**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Record review of Resident #84's admission Record showed he/she admitted to the facility on [DATE] with the following diagnoses: -Essential primary hypertension (high blood pressure). -Acute kidney failure, unspecified. -Cardiac arrhythmia (irregular or abnormal heart beat) unspecified. -Rheumatic multiple valve disease (a condition in which there is permanent damage to heart valves), unspecified. -Unspecified hypothyroidism (abnormally low activity of the thyroid, a gland that regulates growth and development). -Morbid obesity (extreme amount of excess body weight), due to excess calories. -Acute and chronic respiratory failure (a condition in which the blood doesn't have enough oxygen or has too much carbon dioxide), with hypoxia, (absence of enough oxygen to sustain bodily functions). Record review of the resident's Care Plan completed 5/15/20 and reviewed 3/22/21 showed: -He/she had high blood pressure and received medications to treat high blood pressure. -He/she had a goal to remain free of complications related to high blood pressure. -He/she was to be monitored for edema, which was to be documented. The physician was to be notified of any edema. -He/she had a potential for fluid deficit due to taking diuretic medication. -He/she was to be weighed and weight recorded as ordered. -The physician was to be notified of weight loss greater than five pounds. -He/she was to be monitored for weight loss due to hyperthyroidism due to medication. -He/she was on Furosemide related to edema and would exhibit fluctuations in weight. -He/she had a potential nutrition problem related to obesity. -He/she had a goal to maintain weight within five pounds of current weight. -He/she had unplanned/unexpected weight gain related to hypertension and edema. -He/she was to be weighed at the same time of day, in the morning, on the south side scale. -Reasons for weight gain or significant weight changes were to be monitored, recorded and reported to the physician. Record review of the resident's current Physician's Order Summary Report dated 4/6/21 showed he/she had the following orders: -Daily weight, if weight gain of greater than two pounds in 24 hours or greater than five pounds in one week, call doctor. Every day shift for CHF. -Furosemide, tablet 80 mg by mouth, two times a day for fluid retention. -Diltiazem HCL (a medication used to treat high blood pressure), ER Capsule Extended Release 24 hour, 120 mg, one capsule by mouth, one time a day for hypertension. -Levothyroxine Sodium, (a medication that treats underactive thyroid function), tablet 150 micrograms (mcg), one tablet by mouth, one time a day for hypothyroidism. Record review of the resident's Weights and Vitals Summary dated 4/14/21 showed: -From 8/1/20 to 8/31/20, his/her weights were not documented 7 times. -Documented weights from 8/30/20 to 8/31/20, showed he/she had a weight loss of 29.2 pounds. -From 9/1/20 to 9/30/20, his/her weight were not documented 22 times. -From 10/1/20 to 10/31/20, his/her weights were not documented 28 times. -From 11/1/20 to 11/30/20, his/her weights were not documented 18 times. -Documented weights from 11/18/20 to 11/25/20, showed he/she had a weight loss of 6.52 pounds. -From 12/1/20 to 12/31/20, his/her weights were not documented 27 times. -From 1/1/21 to 1/31/21, his/her weights were not documented 25 times. -From 2/1/21 to 2/28/21 his/her weights were not documented 20 times. -Documented weights from 2/20/21 to 2/22/21, showed he/she had a weight gain of 26.8 pounds. -From 3/1/21 to 3/31/21 his/her weights were not documented 17 times. -From 4/1/21 to 4/14/21 his/her weights were not documented 5 times. Record review of the resident's Physician Progress Notes dated 8/12/20 through 3/19/21 showed: -There was no documentation the physician was notified, as ordered, of weight changes of greater than two pounds in 24 hours or greater than five pounds in one week. -There were no changes made in ordered medications since 5/15/20. 4. During an interview on 4/13/21 at 9:55 A.M., LPN A said: -The charge nurse transcribes all orders for new admits and re-admits. -He/she put the orders into the computer. -ADON goes in and does order audit the next day after he/she puts the orders in the computer. -He/she does not know who audits the MARS and TARS. -He/she would notify the physician if a resident had too much weight gain, especially if they have a diagnosis of heart failure. During an interview on 4/8/21 at 12:11 P.M., the resident's Physician and Nurse Practitioner (NP) said: -He/she would expect the nursing staff to follow the physician's orders. -Nurses should be documenting and assessing the residents. During an interview on 4/13/21 at 9:40 A.M., the Assistant Director of Nursing (ADON) said: -Nurses were responsible to make sure orders were transcribed and entered into the computer. -The ADONs monitor the orders. -He/she and other staff review MAR and Treatments Administration Record (TAR) in morning meeting. -He/she notified the Director of Nursing (DON), physician and Nurse Practitioner. -He/she would notify the physician if a resident had a weight change of two pounds in one day, five pounds in five days if there was an order. -He/she would look at the resident's diagnosis and assess the resident. -Weight change of 3% in thirty days and 5% in 60 days. -For daily weights the residents weight was recorded on the TAR. -The nurse was to make sure the resident was weighed daily. -The TAR would flag the residents that needed daily weights. -When a resident was admitted , the nurse would familiarize himself/herself with the resident. -If a resident had a large weight gain, the resident should be reweighed and the physician should be contacted. -The physician should be notified if a resident had a weight change over 2 pounds in a day or over 5 pounds in a month. NOTE: At the time of the survey, the violation was determined to be at the immediate jeopardy level J. Based on observation, interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to remove the IJ violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the D level. MO00183026 Based on interview and record review, the facility failed to monitor and assess for signs and symptoms of infection which lead to one resident (Resident #97) acquiring osteomyelitis and necrosis and eventually partial amputation of his/her finger; failed to follow discharge orders including daily weights, failed to follow subsequent physician's orders for weekly weights, failed to get clarification on conflicting orders for obtaining weights, and failed to notify the physician of excessive weight gain which resulted in one closed record sampled resident (Resident #501) who gained a total of 112.5 pounds (lbs.) from 1/7/21 to 2/1/21 and failed to follow physician orders including daily weights and notifying the physician of weight changes for one sampled resident (Resident #84) out of 22 sampled residents and 16 closed record sampled residents. The facility census was 95 residents. The Administrator was notified on 5/27/21 at 12:56 P.M. of an Immediate Jeopardy (IJ) which began on 4/5/21. The IJ was removed on 4/14/21 as confirmed by surveyor onsite verification. Record review of the facility Assessment and Management of Resident Weights policy revised June 2020 showed: -Staff were to ensure that each resident maintains acceptable parameters of weight and nutrition. -Weights were obtained upon admission and/or re-admission, then weekly for four weeks and monthly thereafter. -Additional weights may be obtained at the discretion of the licensed nurse or the interdisciplinary team (IDT). -A licensed nurse or designee will weigh residents. -If the weight is less than or greater than five lbs. from the previous weight, immediately re-weigh and have a licensed nurse verify the accuracy of the weight. -Weights will be entered into the clinical record on that shift. -Significant weight change management: --Will be reviewed by a licensed nurse. --Significant weight changes are less than or more than 5% in one month, 7.5% in three months or 10% in six months. -Report weight change in the medical record and on the 24-hour report. -Notify the physician and dietitian of significant weight changes and document notification in the nurse's notes. -Residents with significant weight changes will be weighed at least weekly and discussed at the Resident at Risk or other clinical meeting to determine possible causes of weight gain or loss including goals for care. -The care plan will be updated to reflect individualized goals and approaches for managing the weight change. Record review of the facility Physician Order Policy revised on June 2020 showed: -This will ensure that all physician orders are complete and accurate. -The Medical Records Department will verify that physician orders are complete, accurate and clarified as necessary. -A licensed nurse will transcribe orders with date, time and signature of the person receiving the order. -Licensed nurse receiving the order will be responsible for documenting and implementing the orders. -Documentation pertaining to physician orders will be maintained in the resident's medical record. 1. Record review of Resident #97's Face Sheet showed the resident was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of: -Unspecified Dementia (a condition in which a person has an impaired ability to remember, think, or make decisions that is severe enough to interfere with everyday activities) without Behavioral Disturbance. -Fracture of Unspecified Phalanx (bone) of Left Index Finger, Subsequent Encounter with Routine Healing. -Cognitive Communication Deficit (difficulty communicating related to cognitive issues). -Partial Traumatic Metacarpophalangeal (joint closest to the hand rather than the nail) Amputation of Left Index Finger. -Cellulitis (a potentially serious bacterial skin infection which can spread rapidly) of Left Finger . -Unspecified Open Wound of Unspecified Finger with Damage to Nail. Record review of the resident's 3/8/21 Progress Notes showed at the start of the shift the off-going nurse found the resident had a wound to the index finger of his/her left hand. The wound was covered and a call was placed to the on-call Nurse Practitioner (NP) and the resident's family member. Orders were obtained to send the resident to the emergency room (ER) for evaluation and treatment. The resident returned with a fractured finger and orders for (ABT) for an open wound. The resident was to get Cephalexin (generic for Keflex, an antibiotic) 500 milligrams (mg) twice daily for 14 days. Record review of the resident's medical records for his/her ER visit on 3/7/21 showed: -The resident's hospital face sheet showed he/she was admitted for evaluation and treatment on 3/7/21. -The Patient Visit Information, dated 3/7/21 at 9:41 P.M. showed: --The resident was seen for a closed fracture of the tuft (small fragments chipped off the bone edge) of the distal (situated away from the center of the body) phalanx, avulsion (separation of part or all) of nail plate, and avulsion (wound with pulled off or torn away tissue) of soft tissue. --The resident was to take the prescribed antibiotic Cephalexin, 500 mg capsule orally twice daily for 14 days. Record review of the resident's Physician Order Sheet (POS), dated 3/2021 showed the following orders: -Cephalexin, 500 mg tablet two times daily for broken finger, left index finger starting 3/8/21. Record review of the resident's Treatment Administration Record (TAR) for March, 2021 showed orders for: -Cephalexin, 500 mg tablet two times daily for broken left index finger starting 3/8/21. Documentation for this medication showed: --On 3/8/21 for the 8:00 A.M. administration a 7 was indicated on the TAR. The chart key code showed code showed 7 meant the resident was sleeping. --Spaces for documenting the 3/10/21 morning and afternoon doses of Cephalexin and for documenting the morning dose of Cephalexin on 3/11/21 were left blank. --Documentation showed the resident received this medication five out of nine opportunities. --Staff documented they gave the 4:00 P.M. dose of Cephalexin on 3/13/21 even though a 6 was documented the morning of 3/13/21. The key code for 6 indicated the resident was in the hospital. ---NOTE: Further record review showed the resident was hospitalized on [DATE] and returned to the facility on 3/17/21. Record review of the resident's nursing notes for 3/8/21 through 3/12/21 showed: -No documentation by the facility staff why the resident's Cephalexin doses on 3/8/21, 3/10/21, and 3/11/21 were left blank. -No assessment of the resident's left index finger. Record review of the resident's hospital records, dated 3/12/21 through 3/17/21 showed: -The hospital admission History and Physical showed the resident presented to the ER because of a red inflamed left index finger with an avulsion of the left index nail plate and soft tissue avulsion of the pad of the finger. The pad of the finger was blackish brown, concerning of necrosis (dead tissue). The resident was discharged from another hospital on 3/7/21 with orders for Keflex, 500 mg twice daily, but the antibiotic was not given. The left second finger gradually became more erythematous (reddened), painful and swollen. The resident was sent to be seen by the hand surgeon. -The resident was given a diagnosis of cellulitis of the left second finger and received intravenous (administered through the veins) ABT. Magnetic Resonance Imaging (MRI - device that uses strong magnetic fields and radio waves to scan the body or body parts and produce images) was being considered to rule out osteomyelitis (a bacterial or fungal infection that requires antimicrobial (kills micro-organisms) treatment and often surgery). -The resident, who is severely demented, presented to the ER due to worsening finger infection after fracturing it in his/her wheelchair (WC) a few days ago. After the initial injury he/she presented to another hospital ER where he/she was diagnosed with a fracture and prescribed Keflex. Per report the nursing home did not receive this medication and was not giving the resident his/her antibiotic. A large portion of overlying skin around the nail bed was lifted and dangling. The pulp of the finger was hyper-pigmented and had an open wound surrounding the entire nail bed that had purulent (thick yellow, green or brown colored pus) and sanguineous (thin, pale red or pink) drainage. -An operative report, dated 3/14/21 showed: --The resident's injury involved a partial amputation of the tip of the finger. He/She subsequently had increasing redness and drainage from the finger. The patient (resident) presented with a significantly erythematous finger with quite a bit of swelling. He/She seeks revision of the amputation and drainage of any abscess. --The soft tissue of the second digit was amputated and a significant amount of purulence was noted, including the area of the bone. The tissues and bone were consistent with osteomyelitis. Cultures were obtained. Increasing amounts of purulence from the dorsal aspect (back portion) of the finger was noted. As much purulence (a milky or thick green, brown, yellow or white colored drainage with a distinct odor, indicative of infection) material was expressed as possible which extended to about the Proximal Interphalangeal (PIP - second joint from the nail) joint. The bone was quite nauseous. The wound was debrided (a procedure in which damaged tissue or foreign objects are removed from a wound) back to healthy-looking bone, taking the amputation site into the mid area of the middle phalanx. Then the wound was thoroughly irrigated (a process where a steady flow of solution is used across an open wound surface to hydrate and remove debris). The wound was sutured and dressed. -A Discharge summary, dated [DATE] showed: -The resident was admitted for inpatient service for management of finger cellulitis and osteomyelitis. -He/She was treated with intravenous antibiotic therapy and was ordered six more days of oral antibiotics and follow up with the physician in plastic surgery in two weeks. -Discharge orders included Cephalexin, 250 mg every eight hours for six days and Doxycycline Hyclate (an antibiotic used to treat bacterial infection), 100 mg, twice daily for six days. Record review of the resident's nurses' notes, dated 3/17/21 through 3/19/21 showed: -There was no nursing note on 3/17/21 showing the resident had returned to the facility on 3/17/21. -On 3/19/21 there was a late entry skin wound note showing the nurse had assessed the resident's left index finger and confirmed the resident had a partial amputation to the left index finger. The area had three stitches and had light serosanguineous drainage (clear, pale red or pink colored drainage). The area was closed and intact with no signs of infection such as odorous drainage, redness or swelling. During an interview on 4/7/21 at 12:01 P.M., the resident's legal representative said: -He/She was contacted by the facility a month ago and was told the resident's had an accident in which the resident's index finger had been torn. The accident also tore up the resident's index finger nail. -The resident went to the ER and was put on an antibiotic. -Approximately three to four days later he/she received a call from a doctor at the hospital who was following up on the injury. He/She was told there were problems with the resident's finger because the facility forgot to give the resident his/her antibiotic. -While at the facility the index finger became infected and was amputated three weeks ago. During a telephone interview on 4/8/21 at 12:11 P.M., the resident's physician and Nurse Practitioner (NP) said: -He/She expected the resident's antibiotic to be given as ordered. If medications were not given as ordered there was an increased risk of infection. -He/She expected the nurses to monitor for signs and symptoms of infection. -All staff should be following Centers for Medicare and Medicaid Services guidelines related to medication administration and monitoring wounds. --The hospitals had recommended ABT treatment. The resident had orders for ABT and the nurses were responsible for ensuring physician orders were followed. --They expected physician orders for antibiotics to be followed exactly as ordered to decrease risk of infection. If there were any problems related to the ABT medications, they expected nurses to notify them. During an interview on 4/8/21 at 10:34 A.M., Assistant Director of Nursing (ADON) B said: -The resident was on Keflex after returning from the ER following the injury to the second finger and was also on ABT after his/her finger amputation. -Nurses are expected to follow the physician orders as written and nurses are responsible for administering the antibiotic medications and documenting the administration on the MAR. During an interview on 4/13/21 at 1:01 P.M., Certified Medication Technician (CMT) A said: -The nurse was responsible for giving antibiotic medications and for ensuring the resident received it. -Antibiotics are kept on the nurses' medication cart. -If the nurse was too busy to give the antibiotic, he/she might ask the CMT to give it. -Antibiotic medication administration should be documented on the MAR like any other medication. -He/She didn't know if the resident missed any of his/her antibiotic medications. -The CMT is supposed to report to the nurse if a resident's medication had not been delivered to the facility, if his/her scheduled medication was missing, or if he/she refused the medication, -He/She didn't know who the nurse reported to regarding any missed antibiotics or other medications. During an interview on 4/14/21 at 12:37 P.M., LPN B said: -The charge nurse is responsible for ensuring the resident received their antibiotic medications. If the medication is not available from the pharmacy it should be taken out of the Emergency kit (E-kit - contains small quantities of medications which can be dispensed when pharmacy services are not available). -Most types of antibiotics were available in the E-kit, including Keflex. -If a resident refused his/her antibiotic the nurse should report it to the physician. During an interview on 4/14/21 at 1:35 P.M. the Director of Nursing (DON), Assistant Director of Nursing (ADON) B, and the Corporate Nurse Consultant were interviewed and said the following: -If there were holes in the MARs, the ADON should talk to the charge nurse to verify whether or not the resident received his/her medication. There should not be any blank spaces in the MAR. If the medication was refused the refusal can be documented on the MAR. The electronic dashboard should show which scheduled medications were not given and flag it. The charge nurse, ADON and DON could see that it is flagged and the ADON and DON were responsible for monitoring medication administration issues. -The charge nurse was responsible for ensuring antibiotic medications are given as ordered. The nurse should call the physician if an antibiotic was not available or was refused. If an antibiotic was only given half the time it was prescribed and the resident wasn't refusing the medication, it is considered a medication error. -The risk of not giving an antibiotic was that it could result in a potentially worsened infection. It would require the physician to be contacted. The charge nurse should follow up by notifying the physician at the time if a resident's ABT was not available at the facility or was refused. -The ADON and DON were responsible for auditing to ensure medications are administered as ordered. -The physician does rounds at the facility weekly and the Nurse Practitioner is at the facility at least two to three days per week. Physicians can be notified when there are concerns about the residents' medications by telephone or when the physician or Nurse Practitioner are at the facility. 2. Record review of Resident #501's New admission paperwork dated 12/24/20 showed: -Weight on 12/9/20 was 276 pounds (lbs.). -CHF: Lasix (diuretic - increase the amount of water and salt expelled from the body as urine) appears euvolemic (appears to have a normal circulatory or blood fluid volume within the body). Record review of the resident's Discharge Order Summary from the sister facility dated 12/24/20 showed weekly weight times 4 weeks, every day shift, every seven days for weight monitoring for four weeks, start on 12/11/20. Record review of the resident's Order Summary Report dated 12/24/20 showed: -Daily weights for three days every shift for three days' start 12/24/20 and end 12/27/20. -Weekly weight times four weeks, every day shift every seven days start on 12/25/20. Record review of the resident's Weight Monitoring dated 12/24/20 showed the resident weighed 276 lbs. Record review of the resident's Weight Monitoring dated 12/25/20 showed: -Weekly weight times four weeks, every day shift, every seven days start on 12/25/20 and end on 1/22/21. -The resident weighed 274 lbs. -The absence of any requested clarification related to the change in the order or an order to discontinue the previous order for daily weights for three days. Record review of the resident's Weight Monitoring dated 12/27/20 showed the resident weighed 276 lbs. Record review of the resident's admission Minimum Data Set (MDS, is a federally mandated assessment instrument to be completed by facility staff for care planning) dated 12/30/20 showed: -The resident was admitted on [DATE]. -Was cognitively intact, able to make his/her needs known and able to understand others. -CHF was not marked/noted as a diagnosis. Record review of the resident's Weight Monitoring dated 1/7/21 showed: -Weekly weight times four weeks, every day shift every seven days start on 12/25/20 and end on 1/22/21. -The resident weighted 273.6 lbs. Record review of the resident's Nutrition assessment dated [DATE] showed: -Resident's weight was 273.6 lbs., dated 1/7/21. -Resident's weight fluctuates some, suspected in part due to fluid shift. -Right arm was currently edematous (swelling with an excessive accumulation of fluid), monitoring. Record review of the resident's Weight Monitoring dated 1/21/21 showed: -Weekly weight times four weeks, every day shift, every seven days, start on 12/25/20 and end on 1/22/21. -The resident weighed 366.4 lbs. -The resident had a 92.8 lb. (25%) weight gain in 14 days. -Record review of the nurse's notes showed no documentation the nurses had assessed the resident for the rapid weight gain or notified the resident's physician. Record review of the resident's complete weight monitoring showed the absence of: -The daily weight to be completed on 12/26/20. -The first weekly weight to be completed on 1/3/21. -The daily weight that would have been due on 1/14/21. -The daily weight for 1/28/21. Record review of the resident's Nursing Note dated 2/1/21 showed: -The resident complained of chest pain and left arm pain, abdominal breathing, pulse was irregular, difficulty breathing with speaking. -Call placed to the physician, received new order to send the resident to the hospital. -Daughter was notified of the transfer. Record review of the resident's Hospital Discharge summary dated [DATE] showed: -admission Diagnosis: --Acute on chronic respiratory failure with hypoxia and hypercapnia (acute respiratory failure occurs when fluid builds up in the air sacs in your lungs. Chronic respiratory failure the airways that carry air to your lungs become narrow and damaged. Hypoxia is not enough oxygen in the blood. Hypercapnia is too much carbon dioxide in the blood). --Acute or chronic CHF. --Acute Kidney injury (the kidney suddenly cannot filter waste from the blood develops rapidly over a few hours or days, it can be fatal). --Anasarca (the whole body is swollen from head to their feet). -admission weight on 2/1/21 was 386.1 lbs. (a 112.5 lb., 29% weight gain in one month). -Discharge weight on 2/8/21 was 366.9 lbs. (a 19.2 lb, 5% weight loss while in the hospital for seven days). -Resident was discharged on Lasix ((Furosemide) a diuretic - increase the amount of water and salt expelled from the body as urine) 40 milligrams (mg) twice a day. Record review of the resident's Order Summary Report dated 2/8/21 showed Furosemide (Lasix) 80 mg, give one tablet twice a day for edema, start 2/8/21. Record review of the resident's Care Plan related to his/her CHF diagnosis put into place after the resident was readmitted on [DATE] showed: -Resident was on diuretic therapy (Lasix) related to edema. -Monitor and document intake and output as per facility policy. -Administer medication as ordered by the physician. -Encourage compliance with fluid restriction as ordered. -May require modification in order to achieve desired effects while minimizing adverse consequences. Record review of the resident's Nutrition assessment dated [DATE] showed: -Current weight was 370 lbs. (a 3.1 lbs., 1% weight gain in one day) -Weight continues to fluctuate significantly at times, suspect in part due to fluid shift with a history of CHF and edema. -Order for diuretic medication and weight monitoring. -Weight increase of 96.4 lbs., 26% in one month. Record review of the resident's Order Summary Report dated 2/10/21 showed: -Daily weights every day shift, start 2/10/21. -Daily weights for three days every day shift for three days, start 2/10/21. -Weekly weight for four weeks every day shift every seven days, start 2/11/21. Record review of the resident's Daily Weight Monitoring dated February 2021 showed: -The last time the resident was weighed was on 2/9/21 at 370 lbs. -The absence of a daily weight being completed on 2/11/21, 2/12/21, and 2/13/21. Record review of the resident's Nursing Note dated 2/14/21 showed: -Resident complained of difficulty breathing. -Repositioned and pulled up in bed to sit up better. -Resident took a nap for about an hour before calling 911 himself/herself. -Resident was transferred to the hospital, and did not return to the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure an unwitnessed injury, to the second finger of a resident who was severely cognitively impaired was thoroughly investigated and to immediately put interventions in place to prevent further injury. Within less than 30 days the resident sustained a similar injury to his/her third finger. The facility failed to thoroughly investigate the second injury and failed to immediately put interventions in place to prevent further injury. This affected one sampled resident (Resident #97) out of 22 sampled residents. The facility census was 95 residents. The Administrator was notified on 5/27/21 at 12:56 P.M. of an Immediate Jeopardy (IJ) which began on 4/5/21. The IJ was removed on 4/14/21 as confirmed by surveyor onsite verification. Record review of the facility's Care Planning policy, dated 6/2020 showed: -A comprehensive, person-centered Care Plan will be developed for each resident to meet the resident's needs. -Changes will be made to the plan on an ongoing basis for the duration of the resident's stay. Record review of the facility's Incident Investigation policy, dated 8/2020 showed: -The licensed nurse will fill out the Incident/Accident Report as soon as possible after an injury. -Interviews with staff members and other witnesses will be documented. Record review of the facility's Abuse Prevention and Prohibition Program, dated 8/2020 showed: -The facility will promptly and thoroughly investigate injuries of unknown origin. -The investigation might include some of the following: --Relevant documentation. --The resident's medical records. --Interviews with residents, the physician, facility staff, witnesses, and persons making the allegation. --Reviews of events leading up to the alleged incident. -The Administrator will provide written report of the investigation and retain documentation. -Unexplained injuries are promptly and thoroughly investigated by the Director of Nursing/or designee. -The charge nurse on duty will complete an Incident and Accident Report and record the information in the resident's medical record, including documentation of relevant risk factors that predisposes the resident to the incident or injury. The nurse will discuss the situation with the physician. 1. Record review of the Resident #97's quarterly Minimum Data Set (MDS - an assessment tool used for care planning), dated 2/4/21, showed the resident: -Was moderately cognitively impaired. -Required supervision for locomotion (oversight, encouragement and/or cueing). -Used a wheelchair (WC) for mobility. Record review of the resident's 3/8/21 Progress Notes showed: -A nursing note written at 12:12 A.M., showing at the start of the shift the off-going nurse found the resident had a wound to the index finger of his/her left hand. The wound was covered and a call was placed to the on-call Nurse Practitioner (NP) and the resident's family member. Orders were obtained to send the resident to the ER for evaluation and treatment. The resident returned with a fractured finger and orders for Antibiotic Therapy (ABT) for an open wound. -A nursing note written at 3:48 A.M., showed the resident was found after the evening meal on 3/7/21 in his/her room. The resident appeared to have gotten his/her finger caught in the wheelchair while propelling to his/her room after supper. The wheelchair was inspected with no findings of anything out of order. Record review of the resident's medical records for his/her emergency room (ER) visit on 3/7/21 showed: -The resident's hospital face sheet showed he/she was admitted for evaluation and treatment on 3/7/21. -The Patient Visit Information, dated 3/7/21 at 9:41 P.M. showed: --The resident was seen for a closed fracture of the tuft (small fragments chipped off the bone edge) of the distal (situated away from the center of the body) phalanx, avulsion (separation of part or all) of nail plate, and avulsion (wound with pulled off or torn away tissue) of soft tissue. Record review of the resident's Incident Investigation, dated 3/8/21 showed: -An injury incident report showing: --The resident was found on 3/8/21 (the hospital medical report showed the resident went to the ER on [DATE]) after the evening meal in his/her wheelchair in his/her room. The resident's left index finger had a skin tear to the tip and the nail was coming off. Blood was on his/her wheelchair around the wheel. The resident said he/she got caught. The resident appeared to have gotten his/her finger caught in the wheelchair while propelling himself/herself after the dinner meal. The wheelchair was inspected with no findings of anything out of order. --The resident was oriented to self and had impaired memory. There were no predisposing environmental or situational factors contributing to the incident. -The resident was described as follows: --Severely cognitively impaired with restlessness and agitation, cognitive communication deficit, dementia, and anxiety. --Had behaviors of clenching up and grabbing the wheels of his/her wheelchair tightly. --The resident was unable to be interviewed due to cognition related to dementia. -CNA B's interview showed on 3/8/21 after dinner he/she was getting ready to assist the resident into bed when CNA B noticed blood on the resident's bed rail, wheelchair wheel and on the resident's left hand. CNA B reported the resident propelled himself/herself the evening of 3/8/21. The resident had a behavior when other residents walk past the resident of clenching up in reaction and grabbing the wheels of his/her wheelchair tightly while propelling, causing the wheelchair to stop and jerk. -There were no interventions related to preventing further injury mentioned in the investigation. -The investigation did not indicate if the resident's environment had been assessed for other possible causes of the injury. Record review of the resident's Comprehensive Care Plan, dated 2/12/21 showed: -A Skin Integrity Impairment Care Plan, showed an intervention, dated 3/8/21, Maintenance was to inspect the wheelchair to ensure no repairs were needed. -There were no interventions added to the resident's Physical Therapy and Restorative Aide (Certified Nursing Assistants (CNAs) with specialized training to help residents maintain physical, mental, and emotional well-being) care plan, dated 3/8/21; his/her Activities of Daily Living (ADL - feeding, grooming, transfers) Care Plan, initiated 5/24/17; or on any of the resident's other care plans related to the resident's supervision needs while sitting in or propelling himself/herself in his/her wheelchair. Record review of the facility's incident investigation for the resident's second finger injury, undated, showed: -An incident note showing four points: --The resident was noted on 3/26/21 to have a laceration to the third digit of the left hand. --The root cause was the resident was seen by staff chewing on his/her finger. --There was no documentation on the incident note of who wrote the four points (such as a signature or typed name). -There was no documentation included in the incident investigation that the resident's environment was investigated for other possible causes of the injury or documentation of who witnessed the resident chewing on his/her finger and there were no witness statements. -There was no documentation of the situational details related to the injury such as where the resident was when the injury was found, who else was in the environment at the time, whether or not the finger chewing was a new behavior, and whether or not the environment had been checked for other possible causes of the injury. --The left third digit was initially assessed and described on 4/2/21 as follows: The wound location was the third finger, caused by trauma, and measured 3.2 centimeters (cm) in length by 1.6 cm in width by 0.1 cm in depth. -None of the resident's existing care plans had interventions for immediate measures to prevent further injury or indicated the resident's level of supervision needs while using his/her wheelchair. Record review of the resident's nursing notes, dated 3/26/21 through 4/8/21 showed: -There was no documentation of the third digit injury on 3/26/21. -A note written on 3/29/21 at 2:36 P.M., showed the resident's third digit looked much like the second prior to the amputation. The note did not indicate the circumstances in which they discovered the injury. Observation in the dining room on 4/5/21 at 11:03 A.M., showed: -The resident was sitting at the dining room table with the second and third digits of his/her left hand bandaged. The second digit was short as if amputated. Certified Medication Technician (CMT) A was nearby and said one finger was caught in the resident's wheelchair. -Observation showed the resident's wheels had many thin metal spokes. The spokes of the resident's WC were not covered. Record review of the resident's PT treatment encounter notes dated 4/6/21 and 4/8/21 showed: -The resident was given visual cues for correct hand placement to promote WC mobility with the resident unable to follow, requiring maximum assistance for WC mobility. Record review of the resident's OT note, dated 4/8/21 showed spoke guards were placed bilaterally (both sides) on the WC wheels due to previous incidents of catching left fingers in the WC spokes. Observation and interview in the resident's room on 4/8/21 at 9:55 A.M., showed: -The resident was sitting in his/her room in his/her wheelchair facing away from the bedroom door leaning over the front and right side of the WC with his/her right hand about two or three inches from the WC spokes. -A few minutes later CMT A pivoted the resident's WC to face the bedroom door while the resident was still leaning over the front and right side of his/her chair with his/her right hand, within two or three inches of the spokes. After pivoting the chair to face the door, CMT A lifted the resident's right arm away from the spokes and placed it to where the WC arm would provide support while rolling the resident out of the room. -The resident was placed at the dining room table and was observed to repeatedly place his/her right hand on the right side WC spokes and to also touch the right side of the WC with his/her right hand between the front wheel and the right WC brake handle. Observation on 4/12/21 at 1:19 P.M., showed the resident resting quietly in bed with his/her eyes closed. The wheels were covered with a round piece of clear plastic exposing approximately ½ to 3/4 inch of WC spokes near the wheel rim and approximately 1 ½ inches of the hub of the wheel spokes. The plastic was attached to the WC wheel spokes in three places on each side to the WC. During a telephone interview on 4/7/21 at 12:01 P.M., the resident's legal representative said: -He/She was contacted by the facility a month ago and was told the resident had an accident in which the resident's index finger had been torn. The accident also tore up the resident's index finger nail. -He/She received a second call that there was damage to another finger. -He/She was told the facility thought the resident got his/her hand stuck in his/her wheelchair both times. During an interview on 4/7/21 at 12:32 P.M., LPN D said: It was his/her understanding that Maintenance and Occupational Therapy inspected the resident's wheelchair after the injuries and therapy evaluated his/her ability to safely use the wheelchair. During an interview on 4/7/21 at 12:45 P.M., CMT C said the resident tended to put his/her hands into the WC spokes. When being pushed in the wheelchair, the resident would put his/her hands down towards the wheels. From what was reported to him/her, nobody witnessed the injuries. During an interview on 4/7/21 at 2:15 P.M., CNA B said: -He/She discovered the resident's left index finger the day it was injured. -He/She had seen other residents push the resident in his/her WC. Staff would tell the resident to stop when they saw a resident push another resident's wheelchair. -He/She had not noticed anything sharp or hazardous in the resident's room. -The resident's chair was custom made and had thin metal spokes. Most of the residents' wheelchairs have thicker and fewer plastic spokes. During an interview on 4/7/21 at 2:18 P.M., CMT A said: -Someone in therapy brought the resident's third finger injury to his/her attention. -He/She had never noticed anything sharp or hazardous in the resident's room. -He/She had seen other residents push the resident while he/she was in his/her wheelchair. When that happened, the resident might have had his/her hands down around the spokes or would hold onto the spokes of his/her wheelchair. -Staff were to redirect the residents if they catch a resident pushing someone. During an interview on 4/8/21 at 10:20 A.M., the Maintenance Assistant said: -The wheelchair was examined to make sure there were no sharp areas and it functioned properly and safety after the second finger injury. During a telephone interview on 4/8/21 at 12:11 P.M., the resident's physician said: -Management should document and investigate the accident leading to the injury of the resident's finger. -The investigation of injuries of unknown origin should be thorough so that a cause of the accident could be determined and measures could be put in place to prevent further injury. -Management should follow all Centers for Medicare and Medicaid Services guidelines for investigating injuries. During an interview on 4/12/21 at 2:15 P.M., CMT A said: -The charge nurse asked him/her what happened to the resident's third finger. He/She was not asked to write a statement. -Staff were not told what they should do to prevent another injury. -He/She was not aware of any measures immediately put into place to prevent future injuries following either of the two accidents. The facility staff did recently put plastic disks over the resident's WC spokes. During an interview on 4/13/21 at 1:36 P.M., the Therapy Director said: -Staff talked about the index finger injury in the morning meeting on 3/8/21 and discussed it in the Risk meeting on 3/11/21. The therapy department staff were told by the nursing staff they thought the resident's finger got caught in the WC. -Therapy communicated with a wheelchair company to get the resident new wheels because staff didn't know if the resident was injured on the spokes of the wheels. The plastic spoke cover was installed on 4/8/21. He/She communicated back and forth with the wheelchair company and ordered the new wheels over the phone. -He/She learned about the injury to the resident's third finger in the first morning meeting following the accident. Communication with the wheelchair company occurred before the injury to the resident's second finger. Therapy checked out the resident's WC for safety after the injury to the second finger. It was discussed in the morning meetings that Maintenance would also check out the resident's WC after the pointer finger injury. -There had been no adjustments or additions to the resident's wheelchair prior to the arm rest bolster being added and the wheelchair spoke covers being installed on 4/8/21. The only adaptation to resident's wheelchair had been the bolster and spoke covers. -On 4/9/21 the resident's status changed to hospice services (care given at the end of life). The resident had been on Skilled services when the WC wheels were ordered. Medicaid would not cover the new wheels because the resident was now receiving hospice services and Medicaid services ended on 4/8/21. He/She needed to talk with hospice to see if they would pay for the new wheels or if they could provide other options. -The resident had a custom fit chair. During an interview on 4/14/21 at 11:05 A.M., MDS Coordinator B said: -When there were injuries, the charge nurse was responsible for putting in an immediate intervention. -The injury would be discussed in clinical Interdisciplinary (IDT) meetings for a more permanent intervention. -The IDT Meetings included the Administrator, the Director of Nursing (DON), both ADONs, both MDS Coordinators, Social Services, and the Therapy Director or designee. During an interview on 4/14/21 at 12:37 P.M., LPN B said: -He/She was the resident's nurse both times his/her finger was injured. -The CNA reported the index finger injury. It appeared the resident could have gotten his/her index finger caught in his/her wheelchair. The resident kept putting his/her hand near the spokes before the accident to the index finger. -He/She was not aware of any interventions put in place to prevent further injury. -There were no interventions put in place immediately following the third digit injury to prevent future injury. During an interview on 4/14/21 at 1:35 P.M., the DON, ADON B, and the Corporate Nurse Consultant were interviewed and said the following: -If there was a significant injury such as one resulting in a broken bone, the injury should be charted by the charge nurse electronically under Risk Management. -The charge nurse or ADON should put an intervention in place immediately. The injury should be discussed in the next morning meeting to ensure a more permanent intervention was put in place. Management would review and discuss the injury in their weekly Clients at Risk (CAR) clinical meeting. -An investigation should be started after an unwitnessed injury and used to develop interventions. During an interview on 4/29/21 at 7:16 P.M., the Medical Director said: -He/She would have expected staff to thoroughly investigate any injury, especially one that required a hospital visit. -He/She would have expected the facility to interview staff and identify any possible witnesses to the injury. -He/She would have expected the facility staff to develop and put into place appropriate interventions to prevent additional injuries immediately. NOTE: At the time of the survey, the violation was determined to be at the immediate jeopardy level J. Based on observation, interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to remove the IJ violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the D level.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Record review of Resident #502's admission Record dated 4/7/21 showed the resident was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included Atrial Fibrillation (A-fib the upper two chambers of the heart beat quickly and irregularly) and Hypertension (HTN High Blood Pressure). Record review of the resident's admission MDS, dated [DATE] showed: -The resident was admitted on [DATE]. -Had moderately impaired cognition. -Had a diagnosis of A-fib and HTN. Record review of the resident's Order Summary Report dated January 2021 showed: -Losartan Potassium Tablet 50 mg, give one tablet in the morning for HTN, start 12/1/20. --Parameters: Hold for Systolic Blood Pressure (SBP-measures the pressure in your arteries when the heart beats) less than 110, Diastolic Blood Pressure (DBP-measure the pressure in your arteries when your heart rests between beats) less than 60 (normal blood pressure is SBP 120 over DBP 80) or Pulse (heart rate (HR) heart beats per minute normal heart rate at rest is between 60-100) less than 60 start 12/1/20. -Metoprolol Tartrate Tablet 50 mg, give one tablet two times a day for HTN, start 12/1/20. --Parameters: Hold for SBP less than 110, DBP less than 60 or HR less than 60, start 12/1/20. Record review of the resident's MAR dated January 2021 showed: -Losartan Potassium Tablet 50 mg, give one tablet in the morning for HTN, start 12/1/20. --Parameters: Hold for SBP less than 110, DBP less than 60 or HR less than 60, start 12/1/20. ---The resident's Blood Pressure (BP) and HR were not documented and medication administered 18 out of 31 opportunities. ---The resident received the medication on 1/31/21 when his/her BP of 96/75 was outside of the parameters and the medication was administered one opportunity out of 31 opportunities. -Metoprolol Tartrate Tablet 50 mg, give one tablet two times a day for HTN, start 12/1/20. --Parameters: Hold for SBP less than 110, DBP less than 60 or HR less than 60, start 12/1/20. ---The resident's BP and HR were not documented and medication administered 17 out of 62 opportunities. ---The resident received medication when BP was outside of the parameters three out of 62 opportunities. Record review of the resident's Administration Note dated 1/14/2, showed the resident did not receive his/her 8:00 A.M. Metoprolol Tartrate Tablet 50 mg due to the medication was unavailable and was on order from the pharmacy. Record review of the resident's Quarterly MDS dated [DATE] showed he/she: -Was admitted on [DATE]. -Had moderately impaired cognition, sometimes understood others and made self-understood. -Had Debility Cardio-respiratory Conditions (involves multiple systems and disease). -Had HTN. Record review of the resident's Order Summary Report dated February 2021 showed: -Losartan Potassium Tablet 50 mg, give one tablet in the morning for HTN, start 12/1/20. --Parameters: Hold for SBP less than 110, DBP less than 60 or HR less than 60 start 12/1/20. -Metoprolol Tartrate Tablet 50 mg, give one tablet two times a day for HTN, start 12/1/20. --Parameters: Hold for SBP less than 110, DBP less than 60 or HR less than 60, start 12/1/20. Record review of the resident's MAR dated February 2021 showed: -Losartan Potassium Tablet 50 mg, give one tablet in the morning for HTN, start 12/1/20. --Parameters: Hold for SBP less than 110, DBP less than 60 or HR less than 60, start 12/1/20. ---The resident's BP and HR were not documented and medication administered 15 out of 28 opportunities. ---The resident received medication on 2/13/21 when BP of 97/58 was outside of the parameters one out of 28 opportunities. -Metoprolol Tartrate Tablet 50 mg, give one tablet two times a day for HTN, start 12/1/20. --Parameters: Hold for SBP less than 110, DBP less than 60 or HR less than 60, start 12/1/20. ---The resident's BP and HR were not documented and medication administered 21 out of 56 opportunities. ---The resident received medication when BP was outside of the parameters two out of 56 opportunities. Record review of the resident's Care Plan dated 2/8/21 showed: -Avoid taking the blood pressure reading after physical activity or emotional distress. -Give anti-hypertensive medications as ordered. -Monitor for side effects such as orthostatic hypotension (a systolic blood pressure decrease of at least 20 millimeters of Mercury (mm Hg) or a diastolic blood pressure decrease of at least 10 mm Hg within three minutes of standing) and increased heart rate and effectiveness. -Monitor for and document any edema (swelling), notify the physician. -Monitor/document/report as needed (PRN) any signs/symptoms of malignant hypertension (extremely high blood pressure that develops rapidly and causes some type of organ damage), headache, visual problems, confusion, disorientation, lethargy, nausea and vomiting, irritability, seizure activity, or difficulty breathing. Record review of the resident's Order Summary Report dated March 2021 showed: -Losartan Potassium Tablet 50 mg, give one tablet in the morning for HTN, start 12/1/20. --Parameters: Hold for SBP less than 110, DBP less than 60 or HR less than 60 start 12/1/20. -Metoprolol Tartrate Tablet 50 mg, give one tablet two times a day for HTN, start 12/1/20. --Parameters: Hold for SBP less than 110, DBP less than 60 or HR less than 60, start 12/1/20. Record review of the resident's MAR dated March 2021 showed: -Losartan Potassium Tablet 50 mg, give one tablet in the morning for HTN, start 12/1/20. --Parameters: Hold for SBP less than 110, DBP less than 60 or HR less than 60, start 12/1/20. ---The resident's BP and HR were not documented and medication administered 1 out of 1 opportunities. -Metoprolol Tartrate Tablet 50 mg, give one tablet two times a day for HTN, start 12/1/20. --Parameters: Hold for SBP less than 110, DBP less than 60 or HR less than 60, start 12/1/20. ---The resident's BP and HR were not documented and medication administered 1 out of 1 opportunities. During an interview on 4/7/21 at 12:13 P.M., the Nurse Practitioner said: -He/she expected the nurses and CMT to take the resident's blood pressure and pulse before giving the medications. -The nurse or CMT would not know it was safe to give the medication if he/she didn't take the resident's blood pressure and pulse. -Medication should be reordered when the resident had 10 pills left. -No resident should run out of any medication because they were not reordered in time. -He/she should be notified if a medication was not given/held. During an interview on 4/8/21 at 1:30 P.M., ADON B said: -The ADON and DON were responsible to audit to ensure medications were administered per physician orders. -The charge nurse would check the orders for parameters such as blood pressure and pulse, and would contact the physician to verily the parameters. -The charge nurse was responsible to ensure parameters were followed and the resident's physician was notified of any instance the parameters were outside of range. -He/she takes the blood pressure and pulse before administering the medication and documents the blood pressure and pulse on the MAR. -If the blood pressure or pulse was below the parameters, the CMT was to hold the medication and notify the charge nurse. -He/she would not give blood pressure medication if the blood pressure was out of parameters. -He/she was not aware of bad Internet connections on the locked unit. -If the CMT was not entering the blood pressure and pulse into the MAR, the CMT needed training. During an interview on 4/8/21 at 1:45 P.M., CMT A said: -He/she would check the blood pressure first then administer the medication. -He/she would check the MAR to see what the blood pressure parameters were. -He/she would let the nurse know if the blood pressure medication was held due to being out of parameters. -He/she would write the blood pressure down in a note book because the Internet sometimes did not work on the locked unit. -He/She would later enter the information into the resident's electronic medical record or have the nurse enter the information into the resident's electronic medical record. -He/She did not tell anyone of the problem with not being able to document blood pressures in the electronic medical records due to having Internet issues, because he/she thought the DON and administrator already knew about it. -He/She could not explain how he/she was able to document the resident's medication administration in the resident's electronic medical record, but not be able to document the resident's blood pressure in the resident's electronic medical record. -If medication was back ordered he/she would call the pharmacy to check and see where the medication was located and then let the charge nurse know. During an interview on 4/8/21 at 2:00 P.M., LPN C said: -He/she checked the resident's blood pressure and pulse and if out of range he/she would hold the blood pressure medication. -He/she documented on the MAR if the medication was held. -If a resident was low or ran out of a medication he/she would call the pharmacy to make sure they have the order to fill. -He/she would check the E-kit and pull the medication from the E-kit to administer. During an interview on 4/8/21 at 2:50 P.M., CMT B said: -He/she always took the resident's blood pressure and pulse before he/she administered blood pressure medications. -He/she would hold the medication if to low and chart why the medication was held in a progress note. -He/she would notify the charge nurse of the low blood pressure or pulse. -The blood pressure and pulse were documented on the MAR. -He/she looked in the medication cart and medication room to see if the resident's medication has been delivered from the pharmacy. -He/she re-ordered the medications when there was five to seven days left. 3. Record review of Resident #512's admission Record showed the resident was admitted to the facility on [DATE] and re-admitted on [DATE] with a diagnosis of Parkinson's Disease (is a progressive nervous system disorder that affects movement and causes tremors, stiffness or slowing of movement). Record review of the resident Order Summary Report dated November 2020 showed: -Sinement (Carbidopa-Levodopa) (a prescription medicine used to treat the symptoms of Parkinson's Disease ) tablet 25-100 mg, give one tablet three times a day for Parkinson's Disease, start 11/28/20. -Ropinirole HCl (a medication used to treat Parkinson's disease ) tablet 3 mg, give one tablet three times a day for Parkinson's Disease, start 11/28/20. Record review of the resident's Order Summary Report dated December 2020 showed: -Sinement (Carbidopa-Levodopa) tablet 25-100 mg, give one tablet three times a day for Parkinson's Disease, start 11/28/20. -Ropinirole HCl tablet 3 mg, give one tablet three times a day for Parkinson's Disease, start 11/28/20. -No new orders for Carbidopa-Levodopa Tablet 25-250 mg four times a day for 30 days per the resident's neurologist on 12/30/20. -No new order for Ropinirole HCl Tablet 3 mg four times a day per the resident's neurologist on 12/30/20. Record review of the resident's Neurology visit dated 12/30/20 showed: -Parkinson's disease still significantly under treated. -Stop Carbidopa-Levodopa tablet 25-100 mg three times a day (tripled since mid-December). -Start Carbidopa-Levodopa tablet 25-250 mg four times a day for 30 days. -A physicians order to increase Ropinirole HCl tablet 3 mg to four times a day. Record review of the resident's Medication Administration Record (MAR) dated December 2020 showed: -Carbidopa-Levodopa Tablet 25-100 mg, give one tablet three times a day for Parkinson's Disease, start 11/28/20, missed five doses out of 90 opportunities. --NOTE: the resident's neurologist increased the resident's Carbidopa-Levodopa to 25/250 mg four times daily on 12/30/20. No documentation the facility staff transcribed or administered the correct dose on 12/30/20 or 12/31/20. The resident did not get the correct dose eight out of eight opportunities. -Ropinirole HCl Tablet 3 mg, give one tablet three times a day for Parkinson's Disease, start 11/28/20, missed four doses out of 90 opportunities. --NOTE: The resident's neurologist increased the resident's Ropinirole to 3 mg four times daily on 12/30/20. No documentation the facility staff transcribed or administered the correct dose on 12/30/20 or 12/31/20. The resident did not get the correct dose two out of two opportunities. Record review of the resident's Care Plan last reviewed 12/15/20 showed: -Resident was re-admitted to the facility on [DATE]. -At risk for altered comfort related to Parkinson's Disease. -Administer medications as ordered. -Observe and report changes in usual routine, sleep patterns, decrease in functional abilities, decrease in range of motion, withdrawal or resistance to care. Record review of the resident's Neurology visit dated 1/25/21 showed: -Current Medications: --Carbidopa-Levodopa 25/250 mg four times a day. ---Note: Facility MAR reflected he/she was only getting Carbidopa-Levodopa 25-100 mg three times a day. --Ropinirole HCl Tablet 3 mg four times a day. ---Note: Facility MAR reflected he/she was only getting Ropinirole HCl Tablet 3 mg three times a day. -Assessment: --Titer (a way to measure the amount of medication in the bloodstream) for Carbidopa-Levodopa needed to get back to pre-op level before he/she can program Deep Brain Stimulator (a device implanted to stimulate targeted regions of the brain with electrical impulses generated by a neurostimulator) further; frustrating inability for facility to follow his/her orders. -Treatment: --A physician's order to increase Carbidopa-Levodopa Tablet 25-100 mg four times today (1/25/21), then increase to 1.5 pills four times a day starting on 1/28/21, then increase to 2 pills four times a day starting on 1/31/21, then increase to 2.5 pills four times a day starting on 2/4/21. Record review of the resident's Order Summary Report dated January 2021 showed: -Carbidopa-Levodopa Tablet 25-100 mg, give one tablet three times a day for Parkinson's Disease, start 11/28/20. --NOTE: The resident's neurologist increased the resident's Carbidopa-Levodopa to 25/250 mg four times daily on 12/30/20. -Ropinirole HCl Tablet 3 mg, give one tablet three times a day for Parkinson's Disease, start 11/28/20. --NOTE: The resident's neurologist increased the resident's Ropinirole to 3 mg four times daily on 12/30/20. -Carbidopa-Levodopa Tablet 25-100 mg, give one tablet four times a day for Parkinson's Disease, start 1/25/21 End 1/25/21. -Carbidopa-Levodopa Tablet 25-100 mg, give 1.5 tablet four times a day for Parkinson's Disease, start 1/26/21 End 1/28/21. -Carbidopa-Levodopa Tablet 25-100 mg, give two tablet four times a day for Parkinson's Disease, start 1/29/21 End 1/31/21. -Carbidopa-Levodopa Tablet 25-100 mg, give 2.5 tablet four times a day for Parkinson's Disease, start 2/1/21 End 2/4/21. Record review of the resident's MAR dated January 2020 showed: -Carbidopa-Levodopa Tablet 25-100 mg, give one tablet three times a day for Parkinson's Disease, start 11/28/20 discontinued 1/25/21. --NOTE: Carbidopa-Levodpa was increased to 25/250 mg four times daily by the resident's neurologist on 12/30/20. No documentation the facility staff transcribed or administered the correct dose 96 out of 96 opportunities. -Carbidopa-Levodopa Tablet 25-100 mg, give one tablet four times a day for Parkinson's Disease, start 1/25/21 End 1/25/21. -Carbidopa-Levodopa Tablet 25-100 mg, give 1.5 tablet four times a day for Parkinson's Disease, start 1/26/21 End 1/28/21, missed four doses out of nine opportunities. --Note: No progress note to say why the medication was missed. The resident was discharged from the facility on 1/27/21. -Ropinirole HCI Tablet 3 mg, give one tablet three times a day for Parkinson's Disease, start 11/28/20. --Note: Ropinirole HCl Tablet 3 mg was not increased to four times a day as ordered by Neurologist on 12/30/20. No documentaion the facility staff transcribed or administered the correct dose 27 out of 27 opportunities. During an interview on 4/8/21 at 1:30 P.M. with the DON and ADON B, ADON B said: -The ADON and DON were responsible to audit the residents' orders to ensure they were transcribed and administered accurately. -Whoever went with the resident to the appointment would give the paperwork to the charge nurse. -The charge nurse would take off the orders and transcribe the orders to the resident's electronic medical record. -The physician was notified of the orders and should have been documented by staff to the resident's progress notes. During an interview on 4/8/21 at 2:00 P.M., LPN C said: -If he/she took a resident to an appointment, he/she would give the paperwork to the charge nurse. -The charge nurse would take off the orders, document the orders in the resident's electronic medical record, then notify the resident's physician of the new orders. -Staff should document physician notification in the resident's progress notes. -The ADON and DON were responsible to audit to ensure all orders were transcribed and administered accurately. During an interview on 4/8/21 at 3:10 P.M., LPN A said: -When a resident returned from an appointment he/she would go through the paperwork. -He/she would take off any orders and put the order(s) into the computer system. -He/she would notify the physician to verify the orders. -The DON and ADON were responsible to audit to ensure all orders were transcribed and administered accurately. NOTE: At the time of the survey, the violation was determined to be at the immediate jeopardy level J. Based on observation, interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to remove the IJ violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the D level. MO00181055 & MO00182466 Based on observation, interview, and record review, the facility failed to ensure a resident who was severely cognitively impaired received Antibiotic Therapy (ABT) as prescribed for an injury to his/her index (second) finger. The resident's index finger became infected with two infections resulting in the need to partially amputate the resident's index finger. Following the amputation, the resident was placed on two antibiotic medications and the facility failed to ensure the resident received the ABT as prescribed or to contact the physician when the resident refused the medication. This affected one resident (Resident #97) out of 22 sampled residents. In addition, the facility failed to ensure two sampled closed record residents (Resident #502 & Resident #512) out of 16 sampled closed record residents, were free from significant medication errors by failing to administer medications as prescribed by the residents' physician. The facility census was 95 residents. The Administrator was notified on 5/27/21 at 12:57 P.M. of an Immediate Jeopardy (IJ) which began on 4/5/21. The IJ was removed on 4/14/21 as confirmed by surveyor onsite verification. Record review of the facility's Administration Procedures for All Medications policy, undated, showed: -Administer medications in a safe and effective manner. -Prior to removing the medication package or container from the medication cart, check the Medication Administration Record (MAR) for the order. -Check the label against the order on the MAR. -If the resident refuses the medication, document the refusal on the MAR and research the reason for the refusal. -Notify the physician for persistent refusals. -Check for vital signs, other tests to be done during/prior to medication administration. -Obtain and record any vital signs or other monitoring parameters orders or deemed necessary prior to medication administration. -Notify the physician if medication was held for pulse, blood pressure, low or high blood sugar, or other abnormal test results, vital signs, resulting in medication being held. Record review of the facility Physician Orders Policy revised June 2020 showed: -This will ensure that all physician orders are complete and accurate. -The Medical Records Department will verify that physician orders are complete, accurate and clarified as necessary. -A licensed nurse will transcribe orders with date, time and signature of the person receiving the order. -Licensed nurse receiving the order will be responsible for documenting and implementing the orders. -Medication/treatment orders will be transcribed onto the appropriate resident administration record. -Orders pertaining to other health care disciplines will be transcribed onto the appropriate communication system for that discipline. -Documentation pertaining to physician orders will be maintained in the residents' medical record. -Current month's administration records will be maintained in the Medication Administration Record (MAR)/Treatment Administration Record (TAR). 1. Record review of Resident #97's Face Sheet showed the resident was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of: -Unspecified Dementia (a condition in which a person has an impaired ability to remember, think, or make decisions that is severe enough to interfere with everyday activities) without Behavioral Disturbance. -Fracture of Unspecified Phalanx (bone) of Left Index Finger, Subsequent Encounter with Routine Healing. -Cognitive Communication Deficit (difficulty communicating related to cognitive issues). -Partial Traumatic Metacarpophalangeal (joint closest to the hand rather than the nail) Amputation of Left Index Finger. -Cellulitis (a potentially serious bacterial skin infection which can spread rapidly) of Left Finger . -Unspecified Open Wound of Unspecified Finger with Damage to Nail. Record review of the resident's 3/8/21 Progress Notes showed at the start of the shift the off-going nurse found the resident had a wound to the index finger of his/her left hand. The wound was covered and a call was placed to the on-call Nurse Practitioner (NP) and the resident's family member. Orders were obtained to send the resident to the emergency room (ER) for evaluation and treatment. The resident returned with a fractured finger and orders for (ABT) for an open wound. The resident was to get Cephalexin (generic for Keflex, an antibiotic) 500 milligrams (mg) twice daily for 14 days. Record review of the resident's medical records for his/her ER visit on 3/7/21 showed: -The resident's hospital face sheet showed he/she was admitted for evaluation and treatment on 3/7/21. -The Patient Visit Information, dated 3/7/21 at 9:41 P.M. showed: --The resident was seen for a closed fracture of the tuft (small fragments chipped off the bone edge) of the distal (situated away from the center of the body) phalanx, avulsion (separation of part or all) of nail plate, and avulsion (wound with pulled off or torn away tissue) of soft tissue. --The resident was to take the prescribed antibiotic Cephalexin, 500 mg capsule orally twice daily for 14 days. Record review of the resident's Physician Order Sheet (POS), dated 3/2021 showed the following orders: -Cephalexin, 500 mg tablet two times daily for broken finger, left index finger starting 3/8/21. Record review of the resident's Treatment Administration Record (TAR) for March, 2021 showed orders for: -Cephalexin, 500 mg tablet two times daily for broken left index finger starting 3/8/21. Documentation for this medication showed: --On 3/8/21 for the 8:00 A.M. administration a 7 was indicated on the TAR. The chart key code showed code showed 7 meant the resident was sleeping. --Spaces for documenting the 3/10/21 morning and afternoon doses of Cephalexin and for documenting the morning dose of Cephalexin on 3/11/21 were left blank. --Documentation showed the resident received this medication five out of nine opportunities. --Staff documented they gave the 4:00 P.M. dose of Cephalexin on 3/13/21 even though a 6 was documented the morning of 3/13/21. The key code for 6 indicated the resident was in the hospital. ---NOTE: Further record review showed the resident was hospitalized on [DATE] and returned to the facility on 3/17/21. Record review of the resident's nursing notes for 3/8/21 through 3/13/21 showed: -No documentation by the facility staff why the resident's Cephalexin doses on 3/8/21, 3/10/21, and 3/11/21 were left blank or why staff had indicated on the TAR the afternoon of 3/13/21 that the resident was administered Cephalexin when record review showed the resident was in the hospital. Record review of the resident's hospital records, dated 3/12/21 through 3/17/21 showed: -The hospital admission History and Physical showed the resident presented to the ER because of a red inflamed left index finger with an avulsion of the left index nail plate and soft tissue avulsion of the pad of the finger. The pad of the finger was blackish brown, concerning of necrosis (dead tissue). The resident was discharged from another hospital on 3/7/21 with orders for Keflex, 500 mg twice daily, but the antibiotic was not given. The left second finger gradually became more erythematous (reddened), painful and swollen. The resident was sent to be seen by the hand surgeon. -The resident was given a diagnosis of cellulitis of the left second finger and received intravenous (administered through the veins) ABT. Magnetic Resonance Imaging (MRI - device that uses strong magnetic fields and radio waves to scan the body or body parts and produce images) was being considered to rule out osteomyelitis (a bacterial or fungal infection that requires antimicrobial (kills micro-organisms) treatment and often surgery). -The resident, who is severely demented, presented to the ER due to worsening finger infection after fracturing it in his/her wheelchair (WC) a few days ago. After the initial injury he/she presented to another hospital ER where he/she was diagnosed with a fracture and prescribed Keflex. Per report the nursing home did not receive this medication and was not giving the resident his/her antibiotic. A large portion of overlying skin around the nail bed was lifted and dangling. The pulp of the finger was hyper-pigmented and had an open wound surrounding the entire nail bed that had purulent (thick yellow, green or brown colored pus) and sanguineous (thin, pale red or pink) drainage. -An operative report, dated 3/14/21 showed: --The resident's injury involved a partial amputation of the tip of the finger. He/She subsequently had increasing redness and drainage from the finger. The patient (resident) presented with a significantly erythematous finger with quite a bit of swelling. He/She seeks revision of the amputation and drainage of any abscess. --The soft tissue of the second digit was amputated and a significant amount of purulence was noted, including the area of the bone. The tissues and bone were consistent with osteomyelitis. Cultures were obtained. Increasing amounts of purulence from the dorsal aspect (back portion) of the finger was noted. As much purulence (a milky or thick green, brown, yellow or white colored drainage with a distinct odor, indicative of infection) material was expressed as possible which extended to about the Proximal Interphalangeal (PIP - second joint from the nail) joint. The bone was quite nauseous. The wound was debrided (a procedure in which damaged tissue or foreign objects are removed from a wound) back to healthy-looking bone, taking the amputation site into the mid area of the middle phalanx. Then the wound was thoroughly irrigated (a process where a steady flow of solution is used across an open wound surface to hydrate and remove debris). The wound was sutured and dressed. -A Discharge summary, dated [DATE] showed: -The resident was admitted for inpatient service for management of finger cellulitis and osteomyelitis. -He/She was treated with intravenous antibiotic therapy and was ordered six more days of oral antibiotics and follow up with the physician in plastic surgery in two weeks. -Discharge orders included Cephalexin, 250 mg every eight hours for six days and Doxycycline Hyclate (an antibiotic used to treat bacterial infection), 100 mg, twice daily for six days. Record review of the resident's nurses' notes, dated 3/17/21 through 3/19/21 showed: -There was no nursing note on 3/17/21 showing the resident had returned to the facility on 3/17/21. -On 3/19/21 there was a late entry skin wound note showing the nurse had assessed the resident's left index finger and confirmed the resident had a partial amputation to the left index finger. The area had three stitches and had light serosanguineous drainage (clear, pale red or pink colored drainage). The area was closed and intact with no signs of infection such as odorous drainage, redness or swelling. Record review of the resident's March, 2021 POS showed orders for: -Cephalexin tablet, 250 mg. Give one tablet by mouth four times a day for infection of left hand for six days starting 3/17/21. -Doxycycline Hyclate, 100 mg. Give one tablet by mouth two times a day for infection for six days starting 3/17/21. Record review of the resident's MAR for 3/2021 showed: -Orders for Cephalexin, 250 mg. Give one tablet by mouth four times a day for infection of left hand for six days starting 3/17/21. Documentation on the MAR showed: --Blank spaces on 3/17/21 for medication administration times at 4:00 P.M. and 10:00 P.M. --The resident refused the medication on 3/20/21 at 8:00 A.M. --The spaces to document medication administration were left blank on 3/20/21 at 10:00 P.M. and on 3/21/21 at 4:00 P.M. and 10:00 P.M. --On 3/22/21 MAR documentation showed the resident refused the medication at 4:00 P.M. and 10:00 P.M. --The MAR was left blank for the 3/23/21 12:00 P.M. medication administration. --The resident did not receive nine out of 24 opportunities for the ABT, Cephalexin 250 mg. -Orders for Doxycycline Hyclate, 100 mg. Give one tablet by mouth two times a day for infection for six days. Documentation on the MAR showed: --A blank space on 3/17/21 for the 5:00 P.M. medication administration time. --The resident refused the medication on 3/20/21 at 8:00 A.M. --The MAR space was left blank on 3/21/21 for the 5:00 P.M. administration time. --On 3/22/21 the resident refused the medication at the 5:00 P.M. medication time. --The resident received eight out of 12 doses of Doxycycline Hyclate 100 mg, and missed four out of 12 opportunities for the ABT. Record review of the resident's nursing notes for 3/17/21 through 3/23/21 showed there was no documentation explaining the MAR blanks for the two ABT medications or that the physician had been notified when the resident refused the medications. Observation of wound care in the resident's room on 4/7/21 at 12:32 P.M. showed: -The resident's bandage was off his/her second finger. The finger appeared to have been amputated between the distal (joint closest the nail) and proximal (joint closets the distal joint) joints of the left index finger. During an interview on 4/7/21 at 12:01 P.M., the resident's legal representative said: -He/She was contacted by the facility a month ago and was told the resident's had an accident in which the resident's index finger had been torn. The accident also tore up the resident's index finger [NAME][TRUNCATED