Based on observations, staff interviews, and clinical record review, the facility staff failed to develop and institute measures to prevent pressure ulcer development for an individual known to develop pressure ulcers to the left foot/ankle for 1 of 4 residents with pressure ulcers (Resident #26), in the survey. A. The facility staff failed to promote healing of deep tissue pressure ulcer to the left lateral plantar foot and to conduct a complete assessment, reassess and document the status of the pressure ulcer once the wound bed was exposed which resulted in deterioration as evidenced by eschar and drainage at various times, which constituted harm. B. The facility staff failed to promote healing of deep tissue pressure ulcer by not obtaining a treatment for the left great toe pressure ulcer and to conduct a complete assessment, reassess and document the status of the left great toe once the wound bed was exposed, which constituted harm. The findings included: Resident #26 was originally admitted to the facility 11/18/2014 and the resident had never been discharged from the facility. The current diagnoses included; dementia, a-fib, and high blood pressure. The annual Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 6/20/22 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 0 out of a possible 15. This indicated Resident #26's cognitive abilities for daily decision making were severely impaired. In section G (Physical functioning) the resident was coded as requiring total physical assistance of one person with toileting, extensive physical assistance of two plus persons with bed mobility and transfers, extensive physical assistance of one person with dressing and bathing, supervision with physical assistance of one person with eating and activity didn't occur with walking, locomotion, personal hygiene. A review of the facility's matrix revealed Resident #26 had facility acquired pressure ulcers and during the initial tour on 8/28/22 at approximately 5:15 p.m., Resident #26 was observed in his room with Kling wrap to the left lower extremity. The right foot as observed with an increased amount of edema (swelling), and black and blue discoloization. The resident was unable to state what had occurred to either extremity. Historical documentation from the resident's record revealed the resident had experienced repeated pressure ulcers and skin impairment to the left lower extremity including the left proximal foot 6/8/22, a DTI of the left pinky toe 6/2/22, the left outer ankle pressure ulcer 5/18/22, 4/26/2022 left ankle wound infection, 4/5/22 Skin tear to left ankle. On 8/30/22 at approximately 12:35 p.m., the resident was observed in bed reclined on a standard mattress with non-skid shoes to bilateral feet. He was lying on his left side and the left foot was positioned so the left 5the digit and ankle were making contact with the bed and the left great toe was up. On 8/31/22 at approximately 1:10 p.m., Resident #26 was observed in bed again lying on his left side with his left foot, the 5th digit and ankle down against the mattress and the great toe up. No positioning/ offloading devices such as wedges, or pillows heel floats were in use. On 8/31/22 at approximately 11:08 a.m., an interview was conducted with Certified Nursing Assistant (CNA) #1. CNA #1 stated Resident #26 was a long term resident and he is normally cooperative with care, often restless, and attempts to reposition himself. She stated the resident was currently with right foot bruising and swelling and had a bandage on his left foot. CNA #1 stated she had never used positioning devices with the resident. On 8/31/22 at approximately 11:17 a.m., an interview was conducted with Certified Nursing Assistant (CNA) #2. CNA #2 stated he normally gets the resident out of bed in the morning and his gown is usually off and the resident is only a brief and socks. CNA #2 stated the resident is usually lying on his side to face the window (his left side) and there are no positioning devices. CNA #2 also stated the resident had stopped walking when he returned to the unit in June and because of open areas to his foot he doesn't wear his brown dress shoes any longer. He also stated when the resident experiences discomfort related to his contracture he will become resistant. The following active pressure ulcer orders were on the current August 2022 physician order summary and were signed off on the MAR as provided by the licensed nursing staff: 7/8/22- Iodosorb Gel 0.9 % (Cadexomer Iodine) Apply to the bottom of the left foot wound topically, one time a day every Monday, Thursday, and Saturday for the left ankle wound. 8/12/22- Left plantar foot and left ankle wound. Cleanse with normal saline. Pat dry, apply Iodosorb to the wound bed, cover the wound with bordered gauze one time a day every Monday, Wednesday, Friday to the left plantar wound. A. left lateral plantar foot: At the time of the Pressure Ulcer Wound Round on 6/15/22 no weekly skin assessments had been completed since 4/20/22 and there were no nurse's notes or other documentation in the resident's record concerning the resident's left lateral plantar's foot deep tissue injury. It appeared the resident's left lateral plantar's foot pressure ulcer was identified when another pressure ulcer to the left foot was being assessed during wound rounds and left lateral plantar's foot pressure ulcer was first assessed during wound rounds with the wound care physician during Pressure Ulcer Wound Rounds on 6/15/22. The left lateral plantar's foot wound was identified as an unstageable deep tissue injury with intact skin, measuring 1.1 centimeters (cm) by 2.0 centimeters by 0 centimeters. The assessment further revealed the wound bed was without drainage or odor, the wound edges were firm and without redness, and the periwound skin area was intact. The treatment was to cleanse the wound with normal saline, pat dry, apply skin prep and off load, one time a day. The left lateral plantar's foot pressure ulcer was reassessed 6/22/22 during the Pressure Ulcer Wound Rounds. It remained classified as an unstageable deep tissue injury, measuring 1.0 cm by 2.0 centimeters by 0 centimeters. The assessment further revealed the wound bed was without drainage or odor, the wound edges were firm and without redness, and the periwound skin area was intact. The treatment was changed to cleanse with normal saline, pat dry and apply betadine wipes and offload one time a day. The left lateral plantar's foot pressure ulcer was reassessed 6/29/22 during the Pressure Ulcer Wound Rounds. It remained classified as an unstageable deep tissue injury, measuring 1.0 cm by 2.0 centimeters by 0 centimeters and the wound bed was identified with black eschar, no drainage or odor, the wound edges were firm, without redness, and the periwound was intact. The treatment remained the same. The wound was now with nonviable tissue, eschar. The left lateral plantar's foot pressure ulcer was reassessed 7/6/22 during the Pressure Ulcer Wound Rounds. It remained classified as an unstageable deep tissue injury, measuring 0.5 cm by 0.9 centimeters by 0 centimeters with a pink wound bed and without redness, drainage or odor. The periwound was intact. A treatment was to start 7/822 to cleanse with normal saline. Pat dry and apply Iodosorb and cover the wound with a dressing one time a day every Monday, Wednesday, and Friday. The wound bed was pink making it observable and the pressure ulcer should have been staged. The left lateral plantar's foot pressure ulcer was reassessed 7/13/22 during the Pressure Ulcer Wound Rounds. It remained classified as an unstageable deep tissue injury, measuring 0.5 cm by 0.8 centimeters by 0.1 centimeters and the wound bed was without drainage or odor but the wound bed's tissue type and color were not documented, the wound edges were firm and without edges and the periwound was intact. The treatment remained the same. The left lateral plantar's foot pressure ulcer was reassessed 7/20/22 during the Pressure Ulcer Wound Rounds. It remained classified as an unstageable deep tissue injury, measuring 0.5 cm by 1.5 centimeters by 0.1 centimeters. The wound bed tissue type and color were not documented but a small amount of clear serous drainage was documented, the wound edges remained firm and without redness and the periwound was intact. The treatment remained the same. The wound showed deterioration in the width and was now draining. The left lateral plantar's foot pressure ulcer was reassessed 7/27/22 during the Pressure Ulcer Wound Rounds. It remained classified as an unstageable deep tissue injury, measuring 0.5 cm by 1.0 centimeters by 0.1 centimeters. The wound bed tissue type and color were not documented but the wound was with a small amount of clear serous drainage, the wound edges remained firm and without redness and the periwound was intact. The treatment was changed to cleanse with normal saline, pat dry, apply silver alginate to wound and cover with a silicone foam dressing one time a day every Monday, Wednesday, Friday. The left lateral plantar's foot pressure ulcer was reassessed 8/3/22 during the Pressure Ulcer Wound Rounds. It remained classified as an unstageable deep tissue injury, measuring 0.5 cm by 1.0 centimeters by 0.1 centimeters. The wound bed tissue type and color were not documented but the wound continued with a small amount of clear serous drainage, the wound edges remained firm and without redness and the periwound was intact. The treatment was changed to cleanse with normal saline, pat dry, apply Iodosorb to the wound bed, and cover the wound with bordered gauze one time a day every Monday, Wednesday, and Friday. The left lateral plantar's foot pressure ulcer was reassessed 8/10/22 during the Pressure Ulcer Wound Rounds. It remained classified as an unstageable deep tissue injury, measuring 1.0 cm by 2.0 centimeters by 0.1 centimeters. The wound bed tissue type and color were not documented, it was without drainage or odor, the wound edges were firm and without redness and the periwound was intact. An order was given to start on 8/12/22 read; cleanse with normal saline, pat dry, apply Iodosorb to the wound bed, and cover the wound with bordered gauze one time a day every Monday, Wednesday, and Friday. This wasn't a change in the wound order. The left lateral plantar's foot pressure ulcer was reassessed 8/17/22 during the Pressure Ulcer Wound Rounds. It remained classified as an unstageable deep tissue injury, measuring 0.5 cm by 1.5 centimeters by 0.1 centimeters. The wound bed tissue type and color were not documented, it was without drainage or odor, the periwound was intact, the edges were firm and without redness. The treatment remained the same. The left lateral plantar's foot pressure ulcer was reassessed 8/24/22 during the Pressure Ulcer Wound Rounds. It remained classified as an unstageable deep tissue injury, measuring 0.1 cm by 0.1 centimeters by 0.1 centimeters. The wound bed tissue type and color were not documented, it was without drainage or odor, the periwound was intact, the edges were firm and without redness. The treatment remained the same. On 8/30/22 at approximately 12:40 p.m., a wound care observation was conducted with Licensed Practical Nurse (LPN) #5. LPN #5 removed a dressing from Resident #26's left lateral plantar's foot pressure ulcer. The left lateral plantar's foot pressure ulcer pressure ulcer was opened, measuring approximately 0.4 cm by 0.4 cm by 0.2 cm and presented with a pale pink wound bed with no drainage, and no odor. The wound was surrounded by new skin from a previously opened area. LPN #5 cleaned the left lateral plantar's foot pressure ulcer with normal saline, applied Iodosorb Gel and a border dressing. The left lateral plantar's foot pressure ulcer was reassessed by the NP on 8/31/22 at approximately 1:10 p.m., and determined to be opened and without the wound bed was observable to be staged. The NP assessment wasn't made available to the survey team prior to the conclusion of the survey. B. Left great toe: A review of the Pressure Ulcer Wound Rounds documentation revealed Resident #26 was assessed on 8/10/22 with an unstageable deep tissue injury of the left great toe, which measured 0.3 cm by 0.5 cm by 0.1 cm. The wound bed tissue type and color were not documented, it was without drainage or odor, the wound edges were firm and without redness and the periwound was intact. The 8/10/22 NP progress note stated the left lateral great toe was with granulation tissue. A pressure ulcer with granulation tissue should be staged. The Pressure Ulcer Wound Rounds documentation for 8/17/22 revealed the resident was with an unstageable deep tissue injury of the left great toe pressure ulcer increased in size measuring 0.5 cm by 0.5 cm by 0.1 cm. The wound bed tissue type and color were not documented, it was with a small amount of clear serous drainage but no odor, the wound edges were firm and without redness and the periwound was intact. The NP's 8/24/22 progress note stated the resident had a pressure ulcer of the left lateral great toe with granulation tissue but without slough, eschar and signs of infection. The progress note further read the wound treatment was Iodosorb. There was no Pressure Ulcer Wound Rounds documentation for 8/24/22. This wound was documented as resolved on 8/24/22 by the Assistant Director of Nursing. A review of the August 2022 Physician's Order Summary (POS) failed to offer evidence there was a treatment order for the left great toe pressure ulcer. On 8/30/22 at approximately 12:40 p.m., a wound care observation was conducted with Licensed Practical Nurse (LPN) #5. LPN #5 removed a dressing from Resident #26's left lateral great toe. The left lateral great toe pressure ulcer had an open area approximately 0.2 cm by 0.2 cm by 0.1 cm, with a pink wound bed and presented with light yellow drainage. Immediately around the left lateral great toe pressure ulcer was fragile new skin and distally there was blanchable red skin. LPN #5 cleaned the left lateral great toe pressure ulcer with normal saline, applied Iodosorb Gel and a border dressing. The left lateral great toe pressure ulcer was reassessed by the NP on 8/31/22 and determined to be opened with drainage. The NP's assessment wasn't made available to the survey team and a wound care order for treatment of the left great toe were not written after the assessment to be carried out by the licensed nursing staff prior to conclusion of the survey. On 8/31/22 at approximately 11:23 a.m., an interview was conducted with the treating NP and the Wound Care Registered Nurse (RN). The NP stated she didn't change her documentation from deep tissue injury with intact skin because she was under the impression that once a pressure ulcer was classified it had to remain whatever it was identified as until it healed, not that if the wound bed became observable the staging should be changed. The NP also stated she was unaware there had been no treatment orders in place for the resident's left great toe and she thought the resident's left great toe was healed. Upon the NP's reassessment of the resident's left great toe on 8/31/22 at approximately 1:10 p.m., it was identified as opened and with drainage. The NP further stated she was aware the resident favored lying on his left side and the resident's pressure ulcer development was always to the left lower foot and ankle but she hadn't thought to develop a plan to protect the left foot in order to prevent additional pressures ulcers. The NP stated she had ordered nutritional support (Prostat and Juven) to aid in healing of the resident's pressure ulcers. The current care plan had a problem dated 4/22/22 which read; (name of the resident) has a potential for skin impairment related to smoking dry/fragile skin and use of psychotropic medication. The goal read; (name of the resident) potential for impaired skin integrity will be minimized through the review date. The interventions included; float heels as tolerated while in bed. Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate and any other notable changes or observations. The current care plan had a problem dated 7/19/22 which read; resident has a deep tissue injury of the left pinky toe. The goal read; the resident's DTI will be healed by the review date. The interventions included; Treatment as ordered and monitor for effectiveness of treatment. Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate and any other notable changes or observations. Wound consult as ordered. Braden scale completed 6/2/22 revealed Resident #26 had a low risk for pressure ulcer development. It revealed the resident responds to verbal commands, but cannot always communicate discomfort or the need to be turned. OR has some sensory impairment which limits ability to feel pain or discomfort in 1 or 2 extremities. Skin is occasionally moist, requiring an extra linen change approximately once a day. Ability to walk severely limited or non-existent. Cannot bear own weight and/or must be assisted into chair or wheelchair. Eats over half of most meals. Eats a total of 4 servings of protein (meat, dairy products per day. Occasionally will refuse a meal, but will usually take a supplement when offered. Moves in bed and in chair independently and has sufficient muscle strength to lift up. On 9/1/22 at approximately 4:00 p.m., the above findings were shared with the Administrator, Director of Nursing and the Corporate Consultant. An opportunity was offered to the facility's staff to present additional information but no information was provided and no concerns were voiced. M0300: Current Number of Unhealed Pressure Ulcers/Injuries at Step 2: Identify Unstageable Pressure Ulcers 1. Visualization of the wound bed is necessary for accurate staging. 2. If, after careful cleansing of the pressure ulcer/injury, a pressure ulcer's/injury's anatomical tissues remain obscured such that the extent of soft tissue damage cannot be observed or palpated, the pressure ulcer/injury is considered unstageable. 3. Pressure ulcers that have eschar (tan, black, or brown) or slough (yellow, tan, gray, green or brown) tissue present such that the anatomic depth of soft tissue damage cannot be visualized or palpated in the wound bed, should be classified as unstageable, as illustrated at http://www.npuap.org/wp-content/uploads/2012/03/NPUAP-Unstage2.jpg. 4. If the wound bed is only partially covered by eschar or slough, and the anatomical depth of tissue damage can be visualized or palpated, numerically stage the ulcer, and do not code this as unstageable. 5. A pressure injury with intact skin that is a deep tissue injury (DTI) should not be coded as a Stage 1 pressure injury. It should be coded as unstageable. (CMS's RAI Version 3.0 Manual, Chapter 3 page M-8) COMPLAINT DEFICENCY

Based on a resident interview, staff interviews, clinical record review, and review of facility documents, the facility staff failed to provide scheduled around the clock Morphine Sulfate for greater than 24 hours, resulting in constant chest pain with periods of a hammering chest pain which made breathing difficult and increased anxiousness for 1 of 38 residents (Resident #14), in the survey sample. The findings included: Resident #14 was originally admitted to the facility 4/4/22 for rehabilitation and the resident had never been discharged from the facility. The current diagnoses included; scarring related to coronary artery disease with previous bypass surgery, chronic pain syndrome secondary to chronic obstructive pulmonary disease, Long COVID-19, and obstructive sleep apnea, requiring (continuous positive airway pressure) CPAP. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 6/7/22 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #14's cognitive abilities for daily decision making were intact. In section G (Physical functioning) the resident was coded as requiring limited physical assistance of one person with transfers and toileting, supervision physical assistance of one person of one person with bed mobility and walking in the room, supervision with set-up help only with walking off the unit, locomotion, personal hygiene and bathing. During an interview with Resident #14 on 8/31/22 at approximately 1:30, p.m., the resident stated he thought he would have to go to the hospital overnight because of severe chest pain rating 7 out of 10 after receiving the scheduled Lyrica. He stated he experienced periods of constant chest pain, then there was periods of a hammering chest pain which made breathing difficult and increased anxiousness. The resident stated he didn't think to apply his CPAP when his breathing was compromised because he felt a transfer to the hospital was the only answer. The resident voiced these symptoms, in the past, had required transfer to the hospital to manage the pain until it was controlled. The resident stated he had been without the scheduled Morphine Sulfate since receiving the last dose on 8/29/22 at approximately 9:00 p.m., until 6:00 a.m., that morning, 8/31/22. Resident #14 stated the nurses said the Morphine Sulfate hadn't been delivered from the pharmacy. Resident #14 stated the same thing happened approximately 2 months ago but it didn't take as long for the medication to arrive to the facility. The resident stated the nurses don't understand when he has been without the Morphine Sulfate, when he does receive it doesn't control the pain again for at least a day or two. An interview was conducted with Registered Nurse (RN) #2, on 9/1/22 at approximately 11:15 a.m. RN #2 stated on 8/31/22 when she accepted the assignment which included Resident #14 she wasn't informed the Morphine Sulfate wasn't available to the administered and hadn't been available since 8/29/22 at 9:00 p.m. RN #2 stated at approximately 1:00 p.m., when she began passing the 2:00 p.m., medications that she was unable to locate the ordered Morphine Sulfate for Resident #14 but, she saw Norco in the narcotic box for the resident therefore she explained her finding to the Nurse Practitioner (NP) and the NP gave her a onetime order for Norco. RN #2 stated there was no order on the current Physician's Order Summary for Norco yet she didn't realize it was a discontinued medication and should not have stored with the active medications. RN #2 additionally stated she made no other attempts to obtain the Morphine Sulfate and she didn't discuss not having the Morphine Sulfate available to administer with anyone after speaking with the NP, including the pharmacy staff. On 9/1/22 at approximately 2:40 p.m., an interview was conducted with the Director of Nursing (DON), regarding the Morphine Sulfate for Resident #14. The DON stated she wasn't aware there was a concern regarding the Morphine Sulfate until the surveyor asked for documents referencing the drug. The DON stated obtaining a onetime dose of Norco wasn't a substitute for not having the scheduled medication and it wasn't likely to control the Resident's pain. The DON stated she had no further information to present regarding the unavailable Morphine Sulfate. A review of the Physician Assistant - Certified (PA-C) progress note dated 8/15/22 stated the resident's pain didn't improve with use of the Norco therefore a rotation of Morphine Sulfate and an increase in Lyrica were instituted to achieve effective pain control. The August 2022 Physician's order summary revealed an order dated 7/6/22 for Morphine Sulfate Tablet 15 mg; Give 0.5 tablet by mouth every 8 hours for chest wall pain. A review of the medication administration record (MAR) revealed the resident receive the a 10:00 p.m., scheduled dose of Morphine Sulfate on 8/29/22 but on 8/30/22 the Morphine Sulfate wasn't administered at 6: 00 a.m., and 2:00 p.m., the documentation was coded 9, Other/See Nurse Notes, and scheduled dose of Morphine Sulfate wasn't administered at 10:00 p.m., the documentation was coded 11, Held Per Parameters. There were no information referencing parameters for this medication. A review of the nurse's progress note revealed no supporting documentation for the above codes (9, 11) and no assessments indicating the resident's status without administration of the scheduled doses of Morphine Sulfate. A review of the current care plan dated 8/2/22 had a problem which read; (name of the resident) has complaints of chest and neuropathic pain. The goal read; (name of the resident) will have well-controlled pain through review date, 9/11/2022. The interventions included; administer medication/treatment as ordered. Monitor/document side effects and effectiveness. Monitor vital signs during reported chest pain episode (at least q 5 min). On 9/1/22 at approximately 4:00 p.m., the above findings were shared with the Administrator, Director of Nursing and the Corporate Consultant. An opportunity was offered to the facility's staff to present additional information but no information was provided and no concerns were voiced. Morphine sulfate is a strong analgesia used to relieve severe, acute pain or moderate to severe, chronic pain. (pubchem.ncbi.nlm.nih.gov/compound/16051935) Lyrica capsules, oral solution (liquid),and extended-release (long-acting) tablets are used to relieve neuropathic pain (pain from damaged nerves) that can occur in your arms, hands, fingers, legs,feet, or toes if you have diabetes and postherpetic neuralgia (PHN; theburning, stabbing pain or aches that may last for months or years after anattack of shingles) (https://medlineplus.gov/druginfo/meds/a605045.html)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, facility document review and during the course of a complaint investigation the facility staff failed to provide ongoing assessments, monitoring and identification of a change in condition after an unwitnessed fall for 1 of 43 residents in the survey sample, Resident #350. Subsequently, six hours later the Resident Representative visited the resident, identified a change in condition and requested the staff call the physician. The resident was sent to the emergency room and found to have an acute encephalopathic (brain) change as a result of new onset seizure in addition to an acute/subacute infarct right cerebellar hemisphere (stroke), resulting in harm. The findings include: Resident #350 was admitted to the facility on [DATE] with diagnoses to include cerebrovascular disease, type II diabetes, unspecified abnormalities of gait, mobility, and muscle weakness. Approximately 48 hours later the resident was sent to the emergency room (ER) on 4/6/19 and admitted . The facility Admission/readmission Data Collection document dated 4/4/19 assessed the resident as arriving to the facility at 5:30 p.m., oriented to person, usually makes self understood, understands, pleasant and content, no obvious behaviors, required one person assist with bed mobility, transfers, ambulation with use of a walker. Section N3. Fall Risk identified the resident did not have a history of falls in the last 30 to 90 days. The resident was oriented to the bathroom, activities, roommate, mealtimes, call light/bell and staff. The nurse documented, Very pleasant lady with no complaints for skilled nurdsing {sic}. The Physical Therapy Initial Evaluation conducted on 4/5/19 documented the resident presented with decreased overall endurance and cadence as well as CGA (contact guard assist) for all mobility. The resident had a history of stroke with moderate to severe cognition deficits on evaluation and demonstrated good rehab potential as evidenced by active participation with plan of treatment, motivated to return to prior level of function and supportive family/ caregivers. The resident was identified as having one fall in the last year and ambulated at home utilizing a single point cane. The skilled nursing note dated 4/5/19 entered at 1:07 p.m., documented the resident was aware of self and surroundings with episodes of confusion, able to make needs known, and needs assistance with activities of daily living. The complainant alleged in the complaint form received at the Office of Licensure and Certification, that on 4/6/19 upon arrival to the resident's beside at approximately 2:00 p.m., she immediately identified that there was something wrong with the resident. She described the resident as didn't respond to me, shaking her head from side to side and mumbling. The complainant went to the nurses station to ask the nurse what happened. She indicated the nurse came to the room and told her she had found the resident in the bathroom earlier that morning at approximately 8:00 a.m. The complainant asked why was she not notified of the fall, the nurses response was that they normally don't call family members that early, the complainant stated it was now 2:00 p.m. why had she not been called by now. The complainant also asked if the physician had been notified and the nurse stated no because she thought that was the resident's normal state. The complainant told the nurse that she needed to call the physician immediately. The nurse then called the physician and obtained an order to send the resident to the ER for evaluation. Further investigation evidenced the identified nurse as Licensed Practical Nurse (LPN) #6. LPN #6 failed to provide ongoing assessments and monitoring for an acute change in condition for Resident # 350 following the unwitnessed fall in the bathroom from approximately 8:30 a.m. through 2:30 p.m., a total of six hours. There were no assessments, monitoring or neurological evaluations conducted per the facility's policies and procedures; also the incident was not documented until four days later on 4/10/19. The two late entries dated 4/10/19 from LPN #6 were as follows: at 10:54 a.m., resident was found sitting up on the floor in the bathroom with both legs in one pajama pant leg. Also noted to have pull-up half way pulled up. No apparent injuries noted. Able to move all extremities as before. Transferred back to bed with 2 person assist and made comfortable. Noted to be sluggish but responsive to writer. VS-127/73-74-96.9-20-94% RA (room air). Resting quietly in bed at this time. Call bed in reach. The second entry at 11:13 p.m., read as follows: Daughter was in to visit around 2:30 PM and stated that this is not her (the resident) normal self and wanted to know if anything happened to her. Daughter was made aware of resident being found on floor in bathroom. Laying in bed sluggish and now unable to respond or answer questions. VS-126/71-85-97.1 AX (axillary)-98% on room air-18. On-call made aware and new order received to send to ER. LPN #6 was no longer employed at the facility. A voicemail request for an interview was made on 1/27/20 however, prior to exit LPN #6 had not returned the phone call. A review of LPN#6's employee record evidenced an Employee Corrective Action Form dated 4/9/19, date of infraction was 4/6/19. LPN #6 received a written warning for failure to perform fall procedure, failure to notify MD, and failure to assess patient and identify change in condition. LPN #6 declined to sign the form. Re-education was provided on 4/17/19 for fall protocol, neuro checks, notification of MD and Resident Representative (RR) immediately after a fall, any resident change in condition is to be documented and Resident Representative and MD to be notified. LPN#6's employee file and the staffing as worked schedule evidenced date of hire was 3/9/19, facility classroom orientation on 3/27/19, 3/29/19, and 4/1/19. The first work shift on the unit was 4/6/19. There was no orientation staff identified as assigned with LPN #6 on 4/6/19, there was no RN supervisor scheduled until the 3 p.m.-11 p.m. shift. The hospital records evidenced the following documentation, diagnostics and findings: On 4/6/19 at 4:57 p.m.-Presented in the ED (Emergency Department) with altered mental state. Patient was found in the bathroom floor with change in mental status. There was no witnessed fall. On presentation in the ED CT of the head was done (4/6/19 at 7:13 p.m.) with no acute intracranial abnormality. Chest x-ray done shows evidenced of early CHF (congestive heart failure) .Patient was given Lasix IV (a diuretic). Will admit patient for altered mental status work up to rule out stroke. Physical exam-appears lethargic. 4/7/19 at 12:02 a.m.-MRI results-1. Abnormal study 2. Acute/subacute infarct (obstruction of the blood supply/stroke) right cerebellar hemisphere. 4/9/19-Neurology Consult-MRI of brain demonstrated several new areas of ischemia (blood flow is restricted) including right cerebellum. Also EEG (electroencephalogram-a test that detects electrical activity in the brain) with sharp waves arising from the left parietal area. Consistent with cortical irritability and decreased threshold for seizures. She has not been on AED therapy (Anti-epileptic drug) .They report that the day prior she had been conversational. Was able to get herself ready and was walking with a walker. The Details of Hospital Stay-Hospital Course- .There was concern for seizures, therefore EEG was obtained which was suggestive of seizures, showing sharp waves emanating from the right tempoparietal region consistent with cortical irritability. Therefore, neurology started Keppra (anti-epileptic drug) 500 milligram bid (twice a day). Primary Discharge Diagnosis- Principal Problem 1. Metabolic encephalopathy due to probable seizures 3. Acute right cerebellar CVA (stroke). The Nurse Practitioner who gave the order to send the resident to the ER was interviewed on 1/28/20 at 1:15 p.m. She stated when a resident falls they can present without injuries. The main reasons neuro checks are conducted after falls it to catch altered mental status changes/ injuries and assist with determining whether a resident needs to be sent to the ER for emergency interventions. She stated, The neuro checks definitely should have been done. The above findings was shared with the Administrator on 1/28/20 at approximately 2:30 p.m. No additional information was provided prior to exit. The facility Policies and Procedures subject: Fall Management revised date 7/29/19 read in part, as follows: Purpose-Is to identify residents at risk for falls and establish/ modify interventions to decrease the risk of a future fall and minimize the potential for a resulting injury. C. Post Fall Strategies: 2. Initiate Neurological checks as per policy or directed by physician order 3. Notify the Physician and resident representative The facility Policies and Procedures subject: Neurological Evaluation revised 8/22/17 read in part, as follows: Perform neurological checks as follows unless otherwise ordered by the physician: Every 15 minutes for 1 hour. Every hour for the next 4 hours. Every 4 hours for the next 19 hours. Document neurological checks, vital signs and observations on the appropriate form. Place in medical record. Notify physician of any changes in condition. The neurological assessment includes; level of consciousness-alert, drowsy, stuporous, coma, pupil response, hand grasps, extremities and pain response. Complaint deficiency.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a complaint investigation, clinical record review, staff and family interview, and facility documentation, the facility staff failed to ensure 1 of 43 residents (Resident #287) with an indwelling urinary catheter received care and services to include prompt recognition of signs and symptoms of a urinary tract infection and sepsis. The facility staff failed to demonstrate ongoing assessment and monitoring, as well as implement UTI/Sepsis protocols for Resident #287 who presented as symptomatic for UTI and Sepsis. The resident was diagnosed in the local hospital with severe urosepsis and AKI (acute kidney injury/acute kidney failure) resulting in harm. The finding include: Resident #287 was originally admitted to the nursing facility on [DATE] with a principle diagnosis of multiple sclerosis with quadriplegia. Other significant diagnoses included diabetes, depression, neuromuscular dysfunction of the bladder with an onset date of [DATE] and an indwelling urinary catheter, morbid obesity and high blood pressure. Resident #287's most recent hospital stay was on [DATE] through [DATE] for complaints of chest pain and readmitted to the nursing facility with diagnoses of chronic atrial fibrillation. The resident was discharged to the local hospital on [DATE] and did not return to the nursing facility. Resident #287's Minimum Data Set (MDS) in effect prior to the [DATE] discharge from the facility was a quarterly dated [DATE]. The resident was coded a 15 out of a possible score of 15 on the Brief Interview for Mental Status (BIMS) which indicated she was cognitively intact in the skills needed for daily decision making. The resident had the ability to fully understand the staff and was understood. The resident was not coded to reject care that included lab work, taking medications or Activities of Daily Living (ADL) assistance. Resident #287 was assessed to require total dependence on two staff for bed mobility, transfers, toilet use, dressing and bathing. She was coded to need total assistance from one staff for eating, locomotion on and off the facility and personal hygiene. A wheelchair was coded as her main mobility device. The resident was assessed to have an indwelling urinary catheter and was frequently incontinent of bowel. The care plan dated as last revised on [DATE], included Resident #287 had a focus area related to altered bladder elimination and the goals set by the staff was that the resident would not develop symptoms of UTI, and that the resident's risk for septicemia would be minimized/prevented via prompt recognition and treatment of symptoms of UTI, and the resident would not experience complications related to catheter use. The care plan did not indicate a diagnosis of UTI in 2017 prior to discharge [DATE]. Some of the interventions the staff would employ to accomplish these goals included monitor and report to MD (medical doctor) PRN (as needed) for signs and symptoms of UTI that included supra-pubic pain, cloudy urine, altered mental status, abnormal vital signs and behavioral changes. Obtain and monitor labs and diagnostic work as ordered by the physician, report results to MD and follow up as indicated. The nurse's notes dated [DATE] at 6:53 a.m. was written by the 11/7 Licensed Practical Nurse (LPN) #9 (schedule shift at 11 p.m. on [DATE] through 7:00 a.m. on [DATE]) indicated the following: Resident c/o (complaint of) vaginal burning, peri care and catheter care administered. Shower given on 11/7 shift. Effective. Continuing to monitor. The same LPN #9 entered the follow-up nurse's note on [DATE] at 7:12 a.m.: Resident has been displaying behaviors during shift. Hollering out. Resident c/o pain, medications administered, ineffective. Resident continues to holler disturbing roommate and causing agitation. Continuing to monitor. LPN #9 was not available for interview, no longer employed by the nursing facility. The facility initiated an investigation on [DATE] into the Resident Representative's (RR) concerns about delay in care 6/1-2/17 and LPN #9 wrote a statement. The statement indicated when she reported to work for the 11/7 shift ([DATE] at 11:00 p.m. through [DATE] at 7:00 a.m.) the resident was yelling out some. She wrote she and the CNA gave the resident a shower because of her complaints of vaginal burning, performed peri care, administered pain medication between 5:00 a.m. and 6:00 a.m. and reported off to LPN # 10 ([DATE]-[DATE] shift). LPN #10 who took over as the assigned licensed nurse responsible for Resident #287's care on [DATE] for the 7/3 shift was not available for interview, no longer employed by the nursing facility. LPN #10's written statement was not included in the investigation file provided to this surveyor. The Certified Nursing Assistants (CNA's) that were assigned to the resident on [DATE] and [DATE] for all three shifts were not available for interview, no longer employed by the nursing facility. The [DATE]-[DATE] shift CNA indicated in a written statement that she was told by the 11/7 shift CNA that the resident had some screaming during the night. She wrote she got the resident up in the chair for breakfast and she only ate 25 % of he breakfast, ate only a few bites for lunch and ask to go lay down, she was tired and wanted to rest. There were no nurse's notes that demonstrated further assessments and monitoring took place on either the 7/3 shift on [DATE] or the 3/11 shift prior to the SBAR (Situation/Background/Assessment/Recommendation report on [DATE] at 6:12 p.m. The SBAR report indicated the following vital signs: Blood pressure (BP)= 110/60 (marginally low); pulse=120 (tachycardia); respiratory rate=20 and temperature=98.2 F (Fahrenheit) obtained axillary (underarm), oxygen saturation=90% on room air (95-100=normal range). The narrative nursing note portion of the SBAR included the following: Sister in to visit resident (5:46 p.m. on [DATE]) and noted change in her. Resident awake with altered mental status. Resident was assessed and had a heart rate of 120 and O2 sat (Oxygen saturation) of 90% on room air and she was put on O2 @ 5L (liters)/minute via n/c (nasal cannula) & (and) SATs increased to 95%. BS (blood sugar)-113. She will be transferred to (local hospital's name) E.R. (emergency room), 911 called and report called to transfer center. It was annotated on the SBAR that the aforementioned assessment was reported to the physician. The resident had a current operational DNR (do not resuscitate order). LPN #2 signed off as the the licensed nurse who completed the SBAR report, as well as the nurse who was assigned responsible to provide care for Resident #287 on [DATE] for the 3/11 shift. On [DATE] at 3:45 p.m., an interview was conducted with LPN #2. She stated she could not remember if she was given a report on Resident #287 when she started the 3/11 shift on [DATE]. She stated the resident was pleasant and she did not recognize any physical problems. She stated she could not remember if she got out of bed for dinner on [DATE] as usual. She stated the Administrator and Director of Nursing (DON) told her the RR indicated in a letter that a minister had come in during the 3/11 shift and said he told someone about Resident #287's decrease in responsiveness and ask if she assessed the resident due to the minister's concern. She further stated she did go into the room at that time and asked the resident is she was okay, as she was looking out the window at the birds. When asked why she did not take the opportunity to make an assessment of the resident and document it in the nurse's note's she said, I maybe should have. On [DATE], LPN #2 wrote a statement for the Administrator and DON that on [DATE] (no time) the resident was in bed and that the priest who visited stayed in the room no more than 2 minutes and came to her saying the resident was not making much sense. She wrote in her statement that she checked on the resident and asked it she was okay and that the resident said yeha, 20 minutes later she was being sent to the E.R. This information was not shared with the Administrator or the DON prior to the start of the investigation on [DATE]. During the interview with this writer, LPN #2 stated she could not remember whether the resident was up for dinner, but wrote in her statement the resident was in bed at the time she checked on her, which would have been between 5:00 and 6:00 p.m. LPN #2 also wrote that on the previous day ([DATE] during the 3/11 shift) the resident's urine was dark and cloudy with sediment, but that it had always been that way since she had the catheter. LPN #2 further stated during the above interview that although she signed the SBAR, she was not the person who performed the assessment on [DATE] at 6:12 p.m., other nurses were present and she recorded their findings. She said the RR came to the nurse's station [DATE] to ask that someone come to assess Resident #287 because she was not very responsive. She stated she knew the signs and symptoms of a urinary tract infection to include restlessness, behavioral changes, color and sediment of the urine, as well as a possible elevated temperature. She stated she was not sure of signs and symptoms of sepsis, but did attend the recent skills fair on [DATE] but was sure that was not one of the topics. This surveyor verified the skills fair [DATE] did not include signs and symptoms of UTI/sepsis. Recent mandatory inservices were conducted on [DATE] and [DATE] as a requirement for a partnership merger with an organization that assist with strategies to decrease in unnecessary resident readmissions to hospitals. One of the required training's included Understanding Sepsis. Out of 60 nursing staff, four RN's attended, two of the RNs were the DON and the Assistant Director of Nursing (ADON), 7 LPNs and 16 CNAs. LPN #2 did not complete the mandatory inservice on Understanding Sepsis. On [DATE] at approximately 9:30 a.m., an interview was conducted with the Administrator and the Director of Nursing (DON). They stated on [DATE] the RR showed up in the building and wanted to meet with the both of them and that she was tearful and expressed that the resident died the previous day. They stated they started an investigation on [DATE] after the Resident Representative (RR) delivered a letter under their door on [DATE] alleging neglect in care for Resident #287. The letter which indicated that the RR was told by the visiting minister that checked in on [DATE] around 2:56 p.m. that he went to the resident's room to find her moaning and staring in space. The letter indicated the minister approached the nurse's station to let them know of her condition and even mentioned it to the activities director. The activities director wrote a statement [DATE] that indicated on [DATE] at 3:45 p.m., a church volunteer told her he informed a nurse that the resident was not well and she thanked him for making the staff aware. The activities director was no longer employed by the facility and was not available for interview. The letter indicated no one checked on Resident #287 or if they had they would have taken immediate action based on her level of consciousness. The letter also indicated that when the RR arrived [DATE] at 5:15 p.m., she found the resident in bed and not in the dining room as per her usual routine for dinner. The RR indicated in the letter she found the resident in the same condition as the minister and unable to communicate to her what happened, thus she approached the nurse's station to report her condition at which time the the Administrator, DON and a few nurse's went to the resident's room to assess her. The letter indicated the resident was sent to the E.R. admitted to the hospital's ICU and diagnosed with a bad urinary tract infection. The letter indicated the RR visited the resident in ICU the following day and told her she would be back, but the resident died 1.5 hours later. She alleged gross neglect by the facility. The facility concluded their investigation on [DATE] conducted by the Administrator and DON that consisted of interviews with staff, review of facilities policy and procedures and review of medical record. They found the allegation to be unsubstantiated based on their investigation. During the aforementioned interview, the DON was asked what was the expectation of the nursing staff in review of the nurse's notes and the documented change in condition during the 11/7 shift (6/1-2/17). The DON first stated, Maybe there was no need to document anything because she was a long-term care resident and we only document by exception. They washed her up and she felt better. Upon taking a closer look, she agreed there were no documented assessments that would reflect monitoring of a possible UTI after it was noted the resident complained of burning and pain which was a potential symptom. The signs of UTI would have come from nursing actions, which would have been the results of their assessment and monitoring (e.g., vital signs, behaviors, appearance of urine) which was not evident in the clinical record (e.g., nursing notes, vital sign records). The DON agreed that there was no follow-up after pain medication administered in the early morning hours of the 11/7 shift was documented in the nurse's notes as ineffective, as well as further follow-up on hollering and behaviors exhibited during the shift. Additionally, there were no nurse's notes on the 7/3 shift, where in the above CNA's statement she wrote the resident did not eat much, felt bad and requested to go to bed. In addition, the resident did not get up for dinner as usual which exhibited potential decline in physical status and a change in her normal activities. The DON then stated she expected to see vital signs obtained and recorded, level of consciousness documented, further record of the color of the urine, expounding on her behaviors they earlier documented on the 11/7 shift, as well as a call to consult with the physician or nurse practitioner to report the findings and accept guidance for any orders. The DON could not explain lack of a documented assessment from LPN #2 during the 3/11 shift, especially if she checked on the resident after she stated the minister said the resident was not making sense. She could not explain why there was not evidence of any assessment or monitoring until the RR approached the nursing staff to insist someone address Resident #287's change in condition around dinner time on [DATE]. When this surveyor asked to review the 24 hour reports, the DON stated she would look for them. She and the Administrator returned on [DATE] at 10:30 a.m. with the 24 hour report dated [DATE] for 11/7 and 7/3 shift which was blank, and the 3/11 block indicated the resident was sent to the (local hospital name) E.R. at 6:20 p.m. with altered mental status/tachycardia and admitted to the ICU. During the above interview, the Medication Administration Record (MAR) was reviewed to reveal when pain medication was recorded in the nurse's notes as administered on 11/7 shift [DATE], the only pain medication would have been acetaminophen, which was not signed off on the MAR as given during the night shift or early morning hours. The DON stated, She probably gave it and forgot to sign it off on the MAR. The DON stated, I tell nurses, train nurses, but still have problems. We will have to do more. The Administrator and DON presented policies that were in effect during Resident #287's stay that outlined clear guidelines for nursing assessment and monitoring and documentation of such for UTI and sepsis. A time line had been presented to this surveyor completed by the regional nurse regarding the resident's output, which was not in question but whether appropriate assessments, monitoring for signs and symptoms of UTI/Sepsis recognized by the nursing staff with notification to the physician/nurse practitioner. The time line revealed there was no assessment or monitoring throughout the 11/7 shift or on the subsequent two shifts to include vital signs or a call to the physician based on the residents expressed symptoms of burning and unrelieved pain. The time line noted that the sister (RR) was in to visit and noted a change in the resident, after which the staff performed an assessment, exhibited in aforementioned SBAR dated [DATE] at 6:12 p.m. and sent her out 911. The most recent laboratory results were sent out with the resident that were obtained [DATE], a Complete Blood Count (CBC) and Basic Metabolic Panel (BMP) that checked electrolytes, BUN and creatinine (renal function status) none of which warranted treatment. The Administrator and DON stated there were no other labs in 2017 to include a U/A or C&S. On [DATE] at 10:45 a.m., an interview was conducted with the current Nurse Practitioner (NP). She stated she was not the NP during Resident #287's stay, but the attending physician was the same and she was currently in practice with him and felt she could give her professional take on the Resident #287's case by review of the clinical record. She also stated she would be covering for the attending over the next two days. From review of the nurse's notes she stated the nursing staff missed many opportunities to make good assessments and call the physician for further guidance. She stated she actually saw no assessments and monitoring even on the 11/7 shift with the lack of vital signs, visualization of urine, mental and behavioral status. She stated there appeared that nothing was done on the 7/3 and 3/11 shift until the RR informed them something was wrong. Upon review of the SBAR, the NP stated the resident had signs and symptoms of sepsis to include a temperature that was recorded obtained via axilla at 98.2 which was not reliable and 1.5 to 2.0 points would be added for an accurate temperature reading. She stated the resident had just finished antibiotic therapy on [DATE] for a skin infection which often can yield antibiotic resistant infections, like Methicillin Resistant Staphylococcus Aureus (MRSA) or Extended Spectrum Beta-Lactamases (ESBL-in urine) so close assessment and monitoring especially in light of what was already noted was vital with a call to physician or NP to let them know what was going on like the burning, behaviors and ineffective pain management from the medication. The signs and symptoms of Sepsis was brewing and the nursing staff did nothing from what I can see here. To avoid sepsis, the nursing staff have to assess for the signs and symptoms, which it looked like the resident probably had them that required prompt treatment to prevent a septic situation. The NP stated with sepsis the resident's BUN and creatinine would have been elevated upon arrival to the ER with potential Acute Kidney Injury (AKI) with systems failure. During the above interview, the NP stated if there had been a call to the physician during the 11/7 shift on 6/1-[DATE] there could have been a dip stick urine ordered STAT that would have shown nitrates and white blood cells. She stated she knows the facility had the reagent strips for the test in the nursing facility accessible to the nurses. Based on those results that are immediate, an antibiotic could have been ordered. She further stated a STAT Urine Analysis (UA) would have come back in a couple of hours at the first of any concern from the nurses that would have shown white blood cells, red blood cells, bacteria which would have also been highly suggestive of a UTI. She stated, the culture and sensitivity report within 3 days would have shown more specificity and possible need to change antibiotic choice based on sensitivity report. She said she would have also ordered a STAT Complete blood count and renal profile to assess renal function or organ failure from systemic infection. She stated if a call had been made to the attending or NP early on, an order could have also been given to the nurses to just send the resident out for evaluation in the E.R. Review of the hospital records indicated the following: Resident arrival [DATE] at 6:35 p.m., vital signs-BP=99/54 (hypotension); pulse=112 (tachycardic); respiratory rate=22 (tachypnea) and temperature=99.7. Oral mucosa dry. Patient was not able to give information about condition. Labs drawn to reveal blood urea nitrogen (BUN), an indicator of renal function, of 60 (9-26=normal range); Creatinine, also an indicator of renal function, of 2.1 (0.4-1.0=normal range); venous lactic acid, an indicator of a severe infection such as sepsis and septic shock, of 6.36 (.50-2.20=normal). The U/A revealed large amounts of blood (negative is normal), positive nitrates (negative is normal); 40 WBC (0-5=normal); RBC TNTC (Too numerous to count) with 0-5=normal; and 15 ketones (negative=normal). The final results of the culture and sensitivity report came back on [DATE] that indicated an antibiotic resistant organism in the urine of ESBL greater than 100,000 and proteus mirabilis greater that 100,000. The resident was diagnosed with severe acute sepsis and septic shock with evidence of end organ damage to include acute kidney injury (AKI)/acute kidney failure with the focus of infection likely UTI. The resident was started on Intravenous Fluids (IV) for hydration and kidney perfusion, as well as antibiotics. Resident #287 was diagnosed with severe urosepsis and septic shock with acute renal failure, also referred to as AKI (acute kidney injury). She expired on [DATE] at 10:00 p.m. and the cause of death was recorded due to severe urosepsis. On [DATE] at 12:15 p.m., a telephone interview was conducted with the RR. She stated on [DATE] at around 5:15 p.m. she went to the dining room to feed the resident per her normal routine, but did not see the resident. She stated the resident loved to eat and was always up for meals to include the dinner meal. She stated she went to the resident's room to find her listless and unable to communicate as usual, after which she immediately went to the nurse's station to inform the nurse. She said several nurses converged in the room and started to make assessments. She said she made a suggestion that the resident be sent out to the hospital and that the nursing staff agreed with her and took action. She stated she went to the hospital visited the resident and she was not very responsive to her. She stated the resident died the following day from sepsis. The RR said she visited the nursing facility on [DATE] to share some of her concerns. When she left the meeting, she stated she met a staff person in the parking lot who said she was sorry about her loss and told her a minister had been in and saw the resident in the same state, notified the nursing staff and nothing was done, no one went down to assess the resident. She said she went in to retrieve the name of minister from the visitor's log and made a phone call to him once she returned home. According to the RR, the minister recounted exactly what was told to her by the staff person in the parking lot (no longer employed by the facility). The RR stated she gathered her thoughts about what she observed and what the minister observed and felt there was delay and neglect in the care of the resident. She stated she came back to the facility on [DATE] with a letter and a request to address the Administrator and the DON. She said they told her You have already spoken to us about the matter and there is nothing more to talk about. She stated she was more upset about that inference that she could not talk to them than anything, so she slipped the letter under the door and heard no further word from them. This surveyor reviewed the visitor's log that verified a minister from the church and same name she indicated visited residents on [DATE] from 2:35 to 4:25 p.m. On [DATE] at 2:13 p.m., another surveyor completed the infection control review with the DON and the ADON. This surveyor stated the DON and ADON told her regardless of whether a resident had a indwelling urinary catheter or not, they expected assessment and monitoring to take place for resident's that exhibited signs and symptoms of UTI to ensure prompt treatment and to avoid sepsis. They told the surveyor the physician should be called, and a urine dip stick could be ordered by the physician for immediate results and or a U/A and C&S. They indicated during the interview changes in condition that warranted immediate attention related to potential sepsis included elevated temperature, low BP, confusion, behavioral changes and pain, abnormal O2 saturation, increased respiratory rate, and a results of a glucose finger stick if diabetic, as well as a call to the physician. They showed the surveyor an algorithm (dated 2014) the facility used to recognize UTI/sepsis that indicated the same, in addition to evaluation of the ordered labs by the physician and decision to treat in the facility with Oral, IV or subcutaneous fluids if needed for hydration, as well as antibiotics, close monitoring with further evaluation in the E.R. The facility's policy and procedures titled Infections-Clinical Protocol dated revised [DATE] indicated that infection may be suspected based on clinical signs and symptoms and/or temperature. The policy indicated for anyone suspected of having an infection (abrupt change in function, appetite, mental status, etc.), nursing staff will obtain a complete set of vital signs (temperature, heart rate, blood pressure, and respiratory rate) and will identify and document specific details of symptoms and physical findings. Nursing will notify the physician or provider of all pertinent details about the residents condition. The nursing staff will continue this form of monitoring and assessment. The nursing staff and physician or provider will identify possible complications of infection such as sepsis and delirium. Based on the preceding information, the decision would be made by the physician or provider whether additional testing (CBC, U/A to check for WBC, pus and nitrate level) is indicated and whether other active conditions related to infection also need treatment. COMPLAINT DEFICIENCY