Every finding on record at Alden Estates of Shorewood

Based on interview and record review, the facility failed to keep a resident free from accidents and injuries. This applies to 1 of 3 residents (R1) reviewed for accidents/injuries. The findings include:On 08/04/26 at 9:35 AM, R1 was sitting in a wheelchair with a mechanical lift sling under her. V7 (CNA/Certified Nursing Assistant), V8 (CNA), and V9 (Wound Care Nurse) were in the room assisting R1. R1 had a right-hand contracture. R1 was unable to communicate verbally. V7 and V8 applied a brace over R1's head to protect her chest and back. V7 stated the brace was to stabilize R1's fracture. A mechanical lift was noted in the room and V7 stated they had gotten R1 up in the wheelchair via the mechanical lift. The facility's Initial Report faxed to Illinois Department of Public Health dated 07/30/26 for R1 showed On 07/27/26, resident was transferred to (Hospital) due to abdominal pain and was admitted with abdominal pain. (Hospital) sent updates today 07/30/26 stating resident has an acute superior endplate fractures of T11 and L2. (Physician) and R1's son was notified. Investigation initiated immediately. Final report to follow. The initial report did not mention R1 had a fall from a mechanical lift on 07/21/26.On 08/04/26 at 2:55 PM, V3 (CNA/Certified Nursing Assistant) stated on 07/22/26 he and V5 (CNA) were attempting to transfer R1 to bed via mechanical lift. V3 stated he hooked the yellow loops of the sling to the bar, he was in the back of R1, holding her. V3 stated V5 hooked the red loops on the sling to the bar and was in front of R1 controlling the lift. V3 stated the loops that he hooked were secure, he did not know if the loops V5 applied were secure. V3 stated R1 was in the air, near the level of his chest. V3 stated as V5 was turning the lift, the front left loop on the sling became loose, and R1 fell from the sling fast. V3 stated R1's back or buttocks hit the floor, but he supported her head from hitting the floor. V3 stated R1 was screaming in pain after the fall and had redness to her mid back.On 08/04/26 at 3:55 PM, V5 stated he and V3 were using a mechanical lift to put R1 to bed. V5 stated he applied the yellow loops of the sling to the lift and V3 applied the red hooks. V5 stated he operated the lift and as he was closing the legs on the lift, the top right side of the sling detached from the lift. V5 stated R1 fell backwards as she was sliding out of the sling. V5 stated he did not how the sling became detached from the lift. On 08/04/26 at 4:24 PM, V2 (DON/Director of Nursing) stated she was not in the facility when R1 fell from the mechanical lift. V2 stated she was informed by V3 and V5 that the sling came down on one side. V2 stated R1 had redness to her back that could have come from lowering her down to the floor. V2 stated R1 had been complaining of abdominal pain and her family wanted her sent to the hospital for an evaluation. V2 stated R1 was admitted to the hospital on [DATE] with abdominal pain. V2 stated while R1 was admitted to the hospital, a CT (Computed Tomography) was done which showed R1 had a fracture to T (Thoracic)11-L (Lumbar) 2. On 08/04/26 at 4:42 PM, V1 (Administrator) stated the investigation into R1's fall was still ongoing. V1 stated at the present time, she was not sure how the sling loosened and there could have been a malfunction with the lift. Fall Incident report dated 07/21/26 at 7:20 PM showed During RN (Registered Nurse) shift report, CNA (Certified Nursing Assistant) reported that resident is on the floor, observed resident laying on the floor, with mechanical lift sling under her, with her head laying on another CNA lap being supported. Resident awake and saying hello/hello! Resident unable to give description. When asked resident for any discomfort, states I don't know, complete skin check done. Pinkish area on lower back. Mechanical lift sling checked, no tears observed, lift functioning as usual. Assisted resident to bed using mechanical lift by six staff. Initial vital signs taken, emotional support and reassurance provided to resident as repetitively saying hello until she got to bed. Ice pack applied to lower back after incontinence care rendered. Resident not taken to the hospital. Intervention to ensure education provided on ensuring and all responsible parties are notified. Progress Note dated 07/23/26 showed Body assessment done, a light discoloration is noted to the back of right shoulder, but unable to determine if this is a normal skin discoloration or the start of a bruise, will continue to monitor. Call placed to NP (Nurse Practitioner), awaiting call back. Progress Note dated 07/26/26 at 12:00 PM states, Daughter requesting for resident to get a new wheelchair that sits back for comfort. Daughter stated that she has realized that resident is uncomfortable in the wheelchair for long periods of time and would like her in the bed when resident starts making noises. Progress Note dated 7/26/26 at 1:20 PM states, Patient daughter contacted facility and was demanding that an MRI (Magnetic Resonance Imaging) of patients back be completed due to patient being more agitated since fall on 07/21/26. Progress Note dated 07/27/26 at 12:57 PM states, Resident yelling out, writer to bedside to assess needs. Resident localizes pain to her abdomen upon assessment, gestures that she wants to be transferred to bed. Progress Note dated 07/27/26 at 2:53 PM states, Patient's daughter to facility to check on mom, spoke with sister and brother via phone and called writer to patient's room. Writer entered room and daughter states all three kids would like patient to go to the emergency room for further workup. Patient's family does not want to wait any longer and requests MRI to be done of spine and abdomen at hospital. NP notified and gives orders to send patient to emergency room. Progress Note dated 07/27/26 at 3:51 PM states, Patient left facility via non-emergency ambulance transport on a stretcher to hospital. Progress Note dated 07/28/26 12:05 AM states, Writer spoke to RN, patient admitted for abdominal pain. Hospital Computed Tomography (CT) dated 07/27/26 showed Abdominal Wall and Bones: There are superior endplate fractures of T11 down L2 which are the abdominal wall is unremarkable. Diagnostic Radiology dated 07/27/26 showed Reason for Exam: (XR Spine Thoracic 3 views) Spinal Injury. Findings: There is subtle superior endplate fracture of T11 (Thoracic) which appears slightly increased in severity with this could be due to differences in modalities. Impression: Superior endplate fracture of T11 appears slightly increased in severity which could be due to differences in modalities. Magnetic Resonance Imaging (MRI) dated 07/29/26 MRI Spine Thoracic without contrast. Reason for Exam: Fractured lumbar vertebrae. Findings: There are acute fractures along the superior endplate of T11 and L2 (Lumbar) corresponding to findings on prior CT. There is a minimal loss vertebral body height. There is minimal retropulsion of L2 with mild thecal sac effacement. There are mild endplate changes with disc space narrowing most notable in the upper thoracic spine. Impression: Acute superior endplate fractures of T11 and L2.On 08/04/26 at 3:58 PM, V6 (NP/Nurse Practitioner) stated she was the NP for R1. V6 stated she was informed that R1 had a fall from the mechanical lift. V6 stated the fall could have caused R1 to have the fractures to her back. V6 stated she was not aware of R1 having any fractures to her back prior to the fall. The facility's Total Mechanical Lift Policy, dated 01/14/2021, showed Procedure: 1. Check the sling for rips, tears, or abnormal wear prior to use; if noted, take out of circulation immediately, and notify DON or designee. Position mechanical lift so the frame can be centered over the client. Attach the fabric sling to the frame. Note manufactures instructions for specifics of how sling should be attached to the frame.

Based on observation, interview, and record review, the facility failed to follow standard infection control practices, related to gloving and hand hygiene during provisions of medication administration, incontinence care, and handling of soiled linen. The facility also failed to ensure to wear complete personal protective equipment (PPE) when administering intravenous (IV) medication to a resident who is on enhance barrier precaution (EBP). This applied to 5 of 5 residents (R36, R42, R54, R85, R93) reviewed for infection control in the sample of 20. The findings include: 1. According to the face sheet, R36 had multiple diagnoses, including chronic kidney disease, pain in the right knee, hypertension, and muscle weakness. R36's MDS (Minimum Data Set) dated December 28, 2025, showed that R36 was cognitively intact, required supervision or touch-assistance for personal hygiene, and was dependent on staff for toileting hygiene. On December 21, 2026, at 9:40 AM, R36 was lying in bed on an incontinence bed pad, completely soiled and stained with urine and blood. Bed linens were also on the floor next to R36's bedside. V20 came into R36's room with a clean incontinence bed pad and said she had already provided incontinence care to R36 but needed to replace the soiled incontinence pad under R36. V20 said the nurse notified her that R36 had been having blood in her urine. V20 was wearing gloves. V20 removed the soiled incontinence pad under R36 while R36 rolled to the side. V20 placed the soiled incontinence pad covered in urine and blood stains on the floor next to R36's bed. V20 covered R36 with a clean cover and blanket while wearing the same soiled gloves. V20 pushed buttons on the side of R36's bed to elevate R36's head and the foot part of the bed while wearing the same soiled gloves. V20 also picked up R36's call system remote and gave it to R36. V20 picked up a plastic bag from R36's empty trash bin and placed the soiled bed sheets and soiled incontinence pad in the plastic bag. V20 said she usually puts the residents' soiled linens on the leather chair in the residents' room, but she put them on the floor this time because it had blood stains. On December 21, 2026, at 2:49 PM, V2 (DON) said that while handling soiled linens, the CNA should remove gloves and perform hand hygiene with hand sanitizer or soap and water. V2 also said the CNA should re-apply clean gloves before touching the resident or clean surfaces. V2 said that hand hygiene and the application of clean gloves should be performed between dirty and clean tasks to prevent cross-contamination and ensure infection control. V2 also said CNAs are expected to put dirty and soiled linens in a plastic bag and tie them before taking them out to the soiled utility room. V2 said linens and soiled linens should not be placed on the floor in the resident's room to prevent contamination or spread of infection. 2. According to the face sheet, R54 had multiple diagnoses, including stage 4 chronic kidney disease, type 2 diabetes mellitus, severe morbid obesity, and polyneuropathy. R54's MDS (Minimum Data Set) dated October 22, 2025, showed R54 was cognitively intact, required supervision or touch-assistance for personal hygiene, and was dependent on staff for toileting hygiene. On December 21, 2026, at 10 28 AM, V16 was providing incontinence care to R54. R54's incontinence brief and bedsheet were soiled with urine. V16 had gloves on and wiped R54's buttocks and groin with disposable wipes. V16 tucked the soiled bed sheet under R54 on the right side of the bed. V16 applied a clean incontinence brief and cream to R54's buttocks while wearing the same soiled gloves. V16 removed the soiled glove. V16 took one glove out of her pocket and went to the bathroom to grab another. V16 wore the gloves without performing hand hygiene. V16 proceeded to apply cream to R54's groin and went to R54's left side to remove the soiled bed sheet on R54's bed. V16 finished strapping R54's incontinence brief at the front using the same soiled gloves. V16 also put on R54's socks and short pants while R54 was lying on the mattress that was soiled with urine. R54 turned to the left side, and V16 placed the total body mechanical sling lift under R54. V16 said she was going to call another CNA to assist her with transferring R54 into the wheelchair using a total body mechanical lift. V16 removed the soiled gloves. V16 picked up the trash bag with the soiled linens, tied it, and walked out of the room without performing hand hygiene. On December 21, 2026, at 2:49 PM, V2 said while performing incontinence care, the CNA should remove gloves after cleaning the resident's urine and perform hand hygiene using hand sanitizer or soap and water. V2 said the CNA should re-apply clean gloves before touching the resident or touching clean surfaces. V2 said V16 should have performed hand hygiene before exiting R54's room. V2 also said that hand hygiene and the application of clean gloves should be performed between dirty and clean tasks for infection control and to prevent cross-contamination. The facility's Hand Hygiene policy dated October 2024 showed, Policy: It is the policy of the facility that hand hygiene (e.g., hand washing and/or Alcohol-based hand rub, also known as Alcohol-based hand sanitizer (ABHS) is to be performed to reduce the potential spread of pathogens. Guidelines: 1. ABHS should be used: a. Immediately prior to touching a resident. b. Before performance of an aseptic technique or handling invasive medical devices. c. When caring for a resident, when moving from a soiled body site to a clean body site of the same resident. d. After touching a resident or the resident's immediate environment. E. Immediately upon removal of gloves and PPE [Personal Protective Equipment]. 2. Hand hygiene with soap and water should be performed: a. when hands are visibly soiled. b. After any contact with blood, body fluids, or contaminated surfaces. 3. On January 20, 2026, at 4:27 PM, V10 (Nurse) administered Insulin Lispro to R42. V10 did not perform hand hygiene before and after med administration. 4. On January 20, 2026, at 4:35 PM, after medication administration to R42 and without hand hygiene, V10 proceeded to prepare and administer two prescribed insulins to R85. V10 also did not perform hand hygiene after R85's medication administration. 5 During observation of medication pass, R93's bedroom door had an EBP sign posted. On January 21, 2026, at 8:57 AM, V11 (Nurse) checked R93's vital signs without gloves and without hand hygiene before and after vital signs check. Then V11 proceeded to prepare R93's medications. On January 21, 2026, at 9:08 AM, V11 (Nurse) administered oral and IV medications to R93 who has a central IV line in his right arm. V11 did not perform hand hygiene and only wore a pair of gloves when she administered R93's IV medication. On January 21, 2026, at 2:27 PM, V2 (Director of Nursing/DON) stated nurses are to perform hand hygiene before and after monitoring vital signs and medication administration to prevent spread of potential infection. V2 also said that when the nurse administers IV medication to a resident, the nurse should follow the EBP protocol of donning gown and gloves, for protection of the resident against infection. The Enhance Barrier Precaution (EBP) Posting on R93's door shows different instructions including cleaning of hands before entering and when leaving the room, and to wear gloves and gown for the following high contact resident care activities including use or care of devices such as central line, urinary catheter, feeding tube, and tracheostomy.

Based on interview and record review the facility failed to ensure that a resident's advance directive documents, order and care plan were consistent, to reflect the resident's treatment wishes in an event of a medical emergency, based on the facility's advance directives policy and procedure.This applies to 1 of 1 resident (R8) reviewed for advance directive in the sample of 20.The findings include:R8 was admitted to the facility on [DATE] with multiple diagnoses including acute kidney failure, acute on chronic diastolic (congestive) heart failure, and ventricular premature depolarization, based on the face sheet. The same face sheet documented that R8's advance directive was No CPR (Cardiopulmonary resuscitation). Do Not Attempt Resuscitation (DNAR).R8's EMR (electronic medical record) dashboard indicated that the residents advance directive was, No CPR. Do Not Attempt Resuscitation (DNAR).R8's active order summary report as of [DATE] showed an order dated [DATE] for, No CPR. Do Not Attempt Resuscitation (DNAR).R8's active care plan as of [DATE] showed, [R8] has not chosen any Advanced Directives at this time due to personal preference. Code status is full code. This active care plan was initiated by the facility on [DATE].Review of R8's EMR showed no uploaded documentation either an advance directive forms or signed POLST (Practitioner Order for Life-sustaining Treatment) to determine the wishes of the resident in an event of medical emergency.On [DATE] at 9:00 AM, V7 (SSD (Social Service Director)) stated after reviewing R8's EMR, the resident's order summary report showed that the resident has an order for DNR (Do Not Resuscitate), therefore no CPR will be performed if the resident is found to be unresponsive, without pulse and not breathing. V7 stated that for resident's on DNR status, their signed POLST and/or advance directive documents should be uploaded to the EMR to ensure that the wish of the resident is followed. V7 acknowledged that upon her review of R8's EMR, no signed POLST and/or advance directive documents were uploaded in the resident's EMR. V7 stated that since no signed POLST and/or advance directives documents were uploaded in R8's EMR, the facility also requires an actual signed POLST and/or advance directives documentation available in the nursing station inside a black folder for each resident. V7 went to the unit nursing station and looked at the black folder for R8 and stated that there was no actual copy of the POLST and/or advance directive documentations available for the nursing staff to review. During the interview, V7 reviewed R8's active advance directive care plan and stated that based on the care plan, the resident is a full code. V7 acknowledged that there is a discrepancy with regards to R8's code status/advance directive. V7 stated that she will talk to R8 and verify his advance directive wishes because the resident can make decisions for himself. V7 added that R8 has no POA (Power of Attorney) and that R8 is responsible to self.On [DATE] at 9:09 AM, V8 (Registered Nurse) stated that she was the assigned nurse for R8 that morning. V8 was asked what is R8's code status, if the resident was found unresponsive without breathing and pulse. V8 stated that she would first check the EMR dashboard profile and then the active order for the code status which according to V8 showed that R8 was DNR. V8 stated that since R8 had the order for DNR, no emergency action will be performed, if R8 was found unresponsive, without breathing and without pulse. V8 was asked how she will confirm that the DNR order was accurate. V8 responded that a signed advance directives should be uploaded on R8's EMR, which upon V8 checking showed no uploaded advance directive documents. V8 checked the black folder at the nursing station for R8 and acknowledged that there was no actual copy available for review regarding the resident's advance directives. V8 then checked R8's active care plan for advance directive and showed that the resident was a full code. V8 acknowledged that the active order and the active care plan were contradicting and needed to be verified.On [DATE] at 9:12 AM, R8 was in bed, alert and verbally responsive. V7 (SSD) asked R8 if he wanted to be resuscitated, if the staff found him unresponsive, without breathing and without pulse. R8 responded, yes. V7 asked R8 if he wishes his code status to be a full code and R8 responded, yes.The facility's advance directive policy and procedure dated [DATE] showed, The Social Service Director and/or designee will assess, care plan and implement Advance Directives. The same policy showed under procedure, 3. Social Service Director and/or designee will assess if resident had pre-existing advance directives. If so, copies of any/all documents will be requested, uploaded to [EMR] upon receipt, and documented in the resident's care plan. 4. If resident or resident representative has not already made advance directive decisions and chooses not to, Social Service Director and/or designee will document that in the resident's care plan. 6. Advance Directives will be reviewed quarterly, annually and upon any significant changes in cognition. 7. All Advanced directive preferences will be documented in the resident's care plan and updated quarterly, annually and upon any significant changes in cognition. 8. If the resident or resident representative chooses to initiate/change any advance directives, the Social Service Director/designee will document changes and update the plan of care. 9. The resident will have a code status order entered in their physician orders in accordance with advanced directives on file.

Based on observation, interview, and record review, the facility failed to follow its policy on gait belt use during the transfer of a resident with an unsteady gait and risk of falls. This applies to 1 of 1 resident (R97) reviewed for transfer supervision in a sample of 20.The findings include:According to the face sheet, R97 was admitted to the facility on [DATE], and had multiple diagnoses, including a history of falling, polyosteoarthritis, other chronic pain, and hypertension.R97's Facility's Fall Risk assessment dated [DATE], showed R97 was at risk for falls, had an unsteady gait, and had had one to two falls in the past three months. R97's fall care plan, initiated on January 21, 2026, showed R97 was at risk for falls due to weakness from recent hospitalization and a history of falling. R97's (ADL/Activity of Daily Living) care plan, initiated on January 21, 2026, showed R97 had a functional performance deficit due to weakness from recent hospitalization. The same care plan interventions included staff assisting R97 with ADL tasks as needed.On January 21, 2026, at 9:01 AM, R97 was sitting on a chair in her room. V20 (CNA/Certified Nursing Assistant) said R97 was newly admitted to the facility the day before, and it was her first time assisting R97. V20 said she would assist R97 with transferring from the bedroom chair to the wheelchair. V20 brought the wheelchair close to R97's chair and asked whether R97 could stand. R97 stood up while V20 held R97's hand to assist her with transferring to the wheelchair. V20 had a gait belt in her pants side pocket, which she did not put around R97's waist to assist with the transfer. V20 said CNAs are supposed to use the gait belt when assisting the residents with transfers.On January 21, 2026, at 2:49 PM, V2 (DON/Director of Nursing) stated that CNAs are required to transfer residents, and that V20 should have used a gait belt with R97 for safety precautions to prevent falls or injuries to R97.The facility's Gait Belt (Transfer Belt) policy dated September 2020, showed, Policy: To assist with a transfer or ambulation. A gait belt will be used with weight-bearing residents who require hands on assistance.

Based on observation, interview and record review, the facility failed to provide oxygen therapy to a resident as ordered by the physician.This applies to 1 of 2 residents (R87) reviewed for oxygen use in the sample of 20.The findings include: R87's face sheet included multiple diagnoses including COPD (chronic obstructive pulmonary disease), chronic respiratory failure with hypoxia, pneumonia, unspecified organism, need for assistance with personal care, other lack of coordination, other abnormalities of gait and mobility, polyneuropathy, urinary tract infection, site not specified. R87's 5-day MDS (minimum data set) dated January 9, 2026, showed that R87 is cognitively intact and requires substantial maximal assistance in chair/bed-to-chair transfer (the ability to transfer to and from a bed to a chair/or wheelchair). R87's Physician Order Sheet for respiratory showed oxygen per nasal cannula at 2 liters per minute continuous every shift. R87's care plan revised January 15, 2026, included that R87 requires oxygen therapy and is on oxygen at 2 liters by nasal canula continuously related to COPD. Interventions included to administer oxygen per MD [Medical Doctor] orders. On January 20, 2026, at 12:10 PM, R87 was seated in a wheelchair in her room beside V12 (R87's POA/Power of Attorney). R87 had a nasal cannula attached to her nostrils, with the tubing connected to a portable oxygen tank that was placed in a holder at the back of R87's wheelchair. R87's oxygen tank setting was unable to be seen as wheelchair was stationed between bed and wall. An oxygen floor concentrator was also seen behind R87's wheelchair. V12 stated She (R87) got here on Wednesday because of pneumonia from the hospital. She was bedridden at hospital and now they are giving her rehab here. R87 stated that an aide got her out of bed to her wheelchair. R87 was unable to remember who her aide was and at what time she got up. On January 20, 2026, at 12:39 PM, R87 was wheeled out by V12 to the hallway and she pointed to the portable oxygen tank and stated that she does not know if the oxygen is infusing. The portable oxygen tank was checked in V12's presence and the dial showed that it was at red zone and oxygen tank was set at 2 (liters). V13 (Registered Nurse) was notified and V13 checked the portable tank and stated that it is empty. V13 stated Whoever got her out of bed switched her from the concentrator to the portable tank. I believe it should be at 2 liters continuous. V13 continued that she believes that her aide was V17 CNA (Certified Nursing Assistant) but does not know if she was the one who got her up. V13 reported back that she learned that V17 did not get up R87 and that it could have been therapy. On January 20, 2026, at 3:20 PM, V14 (Physical Therapy Assistant) stated that therapy did not get R87 up in the morning and that R87 only received therapy in the afternoon. On January 20, 2026, at 3:35 AM, V2 (Director of Nursing) stated that R87 might have got herself up because she had interviewed V17 and other aides on the floor and they all said that they did not get R87 up. V2 added that yesterday the daughter had remarked that R87 is getting stronger as she is able to get out of bed herself. On January 21, 2026, at 9:42 AM, V16 (CNA), stated that she is assigned to R87 that day. V16 stated that she assists R87 to the wheelchair from her bed to her wheelchair by using a gait belt. V16 stated that R87 can put the nasal cannula to her nose but she noticed that R87 only applies it to one nostril only. V16 stated that the CNA's do not disconnect the oxygen from the floor concentrator and connect to portable oxygen tank as only the nurses are allowed to do that. V16 added We call the nurses when after we transfer her to the wheelchair. On January 21, 2026, at 10:44 AM, V17 stated that she worked on January 20, 2026, and that R87 was assigned to her. V17 stated I don't know who got her up. When I brought water for her (between 7:30-8:00). She was sitting on the side of her bed with her oxygen tubing connected to the floor concentrator. The nurses deal with oxygen. The aides don't connect it from the floor concentrator to the one on her chair.On 01/21/2026 at 2:02 PM, V2 (Director of Nursing) stated that the nurses are in charge of connecting the oxygen. V2 stated that R87 should be on continuous oxygen based on physician order for the same.Facility policy (dated September 2020) for Oxygen (Compressed) gas included as follows:Policy: Oxygen will be provided via compressed gas to the resident per the physician's orders by an RN or LPN (Licensed Practical Nurse). Certified Nurse Assistants/rehab aides may adjust or reapply the nasal cannula or mask only.

Based on interview and record review the facility failed to remove a fentanyl patch as ordered for 1 of 3 residents (R1) reviewed for pain medications in the sample of five.The findings include:The Physician Orders for R1 dated November 2025 showed Fentanyl Patch 72 hour 12 MCG/HR, apply 1 patch transdermally every 72 hours for pain management and remove per schedule.The Medication Administration Record (MAR) dated November 2025 showed Fentanyl patch 72 hours, 12MCG/HR, apply 1 patch transdermally every 72 hours for pain management and remove per schedule. The MAR showed on 11/26 25 at 5:25 PM a 12 MCG patch was applied. The MAR showed on 11/29/25 at 4:19 PM the fentanyl patch was to be removed. A 9 was documented on 11/29/25 at 3:22 PM; the 9 means to see progress notes. On 11/30 25 at 6:00 AM a 12 MCG Fentanyl patch was applied to her right arm.R1' Progress Notes did not show any note on 11/29/25 for the removal of his 12 MCG Fentanyl patch. There was no Progress Note entered related to the 9 documented on R1's MAR on 11/29/25 at 3:22 PM.R1's Care Plan dated 9/19/25 showed, R1 noted to be receiving high risk medication of.opioid medication. Administer pain strategies according to the Mar/Tar (treatment administration record). Provide medications per medical doctor order.On 1/18/26 at 1:27 PM V2 Director of Nursing - DON had her computer to review R1's electronic medical record. V2 stated on 11/29/25 at 3:22 PM it was documented as a 9 on the MAR which means there should be a note. V2 stated the order was changed to remove the fentanyl 12 MCG patch on the 11/30/25 at 6:00 AM and it was supposed to be changed on 11/29/25. The fentanyl patch had been applied in the evening on 11/26/25 and should have been removed 72 hours later. The nurse got confused because the on and off times for the patch were not how it is usually scheduled. The physician order was not followed and should have been. V2 stated on 11/30/25 it showed the nurse put a fentanyl 12 MCG patch on R1's right arm. There is no documentation to show that she removed the old patch. A progress note wasn't put in showing it was removed, and the MAR wasn't prompting it to be removed. V2 stated R1 went to the hospital on [DATE].On 1/18/26 at 3:27 PM, V9 Nurse Practitioner - NP stated the emergency room nurse on 12/1/25 found 2 fentanyl 12 MCH patches on R1 arrived at the hospital. The old fentanyl patch should be removed before the new one is put on.The Face Sheet dated 1/18/26 for R1 showed diagnoses including pathological fracture in neoplastic disease, malignant neoplasm of bone, low back pain, bacteremia, neoplasm related pain, secondary neoplasm of brain, protein-calorie malnutrition, morbid obesity, neuromuscular dysfunction of bladder, pressure induced deep tissue damage, pulmonary embolism, acute embolism of left femoral vein and right iliac vein, secondary malignant neoplasm of liver and bile duct, and malignant neoplasm of bone marrow.The facility's Medication Administration policy (9/2020) showed, drugs must be administered in accordance with written orders of the attending physician.

Based on interview and record review, the facility failed to update and follow all physician orders after resident's outpatient appointment.This applies to 1 resident (R1) reviewed for quality of care.The findings include:R1's Facesheet shows the following diagnoses: Iron Deficiency Anemia, Malignant Neoplasm of Female Breast, Secondary Malignant Neoplasm of Bone, and Secondary Malignant Neoplasm of Bone Marrow.On 9/30/25 at 11:32 AM, V4 (Oncology NP/Nurse Practitioner) said he is very familiar with R1, and saw her in the office with V9 (Oncology Doctor) on 8/21/25. V4 said on 8/21/25, V9 gave the written order to the facility to stop R1's Ribociclib chemotherapy medication until 8/28/25. V4 said Ribociclib is taken every day for 3 weeks and then the patient has 1 week off and R1 was to be off the Ribociclib from 8/21/25 through 8/28/25. V4 said Ribociclib causes bone marrow suppression, so the one week off the medication is important to give the bone marrow time to recover. V4 said he thinks R1's anemia is more related to her cancer as opposed to the Ribociclib chemotherapy. V4 said R1's chemotherapy isn't helping her anemia, but it is not the main cause. V4 said it is hard to say if R1's anemia is a direct cause of the Ribociclib being given during her ordered off week, 8/21/25-8/27/25, or if R1's anemia and need for blood transfusion was coincidental because R1 has a history of anemia.R1's Physician Order Sheet signed by V9 and dated 8/21/25 shows 4 orders:1. CBC Weekly,2. Letvozole to be given daily,3. 2nd cycle of Ribociclib at 400mg to begin 8/28/25. To continue for 21 days, and4. Patient to be evaluated by radiation oncology.R1's MAR (Medication Administration Record) for the month of August shows she received Ribociclib 400mg oral tablet on 8/22, 8/23, 8/24, and 8/25.On 9/30/25 at 12:49 Pm, V2 (DON/Director of Nursing) said it is the nurse's responsibility when resident returns from an appointment with physician orders, to enter those orders into the computer and carry them out. V2 said V7 (LPN/Licensed Practical Nurse) was the nurse assigned to take care of R1 on 8/21/25. On 9/30/25 at 1:20PM, V7 (LPN) said she did not enter order for R1's Ribociclib per the physician's order and verified that she did write a nurse's note on 8/21/25 at 5:52 PM stating R1's daughter dropped off Ribociclib medication to be started on 8/28/25. V7 reviewed R1's Physician Order Sheet signed by V9 (Oncology Doctor) dated 8/21/25. V7 then reviewed R1's orders and confirmed the only order she entered from R1's Oncology Appointment was for weekly CBC. V7 said she did not enter any of the other orders from R1's Oncologist, including the order for Ribociclib.On 9/30/25 at 1:56 PM, V8 (RN/Registered Nurse) said she took care of R1 on 8/26/25. V8's nurse's note written on 8/26/25 at 8:11 AM states Ribociclib 400mg to be resumed on 8/28/25. V8 said she remembers writing that note and it was prompted because she tried to administer Ribociclib to R1 that morning, and R1 told her she could not take it until 8/28/25. V8 said per R1's Physician Order Sheet signed by V9 on 8/21/25, R1's Ribociclib should have been held from 8/21/25 through 8/27/25 and the 2nd cycle should have started on 8/28/25.The facility's policy titled, Physician Orders for Medications or Treatments dated 06/2022 states, A. Policy:.Each medication order is documented in the resident's medical record with the date and signature of the person receiving he order.C. Procedure:.2. The nurse will follow facility-specific procedures to submit orders to pharmacy appropriately, which may include transcribing any telephone or transfer sheet orders to the POS.

Based on observation, interview, and record review, the facility failed to obtain orders for resident medications and failed to have orders for medications at the bedside. The facility failed to make sure residents took all their medication in the presence of the nurse. The facility also failed to make sure that residents had their own personal medications instead of someone else's in their room. This applies to 5 of 5 residents (R10, R19, R57, R65, R127) reviewed for medications in a sample of 23. The findings include: 1. On 11/19/24 at 10:30 AM, during initial tour, R10 was sitting in her wheelchair in her room. On her bedside table, there was an Atrovent inhaler. R10 stated, This is my inhaler from home. It's usually kept in my purse. I don't know why it's here. The nurse gives me another one. On 11/20/24 at 2:35 PM, on R10's bedside table, the Atrovent inhaler continued to be there. R10 stated, Yeah, it's still here. It should be in my purse. I can't find my purse. R10's face sheet shows diagnoses of chronic obstructive pulmonary disease with (acute) exacerbation and acute respiratory failure with hypoxia. R10's POS (Physician Order Sheet) shows an order for Atrovent HFA Inhalation Aerosol Solution 17 MCG (Micrograms)/ACT-1 puff inhale orally one time a day related to chronic obstructive pulmonary disease with acute exacerbation. There is no order for R10 to use her inhaler from home or for it to be at the bedside. R10's MDS (Minimum Data Set) dated 10/25/24 shows a BIMS (Brief Interview for Mental Status) score of 13, which means she is cognitively intact. 2. On 11/20/24 at 10:36 AM, R127 was not in her room. On her bedside table, there was (Brand name eye drops). On the label, it shows her name, and it documents Carboxymethyl Cellulose Sodium 0.5 MG (Milligrams) Ophthalmic Solution. Put 2 drops in both eyes 4 times a day. On 11/20/24 at 2:43 PM, R127 was sleeping on her bed. On her bedside table, the Refresh Tears continued to be there. R127's face sheet shows a diagnosis of glaucoma. Review of 127's POS shows she has no orders for (Brand name eye drops). R127's MDS dated [DATE] shows a BIMS score of 15, which means she is cognitively intact. On 11/20/24 at 3:02 PM, V2 (Director of Nursing/DON) stated, I don't have any residents that have meds at the bedside. All meds should have an order and there should be an order for it to be at the bedside. On 11/21/24 at 11:58 AM, V12 (Licensed Practical Nurse/LPN) stated, If residents bring meds from home, we lock it up in the medication cart. If they want to use it, then we need to get an order or script from the doctor for them to use it and to be stored at the bedside. Facility's policy titled Self-Administration of Medications: 2. The IDT (Interdisciplinary Team) must also determine who will be responsible (the resident or nursing staff) for storage and documentation of the administration of drugs as well as the location of the drug administration. 3. When such is ordered, the following conditions will apply: a. The manner of storage will prevent access by other residents. 4. Storage of legend drugs at the bedside will meet the conditions of the above, and will additionally: a.) Be specifically ordered by the prescriber of the drugs. 46003 3. R19 was admitted to the facility with diagnoses that includes displaced intertrochanteric fracture of left femur, chronic obstructive pulmonary disease, asthma, type 2 diabetes, hypertension, heart failure and poly-osteoarthritis. On 11/19/24 at 12:51 PM, a 2.5-ounce bottle of pain relief cream and 3.53-ounce jar of vaporizing ointment was on R19's over bed table. R19 stated she puts the vaporizing ointment in her nose. On 11/21/24 at 11:38 AM, V16 (LPN) assigned to R19 stated she did not have any residents that were assessed to keep medications at the bed side. On 11/21/24 at 1:49 PM, V2 (DON) stated there are no residents in the facility that can keep medications at the bed side. Staff should have seen R19's medications if they were sitting out. R19 does not have a physician's order for vaporizing ointment or pain relief cream. Review of R19's current physician's order does not include pain relieving cream or vaporizing ointment. 34410 4. On 11/19/24 at 10:59 AM, R57 was on his bed sleeping and found a medication cup with seven pills in it. On 11/19/24 at 11:09 AM, V13 (LPN) stated that she shouldn't have left R57's 9:00 AM medications at his bedside and should have stayed with him until he took all his medications. A record review on the Medication Administration Record (MAR) for November 2024 documented that R57 received 7 medications at 9:00 AM on 11/19/24, including Gabapentin 300 milligrams (mg), Duloxetine 30 mg, Ferrous Sulfate 325 mg, Finasteride 5 mg, a Multivitamin tablet, Colace 100 mg, and Potassium Chloride 20 milli-equivalent. On 11/19/24 at 1:08 PM, V2 (DON) stated that none of their residents were assessed for self-administration of medications, and the nurse should have stayed with R57 to ensure R57 took all his medications. 46409 5. On 11/19/24 at 10:31 AM during initial tour, R65's room was observed to have (Brand name eye drops) in a plastic bag and a medication cup with a white cream, which R65 said was cortisone cream. On 11/21/24 at 12:47 PM, R65 said the eye drops on her bedside table were not hers. R65 said she also used all the cream in the medication cup. V17 (Family Member) said she took the eye drops to the front desk and thought they may have belonged to the resident who was previously in R65's room. On 11/21/24 at 12:51 PM, V15 (Registered Nurse) said R65 was not allowed to have medications at the bedside, including the cortisone cream. V15 said she was not made aware of the resident having eye drops in her room, and there should be an order if the residents were allowed to keep medications at bedside. R65's face sheet showed she was admitted to the facility with diagnoses including hypertension, spinal stenosis, polyosteoarthritis, anxiety disorder, gout, cognitive communication deficit, and muscle weakness. R65's POS (Physician Order Sheet) did not have orders for cortisone cream or (Brand name eye drops).

Based on interview and record review, the facility failed to utilize an appropriate standardized tool/system to justify or warrant the necessity of an antibiotic at the time the antibiotic was ordered. This applies to 4 of 4 residents (R4, R43, R65, R66) reviewed for antibiotic stewardship in a sample of 23. The findings include: 1. R43's face sheet shows she was admitted to the facility on [DATE]. R43's POS (Physician Order Sheet) showed an order dated October 28, 2024, for Nitrofurantoin Monohyd Macro Oral capsule 100 MG (Milligram) Give 1 capsule by mouth two times a day for UTI (Urinary Tract Infection) for 5 days. R43's October 2024 MAR (Medication Administration Record) showed she received the antibiotic from October 28, 2024, through November 2, 2024. R43's Criteria for Infection Report Form-Urinary Tract Infections (UTIs) dated November 1, 2024, showed R43 did not meet criteria to be prescribed antibiotic. R43's labs dated October 28, 2024, showed urine culture results which came back showing 70,000 to 90,000 CFU/ml (Colony-Forming Unit/Milliliters) of E. coli (Escherichia Coli). On November 20, 2024, at 2:31 PM, V2 (Director of Nursing/Infection Preventionist) said R43's urinalysis was collected on October 26, 2024, because she had increasing confusion, which showed she had E. coli. V2 said R43 would not have gotten antibiotics because she only had increasing confusion, which was her baseline. 2. R65's face sheet showed she was admitted to the facility on [DATE]. R65's POS showed orders dated October 22, 2024. The first order was for Bactrim DS Oral Tablet 800-160 MG (Sulfamethoxazole-Trimethoprim) Give 1 tablet by mouth one time only related to urinary tract infection, site not specified for 1 day beginning October 22, 2024, and completed October 23, 2024. The second order was for Bactrim DS Oral Tablet 800-160 MG (Sulfamethoxazole-Trimethoprim) Give 1 tablet by mouth two times a day related to urinary tract infection, site not specified for 9 administrations beginning October 22, 2024, and completed October 27, 2024. R65's October 2024 MAR showed she received the antibiotic on October 22, 2024, through October 27, 2024. R65's Criteria for Infection Report Form-Urinary Tract Infections (UTIs) dated November 1, 2024, showed R65 did not meet criteria to be prescribed antibiotic. On November 20, 2024, at 2:02 PM, V2 said R65 did not present with any symptoms but was flagged for a UTI. 3. R66's face sheet showed she was admitted to the facility on [DATE]. R66's POS showed an order dated October 22, 2024, for Nitrofurantoin Monohyd Macro Oral capsule 100 MG (Milligram) Give 1 capsule by mouth two times a day for UTI (Urinary Tract Infection) for 5 days. R66's October 2024 MAR shows she received the medication from October 23, 2024, through October 27, 2024. R66's Criteria for Infection Report Form-Urinary Tract Infections (UTIs) dated November 1, 2024, showed R66 did not meet criteria to be prescribed antibiotic. R66's labs dated October 21, 2024, showed urine culture results which came back showing 70,000 to 90,000 CFU/ml (Colony-Forming Unit/Milliliters) of E. coli (Escherichia Coli). On November 20, 2024, at 2:26 PM, V2 said R66's symptoms were increasing confusion, and a UA (Urinalysis) was done on October 19, 2024. V2 said R66's UA showed she had E. Coli but did not think the doctor gave an order for an antibiotic because the only symptom she had was increased confusion which was her baseline. 4. R4's face sheet showed she was admitted to the facility on [DATE]. R4's POS shows an order dated September 26, 2024, for Cephalexin Oral capsule 500 MG Give 1 capsule by mouth one time a day related to urinary tract infection, site not specified for prophylaxis. R4's November 2024 MAR shows she received Cephalexin 500 MG with a start date of September 26, 2024, and was receiving it through November 22, 2024. The MAR also showed she received Ciprofloxacin HCl Tablet 250 MG Give 1 tablet by mouth every 12 hours for prophylactic treatment, [possible] UTI for 10 days, which was administered from November 11, 2024, through November 20, 2024. On November 20, 2024, at 3:28 PM, V2 said they completed the McGeer tool after the month was over. V2 said she had not done any of the McGeer tracking tool for any of the residents who were on antibiotics for November 2024. V2 said the McGeer tool was done for tracking the use of antibiotics. The facility's Infection Prevention and Control Manual Antibiotic Stewardship [and] MDROs (Multi Drug Resistant Organisms) policy dated April 2021 showed It is the policy of this facility to provide systematic efforts to optimize the use of antibiotics in order to maximize their benefits to residents, while minimizing both the rise of antibiotic resistance as well as adverse effects to patients from unnecessary antibiotic therapy. The facility will communicate resident assessment information and relation to constitutional criteria for infection (i.e. as outlined in Surveillance Definitions of Infections in Long-Term Care Facilities: Revisiting the McGeer Criteria) to the practitioner, including non-pharmacological interventions that can be accomplished in the facility based on resident assessment.

Based on interview and record review, the facility failed to complete performance review evaluations for 5 of 5 CNAs (Certified Nursing Assistants). This applies to all 79 residents in the facility. The findings include: Facility's CMS (Centers for Medicare and Medicaid Services) Form 671 titled Long Term Care Facility Application for Medicare and Medicaid (11/19/24) shows the facility has a current census of 79. On 11/20/24 at 9:35 AM, V9 (Business Office Manager) stated, Corporate did rate changes for the CNAs and when that happens you are supposed to do a performance evaluation for the staff member. I was supposed to do the performance reviews, but I didn't do them. I'll be honest with you. I started here in April 2023. The supervisors are really supposed to do the performance evaluation, but I'm actually doing them because they are so busy. I'm trying to help them out. But I forgot to do them. On 11/20/24 at 9:42 AM, V2 (Director of Nursing) stated, I do performance evaluations for my nurses. (V9) is not supposed to do the performance evaluations for the CNAs. She's not their supervisor. Currently, our CNA supervisor is V10. She's supposed to do it for this year. But before it was V11 (CNA) supervisor. He quit in October 2024. He should have done them. On 11/20/24 at 9:45 AM, V9 and surveyor reviewed the personnel files for 5 CNAs that were currently working in the facility. The following were noted: 1.V4's (CNA) Employee Personnel Form shows a hire date of 11/16/2021. There were no annual performance reviews for 2022, 2023 and 2024. 2.V5's (CNA) Employee Personnel Form shows a hire date of 4/18/21. There were no annual performance reviews for 2022, 2023, and 2024. V9 did provide an annual performance review for 7/18/21. 3.V6's (CNA) Employee Personnel Form shows a hire date of 11/11/2014. There were no annual performance reviews for 2015, 2016, 2017, 2018, 2020, 2021, 2022, 2023, and 2024. V9 did provide an annual performance review for only 11/11/2019. 4.V7's (CNA) Employee Personnel Form shows a hire date of 12/20/22. There was no annual performance review for 2023. 5.V8's (CNA) Employee Personnel Form shows a hire date of 6/5/2017. There were no annual performance reviews from 2018 to 2024. Facility's policy titled Performance Evaluations (1/2009) shows Procedure: 1. The Personnel Director will utilize the monthly reports from the Payroll Department as they related to evaluations to determine the employees who are due to annual evaluation or for a probationary evaluation 3. The Personnel Director will maintain a list of all evaluation reports which have been sent to the employee's supervisor and require them to be returned by a predetermined date set by the Personnel Director. 4. If the evaluation report is done in tandem with a rate change, then the evaluation report must be returned to the Personnel Director before the evaluation report is discussed with the employee 8. Annual performance evaluations will be completed from the original date of employment or annually from a position change 11. Performance evaluations will be completed by the employee's department supervisor and reviewed by the Administrator. 15. Completed performance evaluations will be placed in the employee's personnel file.

Based on interview and record review the facility failed to change a resident's PICC (Peripherally inserted central) line transparent sterile dressing as ordered by the physician. This applies to 1 of 3 residents (R1) reviewed for PICC line care in the sample of 4. The findings include: R1 was admitted to the facility from the acute care hospital on April 25, 2024. R1 had multiple diagnoses including, mechanical complication of internal right knee prosthesis, infection, and inflammatory reaction due to internal right knee prosthesis, presence of right artificial knee joint and right knee arthritis due to other bacteria, based on the face sheet. R1's initial nursing assessment dated [DATE] showed that the resident was admitted to the facility with a PICC line. R1's IV (intravenous) administration site showed that the resident's PICC line was located on her right arm. R1's order recap report showed an order dated April 25, 2024 to change the PICC line transparent sterile dressing within 24 hours of admission every day shift for 1 day. This order had an end date of April 26, 2024. The order recap report showed an order dated April 26, 2024 to change the PICC line transparent sterile dressing within 24 hours of admission every night shift for 1 day. This order had an end date of April 27, 2024. The same order recap report showed an order dated May 2, 2024 to change the transparent sterile dressing weekly and as needed every Thursday during the night shift. R1's TAR (treatment administration record) dated April 25 showed no documentation that the PICC line transparent sterile dressing was changed on admission. The TAR dated April 26, 2024 with regards to PICC line transparent sterile dressing change within 24 hours of admission showed a 9 code with the initials of V3 (RN/Registered Nurse) in the initial box. The TAR chart code for 9 indicated other-see progress notes. The MAR (medication administration record) for the month of April 2024 showed no documentation that R1's PICC line transparent sterile dressing was changed on admission and/or as needed from April 25 through April 30, 2024. R1's progress notes dated April 27, 2024 at 6:33 AM created by V3 showed, IV PICC: Transparent sterile dressing change within 24 hours of admission every night shift for 1 Day, On order from pharmacy. Further review of R1's progress notes from April 25 through April 30, 2024 showed no documentation that the PICC line transparent sterile dressing was changed as ordered. R1's MAR for the month of May 2024 showed that the PICC line transparent sterile dressing was scheduled for the weekly change during the night shift on May 9, 2024. The MAR dated May 9, 2024 for the said scheduled weekly change showed a 9 code with the initials of V4 (RN) in the initial box. The MAR chart code for 9 indicated other-see progress notes. R1's May 2024 MAR and TAR showed no documentation that the resident's PICC line transparent sterile dressing was changed as ordered from May 9, 2024 through May 14, 2024 (day of discharge). R1's progress notes dated May 10, 2024 at 4:42 AM created by V4 showed, IV PICC: Transparent sterile dressing change weekly and PRN (as needed), every night shift every [Thursday], will change when receive. Further review of R1's progress notes from May 9, 2024 through May 14, 2024 showed no documentation that the PICC line transparent sterile dressing was changed as ordered. On May 29, 2024 at 9:50 AM, V2 (Director of Nursing) stated that she had reviewed R1's medical records including the physician's order, MAR, TAR, and progress notes. According to V2, based on her review, R1's PICC line transparent sterile dressing was not changed within 24 hours of admission as ordered. V2 further stated that R1's PICC line transparent sterile dressing was also not changed on May 9, 2024 for the scheduled weekly change and that there was no documentation to indicate that the PICC line dressing was changed between May 10 and May 14, 2024. V2 stated that if the PICC line dressing changes were not documented in R1's medical records, then the procedure was not performed as ordered by the physician. According to V2, she expects the nurses to follow the physician's orders with regards to PICC line dressing changes, because it is important to change the resident's PICC line dressing to assess and maintain the integrity of the insertion site and to prevent infection. On May 29, 2024 at 11:21 AM, V3 (RN/Registered Nurse) stated that on April 26 and April 27, 2024, she was not able to change R1's PICC line transparent dressing because there were no available supplies in the facility. According to V3, she had placed the order to the pharmacy to deliver the supplies to change R1's PICC line transparent sterile dressing. V3 added that she was not aware if the supplies were delivered, and she does not know who changed R1's PICC line dressing from April 26 through May 1, 2024. On May 29, 2024 at 2:15 PM, V4 (RN) stated that she did not change the transparent sterile dressing on R1's PICC line on May 9 and May 10, 2024, because there were no available supplies in the facility. According to V4, she ordered the supplies from the pharmacy and was waiting for delivery. V4 stated that she does not know who changed R1's PICC line transparent sterile dressing after she had ordered the supplies on May 10, 2024.

Based on observation, interview, and record review, the facility failed to provide timely hygiene and grooming care for residents who requires assistance for activities of daily living (ADL) care. This applies to 4 of 4 residents (R5, R11, R41, R230) reviewed for ADL care in the sample of 19. The findings include: 1. R11 is [AGE] years-old who has multiple medical diagnoses which include dementia, polyarthritis, and chronic pain. R11's Quarterly Minimum Data Set (MDS) dated [DATE], shows that R11 is alert and oriented and requires assistance with ADL care. On December 4, 2023, at 11:45 AM, R11 was sitting in her wheelchair, and neatly dressed. However, R11 displayed overgrown facial hair all over the chin. R11 stated that she wants to be shaven. On December 6, 2023, at 12:10 PM, R11 was eating in the dining room, she remained with overgrown facial hair. R11 still wanted to have her facial hair shaven. V16 (Wound Care Technician/Certified Nursing Assistant) stated that shaving is part of ADL care. 2. R5 is [AGE] years-old who has multiple medical diagnoses which include stage 4 pressure ulcer of the right buttock, multiple sclerosis, type 2 diabetes mellitus, diaper dermatitis, contracture of muscle right lower leg, incontinence without sensory awareness. R5's Annual MDS dated [DATE], shows that R5 is alert and oriented and totally dependent with toileting and personal hygiene. On December 5, 2023, at 11:27 AM, R5 was lying in bed, with indwelling urinary catheter. V5 (Wound Care Technician) and V6 (Wound Nurse) were about to render wound care to R5 when they turned R5 on the left side and it showed that R5 was heavily wet with urine. R5's incontinence brief was heavily saturated with dark brown urine which overflowed to her bed linen and to the mattress. The wound dressing was also wet with urine and there was a strong urine odor. The bed linen that was also wet with dark brown urine had thick line formation of brown ring stain at the edges of the wetness. Apparently, her urinary catheter leaked. R5 stated they (staff) checked her early that morning. On December 5, 2023, at 12:01 PM, V17 (Certified Nursing Assistant/CNA) and V5 (Wound Care Technician) rendered sponge bath to R5. V17 stated that the last time they checked and changed R5's brief was around 7:00 AM. On 12/06/23 at 10:11 AM, V2 (Director of Director/DON) stated that staff should check and change residents for incontinence every 2 hours and as needed. The staff can't let a resident sit in urine and feces for a long period of time. This is for the prevention of skin breakdown, to provide hygiene, and dignity. R5' care plan, which was initiated on October 29, 2022, and had a target goal of March 1, 2024, shows that R5 has an actual alteration in skin integrity related to pressure injury to her right buttock. The same care plan shows multiple interventions which include to keep R5's skin clean and dry, and peri-care after incontinent episodes. 16746 3. R41 had multiple diagnoses including senile degeneration of brain and dementia without behavioral disturbances, based on the face sheet. R41's quarterly MDS (minimum data set) dated August 29, 2023 showed that the resident was cognitively intact. The same MDS showed that R41 required extensive assistance from the staff with regards to personal hygiene. On December 4, 2023 at 9:53 AM, R41 was sitting in her wheelchair in front of the unit nursing station. R41 was alert and verbally responsive. R41's fingernails were long, jagged and with black/brown substances underneath several of her fingernails. R41 stated, My nails are too long, but I do not have the energy to cut them. R41 requested to have her nails trimmed and cleaned. V8 (Licensed Practical Nurse) was at the nursing station during this observation and interview. R41's active care plan initiated on October 27, 2020 showed that the resident had ADL (activities of daily living) self-care performance deficit. The same care plan showed multiple interventions including, Assist with personal hygiene as needed and Provide needed level of assistance and support to complete activities of daily living. 41855 4. R230's EMR (Electronic Medical Record) showed R230 was admitted to the facility on [DATE], with diagnoses that included fracture of superior rim of left pubis, subsequent encounter for fracture with routine healing, polyneuropathy, peripheral vascular disease, overactive bladder, and restless leg syndrome. R230's admission MDS (Minimum Data Set) dated December 1, 2023, showed R230 was cognitively intact. R230's functional abilities on admission showed she was dependent on staff for toileting, shower/bath, upper body dressing, lower body dressing, putting on and taking off footwear. R230 required set-up or clean-up assistance for oral care. R230's therapy care plan showed R230 had impaired ADLs (Activities of Daily Living) in the following areas: bathing, dressing, toileting, clothing management, and toileting hygiene. R230's nursing care plan showed R230 had an ADL functional performance deficit, activity intolerance, and decreased functional ability related to restless leg syndrome, overactive bladder, and polyarthritis. Interventions showed staff are to allow enough time form competition of ADL tasks, assist resident with oral care daily as needed, assist with ADL tasks as needed, and assist with personal hygiene as needed. On December 5, 2023, at 10:17 AM, R230 was in bed in a hospital gown, her hair was stringy and matted to her head. R230 also had long hairs on her chin. R230 said she has not had a shower since she was admitted to this facility, no one has offered to give her a shower, to shave her, or cut her nails. R230 stated she thought because they have to use a mechanical lift to get her out of bed, she could not have a shower. R230 also stated one staff member placed a special shower cap with a special shampoo in it on R230's head and then left the room. R230 said she was not able to swish it around to clean her hair. R230 said she would really like to have a shower, have her hair washed, and have someone shave her chin hairs. On December 5, 2023, at 2:01 PM, R230 was in the occupational therapy room, her hair was stringy and matted to the back of her head. R230 continues to have long chin hairs that are approximately 1/4 inch on both sides of her chin. On December 6, 2023, at 8:31 AM, R230 said her shower days are on Sunday and Thursday but since they have to use a mechanical lift to get her out of bed, R230 thinks she cannot have a shower. R230 said, no one has asked her if she would like to be shaved or have her nails cut. R230 said she also has an overactive bladder and they know it but they wait until she calls them to come check her incontinence brief. R230 said when she puts on her call light, it takes them a long time to answer it. On December 6, 2023, at 12:10 PM, V12 (CNA/Certified Nursing Assistant) and V13 (CNA) were getting R230 up out of bed for the day and into her wheelchair. R230 was wearing a hospital gown. R230 was dressed and then transferred from her bed into her wheelchair using a mechanical lift. V13 brushed R230's hair. V15 (Family Member) was in the room, and she asked V12 about getting R230's hair washed. V12 said they have a shower cap they can use that has shampoo in it. R230 told V12 they have tried it and she did not like it. V12 was asked if there was a reason R230 could not take a shower. V12 said most residents who require the use of a mechanical lift for transfers usually don't take showers because they are bed ridden. V12 said they do have a shower chair and it is possible to use a mechanical lift to place a resident in the shower chair just like they place them into their wheelchair. V15 and R230 both said they had no idea a shower was even an option. On December 6, 2023, at 1:01 PM, V15 said when she came in today, R230 had a dried crusty substance around both eyes and V15 said she asked R230 if she had brushed her teeth. R230 told her no, she had not brushed her teeth. V15 said R230 said she hasn't brushed her teeth in days or washed her face saying no one offers to help her get cleaned up in the morning. V15 said she gave R230 a wash cloth and helped set her up to brush her teeth in bed. On December 6, 2023, at 1:06 PM, V12 said when it is not a resident's shower day, we still check and change them, get them out of bed, help brush their teeth, brush their hair, and nail care. V12 said they will also put lotion on the resident's arms and legs, wash face, hands, armpits, and put on deodorant. V12 said her shifts starts at 11:00 AM and she did not know if V13 had provided any care to R230. On December 6, 2023 at 1:43 PM, V13 said the care provided depends on what the resident can do for themselves. We will help them wash face and hands, brush teeth, brush hair, perineal care, wash armpits, put on deodorant, and wash face. V13 said R230 can brush her hair, wash her face, and brush her teeth herself. On December 6, 2023, at 1:50 PM, V2 (DON/Director of Nursing) said we will always see what the resident can do for themselves, and the staff will help the resident with what they cannot do for themselves. V2 said residents should be checked and changed every two hours and her expectation is that every day; not just shower days, the residents are cleaned up, dressed and out of bed. Morning care consists of incontinence care or taking the resident to the bathroom, personal hygiene including brushing teeth, brushing hair, washing face, hands, armpits, applying deodorant, if resident has dentures, cleaning and putting dentures in the resident's mouth, nail care, and shaving (both men and women). If a resident is diabetic, the staff are only allowed to file the fingernails and not cut them. V2 said diabetics are referred to podiatry to have their fingernails cut. Facility provided a policy dated March 10, 2022, and titled Dressing/Grooming. The policy showed Dressing/grooming refers to the activities provided to improve or maintain the resident's self-performance in dressing and undressing, bathing and washing, and performing other personal hygiene tasks. These activities are individualized to the resident's needs, planned, monitored, evaluated, and documented in the resident's medical record .c. Grooming: i. Maintaining personal hygiene; .iv. Combing hair; v. Washing face and hands; vi. Brushing teeth; vii. Shaving; viii. Applying deodorant; x. Trimming nails . Facility provided a policy dated September 2020, and titled Nails (Care Of). The policy showed All residents will have clean, well-trimmed nails. Procedure .5. Fingernails of diabetic residents are to be cut by the nurse .

Based on observation, interview, and record review, the facility failed to ensure that the resident's peri wound was cleaned prior to application of skin treatment. This applies to 1 of 5 residents (R65) observed for skin conditions in the sample of 19. The findings include: The face sheet and physician order show that R65 is [AGE] years-old who has multiple medical diagnoses which include stage 3 pressure ulcer in the left and right buttocks and diaper dermatitis. In addition, there were multiple treatment creams (Lotrisone external cream, Nystatin-Triamcinolone external ointment, and Zinc Oxide Ointment 20 %) that was ordered for R65 due to skin condition. On December 5, 2023, at 10:22 AM, V6 (Wound Care Nurse) and V5 (Wound Care Technician) rendered wound care to R65's pressure ulcer. V6 cleansed the wound bed and the peri-wound with normal saline, then she applied treatment to the wound bed and covered it with dressing. When V6 completed the pressure ulcer treatment, V6 proceeded to apply combination of treatment creams (Lotrisone external cream, Nystatin-Triamcinolone external ointment, and Zinc Oxide Ointment 20 %) which were mixed together to R65's peri-wound. During the process of treatment application, R65 started urinating. The urine trickled down to R65's left lower buttock. V6 did not stop to clean the resident but instead V6 continued to apply the treatment creams. As a result the urine was getting mixed with the treatment creams and getting spread on the peri wound. V6 stated that R65 has a neurogenic bladder, and it was normal for her to urinate while being turned/reposition or while being provided care. On December 5, 2023, at 4:15 PM, V6 (Wound Care Nurse) stated that R65 has fungal rash in the sacrum, peri-wound, in the left and right buttocks and the groins. She has treatment creams such as Lotrisone, Nystatin, Triamcinolone, and Zinc which she mixes to apply to R65's affected area. On December 6, 2023, at 10:13 AM, V2 (Director of Nursing/DON) stated that when staff are providing wound or skin care and the resident had bladder or bowel incontinence, the staff should provide peri-care right away before they continue the skin or wound care. V2 also stated that staff are to ensure that skin is completely clean prior to applying treatment to prevent worsening of skin breakdown or skin problem. There was no specific care plan addressing R5's fungal rash condition.

Based on observation, interview and record review the facility failed to administer tube feeding as ordered by the physician. This applies to 1 of 1 resident (R60) reviewed for tube feeding in the sample of 19. The findings include: R60 had multiple diagnoses including cerebral infarction due to unspecified occlusion or stenosis of left middle cerebral artery, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, dysarthria and aphasia following cerebral infarction and type 2 diabetes mellitus without complications, based on the face sheet. R60 was admitted to hospice care on June 28, 2023 with terminal prognosis of CVA (Cardiovascular accident). R60's quarterly MDS (minimum data set) October 11, 2023 showed that the resident was cognitively impaired. The same MDS showed that R60 uses feeding tube for nutrition. On December 4, 2023 at 10:32 AM, R60 was sleeping in bed with head of bed elevated. R60 had an ongoing gastrostomy tube feeding of Isosource 1.5 cal (calorie) running at 65 ml (milliliters)/hour as set by the feeding pump. The 1000 ml closed system of Isosource bag that was being used had a label indicating that it was started on December 4, 2023 at 10:00 AM to run at 65 ml/hour. On December 5, 2023 at 10:30 AM, R60 was in bed, awake but non-verbal. R60 had an ongoing gastrostomy tube feeding of Isosource 1.5 cal running at 65 ml/hour as set by the feeding pump. The 1000 ml closed system of Isosource bag that was being used had a label indicating that it was started on December 5, 2023 at 5:00 AM to run at 65 ml/hour. On top of R60's bedside table was an unused 1000 ml tube feeding bag of another Isosource 1.5 cal. R60's active order summary report showed an order dated August 12, 2023 for, NPO (Nothing By Mouth) diet. The same active order summary report showed an order dated August 13, 2023 to infuse 65 ml/hour of Diabetisource 1.2 cal tube feeding, every shift. On December 5, 2023 at 10:35 AM, V3 (Registered Nurse) was asked to check R60's tube feeding. V3 confirmed that the tube feeding that was being delivered to R60 at the time was Isosource 1.5 cal. V3 also confirmed that there was an unused Isosource 1.5 cal tube feeding bag on top of R60's bedside table. V3 was prompted to check R60's tube feeding order, and had confirmed that R60 should receive the ordered Diabetisource 1.2 cal at 65 ml/hour, instead of the Isosource 1.5 cal. According to V3, R60 should receive the Diabetisource 1.2 cal because the resident was diabetic. V3 further stated that she had reviewed R60's active orders and there was no order to change the tube feeding and/or may administer a different tube feeding aside from the ordered Diabetisource 1.2 cal. At 10:40 AM, V3 went inside the unit supply/storage room and 2 bags of Diabetisource 1.2 cal 1000 ml was available in the unit for use. R60's monthly enteral assessment dated [DATE] created by V4 (Registered Dietitian) showed in-part, NPO status. Currently receiving Diabetisource [at] 65 ml/hr (hour) x 24 hours with [water] flush 200 ml [every] 6 hours. Tolerating feeding well. Appears to be well hydrated and nourished. Enteral feeding will provide [R60] with 1872 kcals (kilocalories), 94 g (grams) protein, 1276 ml free water with a total of 2076 ml fluid daily. Enteral feeding will provide [R60] with 100% of energy and hydration needs. The same assessment showed in-part under recommendations, continue enteral feeding as ordered. R60's active care plan initiated on June 7, 2023 showed that the resident was on NPO and required tube feeding. The same care plan showed multiple interventions including administration of tube feeding per physician order. On December 6, 2023 at 10:12 AM, V4 stated that R60 was diabetic and based on her calorie computation, the resident was appropriate to receive Diabetisource 1.2 cal to maintain weight and blood sugar level. According to V4, since R60 was diabetic and on NPO, R60 should receive her ordered tube feeding to ensure proper nutrition and hydration. V4 added that R60, does not need a higher calorie feeding based on the resident's weight and calorie computation. On December 6, 2023 at 10:36 AM, V2 (Director of Nursing) confirmed that the nurses had administered wrong tube feeding to R60 as observed on December 4 and 5, 2023. V2 stated that the nurses' are expected to always follow the physician's orders for tube feeding. The facility's clinical practice guidelines regarding enteral nutritional feeding dated September 2020 showed in-part under procedure, 1. Verify M.D. (Medical Doctor) orders for feeding.

Based on interview and record review the facility failed to provide a resident with an opioid pain medication or muscle relaxant pain medication as prescribed by the physician. This applies to 1 of 4 residents (R69) reviewed for pain management in the sample of 19. The findings include: R69's EMR (Electronic Medical Record) showed R69 was admitted to the facility on [DATE], with multiple diagnoses including, lumbar spondylolisthesis (spinal displacement), lumbosacral spinal stenosis (narrowing of the spinal cord), and arthrodesis (joint fusion). R69's MDS (Minimum Data Set) dated November 3, 2023, showed R69 was cognitively intact. The MDS continued to show R69 had pain in the last five days. R69's pain care plan dated October 28, 2023, showed Alteration in comfort: spinal stenosis and spondylolisthesis status post lumbosacral fusion. The care plan continued to show multiple interventions dated October 28, 2023, including Administer pain strategies according to Medication Administration Record and Treatment Administration Record. On December 4, 2023, at 10:17 AM, R69 said she was admitted on [DATE], and did not receive pain medication until the morning of October 29, 2023. R69 continued to say she had a difficult time participating in therapy because of her pain. V18 (R69's Daughter) said she asked R69's nurse about R69's pain medication and was told the medication would not be delivered to the facility at 3:00 AM. V18 continued to say she asked R69's nurse if the facility has an extra supply of pain medication and was told by the nurse the facility did not have R69's pain medication available. On December 5, 2023, at 1:59 PM, R69 said she was taking pain medication regularly while she was in the hospital prior to being admitted to the facility because she had spinal surgery on Wednesday, October 25, 2023. R69 continued to say when she arrived to the facility on Saturday night, she asked for pain medication throughout the night and only received acetaminophen. R69 said the acetaminophen did not work as well as the other pain medications. R69 said prior to her back surgery, she was taking tramadol four times a day for pain relief. R69's Physical Therapy Evaluation and Plan of Treatment, dated October 29, 2023, at 12:56 PM, by V19 (Registered Physical Therapist) showed R69 said I know I could do more if the medicine works and if I am not in a lot of pain. On December 6, 2023, at 11:06 AM, V11 (Director of Pharmacy Operations) said if medications are ordered for a resident and requested for pharmacy delivery around 4:00 PM to 5:00 PM, then the medications will be delivered to the facility the following day between 2:00 AM and 3:00 AM. V11 continued to say the facility maintains a supply of pain medications in their automated medication dispenser which can be used prior to medication delivery. V11 said facility staff are also able to request a stat medication delivery. V11 said R69's tramadol and oxycodone-acetaminophen were delivered to the facility on [DATE], at 2:00 AM. On December 6, 2023, at 9:47 AM, V9 (RN/Registered Nurse) said she was R69's nurse on October 28, 2023, when she was admitted . V9 continued to say if medications are ordered after 3:00 PM, then they will be delivered at 3:00 AM the following day. V9 continued to say if a resident was requesting pain medication before the delivery V9 would check the automated medication dispenser for the medication and if the medication was not in there then she would get an order for acetaminophen. V9 said she had never made a stat request for medication from the pharmacy. On December 6, 2023, at 1:29 PM, V2 (DON/Director of Nursing) said oxycodone-acetaminophen, tramadol, and tizanidine were in the automated medication dispenser. V2 continued to say R69 should have received the prescribed pain medications instead of the acetaminophen. The facility's undated Inventory List for [the facility], showed the facility had medication stock of oxycodone-acetaminophen, tramadol, and tizanidine. R69's October 2023 MAR (Medication Administration Record) showed R69 had medication orders dated October 28, 2023 for oxycodone-acetaminophen (opioid pain medication) 5/325 mg (milligram) oral tablet, give one to two tablets by mouth every six hours as needed for pain management; tramadol (opioid pain medication) 50 mg oral tablet, give one tablet every 12 hours as needed for pain management; and tizanidine (muscle relaxant) 2 mg oral tablet, give one tablet every six hours as needed for muscle weakness. R69's MAR continued to show R69 first received oxycodone-acetaminophen on October 29, 2023, at 5:57 AM, and first received tramadol on October 29, 2023, at 8:22 AM. R69's hospital documentation titled After Visit Summary, dated October 28, 2023, at 2:04 PM, showed R69 last received oxycodone-acetaminophen on October 28, 2023, at 11:58 AM, last received tramadol on October 25, 2023, at 8:09 PM, and last received tizanidine on October 28, 2023, at 4:52 AM. The documentation continued to show discharge instructions of take pain medication (oxycodone-acetaminophen) as needed for pain. R69's Pain Management Evaluation dated October 28, 2023, at 6:22 PM, showed R69 had undergone a painful procedure and had almost constant pain over the last five days. R69's Weights and Vitals Summary dated December 6, 2023, showed on October 28, 2023, at 6:01 PM, R69 complained of 6/10 (moderate) pain. The documentation continued to show R69 was not pain free until October 29, 2023, at 2:10 PM.

Based on observation, interview, and record review, the facility failed to follow their policy and don recommended personal protective equipment (PPE) while performing wound care to a resident on Enhanced Barrier Precautions (EBP). The facility also failed to follow their policy by not removing soiled gloves after performing incontinence care, and not performing hand hygiene before touching the resident's clean environment. This applies to 3 of 19 residents (R47, R5, and R230) reviewed for infection prevention in the sample of 19. The findings include: 1. R47's face sheet documents a stage 4 sacral pressure ulcer with an onset date of 11/5/2022. R47's skin care plan documents he has an actual alteration in skin integrity related to sacral pressure ulcer. Intervention: Enhanced Barrier Precautions will be implemented during high contact resident care activities for chronic wounds including, but not limited to pressure ulcers. On December 5, 2023 at 9:34 AM with V5 (CNA) and V6 (Wound Care Coordinator) outside R47's room, there is bright orange EBP sign on R47's door that shows staff should wear a gown and gloves during wound care for any skin opening requiring a dressing. V6 and V5 did not put on a gown before providing wound care to R47. V5 removed R47's brief, and repositioned R47 onto his left side during the wound care. R47 had an open wound to his sacrum that was about the size of a quarter. V6's scrubs cames in contact with the resident's bed linens while performing his wound care. After the provision of wound care to R47, V6 stated that she and V5 should have worn a gown before providing wound care to R47 who is on enhanced barrier precautions. On December 6, 2023 at 08:52 AM, V2 (Infection Preventionist/DON) stated that she expects the staff to be 100% compliant with donning gown and gloves when performing wound care to residents on Enhance Barrier Precautions. V2 stated that using gown and gloves during wound care is necessary to protect the resident from getting an infection. The facility's EPB policy dated April 10, 2023 shows the following: In addition to standard precautions, enhanced barrier precautions, will be implemented during high-contact resident care activities when caring for residents with a novel or targeted Multidrug Resistant Organisms (MDRO), chronic wounds or indwelling medical devices. Wound Care: any chronic wound requiring a dressing: The intent of Enhanced Barrier Precautions is to focus on residents with a higher risk of acquiring an MDRO over a prolonged period of time. 29562 2. On December 5, 2023, at 11:27 AM, V6 (Wound Nurse) and V5 (Wound Care Technician) rendered incontinence and wound care to R5 who was heavily saturated with urine and had a bowel movement. V6 cleaned R5's rectal and buttocks area while V5 cleaned the frontal perineum. After V5 completed the peri-care, she continued to assist with positioning R5 for wound care, straightened R5's clean gown, bed linen and pillow while wearing the same soiled gloves. On December 6, 2023, at 10:09 AM, V2 (Director of Director/DON) stated that staff must perform hand hygiene before and after providing care. They should also change gloves and perform hand hygiene in between task. This is done for infection prevention. 41855 3. R230's EMR (Electronic Medical Record) showed R230 was admitted to the facility on [DATE], with diagnoses that included fracture of superior rim of left pubis, subsequent encounter for fracture with routine healing, polyneuropathy, peripheral vascular disease, overactive bladder, and restless leg syndrome. R230's admission MDS (Minimum Data Set) dated December 1, 2023, showed R230 was cognitively intact. R230's functional abilities on admission showed she was dependent on staff for toileting, shower/bath, upper body dressing, lower body dressing, putting on and taking off footwear. R230 required set-up or clean -up assistance for oral care. R230 had been at the facility for less than two weeks at the time of this survey and assessments were still ongoing. R230's therapy care plan showed R230 had impaired ADLs (Activities of Daily Living) in the following areas: bathing, dressing, toileting, clothing management, and toileting hygiene. R230's nursing care plan showed R230 had an ADL functional performance deficit, activity intolerance, and decreased functional ability related to restless leg syndrome, overactive bladder, and polyarthritis. Interventions showed staff are to allow enough time form competition of ADL tasks, assist resident with oral care daily as needed, assist with ADL tasks as needed, and assist with personal hygiene as needed. On December 6, 2023, at 12:10 PM, (CNA/ Certified Nursing Assistant) and V13 (CNA) were getting R230 up out of bed and into her wheelchair but first provided incontinence care. V12 and V13 each opened one side of the incontinence brief. V12 used a wipe and wiped left groin, folded wipe and wiped right groin, folded the wipe and wiped down the middle. With the same gloves, V12 repositioned R230 onto her left side (facing away from her and towards V13). V12 then rolled up the wet brief and placed it under R230. V12 used a wipe to clean R230's anal area. While wearing the same gloves V12 started with, V12 picked up and placed a clean incontinence brief under R230 and then repositioned R230 onto her right side, now side facing V12. V13 pulled the clean brief through and positioned it under R230. V12 and V13 both while still wearing the same gloves repositioned R230 onto her back. V12 and V13 fastened the incontinence brief. V13 grabbed the lotion and applied lotion to R230's left leg. V13 removed her gloves and without performing hand hygiene, put on a new pair of gloves. V13, put lotion into her hand and rubbed lotion onto R230's right leg. On December 6, 2023, at 1:50 PM, V2 (DON/Director of Nursing) said when staff are providing incontinence care or perineal care, they are to remove the incontinence brief, clean all areas front to back, cleaning each area with a different rag or wipe, if they fold rag or wipe in half that is ok, but V2 said her expectation is that they fold it no more than two times. The area needs to be dried well so there is no moisture. When done cleaning the front area, the staff need to remove gloves, perform hand hygiene, and reapply new gloves before turning the resident onto their side to clean the back side. The back side will get cleaned from front to back. When staff are done cleaning the back side, they need to remove gloves, perform hand hygiene, and put on new gloves before touching the new incontinence brief and continuing with the rest of the resident's care. Facility provided policy dated June 4, 2020 and titled, Hand Washing and Hand Hygiene. This policy showed Purpose of hand hygiene is essential in preventing the spread of infectious organisms in healthcare settings. The Guidelines include 1. Hand hygiene must be performed after touching blood, body fluids, secretions, excretions, and contaminated items b) Before contact with a particularly susceptible resident (open wounds, etc.) .d) Before and after touching wounds of any kind. e) Before and after providing personal care for a resident. f) After removing gloves

Based on observation, interview and record review the facility failed to obtain treatment orders and implement interventions for the healing of a pressure injury. This applies to 1 of 3 resident (R2) reviewed for pressure injuries in a sample of 6. Findings include: V9's (Wound Physician) Physician Note dated 1/19/2023 documents R2 with a stage 4 pressure injury to his sacrum, identified on 10/13/2022, measuring 8 X 7 X 2.4 centimeters. On 2/2/2023 at 11:22 AM, R2 was in a bed on a regular mattress. V8 (Nurse) removed the dressing to R2's sacral area which revealed a stage 4 pressure injury. R2's Order Summary Report dated 1/1-1/31/2023 documents R2 admitted to hospice on 1/23/2023 and at that time, all of V9's previous medicated treatment orders for the sacral pressure injury were discontinued. A new order dated 1/23/2023 documents to cleanse the sacral pressure injury and cover with a foam dressing. R2's Order Summary Report dated 2/1-2/28/2023 documents R2 with an order dated 2/3/2023 to cleanse the sacral ulcer, pack with Iodoform, apply Maxorb and cover with a foam dressing every day. These Order Summaries document no medication treatment orders between 1/23-2/2/2023 to treat and promote the healing of R2's sacral pressure injury. R2's Nurse's Note dated 1/24/2023 documents hospice provided a new frame and mattress. 2/2/2023 at 2:10 PM V2 (Director of Nursing) stated R2 had treatment orders and a bed with a low air loss mattress (LALM) until he was admitted to hospice (1/23/2023). V2 stated for some reason hospice did not provide orders for the treatment of R2's pressure injury. V2 also stated hospice brought a new bed and it was supposed to be a bed with a LALM. V2 confirmed R2 should have a LALM due to his stage 4 pressure injury and treatment orders. V2 stated R2's hospice company is not one of the companies the facility generally works with and she is not sure what happened. R2's 10/16/2023 Care Plan for Pressure Injury documents R2 with interventions which include use of a specialized low air loss mattress.

Based on observation, interview and record review the facility failed to provide incontinence care and catheter care in a manner that would prevent infection and maintain hygiene. This applies to 3 of 6 residents (R26, 42 and R113) reviewed for incontinence care and urinary catheter care in the sample of 18. The findings include: 1. R113 was admitted to the facility on [DATE]. R113 had multiple diagnoses which includes, cerebral infarction due to unspecified occlusion or stenosis of the right middle cerebral artery, hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side, generalized muscle weakness and retention of urine, based on the face sheet. R113's admission MDS (minimum data set) dated January 10, 2023 showed that the resident is cognitively intact. The MDS showed that R113 required extensive assistance from the staff with most of his ADL (activities of daily living) including bed mobility, dressing, toilet use and personal hygiene. The same MDS showed that R113 had indwelling urinary catheter. On January 24, 2023 at 2:25 PM, R113 was in bed, alert, oriented and verbally responsive. R113 had a urinary catheter in place. V5 (Treatment Nurse) with the assistance of V6 (CNA/Certified Nursing Assistant) was about to provide treatment on R113's pressure injuries. V5 and V6 turned R113 on his right side. R113 had a small amount of stool. With gloved hands, V5 cleaned R113's anal and bilateral buttock areas and then proceeded to provide pressure injury treatment. V6 then applied a new disposable brief to R113 and then both V5 and V6 fastened the resident's disposable brief. R113's front perineal area, including the urinary catheter insertion site and urinary catheter tubing were not cleaned. To reposition R113 in bed, V6 unhooked the resident's privacy bag (containing the urinary catheter draining bag and part of the catheter tubing) from the bed frame and placed it on top of R113's bed. While V5 and V6 were attempting to turn and reposition R113, the urine that was inside the catheter tubing was visibly noted flowing back towards the urinary catheter insertion site and then back towards the urinary drainage bag. V6 was informed of this observation and was prompted to hang back the privacy bag containing the urinary catheter bag on the bed frame. R113's active order summary report showed an order dated January 4, 2023 for Indwelling urinary catheter care daily and PRN (as needed). R113's care plan initiated on January 10, 2023 regarding indwelling urinary catheter showed multiple interventions including, Position collection bag below the level of the bladder and Catheter care per orders. 2. R42 has multiple diagnoses which includes, acute and chronic respiratory failure with hypoxia, generalized muscle weakness, stage 3 chronic kidney disease, infection, and inflammatory reaction due to indwelling urethral catheter and history of urinary tract infection, based on the face sheet. R42's admission MDS dated [DATE] showed that the resident is cognitively intact. The same MDS showed that R42 required extensive assistance from the staff with most of her ADL including, bed mobility, dressing, toilet use and personal hygiene. On January 24, 2023 at 1:14 PM, R42 was in bed, alert, oriented and verbally responsive. R42 had an indwelling urinary catheter in place. V5 (Treatment Nurse) with the assistance of V6 (CNA/Certified Nursing Assistant) was providing treatment to R42's upper back area. V5 and V6 turned R42 on her left side. R42 had a small amount of stool. With gloved hands, V6 cleaned R42's anal and bilateral buttock areas and then proceeded to provide pressure injury treatment to the resident's sacrococcygeal and buttocks. When the treatment was completed, V5 and V6 applied a new disposable brief to R42 and then fastened the resident's disposable brief. R42's front perineal area, including the urinary catheter insertion site and urinary catheter tubing were not cleaned. R42's active order summary report dated January 19, 2023 showed an order for, Indwelling urinary catheter care daily and PRN (as needed). Further review of R42's active order summary report showed an order dated January 20, 2023 for, Cephalexin oral capsule 500 mg. Give 1 capsule by mouth three times a day related to urinary tract infection, for 14 administrations. R42's urinalysis collected on January 14, 2023 showed that Proteus Mirabilis organisms were identified. R42's active care plan initiated on December 6, 2023 regarding indwelling urinary catheter showed multiple interventions which includes, Provide catheter care and Catheter care per order. On January 25, 2023 at 8:20 AM, V2 (Director of Nursing) stated that when staff are providing bowel incontinence care to a resident, full perineal care should be provided to include, both the resident's front and back private areas as well as providing catheter care by cleaning the urinary catheter insertion site and the (outside) catheter tubing to ensure cleanliness, maintain hygiene and to prevent potential infection. When placing the drainage bag and the catheter tubing, the staff must ensure that it is positioned below the bladder to prevent back flow of urine. According to V2, the staff should have not placed the drainage bag and tubing on the bed to prevent potential back flow. V2 added that the staff should make sure to observe while doing care, that the urine from the catheter tubing will not flow back towards the catheter insertion site, to prevent potential infection. Review of the facility's catheter care policy and procedure dated September 2020 showed in-part, Daily and PRN (as needed) catheter care will be done to promote comfort and cleanliness. 45303 3. The EMR (Electronic Medical Record) showed R26 was admitted to the facility on [DATE], with multiple diagnoses including urinary tract infections, retention of urine, and dementia. The MDS dated [DATE], showed R26 was cognitively intact and was totally dependent on facility staff for transfers between surfaces. The MDS continued to show R26 had an indwelling urinary catheter. On January 25, 2023, at 10:32 AM, R26 was lying in bed. V6 (CNA/Certified Nursing Assistant) took R26's indwelling urinary catheter collection bag from the side of R26's bed and placed the collection bag on R26's lower abdomen. Yellow urine was back flowing in the drainage tubing towards R26. R26's indwelling urinary catheter collection bag was on R26's lower abdomen while V6 and V13 (CNA) transferred R26 from the bed to the recliner using a total body mechanical lift. A R26 sat in the recliner, V6 removed R26's indwelling urinary catheter collection bag from R26's abdomen, and had R26's urine collection bag above the level of R26's bladder as V6 made R26 comfortable in the chair. On January 25, 2023, at 2:30 PM, V2 (DON/Director of Nursing) said indwelling urinary catheter collection bags should be kept below the level of the bladder during resident transfers.

Based on observation, interview, and record review, the facility failed to follow their policy for tracking behaviors for residents receiving psychotropic medications. This applies to 2 of 5 residents (R44 and R27) reviewed for unnecessary medications in a sample of 18. The findings include: 1. On January 23, 2023, at 1:00 PM, R44 was lying in bed, sleeping. On January 24, 2023, at 1:50 PM, R44 was lying in bed, sleeping. On January 25, 2023, at 9:35 AM, R44 was lying in bed, sleeping. The EMR (Electronic Medical Record) showed R44 was admitted to the facility on [DATE], with multiple diagnoses including chronic obstructive pulmonary disease, anxiety, and depression. The EMR continued to show the following targeted behaviors for R44: low moods, sadness, and anxiousness. R44's Order Summary Report dated January 25, 2023, showed the following orders initiated on January 6, 2023, for R44: Alprazolam tablet (antianxiety medication) disintegrating 0.25 mg (milligram), give one tablet by mouth at bedtime related to anxiety disorder, Duloxetine capsule (antidepressant medication) delayed release particles 30 mg, give one capsule by mouth one time a day related to depression. R44's MDS dated [DATE], showed R44 had moderate cognitive impairment. On January 25, 2023, at 2:15 PM, V2 (DON/Director of Nursing) said the CNAs (Certified Nursing Assistants) are responsible for charting whether a resident is exhibiting behaviors or note. V2 continued to say the CNAs should be documenting this every shift. The facility does not have documentation to show R44's behavior tracking was completed while R44 was receiving psychotropic medications. 2. The EMR showed R27 was admitted to the facility on [DATE], with multiple diagnoses including Parkinson's disease, depression, and mild intellectual disabilities. The EMR continued to show the following targeted behaviors for R27: low moods and sadness. R27's Order Summary Report dated January 25, 2023, showed the following order initiated on September 28, 2022, fluoxetine capsule (antidepressant medication) 20 mg, give two capsule by mouth one time a day related to depression. R27's MD dated January 4, 2023, showed R44 had moderate cognitive impairment. The facility does not have documentation to show R27's behavior tracking was completed for the last 30 days. The facility policy titled, PSYCHOTROPIC MEDICATIONS - USE OF, dated 09/2020 showed, PURPOSE: To establish a standardized system to inform residents and/or their responsible parties about psychotropic medications and their side effects . DOCUMENTATION: Prior to the administration of an antipsychotic medication, the following must be documented . 4. Residents who display target behaviors or who take psychotherapeutic medications will have their behaviors quantitatively and objectively documented on the behavior tracking form .

Based on observation, interview and record review, the facility failed to administer medications as ordered by the physician. There were 25 opportunities with 5 timing errors, resulting in 20% medication error rate. This applies to 3 of 10 residents (R42, R114 and R116) observed during the medication pass in the sample of 18. The findings include: On January 23, 2023 at 4:40 PM, State agency representative asked V4 (Nurse) who was seated inside the second floor nursing station, if she will be doing the afternoon medication pass. V4 responded that V3 (Nurse/Assistant Director of Nursing) will be doing the medication pass. During this conversation V3 was walking pass the nursing station. V3 stated, I thought I am just supposed to give the 2:00 PM medications. V4 responded, You now have the keys to the medication cart. During this point, V3 went to the team 1 medication cart and started preparing medications to the residents. 1. On January 23, 2023 at 5:22 PM, V3 stated that she will prepare and administer the 2:00 PM scheduled medications for R42. V3 prepared and administered the following medications to R42: 1 tablet of Hydralazine 100 mg (milligram) , 1 tablet of Cephalexin 500 mg and injected 1 ml (milliliter) of Heparin 50,000 units/ml. R42 has multiple diagnoses which includes, chronic diastolic (congestive) heart failure, hypertensive and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, urinary tract infection and long term (current) use of anticoagulants, based on the face sheet. R42's active order summary report showed orders dated January 20, 2023 for Hydralazine HCl (hydrochloride) 50 mg. Give 2 tablets by mouth three times a day related to hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease or unspecified chronic kidney disease, 100 mg total, Cephalexin 500 mg. Give 1 capsule by mouth three times a day related to urinary tract infection for 14 administrations and Heparin Sodium injection solution 5000 unit/ml. Inject 1 applicator subcutaneously every 8 hours for DVT (deep vein thrombosis) Prophylaxis. R42's January 2023 MAR (medication administration record) for Hydralazine HCl 50 mg showed that this medication was scheduled to be given three times a day, every 6:00 AM, 2:00 PM and 9:00 PM. R42's January 2023 MAR for Cephalexin 500 mg showed that this medication was scheduled to be given three times a day, every 6:00 AM, 2:00 PM and 9:00 PM. R42's January 2023 MAR for Heparin Sodium injection showed that this medication was scheduled to be given every 8 hours at 6:00 AM, 2:00 PM and 10:00 PM. On January 25, 2023 at 11:36 AM, V11 (Physician) stated that he expects the facility to administer any residents medications as ordered and as scheduled. 2. On January 23, 2023 at 5:40 PM, V3 stated that she will prepare and administer the 2:00 PM scheduled IV (intravenous) medication for R116. V3 prepared and administered the Meropenem & Sodium Chloride 500 mg, at 100 ml/hr (milliliter/hour) rate over 30 minutes to R116. R116 has multiple diagnoses which includes, urinary tract infection and ESBL (Extended Spectrum Beta Lactamase) resistance, based on the face sheet. R116's active order summary report showed an order dated January 18, 2023 for Meropenem-Sodium Chloride Intravenous Solution Reconstituted 500 mg/50 ml. Use 500 mg intravenously every 8 hours for ABT/ESBL (antibiotic/Extended Spectrum Beta-Lactamase) in urine for 14 Days. R116's MAR for Meropenem-Sodium Chloride 500 mg, showed that this medication was scheduled to be given every 8 hours at 6:00 AM, 2:00 PM and 10:00 PM. On January 25, 2023 at 2:57 PM, V12 (Physician) stated that the physician's orders should be followed, including the timing of the intravenous medications. 3. On January 23, 2023 at 5:46 PM, V3 stated that she will prepare and administer the 3:00 PM medication for R114. V3 prepared and administered, 1 tablet of Methocarbamol 500 mg to R114. R114 has multiple diagnoses which includes, fracture of the upper end of the right humerus, displaced supracondylar fracture with intracondylar extension of the lower end of the left femur and Parkinson's disease, based on the face sheet. R114's active order summary report showed an order dated January 4, 2023 for, Methocarbamol 500 mg. Give 1 tablet by mouth three times a day for pain management. R114's MAR for Methocarbamol 500 mg, showed that this medication was scheduled to be given three times a day, every 9:00 AM, 3:00 PM and 9:00 PM. On January 25, 2023 at 11:36 AM, V11 (Physician) stated that he expects the facility to administer any residents medications as ordered and as scheduled. Review of the facility's medication administration policy and procedure dated September 2020 showed, Policy: Medications will be administered in accordance with the established policies and procedures. Under the procedure, it showed in-part, 1. Drugs must be administered in accordance with the written orders of the attending physician.

Based on observation, interview and record review the facility failed to assess pressure sores, provide repositioning to prevent new pressure ulcers and prevent the decline of existing sores and failed to update and revise treatment plans with a change in a pressure sore. This applies to two resident of two residents (R2 and R3) reviewed for pressure ulcers from a sample of 15. This deficient practices resulted in both R2 and R3 developing pressure sores while in the facility. The findings include: (1) According to R3's care plan dated initiated 9/30/14, R3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R3 is a [AGE] years old resident that was also admitted for rehabilitation following a right hip replacement at the hospital. R3's initial nursing assessment dated [DATE] showed "no redness noted to buttocks". R3's admission Braden scale dated 9/26/14 showed a score of 20 -category N/A. On 11/25/14 at 09:15am, R3 was observed sitting in wheelchair in her room, when asked about the wound, R3 stated she started feeling some irritation to her buttocks area around the first week of October, she recalled "mentioning it to the nursing staff twice that weekend as the irritation persisted". R3 stated she was applying her personal lotion to the area. R3 stated she "thought the feeling would go away but did not". On 11/25/14 at 09:40am, E3 (Assistant director of nursing) ADON stated R3 was not at risk when she was admitted , however, R3 complained of irritation to her buttocks to a nursing staff on 10/4/14, the staff saw the area and called the physician for treatment order. E3 stated she personally saw R3's buttocks on 10/7/14 and found it was a stage III pressure sore. R3 developed the pressure sore at the facility due to R3's reduced mobility as related to R3's pain from her right hip surgery. The facility waited four days (10/4/14-10/7/14) until E3 - the wound nurse made rounds on 10/7/14 before R3's pressure sore was thoroughly assessed and measured. E3 stated measures were put in place as soon as she saw R3's sore. On 11/25/14 at 1:50pm, E2 (Director of Nursing) DON stated it was difficult for the nursing staff to assess R3's sore due to the location of R3's pressure sore as the sore was hidden in the buttock folds. R3's skin progress note dated 10/5/14 showed R3 was found to have dark blanchable redness and [DIAGNOSES REDACTED] to her buttocks. R3's comprehensive pressure ulcer assessment dated [DATE] showed interventions to relieve pressure sore was started on 10/7/14. Review of the nursing wound and skin assessment (WASA) dated 10/7/14 showed the wound was staged III, with redness, and foul odor and measured 3.5cm in length, 3.0cm in width and less than 0.1cm in depth. Skin progress note for R3 dated 10/12/14 showed R3's wound was getting worse and showing signs and symptoms of infection-bright redness surroundings with foul odor. Review of current physician order [REDACTED]. The other treatment was to apply santyl ointment 250unit/gm, cleanse with normal saline and cover with meplix every day and then every shift. R3's current treatment is to clean with normal saline solution, pat dry, pack with [MEDICATION NAME] alginate 4x4 with silver, cover with abdominal pads and tape. Review of R3's WASA form dated 11/18/14 showed R3's wound at stage IV 1.8cm in length, 2.0cm in breadth and 1.6cm in depth, scant drainage and foul odor. On 11/25/14 at 09:40am, E3 was observed performing pressure sore treatment on R3 in R3's room. E7 (CNA) certified nursing assistant was in the room for standby assist. R3's wound measurement showed 2.9cm in length, 2.8cm in breadth with 2.1cm depth. There was slight drainage on the old dressing. Review of facility's policy and procedure titled 'prevention and treatment of [REDACTED]. Some of the listed potential risk conditions include: "decreased mobility and recent surgery". The policy also showed to: -inspect the skin every shift with care for signs and symptoms of breakdown -position body in bed with pillows of other support devices -boney prominence susceptible to pressure will be protected". On 11/26/14 at 2:05pm, E2 stated "the facility holds the nursing staff responsible for not thoroughly assessing the resident". In review of Z1's (Wound Doctor) notes dated 10/15/14 there was no measurement or a depth description of R3's pressure wounds. There was no indication in Z1's notes of what could have caused R3 to develop the pressure sore. 2) Initial nursing assessment dated [DATE] showed that R2 was admitted to the facility on [DATE] for Respite care. R2 had scar tissue to bilateral buttocks from healed pressure sore, blanchable redness to bottom and bilateral lower and upper extremity [MEDICAL CONDITION] noted. There were no identified open sores and skin was intact. Nursing Braden scale dated 09/21/14, 09/29/14, 10/20/14, 10/27/14 showed that R2 was assessed as moderate risk and on 10/06/14, 10/13/14 N/A ( Not Applicable). On 09/22/14 R2 went to the hospital and came back on 09/29/14 due to [MEDICAL CONDITION]. R2 has [DIAGNOSES REDACTED]. Initial Nursing assessment dated [DATE] showed that R2's buttocks were red and blanchable, 2 areas of MASD ( Moisture Associated Skin Damage) noted, both irregular in shape, peri wound is blanchable, MASD noted to coccyx 3cm x 4 cm, MASD noted to right lower buttocks 1.5 cm x 1.5 cm. On 10/19/14 Skin progress note showed MASD to bilateral buttocks, redness noted with 3 open areas, no drainage and areas were not measured. The next Skin progress note was not done until 11/2/14 with the same documentation of MASD to bilateral buttocks, wound color red, no drainage and again areas were not measured. There were no skin progress notes documented after this date. Nursing WASA ( Wound and Skin Assessment) dated 10/24/14 showed left buttock with unstageable pressure sore identified on the left buttock 3 cm x 3.5 cm with 0.1 cm depth. Under comments it showed that R2 preferred to spend most of her days in her wheelchair "but cushion in place." Assessment identified development of slough to the left buttock with noted odor. The Nursing WASA done on 10/28/14 showed the worsening conditions of the wound measuring 8 cm x 3.5 by 0.3 depth, 95 % slough. On 11/4/14 Nursing WASA showed further worsening with cavity or crater development and undermining of 12 o'clock with 3.5 cm, 50 % slough and moderate exudate. Under additional comments showed 2 cm at 1 o'clock, 1.5 cm at 6 o'clock, 2 cm at 9 o'clock and 2 cm at 11 o'clock. On 11/11/14 WASA showed left buttocks wound with copious exudate with foul odor. Under additional comments showed undermining at 9 o'clock is 2 cm at 6 o'clock is 1.5 cm. Physician ordered [DEVICE] last week due to large amounts of drainage. [DEVICE] started on 11/06/14. MDS ( Minimum Data Set ) dated 10/06/14 showed that R2 was coded 3/3 on bed mobility and hygiene meaning extensive assistance. In bowel and bladder R2 was coded as 2/2 meaning frequently incontinent. R2's current care plan for alteration in skin integrity interventions included: pressure reduction sitting/wheelchair surface. Z1 ( Wound Physician) documentation dated 10/30/14 showed: there was a midline sacrococcygeal ulcer to the left of midline. There is slight extension to the superior aspect of the left buttock. The portion that is extended inferiorly is stage II. However there is a stage IV wound that initially on my examination was unstageable. Gentle probing revealed there is a cavity. Sharp excisional debridement was performed removing skin and subcutaneous tissue. The cavity was noted subcutaneously with some necrosis and slough. Some subcutaneous tissue was trimmed back with scissors as well. The wound was packed with Kerlix gauze. After debridement, the stage IV wound measures 3.4 x 3.0 x 2.7 cm. There is tunneling at 1 o'clock measuring 2.7 cm. There is tunneling at 6 o'clock measuring 2 cm. Tunneling at 9 o'clock is 2.4 cm. Tunneling at the 11 o'clock is 2.4 cm. On 11/25/14 at around 12 noon R2 was observed up in wheel chair. At 12:30 PM R2 was taken to the bathroom. E4 and E5 Certified Nursing Assistants (CNA's) said that R2 is going to have a shower but R2 refuses stating she was tired. E4 and E5 then assisted R2 to stand up. R2 was observed with a folded towel underneath her and adhering to her buttocks with fecal matter. E4 was asked if R2 needed cushion in her wheel chair. E4 stated " I usually don't see it and they don't have it for her ( R2). On 11/26/14 at 9:30 AM E3 ( Wound nurse) said that the onset of R2's wound in her buttocks was in October this year and was unstageable and that was the time they called the wound doctor. On 11/26/14 at 1:40 PM E3 said that R2 had pre-existing pressure sore scar tissue. E3 further stated that R2 prefers to be on her back. The facility puts a pillow to prop R2 to the side and R2 rolls to her back. R2 is also incontinent of bowel and bladder. E3 further stated that hospital did stage R2's wound as DTI ( Deep Tissue Injury), but we did not stage it properly during readmission to the facility. E3 acknowledged that was no care plan to address that R2 was propped and R2 rolls back. R2 was also assessed as moderate risk instead of high risk. Hospital record dated 9/23/14 showed right lower inner buttocks near the perineal area has two suspected DTI. One is 0.8cm long by 1 cm wide of purple skin. The second is approximately 3.4 cm long by 1.5 cm wide of open purple blister. Nearby is also a small stage II pressure ulcer. Bilaterally in the inner buttock is some raised, whitish to flesh colored skin. On 11/26/14 at 11 AM Z1 ( Wound physician) said that he saw R2 in the hospital for R2's leg. Z1 further stated that on 09/23/14 wound care nurse at hospital documented that R2 had areas of breakdown at sacrum and coccyx. Z1 said he saw R2 in the facility on 10/30/14 for leg wound and new sacral wound.

Based on observation, interview and record review the facility's Administrator, Director of Nursing (registered nurse-RN), Assistant Director of Nursing (RN) and Minimum Data Set Coordinator (RN) failed to ensure that all registered nurses (RN) administering IV's have the knowledge and skill to perform these procedures effectively and efficiently. As a result of this failure an immediate jeopardy was identified on 12/10/13. The immediate jeopardy began on 12/9/13. E1 (Administrator), E2 (Director of Nursing) and E3 (Nurse Consultant) were informed of the immediate jeopardy on 12/10/13 at 5:10 PM. The immediacy was removed on 12/10/13 at 8:35 PM. The facility remains out of compliance at a Severity level two, due to the need to monitor the effectiveness of the nurses' ability to administer IVPB mixed and without air [MEDICAL CONDITION]. This applies to 2 of 2 residents (R5, R4) reviewed for intravenous therapy in the sample of 15 and 1 resident in the supplemental sample (R16). The Findings include: On 12/9/13 during the medication pass observation two residents R4 & R5 had intravenous piggy back(IVPB) medication ordered to be administered at 12:00 PM. E4, the registered nurse, stated that she already mixed the IVPB medications for these residents and the medication was hanging ready for administration. R5's record contains a physician's orders [REDACTED]. R5 had his central venous access port sticking out from his shirt. R5's central venous access site was not visible. E4 did not check R5's central venous access site for signs of infection or infiltration. E4 flushed the port with 5 ml of sterile normal saline. E4 started to administer the IVPB when air pockets and air bubbles were seen in the IV tubing. E4 was made aware of the air in the tubing. She tried to clear the IV tubing by wasting more than half of the IVPB solution. R5's IVPB bag was observed on 12/9/13 at 1:30 PM. The IV pump was off. R5 stated that the pump began alarming and he pushed his call light and turned the pump off because the infusion was completed and he does not like listening to the alarm. The IVPB was empty, the IV drip chamber was empty and the IV tubing was empty until it meets the IV Infusion pump. An operative report for R5 dated 9/25/13 that states he had placement of a tunneled central venous catheter. R4 has a physician order [REDACTED]. On 12/10/13 at 12:15 PM E4 stated that the IVPB for R4 was mixed and ready to administer. E4 checked the IV line for bubbles and started draining IV antibiotic into the garbage receptacle until she had drained about half of the IVPB solution into the garbage. E4 was ready to connect the IV to the resident when her attention was directed to the air pockets and air bubbles and the fact that half of the antibiotic solution was drained. E4 then stated that she would get a new IVPB antibiotic for R4. E4 mixed the IVPB leaving clumps of medication that was not in solution and a large clump of medication on top of the plastic cup medication chamber. E4 proceeded to prime the IV tubing with the solution and connected the tubing to the resident and turned the infusion pump on. At that time the surveyor informed E4 that the IV tubing contained large pockets of air (three to four 1.5 inch areas of air) and that there were clumps of undissolved medication in the IV bag. E4 stopped the infusion. E5, a registered nurse, took over to administer the medication. R5 obtained a new IVPB for R4 and began to mix. E5 brought a new IV tubing and after the IVPB was completely mixed (no clumps of medicine) she primed the tubing. E5 required cues to ensure that the tubing would be primed without air. E5 then administered the medication. On 12/10/13 at 3:00 PM E3 stated that nurses do not have return demonstrations/competencies regarding IV medication administration, IV setup or priming IV tubing without air pockets or air bubbles. The facility's job description of the Administrator states, "The Administrator is delegated with full responsibility and authority for the internal operation of the facility in accordance with current Federal, State and Local standards, guidelines, regulations, facility policies and as may be directed..." The facility's job responsibilities of the Administrator include, "Directly supervise employees and instruct staff providing inservice training to promote job knowledge, assure that quality care is being rendered, oversee the recruitment, hiring and training of a qualified staff capable of carrying out authorized programs and make daily rounds to assure that personnel are performing required duties and to assure that appropriate procedures are being followed." The facility's job description of the Director of Nursing states, "Plan, develop, organize, implement,evaluate and direct the Nursing Department, directly supervise employees and instruct staff providing inservice training to promote job knowledge, identify problems, develop and implement solution with the assistance of the Administration, make daily rounds to assure that nursing personnel are performing duties and to assure that appropriate procedures are being followed. Make physical rounds on all residents daily, monitor medication passes and treatment schedules to assure medications are being administered as ordered and that treatments are provided as scheduled participate in the development, maintenance and implementation of quality assurance programs for the nursing department." These job descriptions require these administrative staff to be accountable for nursing practices including the assurance that standards of nursing practice are maintained. The standards of nursing practice with regards to IVs was not maintained and the administrative staff are accountable according to the job description. The facility presented the following plan to remove the immediacy of the situation: 1. Resident's physician, Z2 and the Medical Director Z1 was contacted regarding the possibility that resident R5 did not receive the full dose of medication. Completed on 12/10/13. 2. Facility held QA meeting with the Medical Director on 12/10/13. The facility immediately on 12/10/13 monitored all patients with IV medications (R4, R5, R17, R16) for changes in condition which includes vital signs every shift and will be ongoing until completion 12/12/13. 3. Facility implemented quality assurance tools to ensure that IV tubing were primed properly, created on 12/10/13. 4. A representative from the infusion pump company will provide in service training on IV pump usage 12/12/13. Actions taken by the facility regarding lack of competency for IV's 1. On 12/10/13 both nurses, E4 and E5 will be assessed for their competency in administering IV's by Z3, Regional Nurse Coordinator for the facility's Pharmacy. 2. Nurse management initiated reassessment of competencies for all nurses administering IV's 12/10/13. All nurses will have a competency completed before they are allowed to be placed on the schedule. Competition date for competencies will be 12/12/13. All new hires will be required to complete a competency before administering IV's independently: this will be started immediately on 12/10/13 and be ongoing by the Director of Nursing or designee. 3. Facility held QA meeting with the Medical Director on 12/10/13. The facility monitored all residents on IV's immediately 12/10/13 for changes in conditions which include vital signs every shift and will be on going until completion 12/10/13. 4. The facility implemented quality assurance tools to ensure that competencies were completed for nursing staff, created on 12/10/13. Quality Assurance checks will be on going. Based on the above plan for removal of immediacy and the observation of two competencies (return demonstrations) for E6 and E7 the immediacy was removed on 12/10/13 at 8:35PM.

Based on observation, interview and record review the facility failed to ensure the standards of practice in the administration of intravenous fluids (IV) and IV medications were followed for the proper mixing of IV antibiotics and correctly priming IV tubing without air pockets or air bubbles. As a result of this failure an immediate jeopardy was identified on 12/10/13. The immediate jeopardy began on 12/9/13. E1 (Administrator), E2 (Director of Nursing) and E3 (Nurse Consultant) were informed of the immediate jeopardy on 12/10/13 at 5:10 PM. The immediacy was removed on 12/10/13 at 8:35 PM. The facility remains out of compliance at a Severity level two, due to the need to monitor the effectiveness of the nurses' ability to administer IVPB mixed and without air [MEDICAL CONDITION]. This applies to 2 of 2 residents (R5, R4) reviewed for intravenous therapy in the sample of 15 and 1 resident in the supplemental sample (R16). The Findings include: During medication administration observation on 12/9/13 at 12:05 PM R5's central venous access port was sticking out from his shirt. R5 had a physician order [REDACTED]. E4 cleansed R5's port and flushed with 5 milliliter (ml) normal saline and [MEDICATION NAME] flush (500 units) without checking the site for signs of infection and/or infiltration. E4 connected the IV tubing to the port and was about to begin the infusion when she was made aware that there were several pockets of air in the tubing. E4 removed the tubing from the pump and cleared the tubing after wasting about half of the medication in the IVPB bag. E4 then placed the tubing in the infusion pump and started the infusion. On 12/9/13 at 12:15 PM, E4 connected an IVPB to R4's peripherally inserted central catheter (PICC) line. R4 had a physician's orders [REDACTED]. E4 was about to begin administration when she was made aware of air in the IV tubing. R4's IV tubing contained three to four 1.5 inch areas of air and air bubbles throughout the tubing. E4 wasted more than half of the IVPB to clear the tubing. E4 then got another IVPB from the medication room. E4 mixed the IVPB, connected it to the IV tubing and began the infusion when she was made aware of large (1.5 inch) areas of air and air bubbles throughout the tubing. Also, there was clumps of medication in the IVPB bag. E5, a Registered Nurse, was assigned to complete the medication administration. E5 was able to ensure that the IVPB was mixed properly but needed cues to remove air from the tubing. During the group discussion on 12/10/13 at 10:30 AM, R16 shared her experience with IVPB medication administration. R16 is an alert female admitted to the facility for IV antibiotic therapy for an infected joint replacement. Her Minimum (MDS) data set [DATE] states she has a BIMS (Brief Interview for Mental Status) score of 15. R16 was interviewed on 12/10/13 at 2:40 PM and she said that the first 3 days after admission she had a hard time with her IVPB medications. R16 stated that the IV infusion pump kept alarming and that it took 20 minutes for someone to come and see what her problem is and then another 20-30 minutes for the nurse to come and fix the problem. R16 stated that what should have taken an hour to infuse took two hours or more. R16 stated that part of the problem was that the infusion pump would alarm because she had air bubbles in the IV tubing. R16 stated that for the first 3 days this occurred with every administration. R16 stated that she got her IVPB medications every 12 hours at 6AM and 6PM. R16 had a physician's orders [REDACTED]. On 12/10/13 at 3:00 PM E3 stated that nurses do not have return demonstrations/competencies regarding IV medication administration, IV setup or priming IV tubing without air pockets or air bubbles. On 12/10/13 at 12:30 PM Z4, the pharmacist, stated that IVPB medications that need to be mixed must be mixed thoroughly to ensure the delivery of an accurate dose of medications as well as the prevention of the medication clogging the IV or IV access. The Infusion Nursing Standards of Practice developed by Infusion Nurses Society and revised in 2011 states, "All air shall be purged from syringes, administration sets, needless connectors, and all other pieces added to the catheter...The nurse shall document in the patient's permanent record the signs and symptoms of air embolism, interventions implemented, and patient response to treatment..." Based on observation, interview and record review the facility took the following actions to remove the immediacy: 1. Resident's physician Z2 and the Medical Director Z1 was contacted regarding the possibility that resident R5 did not receive the full dose of medication. Completed on 12/10/13. 2. Facility held QA meeting with the Medical Director 12/10/13. The facility immediately on 12/10/13 monitored all patients with IV medications (R4, R5, R17, R16) for changes in condition which includes vital signs every shift and will be ongoing until completion 12/12/13. 3. Facility implemented quality assurance tools to ensure that IV tubing is primed properly, created on 12/10/13. 4. A representative from the infusion pump company will provide inservice training on IV pump usage on 12/12/13. Actions taken by the facility regarding the lack of competency for IVs 1. On 12/10/13 both nurse's, E4 and E5 will be assessed for their competency in administering IV's by Z3, Regional Nurse Coordinator for facility's pharmacy. 2. Nurse management initiated reassessment of competencies for all nurses administering IV's 12/10/13. All nurses will have a competency completed before they are allowed to be placed on the schedule. Completion date for competencies will be 12/12/13. All new hires will be required to complete a competency before administering IV's independently: this will be started immediately on 12/10/13 and be ongoing by the Director of Nursing or designee. 3. Facility held QA meeting with the Medical Director on 12/10/13. The facility monitored all residents on IVs immediately on 12/10/13 for changes in conditions which include vital signs every shift and will be on going until completion 12/10/13. 4. The facility implemented quality assurance tools to ensure that competencies were completed for nursing staff, created 12/10/13. Quality Assurance checks will be on going. These actions were confirmed by the observation of two return demonstrations of IVPB mixing and priming of IV tubing.

Based on observation, interview and record review the facility failed to ensure that intravenous (IV) tubing was primed without air or air bubbles prior to IV antibiotic administration to prevent infusing air into the resident causing an air [MEDICAL CONDITION]. As a result of this failure an immediate jeopardy was identified on 12/10/13. The immediate jeopardy began on 12/9/13. E1(administrator), E2(director of nursing), E3(nurse consultant) were informed of the immediate jeopardy on 12/10/13 at 5:10 PM. The immediacy was removed on 12/10/13 at 8:35 PM. The facility remains out of compliance at a Severity level two due to the need to monitor the effectiveness of nurses' ability to administer IV's without air [MEDICAL CONDITION]. This applies to 2 of 2 residents (R4, R5) reviewed for Intravenous Therapy in the sample of 15 and one resident in the supplemental sample (R16). The Findings include; On 12/9/13 during medication pass observation two residents R4 & R5 had intravenous piggy back (IVPB) medication ordered to be administered at 12:00 PM. E4, the registered nurse, stated that she already mixed the IVPB medications for these residents and the medication was hanging ready for administration. R5's record contains a physician's orders [REDACTED]. R5 had his central venous access port sticking out from his shirt. R5's central venous access site was not visible. E4 did not check R5's central venous access site for signs of infection or infiltration. E4 flushed the port with 5 ml of sterile normal saline. E4 started to administer the IVPB when air pockets and air bubbles were seen in the IV tubing. E4 was made aware of the air in the tubing. She tried to clear the IV tubing wasting more than half of the IVPB solution. R5's IVPB bag was observed on 12/9/13 at 1:30 PM. The IV pump was off. R5 stated that the pump began alarming and he pushed his call light and turned the pump off because the infusion was completed and he does not like listening to the alarm. The IVPB was empty, the IV drip chamber was empty and the IV tubing was empty until it meets the IV Infusion pump. An operative report for R5 dated 9/25/13 states he had placement of a tunneled central venous catheter. R4 has a physician order [REDACTED]. On 12/10/13 at 12:15 PM E4 stated that the IVPB for R4 was mixed and ready to administer. E4 checked the IV line for bubbles and started draining IV antibiotic into the garbage receptacle until she had drained about half of the IVPB solution into the garbage. E4 was ready to connect the IV to the resident when her attention was directed to the air pockets and air bubbles and the fact that half of the antibiotic solution was drained. E4 then stated that she would get a new IVPB antibiotic for R4. E4 mixed the IVPB leaving clumps of undissolved medication and a large clump of undissolved medication on top of the plastic cup medication chamber. E4 proceeded to prime the IV tubing with the solution and connected the tubing to the resident and turned the infusion pump on. At that time E4 was informed that the IV tubing contained large pockets of air (three to four- 1.5 inch areas of air) and that there were clumps of medication in the IVPB bag. E4 stopped the infusion. E5, a registered nurse, took over to administer the medication. R5 obtained a new IVPB for R4 and began to mix. E5 brought a new IV tubing and after the IVPB was completely mixed (no clumps of medicine) she primed the tubing. E5 required cues to ensure that the tubing would be primed without air. E5 then administered the medication. During the group discussion on 12/10/13 one resident, R16, stated that she had problems with getting her IV antibiotics properly. R16 is a very alert resident with a BIMS (Brief Interview for Mental Status) score of 15 on the Minimum (MDS) data set [DATE]. On 12/10/13 at 2:40PM R16 said that the first three days she was at the facility the IV infusion pump would alarm constantly. When asked why, R16 stated that she would have air bubbles in the tubing and the machine would alarm. R16 stated that it took 1.5 hours to get her antibiotics when it should have taken an hour. R16 stated that when the pump alarmed it took 20 minutes for her call light to be answered and another 20 to 30 minutes to have the nurse come and fix the problem R16 stated that it took three infusion pumps before she did not have these problems. R16 stated that she told a person in administration about the problem and the air in her IV tubing. The form Resident Census and Condition (672) completed by the facility shows that there are 4 residents receiving IV antibiotics. On 12/10/13 at 12:50 PM, Z2 (R4's physician) stated that the amount of air in IV tubing that was described can lead to air [MEDICAL CONDITION]. Z2 stated that an air [MEDICAL CONDITION] can have very serious consequences and even death. Z2 stated that he wants a more experienced nurse to administer IV antibiotic to his residents and that the facility needs to be made aware of these concerns and consequences. On 12/10/13 at 12:30 PM, E2 (director of nursing) Z3 (nurse consultant from the pharmacy) and Z4 (pharmacist) were interviewed. Z4 stated that the consequence of receiving only half of the bag of antibiotic was that the resident did not get the full dose of medication. Z4 stated that it is not OK to infuse IV antibiotics with clumps in the IVPB bag. Z4 stated that these clumps can cause a clog in the IV tubing or in the peripherally inserted central catheter (PICC) or in the Central Venous Catheter. Z4 stated that these are potentially serious consequences of infusing IV solutions with clumps of medicine in the solution. Z4 also said infusing IV medication that has clumps in the solution also has the potential of the resident not receiving the full does of medication. The Infusion Nursing Standards of Practice developed by Infusion Nurses Society and revised in 2011 states, "All air shall be purged from syringes, administration sets, needless connectors, and all other pieces added to the catheter...The nurse shall document in the patient's permanent record the signs and symptoms of air embolism, interventions implemented, and patient response to treatment." R5 had a central venous catheter for IV antibiotic therapy and R4 and R16 had peripherally inserted central catheters (PICC). On 12/10/13, at 5:10 PM E1, E2 and E3 was informed of the immediate jeopardy regarding the possibility of an air [MEDICAL CONDITION] to R4 and R5 during their IVPB administration that an immediate jeopardy situation existed regarding the possibility of an air [MEDICAL CONDITION] to E4 and E5 during their IVPB administration. Based on observation, interview and record review the surveyor confirmed the facility took the following actions to remove the immediacy: The facility presented the following plan to remove the immediacy of the situation: 1. Resident's physician Z2 and the Medical Director Z1 was contacted regarding the possibility that resident R5 did not receive the full dose of medication. Completed on 12/10/13. 2. Facility held QA meeting with the Medical Director on 12/10/13. The facility immediately on 12/10/13 monitored all patients with IV medications (R4, R5, R17, R16) for changes in condition which includes vital signs every shift and will be ongoing until completion 12/12/13. 3. Facility implemented quality assurance tools to ensure that IV tubings were primed properly, created on 12/10/13. 4. A representative from the infusion pump company will provide in service training on IV pump usage on 12/12/13. Actions taken by the facility regarding the lack of competency for IVs: 1. On 12/10/13 both nurses, E4 and E5 will be assessed for their competency in administering IVs by Z3, Regional Nurse Coordinator for Forum Pharmacy. 2. Nurse management initiated reassessment of competencies for all nurses administering IVs on 12/10/13. All nurses will have a competency completed before they are allowed to be placed on the schedule. Completion date for competencies will be 12/12/13. All new hires will be required to complete a competency before administering IVs independently, this will be started immediately on 12/10/13 and be ongoing by the Director of Nursing or designee. 3. Facility held QA meeting with the Medical Director on 12/10/13. The facility monitored all residents on IVs immediately on 12/10/13 for changes in conditions which include vital signs every shift and will be on going until completion 12/10/13. 4. The facility implemented quality assurance tools to ensure that competencies were completed for nursing staff, created on 12/10/13. Quality Assurance checks will be on going." Based on the above plan for removal of immediacy and the observation of two competencies (return demonstrations) for E6 and E7 the immediacy was remove on 12/10/13 at 8:35 PM