**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on complaint investigation, staff interviews, clinical record review, and facility documentation, the facility staff failed to provide the necessary care and treatment for 5 out of 44 residents (Resident #84, #64, #79, #56, and #71) in the survey sample. For Resident #84, the facility staff failed to follow the Nurse Practitioner (NP) orders to provide parenteral Intravenous (IV) fluids as ordered on 02/04/22 at approximately 10:30 a.m., to start Sodium Chloride Solution 0.9%, use 50 ml/hour intravenously (IV) x 24 hours for 2 liters for hydration which was never initiated for a resident who had a decline in oral fluids, decrease appetite and having loose stools. Resident #84 remained in the facility for 28 hours after the order was given on 02/04/22 to start IV fluids. On 02/05/22 at approximately 2:56 p.m., Resident #84 was observed in respiratory distress, unable to obtain blood pressure, and using accessory muscles for breathing. Resident #84 was transferred via 911 (emergent) to the local hospital and admitted on [DATE] with a diagnosis of severe metabolic acidosis, severe dehydration, hypothermia at 89.4 degrees, Urinary Tract Infection (UTI), and Acute Kidney Injury (suspect pre-renal due to dehydration), which constituted harm for Resident #84. For Residents #64 and #79, the facility staff failed to obtain blood sugars as ordered by the physician. For Resident #56, the facility staff failed to recognize, assess and intervene on an acute change in condition for a resident presenting with a four-pound weight gain in a week, increased edema to the resident's right leg, left arm, and face, and episodes of shortness of breath without flowing oxygen. For Resident #71, the facility staff failed to follow physician orders for the care of an IV PICC line. The findings included: 1. Resident #84 was admitted to the nursing facility on 11/10/21. The resident was discharged to the local hospital on [DATE] and did not return to the nursing facility. Diagnosis for Resident #84 included but not limited to Chronic Kidney Disease (not on dialysis) and Type II Diabetes Mellitus. The most recent Minimum Data Set (MDS) was an admission assessment with an Assessment Reference Date (ARD) of 11/17/21 coded the resident on the Brief Interview for Mental Status (BIMS) an 11 of 15 indicating moderate cognitive impairment. Resident #84 was coded total dependence of one with toilet use and bathing, extensive assistance of one with bed mobility and transfer, limited assistance of one with dressing and personal hygiene, and supervision with one assist with eating Activities of Daily Living (ADL). Under section H - (Bladder and Bowel) was coded for always incontinent of bladder and bowel. The care plan created on 11/17/21 and a revision date of 01/11/22 identified Resident #84 with impaired cognitive function or impaired thought process related to an altered mental status. The goal set for the resident by the staff was that the resident will improve their current level of cognitive function through the next review on 03/09/22. One of the interventions/approaches the staff would use to accomplish this goal is to administer medications as ordered. Monitor/document for side effects and effectiveness. On 02/04/22, the Nurse Practitioner's (NP) progress revealed the following information: Resident #84 is being seen today for loose stools, decrease intake, and COVID-19. Resident #84 reports having decreased appetite and increased thirst. Under diagnosis, assessment and plan it included but was not limited to start Sodium Chloride Solution at 50 ml/hour x 2 liters. The review of Resident #84's Medication Administration Record (MAR) revealed the following order: Sodium Chloride Solution 0.9%, use 50 ml/hour intravenously (IV) x 24 hours for 2 liters for hydration or clysis for 3 days, the order remains in pending confirmation. An interview was conducted with License Practical Nurse (LPN) #6 on 03/14/22 at approximately 4:12 p.m. When asked, what does it mean with an order that reads pending confirmation? The LPN stated, that the order was put in Point Click Care (PCC) but the nurse never confirmed the order, so the order was never initiated. A review of Resident #84's clinical record revealed the following documentation entered on 02/05/22 at approximately 2:56 p.m., by LPN #3. Resident #84 noted having respiratory distress, being unable to obtain blood pressure, oxygen saturation of 94% on room air, and heart rate of 102 while using accessory muscles for breathing. A new order was obtained to send to the ER for evaluation and treatment. A phone interview was conducted with Nurse Practitioner (NP) on 03/15/22 at approximately 2:08 p.m. The NP stated she assessed Resident #84 on 02/04/22 due to the staff reporting the resident was having loose stools and not eating. She said that during her discussion with the resident, he voiced to me that he was really thirsty and has no appetite. The NP said IV fluids were ordered and started on 02/04/22. The NP stated, IV fluids were ordered for hydration because Resident #84 was having loose stools and not eating She said the BMP was not ordered as STAT (now order) because I needed time for the IV fluids to hydrate the resident to help determine what further treatment was needed. The NP stated, Unfortunately, his IV fluids were never started and I was never notified. An interview was conducted with LPN#3 on 03/14/22 at approximately 1:46 p.m. The LPN was assigned to provide care and services to Resident #84 on 02/04/22 and 02/05/22 (7-3 shift), the day Resident #84 was evaluated by the NP with new orders to start IV fluids. The LPN said she remembered Resident #84 was not eating or drinking. She said the NP came in and saw Resident #84 and wrote a bunch of new orders but I was never informed that an order to start IV fluids. On 03/15/22 at approximately 9:44 a.m., a phone interview was conducted with LPN #5. The LPN was assigned to provide care and services to Resident #84 on 02/04/22 (11-7 shift). The LPN stated, I don't recall the nurse giving a report that Resident #84 had an order to start an IV to administer IV fluids. On 03/16/22 at approximately 2:53 p.m., an interview was conducted with the Regional Director of Clinical Services. The Regional Director said the nurse(s) should have activated the order in PCC and the IV fluids should have been started as ordered by the (NP). He stated, If the nurse assigned was not able to start the IV, there is always someone in house that could have started the IV. He stated clysis could have been used to hydrate the resident. A phone interview was conducted with the Medical Director on 03/17/22 at approximately 5:11 p.m., when asked if the staff should have started the fluids IV or via clysis, he replied, Absolutely, not receiving the IV fluids could have contributed to his dehydration as well as Acute Renal Failure (AFR). The Medical Director stated, The NP or I should have been notified that Resident #84's IV fluids were never started. A review of the hospital records revealed the following: Resident #84 presented in the emergency room (ER) on 02/05/22 from (name of nursing facility) for further evaluation due to lethargy. The 911 transport revealed the following: Resident serum glucose was 14. The Emergency Medical Service (EMS) placed an IV, gave glucagon and D10 and his glucose increased to 135. The ER records indicated Resident #84's rectal temperature at 89.4 degrees F (hypothermia - low body temperature) and placed on Bair Hugger for low rectal temperature. The resident's blood pressure was 89/40 (normal = 120/80). He was found to be in severe metabolic acidosis and septic shock. The urinalysis with reflex showed large leukocyte esterase, positive nitrites, and a moderate amount of blood with 3+ bacteria. The urine culture revealed more than 100,000 colonies and was positive for Kiebsiella pneumoniae. The resident had a high blood creatinine of 7.2 (0.59-1.04 = normal range). The creatinine test is a measure of how well your kidneys as performing their job of filtering waste from your blood (www.mayoclinic.org). The resident was started on IV sodium bicarbonate, given D50, and admitted to the Intensive Care Unit (ICU). Intravenous Fluids (IV), and IV antibiotic (Zyvox and Zosyn) was also started. Resident #84 is in the ICU, on a ventilator, sedated and unresponsive. The resident will need dialysis per nephrology but is pending due to his acute kidney injury. Resident #84 is being transferred to a higher level of care on 02/12/22. The resident is hemodynamically unstable for conventional hemodialysis and will benefit from continuous renal replacement therapy (CRRT), which this facility doesn't provide. At the time of discharge, resident remains on a mechanical ventilator. A review of the hospital records revealed the following: Resident #84 presented in the emergency room (ER) on 02/12/22 as a transfer from the originated hospital for further evaluation due to hypoglycemia and Altered Mental Status (AMS). The resident was sent here for continuous renal replacement therapy (CRRT), which the previous hospital doesn't provide. The hemodialysis catheter placement was placed and (CRRT) was started on 02/13/22. A debriefing was conducted with the Administrator, [NAME] President of Clinical Services, and Regional Director of Clinical Services on 03/17/22 at approximately 5:45 p.m., Resident #84's issues were presented again. The facility did not present any further information about the findings prior to survey exit. Definitions: -Metabolic acidosis develops when too much acid is produced in the body. It can also occur when the kidneys cannot remove enough acid from the body. Some causes of metabolic acidosis include but are not limited to severe diarrhea and severe dehydration. Treatment is aimed at the health problem causing acidosis. In some cases, sodium bicarbonate may be given to reduce the acidity of the blood. Often, you will receive lots of fluids through the vein (https://medlineplus.gov). -Dehydration occurs when you use or lose more fluid than you take in, and your body doesn't have enough water and other fluids to carry out its normal functions. If you don't replace lost fluids, you will get dehydrated. You can usually reverse mild to moderate dehydration by drinking more fluids, but severe dehydration needs immediate medical treatment. Many people, particularly older adults, don't feel thirsty until they're already dehydrated. That's why it's important to increase water intake when you're ill. Other dehydration causes include but are not limited to diarrhea and or acute diarrhea - that is, diarrhea that comes on suddenly and violently - can cause a tremendous loss of water and electrolytes in a short amount of time. Dehydration can lead to serious complications, including urinary and kidney problems. Prolonged or repeated bouts of dehydration can cause urinary tract infections, kidney stones, and even kidney failure. The only effective treatment for dehydration is to replace lost fluids and lost electrolytes. The best approach to dehydration treatment depends on age, the severity of dehydration, and its cause. Adults who are severely dehydrated should be treated by emergency personnel arriving in an ambulance or in a hospital emergency room. Salts and fluids delivered through a vein (intravenously) are absorbed quickly and speed recovery. -Hypothermia is a medical emergency that occurs when your body loses heat faster than can produce heat, causing a dangerously low body temperature. Normal body temperature is around 98.6. Hypothermia occurs as your body temperature falls below 95 degrees Fahrenheit (https://www.mayoclinic.org). -Urinary tract infection occurs when there is a compromise of host defense mechanisms and a virulent microbe adheres, multiplies, and persists in a portion of the urinary tract. Most commonly, UTIs is caused by bacteria, but fungi and viruses are possible. Urine culture and sensitivity are the gold standards for the diagnosis of bacterial UTIs (https://www.ncbi.nlm.nih.gov). -Acute Kidney Injury occurs when your kidneys suddenly become unable to filter waste products from your blood. When your kidneys lose their filtering ability, dangerous levels of waste may accumulate, and your blood's chemical makeup may get out of balance. Acute kidney failure - also called acute renal failure or acute kidney injury - develops rapidly, usually in less than a few days (https://www.mayoclinic.org/diseases-conditions/kidney-failure/symptoms-causes). -Sodium Chloride Solution 0.9%, solution is used to supply water and salt (sodium chloride) to the body. Sodium chloride solution may also be mixed with other medications given by injection into a vein (https://www.webmd.com/drugs). -Clysis or hypodermoclysis is a relatively safe and effective procedure in a nursing home. The use of clysis in the nursing home is an alternative to intravenous hydration. The use of clysis for short-term hydration has the potential to reduce costs and transfers to the hospital (https://pubmed.ncbi.nlm.nih.gov). -A basic metabolic panel (BMP) is a test that measures eight different substances in your blood. It provides important information about your body's chemical balance and metabolism. Metabolism is the process of how the body uses food and energy. A BMP is used to check different body functions and processes, including kidney function, fluid and electrolyte balance, blood sugar levels, and acid and base balance (https://medlineplus.gov). -Klebiella pneumoniae is one of the bacteria most frequently causing healthcare-associated urinary tract infections (https://www.ncbi.nlm.nih.gov). -[NAME] system is a temperature management system used in a hospital or survey center to maintain a patient's core body temperature (https://www.bairhugger.com). -Mechanical ventilation is a form of life support. A mechanical ventilator is a machine that takes over the work of breathing when a person is not able to breathe enough on their own. The mechanical ventilator is also called a ventilator, respirator, or breathing machine (https://www.continued.com/resp-therapy/courses). 2. The facility staff failed to follow physician orders to obtain blood sugars as ordered by the physician. Resident #64 was admitted to the nursing facility on 11/12/21. Diagnosis for Resident #64 included but not limited to Type II Diabetes Mellitus (DM) with hyperglycemia. The current Minimum Data Set (MDS), a quarterly assessment with an Assessment Reference Date (ARD) of 02/22/22 coded the resident with a 14 out of a possible score of 15 on the Brief Interview for Mental Status (BIMS) indicating no cognitive impairment. The MDS coded Resident #64 requiring total dependence of one with bathing, extensive assistance of one with dressing, limited assistance of one with toilet use and personal hygiene and supervision with transfer and eating for Activities of Daily Living care. Under Section N for the use of insulin injection was coded as received daily during the last 7 days. The care plan created on 11/15/21 identified Resident #64 with a diagnosis of diabetes mellitus. The goal set for the resident by the staff is to be without complications related to diabetes. Some of the interventions/approaches the staff would use to accomplish this goal is monitor/document/report as needed any signs or symptoms of hyperglycemia: increased thirst and appetite, frequent urination, weight loss, fatigue, dry skin, poor wound healing, muscle cramps, abdominal pain and acetone breath (smells fruity). During the initial tour on 03/09/22 at approximately 3:27 p.m., an interview was conducted with Resident #64 who stated, The nurses do not always check my blood sugar. The resident stated my blood sugar is to be check everyday before my meals and at bedtime. Review of Resident #64's physician orders for March 2022 revealed the following order starting on 11/15/21: check blood sugars before meals and at bedtime. Notify the physician for blood sugar less than 60 or greater than 400. 1. Review of January 2022 Medication Administration Record (MAR) revealed blood sugar's were not obtained as ordered by the physician on the following days: 01/18 (before breakfast, 01/19 (at bedtime), 01/20 (before breakfast) and 01/24 (before breakfast). 2. Review of February 2022 Medication Administration Record (MAR) revealed blood sugar's were not obtained as ordered by the physician on the following days: 02/04 (before breakfast), 02/07 (at bedtime), 02/17 (before breakfast, before dinner and at bedtime). An interview was conducted with the Regional Director of Clinical Services on 03/16/22 at approximately 2:53 p.m., who reviewed the documents mentioned above. He stated, the expectations is for all nurses are to obtain blood sugars as ordered by the physician. The Regional Director stated, If it's not documented, it didn't happen. A debriefing was held with the Administrator and [NAME] President of Operations on 03/17/22 at approximately 5:45 p.m., who were informed of the above findings; no further information was provided prior to exit. The policy titled: Obtaining a Fingerstick Glucose Level with a revision date of 10/11. Purpose is to obtain a blood sugar sample to determine the resident's blood glucose level. Documentation read in part: The person performing this procedure should record the following in the resident's medical record: 5. If the resident refused the procedure, the reason(s) why and the intervention taken. 6. The blood sugar results. Follow facility policies and procedure for appropriate nursing interventions regarding blood sugar results (if resident is on sliding scale coverage, and/or physician interventions is needed to adjust insulin or oral medication dosages). 4. The facility staff failed to recognize, assess and intervene on an acute change in condition for a resident presenting with a four pound weight gain in a week, increased edema to the resident's right leg, left arm and face and episodes of shortness of breath without flowing oxygen for Resident #56. Resident #56 was originally admitted to the facility 9/19/16 and readmitted [DATE] after an acute care hospital stay. The current diagnoses included; COPD, congestive heart failure (CHF), and respiratory failure with hypoxia. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 2/15/22 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #56's cognitive abilities for daily decision making was intact. In section G (Physical functioning) the resident was coded as requiring total care of one person with personal hygiene, bathing, dressing, and toileting, extensive assistance of two people with bed mobility and supervision of one person after set-up with eating. Resident #56 was observed seated in a wheel chair in her room. She was wearing a slipper to the right foot and her right lowered leg was with plus two edema and redness. The resident's left arm was also with plus two edema and her face appeared fuller than it was the prior evening. The resident had a portable oxygen tank on the back of her wheel chair but it was on empty and she had a nasal cannula in her nostrils. An interview was conducted with Resident #56 in her room on 3/10/22 at approximately 2: 30 p.m. Resident #56 stated she participated in the Resident Council meeting earlier on 3/10/22 and was waiting for the nurses to put her back in bed. Resident #56 stated she felt heavy as well as a little short of breath and it troubled her for in January 2022 she was hospitalized twice for shortness of breath caused by COPD and congestive heart failure. The resident stated her doctor always told her to weigh daily and if there was a change of three pounds or more to contact the office and to be sure she monitored her intake of fluids. Resident #56 stated she asked Certified Nursing Assistant CNA) #6 to weight her on 3/10/22 and she weighed was 194.5 pounds. Resident #56 stated she's supposed to wear a TED hose to her right leg but the CNA wasn't able to locate one that morning. The resident also stated she received a fluid pill, a heart pill and oxygen to manage her breathing problems caused by COPD and congestive heart failure. The Physician's Order Summary (POS) revealed an order dated 3/1/22 which read; weekly weights to be completed one time a day every Monday related to heart failure. The resident's weight was 190.7 pounds on 3/7/22. Additional orders on the POS read; 8/25/21 Lasix Tablet 40 MG (Furosemide) Give 1 tablet by mouth two times a day for CHF. 08/17/2021- apply TED hose in AM and off in PM two times a day. 12/31/21 Oxygen 2 liters per minute by nasal cannula as needed for oxygen saturations below 92 percent. The resident's diet order dated 8/17/21 read, regular diet, regular texture, thin consistency, no added sodium; 1200 milliliters/24 hour fluid restriction. Fluid Restriction: 1200 cc (720cc with Meals and 480CC provided by Nursing) 7-3 = may give 240 cc 3-11 = may give 120 cc 11-7 = may give 120 cc. The current care plan had a problem dated 2/24/22 which read; resident has altered cardiovascular status r/t hypertension, CHF and cardiomyopathy. The goal read; the resident will be free from complications of cardiac problems through the review date. The interventions included; Assess lung and heart sounds as needed. Medications as ordered. Oxygen at 2 liters per minute via nasal cannula. Vital signs as ordered. Resident is a daily weight An interview was conducted with Licensed Practical Nurse (LPN) #10 on 3/10/22 at approximately 4:35 p.m. LPN #10 stated the resident's portable oxygen tank was empty but she connected the resident to the concentrator and her oxygen saturation was 8 percent. LPN #10 stated she didn't assess or obtain the resident's saturation prior to attaching her tubing to the concentrator. LPN #10 didn't acknowledge the resident's shortness of breath, increased weight or edema to her extremities but she stated the resident offered no concerns. LPN #10 stated she signed off for the resident's TED hose because she relied on the CNA to apply them as ordered. An interview was also conducted with LPN #8 on 3/10/22 at approximately 5:00 p.m. LPN #8 stated the resident's weights are charted and if they flagged, other actions would be taken. An interview was also conducted with the Director of Nursing (DON) on 3/10/22 at approximately 5:10 p.m. The DON stated the resident would be assessed and the physician/designee would be contacted for further instructions. On 3/11/22, Resident #56 was evaluated by the rounding Nurse Practitioner (NP). The NP assessment revealed the following; 3/11/22 staff reported 4.2 pounds weight gain over one week. Plus one edema to the right lower extremity with redness and warmth and fluid filled blisters and plus one edema to the left upper arm. Plan Keflex 500 milligram every twelve hours for seven days, complete blood count, basic metabolic panel, brain natriuretic peptide, chest x-ray and urinalysis and culture and sensitivity. The chest x-ray results findings dated 03/12/22 were as follows; there is cardiomegaly. There is interstitial edema. There is pulmonary venous hypertension. There is no pneumonia, mass, or adenopathy. There is no effusion. There is congestive heart failure. There is no pneumothorax. There is a right base infiltrate increased from 02/23/2022. There is no tuberculosis. On 3/12/22 a new order was received to start for Duoneb every 6 hours for SOB and/or wheezing. On 3/15/22, an order was received to start Furosemide Tablet 20 MG; Give 1 tablet by mouth one time a day for CHF for 5 Days. This was in addition to the previously ordered Lasix 40 mg two times each day. On 3/17/22 at approximately 5:45 p.m., the above findings were shared with the Administrator, VPCS and the [NAME] President of Operations (VPO). No additional information was offered and no concerns were voiced. Heart failure signs and symptoms may include: Shortness of breath with activity or when lying down, fatigue and weakness, swelling in the legs, ankles and feet, rapid or irregular heartbeat, swelling of the belly area (abdomen), very rapid weight gain from fluid buildup . (https://www.mayoclinic.org/diseases-conditions/heart-failure/symptoms-causes/syc-20373142). The above information was obtained 3/24/22. 5. The facility staff failed to follow physician orders for the care of a IV PICC line. Resident #71 was originally admitted to the facility 1/11/22 and readmitted [DATE] after an acute care hospital stay. The current diagnoses included; Incision and drainage of the right knee and placement of antibiotic beads. The five day Medicare Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 2/28/22 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #71's cognitive abilities for daily decision making were intact. In section G (Physical functioning) the resident was coded as requiring total care of one person with bathing, extensive assistance of two people with bed mobility, extensive assistance of one person with personal hygiene, dressing, toileting limited assistance of one person with eating and limited assistance of one after set-up with eating. Resident #71 was observed sitting in a wheel chair in her room on 3/9/22 at approximately 4:45 p.m. The resident stated she had surgery to the right knee and the physician had to go back in it and clean it out because of an infection; as a result she needed to have extensive antibiotic therapy intravenously. The resident further stated some of staff act like they have no idea how to administer the antibiotic. The resident had a PICC to the right upper arm and it was dated 3/9/22. Resident #71 stated the PICC dressing was supposed to be changed 3/5/22 but it wasn't changed until 3/9/22 and it was supposed to be changed again on 3/12/22 but it was now 3/17/22 and it hadn't been changed. Resident #71 stated she was concerned the PICC site may become infected and cause a delay in her going home. The physician order summary revealed the following orders; 2/25/22 IV PICC change needleless connector on admission, weekly every day shift/ Saturday for and as needed thereafter and change after every blood draw. 2/25/22 IV-PICC Measure catheter length on admission and with each dressing change thereafter. 2/25/22 IV-PICC change transparent dressing on admission, then weekly every day shift/Saturday and as needed thereafter. 2/21/22 Ceftriaxone Sodium Solution Reconstituted 2 Grams - Use 2 gram intravenously in the evening for infection related to infection and inflammatory reaction due to internal right knee prosthesis. An interview was conducted with Licensed Practical Nurse (LPN) #15, on 3/17/22 at approximately 1:15 p.m. LPN #15 stated she would take care of the dressing change today. On 3/17/22 at approximately 5:45 p.m., the above findings were shared with the Administrator, VPCS and the [NAME] President of Operations (VPO). The VPSC stated he had spoken to the nurse caring for Resident #71 and the dressing was to be changed today. The below information was obtained from the following web site on 3/25/22 (https://medlineplus.gov/ency/patientinstructions/000462.htm#:~:text=You%20sho uld%20change%20the%20dressing,you%20with%20the%20dressing%20change.) A dressing is a special bandage that blocks germs and keeps your catheter site dry and clean. You should change the dressing about once a week. You need to change it sooner if it becomes loose or gets wet or dirty. COMPLAINT DEFICIENCY 3. The facility staff failed to follow physician orders and obtain blood sugars for Resident #79. The quarterly Minimum Data Set (MDS) assessment dated [DATE] coded Resident #79 was assessed as a 15 on the BIMS assessment. A Care Plan dated 2/28/22 indicated: Potential for complications from Diabetes Mellitus diagnosis. Blood Sugar as ordered by doctor. Check all of body for breaks in skin and treat promptly as ordered by doctor. Diabetes medication as ordered by doctor. Monitor/document for side effects and effectiveness. Dietary consult for nutritional regimen and ongoing monitoring. Consult and notify doctor of any changes in diabetic medications. Inspect feet daily for open areas, sores, pressure areas, blisters, edema or redness. Monitor/document/report PRN any s/sx of hyperglycemia: increased thirst and appetite, frequent urination, weight loss, fatigue, dry skin, poor wound healing, muscle cramps, and pain, Kussmaul breathing, acetone breath (smells fruity), stupor, coma. Monitor/document/report PRN any s/sx of hypoglycemia: Sweating, Tremor, Increased heart rate (Tachycardia), Pallor, Nervousness, Confusion, slurred speech, lack of coordination, Staggering gait. Monitor/document/report PRN any s/sx of infection to any open areas: Redness, Pain, Heat, swelling or pus formation. Monitor/document/report PRN compliance with diet and document any problems. Offer substitutes for foods not eaten. Resident is at risk for injuries from falls related to history of falls, possible side effects from medications, diagnosis of Epilepsy, HTN, Diabetes Mellitus, Atrial Fib. A 01/04/2022 physician order indicated: Blood sugar check daily 4 times a day. Notify MD less 60 or greater than 400. A review of the Medication Administration Record (MAR) indicated: Blood sugars were not taken at the 0600 and the hour on February 17 and 18. Blood sugars were not taken at the 1700 and 2100 hour on the 25th. Blood sugars were not taken at the 0600 hour on the 26th. Resident #79 was noted to have the following physician orders: Insulin Aspart Flexpen 100 unit/ML solution pen injector Inject as per sliding scale: if 0 - 199 = 0 units 200 -250 = 2 units 251- 300 = 4 units 301- 350 = 6 units 351- 400 = 8 units - if over 400 call MD, subcutaneously before meals and at bedtime for DM During an interview on 3/17/22 at 10:10 a.m. with the Corporate Clinical Nurse (CCN), he was asked what did the blank areas of the MAR indicate. The CCN stated that the blank areas indicated the blood sugars were not taken.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. a. Resident #26 was originally admitted to the facility on [DATE] after an acute care hospital stay. The resident was never been discharged from the facility. According to the comprehensive skin assessment dated [DATE] at 8:12 PM a new wound was found on the resident's Sacrum. Acquired in-house. With 100% slough/eschar. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 1/26/22 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 11 out of a possible 15. This indicated that Resident #26 cognitive abilities for daily decision-making were moderately impaired. In section E (Rejection of Care) did the resident reject evaluation or care, marked O behavior not exhibited. In section G(Physical functioning) the resident was coded as requiring extensive assistance from two people with bed mobility and personal hygiene. Requiring extensive assistance of one person with dressing. Requiring total dependence of two persons with toilet use and bathing. Requires supervision with set-up help only with eating. In section M (Skin Conditions) M0150. Risk of Pressure Ulcers/Injuries. Codes as Yes. M0300. Current Number of Unhealed Pressure Ulcers/Injuries at Each Stage. Left Blank. In section M (Skin and Ulcer/Injury Treatments) M1200. Turning/repositioning program: coded as No. Pressure ulcer/injury care: coded as No. The care plan dated 2/04/22 reads: Focus: SKIN INTEGRITY: Resident has potential impairment to skin integrity r/t (relating/ to) cancer, COPD (Chronic Obstructive Pulmonary Disease) heart failure, anemia, Foley catheter, incontinence and need for ADL (Activity of Daily Living) assistance. Goal: The resident will maintain or develop clean and intact skin by the review date. Interventions: Encourage good nutrition and hydration in order to promote healthier skin. Follow facility protocols for treatment of injury. Keep skin clean and dry. Use lotion on dry skin. Observe location, size, and treatment of skin injury. Report abnormalities, failure to heal, s/sx (signs/symptoms) of infection, maceration, etc. to MD (Medical Doctor). The care plan dated 2/04/22 reads: Focus: ADL self-care performance deficit related to Heart failure, Acute kidney failure, Malignant carcinoma of the lung, Malignant neoplasm of the brain. Goal: Resident to maintain the current level of function in (eating) through the next review date. Interventions: BATHING/SHOWERING: Check nail length and trim and clean on bath day and as necessary. Avoid scrubbing & pat dry sensitive skin. Provide a tub bath/shower at least 2 days a week. Provide a sponge bath if a tub bath/ shower cannot be tolerated. Shave and shampoo hair as needed. BED MOBILITY: Requires (Limited to extensive assistance) of (1-2) staff to turn and reposition in bed Q 2-3 hours and as necessary. PERSONAL HYGIENE: Requires (limited to extensive assistance) of (1-2) staff with personal hygiene and oral care. SKIN OBSERVATION: Observe skin for rashes, redness, open areas, scratches, cuts and bruises and report changes for prompt treatment. A review of the Braden Scale assessment for predicting pressure sore risk was completed on 1/11/22 with a score of 18 which indicates Resident #26 is at risk for pressure sore. The remainder of the admission screening was incomplete. A review of the admission screening dated 1/11/22 at 6:36 PM reads: Pressure Ulcers: Is a pressure ulcer present? No. A review of the TAR (Treatment Administration Record) for February 2022 reads: 02/09/2022 00:12 Order Summary: Santyl Ointment 250 UNIT/GM (Collagenase) Apply to sacrum topically everyday shift for wound care. A review of the TAR (Treatment Administration Record) for March 2022 reads: Sacrum: Clean with wound cleanser, apply Dakin's wet-to-dry, and cover with bordered gauze. A review of nursing notes reveal the following: On 1/11/2022 at 6:53 PM resident was admitted to the Long Term Care facility from acute care via stretcher. No distress or complaints. A comprehensive wound evaluation for all new admits was completed by the Wound Care Nurse Practitioner (WCNP) on 1/13/22 at approximately 9:47 PM. The skin evaluation reads: Patient reports no rashes or known dermatologic conditions at the time of this exam. The dermatologic evaluation reads: Patient's skin is intact with no rashes. There are no open wounds on today's comprehensive skin examination. Wound plan of care: Recommend moisturizing bilateral legs and feet for *xerosis. Plan of Care Assessment & Plan explained all necessary basic foot care aspects. Patient understands that proper foot care is key to improved health, based on patient's comorbidities proper foot care is key to promoting the health of limbs. Other elements of Patient Evaluation: Wound rounds completed and reconciled with facility wound nurse today. All questions and concerns answered for staff and patient as applicable. Staff made aware that wound rounds were completed and of any changes in treatment plan. A review of the WCNP's Tissue Analytics (TA) weekly wound assessments revealed the following: Wound evaluation dated 2/08/22 revealed that an unstageable pressure ulcer of the sacrum was acquired in house. Measurements: Length: 5.35 cm. Width: 5.73 cm LxW: 30.66 cm Depth: 0. Observations: %slough/eschar: 100.00. Wound Status: New. Drain amount: Serosanguinous. No odor. Dressing change frequency: Daily. Cleanse wound with wound cleanser. Apply Santyl dressing with bordered gauze. Pressure Reduction/Offloading: Ensure compliance with turning protocol, wedges/foam cushion for offloading, wheelchair cushion, mattress overlay, and specialty bed. A review of the WCNP's weekly wound evaluation revealed resident's wound is stable dated 2/24/22: Unstageable Sacral Pressure Ulcer measurements: Length: 5.88 cm, Width: 6.02 cm, LxW: 35.40 cm, Depth: 0. Observations: % Granulation: 30.00. %Slough/eschar: 100.00. Wound Status: Stable. Drain Amount: Serosanguinous. Odor: Malodorous. Dressing Change Frequency: Daily. Pressure Reduction/offloading: Ensure compliance with turning protocol, wedge/foam cushion for offloading, wheelchair cushion, mattress overlay, specialty bed. Cleanse wound with: Wound cleanser. Apply Dakins moist-to-dry dressings. Bordered gauze. Another review of the WCNP's weekly wound evaluation revealed that the resident's wound is improving dated 3/03/22: Unstageable Sacral Pressure Ulcer of the sacrum. Measurements: Length: 5.94 cm, Width: 5.14 cm. LxW: 30.53 cm. Depth: 0. Observations: % granulation: 20.00. % slough/eschar: 80.00. Wound Status: Improving. Drain amount: Moderate. Drain Description: Serosanguinous. Odor: No odor. Dressing change frequency: Daily. Cleanse wound with: Wound Cleanser. Dakins moist-to-dry dressings and bordered gauze. Pressure Reduction/Offloading: Ensure compliance with turning protocol, wedge/foam/cushion for offloading, wheelchair cushion, mattress overlay, specialty bed. A continued review of WCNP's weekly wound evaluation revealed that the resident had debridement of the sacrum dated 3/10/22: Sacrum unstageable pressure injury. Post (after)-debridement length (cm): 1. 63 as per ulcer noted. width (cm) 0. 96 as per ulcer noted. 100% debrided. Wound plan of care: Recommend obtaining an air mattress and applying foot protectors/heel boots. I am recommending an air mattress for pressure reduction. Plan of Care Assessment & Plan - Patient has a pressure injury; Pressure reduction and turning precautions discussed with staff at the time of visit recommended, including heel protection and pressure reduction to bony prominences. Staff educated on all aspects of care. Explained all aspects of necessary basic foot care. Patient understands that proper foot care is key to improved health, based on patient' s comorbidities proper foot care is key to promoting health of limbs. Factors Affecting Healing: Patient has frequent incontinence which can decrease healing rate of wound. Recommend providing incontinence care as needed, PRN. Increased moisture at wound site can promote poor prognosis of wound healing. Please keep wound site covered and avoid contamination with feces at all times. Other elements of Patient Evaluation: Wound rounds completed and reconciled with wound nurse today. All questions and concerns answered for staff and patient as applicable. Patient was left as requested, lowest locked position with call bell within reach, no restraints in place. Staff made aware that wound rounds were completed and of any changes in treatment plan. A review of the weekly WCNP evaluation reveals Residents wound is improving dated 3/17/22: Unstageable sacral pressure ulcer of the sacrum. Measurements: Length: 7.66 cm. Width: 5.62 cm. LxW; 43.05 cm. Observations: % granulation: 20. % slough/eschar: 80.00. Other: Apply Santyl to necrosis. Wound Stasis: Improving. Draining: Moderate. Drainage description: Serosanguinous. Odor: Malodorous. Dressing Change Frequency: Daily. Cleanse wound with: Wound Cleanser. Dressings: Santyl, Dakin's moist-to-dry. Bordered gauze. Pressure Reduction/offloading: Ensure compliance with turning protocol, wedge/foam cushion for offloading, wheelchair cushion, mattress overlay, specialty bed. On 03/11/22 at approximately 9:39 AM, an interview was conducted with Resident #26 concerning his wounds on his sacrum and lower extremities. He was asked how he got the wounds. He stated, I got it since I've been in here. His heels were observed resting on the bed. No bunny boots or heel protectors were in place. The resident's heels were not floating but resting on his bed/mattress. Surveyor received permission from the resident to observe wound care. On 3/11/22 at approximately 10:45 AM., a wound care observation was made while LPN (Licensed Practical Nurse) #2 administered wound care/treatment to the resident's sacrum. Slough and eschar were present on the wound bed with moderate serosanguinous drainage. The resident tolerated the procedure without difficulty. No issues were noted. On 03/14/22 at 2:47 PM an interview was conducted with LPN #6 concerning Resident #26. She stated, He had an admission screen Braden scale. There's an admission assessment in here (PCC/Point Click Care/ electronic medical records) but it's not complete. It should have been completed. The area on the sacrum was found on 2/09/22 as unstageable. If it's covered in slough or eschar it's unstageable because we don't know what's under it. Upon arrival, we look at the resident's skin with the Wound Care Nurse Practitioner, then weekly. If the CNA sees any issues on the resident's skin they will report it to the nurse. Since I've been looking at his wound every week it's getting better. His sacrum was debrided on 3/10/22. I normally put a note in that I rounded with her but I didn't. On 03/14/22 at 2:47 PM an interview was conducted with LPN #6 (Unit Manager) concerning Resident #26. She stated, He had an admission screening Braden scale on 1/11/22. There's an admission assessment in here [PCC/Point Click Care (electronic medical records)] but it's not complete. It should have been completed. According to LPN#6, the area on the sacrum was found on 2/08/22 as unstageable with slough and eschar. She said, If it's covered in slough or eschar it's unstageable because we don't know what's under it. Upon arrival, we look at the resident's skin with the WCNP, then weekly if any pressure ulcer/wound issues. If the CNAs see any issues on the resident's skin they should report them to the nurse. The LPN continued to say that on 3/10/22 she failed to document that she rounded with the WCNP when the sacrum pressure ulcer was debrided. On 03/15/22 at 1:35 PM an interview was conducted with the WCNP concerning Resident #26's wounds. She stated, When he first got to the facility (1/11/22) he didn't have a wound. My admission skin sweep for the resident was on 1/13/22. When the facility told me to come to look at him he was already unstageable. I initially saw him on February 8th, 2022 (sacrum). I only see it once a week. For prevention: He needs to be turned every (q) 2 hours, heels floated, heel protectors, and an air mattress. The staff says he refuses to be turned and repositioned. I have had a nurse lately that does the dressings as I'm charting. She was asked was the wound found at an advanced stage on his right lateral ankle (2/24/22)? She stated, Yes because he didn't have it on his initial skin assessment. The staff should have communicated if they saw something open, redness, and documented it. I do a skin sweep quarterly on patients that don't have wounds. Most nurses should do weekly skin assessments. A review of the nurse's notes and or skin assessments from 1/31/22 through 2/8/22 did not reveal any skin integrity issues on the sacrum. Although there were no nurse's notes from this timeframe, the WCNP, per the above interview on 3/15/22, was asked by the nursing staff to come to look at his sacrum, which was identified as unstageable. A review of the resident's care plan shows no refusal of care. A review of the resident's care plan and nurse's notes showed no refusal of care to include skin assessments, bed baths, and or incontinence care. A review of ADL documentation records for January, February, and March 2022 show no refusal of care. On 03/15/22 at approximately 2:33 PM two CNAs were observed transferring Resident #26 back to bed via Hoyer lift. The resident was placed in a supine position. CNA #7 was asked if Resident #26 wears bunny boots or heel protectors when in bed. She stated, He has a regular mattress. You would think he would have a specialty mattress because of the pressure sores. On 03/16/22 at approximately 1:39 PM., an interview was conducted with LPN (Licensed Practical Nurse) #2. Concerning Resident #26. She stated, I keep resident off his bottom, turn and reposition him every two hours. His sacral wound looks about the same as when I first interacted with him. On 03/17/22 at approximately 11:38 AM., an interview was conducted with LPN #6/Unit Manager concerning communication with the WCNP. She stated, She would normally email us a spreadsheet of everybody that we saw during wound rounds. The orders either stay the same or change, then we update orders. During the interview, LPN#6 was asked about the following recommendations that the WCNP made after completing her rounds at each assessment that included foot protectors or heel protectors, bunny boots, pressure reduction devices to bony prominences, and air mattress. The original recommendation for the air mattress for pressure reduction was made on 2/8/22. On 3/10/22 and 3/17/22 during the WCNP's wound care assessment, these recommendations were still not implemented and were reiterated in her notes. LPN #6 stated, I would consult with the facility Nurse Practitioner (OSM #1) if the WCNP gives me an order (recommendations) and I will put the orders in. It (the previous recommendations) was an oversight. On 3/17/22 at approximately 12:15 PM., an interview was conducted with [NAME] President of Operations concerning Resident #26. She stated, The skin assessments are done sporadically by nurses they are not consistent. The best time is on the shower days at least once a week. If not getting showers they should be getting the skin assessments weekly. There should be an admission assessment done to include your Braden scale. On 3/17/22 at approximately 5:45 PM a Pre-exit interview was conducted with the Administrator, The [NAME] President of Operations, and the [NAME] President of Clinical Services concerning Resident #26. The [NAME] President of Operations Stated, The DON that was here had a wound care protocol but we can't find it but will re-implement it. *(1) Xerosis-Dry skin makes the skin look and feel rough, itchy, flaky, or scaly. The location where these dry patches form vary from person to person. It's a common condition that affects people of all ages. Dry skin, also known as xerosis or xeroderma, has many causes, including cold or dry weather, sun damage, harsh soaps, and overbathing. You can do a lot on your own to improve dry skin, including moisturizing and practicing sun protection year-round. Try various products and skincare routines to find an approach that works for you. This information was taken from https://www.mayoclinic.org/diseases-conditions/dry-skin/symptoms-causes/syc-20353885. *(2) Unstageable pressure ulcer- Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Further description: Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore stage, cannot be determined. Stable (dry, adherent, intact without erythema or fluctuance) eschar on the heels serves as the body's natural (biological) cover and should not be removed. National Pressure Ulcer Advisory Panel website at http://www.npuap.org/pr2.htm *(3) The Braden Scale for Predicting Pressure Sore Risk is a clinically validated tool that allows nurses and other health care providers to reliably score a patient/client's level of risk for developing pressure ulcers. It measures functional capabilities of the patient that contribute to either higher intensity and duration of pressure or lower tissue tolerance for pressure. Lower levels of functioning indicate higher levels of risk for pressure ulcer development .The Braden Scale is a summated rating scale made up of six subscales scored from 1-4 (1 for low level of functioning and 4 for the highest level or no impairment). Total scores range from 6-23 (one subscale is scored with values of 1-3, only). The subscales measure functional capabilities of the patient that contribute to either higher intensity and duration of pressure, or lower tissue tolerance for pressure. A lower Braden Scale Score indicates lower levels of functioning and, therefore, higher levels of risk for pressure ulcer development. This information is taken from the website https://www.nlm.nih.gov/research/umls/sourcereleasedocs/current/LNC_BRADEN *(4.) Dakin's solution is used to prevent and treat skin and tissue infections that could result from cuts, scrapes, and pressure sores. This information was obtained from: https://www.webmd.com/drugs/2/drug-62261/dakins-solution/details. *(5) SANTYL® Ointment is an FDA-approved active enzymatic therapy that continuously removes necrotic tissue from wounds at the microscopic level. This works to free the wound bed of microscopic cellular debris, allowing granulation to proceed and epithelialization to occur. (<http://www.santyl.com/about>) The facilitity's Policy: Prevention of Pressure Injuries reads: Purpose: The purpose of this procedure is to provide information regarding the identification of pressure injury risk factors and interventions for specific risk factors. Preparation: Review the resident's care plan and identify the risk factors as well as the interventions designed to reduce or eliminate those considered modifiable. Risk assessment: Assess the resident on admission (within eight hours) for existing pressure injury risk factors. Repeat the risk assessment weekly and upon any changes in condition. Skin Assessment: Conduct a comprehensive skin assessment upon (or soon after) admission, with each risk assessment, as indicated according to the resident's risk factors, and prior to discharge. Inspect the skin when performing or assisting with personal care or ADLs (Activity of Daily Living). Inspect pressure points (sacrum, heels, buttocks, coccyx etc. Wash the skin after any episodes of incontinence. Reposition resident as indicated on the care plan. Mobility/Repositioning: Reposition all residents with or at risk of pressure injuries on an individualized schedule, as determined by the interdisciplinary care team. Monitoring: Evaluate, report, and document potential changes in the skin. b. According to the comprehensive skin assessment conducted by the Wound Care Nursing Practitioner (WCNP) on 2/24/22, another pressure injury was first identified in-house on Resident #26's right lateral ankle as unstageable. The ankle was assessed by the WCNP as 100 percent (%) slough/eschar. A review of the Nursing admission Screening listed under Skin Integrity dated 1/11/2 at 6:36 PM reads Color: Normal. Temperature: Warm and Equal. Turgor: Normal. Comments: Both heels are very dry with a thick coat of yellow crust. Pressure Ulcers: Is a pressure ulcer present? No. A review of the TAR (Treatment Administration Record) reads: Right Lateral Ankle: Cleanse with wound cleaner, apply Santyl, cover with bordered gauze everyday shift for wound care. Active 2 /25/2022 7:00 AM. A review of nursing notes reveal the following: On 1/11/2022 at 6:53 PM resident was admitted to the Long Term Care facility from acute care via stretcher. No distress or complaints. A comprehensive wound evaluation for all new admits was completed by the Wound Care Nurse Practitioner (WCNP) on 1/13/22 at approximately 9:47 PM. The skin evaluation reads: Patient reports no rashes or known dermatologic conditions at the time of this exam. The dermatologic evaluation reads: Patient's skin is intact with no rashes. There are no open wounds on today's comprehensive skin examination. Wound plan of care: Recommend moisturizing bilateral legs and feet for xerosis. Plan of Care Assessment & Plan explained all necessary basic foot care aspects. Patient understands that proper foot care is key to improved health, based on patient's comorbidities proper foot care is key to promoting the health of limbs. Other elements of Patient Evaluation: Wound rounds completed and reconciled with facility wound nurse today. All questions and concerns answered for staff and patient as applicable. Staff made aware that wound rounds were completed and of any changes in treatment plan. Based on the WCNP Tissue Analytics (TA) weekly wound assessments for the sacrum pressure ulcer, on 2/24/22 a new pressure ulcer on the right lateral ankle was identified as acquired in-house. The WCNP documented this area as follows: . Unstageable. Measurements: Length: 1.56 cm, Width: 1.37 cm LXW: 2.14 cm, Depth: 0. Observations: % slough/eschar: 100.00. Treatment: Wound Cleanser daily, Santyl dressing. 3/03/22 Right Lateral Ankle: .Length: 1.24 cm, Width: 0.94 cm, LXW: 1.17 cm, Depth: 0. Observations: %slough/eschar: 100.00. Wound Status: Improving. Cleanse wound with wound cleanser daily. Santyl dressing and Bordered Gauze. 3/10/2022 Right Lateral Ankle: . Post debridement Length: 1.63 cm. Width: 0.96 cm. LXW: 1.56 cm. Depth: 0. Observations: %Slough/eschar: 100.00. Wound status: Stable. Cleanse with wound cleanser daily. Apply Santyl dressing and bordered gauze. 3/17/22 Right Lateral ankle: .Length: 1.77 cm, Width: 1.95 cm. LXW: 3.45 cm. Depth: 0. Observations: %slough/eschar: 100.00. Wound status: Stable. Cleanse daily with wound cleanser apply Santyl dressing and bordered gauze. On 03/11/22 at approximately 9:39 AM an interview was conducted with Resident #26 concerning his wounds on his sacrum and lower extremities. He was asked how he got the wounds. He stated, I got it since I've been in here. His heels were observed resting on the bed. No bunny boots or heel protectors were in place. The resident's heels were not floating but resting on his bed/mattress. Surveyor received permission from the resident to observe wound care. On 3/11/22 at approximately 10:45 AM., pressure ulcer treatment observation was made while LPN (Licensed Practical Nurse) #2 administered wound care/treatment to resident's right lateral ankle. The resident tolerated the procedure without difficulty. No issues were noted. On 03/14/22 at 2:47 PM an interview was conducted with LPN #6 (Unit Manager) concerning Resident #26. She stated, He had an admission screening Braden scale on 1/11/22. There's an admission assessment in here [PCC/Point Click Care (electronic medical records)] but it's not complete. It should have been completed. During the interview, LPN #6 said the resident had an unstageable pressure ulcer on his ankle identified on 2/24/22. If it's covered in slough or eschar it's unstageable because we don't know what's under it. She stated, Upon arrival, we look at resident's skin with the WCNP, then weekly if any pressure ulcer/wound issues. If the CNAs see any issues on resident's skin they should report them to the nurse. On 03/15/22 at 1:35 PM an interview was conducted with the WCNP concerning Resident #26's wounds. She stated, When he first got to the facility (1/11/22) he didn't have a wound. My admission skin sweep for the resident was on 1/13/22. When the facility told me to come to look at him he was already unstageable. I initially saw him on February 8th, 2022 (sacrum). I only see it once a week. For prevention: He needs to be turned every (q) 2 hours, heels floated, heel protectors, and an air mattress. The staff says he refuses to be turned and repositioned. I have had a nurse lately that does the dressings as I'm charting. She was asked was the wound found at an advanced stage on his right lateral ankle (2/24/22)? She stated, Yes because he didn't have it on his initial skin assessment. The staff should have communicated if they saw something open, redness, and documented it. I do a skin sweep quarterly on patients that don't have wounds. Most nurses should do weekly skin assessments. A review of the nurse's notes and or skin assessments from 1/31/22 through 2/24/22 did not reveal any skin integrity issues on the right lateral ankle. Although there were no nurse's notes from this timeframe, the WCNP, per the above interview on 3/15/22, discovered a new unstageable pressure ulcer to the right lateral ankle. A review of the resident's care plan and nurse's notes showed no refusal of care to include skin assessments, bed baths, and or incontinence care. A review of ADL documentation records for January, February, and March 2022 showed no refusal of care. On 03/15/22 at approximately 2:33 PM two CNAs were observed transferring Resident #26 back to bed via Hoyer lift. The resident was placed in a supine position. No bunny boots or heel protectors were placed on the resident's lower extremities. CNA #7 was asked if Resident #26 wears bunny boots or heel protectors when in bed. She stated, Therapy will let us know if he needs bunny boots, heel protectors, and float his heels. That would help with his heels, He has a regular mattress. You would think he would have a specialty mattress because of the pressure sores. On 03/16/22 at approximately 1:39 PM., an interview was conducted with LPN #2. Concerning Resident #26. She stated, I keep resident off his bottom, turn and reposition him every two hours. His sacral wound looks about the same as when I first interacted with him. His ankle requires skin prep to the right lateral side. On 03/17/22 at approximately 11:38 AM., an interview was conducted with LPN #6/Unit Manager concerning communication with the WCNP. She stated, She (WCNP) would normally email us a spreadsheet of everybody that we saw during wound rounds. The orders either stay the same or change, then we update orders. During the interview, LPN#6 was asked about the following recommendations that the WCNP made after completing her rounds at each assessment that included foot protectors or heel protectors, bunny boots, pressure reduction devices to bony prominences, and air mattress. The original recommendation for the air mattress for pressure reduction was made on 2/8/22. On 3/10/22 and 3/17/22 during the WCNP's wound care assessment, these recommendations were still not implemented and were reiterated in her notes. LPN #6 stated, I would consult with the facility Nurse Practitioner (OSM #1) if the WCNP gives me an order (recommendations) and I will put the orders in. It (the previous recommendations) was an oversight. On 3/17/22 at approximately 5:45 PM a Pre-exit interview was conducted with the Administrator, The [NAME] President of Operations, and with the [NAME] President of Clinical Services concerning Resident #26. The [NAME] President of Operations Stated, The DON that was here had a wound care protocol but we can't find it but we will re-implement it. Based on observation, staff interviews, and clinical record review, the facility staff failed to provide services to prevent pressure ulcers and promote healing for 2 of 9 Residents with pressure ulcers, the facility staff failed to properly classify, assess, and institute an appropriate treatment/care to Resident #8's pressure ulcer to the left hip to prevent deterioration to unstageable, presenting with 70 percent granulation tissue/30 percent slough (dead tissue) over four days, which constituted harm. For Resident #26, the facility staff failed to provide care and services to prevent pressure ulcer development in two areas prior to identification at an advanced stage; the sacrum with 100% slough/eschar and the right lateral ankle with 100% slough/eschar which constituted harm. The findings included: 1. Resident #8 was originally admitted to the facility on [DATE] and was discharged from the facility for an acute care hospital stay, returning on 3/29/14. The current diagnoses included; dementia, high blood pressure, and adult failure to thrive. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 12.25/21 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 0 out of a possible 15. This indicated that Resident #8's cognitive abilities for daily decision-making were severely impaired. In section G (Physical functioning) the resident was coded as requiring total care of two people with bed mobility, transfers, total care of one person with dressing, eating, toileting, personal hygiene, and bathing. A review of the facility's matrix revealed Resident #8 was coded for having a facility-acquired unstageable pressure ulcer. A review of the clinical record revealed a nurse progress note authored by LPN #10 on 3/8/22 at 3:05 p.m., which read; that the Wound Care Nurse Practitioner (WCNP) was noted in the facility and was made aware that the resident's left hip was worsening. The clinical record offered no evidence that Resident #8 had an opened area to the left hip and there was no assessment and/or documentation of a left hip open area. This was the first documentation of a left hip open area. An interview with LPN #10 on 3/10/22 at approximately 4:15 p.m. revealed the left hip was being treated with; normal saline, dry and apply Triple-antibiotic ointment (TAO) and a border gauze. This was the order for the left buttock scratches. The clinical record revealed a change in condition document dated 3/4/22 which identified a reopened area to the left buttock due to observed self-inflicted and witnessed scratching on more than one occasion. An order was obtained to cleanse the scratches to the left buttock open area with normal saline, dry, and apply Triple-antibiotic ointment (TAO) and a border gauze every day until healed. The left buttock scratches were documented as healed on 3/8/22. An interview was conducted with Licensed Practical Nurse (LPN) #6 on 3/17/22 at approximately 12:05 p.m. LPN #6 stated LPN #16 stated she obtained the left buttock treatment order from the primary Nurse Practitioner (NP) for self-inflicted and witnessed scratches to the left buttock, not a pressure ulcer, just as she documented on the change in condition form The [TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on complaint investigation, staff interviews, clinical record review, and facility documentation, the facility staff failed to provide the necessary care and services for 2 of out 44 residents (Resident #84 and #71) in the survey sample. For Resident #84, the facility staff failed to provide parenteral intravenous (IV) fluids as ordered by the Nurse Practitioner on 02/04/22 at approximately 10:30 a.m., to start Sodium Chloride Solution 0.9%, use 50 ml/hour intravenously (IV) x 24 hours for 2 liters for hydration which was never initiated. Resident #84 remained in the facility for 28 hours after the order was given to start IV fluids before the resident was noted as being in respiratory distress, unable to obtain blood pressure, and using his accessory muscles for breathing. Resident #84 was transferred via 911 (emergent) to the local hospital and admitted on [DATE] with main diagnoses to include severe metabolic acidosis, severe dehydration, hypothermia at 89.4 degrees, Urinary Tract Infection (UTI), and Acute Kidney Injury (suspect pre-renal due to dehydration), which constituted harm for Resident #84. For Resident #71, the facility staff failed to change the peripherally inserted central catheter (PICC) dressings every seven days for site maintenance and prevention of infection. The findings included: 1. Resident #84 was admitted to the nursing facility on 11/10/21. The resident was discharged to the local hospital on [DATE] and did not return to the nursing facility. Diagnosis for Resident #84 included but not limited to Chronic Kidney Disease (not on dialysis) and Type II Diabetes Mellitus. The most recent Minimum Data Set (MDS) was an admission assessment with an Assessment Reference Date (ARD) of 11/17/21 coded the resident on the Brief Interview for Mental Status (BIMS) an 11 of 15 indicating moderate cognitive impairment. Resident #84 was coded total dependence of one with toilet use and bathing, extensive assistance of one with bed mobility and transfer, limited assistance of one with dressing and personal hygiene, and supervision with one assist with eating Activities of Daily Living (ADL). Under section H - (Bladder and Bowel) was coded for always incontinent of bladder and bowel. The care plan created on 11/17/21 and a revision date of 01/11/22 identified Resident #84 with impaired cognitive function or impaired thought process related to an altered mental status. The goal set for the resident by the staff was that the resident will improve current level of cognitive function through the next review on 03/09/22. One of the interventions/approaches the staff would use to accomplish this goal is to administer medications as ordered. Monitor/document for side effects and effectiveness. On 02/04/22, the Nurse Practitioner (NP) progress revealed the following information: Resident #84 is being seen today for loose stools, decrease intake, and COVID-19. Resident #84 reports having decreased appetite and increased thirst. Under diagnosis, assessment and plan it included but was not limited to start Sodium Chloride Solution at 50 ml/hour x 2 liters. The review of Resident #84's Medication Administration Record (MAR) revealed the following order: Sodium Chloride Solution 0.9%, use 50 ml/hour intravenously (IV) x 24 hours for 2 liters for hydration or clysis for 3 days, the order remains in pending confirmation. An interview was conducted with License Practical Nurse (LPN) #6 on 03/14/22 at approximately 4:12 p.m. When asked, what does it mean with an order that reads pending confirmation? The LPN stated, that the order was put Point Click Care (PCC) but the nurse never confirmed the order, so the order was never initiated. A review of Resident #84's clinical record revealed the following documentation entered on 02/05/22 at approximately 2:56 p.m., by LPN #3. Resident #84 noted having respiratory distress, being unable to obtain blood pressure, oxygen saturation of 94% on room air, and heart rate of 102 while using accessory muscles for breathing. A new order was obtained to send to the ER for evaluation and treatment. A phone interview was conducted with Nurse Practitioner (NP) on 03/15/22 at approximately 2:08 p.m. The NP stated she assessed Resident #84 on 02/04/22 due to the staff reporting the resident was having loose stools and not eating. She said that during her discussion with the resident, he voiced to me that he was really thirsty and has no appetite. The NP said IV fluids were ordered and started on 02/04/22. The NP stated, IV fluids were ordered for hydration because Resident #84 was having loose stools and not eating She said the BMP was not ordered as STAT (now order) because I needed time for the IV fluids to hydrate the resident to help determine what further treatment was needed. The NP stated, Unfortunately, his IV fluids were never started and I was never notified. An interview was conducted with LPN#3 on 03/14/22 at approximately 1:46 p.m. The LPN was assigned to provide care and services to Resident #84 on 02/04/22 and 02/05/22 (7-3 shift), the day Resident #84 was evaluated by the NP with new orders to start IV fluids. The LPN said she remembered Resident #84 was not eating or drinking. She said the NP came in and saw Resident #84 and wrote a bunch of new orders but I was never informed that an order to start IV fluids. On 03/15/22 at approximately 9:44 a.m., a phone interview was conducted with LPN #5. The LPN was assigned to provide care and services to Resident #84 on 02/04/22 (11-7 shift). The LPN stated, I don't recall the nurse giving a report that Resident #84 had an order to start an IV to administer IV fluids. On 03/16/22 at approximately 2:53 p.m., an interview was conducted with the Regional Director of Clinical Services. The Regional Director said the nurse(s) should have activated the order in PCC and the IV fluids should have been started as ordered by the (NP). He stated, If the nurse assigned was not able to start the IV, there is always someone in house that could have started the IV. He stated clysis could have been used to hydrate the resident. A phone interview was conducted with the Medical Director on 03/17/22 at approximately 5:11 p.m., when asked if the staff should have started the fluids IV or via clysis, he replied, Absolutely, not receiving the IV fluids could have contributed to his dehydration as well as Acute Renal Failure (AFR). The Medical Director stated, The NP or I should have been notified that Resident #84's IV fluids were never started. A review of the hospital records revealed the following: Resident #84 presented in the emergency room (ER) on 02/05/22 from (name of nursing facility) for further evaluation due to lethargy. The 911 transport revealed the following: Resident serum glucose was 14. The Emergency Medical Service (EMS) placed an IV, gave glucagon and D10 and his glucose increased to 135. The ER records indicated Resident #84's rectal temperature @ 89.4 degrees F (hypothermia - low body temperature) and placed on Bair Hugger for low rectal temperature. The resident's blood pressure was 89/40 (normal = 120/80). He was found to be in severe metabolic acidosis and septic shock. The urinalysis with reflex showed large leukocyte esterase, positive nitrites, and a moderate amount of blood with 3+ bacteria. The urine culture revealed more than 100,000 colonies and was positive for Kiebsiella pneumoniae. The resident had a high blood creatinine of 7.2 (0.59-1.04 = normal range). The creatinine test is a measure of how well your kidneys as performing their job of filtering waste from your blood (www.mayoclinic.org). The resident was started on IV sodium bicarbonate, given D50, and admitted to the Intensive Care Unit (ICU). Intravenous Fluids (IV), and IV antibiotic (Zyvox and Zosyn) was also started. Resident #84 is in the ICU, on a ventilator, sedated and unresponsive. The resident will need dialysis per nephrology but is pending due to his acute kidney injury. Resident #84 is being transferred to a higher level of care on 02/12/22. The resident is hemodynamically unstable for conventional hemodialysis and will benefit from continuous renal replacement therapy (CRRT), which this facility doesn't provide. At the time of discharge, resident remains on a mechanical ventilator. A review of the hospital records revealed the following: Resident #84 presented in the emergency room (ER) on 02/12/22 as a transfer from the originated hospital for further evaluation due to hypoglycemia and Altered Mental Status (AMS). The resident was sent here for continuous renal replacement therapy (CRRT), which the previous hospital doesn't provide. The hemodialysis catheter placement was placed and (CRRT) was started on 02/13/22. A debriefing was conducted with the Administrator, [NAME] President of Clinical Services, and Regional Director of Clinical Services on 03/17/22 at approximately 5:45 p.m., Resident #84's issues were presented again. The facility did not present any further information about the findings. Definitions: -Metabolic acidosis develops when too much acid is produced in the body. It can also occur when the kidneys cannot remove enough acid from the body. Some causes for metabolic acidosis included but not limited to severe diarrhea and severe dehydration. Treatment is aimed at the health problem causing acidosis. In some cases, sodium bicarbonate may be given to reduce the acidity of the blood. Often, you will receive lots of fluids through the vein (https://medlineplus.gov). -Dehydration occurs when you use or lose more fluid than you take in, and your body doesn't have enough water and other fluids to carry out its normal functions. If you don't replace lost fluids, you will get dehydrated. You can usually reverse mild to moderate dehydration by drinking more fluids, but severe dehydration needs immediate medical treatment. Many people, particularly older adults, don't feel thirsty until they're already dehydrated. That's why it's important to increase water intake when you're ill. Other dehydration causes include but are not limited to diarrhea and or acute diarrhea - that is, diarrhea that comes on suddenly and violently - can cause a tremendous loss of water and electrolytes in a short amount of time. Dehydration can lead to serious complications, including urinary and kidney problems. Prolonged or repeated bouts of dehydration can cause urinary tract infections, kidney stones, and even kidney failure. The only effective treatment for dehydration is to replace lost fluids and lost electrolytes. The best approach to dehydration treatment depends on age, the severity of dehydration, and its cause. Adults who are severely dehydrated should be treated by emergency personnel arriving in an ambulance or in a hospital emergency room. Salts and fluids delivered through a vein (intravenously) are absorbed quickly and speed recovery. -Hypothermia is a medical emergency that occurs when your body loses heat faster than can produce heat, causing a dangerously low body temperature. Normal body temperature is around 98.6. Hypothermia occurs as your body temperature falls below 95 degrees Fahrenheit (https://www.mayoclinic.org). -Urinary tract infection occurs when there is a compromise of host defense mechanisms and a virulent microbe adheres, multiplies, and persists in a portion of the urinary tract. Most commonly, UTI is caused by bacteria, but fungi and viruses are possible. Urine culture and sensitivity are the gold standards for the diagnosis of bacterial UTI (https://www.ncbi.nlm.nih.gov). -Acute Kidney Injury occurs when your kidneys suddenly become unable to filter waste products from your blood. When your kidneys lose their filtering ability, dangerous levels of wastes may accumulate, and your blood's chemical makeup may get out of balance. Acute kidney failure - also called acute renal failure or acute kidney injury - develops rapidly, usually in less than a few days (https://www.mayoclinic.org/diseases-conditions/kidney-failure/symptoms-causes). -Sodium Chloride Solution 0.9%, solution is used to supply water and salt (sodium chloride) to the body. Sodium chloride solution may also be mixed with other medications given by injection into a vein (https://www.webmd.com/drugs). -Clysis or hypodermoclysis is a relatively safe and effective procedure in a nursing home. The use of clysis in the nursing home is an alternative to intravenous hydration. The use of clysis for short-term hydration has the potential to reduce cost and transfers to the hospital (https://pubmed.ncbi.nlm.nih.gov). -A basic metabolic panel (BMP) is a test that measures eight different substances in your blood. It provides important information about your body's chemical balance and metabolism. Metabolism is the process of how the body uses food and energy. A BMP is used to check different body functions and processes, including: kidney function, fluid and electrolyte balance, blood sugar levels, and acid and base balance (https://medlineplus.gov). -Klebiella pneumoniae is one of the bacteria most frequently causing healthcare-associated urinary tract infections (https://www.ncbi.nlm.nih.gov). -[NAME] system is a temperature management system used in a hospital or survey center to maintain a patient's core body temperature (https://www.bairhugger.com). -Mechanical ventilation is a form of life support. A mechanical ventilator is a machine that takes over the work of breathing when a person is not able to breathe enough on their own. The mechanical ventilator is also called a ventilator, respirator, or breathing machine (https://www.continued.com/resp-therapy/courses). 2. Resident #71 was originally admitted to the facility 1/11/22 and readmitted [DATE] after an acute care hospital stay. The current diagnoses included; Incision and drainage of the right knee and placement of antibiotic beads. The five day Medicare Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 2/28/22 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #71's cognitive abilities for daily decision making were intact. In section G (Physical functioning) the resident was coded as requiring total care of one person with bathing, extensive assistance of two people with bed mobility, extensive assistance of one person with personal hygiene, dressing, toileting limited assistance of one person with eating and limited assistance of one after set-up with eating. Resident #71 was observed sitting in a wheel chair in her room on 3/9/22 at approximately 4:45 p.m. The resident stated she had surgery to the right knee and the physician had to go back in it and clean it out because of an infection; as a result she needed to have extensive antibiotic therapy intravenously. The resident further stated some of staff act like they have no idea how to administer the antibiotic. The resident had a PICC to the right upper arm and it was dated 3/9/22. Resident #71 stated the PICC dressing was supposed to be changed 3/5/22 but it wasn't changed until 3/9/22 and it was supposed to be changed again on 3/12/22 but it was now 3/17/22 and it hadn't been changed. Resident #71 stated she was concerned the PICC site may become infected and cause a delay in her going home. The physician order summary revealed the following orders; 2/25/22 IV PICC change needleless connector on admission, weekly every day shift/ Saturday for and as needed thereafter and change after every blood draw. 2/25/22 IV-PICC Measure catheter length on admission and with each dressing change thereafter. 2/25/22 IV-PICC change transparent dressing on admission, then weekly every day shift/Saturday and as needed thereafter. 2/21/22 Ceftriaxone Sodium Solution Reconstituted 2 Grams - Use 2 gram intravenously in the evening for infection related to infection and inflammatory reaction due to internal right knee prosthesis. An interview was conducted with Licensed Practical Nurse (LPN) #15, on 3/17/22 at approximately 1:15 p.m. LPN #15 stated she would take care of the dressing change today. On 3/17/22 at approximately 5:45 p.m., the above findings were shared with the Administrator, VPCS and the [NAME] President of Operations (VPO). The VPSC stated he had spoken to the nurse caring for Resident #71 and the dressing was to be changed today. The below information was obtained from the following web site on 3/25/22 (https://medlineplus.gov/ency/patientinstructions/000462.htm#:~:text=You%20sho uld%20change%20the%20dressing,you%20with%20the%20dressing%20change.) A dressing is a special bandage that blocks germs and keeps your catheter site dry and clean. You should change the dressing about once a week. You need to change it sooner if it becomes loose or gets wet or dirty. COMPLAINT DEFICIENCY

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on information gleaned during a complaint investigation, family interview, staff interviews, and a clinical record review, the facility staff failed to admit and transcribe orders to obtain crucial pain medications for over forty-five hours to manage the pain for a resident two days post-surgery after a serious and complex lumbar fusion of the spine, resulting in severe pain which limited participation in day to day activities, the ability to sleep at night and physical decline which constituted harm for 1 of 44 residents (Resident #83), in the survey sample. The findings included: Resident #83 was originally admitted to the facility on [DATE], was discharged to acute care on 11/26/21, returned to the facility on [DATE], and discharged again on 1/1/22, and succumbed on 1/4/22. The diagnoses at the time of the resident's 11/19/21 admission included; status post decompression and fusion of the lumbar spine and polymyalgia rheumatic. The admission Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 11/26/21 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 14 out of a possible 15. This indicated Resident #83's cognitive abilities for daily decision-making were intact. In section G (Physical functioning) the resident was coded as requiring total care of one person with bathing, extensive assistance of two people with transfers, extensive assistance of one person with dressing and toileting, limited assistance of one person with bed mobility and personal hygiene, and supervision after set-up with eating. In sections J0500A and B; the resident was coded that pain made it hard to sleep at night and limited day-to-day activities. At section M1040E; the resident was coded with a surgical wound. On 3/16/22 at approximately 10:30 a.m., an interview was conducted with the resident's listed Responsible party (RP). The RP stated they were familiar with the facility under different ownership for their mother had short stays after a number of hospitalizations. The RP further stated Resident #83 chose the facility for rehabilitation after surgery to regain strength and return home. The RP stated the resident was an eighteen-wheel truck driver and looked forward to getting back in the truck. The RP also stated the night of 11/19/21, Resident #83 arrived at the facility at approximately 6:00 p.m., by stretcher from a local hospital. She stated the resident was with significant functional limitations including transfers, walking, toileting, and other activities of daily living (ADL) and back pain secondary to surgical decompression and lumbar fusion of the spine. The RP stated the unit the resident was assigned to was staffed with one nurse, no other staff, and the nurse was overwhelmed and told her she had no orders to provide care to the resident. During the interview, the RP assured the facility's nurse that wasn't accurate for she had spoken with the hospital's Discharge Planner multiple times to ensure all necessary orders and instructions were provided to the facility prior to the resident leaving the hospital because she was aware of how interruptions in service may occur if all information wasn't provided timely to the facility. The RP stated the nurse told the family upon request for pain medication that she had no orders for medications therefore she couldn't administer any medications to the resident but they could go home and get his medications and they could administer them to the resident. The RP stated that the same evening, the day of admission [DATE], Resident #83 experienced severe pain and needed to void but because of a history of voiding only in a specific position it was necessary for him to get out of bed to void and there was no one to assist the resident. It was the family who had to assist the resident to get out of bed to void. The RP stated the only service the resident received the day of admission was to receive a bedside commode, no medications, no physical assistance. The RP further said during the above interview that over the course of the first two days her brother had to come into the facility and transfer the resident to the commode because the staff wouldn't. She stated the staff's rationale was rehabilitation services hadn't assessed the resident and he was experiencing severe pain on movement. The RP stated on one occasion the resident lay in feces for four hours because he feared the pain which would be inflicted on him by staff yanking on him to clean him up, therefore the resident called for his son to come to the facility and assist him to clean up. The RP also stated on 11/20/21 the nurse staff stated it would be three to four days before the resident's pain medications would arrive to the facility, and it was a relief when they finally arrived almost two days after his admission to the facility. Review of the hospital's Discharge summary dated [DATE] included the following discharge medication orders; Percocet 5/325 milligrams; one tablet by mouth every six hours as needed for pain, Norco 7.5/325 mg; one tablet by mouth every six hours as needed, Prednisone 5mg one tablet by mouth daily and Zanaflex 4mg; one tablet by mouth three times daily as needed. A record review revealed on 11/20/21 at 10:07 a.m., (name of the on-call Nurse Practitioner) called to have a hard prescription sent to the pharmacy for Percocet. The Nurse Practitioner (NP) stated she would send an electronic prescription to the pharmacy and the resident's son was informed when he arrived at the facility. A nurse's progress note dated 11/21/21 at 5:19 p.m. revealed that Resident #83's family members were in the facility demanding to speak with the Director of Nursing because the resident wasn't receiving two medications (a steroid and an antispasmodic) instrumental in treating polymyalgia rheumatic; an inflammatory disorder that causes muscle pain, muscle stiffness, and muscle spasms in various parts of the body which could easily be treated with steroids and an antispasmodic. A progress note was also in the clinical record stating on 11/21/21 at 9:21 p.m., the on-call NP was notified that Resident #83's family desired to have the Prednisone and Zanaflex resumed but the NP deferred the orders to the order until the resident was visited by the in-house Practitioner. During the interview with the RP on 3/16/22 at approximately 10:30 a.m., the RP stated when the resident's medications arrived at the facility from the pharmacy on 11/21/21 the steroid and antispasmodic weren't included and they were the exact medications the hospital Discharge Planner was asked to ensure was included in the orders to the facility for they were required to treat the debilitating symptoms of polymyalgia rheumatic. The RP stated as a result of not receiving the steroid and antispasmodic the resident suffered additional pain, spasms and other rebound symptoms of polymyalgia rheumatic along with the pain related to the spinal surgery. The RP stated the poor care in the facility resulted in her father's unnecessary pain and physical decline. An interview was conducted with Licensed Practical Nurse (LPN) #9 on 3/17/22 at approximately 9:52 a.m. LPN #9 stated she remembered Resident #83 and she was the nurse on duty the evening the resident arrived. She further stated the staff knew she wasn't proficient in admissions and she always worked the overnight shift to avoid admitting residents. LPN #9 stated she had never admitted a resident and the day Resident #83 arrived she was the only direct care staff on the unit; without any other nurses or Certified Nursing Assistants (CNA). LPN #9 stated the front office staff was also aware she was the only caregiver for the shift therefore they came to the unit to assist with answering call lights and providing limited care for the residents prior to going home for the night, but that was all. LPN #9 stated no one told her they were not going to admit Resident #83 to the facility and she didn't. LPN #9 stated she provided the Resident with a bedside commode and a son who was present and very involved in the resident's care assisted him to the toilet. LPN #9 also stated she was aware the resident was experiencing pain and she informed the resident's family that she had no orders to administer any medications to the resident. An interview was conducted with the facility's admission Director on 3/17/22 at approximately 2:30 p.m. The admission Director stated she doesn't have a clinical background, therefore, all clinical concerns are reviewed by the Director of Nursing prior to admissions arrival to the facility. The admission Director stated there were no specific clinical concerns with Resident #83's 11/19/21 admission therefore all of the admission documents were given to the nursing staff for the unit to the resident was to be admitted and the nursing staff didn't ask her to obtain any specific documents from the hospital's Discharge Planner and no concerns were voiced by the nursing staff. Two other staff nurses were telephoned on 3/16/22 and 3/17/22 for interviews regarding the status of Resident #83 during the 11/19/21 admission but the calls were not answered and/or returned. One of the nurses assumed care of the resident on 11/20/21 and telephoned the Nurse Practitioner for a pain medication order and the other was the nurse who opened a Braden Scale for Predicting Pressure Sore Risk assessment but didn't complete any of it or any other admission paperwork on 11/19/21. An interview was conducted on 3/17/21 at approximately 1:30 p.m., with the facility's [NAME] President of Clinical Services (VPCS). The VPCS stated he was unable to provide evidence that the resident received any type of pain management prior to 11/21/21 at 3:50 p.m. when Vicodin 5/325 milligrams (mg) was delivered and administered. The VPCS stated the pain medication Percocet 5/325 mg was included in the resident's orders on 11/19/21, as a hospital discharge medication and it was available in the facility's stat medication box, yet it wasn't withdrawn and administered to the resident and neither was the Norco administered at the time of obtaining the order for it on 11/20/21 for the 5/325 mg dose was also available in the stat box but not the 7.5/325 mg dosage. The VPCS further stated both drugs were in the stat box and could have been given. The VPCS On 3/17/22 at approximately 5:45 p.m., the above findings were shared with the Administrator, VPCS, and the [NAME] President of Operations (VPO). The VPCS stated the nurses working at the facility are competent and there is a resource book available for reference when needed therefore he was unable to explain why there was a delay in the resident's care. The VPO stated she too had reviewed the pain medication delays and felt the resident pain wasn't managed appropriately but she was unable to offer any insight into why the care wasn't provided promptly. COMPLAINT DEFICIENCY