Every finding on record at Avantara Joliet

Based on observation, interview, and record review, the facility failed to ensure residents received required staff assistance for toileting, incontinence care, nail care, hair care, and oral hygiene. This applies to 8 of 10 residents (R6, R12, R40, R47, R67, R99, R105, and R126) in a sample of 27. The Findings Include: 1. The face sheet for R126 shows multiple diagnoses, including displaced intertrochanteric fracture of the left femur (subsequent encounter for closed fracture with routine healing), unspecified fracture of the lower end of the left femur, diaphragmatic hernia without obstruction or gangrene, and cervical spondylosis without myelopathy or radiculopathy. R126 is a [AGE] year-old female who was newly admitted to the facility on [DATE]. The 5-day Minimum Data Set (MDS) dated [DATE], shows R126 is dependent on staff for toileting. On December 21, 2025, at 11:40 a.m., R126 was heard yelling, Help, help, I'm wet, no staff entered the room nor responded to R126's call for help. After approximately five minutes with no response, V8 (Nurse) was located and requested assistance for R126. Upon entering the room with V8 observed R126 lying in bed with the bed linens in disarray. R126 was attempting to pull at her incontinence brief and stated that no one had come to assist her for a long time. Upon assessment, R126's brief was found to be heavily soaked with urine and stool. R126 stated she required assistance due to her recent left hip surgery. V8 stated V13 (Certified Nursing Assistant) was assigned to R126. When interviewed, V13 stated R126 was not assigned to her. V13, V4, and V9 (CNAs) checked the assignment board and confirmed that no CNA had been assigned to R126. All staff stated their shift began at 6:00 a.m. and that from 6:00 a.m. until the time of discovery at 11:40 a.m., no staff had provided bedside care to R126. During this time, V15 (family member of R175, a resident in the room across from R126) reported that R126 had been yelling for approximately five minutes asking for help and stating she was wet. 2. The Electronic Medical Record (EMR) shows R67, a [AGE] year-old male, was admitted to the facility on [DATE], with diagnoses including osteomyelitis of the right foot, peripheral vascular disease, gait and mobility abnormality, intellectual disability, and epilepsy. The MDS dated [DATE], shows R67's cognition is severely impaired and that he required substantial to maximal assistance with activities of daily living (ADLs), including hygiene. The care plan dated September 5, 2025, identified an ADL self-care performance deficit and impaired mobility related to intellectual disability, generalized weakness, and recurrent falls. The care plan specified that R67 required staff assistance for grooming, hygiene, and oral care. On December 21, 2025, at 10:45 a.m., R67 was in the small lounge area. He was noted to have an unkempt, long beard and mustache, long hair protruding from his ears, and long fingernails with sharp edges and black/brown debris underneath. On December 21, 2025, at 12:05 p.m., R67 was in the dining room visiting with V16 (his family member). R67 remained poorly groomed. V16 stated that R67 required oral care. Upon request, R67 smiled and revealed visible thick dental plaque and brown debris between the teeth. V3 (Assistant Director of Nursing) was notified of concerns related to R67's unmet ADL needs. 3. The EMR shows diagnoses for R47 including cellulitis of the left lower limb, lack of coordination, muscle weakness, morbid obesity, chronic kidney disease, and chronic obstructive pulmonary disease. The MDS dated [DATE], shows R47's cognition is moderately impaired and she is dependent on staff for ADLs, including hygiene and grooming. The care plan dated November 18, 2025, identified the need for staff assistance with personal hygiene due to activity intolerance, lymphedema, bilateral lower-extremity cellulitis, and morbid obesity. On December 21, 2025, at 11:30 a.m., R47 was in her room with long fingernails that had sharp edges and black debris underneath. R47 stated she wanted her nails trimmed. V8 was notified of this request. 4. The EMR shows R12 had a diagnosis of cerebral infarction with residual hemiparesis and hemiplegia. The care plan dated February 22, 2025, shows R12 required maximum assistance for ADLs, including hygiene. On December 21, 2025, at 11:11 a.m., R12 was in bed with long fingernails, sharp edges, and black debris underneath. On December 22, 2025, at 12:15 P.M., R12 was in the therapy room and continued to have long, unkempt nails. R12 was also noted to have a significant amount of white flakes visible from his hair onto his shirt. V3 (Assistant Director of Nursing) was present during this observation. 5. R40's face sheet included multiple diagnoses including unspecified dementia, unspecified severity, with other behavioral disturbance, unilateral primary osteoarthritis, left hip, other abnormalities of gait and mobility, muscle weakness (generalized), other lack of coordination. R40's Annual MDS dated [DATE], shows R40 has moderately impaired in cognition and required substantial maximal assistance in toileting, showers and upper body dressing and was dependent on staff for lower body dressing. On December 21, 2025, at 1:03 PM, R40 stated she had not been cleaned up all day and she is soaking wet. There was a strong smell of urine near the resident who was lying in bed. On December 21, 2025, at 1:14 PM, V25 (Certified Nursing Assistant/CNA) stated that she was going to give resident shower now. V24 (CNA) and V25 came into R40's room to get her ready for a shower, but first they changed R40's incontinence brief. R40's incontinence brief and the two green incontinence pads underneath R40 were soaked from front to back with yellow urine. V25 stated she was assigned to care for R40 and was helping with lunch on the other side and that is why she did not come earlier to check on R40. V25 stated that the last time she had changed R40 was this morning around 7:00 AM. R40's care plan revised August 13, 2025, included that the resident requires assistance with all ADLs, presents with frequent incontinence of both bowel & bladder. Interventions included to assist resident with shower/bathing per schedule, staff to check her for incontinence episode every 2 hours and also needs assistance to wash, rinse and dry perineum and that resident needs assistance to change clothing as needed after incontinence episodes. On December 23, 2025 at 4:10 PM, V2 (Director of Nursing) stated CNAs should provide incontinence care as needed and should be checking residents for incontinence minimally every 2 hours. The facility's Incontinence and Perineal Care plan Revised June 30, 2025 showed the following: It is the policy of the facility to provide perineal care to ensure cleanliness and comfort to the resident, to prevent infection and skin irritation, and to observe the residents skin condition. Procedures:1 Do rounds at least every 2 hours to check for incontinence during shift. 6. R6's EMR (Electronic Medical Record) shows R6 was admitted to the facility on [DATE], with multiple diagnoses including end stage renal disease, dependence on renal dialysis, anemia in chronic kidney disease, diabetes, glaucoma, heart failure, and muscle weakness. R6's MDS (Minimum Data Set) dated November 3, 2025, shows R6 is cognitively intact and needs set-up/clean up assistance with oral hygiene and partial/moderate assistance with personal hygiene. R6's MDS also shows R6's vision is severely impaired. R6's care plan dated May 16, 2025, shows R6 requires assistance with all ADLs (Activities of Daily Living). On December 21, 2025, at 11:20 AM, R6 was lying in bed. R6 had a beard that was coarse, long and very thick. R6's hair was long, and it was curling at the base of the neck. R6 stated he wanted a haircut, and his beard shaved. R6 continued to say he has been asking staff to shave off his beard and give him a haircut since October 2025. On December 22, 2025, at 8:58 AM. R6 still had his long, thick beard and long hair. R6 stated the last time his beard was shaved was five to six months ago. R6 continued to say he needs help from staff to shave and cut his hair. On December 22, 2025, at 9:25 AM, V2 (Director of Nursing, DON) stated R6 should be shaved. R6 stated to V2 he would like to receive a haircut, and his beard shaved off. R6 stated he has been waiting for a shave and a haircut since October 2025. R6 continued to say he has asked several nurses many times for a shave and a haircut. 7. R105's EMR shows R105 was admitted to the facility on [DATE], with multiple diagnoses including obesity and hypertensive heart disease with heart failure. R105's MDS dated [DATE], shows R105 is cognitively intact and needs supervision/touching assistance with oral hygiene and partial/moderate assistance with personal hygiene. R105's care plan dated May 22, 2025, shows R105 requires assistance with all ADLs. On December 21, 2025, at 12:08 PM, R105 was sitting up in bed. R105 had hair on her upper lip and chin, which were approximately 0.5 inches long. The hair on her chin was curled. R105's hair looked disheveled, and she stated she does have knots in her hair. R105 stated her facial hair really bothers her and she wanted it removed. R105 further stated she wanted her hair and teeth brushed daily. R105 stated for the past two months she had asked several staff members multiple times to remove her facial hair. R105 stated her hair, and teeth were brushed only on shower days, usually once or twice per week, and she could not recall the last time her hair and teeth were brushed. R105 stated she required staff assistance with these tasks. On December 22, 2025, at 8:52 AM, R105's hair was still disheveled with knots, and R105 still had hair on her upper lip and chin. The hair on her chin was curled. On December 22, 2025, at 9:37 AM, V2 stated R105 should have her hair washed and have her facial hair removed. R105 stated to V2 she also wants her teeth and hair brushed. 8. R99's EMR shows R99 was admitted to the facility on [DATE], with multiple diagnoses including congestive heart failure and malignant neoplasm of uterus. R99's MDS dated [DATE], shows R99 is cognitively intact, and needs set up/clean up assistance with oral hygiene and substantial/maximal assistance with personal hygiene. R99's care plan dated June 9, 2025, shows R99 requires assistance with all ADLs. On December 21, 2025, at 12:13 PM, R99 was sitting up in bed. R99 had disheveled hair with knots. R99 stated she would like her hair and teeth brushed daily. R99 stated she can feel the knots in her hair. R99 stated she gets her hair and teeth brushed once or twice a week on shower days. R99 continued to say she would like her hair and teeth brushed more frequently. R99 stated her hair was brushed last week when she had to go to a doctor's appointment. R99 stated it has been several days since that appointment, and she has not had her hair and teeth brushed. R99 added she needs help from staff to brush her hair and teeth. On December 22, 2025, at 8:53 AM, R99 still had disheveled hair. On December 22, 2025, at 9:42 AM, V2 stated R99 should have her hair washed and brushed. V2 stated residents should have their hair and teeth brushed daily. On December 22, 2025, at 9:51 AM, V2 continued to say she expects her staff to check with residents about their grooming needs every morning and she expects the residents to get daily oral care. The facility's policy titled General Care revised on June 30, 2025, shows under policy statement, the facility will provide care for every resident to meet their needs. The policy further shows under procedure, the facility will assist the resident to meet his/her ADL needs.

Based on observation, interview, and record review, the facility failed to assess and provide G Tube (gastrostomy tube) site care to residents on enteral tube feeding.This applies to 4 of 4 residents (R12, R28, R50, R101) reviewed for G Tube care in a sample of 27.The Findings include:1. According to the face sheet, R28 had multiple diagnoses, including Parkinsonism, nutritional deficiencies, dysphagia of the oropharyngeal phase, and gastrostomy status. R28's Quarterly (MDS) Minimum Data Set, dated [DATE], showed R28 had severe cognitive impairment and impairment to upper and lower extremities on both sides. The same MDS also showed that R28 is dependent on the facility staff for all areas of self-care and mobility. On Monday, December 22, 2025, at 9:00 AM, R28's G Tube site was covered with an undated gauze dressing. The gauze dressing on R28's G Tube site was wet, and there was a large amount of thick yellow-greenish color drainage on and around the G Tube site area when V29 (Nurse) lifted up the gauze dressing around R28's G-tube stoma (the opening on the abdomen connecting the G Tube to the digestive system). R28's skin around the G tube was also moist and red, with rashes. V29 said she did not work at the facility on Saturday, December 20, and Sunday, December 21, 2025, but it did not look like R28's G-tube site had been cleaned during the weekend shifts. R28's POS Physician Order Sheet, showed active orders to cleanse the enteral tube feeding site with wound cleanser, pat dry, and apply dry dressing every night shift and (PRN) as needed in two separate orders dated December 1, 2025. R28's PRN TAR (Treatment Administration Record) with a start date of December 1, 2025, showed to cleanse the enteral tube feeding site with wound cleanser, pat dry, and apply dry dressing. A review of the TAR flowsheet from December 1, 2025, to December 21, 2025, did not show any documentation to show that R28's G tube feeding site cleansing and dressing were performed. R28's Night shift TAR with a start date of December 1, 2025, showed to cleanse the enteral tube feeding site with wound cleanser, pat dry, and apply dry dressing. A review of R28's Night Shift TAR flowsheet from December 1, 2025, to December 21, 2025, showed there was no documentation to show that R28's tube feeding site cleansing and dressing were done on Sunday, December 7, 2025; Sunday December 14, 2025; and Saturday, December 20, 2025. 2. According to the face sheet, R50 had multiple diagnoses, including Parkinson's disease, Dysphagia, gastrostomy status, dementia, history of transient ischemic attack, and cerebral infarction. R50's Quarterly MDS dated [DATE], showed R50 had severe cognitive impairment and was dependent on the facility staff for all self-care and mobility. On Monday, December 22, 2025, at 9:55 AM, V29 was administering medication through R50's G tube. There was a large amount of yellowish-green thick drainage on and around R50's G Tube stoma site, and no gauze dressing was present underneath or on top of the G Tube bumper. V29 said there were foul odors coming from R50's G tube and that V50 should have had a dressing under the G Tube bumper to help with drainage. R50's POS showed an active order on November 21, 2025, to cleanse the enteral tube feeding site with wound cleanser, pat dry, and apply dry dressing every night shift. R50's TAR with a start date of November 21, 2025, to cleanse the enteral tube feeding site with wound cleanser, pat dry, and apply dry dressing every night. Review of R50's TAR flowsheet from December 1, 2025, to December 21, 2025, showed there was no documentation to show that R50's G tube site cleansing and dressing were done on December 9, 2025, December 19 and December 20, 2025. There was no additional PRN order on the TAR to cleanse the G Tube site as needed. On December 22, 2025, V3 (Assistant Director of Nursing/ADON) said the resident's G tube site should always be kept clean and the nurses were supposed to inspect the residents' G tubes site every shift to check for drainage and the skin around the G-tube site to determine whether it needed cleaning. V3 also said the nurses should have called the doctor to notify them of any skin breakdown, yellow or greenish drainage, and foul odors, which are signs of potential infection. In V3 also added that even if the order says to clean the G-tube sites every night shift or PRN, it is the responsibility of every nurse to inspect the residents' g-tube site and clean as needed every shift to prevent skin breakdown, support infection control, and ensure proper placement of the G-tubes. 3. The Electronic Medical Record (EMR) shows that R12 had a diagnosis of cerebral infarction with residual hemiparesis and hemiplegia. The Physician Order Sheet (POS) for December 2025 included an order dated December 2, 2025, to cleanse the gastrostomy tube (G-tube) insertion site with wound cleanser, pat dry, and apply a dry dressing daily. The care plan dated November 26, 2025, documented that R12 had a gastrostomy tube for enteral feeding due to dysphagia. Interventions included maintaining the gastrostomy tube insertion site free from complications and infection, monitoring the site, and following physician orders for gastrostomy tube care and dressing changes. On December 21, 2025, at 11:11 a.m., R12 was lying in bed with an intravenous pole positioned next to the bedside for tube feeding administration. When asked if he had a gastrostomy tube, R12 lifted his gown and exposed the insertion site. The gastrostomy tube insertion site was observed without a dressing. The site also had encrusted material present around the insertion area. On December 22, 2025, at 12:15 p.m., R12 was in the therapy room. Along with V3 (Assistant Director of Nursing), the gastrostomy tube insertion site was assessed. R12 had a dressing to the G tube site at this time. V3 stated that R12 must have a dressing applied to the gastrostomy tube insertion site per physician order. 4. The EMR showed that R101 had diagnoses including vascular dementia, major depressive disorder, anemia, schizophrenia, dysphagia, and gastrostomy status. The Physician Order Sheet for December 2025 included an order dated December 1, 2025, directing staff to cleanse the gastrostomy tube insertion site with wound cleanser, pat dry, and apply a dry dressing daily. The care plan dated August 13, 2025, identified the need to monitor the gastrostomy tube insertion site for signs and symptoms of infection, including drainage. On December 22, 2025, at 12:15 p.m., R101 was lying in bed. Along with V3, the gastrostomy tube insertion site was assessed and there was no dressing at the G tube site. The insertion site had encrusted material present, which had seeped through R101's facility gown. V3 stated that R101 must have a dressing applied to the gastrostomy tube insertion site and that the site should be clean per physician order. The facility's Enteral Tube Feeding Care revised on June 30, 2025, stated, Procedure . 8. Enteral tube stoma care: Site must be cleansed and covered with dry gauze daily. Dry gauze should be placed on top of the G tube bumper, otherwise, a slim layer of light breathable gauze can be inserted under the disc.

Based on observation, interview, and record review, the facility failed to implement its policy regarding the management and care of peripherally inserted central catheter (PICC) intravenous lines, including ensuring that PICC insertion sites were assessed and monitored every shift for signs and symptoms of infection. This applies to 4 of 4 residents (R31, R67, R102, and R125) reviewed with PICC lines in a sample of 27. The findings include: 1. Review of the EMR (Electronic Medical Record) showed that R125's diagnoses included infective bursitis, metabolic encephalopathy, atrial fibrillation, and congestive heart failure. Review of the POS (Physician Order Sheet) for December 2025 showed a physician's order dated December 11, 2025, directing staff to change the PICC dressing and cap using a transparent dressing. The order also required the PICC insertion site to be assessed every shift for signs and symptoms of infection, including drainage, irritation, and redness. The care plan dated December 12, 2025, identified R125 as being at risk for infection related to a PICC line in the right upper arm. The intervention directed staff to assess the PICC insertion site daily for signs and symptoms of infection. On December 21, 2025, at 10:00 a.m., in the presence of V8 (Nurse), R125's PICC line was observed. The PICC line was in the right upper arm. The insertion site was not visible, as it was covered with a gauze dressing secured with a transparent dressing. The gauze dressing was noted to have dried blood, which had seeped through R125's sweater sleeve. V8 stated that she was unable to visualize the insertion site because it was covered with a gauze dressing. On December 22, 2025, at 2:30 p.m., in the presence of V4 (Wound Care Certified Nurse), R125's PICC line was re-evaluated. The insertion site remained covered with a gauze dressing and was not visible. V4 stated, The gauze dressing should not cover the insertion site; you cannot assess for signs of infection. 2. Review of the EMR showed that R67, a [AGE] year-old male, was admitted on [DATE], with diagnoses that included osteomyelitis of the right foot, peripheral vascular disease, abnormal gait and mobility, intellectual disability, and epilepsy. The MDS (Minimum Data Set) dated November 13, 2025, indicated that R67 had severely impaired cognition. Review of the POS for December 2025 showed a physician's order dated December 17, 2025, directing staff to change the PICC dressing and cap using a transparent dressing and to assess the PICC insertion site every shift for signs and symptoms of infection, including drainage, irritation, and redness. On December 21, 2025, at 12:05 p.m., R67 was in the dining room visiting with V16 (his family member). In the presence of V3 (Assistant Director of Nursing), R67's PICC line in the right upper arm was checked. The insertion site was covered with a gauze dressing, which was noted to have dried blood seepage. V3 stated that the insertion site was not visible and could not be assessed for signs of infection. 3. Review of the EMR showed that R102's diagnoses included osteomyelitis, adjustment disorder, diabetes mellitus type II, peripheral vascular disease, chronic kidney disease, and acquired absence of the right leg below the knee. Review of the POS for December 2025 showed a physician's order dated December 2, 2025, directing staff to change the PICC dressing and cap using a transparent dressing and to assess the PICC insertion site every shift for signs and symptoms of infection, including drainage, irritation, and redness. On December 20, 2025, at 11:00 a.m., in the presence of V8 (Nurse), R102's PICC line located in the left upper arm was observed. The insertion site was covered with a gauze dressing secured with a transparent dressing. V8 stated she was unable to assess the insertion site because it was covered with gauze. The care plan dated December 6, 2025, identified R102 as being at risk for infection related to a PICC line in the left upper arm. Interventions directed staff to assess the PICC insertion site for signs and symptoms of infection and to change the PICC dressing as ordered. 4. R31's electronic medical record showed R31 was admitted on [DATE] with diagnoses that included sepsis, metabolic encephalopathy, pneumonia, symptomatic neurosyphilis, and congestive heart failure. R31's infection care plan showed R31 had a right arm single lumen PICC (Peripherally inserted central catheter) line. R31's physician orders showed the following orders dated December 17, 2025: Change intravenous catheter dressing and cap with transparent dressing as needed and every night shift Wednesday. Check site for signs and symptoms of infiltration, infection, drainage, infiltration, and redness during infusion. On December 21, 2025 at 2:24 PM, V20 (Registered Nurse) observed R31's right arm PICC line dressing. The PICC line entry site could not be seen because there was a bio patch over the entry. The facility's Intravenous Therapy policy revised June 30, 2025 showed the following: procedures: 1. All intravenous access will be assessed by the nurse to ensure that no signs and symptoms of infection and infiltration are left unaddressed.

Based on observation, interview, and record review, the facility failed to remove expired medications from the cart and date ophthalmic medications upon opening to determine its expiration date. This applies to 7 of 7 residents (R6, R26, R31, R77, R101, R108, R109) reviewed for medication storage and labeling in the sample of 27. The Findings include:1. R26 was admitted to the facility on [DATE], with multiple diagnoses including Glaucoma. R26's current physician's order sheet (POS) shows an order to start Latanoprost Solution 0.005% solution on May 03, 2025, with orders to instill one drop into both eyes at bedtime. On December 21, 2025, at 11:00 AM, a medication cart observation was conducted with V7 (Registered Nurse/RN). R26's opened Latanoprost 0.005% ophthalmic solution was sitting in the second side drawer of the cart with an expiration date of November 13, 2025.V7 confirmed that R26's Latanoprost was expired and should have been removed from the cart and reordered. V7 said that ophthalmic solutions should be dated with an open and expiration date upon first use.2. R101 was admitted to the facility on [DATE], with multiple diagnoses including Ocular Hypertension. R101's most recent POS shows an order for Dorzolamide HCL Solution 2% to instill one drop in both eyes twice daily starting May 02, 2025. During the medication cart observation with V7, R101 had two opened bottles of Dorzolamide 2% ophthalmic solution in the second side drawer of the cart that were not labeled with an open and expiration date.3. R108 was admitted to the facility on [DATE], with multiple diagnoses including Glaucoma. R108's current POS shows an order for Latanoprost Solution 0.005% with instructions to instill one drop in both eyes at bedtime starting May 03, 2025. During the medication observation with V7, R108's opened Latanoprost 0.005% ophthalmic solution was in the second side drawer of the cart and was not labeled with an open and expiration date. 4. R31 was admitted to the facility on [DATE], with multiple diagnoses. R31's current POS shows an order for erythromycin ophthalmic ointment 5mg/gm with instructions to instill 3.5gm in the left eye at bedtime for an eye infection starting December 17, 2025. On December 21, 2025, at 12:15PM, a medication cart observation was conducted with V20 (RN). R31's opened Erythromycin 5mg/gm ophthalmic ointment was in a basket in the in the top drawer of the cart without an open and expiration date labeled.5. R77 was admitted to the facility on [DATE], with multiple diagnoses including Glaucoma. R77's current POS shows an order for Latanoprost Ophthalmic Solution 0.005% to instill one drop in both eyes at bedtime fifteen minutes prior to evening eye ointment starting May 15, 2025. During the medication observation with V20, R77's opened Latanoprost 0.005% ophthalmic solution was in a basket in the top drawer of the cart without an open and expiration date labeled.6. R109 was admitted to facility on June 17, 2024, with multiple diagnoses including Glaucoma. R109's current POS shows an order for Latanoprost Ophthalmic Solution 0.005% with orders to instill one drop into both eyes at bedtime starting May 04, 2025. During the medication cart audit with V20, R109's opened Latanoprost 0.005% ophthalmic solution was in a basket in the top drawer of the cart without an open and expiration date labeled. V20 confirmed that R31, R77, and R109's medications were not labeled, and that each medication should have an open and expired date on the package.7. R6 was admitted to facility on November 01, 2023, with multiple diagnoses including glaucoma and avulsion of the left eye. R6's current POS shows an order for Bromide Tartrate Solution 0.2% with orders to instill one drop in the right eye twice daily for Glaucoma starting on December 09, 2025. R6 also has an active order for Latanoprost Solution 0.005% with orders to instill one drop into the right eye at bedtime. On December 21, 2025, at 12:45PM, a medication cart observation was conducted with V32 (Licensed Practical Nurse/LPN). R6's opened Latanoprost 0.005% ophthalmic solution was in the top drawer of the cart with an expiration date of November 25, 2025. R6's Brimonidine 0.2% ophthalmic solution was in the top drawer of the cart with an expiration date of November 30, 2025. V32 confirmed that both medications were expired and should have been removed from the cart.On December 23, 2025, at 2:25PM, V31 (LPN) said that when opening medications the nurse should attach a pink label with the date that the medication was opened and the date that it expires. V31 said that eye drops should have an expiration date of forty-two days from date of opening.On December 23, 2025, at 2:34PM, V30 (LPN) said that eye drop solutions come in a plastic bag from pharmacy with a date open/date expire label for staff to fill out when medication is opened. V30 said expired medications should be removed from the cart right away and placed in a return to pharmacy bag.On December 23, 2025, at 2:51PM, V3 (Assistant Director of Nursing) said that the expectation is that upon opening medications, the nurse should label and date the medication with an open date. Ophthalmic solutions should be labeled with an open and expiration date with either the label presented on the bag by pharmacy, or a pink label provided by the facility. V3 said expired medications should be removed from cart and destroyed in a chemical solution used for safe disposal of medications.The facilities Medication Storage Labeling and Disposal Policy dated July 07, 2025, states, It is the facility's policy to comply with federal regulations in storage, labeling, and disposal of medications.

Based on observation, interview, and record review, the facility failed to obtain a treatment order, assess, and treat a resident with skin alteration. The facility also failed to follow the physician's treatment order for a resident with moisture-associated skin dermatitis.This applies to 2 of 2 residents (R48, 123) reviewed skin alteration in a sample of 27.The Findings include:1.According to the face sheet, R48 had multiple diagnoses including, Alzheimer's disease, other lack of coordination, and polyarthritis. R48's Quarterly MDS (Minimum Data Set) dated October 17, 2025, showed R48 had moderate cognitive impairment and required substantial to maximum assistance with toileting hygiene, personal hygiene, lower body dressing, and was dependent on staff for showers or bathing. R48's (ADL) Activity of Daily Living Care Plan initiated on August 12, 2025, showed R48 required assistance with all areas of ADL, and interventions include staff to assisting R48 with showering or bathing per schedule. On December 22, 2025, at 10:29 AM, R48's left front knee had a dressing dated December 15, 2025. The dressing was dirty and saturated with old, serosanguinous (mixture of bodily fluids and bloody drainage from the outside and underneath when V28 (Nurse) removed the gauze dressing. R48 had a small piece of Vaseline gauze dressing beneath the gauze dressing, and there was some redness and a skin tear to the left front knee when the dressing was removed. V28 took a measurement and said the skin tear and redness area on R48's knee was 1.5 cm X 1.5 cm. R48 said she had a skin tear some days ago while in physical therapy from rubbing her knees close together. V28 said she was R48's nurse on December 22, 2025, and December 21, 2025, during the day shift and was not aware that R48 had a left knee skin tear or that there was a dressing on R48's knee since December 15, 20025. V28 also said there was no order for treating R48's left knee skin care, and no TAR (Treatment Administration Record) flowsheet to document R48's left knee skin tear wound care, and it was not communicated in the nurses' shift-to-shift report. The facility's Incident Report, documented by V26 (Nurse) dated December 15, 2025, showed the resident sustained a skin tear on her left knee (front) while with a restorative aide in the therapy room. The same Incident Report documented that R48's physician was notified and an order to cleanse the skin tear, apply dry dressing and change it every three days was obtained. The facility's Skin Alteration Nursing Evaluation documented by V26 on December 15, 2025, showed R48 sustained a skin tear to the front area of her left knee, and there was bloody drainage present. On December 22, 2025, R48's current (POS) Physician Order Sheet did not show a wound treatment order for the left knee skin tear. On December 22, 2025, at 11:20 AM, R48's Physician, Wound Nurse Practitioner, and Nurses' Progress Note documentations were reviewed for December 1, 2025, to December 22, 2025, and there were no documentations regarding R48's left knee skin tear wound assessment, treatment, or condition. Review of R48's Treatment Administration Record for December 2025 showed there was no Treatment Order Flowsheet documentation of R48's left knee (front) skin tear sustained on December 15, 2025. On December 22, 2025, V3 (Assistant Director of Nursing/ADON) stated that R48 should not have had a saturated dressing which was last changed seven days prior. V3 also said the nurses should inspect the R48's knee every shift, and the facility should have had a wound treatment order and TAR for documentation to prevent further worsening of the wound and infection control. 2. The EMR (Electronic Medical Record) showed R123 was admitted to the facility on [DATE], and discharged home on October 17, 2025. R123's documented diagnoses included a displaced fracture of the greater trochanter of the left femur, protein-calorie malnutrition, chronic obstructive pulmonary disease (COPD), nicotine dependence, dermatitis, and malignant neoplasm of the bronchus. Review of the POS (Physician Order Sheet) for October 2025 showed a physician's order dated July 2, 2025, directing staff to cleanse the buttocks with mild soap and water and apply Zinc Oxide Ointment every shift. R123's Skin assessments dated June 5, June 12, June 20, and June 25, 2025, documented that R123 had incontinence-associated dermatitis to the buttocks, measuring 3.0 cm x 3.0 cm. Review of R123's Electronic Treatment Administration Record (ETAR) and POS for the months of July, August, September, and October 2025 showed that Zinc Oxide Ointment continued to be ordered and applied as a preventative measure for skin impairment. However, review of the ETAR for these months revealed multiple instances of missing nurse signatures indicating that the Zinc Oxide treatment had not been administered as ordered. On December 22, 2025, at 2:45 p.m., V22, (Certified Nursing Assistant/CNA), stated that R123 occasionally experienced skin irritation to the buttocks. On December 23, 2025, at 2:59 p.m., V4, (Wound Care Certified Nurse), stated that R123 developed moisture-associated dermatitis to the buttocks on June 12, 2025, which was identified as incontinence-associated dermatitis. V4 further stated that Zinc Oxide Ointment remained in use after the dermatitis healed as a preventative measure to reduce the risk of recurrence. V4 also confirmed that nurses are required to sign the ETAR to show the treatment was done. On December 23, 2025, at 2:42 p.m., V2, (Director of Nursing, DON), stated that it is the facility's policy for nurses to sign the ETAR to document treatments were administered as ordered. V2 explained that if the ETAR was not signed, the treatment was considered not completed. Review of the facility's Skin Care Regimen and Treatment Policy dated July 3, 2025, showed the facility is required to ensure prompt identification, documentation, and appropriate treatment of residents with skin breakdown. The policy further requires nurses to document all assessments and treatments in the EMR.

Based on interview and record review, the facility failed to assess and auscultate the AV (arteriovenous) fistula for a resident receiving hemodialysis according to the physician's order.This applies to 1 of 1 resident (R6) reviewed for dialysis in the sample of 27.The findings include:R6's EMR (Electronic Medical Record) shows R6 was admitted to the facility on [DATE], with multiple diagnoses including end stage renal disease, dependence on renal dialysis, anemia in chronic kidney disease, diabetes, glaucoma, heart failure, and muscle weakness. R6's MDS (Minimum Data Set) dated November 3, 2025, shows R6 is cognitively intact.On December 21, 2025, at 11:20 AM, R6 was lying in bed. R6 stated he has dialysis every Monday, Wednesday, and Friday. R6 had an AV fistula on his right upper arm. R6 continued to say the nurses check his AV fistula sometimes.R6's Order Summary Report shows a physician's order dated May 2, 2025, to assess and auscultate the right upper arm AV fistula every shift for the presence of bruit and thrill and for signs and symptoms of infection. A review of R6's Monitoring Record of assessing the AV fistula from October 1, 2025, to December 22, 2025, shows 39 blank boxes. On December 23, 2025, at 10:11 AM, V2 (Director of Nursing, DON) stated the blank boxes mean the AV fistula was not assessed. V2 continued to say she expects her nurses to follow the physician's order.

Based on observation, interview, and record review, the facility failed to follow pharmacy recommendations for infusing Intravenous Vancomycin to a resident. This applies to 1 of 1 resident (R31) reviewed for significant medication error in the sample 27The Findings include:R31's electronic medical record showed R31 was admitted on [DATE], with diagnoses that included sepsis, metabolic encephalopathy, pneumonia, symptomatic neurosyphilis, and congestive heart failure. R31 has the following physician order dated December 16, 2025: Vancomycin HCI intravenous Solution Reconstituted 1.5 grams. Use 1.5 gram intravenously in the morning for Cholelithiasis for 12 days. On December 21, 2025, at 1:45 PM, R31 had an intravenous (IV) Vancomycin hanging on a pole infusing into his PICC line without the IV pump that was on the same pole. The tubing was not an adjustable drip rate tubing. The bag was half full of liquid about 3 inches high. V20 stated she was R31's nurse and was infusing Vancomycin 1.5 grams in 300 milliliters (of solution) to gravity and it should be infusing over 2.5 hours. The Vancomycin label was on the infusion bag and showed the same. On December 21, 2025, at 2:24 PM, R31's Vancomycin infusion bag was empty. V20 stated she took the medication out of the pump and let it infuse to gravity because the pump wasn't working and R31's Vancomycin infusion was finished. R31's antibiotic care plan showed the following intervention: Administer medications and treatments as ordered. On December 22, 2025, at 11:58 AM, V21 (Registered Nurse) stated she never administers IV Vancomycin by gravity because you are not able to calibrate the rate/drops accurately. V21 stated she always uses the IV pump because it will program to run according to the pharmacy's specifications.On December 23, 2025, at 10:25 AM, V19 (Quality Assurance Manager/Pharmacist) stated that R31 was receiving 1500 mg once daily of Vancomycin in 300 milliliters. V19 stated that R31's Vancomycin should infuse over 150 Minutes (2.5 hours). V19 stated that this has to be infused over 2.5 hours in order to prevent Red Man syndrome. V19 stated that infusing Vancomycin as a bolus (with IV tubing that is not clamped and running to gravity) puts the resident at risk for Red Man syndrome. V19 stated that Red Man syndrome causes a histamine (inflammatory) response, flushing, itching, redness, and can cause pain and irritation to the vessel or lumen of the vessel it is infused into. This is a significant medication in terms of the infusion time to avoid discomfort and side effects. V19 stated that they recommend Vancomycin to be infused via an IV pump. On December 23, 2025, at 4:10 PM, V2 (Director of Nursing) stated V2 stated Vancomycin should only be infused through a pump at the pharmacy's rate recommendation. V2 stated that IV vancomycin should not be given to gravity with the plunger wide open to avoid inaccurate dosing.

Based on observation, interview and record review, the facility failed to provide recommended dietary portions to meet resident nutrition needs and preference. This applies to 2 of 2 residents (R17 and R63) reviewed for dining in the sample of 27. The Findings include: 1. R17's EMR (electronic medical records) included multiple diagnoses including unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, moderate protein-calorie malnutrition, extrapyramidal and movement disorder, gastro-esophageal reflux disease without esophagitis.R17's POS (Physician Order Summary) shows an order for Regular diet, Puree texture, thin liquids consistency, and that Dietician may order therapeutic diet.On December 21, 2025, at 11:43 AM, pureed meal trays that were plated in the kitchen was seen at the steam table in the Memory Care unit. R17's meal ticket showed large portions. R17's plate showed a large portion of pureed meat and a smaller portion of pureed vegetable and mashed potatoes. On December 21, 2025, at 12:00 PM, R17 was fed at nurses' station by V7 (Registered Nurse) and R17 ate 100% of her meal. R17's care plan revised September 29, 2025, included that resident had significant weight loss as evidenced by decrease in BMI [body mass index]. At risk of malnutrition related to weight loss, limited mobility & diagnosis of dementia as evidenced by MNA [Mini Nutrition Assessment] score of 8.Interventions included to provide variety of foods resident prefers, serve diet and mechanically altered texture, as per orders. Honor food and drink preferences/requests, as able.2. R63's EMR included multiple diagnoses including unspecified psychosis not due to a substance or known physiological condition, personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits, vascular dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. R63's POS showed that R63 is on Regular diet, Puree texture, thin liquids consistency and that Dietician may order therapeutic diet.On December 21, 2025, at 12:10 PM, R63's meal ticket showed Pureed meal, double portions and pre-plated meal from the kitchen only had double portion of protein, and one portion of sides mashed potato and pureed vegetables. R63 was fed by V10 (Certified Nursing Assistant)) in dining room of the Memory Care unit and R63 ate 100%. R63's dietary care plan revised November 11, 2025, included that the resident is at risk of malnutrition related to limited mobility, need for mechanically altered texture and oral supplement, diagnosis of dementia & BMI < 21 (underweight)as evidenced by MNA score of 10.Interventions included to see meal tickets for current food and drink preferences/requests, provide between meal supplements/nourishment as prescribed by MD (Medical Doctor), provide diet and mechanically altered texture, as prescribed by MD. Monitor intake and record every meal, provide variety of foods resident prefers, Dietitian/Diet technician to evaluate and make diet and/or supplement change recommendations, as needed.On December 22, 2025, at 10:05 AM, at 1:38 PM and on December 23, 2025, at 11:00 AM, V6 (Dining Service Director) stated that on December 21, 2025, at the lunch meal, R17 had received a large portion of the meat only and not the sides and that R63 had only received double portion of meat and not the sides. V6 added that if it was double protein only, the recommendation would specify that. V6 stated that large portions were added as a food preference for R17 as she was reaching over to grab other resident's food. V6 added that the previous dietitian had made these recommendations, and the orders did not transfer over when they changed the EMR system. On December 22, 2025, at 12:53 PM, V5 (Dietitian) stated that double portions and large portions are of all food items unless otherwise indicated.

Based on interview and record review, the facility failed to ensure a resident was transferred safely. This failure resulted in R1 sustaining a 10-12-centimeter laceration to left lower leg which required 18 sutures. This applies to one resident (R1) reviewed for injuries in a sample of four.The findings include: Resident Incident Report by V13 (LPN/Licensed Practical Nurse) dated 3/24/25 states R1 sustained a laceration to her left lower leg during transfer from wheelchair to bed. V13's Departmental Note dated 3/24/25 shows R1's laceration was reported by V12 (CNA/Certified Nursing Assistant) who performed R1's transfer. On 7/8/25, at 10:43 AM, V13 said she is unsure of R1's wheelchair footrests were on or off her wheelchair at the time of the incident. On 7/8/25 at 10:32 AM, V12 said that during her shift on 3/24/25, she was transferring R1 from her wheelchair to her bed and R1 sustained a laceration to her left leg. V12 said R1's left leg was closest to her bed and when she pivoted R1 towards the bed, she said ouch. V12 said she then looked down and saw a C or V-shaped cut and more blood than V12 has ever seen. V12 said she didn't know if R1 scraped her leg on the bed or the wheelchair during transfer. V2's (Director of Nursing) Detailed Incident Summary dated 3/29/25 states R1's bedframe was noted with blood on it after the incident. On 7/3/25 at 4:43 PM, V2 said that R1's leg might have rubbed against the bed upon transfer. R1's Emergency Department Physician Report dated 3/24/25 states while facility staff were attempting to transfer R1 from wheelchair into her bed, R1 sustained a large 10 to 12 cm U-shaped skin tear to her left lower leg that required [skin adhesive] and 18 sutures to bolster the wound edges and approximate skin edges. The report also states that it is unknown if she fell or bumped or injured her leg on an object while being moved or transferred. The patient did suffer a large skin tear to her left lower leg. V21's (Wound Doctor) progress note dated 4/30/25 shows that R1 has 1 wound on her left lateral leg measuring 11.5 cm x 5 cm with etiology noted as due to trauma/injury.On 7/9/2025 at 11:45 AM, V1 stated that they do not have specific policies for resident transfers and falls, but they may have policies from the previous facility ownership. The facility only provided a Gait Belt policy (revised 7/26/2024) that showed 2. 1-2 staff might also assist a resident while using a gait belt during transfers and ambulation. The provided policy does not include any other guidance for resident transfers, resident mobility, safety measures, staff body mechanics to support the resident during the transfer, or fall/injury prevention.

Based on interview and record review, the facility failed to recognize a resident's significant weight loss of 17.8% in one month and implement timely interventions. This failure resulted in R1's continual weight loss of 24% in three months and eventual hospitalization. This applies to one resident (R1) reviewed for decreased oral intake.The findings include:R1's Weights and Vitals Summary show the following weights:1/6/25 165.2 lbs2/6/25 167.2 lbs3/7/25 169.3 lbs4/9/25 139.2 lbs (17.8% loss in 1 month)5/13/25 135.9 lbs6/13/25 128.6 lbs (24% loss in 3 months)7/7/25 113.2 lbsR1's Nutritional Status Notification written by V19 (Registered Dietician) dated 4/14/25 states, please obtain a new weight. April weight indicated a 30 pound weight loss 17.8% suspect may be in error. V19's Dietary Note written 4/14/25 states: Recommendations: Please re-weigh and continue to follow weight trends. Monitor weight, intake, and skin integrity. Goals: Weight maintenance with no significant changes and no signs or symptoms of dehydration. R1's Dietician requested re-weigh was not documented until over 1 month later on 5/13/25 at 135.9 lbs, showing another 3.3 lb loss.After the noted 30 pound one month weight loss on 4/9/25, the facility's next Nutrition Risk Assessment was not documented until 5/7/25 by V20 (Registered Dietician). V20 writes, Reviewed weight history in detail. Weight changes are noted due to errors in scale/recording not nutritional intake.Varied PO intake 25-75% per RN.Nutrition Diagnosis: Inadequate oral intake related to varied PO intake as evidenced by dementia, specific food preferences, 1:1 feeding assistance and encouragement required.Nutrition Interventions:.2. Add Ensure BID.R1's POS (Physician Order Sheet) shows order dated 5/9/25 for Ensure 240mLs twice a day. R1's MAR (Medication Administration Record) shows Ensure was not given to R1 until 5/12/25.On 7/8/25 at 12:47 PM, V16 (RN/Registered Nurse) said she is very familiar with R1 and noticed her decline around March/April 2025 and her 30 pound weight loss in April. On 7/9/25 at 12:37 PM, V16 said if a resident's weight is taken and shows a significant loss, the resident is supposed to be re-weighed right away to make sure the loss is accurate. V16 said after verifying the loss is accurate, the doctor should be called and the dietician notified to see if they want to add any other interventions and those interventions should be put into place immediately. V16 said a delay in adding weight loss interventions is a big harm because the elderly are a fragile population at greater risk for lowered immunity, illness, skin dryness/tears and dehydration due to weight loss. On 7/8/25 at 12:24 PM V15 (Registered Dietician) said if she is suspecting an inaccurate weight, she requests the resident to be re-weighed on the same day, because if the weight loss is accurate, she wants to know immediately so she can add more nutrition interventions for the resident. V15 said based on the weights documented in the system, R1's weights show an accurate significant weight loss. On 7/8/25 at 2:41 PM V15 said after re-weigh was requested on 4/14/25, the next weight was not documented until 5/13/25. V15 said when a re-weigh is requested it should be done that same day to verify. On 7/9/25 at 11:01 AM, V18 (NP/Nurse Practitioner) said if he was notified about R1's significant weight loss he would have ordered supplements for her and he expects the supplements to be started right away. V18 said supplements should have been started for R1 in April when the 30 pound significant weight loss was noted. On 7/9/25 at 2:37 PM, V2 (DON/Director of Nursing) said a delay in implementing weight loss interventions can lead to further weight loss and a decline in the resident's health overall. On 7/9/25 at 2:20 PM V3 (ADON/Assistant Director of Nursing) said a delay in implementing weight loss interventions is harmful because it can lead to more weight loss, muscle wasting, depleted protein stores, electrolyte deficiency, and dehydration. R1's General Progress Note written on 6/16/25 by V16 (RN) states NP was notified of R1's elevated BUN (Blood Urea Nitrogen) along with other recent lab values and resident's poor intake of food. Orders received to send resident to hospital for evaluation and IV fluids.On 7/3/25 at 5:04 PM, V9 (R1's POA/Power of Attorney) said R1 was admitted to the hospital on [DATE] severely dehydrated and with significant weight loss. V9 said she was not made aware of R1's weight loss and was under the impression R1 still weighed in the 160s. V9 said on 5/29/25 at Care Plan meeting, the facility staff told her R1 weighed 170 lbs (pounds), but she since found out that was a wrong weight. V9 said she should have been called when R1's weight went from 169 lbs to 139 lbs in 1 month. V9 said, I should not have been blind sighted by the 113.6 lbs when she was in the hospital.R1's Care Plan did not include nutrition concerns until initiated on 6/20/25 (after she returned from 6/17/25 hospitalization). This Care Plan states resident is at risk for alteration in nutritional status related to.significant weight loss.On 7/8/25 at 4:17 Pm, V1 (Administrator) said the facility does not have a Weight Loss policy, only a policy titled, Weights. The facility's policy titled Weights last revised 8/19/24 states, Policy Statement: It is the facility's policy to obtain resident's monthly weight unless ordered differently.Procedures:.3. The significant weight changes (monthly (5%), quarterly (7.5%), and every 6 months (10%)) will be assessed and addressed by the IDT which includes but not limited to the Dietician, Physician, Medical Specialist, Speech Therapist, Nutritionist, and Nurses.

Based on interview and record review the facility failed to adequately assess, administer medications, and notify the physician for a resident who had not had a bowel movement in over 3 days on several occasions. This failure contributed to (R1) developing a fecal impaction, pain and inflammation in her colon. This applies to 1 of 3 residents (R1) reviewed for quality of care in the sample of 7. The findings include: R1's face sheet shows she was admitted to the facility on [DATE] with diagnoses including: Unspecified Dementia, Parkinsonism and Constipation. R1's active Care Plan shows she has a cognitive impairment due to dementia, is incontinent of bowel and bladder, and is at risk for constipation due to impaired mobility. R1's constipation Care Plan initiated on 10/5/22 and revised on 1/5/25 shows that R1 will have one soft formed stool every 2-3 days. Interventions listed in the care plan include assess residents past bowel elimination pattern and document every shift, report negative findings to the physician, assess abdomen for distention, guarding, and bowel sounds at least every shift and administer laxatives/stool softeners and enemas as ordered by the physician. R1's Electronic Treatment Administration Record (ETAR) Electronic Medication Administration Record (EMAR), and Physician Order Summary (POS) show an active order from 6/9/23 that states, Monitor bowel movements (BM's) every shift if no BM in 3 days notify MD. On 2/26/25 at 10:25 AM, R1's bowel elimination tracking for January 2025 was reviewed with V7 (Licensed Practical Nurse). R1 had documented BM's on 1/3/25 and not again until 1/8/25 (5 days in between), 1/13/25 and not again until 1/18/25 (5 days again in between) and next on 1/22/25 (4 days in between). R1's EMAR shows she had PRN (as needed) medication orders for Milk of Magnesia (laxative) to be given daily as needed for constipation, and Miralax Powder (laxative) 17 grams every 12 hours as needed. The EMAR and paper copies of the Medication Administration Summary shows neither of these medications were administered in January 2025 to R1. R1's January 2025 Nursing Progress notes and assessment have no documented abdominal assessment or phone calls to R1's physician to notify and obtain orders for lack of bowel movements longer than 3 days. A change in condition note for R1 dated 1/24/25 shows that R1 was sent to a local community hospital for an unrelated medical issue. R1's hospital records show R1 was assessed in the emergency room (ER) on 1/24/25 and admitted to the hospital for an unrelated medical issue. R1's hospital records show a Gastroenterologist consulted for R1 on 1/24/25 and his consultation report shows that a CT scan was performed of R1's abdomen due to abdominal pain and R1 was found to have a distended rectum and an 8-9 cm. (centimeter) area of fecal impaction and Stercoral Proctitis (inflammation of the colon). Hospital records show R1 was started on stool softeners including rectal suppositories and oral laxative medications. On 2/25/25 at 11:22 AM, V7 (LPN) stated if a resident does not have a bowel movement in 3 days, they should assess the resident, administer any PRN medications, and call the doctor. On 2/26/25 at 9:10 AM, V8 (LPN) stated 3 days is the maximum a resident should go without a bowel movement and is she has a resident who has not gone she would document and assess the resident, give PRN medication, and call the doctor. V8 stated the CNAs at the facility are the ones who generally document the bowel movements and if they do not report anyone not having one they have to check the computer and hard copies of BM tracking forms. On 2/26/25 at 1:08 PM, V3 (R1's Physician) stated he does not recall being notified of the gap in R1's bowel movements. V3 stated he cannot do anything about or order medication if no one tells him about it. V3 additionally stated he would expect nurses to utilize PRN medications and do assessments if a resident has not had a bowel movement in 3 days. V3 described Stercoral Proctitis as an inflammation of the colon from a fecal impaction and said signs of an impaction would be pain, abdominal tenderness, or distention. V3 stated if the nursing staff had administered medications or called for orders it is possible R1's fecal impaction could have been avoided. A policy for bowel elimination was requested from the facility on 2/26/25. The policy provided by V2 was titled Urinary Incontinence and did not address bowel movement monitoring.

Based on observation, interview, and record review the facility failed to identify and develop a discharge plan for resident (R1) with a discharge goal to return to the community. This applies to 1 out of 3 residents (R1) reviewed for discharge services. R1's Medical Record showed R1 was admitted to the facility on [DATE] with multiple diagnoses including chronic obstructive pulmonary disease, asthma, congestive heart failure, generalized muscle weakness, and syncope. On 2/07/2025 at 11:40 AM, R1 was sitting in her wheelchair receiving 2 L (liters) of continuous oxygen via a nasal cannula. R1 stated she was frustrated because there had been delays with her discharge the prior week and now her discharge date was changed to 2/11/2025. On 2/07/2025 at 3:30 PM, V10 (R1's daughter) was interviewed via telephone. V10 stated she contacted the facility on 1/27/2025 to initiate a discussion regarding R1's discharge planning to return to her supportive living facility in the community. V10 stated during the meeting it was identified R1 required DME (Durable Medical Equipment) for her new oxygen and nebulizer therapies. V10 stated R1's original discharge date was scheduled for 2/04/2025 but then was cancelled when it was identified R1 needed additional training on how to use her wheelchair with her oxygen safely. On 2/13/2025 at 9:00 AM, V11 (R1's Supportive Living Facility Director of Nursing/DON) stated she had made multiple attempts prior to contact the facility to ensure R1 was ready for a safe return but was unsuccessful. V11 stated V10 then contacted her to inform her of R1's scheduled return date of 2/04/2025. V11 stated she was concerned because on 1/30/2025 she identified the facility had not made proper arrangements for home health services and DME ordering. V11 stated the facility thought R1's family would be obtaining R1's respiratory DME on their own, which was incorrect. V11 continued to say she then became more concerned when informed R1 now required the use of a wheelchair. V11 stated the facility was unable to show her documentation that R1 was trained on the use of her new wheelchair and oxygen equipment. V11 stated she informed V10 and V4 (Social Services) that R1 was not ready to safely return to her supportive living facility. V11 stated R1's delayed discharge could have been avoided if her goals had been identified and addressed appropriately by the facility at the time of admission and during her discharge planning. On 2 /11/2025 at 11:10 AM, V4 (Social Service) stated she was contacted by R1's family to discuss R1's discharge planning on 1/27/2025. V4 stated R1's original discharge date was scheduled for 2/04/2025. V4 stated R1's discharge date was then changed to 2/11/2025 after V11 assessed R1 at the facility. V4 stated discharge planning should be initiated by the facility's staff within 24-48 hours of a resident's admission to identify the resident's discharge goals and needs. V4 stated appropriate discharge planning should be reviewed to ensure the resident is safely discharged . R1's care plan showed a R1 required discharge planning and teaching for a safe discharge initiated on 1/13/2025. The care plan had multiple discharge interventions including Assess needs of resident/family beginning on day of admission and continuing throughout stay. Anticipate needs/services .Involve the resident/family in the discharge process .Assess of community resources should be utilized and contact appropriate personnel . V4's Social Service note dated 1/27/2025 (20 days after R1's admission) stated Writer spoke with patient's daughter [V10] via telephone to discuss patient's discharge .A Care conference was scheduled for Tuesday 1/28/2025 at 10 am via phone to discuss transfer back to [R1's Supportive Living Facility]. R1's Discharge Communication Sheet updated showed R1's original discharge date was scheduled on 2/04/2025. The facility's policy titled Transfer or Discharge, Preparing a Resident for dated 01/2025, stated Policy Statement Residents will be prepared in advance for discharge. Policy Interpretation and Implementation A. When a resident is scheduled for transfer or discharge, the social worker, or designee, will notify nursing services of the transfer of discharge so that appropriate procedures can be implemented.

Based on observation, interview, and record review the facility failed to obtain an oxygen therapy order for a resident (R1) who required the use of continuous oxygen. This applies to 1 out of 3 residents (R1) reviewed for oxygen therapy. R1's Medical Record showed R1 was admitted to the facility on [DATE] with multiple diagnoses including chronic obstructive pulmonary disease, asthma, congestive heart failure, and syncope. R1's MDS (Minimum Data Set) dated 1/13/2025 showed R1 was admitted with continuous oxygen therapy. On 2/07/2025 at 9:25 AM, R1 was sitting in her wheelchair receiving 2 L (liters) of continuous oxygen via a nasal cannula. R1 stated she had recently been admitted to the facility with oxygen. R1 continued to say her oxygen therapy was new and was explained by the facility's staff that she now required the use of continuous oxygen. On 2/07/2025 at 2:20 PM, V8 (Agency Registered Nurse/RN) stated she was told on report that R1 required the use of 2-3 L continuous oxygen. V8 was asked to review R1's orders and stated she was unable to find an order for R1's oxygen therapy. V8 stated that residents receiving oxygen required a physician's order to indicate how much oxygen should be administered. On 2/11/2025 at 10:15 AM V3 (Assistant Director of Nursing/ADON) stated R1 was admitted with 2 L of oxygen therapy. V3 stated she also reviewed R1's orders and was unable to find an order for oxygen. V3 stated the facility expects nurses to review, obtain, and transcribe admission orders, accordingly, including oxygen orders. V3 stated residents receiving oxygen should be monitored to ensure they are safely receiving oxygen therapy as ordered. R1's care plan showed a nursing problem of impaired gas exchange initiated on 1/20/2025. The care plan had multiple interventions including R1's need for oxygen use and to maintain her oxygen administration as ordered. R1's Physician Orders report dated February 2025, showed R1's oxygen order was obtained on 2/07/2025 (during the survey). R1's oxygen order O2 2 LITERS PER NASAL CANNULA CONTINOUS TO KEEP O2 SAS >90%. MONITOR O2 SATS QSHIFT. The facility's policy titled Procedure: Oxygen Administration dated 12/2024, indicates The purpose of this procedure is to provide guidelines for safe oxygen administration. Preparation A. Verify that there is a physician's order for this procedure. Review the physician's orders or community protocol for oxygen administration. B. Review the resident's care plan to assess for any special needs of the resident.

Based on interview and record review the facility failed to send an escort with a resident for an outside imaging appointment. This applies to 1 of 3 residents (R1) reviewed for transportation and escort to medical appointments, in the sample of 3. The findings include: R1 admitted to the facility with diagnoses including but not limited to chronic combined systolic and diastolic heart failure, atherosclerotic heart disease of native coronary artery without angina pectoris, ischemic cardiomyopathy, hypertensive heart disease with heart failure, nonrheumatic mitral (valve) insufficiency, COPD (chronic obstructive pulmonary disease, type 2 diabetes mellitus with foot ulcer, abnormalities of gait and mobility, unsteadiness on feet, and mild cognitive impairment of uncertain or unknown etiology, based on the diagnosis/history report. R1's elopement risk screening and evaluation dated December 13, 2024, showed a score of 8. The same elopement risk screening showed that if the score was 10 or more the resident is at risk. R1's progress notes dated January 16, 2025, at 2:05 PM, created by V4 (RN/Registered Nurse) showed, Patient out to appointment via [ride-sharing service car]. Patient to obtain X-rays with Disc and return to facility. On January 22, 2025, at 1:05 PM, V8 (Ward clerk/transportation scheduler) stated that when a resident has a scheduled outside appointment, their respective insurance company are called in advance to schedule for the transportation. According to V8, it is the insurance company who determines what type of transportation is needed by the resident based on the information regarding their mobility. V8 stated for Medicaid residents, the insurance company would ask if the resident is ambulatory and can transfer, if so, the insurance company would use a ride-sharing service car and if the resident used a wheelchair, the insurance company would use either medical-vans or regular ambulance company to transport a resident. V8 further stated that the insurance company would also ask if the resident will be traveling alone or with companion. According to V8, for R1 she called the insurance company for the resident's transportation to and from the appointment for January 16, 2025. Since R1 was ambulatory and could transfer independently, the insurance company had a ride-sharing service car used to transport R1 to his appointment on January 16, 2025. According to V8, she was asked by the insurance company if R1 was traveling alone or with companion and she said, alone. V8 stated that R1,had been sent out to his other appointments before using the ride-sharing service car without an escort and had come back without concerns. No one from nursing told me that he needed someone to go with him to his appointment. On January 22, 2025, at 3:28 PM, V1 (Administrator) stated that on January 16, 2025, R1 went to his imaging appointment using a ride-sharing service car without an escort. V1 stated that even though the imaging office was just around the corner, close to the facility, the facility should have sent a staff with R1. V1 also stated that when she learned that R1 did not come back to the facility in a reasonable time after his appointment on January 16, 2025. All facility staff made sure that residents are accounted on each floor and some staff went out of the facility to look for R1, including at the imaging office and the hospital ER (emergency room ) which was next door to the facility. V1 stated that the police, R1's family and physician were notified. V1 stated R1 was found by V2 (Director of Nursing) and V3 (Assistant Director of Nursing) sitting in the hospital ER (next door to the facility). On January 22, 2025, at 4:16 PM, V2 (Director of Nursing) stated that R1 should have been sent out to his appointment on January 16, 2025, with a staff escort due to his changing mental status. According to V2, most of the time, R1 is with it and able to answer questions appropriately, but there are times that he gets confused. V2 stated that she was off on January 16, 2025, when R1 went to his appointment using a ride-sharing service car and she was not aware that the facility did not schedule a staff to accompany the resident. V2 stated that on January 16, 2025, at around 4:50 PM, she received a text message from the facility that R1 did not return to the facility after his imaging appointment. When she (V2) arrived at the facility, the facility staff had already started looking for R1 in the building and surrounding areas and the police had already been notified that R1 was missing. V2 also stated she (V2) and V3 (Assistant Director of Nursing) took their respective cars and went to the hospital ER next to the facility and upon entering the ER, she saw R1 sitting at the waiting area with his cane on his lap. V2 stated that R1 had no visible injury. V2 stated that she asked, R1 where he had been and the resident responded, I do not know why the ambulance brought me here.

Based on interview and record review, the facility failed to ensure a resident's Physician/Nurse Practitioner was immediately notified of a fall where the resident had hit his head. This failure resulted in an over six-hour delay in hospitalization and treatment. This applies to 1 of 3 residents (R3) reviewed for notification of changes. Findings include: The facility's 1/6/25 reportable Serious Injury Incident form for R3 showed Resident noted on his right side next to his bed. Resident was transferred to hospital. admitted with 4 [millimeter] hyper density left frontoparietal lobe suspicious for a small focus of intraparenchymal hemorrhage . R3's 1/4/25 progress note showed 9:30 PM, resident observed, laying on the floor on his right side, next to his bed, bruise noted, on right side of face with swelling .call out to [Nurse Practitioner (V16)] .neuro-check in progress . This progress note was timed at 11:48 PM, two hours after R3's fall. R3's 1/5/25 progress note showed [Nurse on Duty] called Dr. on call, NP [V16], to get orders. Waiting on call back. Resident will continue to be monitored for safety . This progress note was timed at 4:10 AM, over six hours after R3's fall. R3's 1/5/25 progress note from 4:22 AM showed Received a call back from [V16] at 4:13 AM, orders to send resident to ER (emergency room ) for further assessment. R3's nursing progress note does not show the time R3 went to the hospital or how he was transported. On 1/9/25 at 2:00 PM, V1 (Administrator) stated when the night nurse had come on duty, she called the Nurse Practitioner on call to get orders. V1 stated R3's fall was unwitnessed. On 1/10/25 at 3:10 PM, V16 (Nurse Practitioner) stated he does not recall every detail and he was not alarmed by the initial call he received- there was no obvious injury. V16 stated when they called him again though he thought there was something wrong. V16 stated he has to make decisions based on the information that is given to him. V16 stated if the resident hits their head and the resident is on Coumadin (anti-coagulant medication), you send them to the hospital. R3's Face Sheet showed diagnoses that include long term use of anticoagulant and personal history of venous thrombosis and embolism. R3's January 2025 Physician Order Sheet showed a 1/2/25 order for 3mg of Coumadin daily, and a standing order for Resident on Anticoagulant monitor for signs of bleeding.,, The facility's Change in a Resident's Condition or Status policy (revised 2/2022) showed A. The nurse will notify the resident's Health care provider or physician on call when there has been a (an) 1. Accident or incident involving the resident 5. Need to alter the resident's medical treatment significantly; 6. Need to transfer the resident to a hospital/treatment center .

Based on observation, interview and record review, the facility failed to assist residents identified as needing assistance with personal hygiene and grooming. This applies to 6 of 6 residents (R13, R44, R49, R91, R106 and R125) reviewed for ADLs (activities of daily living) in the sample of 21. The findings include: 1. R13 face sheet shows multiple diagnoses including vascular dementia, generalized muscle weakness and hemiplegia following cerebral infarction affecting left nondominant side, based on the diagnosis/history report. R13's quarterly MDS (minimum data set) dated July 4, 2024, showed that the resident was moderately impaired with cognitive skills for daily decision making. The same MDS showed that R13 required maximum assistance from the staff with personal hygiene. On August 26, 2024, at 10:48 AM, R13 was in bed, alert and verbally responsive with confusion. R13's fingernails were long and jagged with brown substances underneath the nails. R13 stated that she wants the staff to trim and clean her fingernails. On August 27, 2024, at 11:51 AM, R13 was in bed, alert and verbally responsive. R13's fingernails were long and jagged with black substances underneath the nail beds. V3 (Assistant Director of Nursing) was present during the observation and confirmed that R13's fingernails needed trimming and cleaning. R13's active care plan initiated on January 11, 2024, showed that the resident requires staff assistance with all her ADLs. 2. R91 had multiple diagnoses including cerebral infarction due to thrombus of left anterior cerebral artery, hemiplegia following cerebral infarction affecting right dominant side and weakness, based on the diagnosis/history report. R91's quarterly MDS dated [DATE], showed that the resident was severely impaired with cognition. The same MDS showed that R91 required maximum assistance from the staff with personal hygiene. On August 26, 2024, at 11:36 AM, R91 was in bed, alert and verbally responsive. R91 had accumulation of long facial hair and his fingernails were long and jagged with black substances underneath the nails. V5 (CNA/ Certified Nursing Assistant) was present during the observation. R91 stated that he needed help from the staff with trimming and cleaning of his fingernails and he needed staff assistance with shaving. On August 27, 2024, at 12:01 PM, R91 was in bed, alert and verbally responsive. R91 had accumulation of long facial hair and his fingernails were long and jagged with black substances underneath the nail beds. V3 (ADON, Assistant Director of Nursing) was present during the observation and confirmed that R91's fingernails needed trimming and cleaning, and that the resident needs staff assistance with shaving. R91's active care plan initiated on June 25, 2021, showed that the resident requires staff assistance with all his ADLs. 3. R106 had multiple diagnoses including Parkinsonism, dementia, and generalized muscle weakness, based on the diagnosis/history report. R106's quarterly MDS dated [DATE], showed that the resident was severely impaired with cognitive skills for daily decision making. The same MDS showed that R106 required total assistance from the staff with personal hygiene. On August 26, 2024, at 11:09 AM, R106 was in bed, alert but non-verbal. R106's fingernails were long and jagged. V5 was present during the observation. On August 27, 2024, at 11:56 AM, R106 was in bed, alert but non-verbal. R106's fingernails were long and jagged. V3 was present during the observation and confirmed that R106's fingernails needed trimming and filing to prevent the resident from scratching and/or injuring herself. R106's active care plan initiated on March 13, 2024, showed that the resident had self-care deficit requiring total assistance with ADL care. The same care plan showed multiple approaches including, provision of care as needed and provision of assistance with personal care. 4. R125 had multiple diagnoses including dementia, need for assistance with personal care and generalized muscle weakness, based on the diagnosis/history report. R125's quarterly MDS dated [DATE], showed that the resident was moderately impaired with cognitive skills for daily decision making. The same MDS showed that R125 required maximum assistance from the staff with personal hygiene. On August 26, 2024, at 11:26 AM, R125 was sitting in bed, alert and verbally responsive. R125 had accumulation of long and curling facial hair on her chin, on both sides of her face and above her lips. R125's fingernails were long and jagged with black substances underneath the nails. According to R125 she needed help from the staff to trim and clean her fingernails and to shave her facial hair. On August 27, 2024, at 12:06 PM, R125 was sitting in her wheelchair inside the unit television area (in front of the nursing station). R125 was alert and verbally responsive. R125 had accumulation of long and curling facial hair on her chin, on both sides of her face and above her lips. R125's fingernails were long and jagged with black substances underneath the nail beds. V3 was present during the observation and confirmed that R125's facial hair needs to be removed/shaved by the staff and the resident's fingernails needs trimming and cleaning. R125's active care plan initiated on December 4, 2023, showed that the resident requires staff assistance with all her ADLs. The same care plan showed multiple approaches including provision of assistance to R125 with ADLs. On August 27, 2024, at 12:15 PM, V3 (Assistant Director of Nursing) stated that it is part of the facility's nursing care and service to assist any resident requiring assistance with ADLs, including shaving/ removing facial hair and to assist the resident with trimming and cleaning of fingernails to ensure that the president's personal hygiene and grooming are maintained. 36567 5. R49's face sheet showed diagnoses of hemiplegia following cerebral infarct affecting left non dominate side, unspecified osteoarthritis, unspecified dementia, unspecified severity. R49's MDS (Minimum Data Set) dated July 19, 2024, showed that R49 was moderately impaired in cognition and dependent on staff for personal hygiene. On August 26, 2024, at 11:39 AM, R49 lying in bed in her room with a striped shirt on and R49's hair looked disheveled. R49 stated I only have this stripped shirt on. I only have a diaper underneath. They don't even comb my hair. R49's nails appeared long with blackish substance underneath. R49's left hand appeared contracted. R49 stated that she would like her nails trimmed and cleaned. On August 27, 2024, at 10:53 AM, R49 was lying in her bed and fingernails remained long and uncut on both hands with blackish substance underneath most of the nail beds that were visible from contracted hand. The nails in her contracted hand also appeared to be pressing into her palm. R49 remarked They need to be trimmed. This information was relayed to V14 (Registered Nurse) who stated that the Hospice nurse usually comes in and takes care of this task. On August 27, 2024, at 11:02 AM, R49 was seated in a high back chair in front of the wash basin in the bathroom brushing her teeth with her right hand and stated that she needs assistance to wash off toothbrush and her hands. R49's fingernails remained long with blackish substance underneath the nails. The visible nails in her contracted hand also appeared long with blackish substance underneath and were pressing into her palm. This was relayed to V9 (Certified Nursing Assistant) who stated that since R49's left hand is contracted, that she is unable to open R49's fingers. On August 27, 2024, at 1:19 PM, V11 (Rehab Director) stated that R49 refuses therapy to her contracted hands however staff should ensure that R49's fingernails are trimmed so that it will not dig into her palms. R49's care plan revised April 22, 2024, included that R49 has impaired mobility, requires assistance from staff for her ADLs (activities of daily living). Goal for the same included that staff will provide ADL assistance as needed with target date October 19, 2024. 6. R44's face sheet included diagnoses of unspecified Dementia, unspecified severity, Alzheimer's disease, unspecified psychosis. R44's quarterly MDS dated [DATE], showed that R44 was moderately impaired in cognition and is dependent on staff for personal hygiene. On August 26, 2024, at 10:59 AM, R44 was seated in a high back chair in front of nurses station. R44's left arm appeared contracted, and her fingers were curled into a fist and the visible fingernails were noted to be long and pressing into palms. R44's right hand also had long fingernails with blackish substance underneath the nail beds. R44 did not respond to queries and V12 (Activity Aide) stated that R44 is primarily Spanish speaking. On August 27, 2024, at 12:10 PM, R44 was seated in a high back chair and her fingernails remained long and with some of them jagged and with blackish substance underneath the nail beds. This information was relayed to V14 (Registered Nurse) who stated that R44's family comes in and usually takes care of it. R44's care plan revised July 28, 2024, showed that R44 requires staff assistance for all ADLs with goal for this problem for staff will provide the needed assistance for ADLs.

Based on observation, interview, and record review, the facility failed to provide incontinence care in a manner that would prevent urinary tract infection (UTI). This applies to 4 of 5 residents (R26, R117, R126, and R9) reviewed for bowel and bladder care in the sample of 21. The findings include: 1. On August 27, 2024, at 1:16 PM, V18 (Certified Nursing Assistant/CNA) rendered incontinence care to R26 who was wet with urine and had a bowel movement. V18 wiped R26's frontal perineum up and down with wet washcloth, the washcloth got soiled with fecal matter as it went down to the mid perineum. V18 only wiped the outer area of the labial fold and the surface of the groins without wiping deeper into the groins, then V18 proceeded to clean the back perineum. R26's face sheet shows that R26 has a history of UTI. 2. On August 28, 2024, at 10:24 AM, V17 and V18 (Both CNAs) rendered incontinence care to R9 who was wet with urine. V17 cleaned R9's perineum from front to back. However, V17 did not separate the labia to clean the inner folds. 3. On August 28, 2024, at 10:48 AM, V17 and V18 stated they rendered incontinence care to R126 who was wet with urine and had a bowel movement. V17 cleaned R126 from the front to back, V17 cleaned the surface of the groin but did not go deeper into the folds, and she did not clean R126's scrotal area. R126's face sheet shows that R126 has diagnoses of obstructive and reflux uropathy, hydronephrosis with ureteral stricture, calculus of ureter, and benign prostatic hyperplasia with lower urinary tract symptoms. 4. On August 28, 2024, at 10:57 AM, V17 and V18 they rendered incontinence care to R117 who was wet with urine. V17 cleaned R117 from front to back of the perineum. However, V17 did not separate labia to clean the inner folds and cleaned only the surface of the groins without going in deeper into the folds. On August 28, 2024, at 4:11 PM, V2 (Director of Nursing/DON) stated that when staff provides incontinence care the staff must completely clean the resident from front to back. The staff must clean the abdominal folds, the vaginal area, separate the labial folds to clean the inner area, and the whole groins. The staff must wipe in one direction and not up and down. This is to prevent infection. The Facility's Policy and Procedure for Peri-Care dated January 2024 shows: Purpose: The purposes of this procedure are to provide cleanliness and comfort to the resident. to prevent infections, and skin irritation, and to observe the resident's skin condition. Steps in the Procedure: I. For Female Resident: Wash the perineal area, wiping from front to back. a. Separate labia and wash area downward from front to back. b. Continue to wash the perineum including thighs, alternating from side to side, and using downward strokes. J. For Male Resident: Wash the perineal area starting from the urethra and working outward. c. Continue to wipe the perineal area including the penis, scrotum, and inner thighs.

Based on observation, interview and record review, the facility failed to serve ground chicken for residents on mechanical soft diets. This applies to 4 of 4 residents (R67, R105, R109, R296) reviewed for dining in the sample of 21. The findings include: Facility menu spreadsheet for Monday lunch (week 1) showed to serve ground same as base for mechanical soft diet. The base was documented as garlic herb-based chicken breast for mechanical soft diet. On August 26, 2024 at 12:02 PM during meal service in the secure unit dining room on the 1st floor, V8 (Dietary Aide) was plating the food from the steam table. The mechanical soft chicken breast, which was pre-plated in bowls, appeared chopped into varying lengths. V8 stated that it was pre-plated in the facility kitchen. V6 (Dietary Manager), who had come into the vicinity, was showed the same and V6 stated that she will have to ask V7 (Cook) how he prepared it. R67, R105, R109 and R296 were observed to receive the chopped chicken and their diet ticket showed give ground meat. R65 and R109 received meals in the secure unit dining room and R105 and R296 received room trays on the 2nd floor. R105 had poor dentition and R296 was edentulous and did not eat all the chicken. On August 26 at 12:19 PM, V7 (Cook) stated that he chopped up the chicken on a cutting board as the blender was in use by another dietary staff member. On August 28 at 12:35 PM, V15 (Registered Dietitian) stated that for ground consistency a [NAME] should be used as the texture of the product will not be even when chopped. Facility policy and procedure titled Modified Texture Foods (revised January 2024) included as follows: Policy: Provide a standardized process for modified texture foods to meet community-approved diet guidelines and to assure palatability, flavor, texture, and nutritious value. Procedure: -The regular diet menu item will be used to prepare all modified-textured menu items unless otherwise indicated by menu spreads. -Foods requiring modification to other levels (e.g., ground meat, minced and moist, soft and bite sized) will be provided per guidelines established by the community and approved in the diet manual. Facility diet order listing of residents printed on August 26, 2024, showed that R67, R105, R109 and R296 were on mechanical soft diets.

Based on observation, interview, and record review, the facility failed to follow infection control process related to hand hygiene and gloving during provisions of incontinence care. This applies to 5 of 21 residents (R9, R26, R116, R117, R126) reviewed for infection prevention in the sample of 21. The findings include: 1. On August 27, 2024, 1:01 PM, V19 (Certified Nursing Assistant/CNA), rendered peri-care to R116 after he had a bowel movement in the bed pan. V19 cleaned R116 from front to back, she then touched clean bed linen, applied clean incontinence brief, and applied barrier cream, V19 also placed a pillow underneath R116's left lower extremity, placed linen sheet and blanket over R116, adjusted bed height by using bed control and opened the privacy curtain, while wearing the soiled gloves all throughout these procedures. 2. On August 27, 2024, at 1:16 PM, V18 (CNA) rendered incontinence care to R26 who was wet with urine and had a bowel movement. V18 cleaned R26 from front to back perineum, applied barrier cream, applied a clean disposable brief, repositioned R26, and placed linen, and blanket over R26, while wearing the same soiled gloves all throughout the care. 3. On August 28, 2024, at 10:24 AM, V17 and V18 (Both CNAs) rendered incontinence care to R9 who was wet with urine. V17 cleaned R9's perineum from front to back, applied clean disposable brief, repositioned R9, assisted R9 to put the pants on, opened R9's closet to get a sweatshirt, and transferred R9 via mechanical lift while wearing the same gloves all throughout the care procedure. 4. On August 28, 2024, at 10:48 AM, V17 and V18 rendered incontinence care to R126 who was wet with urine and had a bowel movement. V17 cleaned R126's perineum from front to back, applied new disposable brief, and repositioned R126 while wearing the same set of gloves all throughout the care. 5. On August 28, 2024, at 10:57 AM, V17 and V18 rendered incontinence care to R117 who was wet with urine, V17 cleaned R117's perineum from front to back, applied incontinence brief and repositioned R117, and adjusted bed height using the bed remote control while wearing the same gloves. On August 28, 2024, at 3:57 PM, V2 (Director of Nursing/DON) stated that staff should follow protocol for when providing incontinence care. The staff must perform hand hygiene before and after care, they should change gloves and perform hand hygiene in between glove changes and in between tasks to prevent the spread of infection. Facility's Policy and Procedure for Hand Hygiene dated August 2024 shows: This community considers hand hygiene the single most important practice to prevent infections and promote resident safety. Evidence based hand hygiene guidance is practiced to reduce the risk of transmission pathogenic microorganisms to residents, associates, and visitors. Policy Interpretation and Implementations: F. Hand Hygiene is practiced: 3. Before moving from work on a soiled body site to a clean body site on the same resident. 4. After touching a resident or the resident's immediate environment. 5. After contact with blood, body fluids, or contaminated surfaces. H. The use of gloves does not replace hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections.

Based on interview and record review the facility failed to ensure that a resident's signed POLST (Practitioner Order for Life-Sustaining Treatment) form and physician's order are consistent to reflect the resident's treatment wishes in an event of a medical emergency. This applies to 1 of 1 resident (R47) reviewed for advance directives in the sample of 21. The findings include: R47 had multiple diagnoses including dementia with other behavioral disturbance, based on the diagnosis/history records. R47's face sheet showed that the resident's code status was, Full Code. R47's quarterly MDS (minimum data set) dated [DATE], showed that the resident was moderately impaired with cognitive skills for daily decision making. R47's active physician's order showed an order dated [DATE], for full code. The same active physician's order showed an order dated [DATE], for hospice care with admitting diagnosis of dementia. R47's medical chart (physical records) showed a signed POLST form dated [DATE], with instructions that if the resident is in cardiac arrest and has no pulse, No CPR (cardiopulmonary resuscitation): Do Not Attempt Resuscitation (DNAR) was selected. The said POLST form was signed by R47's State guardian (legal representative) and the Physician. R47's active advance directive care plan initiated on [DATE], showed under goal and target date, Resident will have their preferences followed and reviewed through next review period, [[DATE]]. The same care plan showed approaches including, Obtain Advance Directive, as indicated by resident/resident representative. On [DATE], at 11:32 AM, V4 (Licensed Practical Nurse) stated that she was the assigned nurse for R47 that morning. V4 stated that in case of a medical emergency while R47 is inside her room, the first thing she would check is the color of the name tag on R47's wall by the door. According to V4, the facility uses a green name tag on the resident's wall by the door to indicate a full code status and the facility uses a white name tag on the resident's wall by the door to indicate DNR (Do Not Resuscitate) status. With V4, R47's name tag on the wall by the door was observed to be green in color which according to V4, R47 was a full code. V4 stated that in case of a medical emergency while R47 is away from her assigned room, R47's medical chart (physical records) which is accessible at the nursing station should be checked for availability of signed POLST form and copy of the active physician order to determine the resident's code status. Upon review of R47's medical chart, V4 stated that the resident had a signed POLST form showing that no CPR should be performed and that R47 had a DNR status. V4 reviewed the active physician order for R47 and stated that the resident was a full code which meant that CPR should be performed. According to V4, R47 had inconsistent and conflicting code status based on the physician order for full code and the signed POLST form for DNR. V4 stated that there is confusion as to what code status to follow for R47 in case of a medical emergency. V4 added that based on the conflicting code status for R47, she will follow the physician's order to perform CPR in case of R47's medical emergency. On [DATE], at 12:09 PM, V3 (Assistant Director of Nursing) confirmed during the interview that if a medical emergency happened inside a resident's room, the nursing staff were instructed to check the color of the name tag on the resident's wall by the door. V3 stated that a green name tag meant that the resident has a full code status, therefore CPR should be performed, and the white name tag meant that the resident has a DNR status, therefore no CPR should be performed. According to V3, the color of the name tag on each resident's wall by the door are constantly updated based on the physician's order and the available signed POLST form, and that the two documents should always be consistent. V3 further stated that if a medical emergency happened away from the resident's room, the nurses should check the resident's medical chart located at the nursing station to confirm the availability of the signed POLST form and the active physician's order for code status. With V3, the color of the name tag on R47's wall by the door was observed and the signed POLST form and active physician's order were reviewed from R47's medical chart. V3 acknowledged that R47's code status was inconsistent, conflicting and confusing because the physician's order does not reflect the wishes on the available signed POLST form. The facility's policy and procedure regarding Advance Directives and Code Status dated [DATE] showed in-part under procedure statement, Advance directives will be respected in accordance with state law and community policy. The policy under interpretation and implementation showed in-part, 2. Initiating a new Advance Directive or Changing an Advance Directive. A. Social Service . 2. Advanced Directive signed, a. Notify nursing to obtain corresponding physician's order, as needed, b. Scan into electronic chart, or place into paper chart, c. Update Resident Code Status Identifiers, d. Care plan per resident wishes as identified on the Advanced Directive. B. Nursing 1. Check that the Resident Code Status Identifiers are correct, 2. For DNR or other choices identified on an Advanced Directive a. Obtain and enter a physician order after confirmation that the community required form is signed, b. Care plan per resident wishes as Identified on the Advanced Directive, 3. Choice reviewed routinely, at the quarterly care conference, when there is a significant change and per resident/resident representative request.

Based on interview and record review, the facility failed to provide a safe transfer with a mechanical lift for 1 resident (R1). This failure resulted in R1 falling off the side of her bed and obtaining an 8cm (centimeter) laceration to her head requiring 15 staples. This past noncompliance occurred from June 23, 2024, to July 13, 2024. This failure applies to 1 of 3 residents (R1) reviewed for safety and supervision in the sample of 13. The findings include: R1's electronic face sheet printed on 7/31/24 showed R1 has diagnoses including but not limited to lymphedema, repeated falls, hypertension, cognitive impairment, and morbid obesity. R1's facility assessment dated [DATE] showed R1 has severe cognitive impairment and requires substantial/maximum assistance with transfers. R1's care plan dated 12/29/21 showed, Risk for falls and/or fall related injury related to decreased mobility, recent acute medical condition .keep within visibility of staff when up in chair, high risk for falls identifier in place. R1's fall risk assessment dated [DATE] showed R1 is a significant fall risk. R1's local hospital record dated 6/23/24 showed, Patient presents to the emergency department after sustaining a witnessed fall at her nursing home. She is unable to answer questions appropriately due to baseline cognitive deficit. Fall was witnessed and observed to have no loss of consciousness however did sustain a wound to her head which is bleeding .there is an approximate 8cm laceration to the superior portion of the scalp running in a sagittal plane on the right side of the head. Procedure: laceration repair .location: scalp length: 8cm, staples: 15. On 7/30/24 at 10:17AM, R7 (R1's roommate) stated, I heard (R1) fall. The CNA (certified nursing assistant) was putting her in bed, and I think when the CNA backed the lift away, (R1) fell and it sounded like (R1) hit the dresser and then the floor. She was in the corner crying and reached out her hand to me when I came around the curtain to see if she was ok. Her hand was all bloody and she was holding her head, so I knew something bad happened. There was no other CNA in the room except for the one girl. On 7/30/24 at 12:31PM, V4 and V6 (CNAs) stated, When we transfer residents using the sit to stand machine, it is always a 2-person transfer. It has always been that way here as far as we know. (R1) is not safe at all to be sitting on her own on the edge of the bed. That's why you have to have 2 people with the transfer, while 1 person is removing the lift, 1 person can stay with the resident to be sure they don't fall. On 7/31/24 at 9:23AM, V5 (CNA) stated, I took (R1) to her room to lay down and when I got her up in the machine and over to the bed, I set her down on the bed and when I was removing the lift, she fell forward. She hit her head on the table by her bed and then hit her head on the floor. I immediately went and got the nurse to assess her. I removed the lift in a manner where the lift was in front of me, and I was behind it and too far from (R1) to even be able to try to save her from falling because the lift was between us. On 7/31/24 at 1:31PM, V10 (R1's nurse practitioner) stated, (R1) is generally weak and not good at following directions due to her severe cognitive impairment. I guess this would have been an avoidable incident and 2 staff members probably should have been with her. On 7/31/24 at 1:50PM, V2 (Director of Nursing) stated, Prior to this incident, my expectation was for 2 staff to perform a sit to stand transfer as this is our policy. (V5) hasn't worked here that long, less than 3 months but she still should know the expectations. This incident could have been avoided if (V5) had another staff person with her who could have ensured (R1) was safe on the bed while (V5) backed the lift away from (R1). The facility's policy titled, Procedure: Lifting Machine, Using a Portable dated 12/2017 showed, The purpose of this procedure is to help lift residents using a manual lifting device. General guidelines: Two nursing associates are required to perform this procedure. Procedure for sit to stand: I. Crank (or raise) the resident up with the lift. Your helper guides the resident by holding the sling. J. Swing the frame of the lift over the bed and slowly lower the resident down onto the bed. K. remove the sling and waist belt from under/behind the resident. L. Reposition the bed covers. Position the resident in a comfortable position that promotes good body alignment .N. Remain with the resident until he or she is comfortable and free from any adverse effects from the transfer .P. Remove the equipment and supplies from the room. Prior to the survey date of 7/30/24, the facility took the following actions to correct the noncompliance on 6/23/24: 1. Resident (R1) was sent to the emergency for evaluation and treatment and has returned to the community. Resident was reassessed by (V7-Licensed Practical Nurse) with no further adverse effects noted at this time. 2. Other residents requiring a sit to stand [lift] have the potential to be affected-these residents were assessed for any falls that occurred in the last 30 days and no further residents were identified. Care plans will be reviewed and updated as needed. 3. QAPI [Quality Assurance and Performance Improvement] meeting held 6/25/24 by the interdisciplinary team and this plan of correction was developed and implemented. 4. Medical director was notified on 6/26/24 and is in agreement with this plan of correction. 5. All direct care licensed nurses and CNA's will be re-educated by the Director of Nursing or designee on or before 7/3/24 on ensuring resident is safe/secure before leaving the room or stepping away from the patient for any reason/not to be left sitting at edge of bed when preparing to use the sit-to-stand. 6. The policy and procedure: Lifting Machine, Using a Portable has been reviewed by the IDT [Interdisciplinary Team] on 6/25/24 and is deemed appropriate. 7. Under the direction of the QAPI committee, the Director of Nursing or Designee will audit 3 resident transfers with a sit-to-stand each week to ensure resident safety is maintained when preparing to use the lift. Audits will be submitted and reviewed by the QAPI committee for management of ongoing compliance and will continue until otherwise deemed by QAPI. Completion date: 7/3/24 Based on the facility's Staff Education Sign off Sheet, in-services were not completed for all staff until 7/13/24.

Based on observation, interview, and record review, the facility failed to ensure a resident who was retaining urine had his bladder scanned and was catheterized. These failures resulted in the resident being hospitalized with urosepsis for eight days. This applies to 1 of 3 residents (R1) reviewed for urinary catheters. The findings include: On 04/17/24 at 1:45 PM R1 was in his room sitting in a high back wheelchair. R1 was alert and oriented x 3. R1 had an indwelling urinary catheter draining yellow urine and a right arm PICC (Peripherally Inserted Central Catheter for intravenous [IV] medication). R1 said on 04/05/24, he had a fever and chills, and prior to the fever and chills, he was having bladder spasms that he reported to the nurses. R1 said he saw the physician and received orders for a bladder scan and to be intermittently catheterized every four hours because he has a history of urinary retention. R1 said the nurses did not do the bladder scans to see if I needed to be catheterized. I would need to be catheterized if I had more than 400 ml of urine in my bladder. R1 said that did not happen every four hours. R1 said when he was admitted to the hospital on 04/05/24, he was diagnosed with urosepsis, and now must be on IV antibiotics daily at 4:00 AM for a month and was not happy about it. R1 Physician Order Sheet (POS) showed a March 10, 2024, order as May straight cath. (If more than 400 cc foley needed.) R1's March 10, 2024, progress note from 10:22 AM showed Writer paged [MD regarding] results received from renal ultrasound done yesterday .was informed NP [Nurse Practitioner name] was covering. Writer spoke with NP asked if urine was collected for UA & C/S [urinalysis and culture/sensitivity], writer informed her that an order was in place for urine to be collected but has not at this time, writer stated to NP that she will attempt to collect urine this shift. NP gave orders to straight cath as needed, if retaining more than 400 cc of urine, foley catheter will be needed. R1's progress notes from March 12, 2024, showed a temperature of 99 degrees Fahrenheit and complaints of nausea. R1's March 17, 2024, note from 10:28 PM showed Bladder scanned at [8:30 PM] 786 ml residual, straight cathed .200 ml from straight cath. Paged MD for clarification on bladder scan orders no return call. [Power of Attorney] called with concerns about [patient] not emptying his bladder . No progress note was included that showed an indwelling urinary catheter was placed per order. R1's March 18, 2024, progress note from 4:50 PM showed Message left for urologist [name] office regarding resident's order for [post-void residual (PVR)] every 4 hours. According to staff resident has been urinating ok and having multiple wet briefs. Bladder scans performed with small PVR amounts A 5:14 PM addendum showed Resident bladder scanned at 5pm 554 was amount. Wants to be straight cathed after he eats. Will notify [MD name] office with residual amount and get clarification on how long he should have PVR/bladder scans done. R1's 5:59 PM progress note showed straight cath resident able to get over 700 cc urine. Upon changing resident, he had a full brief of urine as well. R1's 9:52 PM note showed Bladder scan performed stating 550. Straight cath resident able to retrieve 500cc urine. No progress notes showed an indwelling urinary catheter was placed per order. A handwritten nursing note from March 19, 2024, in R1's EMR (Electronic Medical Record) showed R1 was catheterized, and 575 ml of urine was drained. No other progress notes were included again until March 31, 2024 (twelve days), when a 9:26 PM note showed Writer went to do bladder scan on patient, noted covers to be soiled with urine, bladder scan showed no retaining of urine. Writer voiced to resident that bladder scan showed nothing and resident stated to writer that I am not concerned with the retention, I am concerned with possible infection, writer then asked resident was he having any burning when urinating and he stated yes, writer asked resident how long he has been having this symptom and he stated for about two days now. Writer spoke with [MD] . orders given to collect urine for UA & C/S . No note showed an indwelling urinary catheter was placed per order. R1's POS/physician order contained the March 31, 2024 order to Collect urine for [urinalysis] and [culture and sensitivity]. The next progress note in R1's EMR on April 4, 2024 (four days after the order) that showed Clean catch done to collect UA C/S. Collected dark amber colored urine . R1's April 5, 2024, nursing note from 6:55 PM showed an ambulance company was at the facility to transport R1 to the hospital. R1's note at 10:36 PM showed R1 was diagnosed with urosepsis. On 04/18/24 at 11:50 AM V6 (Nurse Practitioner) said he was notified of R1 having dysuria prior to his last admission to the hospital. V6 said R1 was hospitalized on [DATE] with urosepsis. V6 said the Nurse Practitioner that was on call on 03/10/24 gave orders for the bladder scans every four hours and to straight catheterize R1. V6 said he was not aware of the nursing staff not performing the bladder scans and straight catheterizing R1 as ordered. V6 said it is his expectation that the nurses follow all orders. V6 said the nurses should have done the bladder scans and straight catheterized R1 as ordered because urinary retention and not emptying the urine from the bladder could have caused an infection and R1 becoming septic. Under R1's Assessment and Plan in the April 12, 2024, hospital Infectious Disease Physician Report, it showed Sent in due to altered mentation, confusion, refusing meds, and had fever of 102.4. 1. Sepsis present on admission with bacteremia lactic acidosis R1 was admitted back to the facility on [DATE] at 9:12 PM with diagnoses of UTI/sepsis. On 04/17/24 at 1:00 PM V5 (Licensed Practical Nurse) said on 04/05/24 she was the nurse taking care of R1 and she straight catheterized R1 that morning and got 200 ml of urine. V5 said R1 told her he was not feeling good that morning and he had a urinalysis pending. V5 said in the evening, R1 had chills and was shaking and R1 had a low-grade temperature and wanted to go to the hospital. V5 said R1 was transferred to the hospital and admitted with urosepsis. V5 said she was aware of R1 orders for bladder scans every 4 hours and straight catheterization every shift. V5 said on 04/05/24, she had only straight catheterized R1 but in the past, she would do bladder scans. V5 said she was aware of R1 having urinary retention. V5 said if a resident with urinary retention does not receive bladder scans or straight catheterization, they could develop a UTI/urinary tract infection. V5 said all nurses should follow the bladder scan and straight catheterization orders as written. V5 said the bladder scan should have been done every four hours as ordered. On 04/17/24 at 11:19 AM V2 (Director of Nursing) said on 04/05/24 the nurse on the floor texted the on-call phone and said R1 was having chills and had a temp of 99.3. V2 said she had no knowledge of R1 having a history of urinary retention. V2 said she was made aware after R1 was admitted to the hospital of R1's order for bladder scans and to be straight catheterized when needed. V2 said since R1 had orders for bladder scans every four hours, the bladder scans and straight catheterization should have been done as ordered. V2 said if orders are not followed for bladder scans and straight catheterization, the outcome could be urinary retention, a rupture, and an infection. V2 said her expectation is for the nurses to follow physician orders. V2 said she knows that the bladder scans and straight catheterizations were not done as ordered and the resident had to be hospitalized . R1's Face Sheet included diagnoses of urinary tract infection, abnormalities of gait and mobility, Parkinson's, dysarthria and anarthria, adult failure to thrive, and low back pain. The facility's January 2024 Catheterization, Residual Use policy showed Documentation: the following information should be recorded in the resident's medical record; the date and time the procedure was performed, all assessment data obtained during the procedure, how the resident tolerated the procedure, the amount of residual urine obtained, the character of the residual urine obtained Reporting: notify the physician of the amount of the residual urine, if any, and if there are any abnormalities in the character of the urine

Based on observation, interview and record review the facility failed to identify the cause of an injury for one resident (R96). R96 sustained a [MEDICAL CONDITION] distal leg caused by trauma. The facility also failed to transfer one resident (R13) in a safe manner. R 96 and R13 are two of four residents reviewed for safe transfers in the sample of 20. The findings include: 1) On 10/23/2018 at 1 PM, R96 was observed lying in bed. R96 was confused. When V11 (Certified Nurse Aide) pulled back her covers, R96's lower right leg had an ace wrap from her foot up her leg. V11 stated she did not know what happened to her. V10, (R96's daughter) came to visit on 10/23/2018 at 12 PM. V10 said, My mother's leg got fractured; but no one knows how it happened. I believe someone injured my mother while she was being transferred using the lift. I have seen some of the certified nurse aides transfer her without using the lift, two aides on each side transferring her from bed to her chair. I tell them that's not the way you do it, but they said we can do it this way. I have seen other staff transfer with the lift, but don't support her feet. I was here one weekend and saw that my mother's leg was swollen and red and I told the nurse. She did the doppler and nothing was found. But an x-ray was done later and showed she had a fracture. V10 said she was told by the doctor treating R96's fracture that it was the result of an injury. V7 (nurse) taking care of R96 on 10/16/2018, was interviewed on 10/23/2018 at 2:30 PM. V7 said no one told her that R96 had a fall or incident. V7 stated, She's bed bound unless we get her out of bed. She's not bearing weight. If she did not get hurt during a transfer with the lift, what could it be? V7 stated the staff received training using the lift after R96 was injured. The nurse practitioner (V4) was interviewed on 10/25/2018 at 12:30 PM. V4 said she was called the weekend R96 had bruising and swelling. V4 gave the order for R96's x ray and transfer to the hospital. V4 stated, I have no idea how that happened (R96's fracture). I was told (R96) had bruising, redness and swelling . The bruising to me indicated it could be from an injury . I thought (R96) had an injury . V8, V9 and V6 (certified nurse's aides) that work on R96's unit, were interviewed on 10/24/2018. They gave the following statements: At 1:30 PM, V8 said, there was training given after R96 was injured. At 1:25 PM V9 stated, I had training on how to use the mechanical lifts last week after R96 broke (R96's) foot. At 1:20 PM V6 (restorative CNA) said, We did the training last week. There were 2 different sessions. We did it because R96 broke (R96's) foot. I retrained the CNA's. V5 is one of the nurses working on R96's unit. V5 was interviewed on 10/24/2018 at 1 PM. V5 stated, They told us all to do the lift training right after R96 fractured her foot. V2, DON (Director of Nursing) was interviewed on 10/25/2018 at 2:46 PM. V2 said, My conclusion was that R96's injury was caused by her severe osteopenia. V2 could not identify or explain what diagnostic assessment was done to support that R96's fracture was due to severe osteopenia. Then V2 said, R96's fracture could have happened when she was transferred by staff using the full body mechanical lift. The aides get R96 up every day to her chair and her fracture could have happened during a transfer. Staff was given an in-service and training on proper use of mechanical lifts after R96 was injured. R96's Face Sheet showed R96 was admitted to the facility on [DATE]. R96 had [DIAGNOSES REDACTED]. The same clinical record did not indicate that R96 has osteopenia. R96's Minimum Data Set, dated dated dated (MONTH) 28, (YEAR) documents R96 with severe cognitive impairments and requiring extensive assistance of 2 staff for transfers. R96's care plan, dated 10/12/2018, shows R96 has a self-care deficit requiring extensive assistance for transfers using a mechanical lift. On (MONTH) 25, (YEAR) at 10:02am, V2 (Director of Nursing) stated 2 staff persons are required to transfer R96 with a mechanical lift. Review of R96's Investigation into her Injury of Unknown Origin, date 10/16/2018, showed the following: R96 noted on Monday (MONTH) 15, (YEAR) to have some redness and swelling to R96's right lower extremity by nurse. RN had called nurse practitioner and asked for Doppler studies bilaterally as well as x-ray of (R96's) right lower extremity. After x-ray report came back, it was noted that patient had a comminuted [MEDICAL CONDITION] malleolus and an un-displaced [MEDICATION NAME] end of the tibia . How Was Situation Handled: .In-services completed on unit today for transfers using the . (mechanical) lift with all employees working currently with this patient (R96) . R96's Radiology Report, dated, 10/15/2018, showed: Radiographic examination of the right ankle demonstrates comminuted fractures of lateral malleolus and undisplaced [MEDICATION NAME] fracture of distal end of tibia. There is soft tissue swelling around right ankle. The U.S. National Library of Medicine MedlinePlus.gov Website showed: A comminuted fracture is one which the bone has been fractured into two or more fragments. It makes reference that this type of fracture takes a lot of force for someone to get. A car accident or serious fall can cause this type of injury. 2) 10/23/18 at 2:07 PM R13 sat in a high back reclining wheelchair. V12 and V13 (Nursing Assistants) placed the mechanical lift sling under R13 and lifted R13 from the wheelchair to the bed. During this transfer the back of the sling was resting across R13's lumbar area and R13's bottom was hanging down and not supported by the sling. V13 stated it is difficult to place the sling correctly under R13 while R13 is in the reclining wheelchair. V12 stated the bottom part of the sling should have been under R13's bottom to support R13 during the transfer for safety. R13's Minimum Data Set, dated dated dated (MONTH) 4, (YEAR) documents R13 requiring the extensive assistance of 2 staff for all transfers. R13's Care Plan for Falls dated (MONTH) 23, (YEAR) documents R13 requiring use of the mechanical lift for transfers.

Based on interview and record review the facility failed to complete initial and weekly wound assessments and failed to identify deterioration, dehiscence and infection of a post-surgical wound. This applies to 1 of 4 residents (R1) reviewed for surgical wounds in a sample of 4. This failure resulted in R1's surgical wound deteriorating and developing a post-operative infection requiring surgery and a wound vac placement. Findings include: R1's hospital Discharge Instructions dated (MONTH) 18, (YEAR) document R1 being discharged to the facility for after care of a femoral-popliteal bypass surgery. Instructions include to notify Cardiovascular Surgeon (V6) of incision redness, swelling, drainage or foul smell and to paint right groin incision with [MEDICATION NAME] twice per day and cover with a dressing. R1's Admission Skin Evaluation Report dated (MONTH) 18, (YEAR) documents R1 admitted to the facility with 27 staples to a groin incision measuring 7 centimeters (cm) by 0.1 cm. A picture of the right groin surgical incision dated (MONTH) 18, (YEAR) show staples intact and the incision closed. R1's (MONTH) (YEAR) Physician order [REDACTED]. R1's Departmental Note dated (MONTH) 29, (YEAR) as a late entry for (MONTH) 25, (YEAR) documents R1's incision was intact and staples in place Wound and Peri wound noted to not have a any staining from [MEDICATION NAME] as order to be applied twice daily by floor nursing .informed the nurses that the wound is to be painted with [MEDICATION NAME] twice daily per surgeon orders and to be monitored each shift . This is the only Departmental Nursing note between (MONTH) 19, (YEAR) and (MONTH) 28, (YEAR) documenting a wound assessment. A Daylight Assessment Note dated (MONTH) 23, (YEAR) documents the groin wound intact but no other wound characteristics and measurements were identified. There was no comprehensive wound assessments, weekly wound assessments or evidence in Departmental Notes (MONTH) 18, (YEAR) through (MONTH) 28, (YEAR) of a comprehensive wound assessment being completed initially or weekly in R1's clinical record. On (MONTH) 20, (YEAR) at 2:32pm, V2 (Director of Nursing) stated the procedure for monitoring and assessing wounds at the facility consists of an initial assessment by the admitting nurse, then the next working day a comprehensive wound assessment is completed initially then every week; these assessments document wound characteristics, measurements, and changes. V2 stated the facility does not have evidence R1's wound assessments being completed per the facility procedure. On (MONTH) 20, (YEAR) at 5:34pm, V6 (Cardiovascular Surgeon) stated, V6 completed a huge surgery for [REDACTED]. V6 stated R1 then reported back to V6's office on (MONTH) 28, (YEAR) and R1 was found to have an extensive wound infection, the wound had deteriorated and staples were sticking out all over. V6 stated, That being said, when (R1) came in it was not a wound that fell apart in 12 hours, it deteriorated over a few days. (R1's) staples were falling out and the wound was foul smelling. It should have been identified sooner. I do not think the people on the ground were observing (R1) closely. V6 continued stating R1's infection should have been identified sooner and the wound care team should have been monitoring. V6 stated, if it was identified sooner the outcome likely would have been better and the quicker it (infection and wound deterioration) was identified I may have been able to treat (R1) sooner and avoid surgery or at least a more limited surgery. (R1) required extensive surgery hours after admission due to infection because it was so bad. The hospital Discharge Report dated for R1's (MONTH) 28, (YEAR) admission documents pre-operative [DIAGNOSES REDACTED]. The procedure completed was a right groin incision and drainage, antibiotic irrigation and a wound vac placement. This report documents Discharge [DIAGNOSES REDACTED].

Based on observation, interview and record review, the facility failed to provide treatment and services to promote healing and prevent the worsening of R1's pressure injury on R1's coccyx. The facility also failed to consistently implement the plan of care to maintain head of bed at lowest elevation. This failure resulted in the worsening of R1's identified [DIAGNOSES REDACTED] (superficial reddening of the skin) on R1's coccyx to the development of necrotic area (Unstageable) wound on R1's coccyx. This applies to one of three (R1) residents reviewed for the development of pressure injury in the sample of 8 residents. The findings include: R1 is an [AGE] year old resident dependent on staff for all activities of daily living and R1's current wound rounds plan dated (MONTH) 27, (YEAR) showed to off load pressure. R1's skin care plan for skin care documented an intervention to maintain head of bed at lowest elevation. On (MONTH) 29, (YEAR) at 10:45 AM, R1 was noted sitting in an upright position in bed (at an 80 degree angle). R1 was noted to be sleeping. R6 (R1's roommate) stated, (R1) does not talk and has a sore on R1's buttocks from sitting for too long. No, they really do not take (R1) to the bathroom. They (staff) come and change R1's diaper. At 12:40 PM, R1 remained in the same position in bed (at 80 degree angle). At 3:01 PM, R1 was noted in bed sleeping, flat on R1's back. A wrinkled draw sheet and a towel underneath R1's lower back (buttocks and mid-thigh) were noted. V3 (Nurse) was asked to check R1 for incontinence. R1's disposable incontinence brief was noted to be saturated with urine and soiled with feces. R1's buttocks and wound dressing were smeared with feces. V9 (wound nurse) and V10 (wound nurse) described R1 as non-verbal, pleasant and cooperative with care. V9 and V10 also described R1 as dependent on staff with activities of living and needing staff to perform repositioning. On (MONTH) 30, (YEAR) at 1:49 PM, V1 (Administrator) explained that on (MONTH) 24, (YEAR), R1's Power of Attorney requested a meeting with (V1) and the ex-Director of Nursing to discuss the development and worsening of R1's pressure injuries. V1 said, R1's family presented pictures of R1's wounds (coccyx, and on the right and left toes.) They said R1's wound was caused by us (acquired in the facility) and R1's family wants to know what we are going to do about it. I told them that the wound care team will investigate it. R1 is a heavy wetter and sits in R1's chair for a long time and at night R1's excessively wet. According to the wound team when they are doing their rounds they always found R1 excessively wet. The problem is the night shift; they (staff) are not turning R1 enough or not changing R1 enough. I should have addressed this right away. On (MONTH) 29, (YEAR) and on (MONTH) 30, (YEAR), V9 and V10 (Wound Nurses) presented the wound rounds documentations (with pictures) and explained, On (MONTH) 5, (YEAR) the nurse noted an [DIAGNOSES REDACTED] (superficial reddening of the skin) on R1's coccyx but documented it as a Stage 2, then documented it as healed. This assessment was incorrect, it was not a Stage 2 yet it's just an [DIAGNOSES REDACTED]. On (MONTH) 13, (YEAR) (8 days after) when we were first notified by the floor nurse and this area was a Stage 2 already (measured at 2.0 cm X 2.0 cm X 0.2 cm). On (MONTH) 2, (YEAR) assessment the wound was covered with necrotic (black) area (Unstageable pressure injury, measured at 3.0 cm X 2.5 cm X 0.2 cm. On (MONTH) 29, (YEAR) R1's pressure injury on the coccyx was identified by V9 and V10 with 100% necrotic area measuring 3.0 cm length X 3.0 cm width X 1.20 cm depth. On (MONTH) 30, (YEAR) at 11:15 AM, via phone interview, V11 (Wound Doctor) stated, I was asked to evaluate R1 that has an Unstageable pressure area (on the sacro-coccygeal) due to necrosis. I probably saw R1 2-3 times only. Yes, this is pressure related because the wound was located on a bony area. R1 should not had been positioned in an 80 degree angle, because it would result in increased pressure on the wound. The area (coccyx) should have been off loaded to promote healing. My recommendation is to position R1 from side to side only when in bed. I do not have any recommendation regarding incontinence aside from keeping the area clean and dry.

Based on interviews and record review the facility failed to ensure that an anticonvulsant medication was administered as ordered by the physician. This applies to one of three residents (R1) reviewed for significant medication error. This failure resulted in R1 having a [MEDICAL CONDITION] episode on April 30, 2016 that required hospitalization . R1 missed 9 doses of the anticonvulsant medication ordered twice daily from April 25 through April 30, 2016. The findings include: R1 was originally admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. R1's quarterly MDS (minimum data set) dated April 7, 2016 showed a BIMS (Brief Interview for Mental Status) score of 03, indicating that the resident is severely impaired with cognition. The same MDS showed that R1 would require extensive assistance from the staff with most of her ADL's (activities of daily living). R1's incident report dated April 30, 2016 showed, Resident was admitted to the facility on [DATE]. Medication review noted that she missed 9 doses of [MEDICATION NAME]. The facility's final report to the State agency regarding potential medication variance dated, May 6, 2016 showed that on April 30, 2016, R1 was sent to the hospital as a result of a witnessed [MEDICAL CONDITION]. The hospital phoned with questions regarding R1's medication list. It was discovered at that time that there was a potential medication error. The same report showed, It was determined that there was an order given for [MEDICATION NAME] that had not been processed. The family and physician of R1 were notified by the facility. R1's departmental notes dated March 15, 2016 showed that at 5:10 AM, the resident was observed having [MEDICAL CONDITION] episode and became unresponsive. The facility called 911 and R1 was transported to the hospital emergency room . R1's hospital records for admitted [DATE] showed that the resident was admitted to the hospital for [MEDICAL CONDITION]. R1 returned to the facility on [DATE], with multiple medication orders which included an anticonvulsant medication, Levetiracetam liquid ([MEDICATION NAME]) 500 milligram per gastrostomy tube twice daily. R1's POS (physician order [REDACTED]. R1 was readmitted to the facility on [DATE] with multiple hospital discharge orders which included the anticonvulsant medication, Levetiracetam liquid ([MEDICATION NAME]) 500 milligram per gastrostomy tube twice daily. R1's physician order [REDACTED]. R1's departmental notes dated April 30, 2016 showed that at 5:35 AM, the head of R1's bed was lowered after the resident received a bolus gastrostomy tube feeding, As the head of bed was lowered resident screamed out and then her body began shaking, resident became unresponsive, white foam is noted from resident's mouth. The facility called 911 and R1 was transferred to the hospital emergency room . R1's hospital records (History and Physical) dated April 30, 2016 showed, Per my discussion with the daughter this morning, she had witnesses [MEDICAL CONDITION] at the nursing home, and she had frothing in the mouth and generalized body jerking; it was 1 episode. R1's hospital neurology consultation report dated May 1, 2016 showed under the history of present illness that the resident was not given her anti-[MEDICAL CONDITION] therapy medication for 9 doses. The same consultation report showed under impression, The patient has dementia and [MEDICAL CONDITION] disorder. There has been recurrence of [MEDICAL CONDITION] due to patient not getting the medication. In an interview held on May 12, 2016 at 12:12 PM, E3 (nurse) stated that on April 25, 2016 she was working as a unit manager and was helping E4 (nurse) readmit R1 to the unit. Per E3, Z1 (physician) was in the facility on April 25, 2016 and gave the order to her and to E4 to continue all orders from the hospital. According to E3, she told E4 that she will transcribe Z1's orders for R1 by placing the orders in the electronic system. E3 stated that she reviewed the hospital discharge orders, placed a check mark on the discharge orders to indicate that it was transcribed in the facility's electronic physician orders [REDACTED]. Per E3, during the time when she was transcribing R1's orders in the computer, she (E3) was called away from the computer at least three times to attend to other matters, since she was the unit manager. According to E3, she probably transcribed the orders on the electronic physician order [REDACTED]. In an interview held on May 12, 2016 at 12:50 PM, E4 stated that she was the assigned nurse to R1 when the resident was readmitted to the facility on [DATE]. E4 stated that during R1's readmission, she was extremely busy so, E3 volunteered to verify and transcribed the orders for R1. Per E4, she did not review or check R1's admission orders [REDACTED]. The facility's policy and procedure regarding medication reconciliation showed that, Upon admission to the facility, the admitting nurse will review the discharge orders including the medications from the sending organization. The nurse will compare the medication information the Hospital/ Home Health/ resident/ family provides with the medication order to identify and resolve discrepancies. Within three (3) hours of admission, the nurse assigned to the care of the patient will review admission orders [REDACTED]. Throughout care all MEDICATION ORDERS FOR [REDACTED]. R1's care plan initiated on April 25, 2016 shows that the resident has a potential for injury related to [MEDICAL CONDITION] activity. The goal and part of the approaches showed that the medication will be administered as ordered. In an interview held on May 16, 2016 at 11:30 AM, E2 (Director of Nursing) stated that after review of R1's medications it was noted that the resident missed 9 doses of her anticonvulsant medication from the day R1 was readmitted (April 25, 2016) to the facility until the day of discharge (April 30, 2016) to the hospital due to [MEDICAL CONDITION] activity.

Based interview and record review the facility failed to assess, monitor, protect and document findings for a Implanted Vascular Access Device. This resulted in R1 being hospitalized with bruising, swelling and pain. R1 had surgery to stop bleeding from blood vessels torn at the site of the device. This applied to one resident (R1) out of three reviewed for resident injury, neglect and transfers. The findings include: R1 was admitted to the facility November 11, 2009 and readmitted on [DATE] per the admission face sheet. The current Physician order [REDACTED]. R1's admission assessment dated [DATE] showed R1 had an implanted port on the left side of the chest. The assessment showed the port was accessed and dressing changed on August 31, 2015. The nursing note dated September 2, 2015 showed R1 had a port on the left side of the chest that was accessed and changed on August 31, 2015. The note lacks any description of the site or how it is accessed. The note does not show if the access was working and had a blood return. The Physician order [REDACTED]. The Physician also ordered for the dressing of the access device to be changed every Sunday. The care plan in R1's clinical record showed the staff were to measure intake and output for the duration of fluids. The staff were to administer Intravenous medications as ordered, protect the access device from injury, monitor the insertion access site, change the dressing to the insertion site as ordered and to change Intravenous tubing as directed. R1's clinical record lacked a Medication Administration Record [REDACTED]. R1's clinical record lacked consistent documentation of the site or its use. A nursing note dated September 3, 2015 at 6:37 AM, 10:58 AM showed the access was used and remained intact. The next note describing the use of the access was on September 9, 2015 at 1:15 AM. The note does not mention the site only the use of the device. There was no document showing the use of the device or an assessment of the site. The clinical record had no documentation to show a dressing/needle change was done. An incident report September 10, 2015 showed the facility received a call from R1's daughter while at an appointment with the Physician. R1's family told the facility R1 was being admitted to the hospital for a bruise on her left breast and chest. The report showed staff interviewed was able to use the port on September 9, 2015 during the 2:00 to 10:30 PM shift. R13 Registered Nurse reported the device was used and there was a positive blood return. On November 12, 2015 at 1:00 PM Z1 Medical Doctor stated R1 came to his office from the nursing home with a large bruise and swelling on the left breast and chest. Z1 said blood vessels were torn and caused bleeding into the lower chest and breast area. Z1 said the area was very painful for R1. Records from the community hospital showed attending notes by Z2 an assessment that, The blood was probably leaking from the trauma related to the manipulation of the access device that happened when R1 was pulled. The note also describes R1 as having severe tenderness to the area. On November 10, 2015 at 2:36 PM E11 CNA (Certified Nursing Assistant) said R1 did complain of pain to her arm. E11 pointed to the left side and said that was the side the arm was hurting. E11 cared for R1 on September 9, 2015 on the afternoon shift. On November 10, 2015 at 2:47 PM, E12 CNA said via telephone that care was provided to R1 on September 10, 2015 in the morning. R1 had so much pain in her arm I could not finish dressing R1. I went and got E17 registered nurse. On November 12, 2015 at 11:45 PM E9 LPN (Licensed Practical Nurse) said on September 8 R1 complained of pain to the left arm. E9 gave R1 pain medication. E9 said there was no bruise at that time. E9 stated, The resident told me the arm was hurting from the aides lifting her under the arms. There is no documentation of any assessments for these complaints made by R1 in R1's clinical record. Care plans for Intravenous Therapy in R1's clinical record dated September 2, 2015 showed the staff were to monitor the insertion access site and protect from injury.

Based on observation, interview and record review the facility, failed to evaluate/assess the cause of new onset pain and failed to develop and implement interventions to provide treatment in a timely manner for 1 of 3 sampled residents. This resulted in (R1) experiencing acute pain and fractured left ankle that was untreated for [REDACTED]. The findings include: R1 was admitted to the facility on [DATE]. R1 has multiple [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) comprehensive assessment for R1, dated June 24, 2015 was reviewed on September 23, 2015. R1 was assessed by the facility to be cognitively aware with a BIMS (brief interview of mental status) score of 11/15. R1 requires extensive assistance in all areas of activities of daily living. R1 has a physicians order for 50% weight bearing on the right lower extremity. R1 was assessed to be full weight bearing on the left leg and require a mechanical lift for transfers on August 29. 2015. R1 sustained a [MEDICAL CONDITION] ankle prior to admission. E10 (physical therapy assistant) and E11 (director of physical therapy) were interviewed on September 22, 2015 at 2PM. E10 was asked to review his daily therapy note for September 11, 2015 and written statement September 15, 2015. E10 stated R1 was brought to therapy on September 11, 2015. The note read R1 cried out in pain when the left ankle was tender to touch, swelling in the lateral maleous, resident stated someone dropped something on her ankle during the transfer from bed to chair. E10 said R1 attempted to perform a few exercises unsuccessfully. E10 said he reported this to E11. E11 said E10 did report this to her and she instructed E10 to report this to the nurse. E10 stated returning R1 to the unit and reported to E6 (nurse), about R1's new complaints of pain in the left ankle and left leg, unable to participate in routine therapy exercises and R1 said someone dropped something on her foot during a transfer. E10 stated suggesting to E6 and x-ray of the left ankle before more therapy was done on the left extremity. E10 was asked if this was new pain. E10 said yes, R1 prior to this date was able to perform the routine activities. A review of the daily therapy note from September 7, 2015 to September 10, 2015 show R1 was able to participate in the routine exercises without complaints of pain. R1 had not complained before said E10. E10 stated R1's pain was in the left ankle and lower leg. E10 stated R1 was unable to participate in routine physical therapy exercises. E6 was interviewed on September 22, 2015 ay 9:45 AM. E6 was asked if E10 reported R1's complaints of pain in the left ankle and the inability to perform the routine therapy exercises on September 11, 2015. E6 stated yes to both questions. E6 denied E10 suggesting an x-ray of R1's left leg and ankle. E6 was asked if Z2 (primary care physician) of R1 was notified on this day of the new pain and decreased ability to participate in physical therapy exercises due to increased pain. E6 stated, no she did not notify Z2. E6 stated R1 was given a pain pill for the pain. E6 was asked if R1's left ankle and left leg were evaluated or assessed. E6 stated, I did not take off R1's sock . The nurse ' s progress notes were reviewed for September 11, 2015 for the 6AM to 2:30 PM time frame. There were no notations documented for that time frame for R1's of complaints of pain or an assessment of the condition of the left ankle or left foot. R1's progress note dated September 18, 2015 (late entry) by E6 (nurse) describe the bruise found on September 14, 2015 was 4 cm X 4 Cm purplish/blue bruise on R1's left ankle area with a 1 1/2 inch length and 1 inch wide intermittent purplish/pink bruising going up calf. E5 (wound care nurse) stated on September 23, 2015 while conducting a weekly skin assessment of R1's heels. R1 stated she found purplish/blue bruises and swelling of R1's left ankle and left leg. E5 stated R1 complained of pain and she notified E6 (charge nurse). E5 stated E6 was shown the bruises and swelling and E6 said she would notify Z2. R1 was observed on September 22, 2015 in bed. R1 was alert and oriented. R1 was asked to recall what caused her left ankle and leg pain and injury. R1 said two CNA's stood her and put her into bed without using the machine. R1 said they are suppose to use the machine to put me in bed and they did not. R1 stated not wanting to continue the interview and said she did not want to get anyone in trouble. E2 was asked why the facility did not notify Z2 on Friday September 11, 2015 when R1 complained of pain and swelling was observed by E10 in the left ankle and left leg, instead of three days later on Monday September 14. 2015. E2 stated. not knowing why, resident tells some stories or I guess the staff wanted to see if R1 would continue to complain of pain. An interview with E3 (certified nursing assistant) on September 23, 2015 was conducted in the facility's conference room via telephone. E3 said R1 told her on Friday September 10, 2015, that last night two CNA's (certified nursing assistants) put her to bed without using the lift machine and said her legs were twisted. E3 stated this would have been Thursday night September 10, 2015. E3 stated R1 complained of having pain in the ankle and lower foot when this happened. E3 said she reported this to E6 (nurse)after hearing this from R1. The facility's staffing schedule show, E3 and E6 work the 6 a.m. to 2:30 p.m. shift on September 11, 2015. A review of E2's (director of nurses) witness interviews dated September 14, 2015 show E3 gave a written statement which detailed R1's complaints of pain and two CNA's dragged her into bed without using the machine and E6 nurse was notified. On September 24, 2015 at 10:45 AM via telephone Z2 stated he was not notified on Friday September 11, 2015 by the facility regarding R1's complaint of new pain to the left foot/ankle and inability to participate in routine physical therapy exercises. Z2 stated on Monday September 14, 2015 the facility nurse called and reported R1 had bruises on the left ankle and pain. Z2 stated he ordered an x-ray of R1's left ankle. Z2 said the results were R1 had a spiral fracture involving the left fibula. Z2 stated he gave orders for the facility to transfer R1 to the emergency room for evaluation and treatment Z2 on September 24, 2015 at 10:45 AM, was told R1 began to complain of pain in the left ankle on Friday September 11, 2011 when in physical therapy. E10's (physical therapy note dated September 11, 2015 was read to Z2, c/o (complained) of pain in left ankle today rated 7/10 cried out in pain when ankle was touched .noted swelling in lateral maleous. Z2 stated he was not notified or made aware of R1's physical condition. A review on September 22, 2015 of E2's left ankle and leg x-ray report conducted in the emergency roiagnom on [DATE], show an obliquely oriented nondisplaced fracture involving the distal left fibula with slight cortical irregularity along the medial malleolus raising concern for a nondisplaced fracture in this region.

Based on record review and interview the facility failed to develop and implement policy and procedures in the care and treatment of [REDACTED]. This failure contributed to R1 developing a worsening, non-healing surgical wound. The findings include: Review of readmitting nursing note dated 9/2/14 (original admit of 8/22/14) states R1 is a [AGE] year old admitted with history of CABG (coronary artery bypass graft). Per admission skin evaluation dated 8/22/14 R1 is noted to have surgical wounds to mid chest, 2 small abdominal incisions and left upper and lower inner thigh. A nurse ' s note dated 8/26/14 states the CABG was performed 8/20/14. R1's readmitting POS (physician order [REDACTED]. Cover with dry dressing. Change daily and prn(as needed)." E5 (nurse) stated on 10/15/14 at 2:05pm that she had been caring for R1 for several weeks and began noticing his left upper thigh wound was not healing and was in fact, getting worse. E5 said there was no baseline assessment of the wound other than it had steristrips. These steri strips fell off and the wound became circular, instead of incisional, about the size of a quarter with about 80% slough, said E5. When asked if this worsening progression was documented in the medical record, E5 stated they do not chart on surgical wounds. E5 said she did notify the wound nurse (E4) on 9/23/14 who said it was ok to get the order changed to Santyl. However there is no nursing documentation regarding why this change was necessary. E5 said that she discharged R1 on 10/3/14 after showing R1's family member how to change the dressing but did not give any supplies to go home with other than the santyl ointment. E5 said she entered a 'late entry' of R1's wound description 8 days after discharge. A non-pressure wound report was provided to the survey team at 10:45am on 10-15-14 and R1 was not included in the list of residents with non-pressure wounds. E4 stated at 11:40am that when a patient comes in with normal surgical wounds, steri-strips or staples, the wound team does not follow them. The staff nurses change the dressings daily and that's why they are not placed on the non-pressure wound report. E4 went on to add that the admitting nursing assessment of R1 does not contain a description of the wound, and E4 stated the facility does not have policies and procedures for assessing, monitoring and documenting non-pressure wounds. The policy and procedure for pressure sores is applied to the management of other facility wounds. The pressure ulcer treatment policy (draft of 3/18/13) documents, " Residents with pressure ulcers will have appropriate assessments, interventions and evaluation of treatment implemented." The procedure for Pressure Ulcer Assessment and Evaluation (page 3) documents, " that daily monitoring will be performed and documented, including the presence of possible complications." This policy continues to add that the pressure ulcers should be evaluated at least weekly and the evaluation documented in the clinical record. This includes: Location, size, description of wound bed and type of tissue and description of tissue the surrounding wound. E4 confirmed that this had not been done to R1's worsening left upper thigh post surgical wound. Nor was it done or documented upon discharge on 10/3/14. Admitting nursing skin evaluation form dated 8/22/14 shows a body diagram and identifies R1 with 5 wound sites. The narrative assessment grid lists all 5 locations as incision wounds but only documents the measurements of 2 of the wounds (small mid abdominal incisions). The mid chest and 2 left thigh incisions are not measured and only state there is no drainage. E4 stated that surgical wounds are not monitored or evaluated and charted on unless there is a negative development. E4 was unable to provide documented descriptive assessment of R1's left thigh wound from the original admitted (8/22/14) until date of discharge 10/3/14. E4 confirmed there was no care plan specific to R1's surgical wounds.

Based on observation, interview and record review, the facility failed to identify new pressure ulcers, obtain orders for care and treatment of [REDACTED]. This failure resulted in R3 developing new wounds while in the facility without physician notification and also resulted in wounds deteriorating without changes in care. Findings include: 1). R3 was an [AGE] year old female admitted to the facility on [DATE]. Her medical records documented the following Diagnoses: [REDACTED]. R3's admission assessment documented she was admitted with one pressure ulcer on her left buttock. Her medical record showed she acquired other pressure ulcers in the facility. R3's Wound Care sheets documented the following pressure ulcers and assessment dates: 8/8/14 Left buttocks, slough 80%; 8/22/14 coccyx 100% slough; 8/22/14 Right buttock 60% slough R3's Medicare nursing notes for 8/22/14- 9/7/14 document: Integumentary- Dressing to coccyx present and intact; some included -no new skin issue. Her Medicare nursing documentation on 9/7/14 documented " intact " . The development of 2 pressure ulcers was not reflected in the documentation. R3's care plan for pressure ulcers documented: See POS and TAR for current orders. R3's POS (physician's orders [REDACTED]. There were no orders noted in R3 ' s medical record for the acquired coccyx and right buttock wounds. R3's TAR (Treatment Administration Record) contained no documentation of treatments being performed on her coccyx or right buttock. R3's coccyx wound measured (8/22/14) 1.10 X 0.7; area 0.77cmSQ and (9/5/14) the wound increased to 1.9 X 1.7, area 3/23 cmSQ with no treatment orders. R3's right buttock pressure ulcer measured (8/22/14) 1.10 X 2.00, area 2.20cmSQ and (9/5/14) 2.00 X 1.70 X unknown, area 3.40cmSQ with no treatment orders. On 10/2/14 at 11:45am, E4 (Wound Care Nurse) stated that R3 was admitted with one wound to her left buttock. E4 stated on admission, the pressure ulcer contained slough, but she didn't know what color, because it wasn't documented. E4 stated " I would say yellow. " E4 added the treatment order on 8/7/14 was for Santyl ([MEDICATION NAME] agent). E4 stated R3's pressure ulcer was unstageable with 100% slough, but she changed the order to a [MEDICATION NAME] dressing. E4 added the facility's policy for pressure ulcers is to turn and reposition the resident every 2 hours. E4 also stated that if the resident is in a wheel chair (w/c) the policy is to reposition them as frequent as possible, every 1-2 hours. E4 was presented with the wound sheets identifying the coccyx and right buttock ulcers and asked to present physician's orders [REDACTED]. It was just written for left buttock as far as I can tell. Even into the next month, it still says left buttock. " When asked why there weren't orders for the 2 acquired wounds, E4 stated the facility placed a [MEDICATION NAME] dressing on all the wounds. Although there was documented slough tissue in the wounds, E4 stated " we wanted to keep the same treatment for [REDACTED]. R3's assessment sheet for the right buttock ulcer documents: probable decline, E4 stated the wound was identified with 60% slough and unstageable. E4 stated there were no orders " the only thing is left buttocks. " On 8/28/14, the right buttock wound sheet documented no improvement. When asked about treatment orders, E4 stated, " It's still the same. " On 9/5/14 the assessment sheet documented the wound had increased in area size. E4 also stated there were no written orders for the coccyx wound that R3 acquired. On 10/6/14 at 9:50am, E6 (Nurse) stated R3 had pressure ulcers on her coccyx area and both buttocks. E6 stated treatments for the pressure ulcers would be documented in the Medicare nursing notes and on the TAR. When asked to present such documentation. E6 stated the treatments for R3's coccyx and right buttocks are not documented on her TAR. E6 then checked the computerized TARs and stated " I don ' t see it in here. " R3's MDS (Minimum Data Set) Assessment 8-14-14 codes R3 as having only one unstabable ulcer due to slough. R3's care plan dated 8-7-14 and updated 8-22-14 in Skin Integrity documents under approaches to: "Assess and document length, width and depth in centimeters; presence of tunneling or undermining, tissue type, drainage, odor, pain, wound margins" and "Daily skin checks with care and record" and "notify the physician if no progress." The CNA Daily check sheet for R3 is coded as "0" (meaning no skin issues) for August 7 to August 14 when R3 had been admitted to the facility with a skin issue. Additionally when R3 developed new skin issues in the facility, the daily skin sheet continued to document "1" (meaning skin issue present but not new.) On 10/6/14 Z1 (Physician) stated the facility used to send weekly reports of notification of pressure ulcers. Z1 stated, " When it gets to the point that it's getting worse or out of hand, they give us a call. " Z1 stated he did not receive a call that R3 developed or had worsening wounds in the facility. Z1 stated if the facility had informed him of such he or Z2 (Nurse Practitioner) would've looked at R3's wounds. A review of Z2's progress notes dated 8-27-14 and 9-2-14 for R3 do not address any of R3's wound nor the development of new wounds. 2). R4 is an [AGE] year old female whose medical record documents the following Diagnoses: [REDACTED]. R4's Wound care sheets document she was admitted with a Stage 2 pressure ulcer on her coccyx. The report documents the measurements as 5.9 X 5.0 X 0 with light serous drainage. Her treatment order documented [MEDICATION NAME] dressing two times a week and as needed. R4's wound care report dated 9/25/14 documents the wound is 5.9 X 5.0X 0 and beefy red - pale pink in color. However, the picture of the wound showed the center was purple and consistent with deep tissue injury (DTI). The report continues to document drainage from the wound. The documentation did not mention the purple area or interventions thereof. On 10/1/14 the wound now measured 10.2 X 6.00 X unknown. The facility now ordered [MEDICATION NAME] and [MEDICATION NAME]. The wound sheet documented 90% necrotic tissue. On 10/2/14 visualization of R4 wound showed large amount of brown soft necrotic tissue. On 10/2/14, between 9:00- 11:00am, R4 was sitting in her wheel chair. E7 (Certified Nursing Assistant/CNA) stated R4 had been sitting in the chair since 8:00am. R4 was noted in the same position without relief at random intervals. On 10/6/14, R4 was sitting at the nursing station in her chair between 9:00am -12:00pm. R4 was in the same position at various intervals. When asked how long she had been sitting in the chair, E8 (CNA) stated since 7:00am. 10/2/14 at 1:10pm, E9 (Wound RN) stated she wrote the order for R4 to have a [MEDICATION NAME] dressing two times a week. E9 looked at the photo with the purple discoloration and stated " I see the purple here; yes it appears to be deteriorating. " E9 stated, "The only thing we could do for DTI is remove the pressure. " E9 was asked to present documentation on the assessment of the DTI and the decision to keep the current intervention. E9 looked through R4's medical records and did not find documentation on the decline. E9 stated that she faxed a copy of the report to Z3 (Medical Doctor) but did not speak to him about R4 ' s wound. R4's medical record documents an order for [REDACTED]. On 10/6/14 Z3 (Medical Doctor) stated he relies on the wound care nurse to implement treatment orders. Z3 stated he received no call specifically stating R4 ' s wound had declined. Z3 stated it is not appropriate for a [MEDICATION NAME] dressing two times a week if a pressure ulcer has DTI and drainage. Z3 stated, " If it's declined, they can call me and I can refer her to a wound care doctor. If they are applying a dressing only two times a week and it's draining. That ' s not appropriate. " The facility ' s policy for pressure ulcers documents: Policy Statement-Residents with pressure ulcers will have appropriate assessments, interventions and evaluation of treatment implemented. The resident ' s Licensed independent Practitioner (LIP) will be notified of all pressure ulcers. A LIP order is required for all pressure ulcer treatments. Notification and licensed Independent Practitioner Orders- c. The licensed independent practitioner may request pressure ulcer treatment to follow the facility protocol for pressure ulcer treatment. Specific wound dressing orders will then be confirmed with the licensed independent practitioner based on characteristic of the wound. When a pressure ulcer is present, daily monitoring will be performed and documented. Monitoring includes: -An evaluation of the ulcer if no dressing is present -An evaluation of the status of the dressing, if present (whether it is intact and whether drainage, if present, is or is not leaking). -The status of the area surrounding the ulcer (that can be observed without removing the dressing). -The presence of possible complications, such as increasing area of ulceration or soft tissue infection Pressure ulcers should be evaluated at least weekly and the evaluation documented in the clinical record. Evaluation of pressure ulcers should include: -Location of pressure ulcer -Stage of ulcer -Presence of tunneling, sinus tract or undermining. -Description of tissue surrounding wound and wound edges

Based on Interview and Record Review the facility failed to: 1) Supervise/monitor one resident R2, during meal time, who had been assessed at high risk for aspiration/choking. 2) Have policies in place for Aspiration Precautions, Cardiopulmonary Resuscitation (CPR)and The Heimlich Maneuver. 3) Follow physician's orders [REDACTED]. This resulted in R2 choking while eating unsupervised and becoming non-responsive in the facility. R2 was taken to the community hospital and expired 9 days later. As a result of these failures an Immediate Jeopardy was identified on [DATE]. The facility was informed of the Immediate Jeopardy on [DATE] at 2:10 PM. The Immediate Jeopardy began on [DATE] during the evening meal when R2 was left alone unsupervised to eat the meal. While the immediacy was removed on [DATE], the facility remains out of compliance at Severity Level 2. Additional time is needed to monitor and evaluate the effectiveness of the implementation of policies and procedures. Findings include: The clinical record indicated that R2 was admitted to the facility with [DIAGNOSES REDACTED]. R2 was assessed on [DATE] by Speech Therapy per note in R2's clinical record as being at "risk for choking, aspiration, dehydration, and malnutrition". R2 had one episode of "suspected aspiration", during medication pass that was documented on [DATE] in the speech therapy note. Speech therapy was working with R2 to change R2's diet from nothing by mouth with tube feeding, to puree, and then finally to mechanical soft. On [DATE], R2 was discharged from Speech Therapy. On the discharge document from Speech Therapy for this date, under skilled therapy techniques it is documented; swallowing: Compensatory swallow techniques, Aspiration Precautions, Multiple swallow, Cues to throat clear/cough, Cues verbal/visual/tactile. The Assessment for this date does not document an assessment for R2 to eat alone in a room unsupervised. A review of the facility's Minimum Data Set for R2, dated [DATE] scored eating at a two which would required R2 needing assistance with meals. A review of nursing notes dated [DATE] documented that E7(Restorative Nurse) said, "R2 is able to feed herself with verbal cues although at times she requires staff assist to get started eating." During a phone interview on [DATE] at 10:15 AM, Z4 (R2's family member) stated, "I always had to cut up her food. R2 was supposed to have help with eating. " During a phone interview on [DATE] at 10:00 AM, E5 (Certified Nursing Assistant) stated, "I brought her tray in around 5:10 PM and she said the food did not look good. I cut up her food and brussel sprouts. I left the room. She ate alone by herself sometimes. I did not see her until after 5:40 PM when she was non-responsive." On [DATE] at 2:40 PM E6 (Registered Nurse) stated, "I saw R2 about 5:00 PM before the dinner tray came. I then went back to the room about 5:35 PM and saw that R2 was not responsive. I checked her mouth and did a finger sweep. I thought she choked. I called 911 right away. R2 was a full code. I did not give a rescue breaths. E3 (Director of Nursing) came up right away." The staffing schedule for [DATE] and confirmed by E6 indicated that there was no other staff on the unit. There were only 11 to14 residents. This left R2 alone unsupervised for approximately 25 minutes while eating dinner. On [DATE] at 12:38 PM, E3 stated, "We have no documentation of what we did during the emergency. We do not have any policies for Cardiopulmonary Resuscitation or the Heimlich maneuver." During a phone interview on [DATE] at 1:56 PM, Z3 (R2's Attending Physician) said, "I do not recall looking at records indicating that R2 was safe to eat by herself. If I wrote an order for [REDACTED]. I do not recall if I was told that R2 was eating meals alone in her room without supervision." Review of R2's clinical record reflected a physician order [REDACTED]. The Community Fire Department Ambulance Service, documented that on [DATE] at 6:06 PM under assessments, "Airway Partially Obstructed-Foreign Body." The local hospital emergency room History and Physical Report, documented by Z2 (community hospital physician), under "Chief complaint: Respiratory failure and Choking in Nursing home." The community hospital record showed that R2 never recovered and expired 9 days later. The removal plan was accepted on [DATE] at 1:45pm. Surveyor confirmed that the facility took the following actions to remove the Immediate Jeopardy: A) On [DATE] at 2:10 PM the facility sent a letter documenting that they inserviced staff on in room patient dining safely, and Aspiration Precautions Guidelines. The facility also included a new assessment tool for safety to eat unsupervised as well as a new assessment tool for the resorative nurse for people with swallowing disorders and are on Aspiration Precautions. B.) On [DATE] at 1:00 PM employee records for the inservice with the employee signature and date were recieved in the office. C.) On [DATE] at 8:30 AM, the only residents eating in their room were alert and oriented times three. They were not on Aspiration Precautions or diagnosed with [REDACTED]. D.) Several staff were able to verbalize the new dining plan and the policy for Aspiration Precautions. Residents who are not oriented will not be allowed to eat unsupervised as well as residents with swallowing disorders or Aspiration Precations. On [DATE] at 2:17 pm additional documents were recieved from the facility. These include: A policy for documentation for major events. A sign in sheet attached of staff that attended. Policy outlining procedures nursing staff is to follow when providing CardioPulmonary Resuscitation.

Based on record review, interview and observation facility failed to : - assess and monitor an allergic adverse reaction to a medication and notify the physician in a timely manner for 1 of 24 sampled residents (R16). This failure resulted in the resident experiencing a localized reaction for an extended period of time (7/05 - 8/31/11), without medical intervention. - follow facility policy and procedures for assessment, care and maintenance of Peripherally Inserted Central Catheters (PICC lines), for two of three residents in facility with PICC lines (R2 and R17). - clarify PICC line flush orders with the physician for amount and frequency as included in PICC line policy and procedure Findings include; 1) R16 is an [AGE] year old totally dependent, non-verbal resident that was admitted to facility on 3/14/11. R16 has been on [MEDICATION NAME]-[MEDICATION NAME]es to reduce oral secretions since prior to 4/06/11. On 8/31/11 at 12PM R16 was observed with a red rash to area around and under both ears. There was a [MEDICATION NAME] dated 8/31/11 under the left ear and one patch dated 8/31/11 behind the right ear. R16's husband and E10 (nurse), both told surveyor the red rash is from the [MEDICATION NAME]es. E10 said she was not aware if the physician is aware of the rash. On 8/31/11 E10 notified R16's physician of these rashes from the [MEDICATION NAME]es. R16's physician initially ordered to change the application site but the pharmacy told E10 this patch can only be applied behind the ears. On 8/31/11 E10 told the surveyor the pharmacy recommended the [MEDICATION NAME] be discontinued and replaced with [MEDICATION NAME] ophthalmic solution sub-lingually to reduce oral secretions. R16's 8/31/11 physician order [REDACTED]. The facility took pictures of the rashes on 9/02/11 (the 3rd day after patches discontinued and [MEDICATION NAME] cream initiated) and the area was still discolored with slight redness. R16's 7/05/11 nurses note included "area behind ears with redness from Scop. patches; MD informed". No other nurses note about the rash between 7/06 - 8/30/11. 2) Facility has 3 current residents with PICC lines including R2 and R17. Facility"s PICC line policy and procedure includes: "When a patient/resident is transferred with a PICC/Midline catheter, the following information shall be obtained, if possible and kept in the clinical record. - Type of catheter -tip placement - the total length placed inside the resident and how much is outside. - placement verified with X-Ray. - date, time and person who inserted the catheter." " Residents transferring to the ministry with an existing PICC line must have a recent X-Ray to confirm correct placement prior to use. If there is no recent X-Ray confirming placement, the ministry shall contact the transferring facility for a copy of the X-Ray and if not available, an X-Ray for placement will be completed prior to using. Dwell times for a PICC line : 1 year and for Midline: 4 weeks. Under procedure section of protocol : "D. Measure and record upper arm circumference every 7 days. 1. Measure 4 inches above catheter insertion site. 2. Notify the physician if arm measurement has increased by greater than 2cm. E. No blood pressures or venipunctures in the PICC/Midline arm. G. Assess for redness, swelling, drainage, tenderness at the insertion site; redness, swelling, warmth, tenderness along the catheter direction or catheter migration. H. Document the condition of the site, condition of the catheter, external length, any special measures taken and tolerance of any procedure." The protocol also includes port flushing directions which differ based on the type of catheter (open ended or closed ended ). The directions also include that only a registered nurse (RN), may flush a open ended where as a Intravenous (IV), certified licensed practical nurse (LPN), may flush a close ended catheter. The protocol is directive on when, how and what to use to flush and the amount and type of solution to use for flushing. R2's physician (MD), orders for PICC line flush : "Flush PICC with 10cc saline every shift." R17's 8/18 - 8/31/11 MD orders for PICC line flush: "Flush PICC every shift and with every antibiotic infusion." On 8/31/11 E11 (medicare unit manager/ nurse ), stated she was unaware of how much saline to use to flush PICC line or exactly when. E11 said she believed PICC line dressing changes are done every three days and as needed and PICC lines are to be flushed with 5cc saline after each antibiotic infusion. On 8/31/11 E11 and E12 (nurse), the told surveyor they were unsure if arm circumferences and external PICC line catheter lengths were assessed or not. Facility"s PICC line protocol also includes : III. Dressing change: B. First dressing change is completed 24 hours post insertion, then every 7 days and as needed (PRN), if dressing becomes compromised or if dressing becomes no longer occlusive. "G. Document condition of insertion site, amount of external catheter (from insertion site to tubing) and tolerance to the dressing change. **If the amount of external catheter is greater than is charted at insertion, notify the physician." R2 was readmitted to facility 7/30/11 with a PICC line. R2's 7/31/11 Admission Assessment section h. includes "right PICC line intact." R17 was admitted [DATE] with a PICC line. R17's Admission Assessment section h. includes "right arm PICC line single lumin." The admission assessment directs nurses to describe location / length of catheter in text if PICC line is present. R2 and R17's admission nursing assessment, nurses notes and medication administration records (MAR's) did not include PICC line assessments as per facility PICC line policy and procedure. There are no assessments of arm circumferences, external catheter length measurements, insertion date and insertion information as per facility protocol. R2 and R17's medical records and care plans did not include the type of catheter, placement verification prior to the use of them, initial or periodic catheter length and site assessments as per above protocol direction. Care plans are not descriptive of care and maintenance of site and arm as per protocol. R17's care plan documents "N/A" under IV therapy section. Based on observation, record review and interview the facility failed to assess and identify an abscess on 1 of 24 sampled resident (R15) left ischial site until the abscess was opened, infected, and with slough tissue. As a result of this failure R15 remains with a deep left ischial wound with draining and undermining to the site. The finding includes: Review of the facility's wound report addressing wounds other than pressure wounds showed R15 had developed a wound at the facility to the left ischial tuberosity. Interview with E4 (RN- Wound Nurse) noted E4 to say, "The site was identified as an abscess on 6/28/11." It was opened, infected, and with slough tissue when it was first identified. Review of the Wound Assessment Details Report for R15 dated 6/28/11 showed a photo of R15's wound/abscess. The wound was opened, reddened, infected,draining, and with yellowish slough tissue. The peri wound site directly beneath the wound was reddened with maceration and induration. E4's documentation of the wound/abscess on 6/28/11 showed the site to be open,with 100% slough tissue, serosanguinous drainage with suspected infection. The site measured 1.30 cm x 1.50 cm x 0.30 cm. with no undermining and/or tunneling. The peri wound was documented with [DIAGNOSES REDACTED], maceration and induration. There was no measurement of the peri wound. Review of physician's orders [REDACTED]. On 9/1/11 at 2:05 p.m. E4 was observed performing treatment on E4's left ischial wound/abscess site with E9 (RN -wound nurse) present for standby assistance. When E4 removed the old dressing from E4's ischial site a large amount of sero-purulent drainage was noted. E4's ischial site was also packed with an Iodine packing. E4 cleaned and measured R15's ischial site. The site measured 1.0 cm x 1.2 cm x 3.2 cm. In comparison with the initial measurements on 6/28/11 the depth of the wound has increased from .30 cm to 3.2 cm. Tunneling was also noted to the wound/abscess site. E4 measured the tunneling of the wound. At the 12:00 site the tunneling measured 5.8 cm, at 3:00 the tunneling measured 2.0 cm, at 6:00 the tunneling measured 1.3 cm, and at 9:00 the tunneling measured 1.4 cm. After E4 measured the site, E4 packed the site with the Iodine gauze. During the packing of the site, R15 complained of pain and was observed jerking, twitching, and pulling away as E4 packed the site with the Iodine gauze. On 9/1/11 E4 and E2 (Director of Nurses) was questioned as to why R15's wound/abscess was not identified until it was opened, infected, and with slough. The responses from E4 and E2 was. "I don't know." A policy on skin checks for residents was also requested from E2 on 9/1/11. E2 stated, "We don't have a policy on skin checks but the CNA's are supposed to do skin checks daily."

Based on interview and record review, the facility failed to ensure accurate delivery of medication by giving the wrong medication, by not verifying the physician's orders [REDACTED]. This action resulted on a significant medication error. An immediate jeopardy was identified on 03/18/11 at 1AM. The immediate jeopardy was determined to have begun on 03/18/11 at 1AM. E4 failed to verify physician's orders [REDACTED]. The immediacy was removed on 03/18/11. This is a Past Noncompliance deficiency. Findings include: Record review showed that R2 is [AGE] year old and was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the POS [REDACTED]. IV (Intravenous) every 8 hours for 7 days and [MEDICATION NAME] 600 mg IV every 8 hours for 7 days. R2 had [MEDICAL CONDITION] infection in her stool. Nurses notes dated 03/18/11 reflect the following: 12:50 AM: Received a call from Stratford unit to notify writer E4 (Nurse) that resident IV medication had been delivered by the on call pharmacy. 1AM: Gemcitabine 1 gm was reconstituted and added to a 100ml 0.9 % NaCl bag and delivered to R2 via right arm PICC (Peripheral Intravenous Central Catheter) at 200ml/hr over 30 minutes. 1:40AM Also added at this time [MEDICATION NAME] 600 mg to a 100ml 0.9 NaCl bag and delivered to the resident via right arm PICC (Peripheral Inserted Central Catheter) at 200 ml/hr over 30 minutes. 4:50 AM Received a call from pharmacy stating S/S (Signs and Symptoms) and side effects of the medication that needed to be monitored with administration of the drug Gemcitabine as follows; hay fever, rash, [MEDICAL CONDITION], nausea and vomiting, dyspnea, pain, constipation and to follow up with physician in terms of any needed lab work. Physician on call notified with order for CBC (Complete Blood Count), CMP (Complete Metabolic Profile) Stat (Immediately) and follow up with primary physician. 7AM Also called the resident's spouse and made aware of the IV medication given, that the physician was already made aware and that the staff is monitoring the resident as indicated by pharmacy. Verbalized understanding. 10AM: Writer (E8 nurse) went into resident's room to give morning medications, upon arriving in resident's room daughter at bedside, resident observed weaker than previously, vitals taken (B/P 128/75, HR 72, Resp 20 , O2 sat 91 on 4 L of oxygen). Resident's mouth was open, some nectar thickened water given and she swallowed it, then resident informed that her medication was being given, upon putting a little bit of the medicines (all crushable medications crushed per order and mixed in apple sauce) in her mouth, resident didn't swallow, resident was encouraged to swallow for 10 minutes, some nectar thickened water was given but resident wouldn't swallow. Medication was scooped out of resident's mouth and oral care performed. 10:45: AM Upon arriving back in resident's room, observed slightly unresponsive but breathing, with thready pulse, responded to name after several call out. Nurse (E8 writer) immediately went to the nurses station, attending physician happened to be on the phone with another nurse, physician immediately notified. MD (Physician) communicated to writer to send resident to hospital. DON ( Director of Nursing) notified immediately. As writer was about to put through to 911, resident's son came out to the nurses station and said "I can't feel her pulse anymore, I think she is gone." Nurse (writer ) asked another RN on the unit to call 911, then immediately went into resident's room, resident observed not breathing, with very weak (almost undetectable) pulse. B/P (Blood Pressure) was undetectable. Resident's son (POA) communicated to writer in the room "She's a DNR ( Do Not Resuscitate), let her go, don't try to bring her back." 12:05 PM All vitals undetectable, fire and police department arrived, EKG readings by the police department revealed asystole. Review of R2's Incident report done by E4 (Nurse ) dated 03/18/11 is as follows: Narrative of injuries and Description of injuries, IV ( Intravenous ) [MEDICATION NAME] 1 gm was scheduled at 1 AM via right arm PICC (Peripheral Inserted Continuous Catheter). Shortly before IV was due to be given, writer received a call from Stratford unit enquiring if we have above resident on our unit and if we are expecting any IV medications. We responded & P/U ( Picked up ) the medication. Medication delivered by on call pharmacy was addressed to the resident & noted as Gemcitabine 1 gm x2 vials. Writer diluted 1 vial in 20 ml of 0.9 NaCl and mixed in a 100 ml bag and infused at 200 ml/hour. Immediate Actions taken: Received call shortly before 5AM from pharmacy & made aware of the S/S (signs/symptoms) to watch out for with the administration of Gemcitabine as follows, fever, rash. [MEDICAL CONDITION], pain, constipation and dyspnea. Z1 (on call physician) notified of medication given and received order for Stat (immediately) CBC ( Complete Blood Count ), CMP (Complete Metabolic Profile), repeat and follow with Z2 (attending physician) during office hours. R2 assesses frequently with V/S (Vital signs) noted WNL (Within Normal Limits). The spouse also called and notified of drug line of action being taken to care for the resident. When interviewed on 03/24/11 at 9:10 AM. E4 stated, "during shift change the PM nurse told me that (R2) has an IV antibiotic order and was due at 1 AM. The medication [MEDICATION NAME] is available at our EDK (Emergency Drug Kit). Shortly before it was due I was looking for an IV pole and my coworker on second floor said that I got a phone call from the unit downstairs to get the medication for the resident. CNA (Certified Nursing Assistant) gave the medication in a paper bag and I looked at the bag, has resident's name (R2) on it. I opened the bag and there were 2 bottles of medication Gemcitabine 1 Gm each bottle. I thought the pharmacy sent the medication because the order was 1 gm and the one we have at EDK is 2 gm. I assumed that was the trade name for [MEDICATION NAME]. I diluted the 1 bottle with 25 ml. NaCl then added to a 100 ml of 0.9 NaCl bag. I infused the mixed medication at 200ml. per hour at 1 AM for 30 minutes. [MEDICATION NAME] IV antibiotic taken from EDK was given after finishing the Gemcitabine. I took 600 mg from 900 mg diluted with 100ml. bag of 0.9 NaCl given 200 ml per hour over 30 minutes. After that I went ahead to do other job duties that night. I started passing medications at 4:30 AM and I was just coming out of R2's room around 4:50 AM that my coworker said that I have a phone call from pharmacy. I answered the phone, a lady from the pharmacy asked me if I gave the IV medication (to R2) that was sent last night. I told her yes because it was due at 1 AM. Pharmacy said, I am sorry to tell you that was not the correct medication. Explaining that it was hectic that night and overwhelmed. I told her I don't know what to do right now but I told her I will call the physician. I asked her what S/S or side effects to look for. After that I came out of the room and called physician. Physician ordered CBC, CMP Stat and follow up with Z2 . Called husband told him that this medication [MEDICATION NAME] is due and pharmacy sent Gemcitabine and was given. Pharmacy called back and told the side effects to watch for. E4 was asked why she did not check the medication. E4 said that "I don't know every time they sent medications it is always the right medication. I didn't go further because it says 1 gm exact dose from POS (Physician order [REDACTED]. " E5 (Nurse ) was interviewed on 03/28/11 at 3:55 PM by phone and stated "I was working on first floor Stratford unit. Around 12:00- 12:10 AM on 03/18/11 received a brown small bag from the hospital pharmacy. There was one vial of medication and pink receipt on it with PVF (facility initial). I opened the bag there was 1 gm vial of medication, unfamiliar medication so I called Cambridge unit to ask if they are waiting for an IV medication and the nurse (E6 ) answered the phone then passed the phone to (E4). (E4) said that she was waiting for an IV medication. I told (E4) the name of the medication (Gemcitabine) and spelled it out because I can't pronounce correctly, not familiar. (E4) said yes she is waiting for this medication. (E4) came down after 10 minutes and took the medication with the pink receipt. No other medications were delivered at that time. No resident's name and was not labeled." Z3 (Hospital Director of Pharmacy) was asked if there was a label for this medication. Z3 stated that there was no label because this medication (Gemcitabine) was not for this patient (R2). Technician gave the wrong bag to the driver and this bag is supposed to go to a different office. There was no name or label on the vials. Bag labeled with a physician's name. E4, E5 and Z3 have conflicting statements. Z2 ( Physician ) was also interviewed on 03/23/11 at 3:15 PM stated that he was informed by Z1 (on call physician) that the facility mistakenly gave a wrong medication. Z2 said that he got a call from a nurse in the late morning, 10 or 11, that R2 was not doing good, change of mental status. I ordered R2 transferred to the hospital immediately. Z2 was asked if giving the wrong medications could contribute to R2's death. Z2 replied "I don' t think so, (R2) is [AGE] years old and had multiple medical problems. It could be unfortunate coincidence." Picture copy of the box provided by the facility says Gemcitabine 1 gm Cytotoxic agent. To reconstitute: Add 25 ml of 0.9 % NaCl injection (without preservatives ) to make a solution containing 38 mg/ml. Shake to dissolve. Review of precautions and warnings with Gemcitabine showed that may potentially cause kidney damage or liver problems, decrease bone marrow ability to produce blood cells or cause lung damage. A history of low levels of white blood cells in the blood, any infection, kidney disease including kidney failure, liver disease and any allergies [REDACTED]. R2 has an infection and an allergy to medications like [MEDICATION NAME] and [MEDICATION NAME]. Review of time card log showed that E4 worked on 03/16/11 from 10:06 PM to 7:46 am the following day (03/17/11). E4 came back to the facility to worked on the same day from 2:08 PM to 10:51 AM. E4 worked a total hours of 30 hours and 23 minutes in a span of 36 hours and 43 minutes when the medication error occurred. Review of the facility's policy and procedures on medication administration showed: II. Medications are administered in accordance with written orders of the attending physician. If dose seems excessive considering the resident's age and condition, or a medication order seems to be unrelated to the resident's current [DIAGNOSES REDACTED]. XVI. Prior to administration, the medication and dosage schedule on the resident's MAR indicated [REDACTED]'s orders are checked for the correct dosage schedule. XXII Inspect [MEDICATION NAME] and/or intravenous solutions prior to their use. -Should it become necessary to add medication (s) to these solutions, it must be prescribed by the physician, administered by the same person administering the solution(s), and in consultation with the pharmacist. The facility staff did not follow above policy and procedure. E4 did not verify the medication was the right medication prior to administration. E2 Director of Nursing and E7 Assistant Administrator was informed of the immediate jeopardy on 04/13/11 at 9:40 AM. The facility took the following actions to remove the immediacy of the situation and completed the following correction by March 21, 2011. - Nursing staff received in service training on medication administration, verifying medications delivered, verifying medication labels, IV medication management, re-constitution of medication and general principles for preventing medication errors. -Nursing staff audited all Iv medications in the facility for residents receiving such medications to ensure that the medications that have been ordered for residents are the medications that were delivered by the pharmacy. - Facility contacted hospital pharmacy to advise of medication error due to the delivery labeling error. Hospital pharmacy acknowledge its error and indicated it would investigate its process regarding medication delivery labeling and how to prevent recurrence.

Based on record review and interview, the facility's pharmacy failed to ensure proper labeling, delivery and provision of medication according to professional principle on one out of three resident sampled (R2). This action resulted on a significant medication error. An immediate jeopardy was identified on 03/18/11 at 1AM. The immediate jeopardy was determined to have begun on 03/18/11 at 1AM. E4 failed to verify physician's orders [REDACTED]. The immediacy was removed on 03/18/11. This is a Past Noncompliance deficiency. Findings include: Record review showed that R2 is [AGE] year old and was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the POS [REDACTED]. IV (Intravenous) every 8 hours for 7 days and Cleocin 600 mg IV every 8 hours for 7 days. R2 had Clostridium difficile infection in her stool. Nurses notes dated 03/18/11 reflect the following: 12:50 AM: Received a call from Stratford unit to notify writer E4 (Nurse) that resident IV medication had been delivered by the on call pharmacy. 1AM: Gemcitabine 1 gm was reconstituted and added to a 100ml 0.9 % NaCl bag and delivered to R2 via right arm PICC (Peripheral Intravenous Central Catheter) at 200ml/hr over 30 minutes. 1:40AM Also added at this time Cleocin 600 mg to a 100ml 0.9 NaCl bag and delivered to the resident via right arm PICC (Peripheral Inserted Central Catheter) at 200 ml/hr over 30 minutes. 4:50 AM Received a call from pharmacy stating S/S (Signs and Symptoms) and side effects of the medication that needed to be monitored with administration of the drug Gemcitabine as follows; hay fever, rash, edema, nausea and vomiting, dyspnea, pain, constipation and to follow up with physician in terms of any needed lab work. Physician on call notified with order for CBC (Complete Blood Count), CMP (Complete Metabolic Profile) Stat (Immediately) and follow up with primary physician. 7AM Also called the resident's spouse and made aware of the IV medication given, that the physician was already made aware and that the staff is monitoring the resident as indicated by pharmacy. Verbalized understanding. 10AM: Writer (E8 nurse) went into resident's room to give morning medications, upon arriving in resident's room daughter at bedside, resident observed weaker than previously, vitals taken (B/P 128/75, HR 72, Resp 20 , O2 sat 91 on 4 L of oxygen). Resident's mouth was open, some nectar thickened water given and she swallowed it, then resident informed that her medication was being given, upon putting a little bit of the medicines (all crushable medications crushed per order and mixed in apple sauce) in her mouth, resident didn't swallow, resident was encouraged to swallow for 10 minutes, some nectar thickened water was given but resident wouldn't swallow. Medication was scooped out of resident's mouth and oral care performed. 10:45: AM Upon arriving back in resident's room, observed slightly unresponsive but breathing, with thready pulse, responded to name after several call out. Nurse (E8 writer) immediately went to the nurses station, attending physician happened to be on the phone with another nurse, physician immediately notified. MD (Physician) communicated to writer to send resident to hospital. DON ( Director of Nursing) notified immediately. As writer was about to put through to 911, resident's son came out to the nurses station and said "I can't feel her pulse anymore, I think she is gone." Nurse (writer ) asked another RN on the unit to call 911, then immediately went into resident's room, resident observed not breathing, with very weak (almost undetectable) pulse. B/P (Blood Pressure) was undetectable. Resident's son (POA) communicated to writer in the room "She's a DNR ( Do Not Resuscitate), let her go, don't try to bring her back." 12:05 PM All vitals undetectable, fire and police department arrived, EKG readings by the police department revealed asystole. Review of R2's Incident report done by E4 (Nurse ) dated 03/18/11 is as follows: Narrative of injuries and Description of injuries, IV ( Intravenous ) Azactam 1 gm was scheduled at 1 AM via right arm PICC (Peripheral Inserted Continuous Catheter). Shortly before IV was due to be given, writer received a call from Stratford unit enquiring if we have above resident on our unit and if we are expecting any IV medications. We responded & P/U ( Picked up ) the medication. Medication delivered by on call pharmacy was addressed to the resident & noted as Gemcitabine 1 gm x2 vials. Writer diluted 1 vial in 20 ml of 0.9 NaCl and mixed in a 100 ml bag and infused at 200 ml/hour. Immediate Actions taken: Received call shortly before 5AM from pharmacy & made aware of the S/S (signs/symptoms) to watch out for with the administration of Gemcitabine as follows, fever, rash. edema, pain, constipation and dyspnea. Z1 (on call physician) notified of medication given and received order for Stat (immediately) CBC ( Complete Blood Count ), CMP (Complete Metabolic Profile), repeat and follow with Z2 (attending physician) during office hours. R2 assesses frequently with V/S (Vital signs) noted WNL (Within Normal Limits). The spouse also called and notified of drug line of action being taken to care for the resident. When interviewed on 03/24/11 at 9:10 AM. E4 stated, "during shift change the PM nurse told me that (R2) has an IV antibiotic order and was due at 1 AM. The medication Azactam is available at our EDK (Emergency Drug Kit). Shortly before it was due I was looking for an IV pole and my coworker on second floor said that I got a phone call from the unit downstairs to get the medication for the resident. CNA (Certified Nursing Assistant) gave the medication in a paper bag and I looked at the bag, has resident's name (R2) on it. I opened the bag and there were 2 bottles of medication Gemcitabine 1 Gm each bottle. I thought the pharmacy sent the medication because the order was 1 gm and the one we have at EDK is 2 gm. I assumed that was the trade name for Azactam. I diluted the 1 bottle with 25 ml. NaCl then added to a 100 ml of 0.9 NaCl bag. I infused the mixed medication at 200ml. per hour at 1 AM for 30 minutes. Cleocin IV antibiotic taken from EDK was given after finishing the Gemcitabine. I took 600 mg from 900 mg diluted with 100ml. bag of 0.9 NaCl given 200 ml per hour over 30 minutes. After that I went ahead to do other job duties that night. I started passing medications at 4:30 AM and I was just coming out of R2's room around 4:50 AM that my coworker said that I have a phone call from pharmacy. I answered the phone, a lady from the pharmacy asked me if I gave the IV medication (to R2) that was sent last night. I told her yes because it was due at 1 AM. Pharmacy said, I am sorry to tell you that was not the correct medication. Explaining that it was hectic that night and overwhelmed. I told her I don't know what to do right now but I told her I will call the physician. I asked her what S/S or side effects to look for. After that I came out of the room and called physician. Physician ordered CBC, CMP Stat and follow up with Z2 . Called husband told him that this medication Azactam is due and pharmacy sent Gemcitabine and was given. Pharmacy called back and told the side effects to watch for. E4 was asked why she did not check the medication. E4 said that "I don't know every time they sent medications it is always the right medication. I didn't go further because it says 1 gm exact dose from POS (Physician order [REDACTED]. " E5 (Nurse ) was interviewed on 03/28/11 at 3:55 PM by phone and stated "I was working on first floor Stratford unit. Around 12:00- 12:10 AM on 03/18/11 received a brown small bag from the hospital pharmacy. There was one vial of medication and pink receipt on it with PVF (facility initial). I opened the bag there was 1 gm vial of medication, unfamiliar medication so I called Cambridge unit to ask if they are waiting for an IV medication and the nurse (E6 ) answered the phone then passed the phone to (E4). (E4) said that she was waiting for an IV medication. I told (E4) the name of the medication (Gemcitabine) and spelled it out because I can't pronounce correctly, not familiar. (E4) said yes she is waiting for this medication. (E4) came down after 10 minutes and took the medication with the pink receipt. No other medications were delivered at that time. No resident's name and was not labeled." Z3 (Hospital Director of Pharmacy) was asked if there was a label for this medication. Z3 stated that there was no label because this medication (Gemcitabine) was not for this patient (R2). Technician gave the wrong bag to the driver and this bag is supposed to go to a different office. There was no name or label on the vials. Bag labeled with a physician's name. E4, E5 and Z3 have conflicting statements. Z2 ( Physician ) was also interviewed on 03/23/11 at 3:15 PM stated that he was informed by Z1 (on call physician) that the facility mistakenly gave a wrong medication. Z2 said that he got a call from a nurse in the late morning, 10 or 11, that R2 was not doing good, change of mental status. I ordered R2 transferred to the hospital immediately. Z2 was asked if giving the wrong medications could contribute to R2's death. Z2 replied "I don' t think so, (R2) is [AGE] years old and had multiple medical problems. It could be unfortunate coincidence." Picture copy of the box provided by the facility says Gemcitabine 1 gm Cytotoxic agent. To reconstitute: Add 25 ml of 0.9 % NaCl injection (without preservatives ) to make a solution containing 38 mg/ml. Shake to dissolve. Review of precautions and warnings with Gemcitabine showed that may potentially cause kidney damage or liver problems, decrease bone marrow ability to produce blood cells or cause lung damage. A history of low levels of white blood cells in the blood, any infection, kidney disease including kidney failure, liver disease and any allergies [REDACTED]. R2 has an infection and an allergy to medications like vancomycin, Ativan and Phenobarbital. Review of time card log showed that E4 worked on 03/16/11 from 10:06 PM to 7:46 am the following day (03/17/11). E4 came back to the facility to worked on the same day from 2:08 PM to 10:51 AM. E4 worked a total hours of 30 hours and 23 minutes in a span of 36 hours and 43 minutes when the medication error occurred. Review of the facility's policy and procedures on medication administration showed: II. Medications are administered in accordance with written orders of the attending physician. If dose seems excessive considering the resident's age and condition, or a medication order seems to be unrelated to the resident's current [DIAGNOSES REDACTED]. XVI. Prior to administration, the medication and dosage schedule on the resident's MAR indicated [REDACTED]'s orders are checked for the correct dosage schedule. XXII Inspect parenterals and/or intravenous solutions prior to their use. -Should it become necessary to add medication (s) to these solutions, it must be prescribed by the physician, administered by the same person administering the solution(s), and in consultation with the pharmacist. The facility staff did not follow above policy and procedure. E4 did not verify the medication was the right medication prior to administration. E2 Director of Nursing and E7 Assistant Administrator was informed of the immediate jeopardy on 04/13/11 at 9:40 AM. The facility took the following actions to remove the immediacy of the situation and completed the following correction by March 21, 2011. - Nursing staff received in service training on medication administration, verifying medications delivered, verifying medication labels, IV medication management, re-constitution of medication and general principles for preventing medication errors. -Nursing staff audited all Iv medications in the facility for residents receiving such medications to ensure that the medications that have been ordered for residents are the medications that were delivered by the pharmacy. - Facility contacted hospital pharmacy to advise of medication error due to the delivery labeling error. Hospital pharmacy acknowledge its error and indicated it would investigate its process regarding medication delivery labeling and how to prevent recurrence.

Based on record review and interview the facility failed to develop and implement interventions for the use of an appropriate assistive device as a measure to prevent a resident (R1) from falling. As a result: On 2/7/11 R1 who is unstable to transfer and ambulate, got up from bed, ambulated and fell and sustained right hip fracture. This is for one of three (R1) residents in the sample. Findings include: R1's admission record indicated she was originally admitted to the facility on [DATE] after she underwent a left lower lobe thoracotomy for squamous cell [DIAGNOSES REDACTED]. After R1 was admitted to the facility she was hospitalized from [DATE] to 1/22/11 for evaluation and treatment of [REDACTED]. On 2/7/11 the facility sent R1 to hospital for the evaluation and treatment of [REDACTED]. A review of R1's Nurses Notes and facility incident reports indicated during her stay (12/22/10 - 2/7/11) in the facility she fell on 1/12/11 while reaching for the Oxygen tubing. On 1/13/11 the facility added to the fall prevention interventions 'encourage to use call light when needing something, and add clip alarm while in bed.' R1 also moved close to the Nurses Station for close supervision. It was also documented on 2/7/11 at 9:30 pm that R1 was found on floor. This time per Nurses Notes and incident report, the staff heard R1 yelling for help. When the staff responded R1 was found on the floor couple feet away from her foot of bed on her way to bath room. The bed alarm was unclipped, bed was in low position. R1 sustained a bump on back of her head and complained of pain all over. At the Hospital it was diagnosed that R1 sustained right hip fracture. The facility identified R1 to be at risk for falling per Minimum Data Set (MDS) assessment of 1/7/11 and 2/7/11). The MDS also identified R1 to be unstable, but able to stabilize without human assistance in the areas (a) moving seated to standing, walking, moving on and off toilet, (b) transfer to and from bed to chair. However the the MDS also indicated turning around and face opposite direction activity did not occur. R1 12/22/10 care plan for fall prevention interventions are generalized not specific to her needs. Examples of non-specific interventions are: (a) 'frequent visual checks,' this intervention is generalized. (b) 'instruct and remind resident to avoid rising rapidly,' R1 is confused and unable to recall one out of three words. It is unclear how the facility will ensure R1 will follow the instructions. (c) 'side rails based on assessment,' it is not clear with the intervention if R1 is to have side rails, if so what kind and why? (d) on 1/13/11 after her falling on 1/12/11 the facility added an intervention 'encourage to use call light when needing something and add clip alarm while in bed,' again when R1 is confused and disoriented how the facility will ensure that she will comply with staff encouragement. The facility incident investigation of 2/7/11 staff interviews indicated R1 is confused, knows how to remove the alarm when ever she tries to get up by herself. The investigation also indicated she R1 has short term memory impairment, does not remember to use call light, require staff assist for transport, transfers sit to stand with standby assistance. E4, the Nurse who was on duty on 2/7/11 evening shift stated that per R1's Certified Nurse Aide (CNA) she met all of R1's needs before she put her to bed. E4 stated R1 unclips the alarm when she is in chair and when in bed when ever she wants to get up out of confusion. E4 also stated R1 gets irritated with the alarm sound when ever she moves and refuses to have it on. R1's such behavior from confusion has been more frequent after her recent hospitalization for decline in her medical condition. If there was a movement sensor alarm on bed probably the staff would have been able to get to R1 before she got out of bed. E6, the Certified Nurse Aide (CNA) who was assigned for R1 on 2/7/11 evening shift was interviewed on 2/17/11. E6 stated that when R1 was originally admitted (12/22/10) to the facility she was taking care of R1 because her room was in her section of the hall. E6 has not taken care of R1 after she was moved to another room nearer to Nurses Station. On 2/7/11) was the first day she was assigned to care for R1 since (1/22/11) her readmission after hospitalization . E6 also indicated R1 got increasingly confused, after her hospitalization . E6 stated she put R1 to bed just 20 minutes before she fell . R1 had her bed alarm clipped to her blouse, bed side rails were up, bed was in low position, does not recall if there was a floor mat on the floor. No one heard R1's bed alarm go off, she heard from the hallway R1 calling for help. When E6 responded she found R1 on the floor couple steps away at the foot of bed on way to bath room. R1's bed alarm was unclipped from her blouse and it was on her bed. E6 concluded, if there was a movement sensor alarm on her bed, may be she would have caught her before she got out of bed. On 2/17/11 E5, the Director of Nurses stated the facility implements progressive restrictive measures. E5 indicated during the investigation of the incident they became aware that the direct care staff knew that R1 was removing the clip alarm. The next intervention for R1's fall prevention would have been chair belt with removal sensor, and movement sensor bed alarm when returned to the facility, but she did not come back. E5 concluded placing movement sensor bed alarm was not quick enough.