to remove the dressing to the right hip in 5 days. The discharge orders, dated 12/19/2022, indicated to follow up with the surgeon on 01/04/2022 at 9:00 a.m.
Record review of the weekly wound tracking worksheet dated 01/02/2023 - 01/06/2023, failed to indicate any documentation of Resident #119's surgical incision to the right hip with 29 staples.
Record review of a comprehensive care plan, dated 01/10/2023 and revised on 01/11/2023, indicated Resident #119 had a hip fracture from a fall at her home. The goal was Resident #119 would return to the prior level of function with the interventions of monitor, document, and report to the physician hip fracture complications. The comprehensive care plan did not mention the right hip surgical incision.
Record review of a progress note, dated 01/11/2023, indicated the charge nurse notified the medical director concerning Resident #119 continued to have staples in her right hip area, and Resident #119 had missed 2 appointments with the surgeon. The staples were clean, dry, and intact with no drainage. The note indicated Resident #119 had redness to the top and bottom areas of the staples. Resident #119's appointment has beenwere rescheduled for 01/16/2023 at 1:20 p.m. The note indicated the charge nurse had requested for the staples to be removed.
Record review of Resident #119 physician's orders indicated the medical director ordered, on 1/12/2023, the removal of Resident #119's staples to her right hip. Record review indicated this was the only physician's order obtained to remove Resident #119's staples.
During an observation and interview on 1/10/2023, Resident #119 said she was worried about her surgical incision to her hip having the staples remaining so long. Resident #119 said she was not sure when she will would see the surgeon. Resident #119 said she was aware of the missed appointments.
During an interview on 01/10/2023 at 2:30 p.m., Resident #119's surgeon's office indicated her appointment was scheduled for 01/04/2023 but was cancelled by the facility and the new appointment was 1/11/2022 at 9:00 a.m. The physician's office indicated the facility's transportation van was out of service.
During an interview with the Transportation Aide on 01/10/2023 at 2:40 p.m., she said the facility van has had been in the shop, the non-emergency transportation the alternate transportation method was booked up, and she had to reschedule Resident #119's appointments.
During an observation and interview on 01/11/2022 at 10:45 a.m., Resident #119's right hip had 29 staples. The surgical incision appeared red in color around the staples. Resident #119's nurses, LVN Y and LVN B, indicated Resident #119's appointment was now rescheduled again for 1/16/2022 at 1:20 p.m. due to the facility van not available due to being in the shop. LVN B and LVN Y said they had not notified the surgeon of the missed appointments and to clarify the need for removal of the staples. The nurses said the surgical incision could become infected and the staples could grow into the skin due to the staples being in the leg since before her admission on [DATE]. LVN B and LVN Y said staples usually were removed in 7-14 days.
Record review of a progress note dated 01/11/2023 indicated the charge nurse notified the medical director concerning Resident #119 continued to have staples in her right hip area, and Resident #119 had missed 2 appointments with the surgeon. The staples were clean, dry, and intact with no drainage. The note indicated Resident #119 had redness to the top and bottom areas of the staples. Resident #119's appointment has been rescheduled for 01/16/2023 at 1:20 p.m. The note indicated the charge nurse had requested for the staples to be removed.
Record review of Resident #119 physician's orders indicated the medical director ordered on 1/12/2023 the removal of Resident #119's staples to her right hip.
During an interview on 01/17/2023 at 1:55 p.m., the Regional Nurse Consultant said removal of staples was according to the physician's orders. The Corporate Nurse said the nurses and DON were responsible for notifying the physician for orders regarding the removal of the staples when appointments were missed. The Corporate Nurse said the surgical incision could become infected when the staples were left too long.
During an interview on 01/17/2023 at 4:55 p.m., the Interim Administrator indicated he was not a nurse, had never had staples, and was unsure of the risk. He stated but the nurses were responsible.
Record review of the American family physician website, located at https://www.aafp.org/pubs/afp/issues/2008/1015/p945.html accessed on 01/23/2023, indicated on Table 2 the staples to legs should be removed in 10 to 14 days.
Record review of the facility's a Wound Treatment Management policy, dated 07/01/2022, indicated to promote wound healing of various types of wounds, it is the policy of this facility to provide evidence-based treatments in accordance with current standards of practice and physician orders. 1. Wound treatments will be provided in accordance with physician orders, including the cleansing method, type of dressing, and frequency of dressing change. 2. In the absence of treatment orders, the licensed nurse will notify physician to obtain treatment orders. This may be the treatment nurse, or the assigned licensed nurse in the absence of the treatment nurse. 5. Treatment decisions will be based on: a. Etiology of the wound: ii. Surgical

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Record review of Resident #5's electronic face sheet, dated 01/13/23, revealed a [AGE] year old female who was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included multiple sclerosis (a chronic, typically progressive disease involving damage to the sheaths of nerve cells in the brain and spinal cord, whose symptoms may include numbness, impairment of speech and of muscular coordination, blurred vision, and severe fatigue), sepsis (a serious condition resulting from the presence of harmful microorganisms in the blood or other tissues and the body's response to their presence, potentially leading to the malfunctioning of various organs, shock, and death), anxiety (what we feel when we are worried, tense or afraid), high blood pressure, and Alzheimer's ( a type of dementia that affects memory, thinking and behavior).
Record review of Resident #5's quarterly MDS assessment, with an ARD of 10/26/22, revealed under Section B, Hearing, Speech, and Vision, was coded as a 0 indicating she understands and was understood by others. Section C, Cognitive Patterns, under section C0500 Brief Interview for Mental Status, which indicated a score of 14 which indicated the resident was cognitively intact. Section G, Function Status, under section B indicated she needed extensive assistance with bed mobility, personal hygiene, total assist with transfers, dressing, bathing, and supervision with eating. Section M, Skin Condition, under section M1200 she received pressure ulcer/injury care and application of nonsurgical dressing during the look back period.
Record review of Resident #5's comprehensive person-centered care plan, dated initiated 12/27/17, and revised on 01/13/23. revealed the Focus indicted: Resident #5 was at risk for further skin breakdown, also had a wound to right, distal, lateral calf lower leg and pressure area to right ischium related to immobility, incontinence, and disease process. Intervention indicated: Keep physician and RP informed of my progress.
During observation and interview on 1/10/23 at 9:02 a.m., Resident #5 was in her bed with her heels not floated and lying flat on top of one pillow. There was no wedge present to float the heels and no pressure relieving boots present. Resident #5 said she did not know what heel protectors were, but she had not had the boots on in a while. She said normally her feet were elevated.
Record review of Resident #5's skin assessment completed on 01/05/23, did not reveal the 4 new pressure areas to right and left foot. It did indicate: Left Ischium stage 4 measuring 1.0X0.5X0.5cm, Right Ischium stage 4 measuring 3.0X0.4X0.2cm, Sacrum stage 3 measuring 3.0X2.7X0.3 and right ankle stage 4 measuring 3.0X0.5X0.1cm. In the comment box it indicated; New unstageable areas to feet, we will be using skin prep daily.
Record review of Resident #5's wound care notes, dated 12/29/22 indicated: Site1, Left Ischium stage 4 measuring 1.0X0.5X0.5cm, Site2, Right Ischium stage 4 measuring 3.0X1.0X0.2cm, Site3, right calf stage 4 measuring 3.0X0.5X0.1cm and Site 6, Sacrum stage 3 measuring 3.0X2.7X0.3cm.
Record review of Resident #5's [NAME] notes, dated 01/05/23, indicated the above wounds and 2 new areas: Site 7, Unstageable DTI of the right foot measuring 3.0X1.0cm. Site 8, Unstageable DTI of the left foot measuring 3.0X2.0cm. It did not reveal 4 new areas on 01/05/23 only 2 new areas.
Record review of Resident #5's physician orders., Apply heel protectors to feet while in bed. 1) Apply skin prep once daily to unstageable DTI (deep tissue injury) on outer aspect of right foot, 2) Apply skin prep once daily to unstageable blister to inner left foot arch, 3) Apply skin prep once daily to unstageable DTI on inner aspects of left foot,4) Apply skin prep once daily to unstageable blister to inner aspect of right foot.
Record review of Resident #5's wound care note, dated 01/12/23, indicated the following: Site 1,Left Ischium stage 4 measuring 0.8X0.5X0.5cm, Site 2,Right Ischium stage 4 measuring 2.0X0.4X0.2cm, Site 3,right ankle stage 4 measuring 0.2X0.1X0.1cm,Site 6, Sacrum stage 3 measuring 3.0X2.7X0.cm, Site 7, Unstageable DTI of the right foot measuring 2.0X1.0cm Site 8, Unstageable DTI of the left foot measuring 3.0X2.0cm, Site 9, stage 2 pressure wound of left medial foot measuring 6.0X1.0X0.1cm, Site 10, unstageable ulcer on right foot with no measurements.
Record review of Resident #5's treatment record, dated 01/12/23, indicated: the following treatment orders started 01/11/23:.
Apply skin prep once daily to unstageable blister to inner aspect of right foot.
Apply skin prep once daily to unstageable DTI to outer aspect of right foot.
Apply skin prep once daily to unstageable blister to inner left foot arch.
Apply skin prep once daily to unstageable DTI on inner aspects of left foot.
Record review of Resident #5's physicians orders dated 01/13/23 indicated an order for heel protectors to feet when in bed started on 05/04/22.
During an observation on 1/11/23 at 10:31 a.m., Resident #5 was observed in her bed watching television. Her heels were not floated and were lying flat on top of one pillow. There was no wedge present to float the heels and no pressure relieving boots present.
During an observation and interview on 01/11/23 at 11:10 a.m., ADON G performed wound care on Resident #5, 4 dark purple areas which were not noted on the treatment sheet to left and right foot were observed. They presented as a deep tissue injury (DTI). The ADON G said those were identified last week on 01/05/23 on rounds with the Wound Care Doctor. ADON G said she forgot to add them last week on the treatment record because her computer was messed up. ADON G said without orders being on the treatment administration record (TAR), treatments could go untreated.
During an observation on 01/11/23 at 12;25 p.m., ADON G measured Resident #5 other 2 new areas, presenting as DTI that were not on the 01/05/23 wound care notes, right side of foot at 2.0X2.0 cm and left inner top of foot at 3.0x2.0cm.
During a phone interview on 01/12/23 at 9:24 a.m., Wound Care Doctor said Resident # 5 had 2 new identified areas to the right and left feet on today's rounds. He said they identified 2 other new areas to right and left feet last week on rounds but was not aware the treatment orders had not be implemented. The Wound Care Doctor said ADON G called him yesterday on 01/11/23 about the 2 new areas and orders were given.
During an observation on 1/12/23 at 5:23 p.m., Resident #5 was in her bed with heels floated with a wedge underneath her lower legs but no pressure relieving boots were present.
During an observation and interview on 01/13/23 at 2:57 p.m., Resident #5 was in her bed with heel protectors on, but they hung off her feet. Resident #5 feet and toes were touching the footboard and her feet were not off the bed. LVN H said she was aware Resident #5 had 2 new pressure injuries. LVN H said she knew Resident #5 was supposed to have on the heel protectors but felt they could cause her more harm than good. LVN H said she mentioned her concerns to the weekend treatment nurse only.
During an interview on 01/13/23 at 3:04 p.m., CNA T went into Resident #5's room and said she was not aware she was supposed to be putting heel protectors on the resident. CNA T said she had just been offloading her heels with 2 pillows. CNA T saw Resident #5 feet touching footboard and feet were not really offloaded of bed with the 2 pillows, LVN H and CNA T repositioned Resident #5. CNA T said now she realized improper offloading or not wearing heel protectors could cause more skin issues.
During an interview on 01/13/23 at 3:57 p.m., CNA V said she was aware Resident #5 had wounds and her feet were supposed to be offloaded with pillows. CNA V was not aware of heel protectors.
During an interview on 1/17/23 at 2:06p.m., the RNC said the primary nurse should follow up on skin issues and did treatments as ordered. The RNC said the nursing administration were to follow up on all treatments. The RNC said it was a lot of changes at the facility and she had not had time to get all forms in place. The RNC said failure to do treatment could cause numerous things to go wrong with the wounds as well as the resident.
During an interview on 01/17/23 at 2:25 p.m., ADON D said she expected if any nurse identified a new skin area to measure, call the doctor and get treatment orders. ADON D said her and ADON G were doing treatments until they hired someone but when they were not at the facility the nurses should take charge of any new wounds identified. ADON D said failure to do treatments could cause wounds to deteriorate or get an infection.
During an interview on 1/16/2023 at 10:25 a.m., the Weekend RN said she was not checked off on wound care, but she had experience in nursing with hospice, home health, and hospital patient care. The Weekend RN said she would stay until the treatments were completed on the weekends she worked. The Weekend RN said if she had to delegate the floor nurses to complete the treatments, she would give a report to the nurse indicating who remained on the treatment schedule.
4.Record review of Resident #49's electronic face sheet, dated 01/13/23, revealed a [AGE] year old female who was admitted to the facility on [DATE] with diagnoses which included Respiratory failure (a serious condition that makes it difficult to breathe on your own), gastrostomy status (an opening into the stomach from the abdominal wall, made surgically for the introduction of food), anxiety (what we feel when we are worried, tense or afraid), high blood pressure(elevated blood pressure), and stroke(occurs when something blocks blood supply to part of the brain or when a blood vessel in the brain bursts).
Record review of Resident #49's quarterly MDS assessment, dated 01/04/23, revealed under Section B, Hearing, Speech, and Vision, she was coded as a 3 indicated Resident #49 rarely understands and was rarely understood by others. Section C, Cognitive Patterns, under section C0700 indicated she has short term memory loss, C0800 indicated long term memory problems, and C0100 coded as a 3 indicating Resident #49 had severely impaired decision making. Section G, Function Status under section G0110 indicated she required total assist with bed mobility, personal hygiene, dressing, bathing, and eating.
Record review of Resident #49's care plan did not reveal anything related to a left thumb injury noted on 01/02/23.
Record review of Resident #49's nurses note did not reveal any documentation about left thumb injury identified on 01/02/23 until 01/11/23.
Record review of Resident #49's physicians orders, dated 01/13/23, revealed an order, dated 01/11/23, to clean area to left thumb with wound cleanser apply collagen and dry dressing. Change every day and as needed.
During an observation on 01/10/23 at 12:32p.m., with the DON, a band aide was observed to Resident #49's left thumb. Resident #49 left hand was contracted.The DON removed the band aid and revealed a small open area to the left thumb. The DON said she was unaware of any area to Resident #49's thumb prior to removing the band aid. ADON G came to measure the left thumb revealing measurements of 2.0x1.0 cm (centimeters). The ADON G indicated she was going to classify this area a stage 2 to left thumb.
During an interview on 01/10/23 at 1:01 p.m., ADON G said she was not aware of any issue with this Resident #49's hand but she was not assigned to her hall. ADON G said she and ADON D were responsible for all skin assessments and treatments until they hired a wound care nurse.
During an interview on 01/11/23 at 4:48 p.m., ADON D said she was unaware Resident #49's had an open area to left thumb until yesterday. ADON D said after stage 2 was identified yesterday on Resident #49's thumb she notified the physician, obtained orders, and notified daughter.
Record review of Resident # 49's skin assessment dated [DATE] did not indicate any areas to left thumb.
Record review of Resident # 49's skin assessment dated [DATE] did indicate a stage 2 to left thumb measuring 2.0X1.0 cm.
During a phone interview on 01/12/23 at 10:45 a.m., the hospice nurse said she went to the facility to assess Resident #49's thumb on 01/02/23 because the family member called. The hospice nurse said she gave verbal orders to a male nurse. The hospice nurse said the order was to cleanse the left thumb daily, pat dry, apply Neosporin and leave open to air, notify if any changes. The hospice nurse said she did not measure the area but did leave a note from her visit for the DON. The hospice nurse said she never heard from the DON.
Record review of Resident #49's hospice note dated 01/02/23 indicated, Left hand is contracted with left hand guard not in place at this time. Abrasion on left thumb is noted without drainage from possible handguard. Wound care orders given to Nurse U to cleanse area with warm water and soap, pat dry apply Neosporin and leave open to air, if drainage occurred apply bandage.
During an interview on 01/13/23 at 11:08 a.m., LVN N said he did not remember the exact date, but he felt it was around 01/04/23 when the night nurse LVN U gave report about Resident #49's thumb with an abrasion. LVN N said he told LVN U he would take care of it. LVN N said the nurse practitioner from hospice went and looked at the left thumb and gave an order to apply a dressing daily. LVN N said he did not remember what happened, but he did not write the order, nor measure the area or fill out an incident report as he should. LVN N said the family member was there and was aware of area to the left thumb. LVN N said failure to follow through with orders could lead to infection or worsen wound.
During an interview and observation on 1/15/23 at 6:00 p.m., observed the left thumb with dressing in place dated 1/15/23. LVN T said she was one of Resident #49's main nurses and she was not aware of the stage 2 to left thumb prior to today.
During an interview on 01/17/23 at 6:30 p.m., LVN U said she was not aware of any open area on Resident #49's hand. LVN U said she remembered an indention only on Resident #49's hand. LVN U said she reported it to ADON D and LVN N so they could monitor for any changes, not because of anything opening on her thumb.
During an interview on 1/17/2022 at 4:39 p.m., the Interim Administrator said he would expect the nurses to input the wound care orders on admission, expected the wounds to be measured, expected the treatments to be implemented. The Interim Administrator said not receiving wound care could cause a serious health issue.
During an interview on 1/17/2023 at 5:31 p.m., the CEO said a new treatment nurse was hired and started on 1/16/2023. The CEO said he believed the DON and the Administrator were not working together as a team therefore they missed important information overall about the facility. The CEO said the DON had never held a director of nurse's position and he went on to say he believed she did not know the priorities. The CEO said the facility used agency staff and possibly things have been missed or go unnoticed for periods of time which played a vital role in the overall care of the residents.
Record review of a Wound Treatment Management policy, dated 07/01/2022, indicated:
Policy:
To promote wound healing of various types of wounds, it is the policy of this facility to provide
evidence-based treatments in accordance with current standards of practice and physician orders.
Policy Explanation and Compliance Guidelines:
1. Wound treatments will be provided in accordance with physician orders, including the cleansing
method, type of dressing, and frequency of dressing change.
2. In the absence of treatment orders, the licensed nurse will notify physician to obtain treatment orders.
This may be the treatment nurse, or the assigned licensed nurse in the absence of the treatment nurse
This was determined to be an Immediate Jeopardy (IJ) situation on 01/12/2023 at 4:55 p.m. The Administrator was notified. The Administrator was provided with the IJ template on 01/12/2023 at 4:59 p.m.
The following Plan of Removal submitted by the facility was accepted on 1/13/2023 at 5:06 p.m. and included the following:
1.
Facility has hired a wound treatment nurse to begin 01/16/2023. The ADON's will receive wound care training as well as the new wound care nurse with the wound care physicians. The new wound treatment nurse will receive training on wound identification, treatment as well as order completion. The DON and chief nursing officer to monitor performance.
2.
ADON will check people with wounds, check current wound orders and current treatments to ensure correct treatments are ordered and correct treatments are done. DON and Administrator counseled. Completed 01/13/2023
3.
All direct care staff in-serviced to check each resident each shift for appropriate date of dressings to wounds. If missing, DON notified immediately. Complete 01/12/2023
a.
Offloading resident feet Completed 01/13/2023
b.
Use of heel protectors Completed 01/13/2023
4.
ADON counseled on Follow through with implementation of dietary orders timely. Completed on 01/12/2023
5.
Treatment nurses implement recommendations by wound care physician as written. Completed 01/12/2023
6.
ADON review dietary recommendations and implement recommendations immediately. Complete 01/13/2023 (as dietician arrives and completes recommendations)
7.
Treatment nurses follow company recommendations regarding appropriate equipment for wound management. Example: low air loss mattresses, repositioning equipment. Complete on 01/13/2023
8.
All direct care staff in-serviced for turn and repositioning. Complete 01/12/2023
9.
Facility skin sweep completed 01/13/2023
10.
Nursing staff in-serviced on skin assessment upon admission to include wound measurements if any wounds are identified. Completed on 01/13/2023.
Record review of in-service training report for turning and reposition dated 1/12/23 indicated: Residents who are unable to turn themselves need to be turned and repositioned every two hours. Positioning devices should be used such as pillows, wedges, etc to help off load and to bad bone areas. If resident refuse, notify charge nurse and charge nurse to document.
Record review of in-service training report dated 1/12/23 indicated direct care staff were in-serviced on skin assessments and reporting skin change, dressing change. The in-service included: 1. RNs, LVNs, and CNAs were to inspect skin of residents daily. CNAs report any change in skin to nurse. If dressing is not dated for that day during care, notify your nurse. 2. RNs and LVNs skin assessment should be done when caring for residents and treatments as ordered. Check dates on wounds and if not completed or changed as ordered, change dressing. 3. If notice change in wound, call physician and update change.
Record review of in-service training report dated 1/12/23 indicated to implement all orders in a timely manner. 1. Dietary, wound care treatments, and any other orders must be implemented in a timely manner. 2. Orders must coincide with treatment and carried out as ordered.
Record review of in-service training report dated 1/12/23 indicated nurses were in-serviced on skin assessments. The in-service included: skin assessments to be completed on admission by the admitting nurse. A full head to toe with measurements of any wounds, old or new. If no orders come with the resident, obtain orders from attending physician and treat as well as document before leaving at the end of shift. Report to oncoming nurse and oncoming nurse to follow up. Skin should be checked daily each shift by nurse and CNA.
Record review of in-service training report for low air loss mattress dated 1/13/23 indicated nurses were in-serviced on the following:
1)What is a low air loss mattress?
A low air loss mattress is a mattress designed to prevent and treat pressure wounds. The mattress is composed of multiple inflatable air tubes that alternately inflate and deflate, mimicking the movement of a patient shifting in bed or being rotated by a caregiver, never leaving the patient in one position for any extended length of time. This action relieves pressure under the body - particularly in parts with less padding, like hips, shoulders, elbows, and heels - and helps ensure proper air circulation, helping to prevent, manage, and treat the occurrence of pressure wounds.
2)Who can benefit from a low air loss mattress?
Low air loss mattresses can be used for both the prevention and treatment of pressure wounds, and are well suited to any patients susceptible to these events such as those who are immobilized or lack adequate sensory perception (e.g. those with spinal cord injuries or neurological conditions), or patients with medical conditions affecting blood flow; essentially any patient that is unable to shift and reposition themselves while lying in bed.
3)Medical documentation for low air loss mattresses must include:
o
Frequent Changes in Body Position All medical records and charts must demonstrate that the patient requires frequent changes in body position or have an immediate need for changes in body position.
o
Need for Elevation Make sure to document that the patient needs to have their head elevated more than 30 degrees and list the reason(s) why. This is one of the key elements in whether the patient qualifies for coverage.
o
Medical Condition Requiring Frequent Changes in Body Position In order to qualify for coverage, the patient must have a condition that requires their body to be positioned in ways not possible in an ordinary bed. Make sure to outline the condition and explain why a regular bed won't suffice.
o
Changes in Body Position to Alleviate Pain If the patient experiences pain in certain positions, make sure to document it. List how repositioning the patient will alleviate these pains and why they cannot be alleviated in an ordinary bed.
o
The Need for Traction Equipment If the patient requires traction equipment, detail because traction equipment is necessary.
4)The in-service also included that a physician had to give the order for a low air loss mattress, the setting was set according to the resident's weight; and nurses were to check every shift for accurate weight and proper functioning.
An in-service dated 01/13/2023 with the topic of heels and offloading included what causes heel breakdown, who is at risk for heel breakdown, prevention of heel pressure ulcers, heel specific constant low pressure constant low-pressure devices, pillows and wedges, and an order must be written for heel protectors, and use pillows for offloading.
1.Who is at risk for heel breakdowns?
o
immobility, age, mental status, nutrition, chronic illness, and orthopedic surgical procedures, especially hip pinning, and hip replacement surgeries.
2. What can you do to prevent pressure ulcer?
o
Skin assessment is key to pressure injury prevention, classification/diagnosis, and treatment. All residents should have a skin assessment to determine its' general condition and identify factors that increase the risk for PI development.
o
Malnourished are at increased risk of pressure injury development due to their compromised ability to maintain healthy skin and mucosa. Hydration and nutritional support should be aimed at preventing and correcting these deficits.
o
Increased moisture on the skin or excessive dryness can exacerbate pressure injury development due to the risk of skin breakdown and altered skin integrity. Keep residents clean and dry and apply barrier cream after each incontinent episode. When given a shower, dry thoroughly and inspect skin for any new areas and report to nurse or physician.
3. What can you do for mobility and positioning?
o
For residents who need assist or unable to assist with moving themselves, it is recommended that they be repositioned every two hours.
o
Always check the positioning of the bony prominences (e.g. shoulders, elbows, ankles, ears) and heels when repositioning the patient into any position. Heels should be suspended off the bed using pillows or heel pads for residents spending prolonged periods in bed.
o
For residents who are unable to assist in moving themselves, use appropriate transfer assistance devices (e.g. sheets) to reduce friction and shear forces. Always lower the bed head before repositioning patients.
o
To reduce shear forces on the sacrum, the head of the bed should be raised in conjunction with the knee bend and/or pillows under the knee.
Monitoring included:
Interview on 01/17/2022 from 4:43 p.m. until 6:00 p.m. the surveyors confirmed the facility implemented their plan of removal sufficiently to remove the IJ by:
Interviews with 3 (6am-6pm) nurses LVN B, LVN D and LVN R, 2 (6pm-6am) nurses LVN U and LVN HH who indicated they had received a written in-service regarding the use of low air loss mattress and monitoring, providing wound care, notifying the physician, and implementing physician orders. LVNs said they were in-serviced on confirming the orders in the queue, how to check orders for completion, how to complete skin assessments with measurements and documentation, when to notify the physician with any new or wound changes, why and how to properly set an air mattress and to monitor throughout the shift for placement and function and why and how to properly offload heels and to monitor for placement throughout shift.
Interviews with 4 CNAs (6am-6pm) CNA FF, CNA GG, CNA D, and 4 CNAs (6pm-6am) CNA MM, CNA OO, CNA PP and CNA LL indicated they were in-serviced on obtaining weights on admission, reporting any new skin issues to the nurse, notifying the nurse if any dressing is soiled, dislodged or without a date and document on the skin sheets any new skin issues.
The Interim Administrator, Regional Nurse Consultant, and CEO were informed the Immediate Jeopardy was removed on 01/17/2023 at 6:06 p.m. The facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy and a scope of pattern due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.
Based on observation, interview, and record review the facility failed to ensure residents with pressure ulcers received the necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection, and prevent new ulcers from developing for 4 of 20 residents (Residents #5, #49, #120, and #121) reviewed for pressure injury.
*The facility failed to provide wound care to Resident #121s sacral pressure injury until 12/29/22, which was 15 days after his admission with pressure injuries.
*The facility failed to consistently provide wound care for Resident #121 after beginning wound care, missing treatments on 1/1/23 and 1/7/23.
*The facility failed to implement a dietician recommendations of Pro-stat (given to provide body with additional protein to promote healing) for Resident #121 on 12/18/22 until 12/26/22 , 8 days after the recommendation was made.
*The facility failed to administer the initial and on-going minerals and vitamins to Resident #121 as ordered by the wound care physician on 1/22/22.
*Resident #121's sacral wound deteriorated and increased in size from 0.5 cm x 0.4 cm x undetermined depth on 12/14/2022 to 4.0 cm x 3.0 cm x 0.1 cm on 12/22/2022. Resident developed an infection in his wound and was admitted to the hospital 1/11/23 with a diagnosis of sepsis secondary to an unstageable sacral decubitus wound. Resident # 121 died 1/22/23.
*The facility failed to measure Resident #120's sacral wound upon admission.
*The facility failed to implement the wound care physician's orders to offload Resident #120's pressure ulcer.
*The facility failed to provide Resident #120 a low air loss mattress to prevent wound decline.
*The facility failed to provide daily wound care to Resident # 120's sacral wound as ordered on 01/4/2023, 01/05/2023, 01/06/2023, and 01/08/2023.
*The facility failed to prevent Resident #120's wound from becoming infected requiring which required hospitalization.
*The facility failed to prevent Resident #5 from developing two new DTIs (deep tissue injuries), one on her left inner bottom of her foot, and one on the right outer foot. (DTIs caused from bilateral feet pressure against each other)
The facility failed to document newly identified DTIs and implement treatment orders for Resident #5 when the wound care physician identified the new wounds on 1/5/23.
*The facility failed to identify the onset or followup orders for the left thumb of Resident #49 which resulted in a stage 2 pressure injury.
An immediate Jeopardy (IJ) situation was identified on 01/12/2023 at 4:35 p.m. While the IJ was removed on 01/17/2022, the facility remained out of compliance at a scope of a pattern with actual harm that was not immediate jeopardy, due to the facility's need to evaluate the effectiveness of the effectiveness of the corrective systems.
These failures placed residents at risk of pain, worsening of wounds, wound infection, emotional distress, harm or even death.
Findings included:
1. Record review of Resident #121's face sheet, with the printed date of 1/13/2023, indicated a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses which included Sepsis (severe complication of an infection) due to pneumonia, muscle weakness, acute kidney failure, high blood pressure, and malnutrition (lack of caloric intake).
Record review of Resident #121's The admission MDS revealed it was not completed.
Record review of a Resident #121's Baseline Care Plan, dated 12/14/2021, indicated Resident #121 required extensive assistance with his ADLs, he had a skin concern of a pressure ulcer to the sacrum, with the goals of the wound to show signs of healing with area decreasing in overall size. The interventions included to provide the wound care/preventative skin care, weekly skin checks, turn and reposition, and notify the physician of any changes in the wound or emerging wounds. The physician orders listed in Section M of the Baseline Care plan did not reveal a wound care order with the medication orders.
Record review of an Admission-readmission Assessment, dated 12/14/2022, indicated Resident #121 was admitted to the facility on [DATE] from a hospital. The assessment indicated Resident #121 had a pressure injury to his vertebrae (upper-mid back) measuring 0.2 cm x 0.2 cm x undetermined depth, a coccyx pressure ulcer measuring 0.5 cm x 0.4 cm x undetermined, and a pressure ulcer to the left buttock measuring 0.5 cm x 0.5 cm x undetermined depth.
Record review of a Skin and Wound -total Body Skin Assessment, dated 12/14/2022, indicated Resident #121's skin turgor (skin elasticity) had poor elasticity, the skin color was normal, temperature was cool, the moisture was normal, the condition dry, and had 3 [TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure the residents environment remained free of accident hazards by not adequately monitoring the proper storage of oxygen cylinders for 2 of 2 residents, (Resident #'s 16 and 40), proper transfer for 1 of 1 resident (Resident #38) and timely completion of smoking assessments for 1 of 1 resident (Resident #54).
The facility failed to store oxygen properly for Resident # 40.
The facility failed to ensure Resident #16 oxygen cylinder was properly secured.
The facility failed to ensure Resident #38 was transferred using a gait belt.
The facility failed to ensure Resident #54 had a smoking assessment completed quarterly.
These deficient practices could place residents at risk of injury.
Findings include:
1. Record review of a face sheet dated 01/13/2023 indicated Resident #38 was admitted on [DATE] and readmitted on [DATE] with the diagnosis of a stroke, generalized weakness, right sided paralysis following a stroke.
Record review of the comprehensive care plan dated 12/13/2022 Resident #38 required assistance with his ADLs to maintain a sense of dignity by being clean, dry, free of odors, well groomed, and no measurable decline in transferring, bed mobility, ADL functional ability with the interventions of assessing risk factors for deterioration and elimination risks, assist with ADLS, and document and report any deterioration in status to the physician.
During an observation and interviews on 01/10/2023 at 11:30 p.m., Resident #38 was assisted from his bed to the wheelchair by CNA P and LVN L. CNA P began transferring Resident #38 putting her arms underneath his arms, when Resident #38 legs become weak, and he started to go down, then LVN L assisted Resident #38 underneath one of his arms. CNA P said she should have used a gait belt to transfer Resident #38 because he could have fallen. CNA P had a gait belt around her waist. LVN L said today was the first time she had provided care to Resident #38, and she did not realize he was so week. LVN L said she should use a gait belt when transferring a resident. LVN L she should have looked at Resident #38's care plan prior to care for his transfer assistance needs.
During an interview on 01/17/2023 at 1:55 p.m., the Regional Nurse Consultant said a gait belt should be used when transferring a resident. The corporate nurse the care plan should be used to determine a resident's transfer needs. The corporate nurse said the ADONs, and the DON were responsible for ensuring CNA checkoffs were completed. A request was made to the corporate nurse for CNA Woods skill check offs, but one was not provided.
During an interview on 01/17/2023 at 4:55 p.m., the Interim Administrator said he expected nursing staff to use proper procedures when transferring a resident such as use of a gait belt. The Interim Administrator said the resident, or the staff could get injured with an improper transfer.
2. Review of Resident #40's electronic face sheet dated 01/13/23 revealed she was admitted to the facility on [DATE] with diagnoses of respiratory distress (a serious lung condition that causes low blood oxygen), anxiety disorder (mental conditions characterized by excessive fear of or apprehension about real or perceived threats), high blood pressure, fluid overload (a condition where you have too much fluid volume in your body), and muscle weakness.
Review of Resident #40's MDS assessment with an ARD of 01/04/23 revealed under Section B, Hearing, Speech, and Vision, she was coded as 0 indicated Resident #34 understands and was understood by others. Section C Cognitive Patterns, under section C0500 Brief Interview for Mental Status, which indicated a score of 12 for moderately impaired cognition. Section G, Function Status, under section B indicated she needed supervision with bed mobility, transfers, dressing, eating and toileting. Section O, Treatments, Procedures, and Programs, under section 00100 indicated oxygen was used in last 14 days.
Review of Resident #40's physicians order dated 01/13/23 indicated: may wear oxygen at 2 liters via nasal cannula continuously.
Review of Resident #40's comprehensive person-centered care plan dated 03/25/21 when it was initiated, and it was revised on 09/09/22. Focus indicted: Resident #40 has the diagnosis of acute respiratory failure with hypoxia, acute respiratory distress syndrome and history of COVID-19 and has the potential for complication. Interventions: monitor for signs and symptoms of respiratory distress and report to physician as needed, monitor document report abnormal breathing patterns to MD, maintain a clear airway and administer medication as ordered.
During an observation on 01/09/23 at 12:19 p.m., Resident #40 was sitting in her wheelchair next to bed with oxygen cylinder sitting next to entry door unsecure.
During an observation on at 01/10/23 at 3:58 p.m., oxygen cylinder sitting beside canister holder in Resident #40's room.
During an interview on at 01/10/23 at 4:20 p.m., CNA P observed Resident #40's oxygen cylinder next to wall unsecure. CNA P said she was not aware if oxygen cylinders could be in the room unsecure. CNA P said she would go ask the charge nurse to verify.
During an interview on 01/10/23 at 4:26 p.m., ADON A observed an oxygen cylinder on the floor in Resident #40's room. ADON A said the oxygen cylinder should not be in the room unsecure. ADON A said failure to secure oxygen can be dangerous for everyone, it could explode.
During an interview on 01/10/23 at 04:48 p.m., LVN L said oxygen cylinders should not be on the floor unsecure. LVN L said an unsecure oxygen cylinder could be dangerous for many reasons.
During an interview on 01/17/23 at 2:06 p.m., RNC said she expected oxygen cylinders to be always secure in a canister or back of wheelchair holder. The RNC said the risk of oxygen cylinders being unsecure could lead to them falling over or blowing up related to compressed air. The RNC said she expected all staff to know oxygen cylinders should never be freestanding.
Based on observation, interview, and record review the facility failed to ensure the residents environment remained free of accident hazards by not adequately monitoring the proper storage of oxygen cylinders for 2 of 2 residents, (Resident #'s 16 and 54), proper transfer for 1 of 1 resident (Resident #38) and timely completion of smoking assessments for 1 of 1 resident (Resident #54).
The facility failed to ensure Resident #54 had a smoking assessment completed quarterly.
These deficient practices could place residents at risk of injury.
Findings include:
3. Record review of Resident #54's face sheet, dated 1/13/23, revealed the resident was [AGE] year old female who admitted to the facility on [DATE] (readmission [DATE]) with diagnoses which included: chronic obstructive pulmonary disease (a chronic inflammatory lung disease that causes obstructed airflow from the lungs), unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, or anxiety (a mental disorder in which a person loses the ability to think, remember, learn, make decisions, and solve problems), disorder of the arteries and arterioles (a buildup of fatty deposits in the arteries), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), anxiety disorder (a condition in which a person has excessive worry and feelings of fear, dread, and uneasiness), hallucinations (an experience involving the apparent perception of something not present), and dependence on supplemental oxygen.
Record review of Resident #54's Quarterly MDS assessment, dated 12/29/22, revealed the resident's BIMS score was 4, which indicated severe cognitive impairment. The resident required total dependence with locomotion off unit, extensive assistance with transfer, dressing, toilet use, and personal hygiene, and supervision for the tasks of locomotion on unit and eating.
Record review of Resident #54's care plan, undated, revealed Resident #54 with a focused that indicated I am at risk for Respiratory infections/distress, Hypoxia, SOB, and cough related to DX of COPD and dependence on supplemental oxygen. I continue to want to go smoke once daily. I will immediately start desaturation, and this is very risky for me. Only a nurse can take me to smoke. I will be educated and encouraged to start cessation. I have agreed and will start smoking cessation by using nicotine patch. I can continue to ask to smoke even though my O2 saturation put me at great risk and am not using the patch. My O2 saturation low even with O2 and it is not safe to smoke, but I continue to ask. Hospice will not write an order to not smoke as this is a resident right, but nursing judgement is used here because if I smoke my O2 saturation drop to the 30's and this is detrimental to my health and safety. Nicotine addiction- I am a smoker: I have been assessed to be: Supervised smoker. A new focus indicated I smoke Traditional cigarettes. I had decided that would try nicotine patches to aid in quitting but have now decided I want to continue to smoke. Intervention for this focus is to complete smoking assessment as per facility policy, no Oxygen present while in smoking area, and will be aware & practice safe smoking techniques.
Record review of electronic medical records for Resident #54 had a smoking assessment completed on, 3/19/21, 6/18/21, 9/18/21, and 12/18/21 no others smoking assessment dated [DATE], indicated that the resident is cognitive capable of making decision to smoke, the resident does not understand facility smoking policy due to diagnosis of dementia, resident has a history of smoking-related problems that would be hazardous to self or others because oxygen saturation while smoking. It further indicated the resident requires the supervision of a licensed nurse when smoking due to concerns with her oxygen saturation dropping, so the nurse can assist accordingly in such a situation.
During observation and interview on 1/9/23 at 09:44 AM with Resident #54, she said that she required assistance from staff with smoking. She said the social worker had not talked to her about smoking. She said she was not involved in any care plan meeting about smoking. She said the staff do not take her to smoke and just inform her that a nurse will come soon. She said she had not been out to smoke today yet. She said she only wants to smoke one time a day and that is at the 10AM slot.
During observation and interview on 1/10/23 at 11:47 AM with Resident #54, she said she asked a nurse to take her smoking during the 10 AM smoking slot but no one ever came.
During observation and interview on 1/11/23 at 02:34 PM with Resident #54, she was observed in observed in the lobby area near the nurse's station. She said she was waiting to go for a smoke break and has been waiting since 10 AM. She said she asked nursing staff, and no one has taken her.
During observation and interview on 1/12/23 at 11:12 AM with Resident #54, she was observed in bed watching TV. She said she had been out to smoke earlier, but she cannot remember who had taken her to do so.
During interview on 1/9/23 at 9:57 AM with LVN L, she said she was told from DON that Resident #54 is no longer allowed to smoke due to oxygen saturation decreasing. She said she is aware that the resident if free to make her own decision about smoking. She said the social worker was responsible for completing the smoke assessment.
During interview on 1/17/23 at 1:54 PM with LVN O, she said nursing staff do not complete smoking assessment. She said the social worker was responsible for getting those completed. She said she was not sure if Resident #54 has had one completed. She said she would not normally check a smoking assessment and that either DON or social worker would inform them of any changes in the resident.
During interview on 1/13/23 at 1:13 PM with the Social Worker, she said she was responsible for completed smoking assessment on all smoking residents. She said she was aware that Resident #54 was a smoking resident even though she was not listed on the smokers list provided by facility. She said Resident #54 only smokes about once a day. She said she could not locate a resident smoking assessment for Resident #54, but she would complete one today. She said she was not aware that it was overdue because she is a new social worker to the facility. She the assessment informed staff of the type of care that is needed for the resident for smoking and what the parameters of that care is. She said Resident #54 must have a nurse with her during smoking times due to her oxygen saturation decreased. She said Resident #54 has been prescribed a nicotine patch but refuses to allow staff to place it on her. She said the risk to residents if a smoking assessment was not conducted on admission, quarterly or any time there is a change of condition was that they could have accidents or burn themselves or others.
During interview on 1/17/23 at 4:22 PM, with the Regional Corporate Nurse who said she expects staff to complete a smoking assessment according to facility policy which is on admission, if applicable, quarterly, and/or if there was a change of condition. She said the person responsible for this task is the social worker. She said she was not aware that Resident #54 had not had a smoking assessment conducted since 12/21.
Record review of the undated facility smoking policy, revealed 18. Smoking assessment will be completed on admission, quarterly, and as needed only on residents who use tobacco and E-cigarette .
4. Record review of a face sheet dated 01/11/23, indicated Resident #16 was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses of diabetes (chronic condition that affects the way the body processes blood sugar), end stage renal disease (kidneys cease functioning on a permanent basis), and high blood pressure.
Record review of the quarterly MDS assessment dated [DATE], indicated Resident #16 was usually understood and usually understood others. The MDS revealed Resident #16 BIMS score was a six, indicating she had severe impaired cognition. The MDS indicated Resident #16 required supervision with transfers, locomotion, dressing and toileting. Resident #16 required limited assistance with bed mobility, eating, and personal hygiene and extensive assistance with bathing. The MDS under Section O (Special Treatments, Procedures, and Programs) did not have oxygen therapy checked as being received.
Record review of the other summary report dated 01/11/23 did not reveal Resident #16 had an order for oxygen.
During an observation on 01/09/23 at 10:15 AM, Resident #16 had an oxygen cylinder in a wheelchair sleeve freestanding at the corner of the left side of her room. Resident #16 was not in the room.
During an observation on 01/09/23 at 03:54 PM, Resident #16 continued to have the oxygen cylinder in the corner of the left side of the room. Resident #16 was not in the room.
During an observation and interview on 01/10/23 at 4:25 PM, Resident #16 continued to have an oxygen cylinder in a wheelchair sleeve freestanding at the corner on the left side of her room. LVN H said the oxygen cylinder should not be left freestanding because it can be dangerous for the resident if it falls over it can explode. LVN H said the oxygen cylinder should be secured behind the wheelchair or on a rolling stand. LVN H indicated everyone was responsible for ensuring the oxygen cylinders are properly secured.
During an interview on 01/17/23 at 12:51 PM, ADON A said she expected the oxygen cylinders to be properly secured on the wheelchair or in a rolling stand. ADON A said the oxygen cylinders should not be freestanding as they can fall over and explode which can therefore cause serious harm to the residents.
During an interview on 1/17/23 at 1:57 PM, the RNC said she expected the oxygen cylinders to be properly secured. The RNC said if the oxygen cylinder was knocked over it could cause serious harm to the residents. The RNC said she expected everyone that goes in and sees it should be able to tell that it needs to be secured.
During an interview on 01/17/23 at 5:00 PM, the Interim Administrator said he expected the oxygen cylinders to be stored in the oxygen storage room so they will not get knocked over.
Record review of the facility's policy titled Oxygen Safety dated 12/01/22 indicated .the policy of this facility is to provide a safe environment for resident's staff, and the public .Cylinders will be properly chained or supported in racks or other fastenings (i.e. sturdy portable carts, approved stands) to secure all cylinders from falling, whether connected, unconnected, full, or empty .when small-size (A,B,D, or E) cylinders are in use, they shall be attached to a cylinder stand or to a medical equipment designed to receive and hold compressed gas cylinders .
Record review of a Safe Lifting and Movement of Residents policy dated July 2017 indicated in order to protect the safety and well-being of staff and residents, and to promote quality care, this facility uses appropriate techniques and devices to lift and move residents. 2. Manual lifting of residents shall be eliminated when feasible. 4. Staff responsible for direct resident care will be trained in the use of manual (gait/transfer belts, lateral boards) and mechanical lifting devices.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain acceptable parameters for nutritional status such as usual body weight or desirable body weight range by failing to provide nutritional and hydration care and services to residents consistent with the resident's comprehensive assessment for 4 of 21 Residents reviewed for weight loss. (Resident #'s 32, 38, 119, 220)
1.The facility did not address Resident #32's weight loss of 12.7-pounds in one month.
2.The facility failed to provide Resident #32 her magic cup (nutritional ice cream) with lunch and dinner meals. The facility failed to have the dietician to address Resident #32 weight loss.
3.The facility did not address Resident #38's weight loss of 35 pounds since admission on [DATE].
4.The facility did not obtain an admission weight for Resident #119. The facility did not address Resident #119's weight loss of 30 pounds.
5.The facility failed to ensure Resident #220 received an accurate weight upon admission or within the two weeks following.
6. The facility failed to implement dietician recommendations timely for Resident #220.
An Immediate Jeopardy (IJ) situation was identified on 01/13/2023 at 1:20 p.m. While the IJ was removed on 01/17/2022, the facility remained out of compliance at a scope of a pattern with the severity of potential for harm that was not immediate jeopardy, with a scope identified as a pattern due to the facility's need to evaluate the effectiveness of the corrective systems.
These failures could place residents at risk for decreased nutritional status, decline in health, serious illness, or hospitalization.
Findings included:
Record review of the CMS 672, dated 01/09/2023, indicated in Section G, other. F140 1 resident with unplanned significant weight loss/gain.
1). Record review of Resident #32's face sheet, dated 1/13/2023, indicated Resident #32 was a [AGE] year-old female who was admitted to the facility on [DATE] with the diagnosis diagnoses which included of stroke, pain, seizures, dysphagia (difficulty swallowing) and malnutrition (lack of nutrition).
Record review of Resident #32's consolidated physician's orders dated 01/13/2023 indicated Resident #32 had a diet order of mechanical soft and nectar thickened fluids dated 02/05/2022, and a magic cup with lunch and dinner dated 09/06/2021.
Record review of Resident #32's computerized weights indicated her weight was 153.8 pounds on 12/09/2022 and 141.1 pounds on 01/06/2023.
Record review of a comprehensive care plan dated 04/08/2023 and revised on 05/03/2021 indicated Resident #32 required assistance with her ADLs including assistance with eating, with staff to feed Resident #32 if she was unable to complete the task. The care plan indicated Resident #32 was at risk for weight loss with the goal of maintaining her current level of weight through 02/16/2023. The interventions included monitor for signs of malnutrition, a weight every month, and report a loss or gain of more than 5%. The comprehensive care plan also indicated Resident #32 was receiving a therapeutic diet and was at risk for nutritional deficit. The goal was Resident #32 would consume adequate fluid and would consume 75% or more of the meals served with no associated weight loss through next review dated 04/08/2021. The interventions included administer snacks, and supplements as ordered, and provide a magic cup with lunch and dinner dated 07/07/2021.
Record review of an Annual MDS dated [DATE] indicated Resident #32 was sometimes understood and sometimes understands, and Resident #32's BIMs score was 00 indicating severe cognitive impairment. The MDS indicated Resident #2 required total assistance of one staff with meals. The MDS in Section K indicated Resident #32 did not have a swallow disorder or signs of a swallowing disorder. Section K also indicated Resident #32's height was 70 inches, and her weight was 147 lbs. with no weight loss or weight gain documented.
Record review of a weight record dated 01/13/2023 indicated Resident #32's 180 days prior was 151.8 pounds., 90 days prior weight was 152.8 pounds., and on 01/06/2023 Resident #32's weight was 141.1 pounds.
Record review of the dietician reports revealed the following:
-On *10/22/2022, there was: no mention of recommendations for weekly weights for Resident #32.
-On *11/11/2022, there was: no mention of recommendations for weekly weights for Resident #32.
-On *11/30/2022, there was: no mention of recommendations for weekly weights for Resident #32.
-On *12/10/2022, there was: no mention of recommendations for weekly weights for Resident #32.
- On *12/18/2022, there was: no mention of recommendation for weekly weights for Resident #32.
On *01/08/2023 and 01/09/2023, there was: no mention of recommendations for weekly weights for, Resident #32.
During observations on 01/10/2013 - through 01/11/2023 for Resident #32 revealed the following:
-On *01/10/23 at 12:55 p.m., there was no supplement with the Resident #32's lunch meal.
-On *01/10/2023 at 5:55 p.m., there was no magic cup with her Resident #32's evening tray.
- On *01/11/2023 at 12:25 p.m., there was no magic cup with her Resident #32's lunch tray.
-On *01/11/2023 at 6:00 p.m., there was no supplement with her Resident #32's evening tray.
During an interview with the DON on 01/11/2023 at 3:26 p.m., The DON said she inputs the resident's weights in the computer after their weight was obtained. The DON said the person obtaining the weights just logs the weight obtained. The DON said when she reviews the weights, she stars them for a reweight to verify. The DON said the hospital weights were often not correct therefore it was important to have a weight.
Record review of the undated dietary supplement list, there were no residents receiving a magic cup at lunch or dinner.
2) Record review of Resident #38's face sheet, dated 1/13/2023, indicated Resident #38 was an [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE] with the diagnosis diagnoses which included of stroke, diabetes (too much sugar in the blood), chronic kidney disease (longstanding disease of the kidney), and muscle weakness.
Record review of the consolidated physician orders dated 1/13/23 indicated Resident #38 did not have a diet ordered. Resident #38 had orders in a que including the diet order waiting for processing.
Record review of Resident #38's comprehensive care plan dated 11/29/2022 there was no care plan addressing the risk of weight loss or actual weight loss.
Record review of the clinical records for Resident #38 indicated the Initial MDS was not completed.
Record review of Resident #38's weights indicated his weight on 11/18/2022 was 225 pounds, his weight on 11/29/2022 was 200 pounds, his weight on 12/17/2022 was 242 pounds, and on 01/06/2023 was 190 pounds.
Record review of a dietician progress note dated 11/30/2022 indicated Resident #38 weight was 200.0 pounds with a height of 73 inches. The dietician's note indicated Resident #38 had a regular diet with thin liquids, he could feed himself with supervision. The goal of the recommendations was he would maintain weight without a significant change. And the recommendations were to continue the diet.
Record review of a dietician's consultant, dated 11/30/2022, indicated Resident #38 had no recommendations even though the weights indicated he had already lost 25 pounds.
Record review of a dietician's consultant report dated 12/10/2022 indicated Resident #38 was not evaluated.
Record review of a dietician's consultant report dated 12/18/2022 indicated Resident #38 was not evaluated.
Record review of a dietician's consultant report dated 01/08/2023 indicated Resident #38 was not evaluated.
During an observation on 01/09/2023 at 1:05 p.m., Resident #38 was eating lunch in his room. Resident #38 remains on isolation precautions for C-diff, an infection causing profuse diarrhea.
During an observation on 01/10/2023 at 1:15 p.m., Resident #38 was eating lunch while lying in his bed.
Record review of a dietary profile dated 01/11/2023 indicated Resident #38 was receiving a regular diet with no dietary supplements.
3) Record review of a face sheet dated 01/11/2023 indicated Resident #119 was an [AGE] year-old female who admitted on [DATE] with the diagnoses of joint replacement surgery, muscle weakness, and high blood pressure.
Record review of the admission MDS dated [DATE] indicated Resident #119 understood others and she was understood. The MDS indicated Resident #119 had problems with recall and her BIMs score was an 11 indicating she had moderate impairment with cognition. The MDS indicated Resident #119 required extensive assistance of one staff member with eating. The section GG of the MDS indicated Resident #119 was independent eating with no assistance. The MDS indicated Resident #119 weight was 130 pounds in the section K0200. The MDS indicated Resident #119 had no weight loss or weight gain in the section of K0300.
Record review of a hospital medication consolidation record dated 12/19/2022 indicated on 12/14/2022 Resident #119's weight was 160 pounds, and her height was 62 inches.
Record review of a Dietary Profile dated 12/28/2022 indicated Resident #119 was receiving a regular diet and did not require any nutritional supplements.
Record review of Resident #119's weights indicated only one weight was obtained since admission on [DATE] of 130 pounds.
Record review of a Dietician Progress Note dated 01/08/2023 indicated Resident #119 was eating 50-75 % of meals, her weight was 130 pounds and stable. The note also indicated Resident #119 had no skin issues. The notes comments indicated the diet was regular diet with thin liquids, to maintain weight without significant change over the next three months and to continue current diet. The dietician note does not indicate there was a significant weight loss from the hospital weight of 160 pounds and the facility weight of 130 pounds.
Record review of the Dietician Recommendation indicated on 01/08/2023 Resident #119 had no recommendations.
Record review of the comprehensive care plan dated 01/10/2023 indicated Resident #119 was receiving a regular diet with the goal of her weight remaining stable through the next review. The interventions included allow choices in food items, and provide snacks or supplements as ordered.
During an observation on 01/10/2022 Resident #119 had consumed 50 % of her meal while in her bed.
Record review of the consolidated physician's orders dated 01/11/2022 indicated Resident #119's diet was a regular diet with thin liquids started 12/19/22.
4. Record review of Resident #220's face sheet, dated 1/13/23, revealed the resident was [AGE] year old male who admitted to the facility on [DATE] with diagnoses which included: chronic obstructive pulmonary disease (a chronic inflammatory lung disease that causes obstructed airflow from the lungs), sepsis (the body's extreme response to an infection), Type 2 diabetes mellitus without complications (an impairment in the way the body regulates and uses sugar (glucose) as a fuel), peroration of intestine (a loss of continuity of the bowel wall), paroxysmal atrial fibrillation (terminates spontaneously or with intervention within seven days of onset), heart failure (a condition that develops when your heart doesn't pump enough blood for your body's needs), and acute cystitis without hematuria (a sudden inflammation of the urinary bladder).
Record review of Resident #220's Quarterly MDS assessment was not completed and was not due according to admit date .
Record review was attempted of Resident #220's baseline care plan but one was not completed. No comprehensive care plan was due according to admit date .
Record review of Dietary consult visit dated, 1/8/23, for updated nutritional assessments. It was recommended that Resident #220 his tube feeding, Glucerna, be increased 650 ML per hour from 500 ML per hour, as prescribed on discharge summary, and water increased to 35 ML per hour from 20ML per hour, as prescribed on discharge summary. Dietician requested accurate height and weight be completed as none was available.
Record review of hospital discharge documents dated 12/29/22 indicated Resident #220 weighted 90.5 Kg (199.52 pounds) on 12/29/22, date of discharged . Record review of weight check on 1/11/23 indicated Resident #220 weighed 164.8 for a total weight loss of 34.3 (17.40 percent). This showed significant weight loss in less than a 30-day period .
During observation on 1/9/23 at 5:45 p.m., Resident #220 was asleep in his bed. The head of the bed was elevated, and he was receiving his tube feeding via pump . The pump read 500 ML per hour of Glucerna and 20ML per hour of water.
During observation of weight check for Resident #220 on 1/11/23, CNA S conducted an in-bed weight and the scale indicated, 164.8.
During observation and interview on 1/11/23 at 09:49 AM with Resident #220, he said he was new the facility and was just placed back on the regular floor. He said he contracted COVID-19. He said he had not been weighed when he arrived. He said he was weighed, maybe a day ago. He said he was unsure if he has lost any weight. He said he received his food through tube feeding placed while in the hospital prior to his admission. He said he has not seen anyone that said they was a dietician or nutritionist.
During observation of weight check for Resident #220 on 1/13/23, CNA S conducted an in-bed weight and the scale indicated, 162.4.
During interview on 1/13/23 at 3:57 PM with CNA S, she said the DON usually had her to complete the weights weekly or monthly for residents. She said she knew she had to weigh new admits four times weekly and then it depended on if they have had any issues if she had to continue. She said she must weigh all residents at the beginning of the month. She said the weights must be done before the dietitian visits for the month. She said when she completed all the weights, she gave them to the DON, and usually within the next few days she would ask her to re-weigh a resident if needed. She said the DON entered all the weights into the electronic medical records, to her knowledge, after they have been reviewed and corrected.
During an interview on 01/12/2023 at 2:24 p.m., the ADON A indicated there were no weekly standards of care meetings to review each resident with wounds, weight loss, or accidents.
During an interview on 01/17/2023 at 1:36 p.m., LVN L indicated residents should be weighed on admission. LVN L indicated with not knowing the admission weight there could be a weight loss leading to skin problems, and even the loss of mobility.
During an interview on 01/17/2023 at 2:39 p.m., the Regional Nurse Consultant indicated she was unaware of weight loss issues. The corporate nurse indicated new admissions should have a weight once a week for 4 weeks or until stable. The corporate nurse indicated the admitting nurse was responsible for obtaining the admission weight. The corporate nurse indicated there was not a reason for the admission or weekly weights not being obtained.
During an interview on 01/17/2023 at 4:55 p.m., the Interim Administrator indicated the physician should be notified when the resident's weight falls in the parameter areas either a loss or a gain. The Interim Administrator indicated health issues could arise when weights were not monitored. The Interim Administrator indicated the charge nurses, and DON were responsible for the monitoring of weights.
Record review of a Nutritional Management policy dated 07/01/2022 indicated the facility provides care and services to each resident to ensure the residents maintains acceptable parameters of nutritional status in the context of his or her overall condition. 2. Identification/Assessment: a. Nursing staff shall obtain the resident's height and weight upon admission, and subsequently in accordance with facility policy. C. A comprehensive nutritional assessment will be completed by a dietician within 72 hours of admission, annually, and upon significant change in condition. Follow-up assessments will be completed as needed.
Record review of a Weight Monitoring policy dated 07/01/2022 indicated based on the resident's comprehensive assessment, the facility will ensure that all residents maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise. Compliance Guidelines: Weight can be a useful indicator of nutritional status. Significant unintended changes in weight (loss or gain) or insidious weight loss may indicate a nutritional problem. 5. A weight monitoring schedule will be developed upon admission for all residents: A. Weights should be recorded at the time obtained. B. newly admitted residents-monitor weight weekly for 4 weeks, Residents with weight loss -monitor weight weekly. 6. Weight analysis: The newly recorded resident weight should be compared to the previous recorded weight. A significant change in weight is defined as: a. 5% change in one month, b. 7.5% change in 3 months, c. 10% change in 6 months. Documentation: a. The physician should be informed of a significant change in weight and may order nutritional interventions.
These were determined to be an Immediate Jeopardy (IJ) on 01/13/2023 at 1:20 p.m. The Administrator was notified on 01/13/2023 at 1:20 p.m. that an Immediate Jeopardy (IJ) was identified due to the above failures. The Administrator was provided with the IJ template The IJ template was provided on 01/13/2023 at 1:25 p.m.
The following Plan of Removal submitted by the facility. The plan of removal for F692 was accepted on 01/15/2023 at 5:16 p.m. and included the following:
Weight:
Residents at the care center reweighed to compare to January weights by DON, ADON, and transportation aide completed 01/14/2023: verified by record review of weekly weight logs.
Any significant increase or decrease in weight addressed by notifying MD, dietician, and family. DON made notifications completed by 01/14/2023; verified by record review of resident printed orders.
Any identified increase or decrease in weight was placed on weekly weights x 4 weeks and or until weight has been stabilized or until MD orders discontinue. Completed on 01/14/2023: verified by record review of the weekly weight log.
Any new orders implemented immediately by licensed care staff. Completed 01/14/2023: verified by record review of the printed physician's orders.
Admitting nurse or CNA will obtain admission weights with follow up by the ADON within 24 hours.
admission will have weekly weights x 4 weeks or until stable weights.
Monitoring by DON, ADON, and MDS to prevent further systemic failure.
Record review of weekly weight variance record dated 1/14/23 indicated 19 residents had weight variances identified. Record review of the physician orders indicated the physician had implemented supplements, dietician referrals, and weekly weight monitoring.
Record review of in-service training report dated 1/12/23 indicated to implement all orders in a timely manner. 1. Dietary, Wound consultant treatments, and any other orders must implemented in a timely manner. 2. Orders must coincide with treatment and carried out as ordered.
Interviews on 01/17/23 from 5:00 p.m. until 5:48 p.m. the surveyor confirmed the facility implemented their plan of removal.
Interviews with 3 (6am-6pm) nurses LVN B, LVN D and LVN R, 2 (6pm-6am) nurses LVN U and LVN HH ,said they were in-serviced on obtaining weights on admission then every week for 4 weeks or stable, reporting weight changes to the physician.
Interviews with 4 CNAs (6am-6pm) CNA FF, CNA GG, CNA D, and 4 CNAs (6pm-6am) CNA MM, CNA OO, CNA PP and CNA LL indicated they were in-serviced on obtaining weights on admission.
The CEO and interim Administrator were informed the Immediate Jeopardy was removed on 01/17/23 at 6:16 p.m. The facility remained out of compliance at a severity level of potential for harm that is not immediate jeopardy and a scope of pattern due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure respiratory care was provided consistent with professional standards of practice for 3 of 20 residents reviewed for respiratory care. (Resident #51, Resident# 35, Resident #36).
The facility did not ensure Resident #51's oxygen concentrator filters was free from gray like substances.
The facility failed to date the oxygen tubing for Resident #35 and Resident #36.
The facility failed to provide oxygen concentrator filters for Resident #35, and Resident #36.
These failures could place residents who required respiratory care at risk for respiratory infections.
1.Record review of the face sheet dated 01/13/23 indicated Resident #51 was [AGE] years old female admitted [DATE] and readmitted [DATE] with diagnoses of Left hip fracture, high blood pressure, atrial fibrillation (abnormal heartbeat) and muscle weakness.
Record review of the MDS assessment dated [DATE] for significant change of status indicated Resident #51 in section B was usually understood and usually understood others. The BIMS (Brief Interview for Mental Status) was a 15 indicated Resident #51 was cognitive intact. The MDS in section G indicated Resident #51 required supervision with bed mobility, transfers, eating, transfers, and person hygiene and extensive assist with bathing. Section O, Special Treatments, Procedures, and Programs, under section 00100 did not indicate oxygen therapy.
Review of Resident #51's physician's orders dated 01/13/23 indicated, Change respiratory tubing, mask, bottled water, clean filter every 7 days on Sunday night.
Review of Resident #51's physician's orders dated 01/13/23 indicated, Oxygen at 2 liters at bedtime.
Review of Resident #51's comprehensive person-centered care plan dated 04/14/20 when it was initiated, and it was revised on 09/11/22. Focus indicted: Resident #51 was at risk for shortness of breath related to decreased energy and fatigue. Intervention: Apply medication, oxygen and administer nebulizer treatments as ordered by physician.
During an observation on 01/09/23 at 12:26 p.m., Resident #51 was in his room sitting in his wheelchair. Resident #51's oxygen concentrator filter noted with gray like material.
During an observation on 01/10/23 at 4:21 p.m., Resident #51's oxygen concentrator filter noted with gray like material.
During an interview on 01/13/23 at 4:51 p.m., LVN N observed Resident #51's oxygen filter with gray like material. LVN N said filters are supposed to be cleaned on Sunday night. LVN N said failure to clean filters could cause respiratory failure and infection.
2. Record review of Resident #35's electronic face sheet, dated 01/13/23, revealed an [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Metabolic encephalopathy (is a problem in the brain. It is caused by a chemical imbalance in the blood), diabetes, high blood pressure, Chronic obstructive pulmonary disease (COPD) (is a chronic inflammatory lung disease that causes obstructed airflow from the lungs), and dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities).
Record review of Resident #35's quarterly MDS assessment, with an ARD of 10/07/22, revealed under Section B, Hearing, Speech, and Vision, she was coded as 1 for usually understand and usually understood by others. Section C, Cognitive Patterns, under section C0500 Brief Interview for Mental Status, which indicated a score of 10, which indicated moderately impaired cognition. Section G, Function Status, under section G0110 indicated she needed supervision with bed mobility, transfers dressing, eating, personal hygiene and toileting. Section O, Special Treatments, Procedures, and Programs, under section 00100 did not indicate oxygen therapy.
Review of Resident #35's physician's orders dated 01/13/23 indicated, Change respiratory tubing, mask, bottled water, clean filter every 7 days on Sunday night.
Review of Resident #35's physician's orders dated 01/13/23 indicated, Oxygen at 2 liters as needed.
Review of Resident #35's comprehensive person-centered care plan dated 08/26/19 when it was initiated, and it was revised on 09/20/22. Focus indicted: Resident #35 was at risk for shortness of breath, chest pain, increased edema .related to congestive heart failure. Intervention: Apply oxygen and administer nebulizer treatments as ordered and monitor for effectiveness.
During an observation on 01/09/23 at 9:40a.m., Resident #35 was sitting in her recliner with oxygen on. Resident #35 had oxygen tubing connected to her concentrator and located on back of her wheelchair. Resident #35 had neither oxygen tubing dated nor a concentrator filter.
During an observation on 01/10/23 at 9:13 a.m., Resident #35 was sitting in her wheelchair with oxygen tubing not dated or bagged. Resident #35 did not have a filter on her concentrator.
During an observation and interview on 01/10/23 at 4:59 p.m., LVN K, observed Resident #35 's oxygen tubing on floor, not bagged, no date and no filter on concentrator. LVN J said oxygen tubing should be changed and dated on Sunday nights. LVN J said the tubing should be dated and filters rinsed out weekly for infection reasons.
During an observation on 01/11/23 at 9:15 a.m., Resident #35's oxygen tubing on floor and no filter on concentrator.
3.Review of Resident #36's electronic face sheet dated 01/13/23 revealed an [AGE] year old male admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses of Metabolic encephalopathy (is a problem in the brain. It is caused by a chemical imbalance in the blood), high blood pressure, pneumonia, depression, and dementia.
Review of Resident #36's quarterly MDS assessment with an ARD of 09/29/22 revealed under Section B, Hearing, Speech, and Vision, he was coded as 1 for usually understands and usually understood by others. Section C, Cognitive Patterns, under section C0500 Brief Interview for Mental Status, which indicated a score of 10 for moderately impaired cognition. Section G, Function Status, under section B indicated he needed supervision with transfers and toileting. Section O, Special Treatments, Procedures, and Programs, under section 00100 did not indicate oxygen therapy.
Review of Resident #36's physician's orders dated 01/13/23 indicated, Change respiratory tubing, mask, bottled water, clean filter every 7 days on Sunday night.
Review of Resident #36's physician's orders dated 01/13/23 indicated, Oxygen at 2 liters as needed.
Review of Resident #36's comprehensive person-centered care plan with target date of 12/28/22 did not reveal a care plan for oxygen.
During an observation on 01/09/23 at 10:41 a.m., Resident #36 was sitting in his recliner with oxygen on at 2 liters. Resident #36 oxygen tubing had no date and no filter noted on concentrator.
During an observation on 01/10/23 at 9:33 a.m., Resident #36 was sitting in his recliner with oxygen on at 2 liters via nasal cannula. Oxygen tubing noted with no date and no filter noted on concentrator.
During an observation and interview on 01/11/23 at 4:28 p.m., LVN L went into Resident #35's and Resident#36's room and verified neither had dates on their oxygen tubing or filters on their concentrators. LVN L said they both should have filters on their concentrators for infection reasons. LVN L said she did not have any filters but would have maintenance to replace.
During an interview on 01/16/23 at 6:40 p.m., LVN X said they clean filters, change the oxygen/HHN tubing on Sunday nights and date the tubing. LVN X said this was done to prevent infection and respiratory issues.
During an interview on 01/17/23 at 2:06p.m., the RNC said she expected oxygen tubing to be changed weekly and dated and bagged when not in use and concentrator filters to be cleaned weekly and as needed. The RNC said failure to change or keep clean could lead to respiratory infection. The RNC said the ADON's should be monitoring to make sure oxygen, HHN and filters are changed or cleaned.
During an interview on 01/17/23 at 2:30p.m., RNC said they did not have a policy on respiratory care.
During an interview on 01/17/23 at 5:00p.m., the interim administrator said he expected charge nurses to follow physicians' orders on respiratory equipment. The interim administrator said the administrative nurses to follow up and failure to follow could cause respiratory issues.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure dialysis services were provided consistently with professional standards of practice for 1 of 1 resident (Resident #16) reviewed for quality of care.
The facility failed to keep ongoing communication with the dialysis facility for Resident #16.
This failure could place the residents, who received dialysis, at risk for complications and not receiving proper care and treatment to meet their needs.
Findings included:
Record review of a face sheet dated 01/11/23, indicated Resident #16 was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses of diabetes (chronic condition that affects the way the body processes blood sugar), end stage renal disease (kidneys cease functioning on a permanent basis), and high blood pressure.
Record review of the quarterly MDS assessment dated [DATE], indicated Resident #16 was usually understood and usually understood others. The MDS revealed Resident #16 BIMS score was a six, indicating severe impaired cognition. The MDS indicated Resident #16 required supervision with transfers, locomotion, dressing and toileting. Resident #16 required limited assistance with bed mobility, eating, and personal hygiene and extensive assistance with bathing. The MDS under Section O (Special Treatments, Procedures, and Programs) had dialysis checked.
Record review of the other summary report dated 01/11/23 revealed Resident #16 had an order to transport to dialysis center on Monday, Wednesday, and Friday via facility van.
Record review of the comprehensive care plan dated 03/30/22 indicated Resident #16 had impaired renal function, received dialysis three times a week, and was at risk for shortness of breath, chest pain, and infection to shunt site. The care plan had interventions to monitor the resident's condition pre and post dialysis and report abnormalities to the medical director.
Record review of the Resident #16's dialysis communications sheets revealed the facility had not completed the upper portion of the dialysis communication sheet which included the resident's vital signs, condition, or new orders prior to leaving the facility for the following dates:
*12/21/22
*12/23/22
*12/26/22
*12/28/22
*12/30/22
*01/02/23
*01/04/23
*01/06/23
*01/09/23
*01/11/23
During an interview on 01/13/22 at 08:53 AM, LVN H indicated that she completes the upper portion of the dialysis communication prior to Resident #16 leaving for dialysis and she places it at the nurse's station for transport to get. LVN H said transport does not always get them.
During an interview on 1/13/23 at 03:18 PM, the RN at the dialysis clinic said she has not been receiving the dialysis communication consistently from the facility.
During an interview on 01/13/23 at 05:34 PM, LVN N said the charge nurse for Resident #16 was responsible for completing the upper portion of the dialysis communication sheet prior to resident leaving for dialysis. LVN N said the vital signs, medications taken that morning and any medications due at dialysis should be filled out. LVN N said by not filling out the dialysis communication sheet could place the resident at risk for being placed on the dialysis machine, have an adverse reaction, and die.
During an interview on 01/17/23 at 11:38 AM, LVN O said she does not send a dialysis communication form every time Resident #16 leaves for dialysis. LVN O said by not completing the dialysis form, the resident could be risk for having her blood pressure drop during dialysis treatment if the facility was not aware her blood pressure had been low prior to treatment.
During an interview 01/17/23 at 12:51 PM, ADON A said she expected the dialysis communications sheet be filled out prior to each dialysis treatment and given to the transport personnel. ADON A said the risks for not completing the dialysis communication prior to dialysis treatment and noting any changes the resident had, could cause Resident #16 to have complications during dialysis treatment.
During an interview on 01/17/23 at 01:57 PM, RNC said she expected the facility nurse to fill out the top portion of the dialysis communication sheet prior to Resident #16 leaving for dialysis. RNC said by not completing the dialysis sheet, the resident was at risk for a poor outcome during treatment if the resident was having issues prior to treatment and the dialysis clinic was not aware of them.
During an interview on 01/17/23 at 05:00 PM, the Interim Administrator said he expected the dialysis communication sheet be filled out for each dialysis resident. The Interim Administrator said by not completing the sheet will cause each facility to not be informed of the resident's health status.
Record review of the facility's policy titled Hemodialysis dated 07/01/22 indicated . The facility will provide the necessary care and treatment, consistent with professional standards of practice, physician orders, the comprehensive person-centered care plan, and the resident's goals and preferences, to meet the special medical, nursing, mental, and psychological needs of the residents receiving hemodialysis .the licensed nurse will communicate to the dialysis facility telephonic communication or written format, such as a dialysis communication form or other form, that will include, but not limited itself to: timely medication administration (initiated, held, or discontinued) by the nursing home and or/dialysis. Physician/treatment orders, laboratory values, and vital signs .changes and/or decline in condition unrelated to dialysis

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of Resident #30's electronic face sheet dated 01/13/23 revealed a [AGE] year-old female was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses of diabetes, muscle weakness, Parkinson (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination), high blood pressure and dementia.
Review of Resident #30's quarterly MDS assessment dated [DATE] revealed under Section B, Hearing, Speech, and Vision, he was coded as 0 for understands and 1 as usually understood by others. Section C, Cognitive Patterns, under section C0500 Brief Interview for Mental Status, which indicated a score of 12 for moderately impaired cognition. Section G, Function Status, under section B indicated she needed limited assist with bed mobility, supervision with transfers, dressing, eating, hygiene, bathing, and toileting. Section N, Medication, under N0410 revealed Resident#30 received 7 doses of antipsychotic medication over the last 7 days of the look back period
Review of Resident #30's comprehensive person-centered care plan dated 10/14/22 did not indicated anything about Seroquel.
Review of Resident #30's physicians ordered revealed an order for Seroquel (a medication that works in the brain to treat schizophrenia)25MG, Give 1 by mouth at bedtime for insomnia.
Review of Resident #30's pharmacy recommendations on 10/24/22 indicated; CMS does not allow antipsychotic agent to be used as hypnotics. On 11/16/22 indicated: the following order have incorrect or inappropriate diagnosis and or reasons for use of Seroquel.
During an interview on 01/13/23 at 3:00 p.m., the DON said she had not received December pharmacy recommendations and she would notify pharmacy. The DON said she did not know why Resident #30's pharmacy recommendations had not been done.
During an observation and interview on 1/16/23 at 10:15 a.m., LVN R looked at Resident #30's medication administration record and verified order for Seroquel 25MG at bedtime for insomnia. LVN R said Seroquel was not indicated for insomnia. LVN R said Seroquel was usually given for diagnosis of Schizophrenia. LVN R said nurses had been given an in-service about making sure they had the correct diagnosis for Psychoactive medication. LVN R said failure to make sure you had proper diagnosis could lead to residents receiving the wrong medication.
During an interview on 01/17/23 at 2:06 p.m., the RNC said she would expect the nurses to enter a diagnosis for each medication and to ensure the diagnosis was appropriate for each medication. The RNC said nursing management and the pharmacy consultant checked the orders and were responsible to ensure residents are receiving the correct medication. The RNC said failure to have correct medication could lead to side effects from the wrong medication.
During an interview on 01/17/23 at 2:25 p.m., ADON D said she expected the charge nurse when receiving the order to have the correct diagnosis. ADON D said the ADON'S are responsible to follow up on new orders to ensure proper diagnosis. ADON D said Seroquel was not the correct medication for insomnia. ADON D said failure to have correct diagnosis could lead to residents receiving unnecessary medication.
During an interview on 01/17/23 at 5:00 p.m., the interim administrator said he was not a nurse but was aware this type of medication required a consent and expected nurse management to follow up on all orders.
3. Review of Resident #36's electronic face sheet dated 01/13/23 revealed a [AGE] year old male admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses of Metabolic encephalopathy (is a problem in the brain. It is caused by a chemical imbalance in the blood), high blood pressure, pneumonia, depression, and dementia.
Review of Resident #36's quarterly MDS assessment dated [DATE] revealed under Section B, Hearing, Speech, and Vision, he was coded as 1 for usually understands and usually understood by others. Section C, Cognitive Patterns, under section C0500 Brief Interview for Mental Status, which indicated a score of 10 for moderately impaired cognition. Section G, Function Status, under section B indicated he needed supervision with transfers and toileting. Section N, Medication, under N0410 revealed Resident#36 received 7 doses of anxiety medication and 0 hypnotic medication over the last 7 days of the look back period.
Review of Resident #36's comprehensive person-centered care plan dated 06/23/20 when it was initiated, and it was revised on 09/11/22. Focus indicted: Resident #36 have episodes of insomnia . Intervention: Give medication as ordered.
Record review of Resident#36's physician orders dated 01/13/23 revealed and order for Lorazepam 0.5MG, Give 1 tablet at bedtime for insomnia.
Record review of Resident #36's medication administration record indicated; Resident #36 received Lorazepam 0.5 MG nightly from 01/01/22 through 01/13/22.
During an interview on 1/16/23 at 10:00 a.m., LVN O said when receiving orders for psychoactive medication you must know the diagnosis and monitor for side effects. LVN O said failure to have correct diagnosis for medication could lead to resident receiving the unnecessary medication.
During an interview on 01/17/23 at 2:06 p.m., the RNC said she would expect the nurses to enter a diagnosis for each medication and to ensure the diagnosis was appropriate for each medication. The RNC said nursing management and the pharmacy consultant checked the orders and were responsible to ensure residents are receiving the correct medication. The RNC said failure to have correct medication could lead to side effects from the wrong medication.
During an interview on 01/17/23 at 2:25 p.m., ADON D said she expected the charge nurse when receiving the order to have the correct diagnosis. ADON D said the ADON'S are responsible to follow up on new orders to ensure proper diagnosis. ADON D said lorazepam was not the correct medication for insomnia. ADON D said failure to have correct diagnosis could lead to residents receiving unnecessary medication.
During an interview on 01/17/23 at 5:00 p.m., the interim administrator said he was not a nurse but was aware this type of medication required a consent and expected nurse management to follow up on all orders.
Record review of facility policy Unnecessary Drugs-Without Adequate Indications for Use dated 07/01/22 indicated, It is the facilities policy that each resident drug regimen is managed and monitored to promote or maintain the resident's highest practicable mental, physical, and psychosocial well-being free from unnecessary drugs. Indication for use is identified, documented clinical rationales for administrating a medication that is based upon an assessment of the resident's condition and therapeutic goals and is consistent with the manufacturer's recommendations and or clinical practice guidelines, clinical standards of practice, medication reference, clinical studies,
Based on interview and record review the facility failed to have target behavioral monitoring in place for behaviors associated with the use of psychotropic medications and to ensure residents who had not used psychotropic drugs were not given these drugs unless the medication was necessary to treat a specific condition as diagnosed and documented in the clinical record for 3 of 20 reviewed for unnecessary psychotropic drugs (Resident #30, Resident #271, and Resident #36).
The facility failed to have an appropriate diagnosis or indication of use for Resident #30's Seroquel (antipsychotic).
The facility failed to adequately monitor Resident #271 behaviors and side effects regarding her antidepressant and antianxiety medications.
The facility failed to have an appropriate diagnosis or indication of use of Lorazepam (a medication used to treat anxiety) for Resident #36.
These failure could place residents at risk of receiving unnecessary psychotropic medications with possible medication side effects, adverse consequences, decreased quality of life and dependence on unnecessary medications.
Findings included:
1. Record review of a face sheet dated 01/13/23 indicated Resident #271 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of right fibula fracture (break in bone that stabilizes and supports your ankle and lower leg muscle), right tibia (shin bone) fracture, anxiety, depression (mood disorder that causes persistent feeling of sadness or loss of interest), and dementia (memory loss).
Record review of the Resident #271's admission MDS dated [DATE], indicated Resident #271 was understood and understood others. The MDS revealed Resident #271 had a BIMS score of 12, indicating she had mildly impaired cognition. The MDS indicated Resident #271 required extensive assistance with two-person assist for bed mobility, transfers, locomotion, dressing, eating, toileting, and personal hygiene. Resident #271 was totally dependent on bathing. The MDS under section D0200, Resident Mood Interview, indicated Resident #271 had experienced feeling tired or having little energy and trouble concentrating over the last 2 weeks. The MDS revealed under section I, Active Diagnoses, had I5700, Anxiety disorder, and I5800, Depression, checked. The MDS under section N0410, medications received within the last 7 days, had six days Resident #271 received antidepressant medications. The MDS indicated Resident #271 did not receive anti-anxiety medications.
Record review of the order summary report dated 01/11/23 indicated Resident #271 had the following orders with start date of 12/20/22:
*Buspirone 10mg tablet give one tablet every eight as needed for anxiety
*Cymbalta 30mg delayed release capsule give three capsules one time a day for depression, give 3 capsules to equal 90mg.
*Doxepin HCL 10mg capsule give five capsules by mouth in the evening for anxiety, give five capsules to equal 50mg
*Paxil 40mg tablet give one tablet by mouth one time day for depression
* Remeron 15mg disintegrating tablet give one tablet by mouth at bedtime for depression
The order summary report did not indicate Resident #271 had any behavior or side effect monitoring for the use of antidepressant or antianxiety medications.
Record review of the comprehensive care plan dated 01/10/23 indicated Resident #271 uses antidepressant medications with an intervention to monitor/document/report to medical director as needed ongoing sign and symptoms of depression unaltered by antidepressant meds: sad, irritable, anger, never satisfied, crying, shame, worthlessness, guilt, suicidal ideations, negative mood/comments, slowed movement, agitation, disrupted sleep, fatigue, lethargy, does not enjoy usual activities, changes in cognition, changes in weight/appetite, fear of being alone or with others, unrealistic fears, attention seeking, concern with body functions, anxiety, and constant reassurance.
During an interview on 01/13/23 at 05:34 PM, LVN N said antidepressant and antianxiety medications require to have behavior and side effect monitoring. LVN N said by not monitoring for behaviors or side effects the resident was at risk for taking something they don't need or have an adverse side effect and staff would be unaware of it.
During an interview on 01/17/23 at 12:51 PM, ADON A said a resident receiving antidepressant or antianxiety medications should have behavior and side effect monitoring as well. ADON A said if they are not monitoring the side effects or the behaviors they will not know when to notify they medical director regarding the need for medication changes.
During an interview on 01/17/23 at 1:57 PM, the RNC said she the nurse entering the order for the antidepressant or antianxiety medication is responsible for ensuring the order for side effect and behavior monitor was included as well. The RNC said by not monitoring side effects or behaviors of antidepressant or antianxiety medications, the staff might miss new behaviors or side effects of new medications.
Record review of the policy titled Unnecessary Drugs- Without Adequate Indication for Use dated 07/01/22 indicated .It is in the facility's policy that each resident's drug regimen is managed and monitored to promote or maintain the resident's highest practicable mental, physical and psychosocial well-being free from unnecessary drugs .Indication for use is identified, documented clinical rationales for administrating a medication that is based upon an assessment of the resident's condition and therapeutic goals and is consistent with the manufacturer's recommendations and or clinical practice guidelines, clinical standards of practice, medication reference, clinical studies, or evidence-based review articles that are published in medical and or pharmacy journals .Each resident's drug regimen will be reviewed on an ongoing basis, taking into consideration the following elements: a. dose (including duplicate therapy, b. duration of use, c. indications and clinical need for medication, d. adequate monitoring for efficacy and adverse consequences, e. preventing, identifying and responding to adverse consequences, f. any combination for the reasons stated above .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Record review of Resident #5's face sheet, dated 01/13/23, indicated, a 63- year- old female, who was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included: neuromuscular dysfunction of bladder (when a person lacks bladder control due to brain, spinal cord or nerve problems), hypokalemia (a lower than normal potassium level in your bloodstream), overactive bladder (when the muscles of the bladder start to contract on their own even when the volume of urine in your bladder is low), multiple sclerosis (a disorder of the central nervous system marked by weakness, numbness, a loss of muscle coordination, and problems with vision, speech, and bladder control), and generalized muscle weakness.
Record review Resident #5's annual MDS assessment, dated 10/26/22, revealed in section B, the resident was usually understood and usually understood others. The BIMS (Brief Interview for Mental Status) was a 14, which indicated Resident #5 was cognitively intact. Section G indicated Resident #5 required supervision with eating and locomotion on and off the unit. Resident #5 required total dependence with transfer, dressing, and toilet use. Resident #5 required extensive assistance with bed mobility and personal hygiene.
Record review of Resident #5's comprehensive care plan, dated 01/13/23, indicated Resident #5 had a diagnoses which included urinary retention, neuromuscular dysfunction of bladder, and overactive bladder with the presence of a catheter. The interventions for this focus stated: change bag/tubing every two weeks or as needed per physician orders.
During interview and observation with Resident #5 on 01/09/23 at 10:13 AM, she was observed sitting in her wheelchair watching television in her room. Her catheter bag was visible and urine could be seen, there was; no privacy bag on the wheelchair or visible in the room. Resident #5 said she did not remember if staff covered it after she was assisted with transferring from her bed to wheelchair. She said she could not see it as she had limited use of her neck. She said she would prefer it always remained covered for her privacy . The catheter bag could be seen from the hall when the door was open. Resident #5 had a roommate that saw the catheter bag without a cover.
During interview and observation with Resident #5 on 1/10/23 at 9:02 AM, she was observed in bed watching television. Her catheter bag was hung off the side of the bed that faced the room door, there was no privacy bag covering it. Resident #5 said she did not have any catheter care today. She was unsure if the bag had been there and removed, or never placed.
During interview and observation with Resident #5 on 1/11/23 at 2:12 PM, she was observed in bed watching television. Her catheter bag was hung off the side of the bed that faced the room door, there was no privacy bag covering it. Resident #5 said she would prefer the bag be covered for her privacy. She said she was embarrased by the bag being uncovered.
During an interview on 01/17/23 at 12:51 PM, ADON A, she said she expected all staff to ensure catheter bags were covered with a privacy bag if they noticed it was not covered. She said these things could lead to residents' embarrassment and emotional harm.
During an interview on 01/17/23 at 1:11 p.m., CNA S said if she was to provide care to a resident, she would close the door to provide privacy. She said would inform nursing staff if a catheter bag was not covered as CNAs could not perform any catheter care.
During an interview on 01/17/23 at 1:13 p.m., LVN C said the door to any resident's room should be closed when care was provided to preserve their dignity. She said she would ensure the resident's catheter bag was in a privacy bag at all times to ensure there was no embarrassment and shame to the resident.
During an interview on 01/17/23 at 1:57 PM, the RNC said the residents had the right to ask for assistance to go the bathroom. The RNC said by not assisting them could be a dignity issue or cause infections. She said each resident had a right to privacy in all care. She said a catheter bag should not left for others to see the contents. She said there should be a privacy bag that covered it at all times. She said she expected all nursing staff to ensure this was done for resident's privacy. The RNC said this could cause emotional harm and loss of dignity to the resident.
Record review of the facility's policy titled Resident Rights revised on 02/21, indicated Employees shall treat all residents with kindness, respect, and dignity .Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: a. a dignified existence; b. be treated with respect, kindness, and dignity; c. be free from abuse, neglect, misappropriation of property, and exploitation .
Record review of the facility's policy on promoting and maintaining resident dignity policy, dated 7/1/22 indicated, It is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment that maintains or enhances residence quality of life by recognizing each resident individuality. number one all staff members are involved in providing care to residents to promote and maintain residence dignity and respect residents' rights . #12 states maintain resident privacy.
Based on observation, interviews and record review, the facility failed to ensure residents had the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility for 2 of 16 residents ( Resident #271 and Resident #5) reviewed for resident rights.
*The facility failed to ensure CNA Z treated Resident #271 with dignity when she did not take her to the bathroom on 01/09/23 when asked by the resident.
*The facility failed to ensure Resident #5's catheter bag had a privacy cover.
These deficient practices could place residents at risk of loss of dignity.
Findings include:
1. Record review of Resident #271's face sheet, dated 01/13/23, indicated a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses which included right fibula fracture (break in bone that stabilizes and supports your ankle and lower leg muscle), right tibia (shin bone) fracture, anxiety, depression (mood disorder that causes persistent feeling of sadness or loss of interest), and dementia (memory loss).
Record review of the Resident #271's admission MDS, dated [DATE], indicated Resident #271 was understood and understood others. Resident #271 had a BIMS score of 12, which indicated she had mildly impaired cognition. Resident #271 required extensive assistance with two-person assist for bed mobility, transfers, locomotion, dressing, eating, toileting, and personal hygiene. Resident #271 was totally dependent on bathing. Under section H, bladder, and bowel, indicated Resident #271 was frequently incontinent of bowel and bladder.
Record review of the comprehensive care plan, dated 01/10/23, indicated Resident #271 required assistance with ADLs. The care plan did not have any goals or interventions completed.
During an interview on 01/10/23 at 05:21 PM, Resident #271 said on 01/09/23 around 07:30 PM, CNA Z came to answer the call light. Resident #271 said she asked CNA Z to assist her to the bathroom and CNA Z said no, there was no one there to help her get you up. Resident #271 said she had to urinate in her disposable brief. Resident #271 said by CNA Z not assisting her to the bathroom, it made her feel belittled.
During an interview on 01/11/23 at 12:48 PM, the Administrator said she had spoken to Resident #271 on 01/10/23. The Administrator said she filled out a grievance report. The Administrator said Resident #271 told her CNA Z did assist her in putting her pajamas on and did change her several hours later. The Administrator said she spoke with CNA Z, and CNA Z reported to her that she did assist Resident #271 to the bathroom with the help of CNA W. The Administrator said Resident #271 pressed her call light again that night while CNA W was on break and CNA Z did not take her to the restroom at that time because she didn't think to ask the nurse for help.
Record review of Resident #271's grievance report, dated 01/10/23, indicated Resident #271 said the staff assisted her with pajamas, then assisted her to bed. Resident #271 said when she was in bed she became wet but had to wait several hours for help. Results of action taken indicated the administrator filled out grievance report and did education with the aides.
During an interview on 01/11/23 at 6:19 PM, CNA Z said she did not take Resident #271 to the bathroom at that time because Resident #271 required two-person assist for transfers and she asked Resident #271 if she could wait until she had assistance. CNA Z said she didn't think to ask the nurse for assistance in taking Resident #271 to the restroom.