VAL VERDE NURSING AND REHABILITATION CENTER

Based on observations, interviews, and record reviews the facility failed to store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys and the facility failed to label all drugs and biologicals used in the facility, in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable for 1 of 4 medication carts, reviewed for security and medication storage and labeling, in that:<BR/>1. <BR/>The keys for the 300-400 hall cart were unattended, unsecured, and laid upon a counter at the 300-400 hall nurse's station.<BR/>2. <BR/>An undated insulin pen for Resident #35 was intended for use and stored in the 300-400 hall medication cart. <BR/>These failures could place residents at risk of adverse effects and ineffective therapeutic effects of their medication; to include misappropriation of medication property.<BR/>The findings included:<BR/>1.<BR/>During an observation and interview on 04/03/2023 at 02:33 PM revealed a set of keys on a lanyard, unattended, unsecured, which laid upon the counter at the nurses 300-400 hall station. Surveyor retrieved the keys and observed no nursing staff within view. Residents observed ambulating in the 300-400 hall. The 300-400 hall medication cart was observed stationed by the 300-400 hall nurse station. The keys were used to attempt to open the 300-400 hall cart and the cart opened, and was observed to contain residents' medications; This surveyor locked the cart. The 300-400 hall was observed for nursing staff and revealed LVN B to exit a resident's room. This surveyor approached LVN B and provided the keys. LVN B stated, You should not have those keys! and asked, Where did you get them? LVN B stated the keys were the medication aide keys for the medication aide cart. LVN B stated the Medication Aide U was responsible for the keys and believed she had clocked out at 02:00 PM since her schedule was 06:00 to 02:00 PM. LVN B stated Medication Aide should have reported and given LVN B the keys when she finished her shift. <BR/>During an interview on 04/05/2023 at 10:28 AM, Medication Aide U stated on 04/04/2023 at 02:00 PM she approached LVN B and placed the medication cart keys by her while she sat at the nurse's station. Medication Aide U stated she believed LVN B saw her place the keys by her and believed she would take the keys into her possession. Medication Aide U stated she should have given a verbal report and handed her the keys. Medication Aide U stated residents could have been harmed by not having their medications secured. <BR/>During an interview on 04/04/2023 at 05:10 PM, the DON stated the keys to nursing carts are the responsibility of each nurse and the keys are to be secured and never be left unattended and unsecured. The DON stated medication Aide U should have given report and the keys to the charge nurse LVN B. <BR/>2.<BR/>During a nurse cart review and interview on 04/05/2023 at 11:29 AM, revealed LVN B in care of the 300-400 hall nurses' cart. Review of the 300-400 hall nurse cart revealed Resident #35's insulin injection pen stored within the cart. Resident #35's insulin injection pen was not dated with the date the pen was taken out of refrigeration and placed into use. LVN B reviewed #35's insulin injection pen an identified the medication as Admelog Solostar [a fast acting human insulin]. LVN B stated the insulin injection pen was to be kept refrigerated until placed into use. LVN B stated when Resident #35 needs the insulin as ordered, the pen is removed from refrigeration, dated with the date the pen is placed into use, and dated with a date 28 days later, as a discard date, per the manufacture's recommendations. LVN B stated she did not know when the injection pen was removed from refrigeration and / or when to discard the injection pen. LVN B stated she would report to the DON and the pharmacist. LVN B stated if the insulin injection pen is out of refrigeration past the 28 days Resident #35 may not receive the therapeutic effects of the insulin. <BR/>During an interview on 04/05/2023 at 05:40 PM, the DON stated all insulin injection pens are stored in the facility's medication room inside a refrigerator under refrigeration as per the manufacturer's and pharmacy recommendations. The DON stated whenever an insulin medication is removed from refrigeration it must be labeled with the date placed into service and then labeled with a discard date as recommended by the manufacturer. The DON stated the dates are guarantees the medications would be discarded prior to losing their efficacy. <BR/>A record review of the Ademlog Solostar insulin injection pen's manufacture's guidelines revealed, Storage and handling: dispensing: The original sealed carton with the enclosed instructions for use. Do not use after the expiration date. Not in use unopened Admelog should be stored in a refrigerator 36 degrees Fahrenheit to 46 degrees Fahrenheit, but not in the freezer. Do not use Admelog if it has been frozen. In use open Admelog solostar pens should be stored at room temperature below 86 degrees Fahrenheit and must be used within 28 days or be discarded, even if they still contain Admelog.<BR/>A record review of the facility's Medication and Disposal policy, dated 10/01/2019, revealed, drugs which have been dispensed for individual residents, are not to be used beyond the expiration date indicated by the manufacturer, by the pharmacy, or based on the following criteria. the facility is to strictly adhere to the expiration dating . for multi dose vials of injectable drugs: date and initialed when opened; the expiration date for the multi dose injectable vials is the manufacturers printed date, unless otherwise indicated by the manufacturer. it is the responsibility of all nurses who administer medications to monitor the expiration dates of the medications. expired medications will not be administered in the facility. all expired medications will be disposed of per facility policy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews the facility failed to ensure, in accordance with accepted professional standards and practices, complete, accurately documented, readily accessible, and systemically organized medical records for each Resident, for 2 of 39 residents (Residents #14 and #140) reviewed for accurate records, in that: <BR/>1. <BR/>LVN B did not document Resident #140's physicians orders for a urinalysis with a culture and sensitivity.<BR/>2. <BR/>LVN B did not document Resident #14's SBAR to the physician and the physician's order.<BR/>These failures placed residents at risk for injury by inaccurate / missing records. <BR/>The findings included: <BR/>1. <BR/>Resident #140<BR/>A record review of Resident #140's admission record revealed an admission date of 05/23/2020, and a hospital emergency discharge date of 05/07/2022, and diagnoses which included neuromuscular dysfunction of bladder and bladder neck obstruction [when a person lacks bladder control due to brain, spinal cord or nerve problems].<BR/>A record review of Resident #140's quarterly MDS, dated [DATE], revealed Resident #140 was a [AGE] year-old male without cognitive mental impairment evidenced by a 15 out of 15 score on a BIMS. Resident #140 had a suprapubic catheter [a surgically created connection between the urinary bladder and the skin used to drain urine from the bladder in individuals with obstruction of normal urinary flow] and a history of urinary tract infections. Resident #140 was frequently incontinent of bowels. Resident #140 was not weight bearing and used a wheelchair to ambulate. <BR/>A record review of Resident #140's care plan, dated 04/06/2023, revealed, The resident has an activities of daily life self-care performance deficit related to contractures to the left leg and above knee amputation; toilet use; the resident is totally dependent on staff for toilet use. Resident is incontinent of bowel and required staff to check every two hours. staff to help provide catheter care and empty out the urine collection bag. The resident has suprapubic catheter at risk for UTI sepsis. The resident has suprapubic catheter; position catheter bag and tubing below the level of the bladder . monitor record report to medical doctor for signs and symptoms of urinary tract infection pain burning blood thinning hearing cottages fever chills altered mental status. <BR/>A record review of Resident #140's nursing progress notes revealed LVN B documented on 04/06/2022, resident back from urology appt. NP E requested for resident to have SP drain to gravity and no belly bag. facility to collect UA and send to [local hospital] for C/S. and to continue with current medications. Follow up in four months [DATE], at 1350. This SN advised resident that I needed to change foley bag [urine collection] to either a leg bag or normal foley bag, resident refused and stated he wants AM shift to change it.<BR/>A record review of Resident #140's laboratory report, dated 04/12/2022, revealed Resident #140, collected 04/07/2022, urine culture final organism 1 proteus mirabilis .organism 2 enterococcus faecalis. [Proteus mirabilis a bacterium known to cause serious infections in humans. Enterococcus faecalis a bacterium can cause life-threatening infections].<BR/>During an interview on 04/05/2023 at 2:25 PM LVN B received a report of her documentation for Resident #140 on 04/06/2022 where she documented Resident #140 had returned from their urology appointment and had a new order for a UA with a CS. LVN B stated she could not recall the details but stood on the accuracy of her note. LVN B was asked to demonstrate her documentation for the physicians' order for the UA with C&S. LVN B stated she reviewed Resident #140's record and could not find any order for Resident #140 to have a UA with a C&S on 04/07/2022. In response to the lack of a documented order for the UA with C&S LVN B stated, I am human and I can make mistakes. <BR/>During an interview on 04/07/2023 at 03:48 PM, the DON and the ADON, the DON stated Resident #140 had a need for a suprapubic catheter related to a neurogenic bladder, which was to drain via gravity to a dependent urine collection bag positioned below the bladder. The DON stated Resident #140 was seen on 04/06/2022 by Dr. F and returned to the facility with new orders from Dr. F's NP E, for a UA w/ CS to be collected and sent to the local hospital, no order for the UA was evidenced in the record, however the UA sample was collected and sent to the local hospital on [DATE]. when the DON was asked what should have happened the DON stated she refused to answer.<BR/>During an interview on 04/07/2023 at 10:50 AM the Medical Director stated he was familiar with Resident #140 and recalled Resident #140 had a history of recurrent UTI's related to his suprapubic catheter. The Medical Director was given a report of survey findings to include Resident #140 was recognized with a urinary tract infection on 04/12/2022, specifically the pathogens enterococcus faecalis and proteus mirabilis, without any documentation for communication with a physician, without any documented order for a urinalysis lab, and no report to a physician for the 2 pathogens identified. The Medical Director stated Resident #140 should have been supported with an opportunity for a physician to intervene and possibly provide various supports to address the infections prior to Resident #140's hospital transfer. The Medical Director stated he could not recall if he had been given a report but if he had been given a report, he would have intervened. The Medical Director was given a report of survey findings to include Resident #140 was assessed during his time at the facility with the infection to be free from signs and symptoms of infection to include Resident #140 was without a fever, and had vital signs within normal limits; the Medical Director stated the fact was Resident #140's urinalysis lab revealed a serious double pathogen infection and was enough to warrant treatment. The Medical Director stated in his medical practice he has encountered a patient without any signs and symptoms of infection other than a positive infection lab result and he would not ignore the lab result and would intervene with some type or types of treatment to eliminate the infection.<BR/>2. <BR/>Resident #14<BR/>A record review of Resident #14's admission record, dated 04/04/2023, revealed an admission date of 02/18/2023, with diagnoses which included personal history of transient ischemic attack, TIA, and cerebral infarction [Infarction refers to death of tissue. A cerebral infarction, or stroke, is a brain lesion in which a cluster of brain cells die when they don't get enough blood].<BR/>A record review of Resident #14's admission MDS, dated [DATE], revealed Resident #14 was a [AGE] year-old female admitted from her home. Resident #14 was assessed with no impaired mental cognition evidenced by a 15 out of 15 BIMS score. Resident #14 was assessed with urinary and bowel incontinence and needed extensive assistance with all activities of daily life. Resident #14 was assessed with a status of medically complex to include a diagnosis of hemiplegia [Hemiplegia is a condition caused by brain damage that leads to paralysis on one side of the body].<BR/>A record review of Resident #14's care plan, dated 04/04/2023, revealed, The resident has an activities of daily life self-care performance deficit related to decreased mobility, hemiplegia to the right side, intervention: bathing / shower; the resident requires assistance by staff with bathing showering as necessary.<BR/>A record review of Resident #14's nursing progress notes revealed LVN B documented on 03/24/2023, CNA notified this SN that upon showering resident she noticed bugs on hair. Upon assessment it was verified resident has an infestation of head lice. DON was notified and contact isolation in place until Treatment is completed.<BR/>A record review of Resident #14's nursing progress notes revealed LVN T documented on 03/25/2023, Lice treatment was applied as indicated this am. Continues on contact isolation. Denies pain or discomfort.<BR/>During an interview on 04/05/2023 at 2:25 PM LVN B stated on 03/24/2023 she assessed Resident #14 with head lice, text messaged the medical director and the DON. LVN B stated she received an order from the medical director to treat the head lice. LVN B stated the DON gave her the medication and Resident #14 was treated for head lice. LVN B was asked to demonstrate the documented communication with Resident #14's physician, the order for the medicated shampoo for lice, and the documentation for communication with the DON. LVN B stated she could not demonstrate the documentation because she did not document the events in Resident #14's medical record. LVN B stated she believed the DON would have done the documentation since she gave the DON a report. LVN B stated in retrospect she should have documented the SBAR, the order, and the follow up. LVN B stated, I am human and I can make mistakes.<BR/>During an interview on 04/07/2023 at 03:48 PM, the DON stated on 03/08/2023 LVN B alerted her that Resident #14 had head lice. The DON stated she retrieved the head lice medicated shampoo from the medication storeroom and provided the medication to LVN B. the DON stated the expectation is for nurses to document all communications with physicians, new orders, and follow ups in the residents' medical records.<BR/>During an interview on 04/07/2023 at 10:50 AM the Medical Director stated he could not recall if he had been given a report for Resident #14's head lice. The medical director stated the expectation was for all physician communications, orders, and nursing follow ups to be documented accurately in the resident's medical record. <BR/>A policy for accurate records was requested on 04/06/2023 and was not provided. The policy for Laboratory Services and Reporting partially addressed Resident #140.<BR/>A record review of the facilities Laboratory Services and Reporting policy dated, 04/08/2023, Revealed, the facility must provide or obtain laboratory services in ordered by a physician, positions assistant, nurse practitioner, or clinical nurse specialist in accordance with state law. Policy and explanation and compliance guidelines: the facility must provide or obtain laboratory services to meet the needs of its residents. The facility is responsible for the timeliness of the services. Should the facility provide its own laboratory services, the services must meet the applicable requirement for laboratories. if the laboratory chooses to refer specimens for testing to another laboratory, the referral laboratory must be certified in the appropriate specialties and subspecialties of service in accordance with requirements. assist the resident in making transportation arrangements to and from the laboratory if necessary. All laboratory reports will be dated and contain the name and address of the testing laboratory and will be filed in the residence clinical record. Promptly notified the ordering physician, physician assistant, nurse practitioner, or clinical nurse specialist of laboratory results that fall outside the clinical reference range. If unable to reach the ordering prescriber with abnormal lab results the medical director will be notified.

**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 for each resident, consistent with the resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 2 of 16 residents (Resident #24, #46) reviewed for care plans, in that:<BR/>1. The facility failed to ensure wound care management was included on the Care Plan for Resident #24 when he developed pressure injury wounds on 4/17/2024. <BR/>2. The facility failed to ensure significant weight loss was included on the Care Plan for Resident #46 after she lost 7.14% of her body weight from 3/6/2024 to 4/8/2024. <BR/>This failure could place residents at risk of not receiving the care needed to maintain their highest, most practicable, physical, social, and psychosocial level of well-being.<BR/>The findings were: <BR/>1. Record review of the admission Record revealed Resident #24 was a [AGE] year-old male originally admitted on [DATE]. <BR/>Record review of the comprehensive MDS assessment, dated 4/15/2024 revealed Resident #24 was rarely or never understood [therefore a BIMS assessment could not be completed]. Resident #24 had short- and long-term memory problems; and was moderately impaired in cognitive skills for daily decision making. Active diagnoses included pneumonia [infection in the lungs caused by bacteria, viruses or fungi that causes lung tissue to swell, cause fluid or pus to develop in lungs], and pressure ulcer of the left buttock, stage 2 [sore that has broken through the top layer of the skin and part of the layer below]. Under section M - Skin Condition, Resident #24 was coded as having a formal and clinical assessment for determination of Pressure Ulcer/Injury risk and was rated as not at risk of developing pressure ulcers/injuries and did not have any unhealed pressure ulcers/injuries.<BR/>Record review of Care Plan, printed 5/10/2024 at 12:11 PM, revealed Resident #24 had a problem area of ADL self-care performance deficit, with interventions that indicated he was totally dependent on staff for reposition and turning in bed and as necessary, revised on 4/9/2024; and required skin inspection every shift, revised on 3/29/2024. No additional problem areas or interventions related to skin or wound care management were included. <BR/>Record review of Daily Skilled Note dated 4/18/2024 at 1:45 PM authored by LVN C, revealed indication that skin was not intact. <BR/>Record review of Order Details revealed Resident # 24 had orders to cleanse with wound cleanser, pat dry apply silvasorb, cover with non-adherent dressing and secure with tape one time per day to stage 2 [pressure injury] to left and right buttocks with start dates of 4/18/2024. <BR/>In an interview on 5/10/2024 at 2:54 PM, the DON stated the resident had returned from the hospital on 4/09/2024. The DON stated the Wound Care Nurse was out on leave at this time, and the wound care management was delegated to various nurses each day to cover while the Wound Care Nurse was out. The Resident #24's pressure injury wounds had resolved 3/27/2024 prior to his hospitalization. <BR/>In an interview on 5/10/2024 at 3:55 PM, the DON stated due to Resident 24's declining health status related to pneumonia, the pressure injuries developing were unavoidable as the area was friable due to previous, healed pressure injuries and the residents' diminished capacity to independently self-reposition as an energy conservation coping strategy. The DON stated that the wounds developed on 4/18/2024, but the nurse [LNV B] that assessed and documented the wounds that day was currently out on leave. The DON stated the wounds were discussed in medical morning meeting and physician orders were received for wound care treatment that day [4/18/2024]. The DON stated that Resident #24's care plan should have been updated to reflect the change in his condition and wound care management interventions within 2 weeks, if not sooner, of the wounds being discovered. The DON stated it was normally the responsibility of the Wound Care Nurse to update the Care Plan regarding wound care management; however, in this case, while the Wound Care Nurse was out, it was the responsibility of the nurse who discovered, and documented the wounds to update the Care Plan. The DON stated the risk of not having the care plan updated was that something could be missed, or delay treatment. <BR/>2. Record review of Resident #46's Face Sheet, dated 5/10/2024, reflected a [AGE] year-old female resident initially admitted on [DATE] with diagnosis including pressure ulcer of sacral region, stage 4, and type 2 diabetes mellitus without complications. <BR/>Record review of Resident #46's Quarterly MDS Assessment, dated 4/4/2024, reflected Resident #46 had a BIMS score of 9, indicating the resident was moderately impaired. Further review of the Quarterly MDS Assessment reflected that Resident #46 had lost 5% or more in the last month or loss of 10% or more in last 6 months while not on a physician-prescribed weight-loss regimen. <BR/>Record review of Resident #46's Dietary Progress Note, dated 4/9/2024, reflected that Resident #46 had a significant weight loss, was started on Megace, an appetite stimulant, and a recommendation to add fortified food to resident meals. <BR/>Record review of Resident #46's Comprehensive Person-Centered Care Plan, dated 5/10/2024, reflected no problems, goals, or interventions relating to Resident #46's significant weight loss. <BR/>In an interview on 5/10/2024 at 2:36 PM, the DON stated significant weight loss should be care planned as it is a significant change. The DON stated the MDS Nurse oversaw updating Care Plans and that they monitor any changes during morning meetings to determine if they are significant changes. <BR/>In an interview on 5/10/2024 at 2:45 PM, the MDS Nurse stated she was unsure of why the significant weight loss was care planned and that the care plan generally is updated when there is a significant change such as weight loss.<BR/>Record review of the facility policy entitled, Pressure Injury Prevention and Management, dated 8/15/2022, reflected under the heading Policy Explanation and Compliance Guidelines in section 4. Interventions for Prevention and to Promote Healing step f.) Interventions will be documented in the care plan and communicated to all relevant staff. Under section 6. Modifications of Interventions step b.) interventions on a resident's plan of care will be modified as needed .ii.) new onset or recurrent pressure injury development. <BR/>Record review of the facility policy entitled, Care Plan Revisions Upon Status Change, dated 10/24/2022, reflected under the heading Policy Explanation and Compliance Guidelines in section 2. Procedure for reviewing and revising the care plan .step d.) The care plan will be updated with new or modified interventions. F.) care plans will be modified as needed by the MDS Coordinator or other designated staff member.

**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 offered a therapeutic diet when there was a nutritional problem, and the health care provider orders a therapeutic diet for 1 of 8 Residents (Resident #46) reviewed for nutritional status in that: <BR/>The facility failed to ensure Resident #46 was receiving the ordered therapeutic diet.<BR/>These failures could place residents who are dependent on staff for their nutrition and hydration at risk for nutritional deficit, weight loss, skin breakdown, and overall decline in quality of life. <BR/>Findings included:<BR/>Record review of Resident #46's Face Sheet, dated 5/10/2024, reflected a [AGE] year-old female resident initially admitted on [DATE] with diagnosis including pressure ulcer of sacral region, stage 4, and type 2 diabetes mellitus without complications.<BR/>Record review of Resident #46's Quarterly MDS Assessment, dated 4/4/2024, reflected Resident #46 had a BIMS score of 9, indicating the resident was moderately impaired. Further review of the Quarterly MDS Assessment reflected that Resident #46 had lost 5% or more in the last month or loss of 10% or more in last 6 months while not on a physician-prescribed weight-loss regimen. <BR/>Record review of Resident #46's Comprehensive Person-Centered Care Plan, dated 5/10/2024, reflected no problems, goals, or interventions relating to Resident #46's significant weight loss. <BR/>Record review of Resident #46's weight record reflected that on 3/6/2024, she weighed 145.6 lbs.; on 4/8/2024, she weighed 135.2 lbs. which is a -7.14% loss. <BR/>Record review of Resident #46's orders reflected, Regular diet Mechanical Soft texture, Regular Liquids consistency, for fortified foods all meals -snacks of choice between meals with an order date and start date of 4/12/2024. Further review reflected that Resident #46 was on Megestrol Acetate Oral suspension for an appetite stimulant with an order date and start date of 4/18/2024. <BR/>Record review of Resident #46's Dietary Progress Note, dated 4/9/2024, reflected that Resident #46 had a significant weight loss, was started on an appetite stimulant, and a recommendation to add fortified food to resident meals. <BR/>Record review of Resident #46's meal ticket for lunch on 5/8/2024, and dinner on 5/10/2024 did not reflect that the resident was to have fortified foods at all meals. Further record review of other residents' meal tickets revealed their fortified diets listed on their meal tickets. <BR/>Observation on 5/8/2024 at 12:35 PM, Resident #46 was observed in her room. Resident #46 requested a hamburger from the kitchen and was provided one. Interview attempt was not successful, as the resident declined to speak to surveyor. <BR/>Interview on 5/10/2024 at 2:15 PM, the Dietary Manager stated that dietary orders are automatically input into the system used to create meal tickets. The Dietary Manager stated he was not aware any of the meal tickets were incorrect, as they are automatically input based on the residents' orders. The Dietary Manager stated that nursing staff was in charge of inputting orders and he did not verify them. <BR/>Interview on 5/10/2024 at 2:36 PM, the DON stated that orders for fortified meals are input into their electronic health record system and on the meal ticket by the next meal, as the meal ticket is based on resident orders. The DON states she is unsure why it is not on the meal ticket, as the orders were input correctly into the electronic health record system. The DON stated there was not a way of knowing if the resident was provided their therapeutic diet as ordered, but that the resident has gained a pound since their order was input for Megestrol, the appetite stimulant. <BR/>Record review of policy titled, Diet Order Accuracy, dated 10/2018, reflected, The facility will conduct routine audits of the diet orders to ensure that residents receive the diet as ordered by the physician.

Based on observations, interviews, and record reviews the facility failed to store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys and the facility failed to label all drugs and biologicals used in the facility, in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable for 1 of 4 medication carts, reviewed for security and medication storage and labeling, in that:<BR/>1. <BR/>The keys for the 300-400 hall cart were unattended, unsecured, and laid upon a counter at the 300-400 hall nurse's station.<BR/>2. <BR/>An undated insulin pen for Resident #35 was intended for use and stored in the 300-400 hall medication cart. <BR/>These failures could place residents at risk of adverse effects and ineffective therapeutic effects of their medication; to include misappropriation of medication property.<BR/>The findings included:<BR/>1.<BR/>During an observation and interview on 04/03/2023 at 02:33 PM revealed a set of keys on a lanyard, unattended, unsecured, which laid upon the counter at the nurses 300-400 hall station. Surveyor retrieved the keys and observed no nursing staff within view. Residents observed ambulating in the 300-400 hall. The 300-400 hall medication cart was observed stationed by the 300-400 hall nurse station. The keys were used to attempt to open the 300-400 hall cart and the cart opened, and was observed to contain residents' medications; This surveyor locked the cart. The 300-400 hall was observed for nursing staff and revealed LVN B to exit a resident's room. This surveyor approached LVN B and provided the keys. LVN B stated, You should not have those keys! and asked, Where did you get them? LVN B stated the keys were the medication aide keys for the medication aide cart. LVN B stated the Medication Aide U was responsible for the keys and believed she had clocked out at 02:00 PM since her schedule was 06:00 to 02:00 PM. LVN B stated Medication Aide should have reported and given LVN B the keys when she finished her shift. <BR/>During an interview on 04/05/2023 at 10:28 AM, Medication Aide U stated on 04/04/2023 at 02:00 PM she approached LVN B and placed the medication cart keys by her while she sat at the nurse's station. Medication Aide U stated she believed LVN B saw her place the keys by her and believed she would take the keys into her possession. Medication Aide U stated she should have given a verbal report and handed her the keys. Medication Aide U stated residents could have been harmed by not having their medications secured. <BR/>During an interview on 04/04/2023 at 05:10 PM, the DON stated the keys to nursing carts are the responsibility of each nurse and the keys are to be secured and never be left unattended and unsecured. The DON stated medication Aide U should have given report and the keys to the charge nurse LVN B. <BR/>2.<BR/>During a nurse cart review and interview on 04/05/2023 at 11:29 AM, revealed LVN B in care of the 300-400 hall nurses' cart. Review of the 300-400 hall nurse cart revealed Resident #35's insulin injection pen stored within the cart. Resident #35's insulin injection pen was not dated with the date the pen was taken out of refrigeration and placed into use. LVN B reviewed #35's insulin injection pen an identified the medication as Admelog Solostar [a fast acting human insulin]. LVN B stated the insulin injection pen was to be kept refrigerated until placed into use. LVN B stated when Resident #35 needs the insulin as ordered, the pen is removed from refrigeration, dated with the date the pen is placed into use, and dated with a date 28 days later, as a discard date, per the manufacture's recommendations. LVN B stated she did not know when the injection pen was removed from refrigeration and / or when to discard the injection pen. LVN B stated she would report to the DON and the pharmacist. LVN B stated if the insulin injection pen is out of refrigeration past the 28 days Resident #35 may not receive the therapeutic effects of the insulin. <BR/>During an interview on 04/05/2023 at 05:40 PM, the DON stated all insulin injection pens are stored in the facility's medication room inside a refrigerator under refrigeration as per the manufacturer's and pharmacy recommendations. The DON stated whenever an insulin medication is removed from refrigeration it must be labeled with the date placed into service and then labeled with a discard date as recommended by the manufacturer. The DON stated the dates are guarantees the medications would be discarded prior to losing their efficacy. <BR/>A record review of the Ademlog Solostar insulin injection pen's manufacture's guidelines revealed, Storage and handling: dispensing: The original sealed carton with the enclosed instructions for use. Do not use after the expiration date. Not in use unopened Admelog should be stored in a refrigerator 36 degrees Fahrenheit to 46 degrees Fahrenheit, but not in the freezer. Do not use Admelog if it has been frozen. In use open Admelog solostar pens should be stored at room temperature below 86 degrees Fahrenheit and must be used within 28 days or be discarded, even if they still contain Admelog.<BR/>A record review of the facility's Medication and Disposal policy, dated 10/01/2019, revealed, drugs which have been dispensed for individual residents, are not to be used beyond the expiration date indicated by the manufacturer, by the pharmacy, or based on the following criteria. the facility is to strictly adhere to the expiration dating . for multi dose vials of injectable drugs: date and initialed when opened; the expiration date for the multi dose injectable vials is the manufacturers printed date, unless otherwise indicated by the manufacturer. it is the responsibility of all nurses who administer medications to monitor the expiration dates of the medications. expired medications will not be administered in the facility. all expired medications will be disposed of per facility policy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 2 of 8 (Residents #23 and #30) residents reviewed for medications in that:<BR/>1. Resident #30's Midodrine (to treat orthostatic hypotension) did not have parameters and were not reordered after she returned from the hospital.<BR/>2. on 3/15/2023 Resident #30's blood pressure was elevated and Midodrine was documented as administered with no order for parameters. <BR/>3 Resident #23's hypertensive medication was documented as administered 4 hours late. <BR/>This failure could place residents with blood pressure medication orders and could result in residents change in condition. <BR/>The Findings were:<BR/>1. Record review of Resident # 30's admission Record dated 4/6/2023 revealed she was admitted on [DATE], readmitted on [DATE] with diagnoses of, chronic, combines systolic (congestive) and diastolic (congestive) heart failure, y, anxiety, major depressive disorder, colostomy, tracheostom y, diabetes II, speech disturbance, and generalized edema. <BR/>Record review of Resident #30's telephone order dated 4/30/2022 revealed Midodrine HCI tablet 10 mg give 1 tablet by mouth three times a day for hypotension hold for SBP &gt;120 DBP&gt;80, pulse &gt;60.<BR/>Record review of Resident # 30's telephone order dated 3/1/2023 revealed Midodrine HCI tablet 5 mg give 1 tablet by mouth three times a day for hypotension by LVN I. <BR/>Record review of Resident # 30's hospital discharge records dated 3/4/2023 revealed Midodrine 5 mg tab, feed tube three times a day #10 tab. <BR/>Record review of Resident # 30's telephone order dated 4/6/2023 revealed Midodrine HCI tablet 5 mg, give 1 tablet by mouth three times a day for hypotension hold for SBP&gt;110 DBP&gt;70 by the DON.<BR/>Record review of Resident #30 consolidated physician orders for April 2023 revealed order for Midodrine HCI oral tablet 5mg, give 1 tablet by mouth three times a day for hypotension, start dated 3/1/2023. The hours for administration of the Midodrine medication was 7 am, 5pm, and 7pm. <BR/>Record review of Alert Black BOX Warning- MIDODRINE Ant hypotensive, alpha1agonist Warnings The timing of doses is important and is individualized to the patient. Do not give within the 4 hours of bedtime to avoid supine hypertension.1<BR/>Record review of Resident # 30's Medication Administration record for March 2023, revealed on 3/15/2023 at 5 PM, the medication Midodrine was administered by MA Y the charge nurse that day was RN AA, according to the DON.<BR/>Record review of Resident #30's blood pressure on 3/15/2023 at 4:29 PM was 176/85., this was documented under vitals in resident records in the software system. <BR/> .<BR/>Record review of Resident #30's Initial Nursing Evaluation dated 3/5/2023 revealed re-admission via stretcher, from hospital for respiratory failure, congested heart failure and tracheostomy by LVN B. The record Initial Nursing Evaluation revealed mobility-dependent, tracheotomy collar, bowl/bladder incontinence, required manual wheelchair. <BR/>Record review of Resident # 30's progress note revealed no other blood pressure for 3/15/2023, no note that the nurse called the physician. <BR/>Record review of Resident # 30's Significant Change MDS dated [DATE] revealed section C Cognition BIMs score was 15/15 (cognitively intact) and section O Special treatment and programs, Respiratory Treatments, included oxygen, suctioning and tracheostomy. <BR/>Record review of Resident # 30's care plan dated 3/15/2023 the resident was at risk for activity intolerance related to hypotension, The resident has congestive heart failure-intervention monitor vital signs as needed and as ordered by Md notify of significant abnormalities. <BR/>During an interview on 04/05/2023 at 05:43 PM, Medication Aide V stated Resident #30 was the only Resident in the facility who was prescribed the drug midodrine. MA V stated Resident #30 was prescribed midodrine three times a day, morning, noon, and at bedtime. MA V stated midodrine was a drug that raised blood pressure and should have parameters instructions for example do not give if blood pressure is greater than 110/70. MA V stated Resident #30 ' s midodrine order did not have parameters. MA V stated Resident #30 ' s midodrine order used to have parameters and somehow the parameters were removed. MA V stated if the resident was administered midodrine while her blood pressure was high it could hurt her, maybe cause her a stroke.<BR/>Interview on 04/05/23 at 06:14 PM with RN S stated the medication aide administers Midodrine medication, she does not see parameters on the software program, she did not see blood pressure orders, she did ask staff (not sure of names) about Midodrine, and staff stated she was on Midodrine for a while. <BR/>Interview on 4/7/2023 at 1:44 PM with LVN I, admitting nurse on 3/1/2023 stated if there were not changes in medications from the hospital, then they do not call the physician. Nurse stated she did not call the physician after Resident #30 returned from the hospital. <BR/>Interview on 4/06/2023 at 2:16 PM with the Medical Director stated if Resident #30's blood pressure would go up, the outcome would be that Resident # 30's blood pressure could have gone higher, this medications was designed to raise blood pressure. <BR/>Interview on 4/06/2023 at 7:20 AM, the DON stated she did call the physician and he ordered parameters for medication Midodrine for Resident # 30, after surveyor intervention. DON stated she would check and reassess again, if the blood pressure was high, still high, she would call the physician. The DON stated the CNA's take's the blood pressure and put in the computer. The DON stated she was surprised the nurse did not see it due to that nurse worked at a dialysis. The DON stated she was not sure if the nurse saw the blood pressure. The DON stated she did talk to the physician, and he ordered parameters for Midodrine on 4/6/2023. <BR/>Interview on 4/06/2323 at 8:06 AM with the Administrator discussed midodrine orders and Resident #30 did not have parameters. The Administrator listened to surveyor and did not reply if she was aware of this concerns and how it might affect the resident. <BR/>Interview on 04/06/23 at 8:32 AM with the Medical Director Z (MD) stated DON did talk to him about Resident # 30's Midodrine, he stated he did see Resident #30 in the hospital. MD Z stated he did not review orders after Resident came back from the hospital and expected nurses to call him after a resident returned from hospital to clarification orders. MD Z stated no nurse called him to clarify orders and would expect nurse to call if resident comes back from the hospital. MD Z stated the Midodrine orders would change pending on patient case, such as patients on midodrine for dialysis and patients that have low blood pressure, MD Z stated Resident # 30 was placed on midodrine for hypotension. MD Z stated Resident #30 should have had parameters for Midodrine and not sure why it was dropped. MD Z stated Midodrine was for low blood pressure, hypotension. <BR/>Interview on 4/06/23 at 8:41 AM, MA U stated she administered midodrine to Resident # 30 as prescribed. MA U stated Resident #30's midodrine order had parameters in the past but currently the order had no parameters. MA U stated she understood the drug midodrine raises a person's blood pressure and she checks Resident #30's blood pressure prior to administering the medication. MA U stated she had no opportunity to record the blood pressure data due to the midodrine order had no parameters specified and thus no pop up box to document the blood pressure data. MA U stated if Resident #30 had high blood pressure she would refrain from administering the drug and report the discovery to the charge nurse. MA U stated she regarded a high blood pressure might be 130 / 90. MA U searched the medical record and discovered Resident #30's midodrine order for tomorrow, 04/07/2023, had changed to include parameters which were Hold if blood pressure is greater than 110 Systolic or, 70 diastolic.<BR/>Interview on 04/06/23 at 8:59 AM with RN AA, charge nurse on duty on 3/15/2023, stated she worked for on and off, started back in March 15,2023, being alone, Midodrine she works at dialysis with low blood pressure patients, the DON called her the AM gave it, MA did not tell her the BP was high, she would check BP first and then give meds according to order. DON stated there were no parameters and the MAR and order did not know she did not have parameters and did not know about b/p, no side effects, she does have bed inclined, she is awake until 10/10:30 pm, on her shift, she last worked at facility, she is a prn she was not the admitting nurse. <BR/>Interview on at 04/06/23 09:28 AM, LVN T stated Resident # 30 the MA would administer the Midodrine medication to residents. LVN T stated the MAs would first look at the resident vitals and MA if trigger they will be documented on the software system in resident record under vitals, if BP was too high or too low they would let nurse know. LVN T stated Resident #30 had no side effects from her administration of Midodrine when it was low/high. LVN T stated if the BP was high you call the physician, did not know high blood pressure 176/85, she would have held Midodrine and called the physician. LVN T stated Resident #30 had been good after hospital, she did not remember if she had parameters, she does not remember putting in orders, would call the physician if resident had a change in orders. LVN T stated the process if resident came back from hospital, nurse would call the physician, let the physician know resident was back from hospital and clarify medications. Surveyor asked LVN T did you call the physician after Resident #30 came back from hospital. LVN T stated she does not remember if she called the physician. <BR/>Interview on at 4/07/2023 at 11:54 AM with DON regarding Resident # 30, she stated the new process from corporate, if resident came back to facility from hospital, the nurse would erase the previous medications, never doing that again. The DON said Resident #30's Midodrine parameters were dropped and never picked back up when returning from hospital. The DON stated Resident #30 was in and out of hospital due to health condition. <BR/>Interview on 4/07/2023 at 1:44 PM, with LVN I in regard to Resident # 30 stated she did not finish her admission, Resident # 30 went back out to hospital due to respiratory issues. LVN I stated she was aware of the new admission resident policy to notify physician. LVN I stated she learned this in school and in-services that anything MD communication required documentation and if she could not get a hold of MD, talk to DON/ADON or speak to the medical director. <BR/>2. Record review of Resident #23's admission Record dated 4/7/2023 revealed he was admitted on [DATE], re-admitted on [DATE] with diagnoses of, legal blindness, altered mental status, disorientation, anemia, metabolic encephalopathy, peripheral vascular disease, end stage renal disease and diabetes II. <BR/> Record review of Resident #23's consolidated physician orders for April 2023 revealed Nifedipine ER (extended release) oral tablet extended release 24-hour 60 mg give 1 tablet by mouth two times a day for hypertensive encephalopathy medications should not be crushed, hold if SBP &gt; 100, DBP &lt;60 . <BR/>Record review of Resident #23's MAR (medications administration record) for April 2023 revealed he was ordered Nifedipine ER (extended release) oral tablet extended release 24-hour 60 mg give 1 tablet by mouth two times a day for hypertensive encephalopathy medications should not be crushed, hold if SBP &gt; 100, DBP &lt;60. This was administered on 4/2/2023 at 12:34 PM, instead of 7:30 AM by CMA CC. The next dose was administered at 4:57 PM. <BR/>Record review of Resident #23's Significant change MDS dated [DATE] revealed section C cognition pattern BIMs score 15/15 (cognitively intact) and section O Special Treatments and Programs, other Dialysis. <BR/> Record review of Resident #23's care plan dated 3/21/2023 revealed resident had impaired tissue perfusion related to hypertension, intervention give anti-hypertensive medications as ordered. Monitor for side effects such as hypotension, and increased heart rate and effectiveness, give medications for hypotension ., residents had anemia related to chronic kidney disease intervention-give medications as ordered. <BR/>Interview on 04/06/2023 at 11:08 AM with CMA U stated Resident #23 stated she administers his medications on dialysis days before or after he comes back to facility and had not adverse reactions. CMA U stated the software system window for Nifedipine ER brings up the BP window before the blood pressure medications with parameters are administered. CMA U stated if there was a question about resident s blood pressure and medications for blood pressure, she would ask a nurse.<BR/>Interview on 4/06/2023 at 8:59 AM with RN AA, charge nurse regarding Resident #23 stated he goes to dialysis three times a week (Monday, Wednesday, Friday) his schedule 7:15am-11am, chair time, but sometimes he is late. Resident #23 was bed bound and staff use the Hoyer and takes time to transfer. <BR/>Interview on 4/07/23 at 3:33 PM with the consultant Pharmacist BB stated last time she did a Pharmacy review for the facility was on 3/19/2023, she revealed she had access to residents' chart from home and does come to visit monthly. The Consultant Pharmacist BB stated Resident #30 had order for Midodrine for hypotension. The consultant Pharmacist BB stated Resident #30's review for March 2023 included a recommendation for Midodrine parameters and staff should let MD aware of Midodrine without parameters. The consultant Pharmacist BB stated Resident #23 stated if he missed a medication dose for Nifedipine ER he can take the medication when he can, and if too close take the next medications dose.<BR/>Record review of policy Medication Administration dated 10/24/2022, Medications are administered by licensed nurse, or other staff who are legally authorized to do so in the state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. 8. Obtain and record vital signs, when applicable of per physician orders. When applicable, hold medications for those vital signs outside the physician's prescribed parameters. 17. Sign MAR after administrated. For those medications requiring vital signs, record the vital signs onto the MAR. 20. Correct any discrepancies and report to nurse manager.

**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 for each resident, consistent with the resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 2 of 16 residents (Resident #24, #46) reviewed for care plans, in that:<BR/>1. The facility failed to ensure wound care management was included on the Care Plan for Resident #24 when he developed pressure injury wounds on 4/17/2024. <BR/>2. The facility failed to ensure significant weight loss was included on the Care Plan for Resident #46 after she lost 7.14% of her body weight from 3/6/2024 to 4/8/2024. <BR/>This failure could place residents at risk of not receiving the care needed to maintain their highest, most practicable, physical, social, and psychosocial level of well-being.<BR/>The findings were: <BR/>1. Record review of the admission Record revealed Resident #24 was a [AGE] year-old male originally admitted on [DATE]. <BR/>Record review of the comprehensive MDS assessment, dated 4/15/2024 revealed Resident #24 was rarely or never understood [therefore a BIMS assessment could not be completed]. Resident #24 had short- and long-term memory problems; and was moderately impaired in cognitive skills for daily decision making. Active diagnoses included pneumonia [infection in the lungs caused by bacteria, viruses or fungi that causes lung tissue to swell, cause fluid or pus to develop in lungs], and pressure ulcer of the left buttock, stage 2 [sore that has broken through the top layer of the skin and part of the layer below]. Under section M - Skin Condition, Resident #24 was coded as having a formal and clinical assessment for determination of Pressure Ulcer/Injury risk and was rated as not at risk of developing pressure ulcers/injuries and did not have any unhealed pressure ulcers/injuries.<BR/>Record review of Care Plan, printed 5/10/2024 at 12:11 PM, revealed Resident #24 had a problem area of ADL self-care performance deficit, with interventions that indicated he was totally dependent on staff for reposition and turning in bed and as necessary, revised on 4/9/2024; and required skin inspection every shift, revised on 3/29/2024. No additional problem areas or interventions related to skin or wound care management were included. <BR/>Record review of Daily Skilled Note dated 4/18/2024 at 1:45 PM authored by LVN C, revealed indication that skin was not intact. <BR/>Record review of Order Details revealed Resident # 24 had orders to cleanse with wound cleanser, pat dry apply silvasorb, cover with non-adherent dressing and secure with tape one time per day to stage 2 [pressure injury] to left and right buttocks with start dates of 4/18/2024. <BR/>In an interview on 5/10/2024 at 2:54 PM, the DON stated the resident had returned from the hospital on 4/09/2024. The DON stated the Wound Care Nurse was out on leave at this time, and the wound care management was delegated to various nurses each day to cover while the Wound Care Nurse was out. The Resident #24's pressure injury wounds had resolved 3/27/2024 prior to his hospitalization. <BR/>In an interview on 5/10/2024 at 3:55 PM, the DON stated due to Resident 24's declining health status related to pneumonia, the pressure injuries developing were unavoidable as the area was friable due to previous, healed pressure injuries and the residents' diminished capacity to independently self-reposition as an energy conservation coping strategy. The DON stated that the wounds developed on 4/18/2024, but the nurse [LNV B] that assessed and documented the wounds that day was currently out on leave. The DON stated the wounds were discussed in medical morning meeting and physician orders were received for wound care treatment that day [4/18/2024]. The DON stated that Resident #24's care plan should have been updated to reflect the change in his condition and wound care management interventions within 2 weeks, if not sooner, of the wounds being discovered. The DON stated it was normally the responsibility of the Wound Care Nurse to update the Care Plan regarding wound care management; however, in this case, while the Wound Care Nurse was out, it was the responsibility of the nurse who discovered, and documented the wounds to update the Care Plan. The DON stated the risk of not having the care plan updated was that something could be missed, or delay treatment. <BR/>2. Record review of Resident #46's Face Sheet, dated 5/10/2024, reflected a [AGE] year-old female resident initially admitted on [DATE] with diagnosis including pressure ulcer of sacral region, stage 4, and type 2 diabetes mellitus without complications. <BR/>Record review of Resident #46's Quarterly MDS Assessment, dated 4/4/2024, reflected Resident #46 had a BIMS score of 9, indicating the resident was moderately impaired. Further review of the Quarterly MDS Assessment reflected that Resident #46 had lost 5% or more in the last month or loss of 10% or more in last 6 months while not on a physician-prescribed weight-loss regimen. <BR/>Record review of Resident #46's Dietary Progress Note, dated 4/9/2024, reflected that Resident #46 had a significant weight loss, was started on Megace, an appetite stimulant, and a recommendation to add fortified food to resident meals. <BR/>Record review of Resident #46's Comprehensive Person-Centered Care Plan, dated 5/10/2024, reflected no problems, goals, or interventions relating to Resident #46's significant weight loss. <BR/>In an interview on 5/10/2024 at 2:36 PM, the DON stated significant weight loss should be care planned as it is a significant change. The DON stated the MDS Nurse oversaw updating Care Plans and that they monitor any changes during morning meetings to determine if they are significant changes. <BR/>In an interview on 5/10/2024 at 2:45 PM, the MDS Nurse stated she was unsure of why the significant weight loss was care planned and that the care plan generally is updated when there is a significant change such as weight loss.<BR/>Record review of the facility policy entitled, Pressure Injury Prevention and Management, dated 8/15/2022, reflected under the heading Policy Explanation and Compliance Guidelines in section 4. Interventions for Prevention and to Promote Healing step f.) Interventions will be documented in the care plan and communicated to all relevant staff. Under section 6. Modifications of Interventions step b.) interventions on a resident's plan of care will be modified as needed .ii.) new onset or recurrent pressure injury development. <BR/>Record review of the facility policy entitled, Care Plan Revisions Upon Status Change, dated 10/24/2022, reflected under the heading Policy Explanation and Compliance Guidelines in section 2. Procedure for reviewing and revising the care plan .step d.) The care plan will be updated with new or modified interventions. F.) care plans will be modified as needed by the MDS Coordinator or other designated staff member.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the comprehensive assessment of a resident, the facility failed to ensure that a resident with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 1 of 6 residents (Resident #1) reviewed for pressure sores, in that: <BR/>The facility failed to ensure Resident #1 received wound care and treatment as ordered by a physician.<BR/>-Resident #1's right great toe was not monitored daily for changes once per day as ordered by a physician.<BR/>-Resident #1's right heel was not monitored daily for changes once per day as ordered by a physician.<BR/>-Resident #1's skin tear to the left upper leg was not monitored every shift for signs of infection as ordered by a physician.<BR/>-Resident #1's pressure ulcer to her left buttock was not cleansed with wound cleaner, patted dry and did not have medseptic QA applied every shift as ordered by a physician.<BR/>-Resident #1's pressure ulcer to her right buttock was not cleansed with wound cleaner, patted dry and did not have medseptic QA applied every shift as ordered by a physician.<BR/>-Resident #1's pressure ulcer to her right gluteal fold was not cleansed with wound cleaner, patted dry and did not have medseptic QA applied every shift as ordered by a physician.<BR/>-Resident #1 had a significant weight from August 2023 to September 2023.<BR/>Resident #1 was admitted to the hospital with sepsis presumed to be from an infected sacral decubitus ulcer.<BR/>An IJ was identified on 9/27/2023 at 6:00 p.m., and a template was provided to the facility at this time. While the IJ was removed on 10/1/2023, the facility remained out of compliance at a scope of pattern and a scope of actual harm that is not immediate jeopardy due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. <BR/>These failures could place additional residents at risk for a delay in treatment, hospitalization, loss of limb and/or a significant decline in heelth. <BR/>The findings included:<BR/>Record review of Resident #1's face sheet dated 9/28/2023 revealed she was [AGE] years of age with an admission date of 1/2/2022 and a readmission date of 6/1/2023 with diagnoses which included: Type 2 diabetes mellitus with diabetic neuropathy, end stage renal disease, major depressive disorder, mild cognitive impairment, dysphagia, cognitive communication deficit, urinary tract infection, degenerative disease of nervous system, lack of coordination, morbid obesity, muscle wasting, anemia in chronic kidney disease, fluid overload, anxiety disorder, cerebral infarction, nausea with vomiting, diarrhea. <BR/>Record review of Resident #1's comprehensive MDS dated [DATE] revealed a BIMS score of 10 indicating moderate impairment. Further review under category, Skin Conditions, revealed Resident #1 was indicated as having zero venous and arterial ulcers, and no other ulcers, wounds and skin problems. <BR/>Record review of Resident #1's Care Plan, start date 6/1/2023, stated, (Resident #1) has potential impairment to skin integrity r/t incontinence and decreased mobility. (Resident #1) will be free from skin break down through the review date Interventions included, Monitor/document location, size and treatment of skin injury. Report abnormalities, failure to heel, s/sx of infection, maceration etc. to MD. Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate and any other notable changes or observations.<BR/>Record review of Resident #1's Care Plan, start date, 8/18/2023, stated, (Resident #1) has DTI to left toe. (Resident #1's) Pressure ulcer will show signs of healing and remain free from infection by/through review date. (Resident #1) will have intact skin, free of redness, blisters or discoloration by/through review date. Interventions included, Administer treatments as ordered and monitor for effectiveness.<BR/>Record review of Resident #1's Care Plan, start date, 8/18/2023, stated, (Resident #1) has DTI to right great toe. The (Resident #1s) will Pressure ulcer will show signs of healing and remain free from infection by/through review date. Interventions included, Administer treatments as ordered and monitor for effectiveness.<BR/>Record review of Resident #1's Care Plan, start date, 8/18/2023, stated,(Resident #1) has DTI to right heel. <BR/>(Resident #1's) pressure ulcer will show signs of healing and remain free from infection by/through review date.<BR/>PHYSICIAN ORDERS<BR/>Record review of Resident #1's physician's orders, start date, 7/26/2023, stated, DTI to Right heel-monitor daily for changes.<BR/>Record review of Resident #1's physician's orders, start date, 7/26/2023, stated, DTI - right great toe monitor daily for changes. <BR/>Record review of Resident #1's physician's orders, start date, 8/30/2023 stated, DTI-right great toe monitor daily for changes. Frequency, one time a day. <BR/>Record review of Resident #1's physician's orders, start date, 8/30/2023 stated: DTI to Right heel-monitor for changes. Frequency, one time a day. <BR/>Record review of Resident #1's physician's orders, start date, 8/30/2023 stated: stage 2 to R buttock: cleanse with wound cleanser pat dry apply mediseptic QS. Frequency, every shift. <BR/>Record review of Resident #1's physician's orders, start date, 8/30/2023 stated: Stage 2 to L buttock: cleanse with wound cleanser, pat dry apply mediseptic QS. Frequency, every shift.<BR/>Record review of Resident #1's physician's orders, start date, 9/9/2023 stated: Monitor skin tear left upper leg Monitor every shift for signs of infection until heeled. Frequency, every shift. <BR/>Record review of Resident #1's physician's orders, start date, 9/11/2023 stated: Stage 2 to R gluteal fold cleanse with wound cleanser pat dry apply mediseptic QS. Frequency, every shift. <BR/>TREATMENT ADMINISTRATION: <BR/>Record review of Resident #1's TAR September 2023 stated, DTI - right great toe monitor daily for changes one time a day -Start Date 08/01/2023. Further review revealed holes in the TAR the following: 9/5, 9/6, 9/8, 9/13, 9/14, 9/15. <BR/>Record review of Resident #1's September 2023 TAR stated, TI to Right heel-monitor daily for changes one time a day -Start Date 08/01/2023. Further review revealed holes in the TAR on the following: 9/5, 9/6, 9/8, 9/13, 9/14, 9/15.<BR/>Record review of Resident #1's September 2023 TAR stated, Monitor skin tear left upper leg Monitor every shift for signs of infection until heeled every shift -Start Date 09/09/2023 Further review revealed holes in the TAR for the following:<BR/>Shift 6:00 AM - 2:00 PM - 9/13 thru 9/15, 9/18<BR/>Shift 2:00 PM - 10:00 PM - 9/9, 9/11 thru 9/15<BR/>Shift 10:00 PM - 6:00 AM - 9/9<BR/>Record review of Resident #1's September 2023 TAR stated, stage 2 to L buttock: cleanse with wound cleanser, pat dry apply mediseptic QS every shift -Start Date 08/30/2023. Further review revealed holes in the TAR for the following:<BR/>Shift 6:00 AM - 2:00 PM - 9/4 thru 9/6, 9/8, 9/13 thru 9/15, 9/18<BR/>Shift 2:00 PM - 10:00 PM - 9/5-9/9, 9/11 thru 9/18<BR/>Shift 10:00 PM - 6:00 AM - 9/9<BR/>Record review of Resident #1's September 2023 TAR stated, stage 2 to R buttock: cleanse with wound cleanser pat dry apply mediseptic QS every shift -Start Date 08/30/2023. Further review revealed holes in the TAR for the following:<BR/>Shift 6:00 AM - 2:00 PM - 9/4 thru 9/6, 9/8, 9/13 thru 9/15, 9/18<BR/>Shift 2:00 PM - 10:00 PM - 9/5-9/9, 9/11 thru 9/18<BR/>Shift 10:00 PM - 6:00 AM - 9/9<BR/>Record review of Resident #1's September 2023 TAR stated, Stage 2 to R gluteal fold cleanse with wound cleanser, pat dry apply mediseptic QS every shift -Start Date 09/11/2023. Further review revealed holes in the TAR for the following:<BR/>Shift 6:00 AM - 2:00 PM - 9/13, 9/14, 9/15, 9/18<BR/>Shift 2:00 PM - 10:00 PM - 9/11 thru 9/18<BR/>Shift 10:00 PM - 6:00 AM - 0 missed <BR/>SKIN ASSESSMENTS<BR/>Record review of Resident #1's Weekly Skin Evaluation, effective date, 9/14/2023, revealed: What type of wound(s) does patient have? - A. Pressure Ulcer(s). Further review revealed there these were new since last skin assessment. Type of wound was, Right gluteal fold - Stage 2 to R gluteal fold measuring 2cmx4cm. This document was signed by Treatment Nurse, LVN B. <BR/>Record review of Resident #1's Weekly Pressure Ulcer Evaluation, effective date, 9/14/2023, revealed: date of assessment was 9/11/2023 -Right Great Toe, length 1.5 cm, width 1.5 cm, depth N/A, stage suspected deep tissue injury. Further review revealed the wound developed 8/13/2023 and was, admitted with. This document was signed by Treatment Nurse, LVN B. <BR/>Record review of Resident #1's Weekly Pressure Ulcer Evaluation, effective date, 9/14/2023, revealed: date of assessment was 9/11/2023 - Right Heel, length 4cm, width 4.5cm, depth N/A, stage suspected deep tissue injury. Further review revealed the wound developed 8/13/2023 and was, admitted with. This document was signed by Treatment Nurse, LVN B. <BR/>Record review of Resident #1's Weekly Pressure Ulcer Evaluation, effective date, 9/14/2023, revealed: date of assessment was 9/11/2023 - Right Buttock pressure ulcer, length 5cm, width 6cm, depth .1cm, stage N/A. Further review revealed the wound developed 8/30/2023 and was, in house developed. This document was signed by Treatment Nurse, LVN B. <BR/>Record review of Resident #1's Weekly Pressure Ulcer Evaluation, effective date, 9/14/2023, revealed: date of assessment was 9/11/2023 - Left Buttock pressure ulcer, length 3.5cm, width 4cm, depth .1cm, stage II. Further review revealed the wound developed 8/30/2023 and was, in house developed. This document was signed by Treatment Nurse, LVN B. <BR/>PROGRESS NOTES<BR/>Record review of Resident #1's progress note, dated 6/1/2023 - 6:18 PM, stated, Note Text: Received resident via stretcher by Amistad ambulance. (Resident #1) is a [AGE] year-old female with PMH of HTN, DM, CAD, neuropathy, anxiety, depression, seizure, CVAx2, ESRD on HD M, W, F, with Fresenius, morbid obesity. (Resident #1) is A/Ox4, skin intact, respirations even and unlabored, lung sounds clear to all lobes, active BS to all 4 quadrants, abdomen non distend, non-tender. Left upper extremity shunt functioning properly. (Resident #1) unable to ambulate due to extreme weakness. (Resident #1) is able to help with transfer with assistance, incontinent X2. (Resident #1) with no belongings. RP and MD made aware. (Resident #1) voices no concerns at this time. (Resident #1)) orientated to room, call bell and bed remote control.<BR/>Record review of a typed summary drafted by Resident #1's Hospital Physician, received by email on 9/27/2023, stated:<BR/>Regarding patient (Resident #1) from (Nursing Facility)<BR/>(Resident #1) arrived to (Hospital B) as a transfer from (Hospital A) on 9/19/2023 for the evaluation and management of altered mental status in the setting of sepsis which was presumed to be caused by an infected sacral decubitus ulcer. Upon my initial evaluation the patient was very lethargic and disoriented and there was a very strong odor. After turning her to the side there was a large unstageable sacral decubital ulcer and other surrounding decubital ulcers of varying stage with some noted purulence. The wounds were also noted in the perineal and groin areas near the skin folds. Photos of the wounds are available in the medical record if needed. Due to low blood pressure/shock (Resident #1) was transferred to the ICU to be placed on pressors to maintain blood pressure. She underwent a CT of the abdomen and pelvis with IV contrast to further assess the wound for surgical planning. Incidentally found on the CT scan was the presence of blood clots in both lungs (bilateral pulmonary embolism). Since clots in the lungs typically originate in the legs we next obtained US dopplers of both legs to assess for any further clots and was found to have blood clots in both legs. An echocardiogram was performed to assess for any strain on the heart caused by the blood clots in the lungs, the study did not indicate any strain to the heart.Since her cardiac function was stable the surgeon and anesthesiologist agreed to proceed with debridement of the sacral wound. The wound was extensively debrided to removed any nonviable tissues which required resecting tissue down to the sacral bones (stage 4 pressure ulcer). I have not seen the wound personally since the surgery was performed but per discussion with (Resident #1's) nurse, the wound is approximately the diameter of a basketball. [sic]Due to the location of the wound, near the anus, there is high risk of stool entering and subsequently causing infection within the wound. For this reason (Resident #1) had to be taken back to the operating room for placement of a colostomy to divert stool away from the wound. Once the wound heels it will be possible to reverse the colostomy.<BR/>A wound vac is to be placed to assist in wound healing. Due to the extent of the injury, this wound will take significant time and optimal conditions in order to heel. I am unable to provide more specific details on prognosis/outcome. A specialist in wound care may be able to provide more information.(Resident #1) is to remain on blood thinners for at least 3 months for the management of blood clots in the legs and lungs.The wound on (Resident #1's) back/buttock/perineal area is caused by prolonged pressure to the skin and underlying tissue which results in poor blood flow to the affected tissue. These injuries can be made worse or more likely to get infected when patients are incontinent of urine or stool and are not promptly cleaned. In patients who are bed bound or with limited mobility, these injuries can be avoided or made less likely to occur by frequent repositioning to offload pressure on a particular area for prolonged periods of time. Other measures include making sure the skin is regularly cleaned and dried. For patients at risk for developing pressure injuries, the skin should be regularly monitored for signs of injury so that it can be addressed early in the course of the injury. I am unaware of the care that was being provided at the nursing home to address the decubital ulcers or what measures were being implemented to heel or prevent these injuries. (Resident #1) presented to our facility/care at a late stage in the course of this injury process. If this was the first presentation for evaluation of these injuries then it would be an unusually late recognition on the part of the party responsible for her care and would suggest that she was not being adequately monitored or that the injuries were possibly noted but not being adequately tended to. The presence of clots in the legs and lungs also would indicate that she has been very immobile given that immobility is the greatest risk factor for development of these types of blood clots.<BR/>Interview and attempted observation on 9/22/2023 at 10:51 AM at a hospital ICU (Intensive Care Unit) with Resident #1: Resident #1's Family Member A, revealed Resident #1 had just left for dialysis treatment and would return in approximately 4 hours. During this interview, Family Member A stated the resident had been residing at a nursing facility for the last 3 months. Family Member A said she used to work at a nursing facility and was familiar with protocol specific to resident care. Family Member A indicated staff at the Nursing Facility were not turning, repositioning, or transferring Resident #1 to her wheelchair on the occasions she would visit the resident. Family Member A further stated the Resident #1 was obese and confused and that facility staff had skipped several of the resident's dialysis appointments and also said staff were not adequately feeding the resident and that she had had a significant weight loss. Additionally, Family Member A said Resident #1 had a severe infection in her brain and large pressure wound to sacral area which required surgical intervention at the hospital. Family Member A said Resident #1's wound, .smelled like a dead animal, and that hospital staff had to make special interventions in Resident #1's ICU room in an attempt to mask the odor. Finally, Family Member A said she had signed a DNR for Resident #1 and indicated Resident #1's medical team informed her there was a good chance Resident #1 would not survive much longer. Additionally, Family Member A said medical imaging revealed blood clots in Resident #1's lungs and lower extremities as well as an infection to her brain. Finally, Family Member A mentioned a representative from the facility had just left and was attempting to determine if Resident #1's family was under the impression the facility was responsible for the Resident #1's deteriorating condition. Family Member A showed this investigator a business card whom she purported was a representative of the facility at which time this investigator took a photograph of the business card. A review of this business card revealed an RN D. <BR/>Telephone interview 9/22/2023 at 1:11 PM with Resident #1's Hospital Physician revealed, Resident #1 appeared , .extremely unkempt . upon her admission to the hospital and was discovered to have .blood clots in both her legs and lungs . The doctor explained that he would typically see these symptoms in patients that, .had not been moved enough . or, .kept in one place for extended periods of time. The doctor further stated it was obvious Resident #1, .had not been turned enough . and that, . her wounds were pretty extensive, specific to Resident #1's peri area. The doctor further stated Resident #1 was, .septic upon arrival. <BR/>Interview and record review on 9/26/2023 at 9:55 AM, LVN A was asked to describe Resident #1, and replied that Resident #1 came to the facility for physical therapy, was a dialysis patient, was a diabetic, and was alert and oriented times 4 upon admission. LVN A said the Resident #1 had to go to San [NAME] one time because staff thought she had a stroke. LVN A said when Resident #1 returned to the facility, she became totally dependent on staff for assistance. LVN A said Resident #1 seemed to fail to thrive. LVN A said Resident #1 had a referral for psych services and started to take Zoloft. LVN A also said Resident #1 had to downgrade her diet from regular to puree. When asked if Resident #1 had any wounds, LVN A said that Resident #1 had a stage II to her bottom. When asked why Resident #1 was recently discharged , LVN A said she was not sure. When asked how Resident #1 acquired her wound, LVN A said she was unsure. During a record review at this time, LVN A agreed that multiple wound treatments were missed for Resident #1 during the month of September 2023. When asked why, LVN A indicated she did not know because Resident #1 was not combative and was bedbound so she couldn't run away. LVN A agreed this was a concern and that missed wound treatments could lead to serious infection. When asked again what the breakdown was as to why residents were missing so many treatments, LVN A said there really was no good reason as the treatment nurse would typically administer treatments for wounds and then nursing staff would also divide treatments up if and when the treatment nurse was out of the facility. When asked who the treatment nurse was, the LVN said it was LVN B.<BR/>Interview and record review on 9/26/2023 at 10:31 AM, Treatment Nurse, LVN B was asked to describe Resident #1, LVN B responded that Resident #1 came to the facility with a DTI to her right heel and tip of her right great toe. LVN B said (Resident #1's) bottom started breaking down, and that the, .area between her brief and her leg started breaking down as well. LVN B said Resident #1 started getting another area on her left gluteal fold, and then she went to dialysis on 9/18/2023 and from there was sent to the hospital for low blood pressure, and said (Hospital A) sent Resident #1 to a hospital Hospital B with a diagnosis of encephalopathy. When asked what encephalopathy was, LVN B responded that, it was something in the brain where you get confused, and, get an altered mental status. LVN B said Resident #1's wounds to her peri area were acquired at the facility and that the resident was refusing to be turned. When asked why the resident was refusing to be turned, LVN B said it was because, (Resident #1) wasn't comfortable. When asked why the Hosptial A sent Resident #1 to Hospital B, LVN B responded that she was unsure. When asked if Resident #1's wound was getting infected, the LVN responded that, it wasn't looking great but it didn't have a smell or anything. During this interview, LVN B was shown Resident #1's September 2023 TAR, at which time LVN B confirmed that multiple entries for Resident #1's skin treatments were blank and responded that she may have been working the floor those days. LVN B said that she would have to work the floor if someone called in and would have to also attend to wounds simultaneously. When asked if that posed a problem because she was having to do 2 jobs during a shift, LVN B said she would delegate to other nurses to handle the lower category wounds. When asked what could be done to ensure treatments could never be missed, LVN B said a lot of the 2pm-10pm nurses moved to the hospital which had caused a bit of a strain on staffing. When asked if the facility utilized agency staff, LVN B responded that the facility did not. <BR/>Interview and record review on 9/26/2023 at 11:03 AM, RN C stated she was filling in for the DON as the DON was out of the facility. During this interview, the RN C said she was not that familiar with the residents as she currently only worked PRN. RN C said staffing had been short and she was frequently asked to work. RN C was shown September 2023 TARs for Resident #1 and agreed they had missing entries. When asked what that meant, the RN C said it meant the treatments, didn't occur. When asked what the concern was specific to wound treatments, RN C said it was a concern because the missed treatments could cause the wounds to evolve into serious infections which could lead to sepsis and or death. RN C said this facility had difficulty retaining staff because other facilities in the area were paying more and believed staffing was the reason some of these treatments were being missed. RN C said that if the treatment nurse is required to work the floor, other nurses on the shift will be delegated to do wound care. <BR/>Interview and record review on 9/26/2023 at 2:00 PM, the DON said the facility had the staff they need but had been overlapping their shifts. The DON agreed that if there was a missed entry in the TAR it didn't happen. The DON said Resident #1 was very sick and she said the staff tried to get her family to sign a DNR. The DON said facility staff would fear that when (Resident #1) would go to dialysis, they would send her to the hospital and said that is exactly what happened. The DON said Resident #1 was previously discharged from dialysis because she didn't look right. The DON said Resident #1 was, very young and they were having to spoon feed her. The DON said Resident #1 was much more motivated when she was admitted but started to decline. At this time, the DON was shown Resident #1's September TAR, the DON agreed it was a concern that there were missed wound treatments and that missed wound treatments had the potential to evolve into more serious issues like infections. <BR/>Interview on 9/26/2023 at 3:09 PM, the Medical Director, said he found out recently that there had been missed treatments relative to wound care and that he was very surprised. When asked who was supposed to be doing wound treatments between his visits, the Medical Director responded, LVN B. When asked if he was noticing the decline in Resident #1 and if he would have given different orders, the Medical Director responded that he was not aware of a decline specific to Resident #1's wounds. The Medical Director said he had only heard that another resident had been sent to the ER and insisted on not coming back to the facility and that the resident alleged she was not being provided care for her wounds. The Medical Director further stated this resident had a wound vac. The Medical Director said Resident #1's name came up a couple of times but he could not recall the reason. The Medical Director said Resident #1 was not eating well and had to have IV fluids once or twice and said DON or charge nurse would typically be the one who contacted him when there was a decline. When asked if the Medical Director would come in more than just monthly if a resident experienced a decline, the Medical Director said that he would. The Medical Director said he expected residents would receive nursing care and that he knew skin care was important because a lot of the residents have a lot of vulnerabilities. The Medical Director also stated that staff should be documenting and not missing treatments because the ultimate concern would be that the wounds would get worse. The Medical Director said, A soft tissue wound can lead to infection and lead to hospitalization. The whole idea of being in a nursing home is to avoid hospitalizations. The Medical Director said he was not responsible for training the facility staff. The Medical Director said he was notified and aware of concerns with resident wound care but could not remember the names of the residents for which he had been notified. The Medical Director stated, I probably would have called the DON and asked what was going on with the care the resident was not receiving, when asked what he would have done if he had been notified that a resident did not receive wound care as ordered. The doctor said he, wouldn't like to think there was willful neglect. Finally, the Medical Director stated, there has got to be someone who has to be responsible if the treatment nurse is away so staff have to be more pro-active than reactive.<BR/>Interview on 9/26/2023 at 4:40 PM, LVN B, when asked about training, said she would get relias training quarterly or if and when an incident of abuse and neglect occurred, and said those trainings, occur frequently. When asked if there were any training the last several weeks, LVN B said there was training for covid, hand washing, abuse and neglect and said that was all. LVN B said that staff were told daily that they need to clear their MARs and TARs, meaning to complete all prompted tasks for their shift. When asked if there had been any trainings specific to Resident #1 since she had been discharged to the hospital, the LVN B said training occurred only when the resident started to decline. When asked when this was, the LVN B said it was after the resident came back from one of her admissions from the hospital. When asked if any trainings occurred in response to the Resident #1's most recent discharge, the LVN B indicated there had been no trainings specific to this incident since Resident #1 discharged on 9/19/2023. When asked if any other nurses were qualified to do wound treatment, LVN B said that LVN A and several other LVNs had become qualified. LVN B said those LVN staff do a rotation with me when they get hired. LVN B said staff typically get evaluated annually. LVN B was asked if she had her wound treatment skills evaluated, she responded, yes, by the DON. LVN B was asked when this evaluation took place and said it was in in March or April 2023 and said the evaluations would occur annually. <BR/>Interview on 9/26/2023 at 5:07 PM, DON, stated Resident #1 was sent from dialysis to the hospital. When asked what diagnosis Resident #1 was sent out for the DON responded that she was not sure. The DON said she guessed it was encephalopathy and found out Resident #1 was going to the ER when dialysis called to inform her. When asked if staff had any training since Resident #1 was sent to the hospital relative to encephalopathy or other issues related to the Resident #1's incident the DON responded, no. The DON said Resident #1 was unpredictable and her alert and oriented status would frequently change. The DON said Resident #1 was continent when she arrived to the facility but once she became incontinent, staff noticed Resident #1 had genital warts upon changing her. <BR/>Interview on 9/27/2023 at 5:02 PM, the DON stated the facility's Medical Director came to the facility monthly and talked to residents, reviewed charts/meds, would look at wounds if staff requested. The DON said she was informed of residents' wound status by reviewing a weekly skin report and would check to see who was progressing or declining and who needs what type of interventions.The DON said staff communications began with the CNAs who would inform their charge nurse of concerns and the charge nurse would put those concerns on the 24-hour report and contact physician to get orders. The DON was made aware by staff Resident #1's wounds were getting worse. The last time she had seen the resident had been a little while, and she was under the impression the resident's sacral pressure ulcer had evolved into a stage II pressure ulcer. When asked what facility staff could have done differently for this resident, the DON said facility staff should have sent the resident to the hospital more frequently but said the hospital would just send her back and we had to have a van on standby to pick her up, implying the resident was frequently sent to the hospital. (note: Resident #1 was only sent out 3 times in 3 months including most recent visit).<BR/>Interview on 9/27/2023 at 5:14 PM, the Administrator revealed information obtained during the previous interview with the DON. Additionally, when asked what could have been done differently for Resident #1, the Administrator said, We should have added the resident to patients at risk, and could have sent her to the hospital for slightest decline.<BR/>Interview on 9/28/2023 at 10:42 AM, the Administrator revealed LVN B did not have Wound Care Certification.<BR/>Telephone interview on 9/29/2023 at 12:30 PM, the Medical Director said that had he been made aware that Resident #1's wound status had changed, he would have wanted to have found out the last time Resident #1 saw the vascular surgeon, would have wanted to talk to the treatment nurse, and would have looked for any signs of infection.<BR/>Record review of facility policy, Job Description for Treatment Nurse, revised 3/2015, stated, The Treatment Nurse will provide quality of care to prevent and promote healing of alterations in skin integrity of each resident as determined by resident assessments and individual plans of care . 12. Initiate and continue treatments on residents in the facility with skin breakdown and other conditions requiring treatment. 13. Modify and/or change treatments as necessary and notifying physician for approval. 14. Inform the DON and the assessment nurse of resident change of condition. <BR/>Record review of facility policy, Pressure Injury Prevention and Management, dated 8/15/2022, stated, This facility is committed to the prevention of avoidable pressure injuries and the promotion of healing of existing pressure injuries . The facility shall establish and utilize a systematic approach for pressure injury prevention and management, including prompt assessment and treatmen[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews the facility failed to ensure, in accordance with accepted professional standards and practices, complete, accurately documented, readily accessible, and systemically organized medical records for each Resident, for 2 of 39 residents (Residents #14 and #140) reviewed for accurate records, in that: <BR/>1. <BR/>LVN B did not document Resident #140's physicians orders for a urinalysis with a culture and sensitivity.<BR/>2. <BR/>LVN B did not document Resident #14's SBAR to the physician and the physician's order.<BR/>These failures placed residents at risk for injury by inaccurate / missing records. <BR/>The findings included: <BR/>1. <BR/>Resident #140<BR/>A record review of Resident #140's admission record revealed an admission date of 05/23/2020, and a hospital emergency discharge date of 05/07/2022, and diagnoses which included neuromuscular dysfunction of bladder and bladder neck obstruction [when a person lacks bladder control due to brain, spinal cord or nerve problems].<BR/>A record review of Resident #140's quarterly MDS, dated [DATE], revealed Resident #140 was a [AGE] year-old male without cognitive mental impairment evidenced by a 15 out of 15 score on a BIMS. Resident #140 had a suprapubic catheter [a surgically created connection between the urinary bladder and the skin used to drain urine from the bladder in individuals with obstruction of normal urinary flow] and a history of urinary tract infections. Resident #140 was frequently incontinent of bowels. Resident #140 was not weight bearing and used a wheelchair to ambulate. <BR/>A record review of Resident #140's care plan, dated 04/06/2023, revealed, The resident has an activities of daily life self-care performance deficit related to contractures to the left leg and above knee amputation; toilet use; the resident is totally dependent on staff for toilet use. Resident is incontinent of bowel and required staff to check every two hours. staff to help provide catheter care and empty out the urine collection bag. The resident has suprapubic catheter at risk for UTI sepsis. The resident has suprapubic catheter; position catheter bag and tubing below the level of the bladder . monitor record report to medical doctor for signs and symptoms of urinary tract infection pain burning blood thinning hearing cottages fever chills altered mental status. <BR/>A record review of Resident #140's nursing progress notes revealed LVN B documented on 04/06/2022, resident back from urology appt. NP E requested for resident to have SP drain to gravity and no belly bag. facility to collect UA and send to [local hospital] for C/S. and to continue with current medications. Follow up in four months [DATE], at 1350. This SN advised resident that I needed to change foley bag [urine collection] to either a leg bag or normal foley bag, resident refused and stated he wants AM shift to change it.<BR/>A record review of Resident #140's laboratory report, dated 04/12/2022, revealed Resident #140, collected 04/07/2022, urine culture final organism 1 proteus mirabilis .organism 2 enterococcus faecalis. [Proteus mirabilis a bacterium known to cause serious infections in humans. Enterococcus faecalis a bacterium can cause life-threatening infections].<BR/>During an interview on 04/05/2023 at 2:25 PM LVN B received a report of her documentation for Resident #140 on 04/06/2022 where she documented Resident #140 had returned from their urology appointment and had a new order for a UA with a CS. LVN B stated she could not recall the details but stood on the accuracy of her note. LVN B was asked to demonstrate her documentation for the physicians' order for the UA with C&S. LVN B stated she reviewed Resident #140's record and could not find any order for Resident #140 to have a UA with a C&S on 04/07/2022. In response to the lack of a documented order for the UA with C&S LVN B stated, I am human and I can make mistakes. <BR/>During an interview on 04/07/2023 at 03:48 PM, the DON and the ADON, the DON stated Resident #140 had a need for a suprapubic catheter related to a neurogenic bladder, which was to drain via gravity to a dependent urine collection bag positioned below the bladder. The DON stated Resident #140 was seen on 04/06/2022 by Dr. F and returned to the facility with new orders from Dr. F's NP E, for a UA w/ CS to be collected and sent to the local hospital, no order for the UA was evidenced in the record, however the UA sample was collected and sent to the local hospital on [DATE]. when the DON was asked what should have happened the DON stated she refused to answer.<BR/>During an interview on 04/07/2023 at 10:50 AM the Medical Director stated he was familiar with Resident #140 and recalled Resident #140 had a history of recurrent UTI's related to his suprapubic catheter. The Medical Director was given a report of survey findings to include Resident #140 was recognized with a urinary tract infection on 04/12/2022, specifically the pathogens enterococcus faecalis and proteus mirabilis, without any documentation for communication with a physician, without any documented order for a urinalysis lab, and no report to a physician for the 2 pathogens identified. The Medical Director stated Resident #140 should have been supported with an opportunity for a physician to intervene and possibly provide various supports to address the infections prior to Resident #140's hospital transfer. The Medical Director stated he could not recall if he had been given a report but if he had been given a report, he would have intervened. The Medical Director was given a report of survey findings to include Resident #140 was assessed during his time at the facility with the infection to be free from signs and symptoms of infection to include Resident #140 was without a fever, and had vital signs within normal limits; the Medical Director stated the fact was Resident #140's urinalysis lab revealed a serious double pathogen infection and was enough to warrant treatment. The Medical Director stated in his medical practice he has encountered a patient without any signs and symptoms of infection other than a positive infection lab result and he would not ignore the lab result and would intervene with some type or types of treatment to eliminate the infection.<BR/>2. <BR/>Resident #14<BR/>A record review of Resident #14's admission record, dated 04/04/2023, revealed an admission date of 02/18/2023, with diagnoses which included personal history of transient ischemic attack, TIA, and cerebral infarction [Infarction refers to death of tissue. A cerebral infarction, or stroke, is a brain lesion in which a cluster of brain cells die when they don't get enough blood].<BR/>A record review of Resident #14's admission MDS, dated [DATE], revealed Resident #14 was a [AGE] year-old female admitted from her home. Resident #14 was assessed with no impaired mental cognition evidenced by a 15 out of 15 BIMS score. Resident #14 was assessed with urinary and bowel incontinence and needed extensive assistance with all activities of daily life. Resident #14 was assessed with a status of medically complex to include a diagnosis of hemiplegia [Hemiplegia is a condition caused by brain damage that leads to paralysis on one side of the body].<BR/>A record review of Resident #14's care plan, dated 04/04/2023, revealed, The resident has an activities of daily life self-care performance deficit related to decreased mobility, hemiplegia to the right side, intervention: bathing / shower; the resident requires assistance by staff with bathing showering as necessary.<BR/>A record review of Resident #14's nursing progress notes revealed LVN B documented on 03/24/2023, CNA notified this SN that upon showering resident she noticed bugs on hair. Upon assessment it was verified resident has an infestation of head lice. DON was notified and contact isolation in place until Treatment is completed.<BR/>A record review of Resident #14's nursing progress notes revealed LVN T documented on 03/25/2023, Lice treatment was applied as indicated this am. Continues on contact isolation. Denies pain or discomfort.<BR/>During an interview on 04/05/2023 at 2:25 PM LVN B stated on 03/24/2023 she assessed Resident #14 with head lice, text messaged the medical director and the DON. LVN B stated she received an order from the medical director to treat the head lice. LVN B stated the DON gave her the medication and Resident #14 was treated for head lice. LVN B was asked to demonstrate the documented communication with Resident #14's physician, the order for the medicated shampoo for lice, and the documentation for communication with the DON. LVN B stated she could not demonstrate the documentation because she did not document the events in Resident #14's medical record. LVN B stated she believed the DON would have done the documentation since she gave the DON a report. LVN B stated in retrospect she should have documented the SBAR, the order, and the follow up. LVN B stated, I am human and I can make mistakes.<BR/>During an interview on 04/07/2023 at 03:48 PM, the DON stated on 03/08/2023 LVN B alerted her that Resident #14 had head lice. The DON stated she retrieved the head lice medicated shampoo from the medication storeroom and provided the medication to LVN B. the DON stated the expectation is for nurses to document all communications with physicians, new orders, and follow ups in the residents' medical records.<BR/>During an interview on 04/07/2023 at 10:50 AM the Medical Director stated he could not recall if he had been given a report for Resident #14's head lice. The medical director stated the expectation was for all physician communications, orders, and nursing follow ups to be documented accurately in the resident's medical record. <BR/>A policy for accurate records was requested on 04/06/2023 and was not provided. The policy for Laboratory Services and Reporting partially addressed Resident #140.<BR/>A record review of the facilities Laboratory Services and Reporting policy dated, 04/08/2023, Revealed, the facility must provide or obtain laboratory services in ordered by a physician, positions assistant, nurse practitioner, or clinical nurse specialist in accordance with state law. Policy and explanation and compliance guidelines: the facility must provide or obtain laboratory services to meet the needs of its residents. The facility is responsible for the timeliness of the services. Should the facility provide its own laboratory services, the services must meet the applicable requirement for laboratories. if the laboratory chooses to refer specimens for testing to another laboratory, the referral laboratory must be certified in the appropriate specialties and subspecialties of service in accordance with requirements. assist the resident in making transportation arrangements to and from the laboratory if necessary. All laboratory reports will be dated and contain the name and address of the testing laboratory and will be filed in the residence clinical record. Promptly notified the ordering physician, physician assistant, nurse practitioner, or clinical nurse specialist of laboratory results that fall outside the clinical reference range. If unable to reach the ordering prescriber with abnormal lab results the medical director will be notified.

**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 infection for 1 of 4 residents (Resident #2) reviewed for infection control<BR/>LVN B failed to maintain a sterile environment when performing wound care for Resident #2<BR/>These deficient practices could place residents at-risk for infection due to improper care practices. <BR/>The findings included:<BR/>Record review of Resident #2's a face sheet dated 9/30/2023 revealed Resident #2 was [AGE] years of age and was initially admitted on [DATE]. Resident #2's diagnoses included: type 2 diabetes, severe sepsis (infection in the blood stream) with septic shock, encounter for surgical aftercare following surgery on the digestive system, acquired absence of other specified parts of digestive tract, pressure ulcer of right heel stage 2 (onset 6/13/2023), pressure ulcer left heel stage 2 (onset 6/14/2023), pressure ulcer of sacral region stage 3 (onset 6/14/2023), colostomy status (onset 6/13/2023), depression, lack of coordination, muscle weakness, acute kidney failure. <BR/>Record review of Resident #2's quarterly MDS dated [DATE], stated: Resident #2 had a BIMS score of 15 which indicated cognitive intactness. Further review revealed Resident #2 was totally dependent on staff for transfers and bathing, and required extensive assistance for bed mobility, dressing, toilet use, and limited assistance with bed mobility, and personal hygiene. Additionally, Resident #2 had 2 unstageable pressure injuries and required pressure reducing device for bed, pressure ulcer/injury care, and application of dressings to feet.<BR/>Record review of Resident #2's Care Plan, printed 10/1/2023, revealed (Resident #2) has a DTI to retrocalcaneal. (Resident #2's) DTI to retrocalcaneal bursa (Achilles area) will show signs of healing and remain free from infection by/through review date. (Revision date: 9/26/2023). Interventions included, Administer medications as ordered. Administer treatments as ordered and monitor effectiveness. Assess/record/monitor wound healing. Monitor/document/report PRN any changes in skin status: appearance, color, wound healing, s/sx of infection, wound size (length x width x depth), stage . (Resident #2) has a DTI to left heel. (Resident #2's) DTI will show signs of healing and remain free from infection by/through review date. (Revision date: 9/26/2023). Interventions included, Administer medications as ordered. Administer treatments as ordered and monitor effectiveness. Assess/record/monitor wound healing. Monitor/document/report PRN any changes in skin status: appearance, color, wound healing, s/sx of infection, wound size (length x width x depth), stage . (Resident #2) has impairment to skin integrity d/t has an ostomy. (Resident #2's) will be free of injury /through review date. (Date initiated 5/23/2023, Revision on 6/27/2023). Interventions included, Monitor/document location, size, and treatment of skin injury. Report abnormalities, failure to heel, s/sx of infection, maceration etc. to MD. Provide ostomy care as ordered monitor for skin break down and or irritation to site. Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate and any other notable changes or observations.<BR/>PHYSICIAN ORDERS<BR/>Record review of Resident #2's physician orders, printed 9/30/2023, stated: <BR/>DTI to retrocalcaneal bursa (Achilles area) apply betadine QD one time a day. (Order date 8/14/2023)<BR/>DTI to L heel apply betadine 4x4 gauze and wrap with kerlix QD one time a day. (Order date 8/14/2023)<BR/>SKIN ASSESSMENTS<BR/>Record review of Resident #2's Weekly Skin Evaluation, date of assessment 9/8/2023, stated, Site - left heel. Type, pressure. Stage, suspected deep tissue injury. Date wound developed: 8/14/2023. Wound developed, In house. <BR/>Record review of Resident #2's Weekly Skin Evaluation, date of assessment 9/8/2023, stated, Site - right heel. Type, pressure. Stage, suspected deep tissue injury. Date wound developed: 8/14/2023. Wound developed, In house. <BR/>Interview and record review on 9/26/2023 at 11:03 AM, RN C was shown September 2023 TARs for Resident #2 and agreed they had missing entries. <BR/>Observation and interview on 9/27/2023 at 9:04 AM, LVN B, was observed prepping for Resident #2's treatment to his right heel DTI. During the preparation, LVN B was observed wiping down a bed side table with a disinfectant wipe. LVN B then utilized the same disinfectant wipe to disinfect the scissors being utilized to remove Resident #2's bandages. During an interview at this time, the LVN B was informed of this error and agreed it presented an infection control concern. LVN B proceeded to push the bed side table into Resident #2's room but did not re-sanitize the scissors. <BR/>Observation and interview on 9/27/2023 9:13 AM, LVN B initiated wound treatment for Resident #2's DTI to his right heel. During this observation, LVN B removed Resident #2's bandages and placed Resident #2's exposed heel on Resident #2's mattress. During an interview at this time, LVN B was informed of this observation and agreed that it was a concern relative to wound treatment and infection control. <BR/>Observation on 9/27/2023 at 9:20 AM, LVN B was observed packaging all soiled bandages into a hazardous material bag. LVN B then pushed the bed side table out of Resident #2's room and proceeded to place her hand into her pocket to retrieve a key for her wound cart. LVN B then opened the wound cart and started placing non-used items back into the cart. During an interview at this time, LVN B was informed of this observation and agreed that it was a concern relative to wound treatment and infection control.<BR/>Observation and interview on 9/27/2023 at 2:46 PM, Resident #2 was observed lying in his bed. When asked about Resident #2's wounds to both of his heels, Resident #2 said, I didn't have them until I came here. When asked if they were causing him pain, Resident #2 responded, yes. When asked if Resident #2 required assistance from his bed, Resident #2 responded, yes. When asked if staff were good about getting Resident #2 up to use his walker, Resident #2 responded, they don't ask and neither do I, I guess I should. When asked why Resident #2 acquired the pressure ulcers to his heel, Resident #2 responded, because I lay down too much? Resident #2 then said he was recently informed by an Asian nurse who only comes here on the weekends that the nurses should be treating my wounds every day but they don't and I wish they would.<BR/>Record review of facility policy, title, Infection Prevention and Control Program, revised, 1/2018, stated, The elements of the infection prevention and control program consist of coordination/oversight policies/procedures, surveillance, data analysis, antibiotic stewardship, outbreak management, prevention of infection, and employee health and safety.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure a comprehensive care plan must be developed within 7 days after completion of the comprehensive assessment. Prepared by an interdisciplinary team, that includes but is not limited to, the attending physician, A registered nurse with responsibility for the resident, A nurse aide with responsibility for the resident, A member of food and nutrition services staff for 2 of 8 (Residents #23 and #30) residents that were not invited to care plan conference in that:<BR/>1. Resident #23's chart did not include an IDT care plan conference for after the care plan dated 3/21/2023. <BR/>2. Resident #30's chart did not include an IDT care plan conference after the care plan dated 3/15/2023. <BR/>This could place residents at risk of receiving inadequate interventions not individualized to their care needs. <BR/>The Findings were:<BR/>1. Record review of Resident #23's admission Record dated 4/7/2023 revealed he was admitted on [DATE], re-admitted on [DATE] with diagnoses of cerebral infraction, legal blindness, altered mental status, disorientation, anemia, metabolic encephalopathy, peripheral vascular disease, end stage renal disease and diabetes II. <BR/>Record review of Resident #23's Significant change MDS dated [DATE] revealed section C cognition pattern BIMs score 15/15 (cognitively intact), Section G Functional Status required total dependence for bed mobility, transfers, locomotion off unit, dressing, toilet use, and bathing, her required extensive assistance with two person assist with eating and personal hygiene, Section O Special Treatments and Programs, other Dialysis. <BR/> Record review of Resident #23's care plan dated 3/21/2023 revealed resident had impaired tissue perfusion related to hypertension, intervention give anti-hypertensive medications as ordered. Monitor for side effects such as hypotension, and increased heart rate and effectiveness, give medications for hypotension ., residents had anemia related to chronic kidney disease intervention-give medications as ordered, The resident had an ADL self-care performance deficit related the CVA with hemiplegia, right below knee amputations-intervention floor mattress next to bed, resident bedfast most to the time, allow sufficient time for dressing and undressing, the resident requires assistance with ADL (activity of daily living) and required a wheelchair for mobility. <BR/>Record review of Resident #23's record revealed no IDT care plan conference was documented after the care plan dated 3/21/2023. <BR/>2. Record review of Resident # 30's admission Record dated 4/6/2023 revealed she was admitted on [DATE], readmitted on [DATE] with diagnosis hypercapnia, chronic, combines systolic (congestive) and diastolic (congestive) heart failure, cardiomegaly, anxiety, major depressive disorder, dysphagia, colostomy, tracheostomy, diabetes II, dysphagia, speech disturbance, and generalized edema. <BR/>Record review of Resident # 30's Significant Change MDS dated [DATE] revealed section C Cognition BIMs score was 15/15 (cognitively intact), Section G Functional Status she required extensive assistance with bed mobility, transfers, dressing, toilet use and personal hygiene, she required supervision with one person assistance with eating, she required a wheelchair for mobility and Section O Special treatment and programs, Respiratory Treatments, included oxygen, suctioning and tracheostomy. <BR/>Record review of Resident # 30's care plan dated 3/15/2023 the resident was at risk for activity intolerance related to hypotension, The resident has congestive heart failure-intervention monitor vital signs as needed and as ordered by Md notify of significant abnormalities, Resident with decline in ADL function since recent hospital stay is on skilled physical therapy, Resident had and ADL self-care performance deficit related to respiratory failure with weakness, obesity- intervention- ADL required assistance with staff personnel. <BR/>Record review of Resident #23's record revealed no IDT care plan conference was documented after the care plan dated 3/15/2023. <BR/>Interview on 4/06/2023 at 12:05 PM, MDS J stated she was responsible for having the IDT care plan conference and documenting them in the resident's progress notes. Further interview with DMS J revealed she was not able to find the IDT care plan conference for Resident #23 and #30. Interview with MDS J revealed the harm would be that the resident/family was not aware of medical changes. Interview with MDS J nurse stated the activity director was in charge of making sure the IDT care conferences, she resigned couple weeks ago, know MDS nurse responsible for IDT care conferences. <BR/>Record review of policy Comprehensive Care Plans dated 10/24/2022 It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that included measurable objective and timeframes to meet resident's medical, nursing, and mental and psychological needs that are identified in the resident's comprehensive assessment. 4. The comprehensive care plan will prepare by an interdisciplinary team, that included, but is not limited to attending physician, A registered nurse with responsibility for the resident, A nurse aide with responsibility for the resident, A member of food and nutrition services staff. 5. The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews the facility must provide, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in their choice of activities, individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community for 4 of 8 (Residents #1, #8, #10, and #28) residents reviewed for activities in that:<BR/>1. Resident #1was not offered to attend group activities and no in-room assessment.<BR/>2. Resident #8 was not offered to attend group activities and no in-room assessment.<BR/>3. Resident #10 did not have an activity in-room assessment.<BR/>4. Resident # 28 did not have an activity in-room assessment.<BR/>This failure could place residents at risk for isolation and depression.<BR/>The Finding were: <BR/>Record review of Resident #1, #8. #10 and #28 did not have in-room activity assessments in their resident records. <BR/>1. Record review of Resident #1's admission record dated 4/6/2023 revealed he was admitted on [DATE], re-admitted on [DATE] with diagnoses of acquired absence of right and left leg above knee, seizures, anxiety, and lack of coordination.<BR/>Record review of Resident #1's admission MDS dated [DATE] revealed Section C Cognitive Patterns BIMS score was 15/15 (cognitively intact), Section F Preferences for Customary Routine and Activities, resident was able to respond and staff assessment of daily activities preferences was blank. <BR/>Record review of Resident #1 care plan dated 3/23/2023 revealed the resident is dependent on staff for meting physical, and social needs related to physical limitations, interventions- invite the resident to scheduled activities, provide a program of activities that is of interest and empowers the resident by encouraging/allowing choice, self-expression and responsibility. The resident needs assistance with ADLs as required during the activity, the resident needs 1:1 bedside/in-room visits an activities if unable to attend out of room visits and the resident needs assistance/escort to activity functions. <BR/>Observation on 4/3/2023 at 11:08 AM, , Resident #1 was sitting up in bed, lower extremity amputee, had side rails for positioning, watching television and wheelchair at bedside. Resident was bedbound. Resident #1's room was located at the end of the hall. <BR/>Observation on 04/04/23 04:52 PM Resident #1 was sitting up in bed, lower extremity amputee, had side rails for positioning, watching television and wheelchair at bedside. Resident was bedbound. Resident #1's room was located at the end of the hall. <BR/> Observation on 04/05/23 08:48 AM Resident #1 was sitting up in bed, lower extremity amputee, had side rails for positioning, watching television and wheelchair at bedside. Resident was bedbound. Resident #1's room was located at the end of the hall. <BR/>Interview on 4/04/2023 at 4:58 PM, Resident #1 stated staff don't come to his room and offer him to go activities. Resident #1 stated he had an activity calendar near his bed. Resident #1 stated he would like to see movies, music, build lawn [NAME], arm exercise, exercise fingers, would like to cook-rice and practice cooking. <BR/>2. Record review of Resident # 8's admission record dated 4/6/2023 revealed she was admitted on [DATE] with diagnoses of cervical spondylosis, shortness of breath, repeated falls, muscle wasting ad atrophy and lack of coordination. <BR/>Record review of Resident #8's admission MDS dated [DATE] revealed Section C Cognitive Patterns BIMS score was 14/15 (cognitively intact), Section F Preferences for Customary Routine and Activities, resident was able to respond and staff assessment of daily preferences activities was blank. <BR/>Record review of Resident # 8's care plan dated 3/29/2023 revealed the resident had little or no activity involvement related to physical limitations, interventions- invite/encourage the resident's family members to attend activities with resident in order to support participation, monitor/document for impact of medical problems on activity level and the resident needs assistance/escort to activity functions.<BR/>Observation on 4/3/2023 at 11:56 AM in Resident #8's room revealed she was sitting up in bed and talking with family and watching television looking outside. Resident was bedbound.<BR/> Observation on 4/7/2023 at 11:31 AM in Resident #8's room revealed she was sitting up in bed and talking with family and watching television looking outside. Resident was bedbound.<BR/>Interview on 4/05/2023 at 9:50 AM Resident #8 revealed staff do not come into her room for activity or offer any activities. <BR/>3. Record review of Resident #10 admission record dated 4/6/2023 revealed he was admitted on [DATE], re-admitted on [DATE] with diagnoses of dementia, hemiplegia and hemiparesis following cerebral infraction affecting let non -dominant side, bipolar disorder, left/right knee contractor, dependence on wheelchair, Alzheimer's disease, gastrostomy, major depressive disorder, altered mental status, and lack of coordination. <BR/>Record review of Resident #10's Annual MDS dated [DATE] revealed Section C Cognitive Patterns BIMS no score was severely impaired, Section F Preferences for Customary Routine and Activities, resident was not able to respond and had family response and staff assessment of daily preferences was caring for personnel belonging, receiving shower, family involvement in care and discussions listening to music. <BR/>Record review of Resident # 10 care planned dated 3/29/2023 revealed the resident is independent for meting emotional, intellectual, physical and social needs related to dependent on staff due to physical limitations and cognitive impairment, interventions- invite resident to scheduled activities and ensure that the activities the resident is attending are compatible with physical and mental capabilities. <BR/>Observation on 4/3/2023 at 11:06 AM in Resident #10's room revealed he was lying in bed, with tube feeding machine on, and not interviewable. Also, observed in the dining hall with activity going on. <BR/>Observation on 4/04/23 08:41 AM in Resident #10's room revealed he was lying in bed, with tube feeding machine on, and not interviewable. Also, observed in the dining hall with activity going on. <BR/>4. Record review of Resident #28 admission record dated 4/6/2023 revealed she was admitted on [DATE] with diagnoses of schizophrenia, delusional disorder, major depressive disorder, muscle wasting and atrophy and lack of coordination.<BR/>Record review of Resident # 28's Quarterly MDS dated [DATE] revealed Section C Cognitive Patterns BIMS no score was Moderately impaired, Section F Preferences for Customary Routine and Activities was blank, and staff assessment of daily preferences was blank.<BR/>Record review of Resident # 28 care plan date 4/6/2023 revealed the resident is independent for meeting emotional, intellectual, physical, and social needs related to physical limitation, interventions establish and record the resident prior level of activity involvement and interest by ., invite residents to scheduled activities and provide the resident with materials for individual activities as desired and the resident likes to stay in room and does not like to be bothered by staff. <BR/>Observation on 4/3/2023 at 12:15 PM in Resident #16's door was closed, she was in bed and did not want to be disturbed at the time. <BR/>Observation on 4/3/2023 at 12:15 PM and 4/6/2023 at 11 AM in Resident #16's door was closed, she was in bed and did not want to be disturbed at the time.<BR/>Interview on at 4/6/2023 at 12:40 PM, the Administrator stated she could not find the in room activity book. The Activity Director resigned a few weeks ago. The Administrator could not find the in-room activity calendar, the Administrator said she had seen activity director do in room activity with residents but does not have documentation (could not remember which resident, time or date). The Administrator stated the harm to residents would be residents' mood would be affected and residents would not be able to participate in activities. <BR/>Record review of Activity policy (no date) revealed The facility had an on-going program of activities designed to meet the interests and the physical, mental and psychosocial wellbeing of each resident in accordance with his/her comprehensive assessments. Residents, particularly bedfast and those resident unable to participate in-group activities will be visited by Activity Director Activity Assistant, and/or volunteers and document in the appropriate record. 7 .resident assessments but not less than often than once each quarter. 8. Reassess each resident every 12 months on the activity's component of the Resident Assessment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** POST MPRO<BR/>Based on interviews and record reviews the facility failed to have nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population for 1 of 32 residents (Resident #140) reviewed for infections / infestations, in that:<BR/>1. Resident #140 was diagnosed with a urinary tract infection with 2 different microbial pathogens for which Resident #140 was not treated for over 25 days 04/08/2023 to 05/07/2022 and resulted in Resident #140's hospitalization with a diagnosis of urinary tract infection sepsis [the body's extreme response to an infection] and passed away. <BR/>An Immediate Jeopardy (IJ) situation was identified on 04/07/2023. While the IJ was removed on 04/08/2023, the facility remained out of compliance at a severity level of actual harm that was not Immediate Jeopardy and a scope of isolated.<BR/>This failure placed residents at risk for not receiving necessary care and services resulting in worsening of condition, hospitalization and/or death. <BR/>The findings included:<BR/>1. Record review of Resident #140's admission record revealed an admission date of 05/23/2020, and a hospital emergency discharge date of 05/07/2022, and diagnoses which included neuromuscular dysfunction of bladder and bladder neck obstruction [when a person lacks bladder control due to brain, spinal cord or nerve problems].<BR/>A record review of Resident #140's quarterly MDS, dated [DATE], revealed Resident #140 was a [AGE] year-old male without cognitive mental impairment evidenced by a 15 out of 15 score on a BIMS. Resident #140 had a suprapubic catheter [a surgically created connection between the urinary bladder and the skin used to drain urine from the bladder in individuals with obstruction of normal urinary flow] and a history of urinary tract infections. Resident #140 was frequently incontinent of bowels. Resident #140 was not weight bearing and used a wheelchair to ambulate. <BR/>A record review of Resident #140's care plan, dated 04/06/2023, revealed, The resident had an activities of daily life self-care performance deficit related to contractures to the left leg and above knee amputation; toilet use; the resident is totally dependent on staff for toilet use. Resident is incontinent of bowel and required staff to check every two hours. staff to help provide catheter care and empty out the urine collection bag. The resident has suprapubic catheter at risk for UTI sepsis. The resident has suprapubic catheter; position catheter bag and tubing below the level of the bladder . monitor record report to medical doctor for signs and symptoms of urinary tract infection pain burning blood thinning hearing cottages fever chills altered mental status. <BR/>A record review of Resident #140's nursing progress notes, dated 04/01/2022 , at 03:12 AM, revealed RN A documented, Resident c/o pain to bladder area. c/o burning to stoma area. noted with leakage from stoma area around foley catheter. Catheter irrigated with NS but noted to drain poorly and leak more around stoma area. Unable to aspirate urine residual from catheter with 60cc syringe. Area around stoma cleaned and TAO applied generously around catheter. Belly bag repositioned below resident's scrotum to provide better drainage to gravity. plan to collect urine for ua /c & s this am.<BR/>A record review of Resident #140's nursing progress notes revealed LVN B documented on 04/06/2022 , at 09:35 PM resident back from urology appt. NP E requested for resident to have SP drain to gravity and no belly bag. facility to collect UA and send to [local hospital] for C/S. and to continue with current medications. Follow up in four months [DATE], at 01:50 PM. This SN advised resident that I needed to change foley bag [urine collection] to either a leg bag or normal foley bag, resident refused and stated he wants AM shift to change it.<BR/>A record review of Resident #140's laboratory report, dated 04/08/2022, revealed Resident #140, collected 04/03/2022 .reported 04/08/2022 .detected urinary tract assay results organism's enterococcus faecalis .proteus mirabilis.<BR/>A record review of Resident #140's nurse progress notes revealed LVN C documented on 04/12/2022 , at 10:25 AM, UA with CS results dated 04/07 faxed to Dr. F [urologist] office for review. Culture revealed 2 organisms. Proteus mirabilia and enterococcus faecalis. Pending MD response. <BR/>A record review of Resident #140's laboratory report, dated 04/12/2022, revealed Resident #140, collected 04/07/2022, urine culture final organism 1 proteus mirabilis .organism 2 enterococcus faecalis. [Proteus mirabilis a bacterium known to cause serious infections in humans. Enterococcus faecalis a bacterium can cause life-threatening infections].<BR/>A record review of Resident #140's nurse progress notes, dated 04/13/2022 , at 12:08 PM, revealed LVN C documented, called and left voicemail on Dr. F's office line to follow up with urinalysis results. Pending call back.<BR/>A record review of Resident #140's nurse progress notes, dated 04/19/2022 , at 11:31 AM, revealed LVN C documented, spoke with [medical office person] regarding residents UA with CS results. states she will look into it and relay message to the nurses.<BR/>A record review of Resident #140's nurse progress notes revealed LVN C documented on 05/07/2022, at 08:15 AM, resident noted with severe AMS and complaining of pain. RP has been notified and EMS has been dispatched .resident admitted to [local hospital] med surge room [xxx], DX: UTI, Sepsis as per RN G.<BR/>During an interview on 04/05/2023 at 10:20 AM, LVN C stated nurses enter lab orders into the facility's lab contractor's portal website, then document on the nurses' 24-hr. report and from there the nurse checks the lab's website for the results, print out the results, and then the DON recovers the lab reports and gives them to LVN J the MDS nurse. LVN C was given a report of the survey finding for Resident #140 where on 04/12/2023, 04/13/2023, and 04/19/2023 LVN C attempted to contact Dr. F.; once faxed abnormal lab results to Dr. F's office, then called and left a message for Dr. F, and then called and left a message for Dr. F with office personnel. LVN C was asked if she escalated the inability to provide Dr. F an SBAR to her supervisors, Resident #140's attending physician Dr. H, and ultimately to the facility's medical director; LVN C stated she could not recall the details of a year ago, however LVN C stated, if it was not documented it was not done. LVN C stated the review of her documentation on the dates 04/12/2022, 04/13/2022, and 04/19/2022 appeared as if she was attempting, unsuccessfully, to SBAR Dr. F for Resident #140's UTI infections evidenced by the UA C&S abnormal lab results. <BR/>During an interview on 04/05/2023 at 2:25 PM, LVN B received a report of her documentation for Resident #140 on 04/06/2022 where she documented Resident #140 had returned from their urology appointment and had a new order for a UA with a CS. LVN B stated she could not recall the details but stood on the accuracy of her note. LVN B was asked to demonstrate her documentation for the physicians' order for the UA with C&S. LVN B stated she reviewed Resident #140's record and could not find any order for Resident #140 to have a UA with a C&S on 04/07/2022. In response to the lack of a documented order for the UA with C&S LVN B stated, I am human and I can make mistakes. <BR/>During an interview on 04/07/2023 at 03:48 PM, with the DON and the ADON, the DON stated Resident #140 had a need for a suprapubic catheter related to a neurogenic bladder, which was to drain via gravity to a dependent urine collection bag positioned below the bladder. Resident #140 was non-compliant with the position of the dependent urine collection bag positioned below the bladder and would often reposition the collection bag in between his legs where the bag could be exposed to bacteria related to incontinence of bowels. Resident #140 was assessed by LVN C, on 03/30/2022, with s/s of a UTI and received an order for a UA and CS from NP E which was executed, and the facility received results on 04/05/2022. Resident #140 was seen on 04/06/2022 by Dr. F and returned to the facility with new orders from Dr. F's NP E, for a UA w/ CS to be collected and sent to the local hospital, no order for the UA was evidenced in the record, however the UA sample was collected and sent to the local hospital on [DATE]. The facility received the UA results on 04/12/2022 to reveal 2 urinary bacterium and the report was faxed to Dr. F office at 10:30 AM, on 04/12/2022. The DON stated Resident #140 received a 1-time dose of amoxicillin 2000mg on 04/12/2022 for dental extraction, and the ADON stated amoxicillin is a broad-spectrum antibiotic which the 04/12/2022 UA CS revealed Amoxicillin could treat the infection. The DON stated LVN C attempted three separate times to reach Dr. F and Dr. F's office could not be reached, once by fax, and once with a voice message, and once with an actual call to Dr. F's office with Dr. F's office person who stated she would relay the message to the nurses. The ADON stated Resident #140 was alert and oriented x3, without a fever, no nausea, no vomiting, no diarrhea. The DON stated and read from the hospital admission record dated 05/07/2022, on arrival patient communicated well states he feels fine, he follows commands appropriately, denies any nausea and vomit, abdominal pain, patient is non tachycardic [a heart rate over 100 beats a minute], no distress noted and afebrile [no fever]. He was sent for confusion and facility stated he was talking in word salad [a confused or unintelligible mixture of seemingly random words and phrases]. when the DON was asked what should have happened the DON stated she refused to answer.<BR/>During an interview on 04/07/2023 at 10:50 AM, the Medical Director stated he was familiar with Resident #140 and recalled Resident #140 had a history of recurrent UTI's related to his suprapubic catheter. The Medical Director was given a report of survey findings to include Resident #140 was recognized with a urinary tract infection on 04/06/2022 and again on 04/12/2022, specifically the pathogens enterococcus faecalis and proteus mirabilis, without any documentation for communication with a physician, without any documented order for a urinalysis lab, and no report to a physician for the 2 pathogens identified. The Medical Director was given a report of survey findings to include Resident #140 was assessed with altered mental status on 05/07/2022 and was transferred to the local hospital where Resident #140 was admitted with the diagnosis urinary tract infection sepsis and passed away during his hospital stay. The Medical Director stated Resident #140 should have been supported with an opportunity for a physician to intervene and possibly provide various supports to address the infections prior to Resident #140's hospital transfer. The Medical Director was given survey evidenced data to include the facility unsuccessfully attempted to report to Dr. F, the urologist, on 04/12/2022, 04/13/2022, and again on 04/19/2023. The Medical Director stated the expectation was for the facility staff to have given a report of the double pathogen infection to the next escalated physician to include a report to Resident #140's attending physician, Dr. H, and ultimately himself, the medical Director. The Medical Director stated he could not recall if he had been given a report but if he had been given a report, he would have intervened. The Medical Director stated sepsis is a serious infection where the infection has spread from its origin to the systemic body to possibly include the blood and could have serious injury potentials to include death. The Medical Director stated the report of a double pathogen urinary infection was a serious result and would not have been ignored and required a physician's intervention. The Medical Director stated he has intervened in similar infections and could have treated the infection at the resident's home to include many possible interventions to include, pushing fluids, monitoring for signs and symptoms of infection, oral and intravenous antibiotics, and to ultimately transfer a patient to the hospital. The Medical Director stated there could have been an advantage to treat residents in their home and in theory reduce the possibility for cross contamination of pathogens which could happen at the hospital. The Medical Director was given a report of survey findings to include Resident #140 was assessed during his time at the facility with the infection to be free from signs and symptoms of infection to include Resident #140 was without a fever, and had vital signs within normal limits; the Medical Director stated the fact was Resident #140's urinalysis lab revealed a serious double pathogen infection and was enough to warrant treatment. The Medical Director stated in his medical practice he has encountered a patient without any signs and symptoms of infection other than a positive infection lab result and he would not ignore the lab result and would intervene with some type or types of treatment to eliminate the infection.<BR/>During an interview on 04/07/2023 at 03:48 PM, the DON stated the expectation is for nurses to document all communications with physicians, new orders, and follow ups in the residents' medical records.<BR/>During an interview on 04/07/2023 at 10:50 AM, The medical director stated the expectation was for all physician communications, orders, and nursing follow ups to be documented accurately in the resident's medical record. <BR/>A record review of the National Institute of Aging's website, an official website of the United States government, https://www.nia.nih.gov/health/taking-medicines-safely-you-age , accessed, 04/24/2023, Taking Medicines Safely as You Age revealed, It can be dangerous to combine certain prescription drugs, OTC medicines, dietary supplements, or other remedies .To avoid potentially serious health issues, talk to your doctor about all medicines you take, including those prescribed by other doctors, and any OTC drugs, vitamins, supplements, and herbal remedies. Mention everything, even ones you use infrequently. Starting a new medicine: Talk with your health care provider before starting any new prescription, OTC medicine, or supplement, and ensure that your provider knows everything else you are taking. Discuss any allergies or problems you have experienced with other medicines. These might include rashes, trouble breathing, indigestion, dizziness, or mood changes. Make sure your doctor and pharmacist have an up-to-date list of your allergies so they don't give you a medicine that contains something that could cause an allergic reaction. You will also want to find out whether you'll need to change or stop taking any of your other prescriptions, OTC medicines, or supplements while using this new medicine. Mixing a new drug with medicines or supplements you are already taking might cause unpleasant and sometimes serious problems. For example, mixing a drug you take to help you sleep (a sedative) and a drug you take for allergies (an antihistamine) can slow your reactions and make driving a car or operating machinery dangerous.<BR/>A record review of the manufactures lice shampoo treatment's website, https://ridlice.com/wp-content/uploads/2022/04/RID_Complete_Kit_Insert_English.pdf , accessed 04/24/2023, revealed, WARNINGS: For External use only Do not use near the eyes, inside nose, mouth, vagina, or on lice in eyebrows or eyelashes. See a doctor if lice are present in these areas. Ask a doctor before use if you are allergic to ragweed. May cause breathing difficulty or an asthmatic attack. When using this product keep eyes tightly closed and protect eyes with a washcloth or towel. If product gets in eyes, flush with water right away. Scalp itching or redness may occur. Stop use and consult a doctor if breathing difficulty occurs, eye irritation occurs, skin or scalp irritation continues, or infection occurs. Keep out of reach of children. If swallowed, get medical help or contact a Poison Control Center right away .Use towels to protect eyes and clothes from treatment. Apply RID&reg; Lice Killing Shampoo to DRY HAIR or affected area. Apply enough product to saturate. Thoroughly massage product into scalp, behind ears and onto back of neck. Allow product to remain on hair for 10 minutes, but no longer. Add warm water and massage to form lather. Rinse thoroughly, e.g., in a sink. Repeat this step in 7-10 days to kill any newly hatched lice.<BR/>A record review of the facilities Laboratory Services and Reporting policy dated, 04/08/2023, Revealed, the facility must provide or obtain laboratory services in ordered by a physician, positions assistant, nurse practitioner, or clinical nurse specialist in accordance with state law. policy and explanation and compliance guidelines: the facility must provide or obtain laboratory services to meet the needs of its residents. the facility is responsible for the timeliness of the services. should the facility provide its own laboratory services the services must meet the applicable requirement for laboratories. if the laboratory chooses to refer specimens for testing to another laboratory, the referral laboratory must be certified in the appropriate specialties and subspecialties of service in accordance with requirements. assist the resident in making transportation arrangements to and from the laboratory if necessary. all laboratory reports will be dated and contain the name and address of the testing laboratory and will be filed in the residence clinical record. promptly notified the ordering physician, physician assistant, nurse practitioner, or clinical nurse specialist of laboratory results that fall outside the clinical reference range. if unable to reach the ordering prescriber with abnormal lab results the medical director will be notified.<BR/>This was determined to be an Immediate Jeopardy (IJ) on 04/07/2023 at 08:00 PM. The administrator was notified. The Administrator was provided with the IJ template on 04/07/2023. The following Plan of Removal was accepted on 04/08/2023 at 3:30 PM.<BR/>Plan of Removal Verification, April 8, 2023<BR/>LETTER OF CREDIBLE ALLEGATION<BR/>FOR REMOVAL OF IMMEDIATE JEOPARDY<BR/>Issue: <BR/>F-Tag: 684<BR/>The facility failed to notify MD/Medical director of change in condition and abnormal lab values.<BR/>Resident #140 no longer resides in the building.<BR/>A record review of Resident #140's admission record dated, 04/07/2023, revealed an admission date of and discharge hospital date of 05/07/2022.<BR/>During an interview on 04/07/2023 at 03:40 PM the DON stated Resident #140 was discharged to the hospital on [DATE] for altered mental status.<BR/>Director of Nursing and/ or designee completed a Lab audit, consisting of 39 residents with 5 lab orders from March 1, 2023- April 7, 2023, on 4/8/2023 looking for abnormal values, transcription, and MD/Medical Director notification. Medical Director will be notified if Primary MD does not respond.<BR/>During an interview on 04/08/2023 at 3:53 PM the ADON stated the facility assessed all 39 residents for changes of condition, PCP SBARs, new orders, and lab results for the last month up to 04/07/2023. And discovered 5 residents (#1, #4, #8, #26, and #29), with new orders for labs, SBARS, and progress notes to detail the changes of conditions. AON stated, During an audit we did a lab audit on every single Resident, reviewed for accuracy, specific to include, Progress notes, PCP, communications, orders, lab results, follow with next nurse.<BR/>A record review of Resident #1's medical record revealed orders for labs, dated 03/01/2023. A record review of the resulted labs revealed abnormal results. Continued review of the medical record revealed a progress note by the DON which read, phoned doctor T to discuss resident lab values CBC, Keppra, mag, CMP, phenobarbital, A1C. no new orders received resident to keep appointment to reestablish care next week.<BR/>A record review of Resident #4's medical record revealed lab orders for PT/INR dated 03/18/2023 revealed the Medical Director ordered, recheck in 2 weeks. A record review revealed a progress note dated 03/18/2023 by LVN C, PT/INR results reviewed with medical director. new order to continue same strength and recheck PT INR in two weeks. A record review of the lab result dated 03/31/2023 revealed abnormal results for PT/INR. A record review revealed a progress note, dated 04/05/2023, LVN C documented, PT/INR results from 03/30/2023 reviewed with the medical director. PT - 32.9, INR, 3.3. recheck PT/INR in three weeks. PT INR updated on the log. A record review revealed a new order, dated 04/05/2023, from the medical director, PT/INR in three weeks 04/25/2023.<BR/>A record review of Resident #8's medical record revealed an order, dated 03/27/2023, CBC, CMP, iron, TIBC, ferritin, magnesium. a record review of the lab results revealed an abnormal lab, dated 03/31/2023. A record review of the progress notes revealed the DON documented on 04/08/2023, reviewed lab results CBC, CMP, ferritin, magnesium, iron, with doctor H. no new orders.<BR/>A record review of resident #26's medical record revealed an order dated 03/14/2023 revealed CBC, CMP, lipid, TSH, microalbumin, UA with C&S to be drawn today 03/14/2023 and take into the local hospital laboratory. A record review revealed a progress note dated 03/30/2023, by LVN I, over the phone appointment with doctor W, medical director will refer resident to kidney specialist both referral and lab orders will be faxed to the facility tomorrow morning once the medical director closes the note the medical director verbalized no new orders for 03/14/2023 urinalysis results resident asymptomatic. resident aware and representative stated understood. <BR/>Director of Nursing was reeducated by the Regional Clinical Specialist on 4/8/23 regarding the below education. After receiving the training the Director of Nursing Service or designee will re-educate the current Licensed Nursing (24 Licensed Nurses) staff and any new Licensed Nurses hires prior to working their next assigned shift regarding notification of MD/Medical director of abnormal lab values, change of condition and correct transcription of lab orders. The Medical Director will be notified if Primary MD does not respond in a timely manner. Notification efforts will be documented in progress notes. Current Licensed Nurse staff (24 Licensed Nurses) and any new Licensed Nurse hires will also be re-educated on Abuse, Neglect and Exploitation prior to working their next assignment shift. No staff will be allowed to work until the re-education is completed. Re-education will be completed as of 4/8/23. A policy was developed in regard to the above education on Laboratory Services and Reporting which includes notifying the Medical Director if unable to contact the ordering Physician, Physician extenders, including NP and PA with abnormal lab results. <BR/>A record review of the facility's in-service dated 04/07/2023, revealed the DON received a 1 hr. education to cover orders for UA and CNS should be transcribed to PC in order form. medical director nurse practitioners' physicians' assistants and medical doctors must be informed of abnormal lab results. If no response escalates to the medical director. all efforts to be documented in PCC. all abnormal labs must be called to a physician. changes in condition are called to physician and documented and followed up. Further review revealed the DON's signature and printed name. <BR/>During an interview on 04/08/2023 at 08:18 PM the DON stated she received the 1 hr. in-service and returned the education to all 24 of her nurses. The DON stated any new Licensed Nurses hires prior to working their next assigned shift regarding notification of MD/Medical director of abnormal lab values, change of condition and correct transcription of lab orders. The Medical Director will be notified if Primary MD does not respond in a timely manner. Notification efforts will be documented in progress notes. Current Licensed Nurse staff (24 Licensed Nurses) and any new Licensed Nurse hires will also be re-educated on Abuse, Neglect and Exploitation prior to working their next assignment shift. No staff will be allowed to work until the re-education is completed. Re-education will be completed as of 4/8/23.<BR/>During an interview on 04/08/2023, at 04:04 PM, LVN B stated she was a charge nurse at the facility and usually worked the 02:00 PM to 10:00 PM shift on either the 100-200 hall or the 300-400 hall. LVN B stated she worked 04/08/2023 and received an in-service prior her LVN duties on the floor. LVN B stated the in-services included abuse, neglect, and exploitation prevention, documenting in residents' medical records, to include physicians' communications, SBAR's, orders, lab results, and continuity of care documentation. <BR/>During an interview on 04/08/2023, at 03:54 PM, LVN D stated she was the treatment nurse for the facility from 08:00 AM to 05:00 PM and last worked 04/08/2023. LVN D stated she received in-service training prior to working her shift and included documenting in a residents record any changes of condition, communication with physicians, new orders, lab results, and if a physician cannot be contacted the medical director should be included in a report to include new orders documented in the residents' permanent record. <BR/>Monitoring of the plan of removal included:<BR/>During an interview on 04/08/2023, at 03:54 PM, LVN K stated she is the MDS nurse, works Monday through Friday, 8-5 PM and occasionally works the floor. LVN K stated she was in-serviced 04/08/2023 to include a communication w/ document in the resident's permanent record any change of condition, SBAR to the PCP, and if the PCP is unavailable to escalate the communication to the next PCP to ultimately include the Medical Director. LVN K stated the in-services also included documenting in the Resident's permanent record all orders documenting the communication with the doctor. LVN K stated all lab results are to be reported to the PCP and critical labs are to be immediately reported to a physician up and including the Medical Director. LVN K stated she was also in-serviced on ANE allegations and ANE preventions. <BR/>During an interview on 04/08/2023 at 04:34 PM LVN X stated she worked as an LVN charge nurse and her usual shift was 02:00 PM to 10:00 PM. LVN X stated she received and in-service for ANE allegation reporting, and ANE prevention, as well as, documenting in the residents permanent record any and all PCP communications, changes of conditions, lab results, new orders, and documents PCP communications without new orders in the progress notes, LVN X stated if she could not report to any PCP's she would escalate the order to the Medical Director. <BR/>During an interview on 04/08/2023 at 04:40 PM LVN W, stated she worked the 10:00 PM to 06:00 Am shift as a charge nurse in the facility and received in-service training on 04/08/2023 which included 2 in-services for ANE allegations, ANE prevention, to which a report would be given to the ANE prevention coordinator the Administrator, LVN W stated she received an in-service which included education to document in the residents permanent record any and all communications with the PCP and if the PCP was not available to escalate the SBAR to the Medical Director. <BR/>During an interview on 04/08/2023 at 05:00 pm RN N stated she works as a RN supervisor on the weekends from 06:00 to 02:00 PM. RN N stated she was in-serviced on 04/08/2023 to include education for ANE prevention to include reporting to the Administrator. RN N stated she received an in-service which included education to document in the resident's permanent record any and all communications with the PCP and if the PCP was not available to escalate the SBAR to the Medical Director.<BR/>During an interview on 04/08/2023 at 05::33 PM LVN O stated she worked as an LVN charge nurse and her usual shift was 02:00 PM to 10:00 PM. LVN O stated she received and in-service for ANE allegation reporting, and ANE prevention, as well as, documenting in the residents permanent record any and all PCP communications, changes of conditions, lab results, new orders, and documents PCP communications without new orders in the progress notes, LVN O stated if she could not report to any PCP's she would escalate the order to the Medical Director. <BR/>During an interview on 04/08/2025 at 04:57 PM LVN I stated she last worked 04/07/2023 and was responsible for Resident #4, on 03/18/2023 she received PT/INR lab results for Resident #4, SBAR'ed the Medical Director, received new order from the medical Director, entered the new order into Resident #4's permanent record, entered the new lab order in the facility's lab contractor's website portal, and documents the details in Resident #4's progress notes. LVN I stated on 04/08/2023 she received and in-service for ANE allegation reporting, and ANE prevention, as well as, documenting in the residents permanent record any and all PCP communications, changes of conditions, lab results, new orders, and documents PCP communications without new orders in the progress notes, LVN I stated if she could not report to any PCP's she would escalate the order to the Medical Director. <BR/>During an interview on 04/08/2023 at 05:39 PM RN R stated she was the weekend RN supervisor and worked 06:00 AM - 02:00 PM. RN R stated she received and in-service for ANE allegation reporting, and ANE prevention, as well as, documenting in the resident's permanent record any and all PCP communications, changes of conditions, lab results, new orders, and documents PCP communications without new orders in the progress note. RN N stated if she could not report to any PCP's she would escalate the order to the Medical Director. <BR/>During an interview on 04/08/2023 at 05:39 PM RN S stated she was the weekend RN supervisor and worked 10:00 PM to 06:00 AM. RN R stated she received and in-service for ANE allegation reporting, and ANE prevention, as well as, documenting in the resident's permanent record all PCP communications, changes of conditions, lab results, new orders, and documents PCP communications without new orders in the progress note. RN N stated if she could not report to any PCP's she would escalate the order to the Medical Director. <BR/>[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 2 of 8 (Residents #23 and #30) residents reviewed for medications in that:<BR/>1. Resident #30's Midodrine (to treat orthostatic hypotension) did not have parameters and were not reordered after she returned from the hospital.<BR/>2. on 3/15/2023 Resident #30's blood pressure was elevated and Midodrine was documented as administered with no order for parameters. <BR/>3 Resident #23's hypertensive medication was documented as administered 4 hours late. <BR/>This failure could place residents with blood pressure medication orders and could result in residents change in condition. <BR/>The Findings were:<BR/>1. Record review of Resident # 30's admission Record dated 4/6/2023 revealed she was admitted on [DATE], readmitted on [DATE] with diagnoses of, chronic, combines systolic (congestive) and diastolic (congestive) heart failure, y, anxiety, major depressive disorder, colostomy, tracheostom y, diabetes II, speech disturbance, and generalized edema. <BR/>Record review of Resident #30's telephone order dated 4/30/2022 revealed Midodrine HCI tablet 10 mg give 1 tablet by mouth three times a day for hypotension hold for SBP &gt;120 DBP&gt;80, pulse &gt;60.<BR/>Record review of Resident # 30's telephone order dated 3/1/2023 revealed Midodrine HCI tablet 5 mg give 1 tablet by mouth three times a day for hypotension by LVN I. <BR/>Record review of Resident # 30's hospital discharge records dated 3/4/2023 revealed Midodrine 5 mg tab, feed tube three times a day #10 tab. <BR/>Record review of Resident # 30's telephone order dated 4/6/2023 revealed Midodrine HCI tablet 5 mg, give 1 tablet by mouth three times a day for hypotension hold for SBP&gt;110 DBP&gt;70 by the DON.<BR/>Record review of Resident #30 consolidated physician orders for April 2023 revealed order for Midodrine HCI oral tablet 5mg, give 1 tablet by mouth three times a day for hypotension, start dated 3/1/2023. The hours for administration of the Midodrine medication was 7 am, 5pm, and 7pm. <BR/>Record review of Alert Black BOX Warning- MIDODRINE Ant hypotensive, alpha1agonist Warnings The timing of doses is important and is individualized to the patient. Do not give within the 4 hours of bedtime to avoid supine hypertension.1<BR/>Record review of Resident # 30's Medication Administration record for March 2023, revealed on 3/15/2023 at 5 PM, the medication Midodrine was administered by MA Y the charge nurse that day was RN AA, according to the DON.<BR/>Record review of Resident #30's blood pressure on 3/15/2023 at 4:29 PM was 176/85., this was documented under vitals in resident records in the software system. <BR/> .<BR/>Record review of Resident #30's Initial Nursing Evaluation dated 3/5/2023 revealed re-admission via stretcher, from hospital for respiratory failure, congested heart failure and tracheostomy by LVN B. The record Initial Nursing Evaluation revealed mobility-dependent, tracheotomy collar, bowl/bladder incontinence, required manual wheelchair. <BR/>Record review of Resident # 30's progress note revealed no other blood pressure for 3/15/2023, no note that the nurse called the physician. <BR/>Record review of Resident # 30's Significant Change MDS dated [DATE] revealed section C Cognition BIMs score was 15/15 (cognitively intact) and section O Special treatment and programs, Respiratory Treatments, included oxygen, suctioning and tracheostomy. <BR/>Record review of Resident # 30's care plan dated 3/15/2023 the resident was at risk for activity intolerance related to hypotension, The resident has congestive heart failure-intervention monitor vital signs as needed and as ordered by Md notify of significant abnormalities. <BR/>During an interview on 04/05/2023 at 05:43 PM, Medication Aide V stated Resident #30 was the only Resident in the facility who was prescribed the drug midodrine. MA V stated Resident #30 was prescribed midodrine three times a day, morning, noon, and at bedtime. MA V stated midodrine was a drug that raised blood pressure and should have parameters instructions for example do not give if blood pressure is greater than 110/70. MA V stated Resident #30 ' s midodrine order did not have parameters. MA V stated Resident #30 ' s midodrine order used to have parameters and somehow the parameters were removed. MA V stated if the resident was administered midodrine while her blood pressure was high it could hurt her, maybe cause her a stroke.<BR/>Interview on 04/05/23 at 06:14 PM with RN S stated the medication aide administers Midodrine medication, she does not see parameters on the software program, she did not see blood pressure orders, she did ask staff (not sure of names) about Midodrine, and staff stated she was on Midodrine for a while. <BR/>Interview on 4/7/2023 at 1:44 PM with LVN I, admitting nurse on 3/1/2023 stated if there were not changes in medications from the hospital, then they do not call the physician. Nurse stated she did not call the physician after Resident #30 returned from the hospital. <BR/>Interview on 4/06/2023 at 2:16 PM with the Medical Director stated if Resident #30's blood pressure would go up, the outcome would be that Resident # 30's blood pressure could have gone higher, this medications was designed to raise blood pressure. <BR/>Interview on 4/06/2023 at 7:20 AM, the DON stated she did call the physician and he ordered parameters for medication Midodrine for Resident # 30, after surveyor intervention. DON stated she would check and reassess again, if the blood pressure was high, still high, she would call the physician. The DON stated the CNA's take's the blood pressure and put in the computer. The DON stated she was surprised the nurse did not see it due to that nurse worked at a dialysis. The DON stated she was not sure if the nurse saw the blood pressure. The DON stated she did talk to the physician, and he ordered parameters for Midodrine on 4/6/2023. <BR/>Interview on 4/06/2323 at 8:06 AM with the Administrator discussed midodrine orders and Resident #30 did not have parameters. The Administrator listened to surveyor and did not reply if she was aware of this concerns and how it might affect the resident. <BR/>Interview on 04/06/23 at 8:32 AM with the Medical Director Z (MD) stated DON did talk to him about Resident # 30's Midodrine, he stated he did see Resident #30 in the hospital. MD Z stated he did not review orders after Resident came back from the hospital and expected nurses to call him after a resident returned from hospital to clarification orders. MD Z stated no nurse called him to clarify orders and would expect nurse to call if resident comes back from the hospital. MD Z stated the Midodrine orders would change pending on patient case, such as patients on midodrine for dialysis and patients that have low blood pressure, MD Z stated Resident # 30 was placed on midodrine for hypotension. MD Z stated Resident #30 should have had parameters for Midodrine and not sure why it was dropped. MD Z stated Midodrine was for low blood pressure, hypotension. <BR/>Interview on 4/06/23 at 8:41 AM, MA U stated she administered midodrine to Resident # 30 as prescribed. MA U stated Resident #30's midodrine order had parameters in the past but currently the order had no parameters. MA U stated she understood the drug midodrine raises a person's blood pressure and she checks Resident #30's blood pressure prior to administering the medication. MA U stated she had no opportunity to record the blood pressure data due to the midodrine order had no parameters specified and thus no pop up box to document the blood pressure data. MA U stated if Resident #30 had high blood pressure she would refrain from administering the drug and report the discovery to the charge nurse. MA U stated she regarded a high blood pressure might be 130 / 90. MA U searched the medical record and discovered Resident #30's midodrine order for tomorrow, 04/07/2023, had changed to include parameters which were Hold if blood pressure is greater than 110 Systolic or, 70 diastolic.<BR/>Interview on 04/06/23 at 8:59 AM with RN AA, charge nurse on duty on 3/15/2023, stated she worked for on and off, started back in March 15,2023, being alone, Midodrine she works at dialysis with low blood pressure patients, the DON called her the AM gave it, MA did not tell her the BP was high, she would check BP first and then give meds according to order. DON stated there were no parameters and the MAR and order did not know she did not have parameters and did not know about b/p, no side effects, she does have bed inclined, she is awake until 10/10:30 pm, on her shift, she last worked at facility, she is a prn she was not the admitting nurse. <BR/>Interview on at 04/06/23 09:28 AM, LVN T stated Resident # 30 the MA would administer the Midodrine medication to residents. LVN T stated the MAs would first look at the resident vitals and MA if trigger they will be documented on the software system in resident record under vitals, if BP was too high or too low they would let nurse know. LVN T stated Resident #30 had no side effects from her administration of Midodrine when it was low/high. LVN T stated if the BP was high you call the physician, did not know high blood pressure 176/85, she would have held Midodrine and called the physician. LVN T stated Resident #30 had been good after hospital, she did not remember if she had parameters, she does not remember putting in orders, would call the physician if resident had a change in orders. LVN T stated the process if resident came back from hospital, nurse would call the physician, let the physician know resident was back from hospital and clarify medications. Surveyor asked LVN T did you call the physician after Resident #30 came back from hospital. LVN T stated she does not remember if she called the physician. <BR/>Interview on at 4/07/2023 at 11:54 AM with DON regarding Resident # 30, she stated the new process from corporate, if resident came back to facility from hospital, the nurse would erase the previous medications, never doing that again. The DON said Resident #30's Midodrine parameters were dropped and never picked back up when returning from hospital. The DON stated Resident #30 was in and out of hospital due to health condition. <BR/>Interview on 4/07/2023 at 1:44 PM, with LVN I in regard to Resident # 30 stated she did not finish her admission, Resident # 30 went back out to hospital due to respiratory issues. LVN I stated she was aware of the new admission resident policy to notify physician. LVN I stated she learned this in school and in-services that anything MD communication required documentation and if she could not get a hold of MD, talk to DON/ADON or speak to the medical director. <BR/>2. Record review of Resident #23's admission Record dated 4/7/2023 revealed he was admitted on [DATE], re-admitted on [DATE] with diagnoses of, legal blindness, altered mental status, disorientation, anemia, metabolic encephalopathy, peripheral vascular disease, end stage renal disease and diabetes II. <BR/> Record review of Resident #23's consolidated physician orders for April 2023 revealed Nifedipine ER (extended release) oral tablet extended release 24-hour 60 mg give 1 tablet by mouth two times a day for hypertensive encephalopathy medications should not be crushed, hold if SBP &gt; 100, DBP &lt;60 . <BR/>Record review of Resident #23's MAR (medications administration record) for April 2023 revealed he was ordered Nifedipine ER (extended release) oral tablet extended release 24-hour 60 mg give 1 tablet by mouth two times a day for hypertensive encephalopathy medications should not be crushed, hold if SBP &gt; 100, DBP &lt;60. This was administered on 4/2/2023 at 12:34 PM, instead of 7:30 AM by CMA CC. The next dose was administered at 4:57 PM. <BR/>Record review of Resident #23's Significant change MDS dated [DATE] revealed section C cognition pattern BIMs score 15/15 (cognitively intact) and section O Special Treatments and Programs, other Dialysis. <BR/> Record review of Resident #23's care plan dated 3/21/2023 revealed resident had impaired tissue perfusion related to hypertension, intervention give anti-hypertensive medications as ordered. Monitor for side effects such as hypotension, and increased heart rate and effectiveness, give medications for hypotension ., residents had anemia related to chronic kidney disease intervention-give medications as ordered. <BR/>Interview on 04/06/2023 at 11:08 AM with CMA U stated Resident #23 stated she administers his medications on dialysis days before or after he comes back to facility and had not adverse reactions. CMA U stated the software system window for Nifedipine ER brings up the BP window before the blood pressure medications with parameters are administered. CMA U stated if there was a question about resident s blood pressure and medications for blood pressure, she would ask a nurse.<BR/>Interview on 4/06/2023 at 8:59 AM with RN AA, charge nurse regarding Resident #23 stated he goes to dialysis three times a week (Monday, Wednesday, Friday) his schedule 7:15am-11am, chair time, but sometimes he is late. Resident #23 was bed bound and staff use the Hoyer and takes time to transfer. <BR/>Interview on 4/07/23 at 3:33 PM with the consultant Pharmacist BB stated last time she did a Pharmacy review for the facility was on 3/19/2023, she revealed she had access to residents' chart from home and does come to visit monthly. The Consultant Pharmacist BB stated Resident #30 had order for Midodrine for hypotension. The consultant Pharmacist BB stated Resident #30's review for March 2023 included a recommendation for Midodrine parameters and staff should let MD aware of Midodrine without parameters. The consultant Pharmacist BB stated Resident #23 stated if he missed a medication dose for Nifedipine ER he can take the medication when he can, and if too close take the next medications dose.<BR/>Record review of policy Medication Administration dated 10/24/2022, Medications are administered by licensed nurse, or other staff who are legally authorized to do so in the state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. 8. Obtain and record vital signs, when applicable of per physician orders. When applicable, hold medications for those vital signs outside the physician's prescribed parameters. 17. Sign MAR after administrated. For those medications requiring vital signs, record the vital signs onto the MAR. 20. Correct any discrepancies and report to nurse manager.

Based on observations, interviews, and record reviews the facility failed to store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys and the facility failed to label all drugs and biologicals used in the facility, in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable for 1 of 4 medication carts, reviewed for security and medication storage and labeling, in that:<BR/>1. <BR/>The keys for the 300-400 hall cart were unattended, unsecured, and laid upon a counter at the 300-400 hall nurse's station.<BR/>2. <BR/>An undated insulin pen for Resident #35 was intended for use and stored in the 300-400 hall medication cart. <BR/>These failures could place residents at risk of adverse effects and ineffective therapeutic effects of their medication; to include misappropriation of medication property.<BR/>The findings included:<BR/>1.<BR/>During an observation and interview on 04/03/2023 at 02:33 PM revealed a set of keys on a lanyard, unattended, unsecured, which laid upon the counter at the nurses 300-400 hall station. Surveyor retrieved the keys and observed no nursing staff within view. Residents observed ambulating in the 300-400 hall. The 300-400 hall medication cart was observed stationed by the 300-400 hall nurse station. The keys were used to attempt to open the 300-400 hall cart and the cart opened, and was observed to contain residents' medications; This surveyor locked the cart. The 300-400 hall was observed for nursing staff and revealed LVN B to exit a resident's room. This surveyor approached LVN B and provided the keys. LVN B stated, You should not have those keys! and asked, Where did you get them? LVN B stated the keys were the medication aide keys for the medication aide cart. LVN B stated the Medication Aide U was responsible for the keys and believed she had clocked out at 02:00 PM since her schedule was 06:00 to 02:00 PM. LVN B stated Medication Aide should have reported and given LVN B the keys when she finished her shift. <BR/>During an interview on 04/05/2023 at 10:28 AM, Medication Aide U stated on 04/04/2023 at 02:00 PM she approached LVN B and placed the medication cart keys by her while she sat at the nurse's station. Medication Aide U stated she believed LVN B saw her place the keys by her and believed she would take the keys into her possession. Medication Aide U stated she should have given a verbal report and handed her the keys. Medication Aide U stated residents could have been harmed by not having their medications secured. <BR/>During an interview on 04/04/2023 at 05:10 PM, the DON stated the keys to nursing carts are the responsibility of each nurse and the keys are to be secured and never be left unattended and unsecured. The DON stated medication Aide U should have given report and the keys to the charge nurse LVN B. <BR/>2.<BR/>During a nurse cart review and interview on 04/05/2023 at 11:29 AM, revealed LVN B in care of the 300-400 hall nurses' cart. Review of the 300-400 hall nurse cart revealed Resident #35's insulin injection pen stored within the cart. Resident #35's insulin injection pen was not dated with the date the pen was taken out of refrigeration and placed into use. LVN B reviewed #35's insulin injection pen an identified the medication as Admelog Solostar [a fast acting human insulin]. LVN B stated the insulin injection pen was to be kept refrigerated until placed into use. LVN B stated when Resident #35 needs the insulin as ordered, the pen is removed from refrigeration, dated with the date the pen is placed into use, and dated with a date 28 days later, as a discard date, per the manufacture's recommendations. LVN B stated she did not know when the injection pen was removed from refrigeration and / or when to discard the injection pen. LVN B stated she would report to the DON and the pharmacist. LVN B stated if the insulin injection pen is out of refrigeration past the 28 days Resident #35 may not receive the therapeutic effects of the insulin. <BR/>During an interview on 04/05/2023 at 05:40 PM, the DON stated all insulin injection pens are stored in the facility's medication room inside a refrigerator under refrigeration as per the manufacturer's and pharmacy recommendations. The DON stated whenever an insulin medication is removed from refrigeration it must be labeled with the date placed into service and then labeled with a discard date as recommended by the manufacturer. The DON stated the dates are guarantees the medications would be discarded prior to losing their efficacy. <BR/>A record review of the Ademlog Solostar insulin injection pen's manufacture's guidelines revealed, Storage and handling: dispensing: The original sealed carton with the enclosed instructions for use. Do not use after the expiration date. Not in use unopened Admelog should be stored in a refrigerator 36 degrees Fahrenheit to 46 degrees Fahrenheit, but not in the freezer. Do not use Admelog if it has been frozen. In use open Admelog solostar pens should be stored at room temperature below 86 degrees Fahrenheit and must be used within 28 days or be discarded, even if they still contain Admelog.<BR/>A record review of the facility's Medication and Disposal policy, dated 10/01/2019, revealed, drugs which have been dispensed for individual residents, are not to be used beyond the expiration date indicated by the manufacturer, by the pharmacy, or based on the following criteria. the facility is to strictly adhere to the expiration dating . for multi dose vials of injectable drugs: date and initialed when opened; the expiration date for the multi dose injectable vials is the manufacturers printed date, unless otherwise indicated by the manufacturer. it is the responsibility of all nurses who administer medications to monitor the expiration dates of the medications. expired medications will not be administered in the facility. all expired medications will be disposed of per facility policy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews the facility failed to ensure, in accordance with accepted professional standards and practices, complete, accurately documented, readily accessible, and systemically organized medical records for each Resident, for 2 of 39 residents (Residents #14 and #140) reviewed for accurate records, in that: <BR/>1. <BR/>LVN B did not document Resident #140's physicians orders for a urinalysis with a culture and sensitivity.<BR/>2. <BR/>LVN B did not document Resident #14's SBAR to the physician and the physician's order.<BR/>These failures placed residents at risk for injury by inaccurate / missing records. <BR/>The findings included: <BR/>1. <BR/>Resident #140<BR/>A record review of Resident #140's admission record revealed an admission date of 05/23/2020, and a hospital emergency discharge date of 05/07/2022, and diagnoses which included neuromuscular dysfunction of bladder and bladder neck obstruction [when a person lacks bladder control due to brain, spinal cord or nerve problems].<BR/>A record review of Resident #140's quarterly MDS, dated [DATE], revealed Resident #140 was a [AGE] year-old male without cognitive mental impairment evidenced by a 15 out of 15 score on a BIMS. Resident #140 had a suprapubic catheter [a surgically created connection between the urinary bladder and the skin used to drain urine from the bladder in individuals with obstruction of normal urinary flow] and a history of urinary tract infections. Resident #140 was frequently incontinent of bowels. Resident #140 was not weight bearing and used a wheelchair to ambulate. <BR/>A record review of Resident #140's care plan, dated 04/06/2023, revealed, The resident has an activities of daily life self-care performance deficit related to contractures to the left leg and above knee amputation; toilet use; the resident is totally dependent on staff for toilet use. Resident is incontinent of bowel and required staff to check every two hours. staff to help provide catheter care and empty out the urine collection bag. The resident has suprapubic catheter at risk for UTI sepsis. The resident has suprapubic catheter; position catheter bag and tubing below the level of the bladder . monitor record report to medical doctor for signs and symptoms of urinary tract infection pain burning blood thinning hearing cottages fever chills altered mental status. <BR/>A record review of Resident #140's nursing progress notes revealed LVN B documented on 04/06/2022, resident back from urology appt. NP E requested for resident to have SP drain to gravity and no belly bag. facility to collect UA and send to [local hospital] for C/S. and to continue with current medications. Follow up in four months [DATE], at 1350. This SN advised resident that I needed to change foley bag [urine collection] to either a leg bag or normal foley bag, resident refused and stated he wants AM shift to change it.<BR/>A record review of Resident #140's laboratory report, dated 04/12/2022, revealed Resident #140, collected 04/07/2022, urine culture final organism 1 proteus mirabilis .organism 2 enterococcus faecalis. [Proteus mirabilis a bacterium known to cause serious infections in humans. Enterococcus faecalis a bacterium can cause life-threatening infections].<BR/>During an interview on 04/05/2023 at 2:25 PM LVN B received a report of her documentation for Resident #140 on 04/06/2022 where she documented Resident #140 had returned from their urology appointment and had a new order for a UA with a CS. LVN B stated she could not recall the details but stood on the accuracy of her note. LVN B was asked to demonstrate her documentation for the physicians' order for the UA with C&S. LVN B stated she reviewed Resident #140's record and could not find any order for Resident #140 to have a UA with a C&S on 04/07/2022. In response to the lack of a documented order for the UA with C&S LVN B stated, I am human and I can make mistakes. <BR/>During an interview on 04/07/2023 at 03:48 PM, the DON and the ADON, the DON stated Resident #140 had a need for a suprapubic catheter related to a neurogenic bladder, which was to drain via gravity to a dependent urine collection bag positioned below the bladder. The DON stated Resident #140 was seen on 04/06/2022 by Dr. F and returned to the facility with new orders from Dr. F's NP E, for a UA w/ CS to be collected and sent to the local hospital, no order for the UA was evidenced in the record, however the UA sample was collected and sent to the local hospital on [DATE]. when the DON was asked what should have happened the DON stated she refused to answer.<BR/>During an interview on 04/07/2023 at 10:50 AM the Medical Director stated he was familiar with Resident #140 and recalled Resident #140 had a history of recurrent UTI's related to his suprapubic catheter. The Medical Director was given a report of survey findings to include Resident #140 was recognized with a urinary tract infection on 04/12/2022, specifically the pathogens enterococcus faecalis and proteus mirabilis, without any documentation for communication with a physician, without any documented order for a urinalysis lab, and no report to a physician for the 2 pathogens identified. The Medical Director stated Resident #140 should have been supported with an opportunity for a physician to intervene and possibly provide various supports to address the infections prior to Resident #140's hospital transfer. The Medical Director stated he could not recall if he had been given a report but if he had been given a report, he would have intervened. The Medical Director was given a report of survey findings to include Resident #140 was assessed during his time at the facility with the infection to be free from signs and symptoms of infection to include Resident #140 was without a fever, and had vital signs within normal limits; the Medical Director stated the fact was Resident #140's urinalysis lab revealed a serious double pathogen infection and was enough to warrant treatment. The Medical Director stated in his medical practice he has encountered a patient without any signs and symptoms of infection other than a positive infection lab result and he would not ignore the lab result and would intervene with some type or types of treatment to eliminate the infection.<BR/>2. <BR/>Resident #14<BR/>A record review of Resident #14's admission record, dated 04/04/2023, revealed an admission date of 02/18/2023, with diagnoses which included personal history of transient ischemic attack, TIA, and cerebral infarction [Infarction refers to death of tissue. A cerebral infarction, or stroke, is a brain lesion in which a cluster of brain cells die when they don't get enough blood].<BR/>A record review of Resident #14's admission MDS, dated [DATE], revealed Resident #14 was a [AGE] year-old female admitted from her home. Resident #14 was assessed with no impaired mental cognition evidenced by a 15 out of 15 BIMS score. Resident #14 was assessed with urinary and bowel incontinence and needed extensive assistance with all activities of daily life. Resident #14 was assessed with a status of medically complex to include a diagnosis of hemiplegia [Hemiplegia is a condition caused by brain damage that leads to paralysis on one side of the body].<BR/>A record review of Resident #14's care plan, dated 04/04/2023, revealed, The resident has an activities of daily life self-care performance deficit related to decreased mobility, hemiplegia to the right side, intervention: bathing / shower; the resident requires assistance by staff with bathing showering as necessary.<BR/>A record review of Resident #14's nursing progress notes revealed LVN B documented on 03/24/2023, CNA notified this SN that upon showering resident she noticed bugs on hair. Upon assessment it was verified resident has an infestation of head lice. DON was notified and contact isolation in place until Treatment is completed.<BR/>A record review of Resident #14's nursing progress notes revealed LVN T documented on 03/25/2023, Lice treatment was applied as indicated this am. Continues on contact isolation. Denies pain or discomfort.<BR/>During an interview on 04/05/2023 at 2:25 PM LVN B stated on 03/24/2023 she assessed Resident #14 with head lice, text messaged the medical director and the DON. LVN B stated she received an order from the medical director to treat the head lice. LVN B stated the DON gave her the medication and Resident #14 was treated for head lice. LVN B was asked to demonstrate the documented communication with Resident #14's physician, the order for the medicated shampoo for lice, and the documentation for communication with the DON. LVN B stated she could not demonstrate the documentation because she did not document the events in Resident #14's medical record. LVN B stated she believed the DON would have done the documentation since she gave the DON a report. LVN B stated in retrospect she should have documented the SBAR, the order, and the follow up. LVN B stated, I am human and I can make mistakes.<BR/>During an interview on 04/07/2023 at 03:48 PM, the DON stated on 03/08/2023 LVN B alerted her that Resident #14 had head lice. The DON stated she retrieved the head lice medicated shampoo from the medication storeroom and provided the medication to LVN B. the DON stated the expectation is for nurses to document all communications with physicians, new orders, and follow ups in the residents' medical records.<BR/>During an interview on 04/07/2023 at 10:50 AM the Medical Director stated he could not recall if he had been given a report for Resident #14's head lice. The medical director stated the expectation was for all physician communications, orders, and nursing follow ups to be documented accurately in the resident's medical record. <BR/>A policy for accurate records was requested on 04/06/2023 and was not provided. The policy for Laboratory Services and Reporting partially addressed Resident #140.<BR/>A record review of the facilities Laboratory Services and Reporting policy dated, 04/08/2023, Revealed, the facility must provide or obtain laboratory services in ordered by a physician, positions assistant, nurse practitioner, or clinical nurse specialist in accordance with state law. Policy and explanation and compliance guidelines: the facility must provide or obtain laboratory services to meet the needs of its residents. The facility is responsible for the timeliness of the services. Should the facility provide its own laboratory services, the services must meet the applicable requirement for laboratories. if the laboratory chooses to refer specimens for testing to another laboratory, the referral laboratory must be certified in the appropriate specialties and subspecialties of service in accordance with requirements. assist the resident in making transportation arrangements to and from the laboratory if necessary. All laboratory reports will be dated and contain the name and address of the testing laboratory and will be filed in the residence clinical record. Promptly notified the ordering physician, physician assistant, nurse practitioner, or clinical nurse specialist of laboratory results that fall outside the clinical reference range. If unable to reach the ordering prescriber with abnormal lab results the medical director will be notified.

Based on interview and record review the facility failed to ensure the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week in that: <BR/>The facility was missing 13 days of RN coverage for the last 6 months (October -March 2023).<BR/>This could affect all residents and could result in residents at risk for not receiving necessary care and services.<BR/>The Findings were: <BR/>Record review of the PBJ d ate report dated 3/31/2023 revealed No RN Hours was triggered. <BR/>Record review of RN coverage report from October to March 2023 revealed 13 days with no RN coverage for 8 hours a day. <BR/>Missing dates included:<BR/>-10/22/2022 had no hours,<BR/>-11/5/2022 had 1.50 hours,<BR/>-11/13/2022 had .87 hours,<BR/>-11/19/2023 had 1.50 hours,<BR/>-11/26/2022 had 3.75 hours,<BR/>-11/27/2022 had 1.45 hours,<BR/>-12/17/2022 had 1.97 hours,<BR/>-12/18/2022 had 5 hours,<BR/>-12/31/2022 had no hours, <BR/>-1/7/2023 had no hours,<BR/>-1/8/2023 had no hours,<BR/>-1/29/2023 had 7.15 hours,<BR/>-2/12/2023 had no hours, and<BR/>-3/11/2023 had no hours.<BR/>Interview on 4/4/2023 at 4:16 PM, the Administrator stated the regular weekend RN went on leave and verified they did not have RN coverage for the 13 days for the last 6 months.<BR/>Interview on 4/4/20223 at 4:26PM with the DON and ADON, both RNs confirmed they scheduled the RN coverage as best they could and were aware they were short an RN to cover the weekend shift. <BR/>Interview on 4/05/2023 at 1:03 PM, the Administrator stated she was aware that there were days RNs were not scheduled due to no RN available. The Administrator stated there was no harm to residents, and it was important to have an RN. The Administrator stated the DON was always available by phone if no RN was on schedule to work. The Administrator discussed the RN shortage with corporate and Medical Director and were actively working on hiring an RN. <BR/>Record review of policy, Nursing Services-Registered Nurse (RN) dated October 2022 revealed It is the intent of the facility to comply with Registered Nurse staffing requirements. Definitions: Full time is defined as working 40 hours or more hours a week. 1. The facility will utilize the services of a RN for at least 8 consecutive hours per day, 7 days per week. 2. The facility will designate a RN to serve as the Director of Nursing on a full-time basis. 4. The facility is responsible for submitting timely and accurate date through the CMS Payroll Based Journal (PBJ) system

Based on interview and record review, the facility failed to employ staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition services for 1 of 1 dietary manager reviewed for qualified dietary staff. <BR/>The facility failed to employ a certified dietary manager as required. <BR/>This failure could place residents who consumed food from the kitchen at risk of not having qualified dietary staff providing food and nutrition services.<BR/>The Findings were:<BR/>Record review of staff list with hire date of Dietary Manager (DM) date of hire was 6/4/2018 for maintenance and started as DM on 2/16/2022. <BR/>Interview on 4/03/2023 at 10:20 AM, the DM revealed he was not certified and was in school currently. The DM stated he had been working as DM for over a year. <BR/>Interview on 4/05/2023 at 1: 40 PM, the Administrator stated the DM started in the kitchen position on 2/16/2022. The Administrator had no comments when surveyor asked why the DM was not certified, no policy was provided before exit.

Based on observations, interviews and record reviews the facility failed to ensure store, prepare, distribute and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen in that:<BR/>Kitchen floor missing tile concrete (porous) in the corner of the kitchen. <BR/>A grease trap under the sink that had black grease coming out of the side. <BR/>Kitchen counter had missing pieces. <BR/>This failure could place residents who received meals from the kitchen at-risk for foodborne illness.<BR/>The Findings were:<BR/>Observations in the kitchen on 4/05/2023 at 1:39 p.m. to 2:08 p.m., revealed the floor was missing tile and exposed concrete, under sink area was a grease trap container that had black grease coming out of side, the counter area had pieces of missing tile. The DM grabbed some gloves, after asked by surveyor what the substance coming out of grease trap was, he stated it was grease .(under sink to trap grease) <BR/>Interview on 4/05/2023 at 2:08 p.m., the DM stated maintenance cleans the grease trap and was not sure how often. The DM confirmed a section of the floor was missing tile and exposed concrete. The DM confirmed the counter tile broken and missing tile on the edges. The DM did not reply when asked about the kitchen concerns. <BR/>Observation on 4/05/23 at 3:58 p.m., [NAME] L pureed food for residents using a robot coupe on top of the kitchen counter with missing pieces of tile. [NAME] L did no reply when asked about kitchen concerns. <BR/>Interview on 4/5/2023 at 7:30 p.m., PM surveyor discussed with the Administrator the kitchen concerns and she did not reply. The Administrator stated she only had the LogBook documentation for kitchen policy this and a list of items that needed to be completed in the Kitchen completed by maintenance supervisor. The Administrator stated this list was completed every 6 months.<BR/>Interview on 4/06/2023 at 2:30 PM with Maintenance supervisor M stated he cleaned the grease trap in the kitchen twice a year. The Maintenance supervisor M stated he did not document he cleaned the grease trap. The maintenance supervisor M did not reply when asked about the grease coming out of the grease trap machine. <BR/>Record review of the policy for Kitchen grease trap, LogBook Documentation no date, revealed Kitchen rounds General Cleanliness, equipment well maintained, grease traps in place and clean.

Based on observation, interview and record review, the facility failed to provide the required 80 square foot per resident in 23 of 37 resident rooms (Rooms 7-8, 20,-40) reviewed for bedroom measurements, in that: <BR/>The facility failed to ensure rooms measured the required 80 sq. ft per resident's failure could impede the ability of residents living in these rooms to attain their highest practicable well-being.<BR/>The findings were:<BR/>Observation on 04/03/23 at 12:28 PM, revealed for rooms 7-8, 20-21, 24, 26-32, 34, 36, 39 (which had two beds) was calculated to be between 144 and 155 square foot resulting between 72 and 77.5 square feet per resident. <BR/>Record review of Provider History Profile, updated 02/01/2022, revealed an existing room size waiver from recertification survey, exit date 2/11/2022.<BR/>Interview on 4/3/2023 at 9:40 AM, the DON/Administrator said she wanted to continue with the room waiver as last year. No policy was provided before exit.

Based on observations, interviews and record reviews the facility failed to ensure store, prepare, distribute and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen in that:<BR/>Kitchen floor missing tile concrete (porous) in the corner of the kitchen. <BR/>A grease trap under the sink that had black grease coming out of the side. <BR/>Kitchen counter had missing pieces. <BR/>This failure could place residents who received meals from the kitchen at-risk for foodborne illness.<BR/>The Findings were:<BR/>Observations in the kitchen on 4/05/2023 at 1:39 p.m. to 2:08 p.m., revealed the floor was missing tile and exposed concrete, under sink area was a grease trap container that had black grease coming out of side, the counter area had pieces of missing tile. The DM grabbed some gloves, after asked by surveyor what the substance coming out of grease trap was, he stated it was grease .(under sink to trap grease) <BR/>Interview on 4/05/2023 at 2:08 p.m., the DM stated maintenance cleans the grease trap and was not sure how often. The DM confirmed a section of the floor was missing tile and exposed concrete. The DM confirmed the counter tile broken and missing tile on the edges. The DM did not reply when asked about the kitchen concerns. <BR/>Observation on 4/05/23 at 3:58 p.m., [NAME] L pureed food for residents using a robot coupe on top of the kitchen counter with missing pieces of tile. [NAME] L did no reply when asked about kitchen concerns. <BR/>Interview on 4/5/2023 at 7:30 p.m., PM surveyor discussed with the Administrator the kitchen concerns and she did not reply. The Administrator stated she only had the LogBook documentation for kitchen policy this and a list of items that needed to be completed in the Kitchen completed by maintenance supervisor. The Administrator stated this list was completed every 6 months.<BR/>Interview on 4/06/2023 at 2:30 PM with Maintenance supervisor M stated he cleaned the grease trap in the kitchen twice a year. The Maintenance supervisor M stated he did not document he cleaned the grease trap. The maintenance supervisor M did not reply when asked about the grease coming out of the grease trap machine. <BR/>Record review of the policy for Kitchen grease trap, LogBook Documentation no date, revealed Kitchen rounds General Cleanliness, equipment well maintained, grease traps in place and clean.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to accurately complete assessments for 1 of 6 residents reviewed (Resident #20) for accuracy of assessments, in that: <BR/>Resident #20's MDS assessment was inaccurate. <BR/>This deficient practice could result in diminished quality of care due to inaccurate resident assessment. <BR/>The findings were: <BR/>Record review of Resident #20's face sheet, dated 06/06/2025, revealed the resident was admitted to the facility on [DATE] with diagnoses including: Unspecified Dementia, Cognitive Communication Deficit, and Chronic <BR/>Obstructive Pulmonary Disease. <BR/>Record review of Resident #20's Quarterly MDS, dated [DATE], revealed the resident was rarely or never understood, and Staff Assessment for Mental Status revealed the resident had both short-term and long-term memory problems. Further review revealed the MDS noted the resident was not receiving hospice services. <BR/>Record review of Resident #20's Care Plan, revised 10/22/2024, revealed The resident has a terminal prognosis and is on hospice [company name]. <BR/>Record review of Resident #20's clinical record as of 06/06/2025, revealed an order dated, 10/9/2024, Admit to hospice .<BR/>During an interview with the MDS Coordinator on 06/05/2025 at 2:42 p.m., the MDS Coordinator confirmed Resident #20's Quarterly MDS, dated [DATE], was incorrectly coded no for hospice services and stated the deficient practice was an oversight. <BR/>During an interview with the DON on 06/05/2024 at 3:54 p.m., the DON stated she expected all MDS assessments to be correctly coded. The DON stated the facility followed the RAI manual for MDS assessments and did not have an additional policy regarding MDS assessments.

Based on observation, interview and record review, the facility failed to provide the required 80 square foot per resident in 23 of 37 resident rooms (Rooms 7-8, 20,-40) reviewed for bedroom measurements, in that: <BR/>The facility failed to ensure rooms measured the required 80 sq. ft per resident's failure could impede the ability of residents living in these rooms to attain their highest practicable well-being.<BR/>The findings were:<BR/>Observation on 04/03/23 at 12:28 PM, revealed for rooms 7-8, 20-21, 24, 26-32, 34, 36, 39 (which had two beds) was calculated to be between 144 and 155 square foot resulting between 72 and 77.5 square feet per resident. <BR/>Record review of Provider History Profile, updated 02/01/2022, revealed an existing room size waiver from recertification survey, exit date 2/11/2022.<BR/>Interview on 4/3/2023 at 9:40 AM, the DON/Administrator said she wanted to continue with the room waiver as last year. No policy was provided before exit.

**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 personal privacy and confidentiality of his or her personal and medical records for 1 of 5 residents (Resident #37) reviewed for privacy, in that:<BR/>MA (A) did not lock the computer after she walked away and left it unattended, which exposed Resident #37's morning medication list. <BR/>This failure could place residents at risk of having their medical information exposed to others and cause residents to feel uncomfortable and disrespected. <BR/>The findings include:<BR/>Record review of Resident #37's face sheet dated 6/04/25 reflected an [AGE] year-old female resident who was admitted to the facility on [DATE] with diagnoses which included: Heart Failure (condition in which the heart isn't pumping as well as it should), kidney disease ( means your kidneys are damaged and can't filter blood the way they should) and Peripheral vascular disease(disorder of the blood vessels that affects the legs and feet). <BR/>Record review of Resident #37's Quarterly MDS assessment, dated 3/27/25, reflected a BIMS score of 11, which indicated moderate cognitive impairment. <BR/>During an Observation on 6/04/25 at 8:40 AM revealed MA (A) prepared Resident #37's morning medication and walked away from the computer, leaving the computer screen unlocked ; she was away from the computer for 4 minutes.<BR/>During an interview on 6/04/25 at 8:50 AM, MA (A) stated she was not aware of the option to lock the computer screen and believed minimizing the screen was sufficient. MA (A)noted Resident #37's private medical information might have been exposed when she stepped away from the computer.<BR/>During an interview on 06/05/25 at 2:34 PM, the DON stated her expectation was for the facility nursing staff to uphold HIPAA regulations and lock computer screens when they were away from them. The DON emphasized that all staff members should protect residents' information. The DON expressed concern that leaving residents' charts open and unattended could lead to unauthorized access. The DON also stated she would be responsible for overseeing compliance with this task, and she would monitor it by conducting random computer screen checks.<BR/>Record review of the facility's policy dated 10/1/2019, titled medication administration, reflected: Privacy is maintained at all times for all resident information.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to must comply with the requirements Advance Directives, These requirements include provisions to inform and provide written information to all adult residents concerning the right to accept or refuse medical or surgical treatment and, at the resident's option, formulate an advance directive, This includes a written description of the facility's policies to implement advance directives and applicable State law for 1 of 8 (#15) residents reviewed for Advanced Directives in that:<BR/>Resident #15's telephone order and care plan did not match his Advanced Directives discussed with family via Social Worker.<BR/>This could affect all residents and could result in residents not receiving their last wish. <BR/>The Findings were:<BR/>Record review of Resident # 15's admission Record dated 4/6/2023 revealed he was admitted on [DATE], re-admitted on [DATE] was documented as a DNR (do not resuscitate).<BR/>Record review of Resident # 15's telephone order dated 10/3/2022 was documented as a DNR.<BR/>Record review of Resident #15's Annual MDS dated [DATE] revealed section C Cognitive Patterns BIMS score 9/15 (moderate cognitive impairment). <BR/>Record review of Resident # 15's care plan dated 3/20/2023 was documented full code.<BR/>Record review of Resident # 15's OODNR (out of hospital DNR) was dated on 9/26/2022 and signed by two witnesses. <BR/>Interview on 4/05/2023 at 2:55 PM with SW state Resident #15's chart should have reflected he was a DNR. The SW stated it was important to discuss the Advanced Directive to honor the resident's last wish. The SW stated the family and resident understand and discussed Resident #15's Advanced Directive. The SW stated she immediately lets the nurse aware. This could cause Resident/Family harm if residents wished were not completed-psychological harm. The SW helped Resident #15's family complete the OODNR and place on Resident #15's record. SW stated she was responsible to make sure Resident/Families had or discussed Advanced Directive on admission and during resident stay at facility. <BR/>Record review of the policy Advanced Directive dated December 2017 revealed Advance Directives will be respected in accordance with state law and facility policy. Upon admission, the resident will be provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advance directive if he or she chasses to do so. If resident is incapacitated and unable to receive information about his or her right to formulate an advance directive, the information may be provided to the resident's legal representative. Prior to or upon admission of a resident, the social Services Director or designee will inquire of the resident, his/her family members and/or his or her legal representative, about the existence of any written advance directives. The plan of care for each resident will be consistent with his or her documented Advance Directive.<BR/>Interview on 4/07/23 02:16 PM with the MDS LVN J stated she was responsible for resident care plans; she missed the code status and it's important to make sure the resident had his/her last wishes.

Based on interview and record review, the facility failed to employ staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition services for 1 of 1 dietary manager reviewed for qualified dietary staff. <BR/>The facility failed to employ a certified dietary manager as required. <BR/>This failure could place residents who consumed food from the kitchen at risk of not having qualified dietary staff providing food and nutrition services.<BR/>The Findings were:<BR/>Record review of staff list with hire date of Dietary Manager (DM) date of hire was 6/4/2018 for maintenance and started as DM on 2/16/2022. <BR/>Interview on 4/03/2023 at 10:20 AM, the DM revealed he was not certified and was in school currently. The DM stated he had been working as DM for over a year. <BR/>Interview on 4/05/2023 at 1: 40 PM, the Administrator stated the DM started in the kitchen position on 2/16/2022. The Administrator had no comments when surveyor asked why the DM was not certified, no policy was provided before exit.