Every finding on record at Benedictine Health Center of Minneapolis

Based on interview and document review, the facility failed to provide timely notification for change in condition to the physician for 1 of 3 residents (R1) reviewed for pressure ulcers. R1's hospital discharge summary note dated 6/11/26 identified R1's diagnoses included respiratory failure with hypoxia, anoxic brain damage and encephalopathy, very fragile with many skin tears/wounds to all extremities, a deep tissue pressure injury (DTPI) recurrent fevers/sepsis workup. R1's hospital wound care instructions dated 6/11/26 included:-Coccyx -zinc barrier two times a day (BID) and as needed (PRN) soiling.-Left lateral ankle - cleanse with normal saline (NS). Apply medical grade honey gel. Cover with mepilex dressing. Change Monday, Wednesday, Friday (MWF) and PRN soiling. R1's admission Minimum Data Set (MDS) dated [DATE] indicated R1 is at risk of developing pressure ulcers (PU). The MDS also indicated R1 required extensive total assistance with activities of daily living (ADL).R1's care plan dated 6/30/26, indicated R1 had severe cognition impairment and was at risk for skin breakdown related to pressure due to incontinence, inactivity, immobility, and problem with friction and shearing with staff interventions to inspect skin with care, to evaluate and notify the provider and the family immediately of any new area of skin breakdown.R1's wound report document dated 7/01/26 at 12:57 p.m. R1 had 1.5 cm x 1 cm unspecified ulcer at left ankle.Facility wound summary report dated 7/1/26 provided to the nurse practitioner did not identify R1's left ankle pressure ulcer.During an observation on 7/6/26 at 10:30 a.m., the director of nursing (DON) identified R1 had 1.5 cm x 1 cm PU on the left ankle with scant serosanguinous drainage, no odor noted.On 7/6/26 at 4:59 p.m., director of nursing (DON) stated she expected nursing staff to follow the facility's wound care policy. The DON stated when new or existing skin impairment was identified, nursing staff were required to notify the wound care team, document the measurements and the description. The DON stated she was unable to find an updated care plan related to R1's left ankle PU identified on 7/1/26. The DON confirmed nursing staff did not notify the provider regarding the finding.On 7/6/26 at 12:40 p.m., a nurse practitioner (NP)-A stated she expected nursing staff to follow the facility's change in condition and wound care policies. NP-A stated nursing staff were required to notify the provider of a new or an existing skin impairment status, depending on the resident diagnosis and condition. NP-A confirmed she was not notified regarding R1's left ankle PU. Notification of Changes Policy dated 11/10/2025 directed the facility staff to make appropriate and timely notification to the physician and delegated non-physician practitioner and notification to the resident representative when there is a change in the resident's condition that may require physician intervention. Notify the provider of any abnormalities such as, but not limited to, wounds or rashes on the resident's skin. Document symptom(s), assessment, observations, resident representative and medical provider notification. Monitor and provide treatment as ordered by the attending provider.

Based on observation, interview, and document review, the facility failed to identify, monitor, and provide care consistent with professional standard of practice to an existing pressure injury for 1 of 3 residents (R1) reviewed for pressure sores.R1's hospital discharge summary note dated 6/11/26 identified R1's diagnoses included respiratory failure with hypoxia, anoxic brain damage and encephalopathy, very fragile with many skin tears/wounds to all extremities, a deep tissue pressure injury (DTPI) recurrent fevers/sepsis workup.R1's hospital wound care instructions dated 6/11/26 included the following:Left lateral ankle: Cleanse with normal saline (NS). Apply medical grade honey gel. Cover with mepilex dressing. Change Monday, Wednesday, Friday (MWF) and PRN (as needed) soiling.R1's admission Minimum Data Set (MDS) dated [DATE] indicated R1 is at risk of developing pressure ulcers. The MDS also indicated R1 required extensive total assistance with activities of daily living (ADL).R1's care plan dated 6/30/26, indicated R1 had severe cognition impairment and was at risk for skin breakdown related to pressure due to incontinence, inactivity, immobility, and problem with friction and shearing with staff interventions to inspect skin with care, to evaluate and notify the provider and the family immediately of any new area of skin breakdown.R1's skin evaluation document, dated 6/11/25 at 7:08 p.m. indicated R1 had unhealed pressure injuries in the sacral area. The evaluation did not address R1's left ankle.R1's wound report identified a mid-thoracic back pressure ulcer and a right lower back pressure ulcer, however, did not address R1's left ankle.Review of R1's medical record including skin assessments and progress notes lacked documentation of PU assessment for the left ankle, including measurements, or wound description from 6/11/25 through 6/21/25. During this time period, facility nursing staff were responsible for monitoring and maintaining R1's skin integrity.On 6/21/26 at 11:53 a.m., a progress note indicated R1 had increased heart rate and elevated temperature. Nursing staff sent R1 to the hospital for further evaluation per the provider's order.R1's hospital discharge summary note dated 7/1/26, identified R1 had a history of anoxic injury status post ventricular fibrillation (V-fib) arrest, was dependent on chronic ventilator, and had Percutaneous Endoscopic Gastrostomy (PEG) tube (flexible feeding tube placed directly into the stomach) and indwelling catheter. R1 was admitted to the hospital from the facility on 6/21/26 with severe sepsis and a fever of 103.5 Fahrenheit (F).On 7/1/26 at 3:24 p.m., a progress note indicated R1 returned from the hospital at approximately 11:30 a.m., nursing staff completed skin assessments and performed wound dressing changes.R1's wound report document dated 7/01/26 at 12:57 p.m. identified R1 had 1.5 cm x 1 cm unspecified ulcer at left ankle.During an observation on 7/6/26 at 10:30 a.m., the director of nursing (DON) identified R1 had 1.5 cm x 1 cm PU on the left ankle with scant serosanguinous drainage, no odor noted.During an observation on 7/6/26 at 10:58 a.m., a registered nurse (RN)-A stated R1 had a stage 4 PU on the coccyx area, an excoriation surrounding the wound, and 30% slough present in the wound bed. During continuous observation, R1' s coccyx wound bed was noted to be in contact with the draw sheet.During an interview on 7/1/26 at 12:32 p.m., a registered nurse (RN)-A stated nursing staff had a form to document the skin assessments for the new admissions, including wound measurement and/or descriptions. RN-A explained during a weekly skin assessment, nursing staff were expected to assess existing wounds, compare findings, and document the wounds' progress. RN-A stated any new skin impairment identified should be communicated to the nurse manager and the provider for further instructions. RN-A further stated staff were required to follow the facility infection protocol during wound care.During an interview on 7/1/26 at 2:44 p.m., RN-B stated she assisted the nurse manager, RN-C, with R1's readmission skin assessment. RN-B stated R1 had been hospitalized for six days due to sepsis and had recently returned to the facility. RN-B explained R1 had fragile skin, skin tears on upper and lower extremities, and a PU at the coccyx. RN-B confirmed RN-C was responsible for documenting the status, measurements, and/ or descriptions of the wounds. RN-B stated she was unaware of R1's PU located on the left ankle.During an interview on 7/2/26 at 4:26 p.m., RN-C stated when a new skin impairment was identified, nursing staff were expected to complete an assessment, provide description, and measurements, document the finding in the progress note, notified the nurse manager and the provider, initiate treatment according to the provider's orders, and inform the family. RN-C stated nursing staff did not document any measurement or description about R1's PU at the left ankle from 6/11/26 through 6/21/26. RN-C stated nurses were required to document the size, characteristics, status of existing or reopened skin impairments, and initiated risk management interventions.During an interview on 7/6/26 at 4:59 p.m., the DON stated she expected nursing staff to follow the facility's wound care policy. The DON stated when new skin impairment was identified, nursing staff were required to notify the wound care team, document the measurements and the description. The DON was unable to find an updated care plan related to R1's left ankle PU identified on 7/1/26. The DON confirmed nursing staff did not notify the provider regarding the finding.During an interview on 7/6/26 at 12:40 p.m., a nurse practitioner (NP)-A stated she expected nursing staff to follow the facility's change in condition and wound care policies. NP-A stated nursing staff were required to notify the provider of a new skin impairment, depending on the resident diagnosis and condition. NP-A confirmed she was not notified regarding R1's left ankle PU.The facility Wound Care policy dated 9/1/2018 indicated if a resident is admitted with impaired skin integrity or a new pressure injury or lower extremity wound develops nursing staff implements the following item:Documentation of the skin impairment is completed in the medical record. Staging of Pressure Injury is completed as necessary by trained licensed associates.Standing orders/protocol for skin wound are initiated.Notify attending provider and resident representative. Attending provider determines wound type and may provide additional orders.Notify Supervisor/designee.Evaluate current pressure reduction interventions and revise resident centered care plan.When pressure injury is present, the dressing and/or wound is monitored, as appropriate.Weekly the licensed nurse will stage, measure, and examine the wound bed and the surrounding skin. If wound bed has deteriorated; notify provider.

The facility failed to ensure transmission-based precautions were followed for 2 of 4 (R2 and R3) residents observed for proper infection control practices.Findings include:R2R2's admission Record dated 7/12/2024, indicated R2's diagnoses included anoxic brain damage, tracheostomy (a surgically created opening in the front of the neck and directly into the windpipe), unspecified protein-calorie malnutrition, systemic inflammatory response syndrome (SIRS) and tube-feeding.R2's quarterly Minimum Data Set (MDS) dated [DATE], indicated R2 had severe cognitive impairment and required total extensive assistance of two persons with mechanical lift for transfers.R2's care plan dated 4/23/26, indicated R2 required Enhanced Barrier Precautions (EBP) related to aspiration pneumonia, chronic respiratory failure, and the presence of tracheostomy and gastrostomy tube. The care plan also indicated R2 was dependent on staff for toilet hygiene and transfers with staff interventions included posting clear signage on the door indicating the type of precautions and following EBP direction while providing high contact care activities.During an observation on 7/2/26 at 11:05 a.m., a nursing assistant (NA)-B and RN-A were observed transferring R2 whose room had EBP signage posted on the door. Neither NA-B nor RN-A donned a gown before providing care. NA-B removed the soiled bedding and made the bed without wearing a gown. After the transfer, NA-B picked up the soiled linen from the floor of the resident's room. RN-A parked the mechanical lift in the hallway after use without cleaning or disinfecting the equipment. During an interview on 7/2/26 at 10:23 a.m. NA-B stated a gown, and gloves were expected to be worn during transfers for residents on EBP. NA-B confirmed he should have worn a gown and gloves while providing high contact care activity to R2.During an interview on 7/2/26 at 11:53 a.m., RN-A stated staff usually donned a gown during high-contact activities with R2. RN-A stated EBP signage directed staff on the appropriate PPE (Personal Protective Equipment) to wear based on the care being provided; however, he was unsure whether R2 was on EBP. RN-A confirmed he did not wear a gown while transferring R2 with the mechanical lift and forgot to disinfect the lift after use. RN-A stated the lift should be cleaned after each use to prevent cross-contamination.R3R3's admission Record dated 8/12/2020, indicated R3's diagnoses included traumatic subdural hemorrhage, chronic respiratory failure with hypoxia , tracheostomy, gastrostomy, osteomyelitis, and disruption of wound.R3's quarterly Minimum Data Set (MDS) dated [DATE], indicated R1 had severe cognitive impairment and required total extensive assistance of two persons with mechanical lift for transfers.R3's care plan dated 6/22/26 indicated R3 had gastrostomy-tube site and an open area on the abdomen , as well as tracheostomy. The care plan also indicated R3 was dependent on staff for toilet hygiene and transfers with staff interventions included monitor tube site for sign/symptoms of infection and reporting any concerns to the provider, as well as following EBP during high-contact care activities. During an observation on 7/1/26 at 12:01 p.m., NA-A exited R4's room which had EBP signage posted on the door, while still wearing a gown and gloves. Without removing the gown and gloves, NA-A entered R3's room to get a large brief and then returned to R4's room to continue providing care.During an interview on 7/1/26 at 12:27 p.m., NA-A stated she had received training regarding the facility's infection control protocols. NA-A stated she was providing bed toileting to R4 whose room had EBP signage posted on the door and needed a clean brief. NA-A stated she obtained the brief from R3's room while still wearing a gown and gloves. NA-A stated she should have removed her gown and gloves before leaving R4's room to obtain supplies in order to prevent cross contamination.During an observation on 7/6/26 at 8:47 a.m., RN-E provided trach care and tube-feeding to R3 without wearing a gown. R3's room had EBP signage posted on the door directed staff to wear appropriate PPE.During an interview on 7/6/26 at 9:00 a.m., RN-E stated when a resident had tracheostomy and gastrostomy tube, staff should post EBP signage on the resident's door and follow the facility's infection protocols. RN-E confirmed she did not wear a gown while providing tracheostomy care and administering tube-feeding to R3. RN-E stated she knew the appropriate procedure and should have worn the required PPE to help prevent the transmission of infection.During an interview on 7/6/26 at 4:58 a.m., the director of nursing (DON) stated she expected all staff to be knowledgeable about EBP and to wear appropriate PPE when providing high-contact care to residents on EBP. The facility Enhanced Barrier Precaution policy dated 4/1/2024 indicated enhanced barrier precautions should be followed outside the resident's room when performing transfers and assisting during a high contact activity such as bathing in a shared/common shower room and when working with residents in the therapy gym, specifically when anticipating close physical contact while assisting with transfers and mobility, or any high-contact activities included dressing, transferring, changing linens, and device care or use such urinary catheters, feeding tubes, and tracheostomy.

Based on observation, interview and record review, the facility failed to properly manage a potential scabies outbreak in January 2026, resulting in additional rashes requiring scabies treatment for 2 of 2 residents (R73, R15) reviewed who were prescribed an antiparasitic oral medication. Further, upon discovery of R15 and R73's rashes, the facility failed to take appropriate steps to prevent the spread of possible scabies. This had the ability to affect all 85 residents residing in the care facility. In addition, the facility failed to ensure transmission-based precautions were followed, to include enhanced barrier precautions (EBP) and contact precautions for 2 of 4 residents (R24, R45) observed for proper infection control practices. Findings include: During record review it was discovered that 14 residents on the fourth floor and 2 residents on the second floor had a diagnosis of scabies in their chart dated 1/29/26. R73's annual Minimum Data Set, dated [DATE], indicated R73 was admitted to the care facility on 1/28/22 and dependent on staff for most activities of daily living (ADLs). R73's orders, dated 3/28/26, indicated an order for 2 doses of ivermectin (an antiparasitic medication used in two doses to treat scabies, among other parasitic infections) 15 milligrams (mg) to be given on 3/28/26 and 4/4/26. R73's care plan, printed 4/1/26, lacked evidence R73 was being treated for possible scabies infection and currently on transmission-based precautions. During observation and interview on 3/30/26 at 1:39 p.m., R73 stated he had been itching for weeks and was just recently started on something to help the itching, a pill he took a few days ago. On his door was a sign that indicated staff were to follow enhanced barrier precautions when in his room providing cares. R15's quarterly MDS, dated [DATE], indicated R15 was admitted to the care facility on 8/15/23 and was dependent on staff for most ADLs. R15's orders, dated 3/30/26, indicated an order for 2 doses of ivermectin 18mg to be given on 3/31/26 and 4/7/26. R15's care plan, printed 4/1/26, lacked evidence R73 was being treated for possible scabies infection and currently on transmission-based precautions. During an interview on 4/1/26 at 12:45 p.m., R15's family member (FM)-A stated she comes to the facility every Tuesday to give R15 a shower. FM-A stated R15 has been itching his skin and on 3/24/26 the severity of the itching had increased, stating R15 was severely itching with scratch marks on his chest and buttocks. FM-A stated she spoke with the 4th floor nurse manager and registered nurse (RN)-B on 4/26/26 who suggested they go check R15 for a rash. FM-A confirmed RN-B stated R15 had a rash and had dust mites. FM-A stated that following day an evening nurse told her R15 had scabies. FM-A stated she was not provided education on what scabies was or any precautions she should take for herself. During an interview on 3/31/26 at 3:14 p.m., nurse manager and RN-B confirmed R15 and R72 were both being treated for scabies and R73 should be on contact precautions, not enhanced barrier precautions. RN-B also confirmed there was a scabies outbreak back in January on 4th and 2nd floor. During an interview on 4/1/26 at 8:44 a.m., the infection preventionist (IP), who was in her role since mid-January of this year, stated the medical director (MD) (who has since retired) diagnosed the scabies infection back in January. The IP stated the MD indicated there was no need to do diagnostic skin scrapping of any residents with rashes, to just treat it as if it was scabies and ordered ivermectin as treatment. At that time, all staff were offered ivermectin as a precaution if they wanted to take it, but the IP did not believe there was any staff who developed any symptoms of scabies or staff who took ivermectin. The IP stated she was unsure if any contact tracing was completed for residents who had discharged within 6 weeks prior to the first outbreak to ensure they were aware they were exposed to scabies and was unable to provide any documentation that would show contact tracing was complete. The IP stated the expectation for TBP was that any resident being treated for scabies was on contact precautions until 24 hours after their second dose of ivermectin. The IP stated she was aware of 2 residents who had potential scabies but believed their treatment was done and was unaware they had only received one of two doses. The IP was unaware of any education that had been done with staff regarding scabies including what to monitor for and how to prevent the spread and was not involved in any education for current staff regarding the two new cases of scabies. The IP stated she was providing some general education about scabies to new staff during orientation. The IP confirmed she was not currently doing any contact or line tracing with the current potential scabies outbreak and was not doing any look back contact tracing of who discharged in the past 6 weeks and was possibly exposed to scabies. During an interview on 4/1/26 at 9:00 a.m., the assistant director of nursing (ADON) stated the rashes started out on second floor and originally it was thought to possibly be a cleanliness issue. The ADON stated they did some education with staff and put certain nursing aides in the unit with the rashes and they cleared up. The ADON stated somebody might have had scabies, but it was treated right away. The ADON stated she was not sure exactly what had happened on 4th floor as she was the second-floor nurse manager at the time, but the 4th floor nurse manager, RN-B, told her they had scabies running ramped and still do. The ADON stated the major wave (of scabies) was over, and the floor managers were managing it now. The ADON stated she was not involved in any education regarding scabies, current or past. The ADON was aware of R15 being treated for scabies but no other residents. During an interview on 4/1/26 at 9:15 a.m., the administrator stated he believed the scabies outbreak at the end of January was mostly on second floor and the fourth floor had only one case that was treated. The administrator stated when they started getting multiple residents with a rash their MD was called in to look at the residents' skin and diagnosed the rashes as scabies. During a follow up interview on 4/1/26 at 10:03 a.m nurse manger and RN-B stated staff had completed skin checks of all residents on the 4th floor and currently only R15 and R73 have rashes and are being treated for scabies. RN-B stated she provided education to her staff on Mondays about the new cases of potential scabies, but that staff floated to all floors and there was not dedicated staff to just fourth floor where the 2 residents currently being treated for scabies reside. RN-B stated back at the end of January, during the first outbreak, two staff member had come to her with newly developed rashes and were given ivermectin as treatment. The staff were allowed to continue working during treatment. RN-B stated they had not done any contact tracing. During an interview on 4/1/26 at 10:57 a.m., Infection Control Assessment and Response (ICAR) stated any health care worker (HCW) must immediately be removed from work if they develop any symptoms, to including itching and/or a rash and be referred to their clinician and all HCWs should be educated to monitor their selves for symptoms (i.e. rash or itching). ICAR stated once a symptomatic HCW has been treated, they can come back to work but most wear a gown and gloves with all residents during cares. ICAR stated having two symptomatic HCW continuing to work could be why the facility was seeing another resurgence of scabies. ICAR further stated it would be the facility's responsibility to determine who discharged 6 weeks from the onsite of symptoms to provide them with awareness and education of possible scabies exposure. This along with a list of who is symptomatic, who is not, which staff have worked with symptomatic residents to try to find a connection or source. ICAR also confirmed having a medical record that indicated a resident was being treated for scabies would be an important part of preventing the spread if a symptomatic resident discharged or needed a higher level of care (i.e. hospitalization). During an interview on 4/2/26 licensed practical nurse (LPN)-A stated she was aware there were residents with a rash but was not sure what the treatment was. LPN-A stated she was aware to cover up (with a gown and gloves) when providing care and to wash her hands but was not provided specific education on what the rash was or to monitor herself for any symptoms. During an interview on 4/2/26 at 9:20 a.m., nursing assistant (NA)-C stated she was aware of a couple of residents with rashes but did not know what it was but was told to take precautions and wear a gown when in their rooms and to use a special soap with the residents. NA-C did not recall any specific education on monitoring herself for any rashes or itching. A facility policy titled Scabies, dated 6/2017, indicated Skin infestations by the mite Sarcoptes scabiei var. hominis are commonly known as scabies and are transmitted through direct contact with infected persons; less frequently, transmission may occur through contact with clothing or bed linens. The incubation period – the time from exposure to onset of symptoms – for primary infestation occurs as early as 10 days but is typically 4 to 6 weeks. The policy indicated if a resident is suspected of having scabies, orders would be obtained for skin scraping and the IP had authority to order skin scrapings under the direction of the MD. All suspected infected residents would be placed on contact precautions. The policy further indicated contact investigation would be completed to determine what HCW may need treatment and to provide them with education on scabies. According to the policy, all family members with exposure to scabies would be provided education on scabies, proper treatment, and encourage to obtain treatment from their physician. R24's quarterly Minimum Data Set (MDS) dated [DATE], indicated R24 was unable to talk, was dependent on staff for all activities of daily living, received oxygen, suctioning, had a tracheostomy, a tube feeding and a ventilator. MDS included diagnoses of chronic respiratory failure, diabetes, tracheostomy, gastrostomy tube, dysphagia, autonomic nervous system disorder, and nontraumatic subdural hemorrhage. R24's care plan dated 4/1/26, indicated R24 required Enhanced Barrier Precautions (EBP) related to diagnosis of respiratory failure, presence of tracheostomy and a gastric tube. The care plan's approach directed staff to implement precautions according to facility protocol. The care plan directed staff to apply gloves and gowns prior to high contact activities and hand sanitization after PPE removal. The EBP care plan was initiated on 1/14/25. On 2/25/26 a new goal was added, R24 will not develop newly acquired MDRO or will not develop signs or symptoms of acute infection. This care plan was last reviewed on 11/25/25. R24's care plan dated 4/1/26, also indicated R24 had scabies on his left hand and arm. The care plan didn't direct staff to follow contact precautions. Care plan identified 1/29/26 as the start date of the problem. This care plan was last reviewed on 1/29/26. During observation on 3/30/26 at 5:46 p.m., a Contact Precautions sign was taped to resident's door. The sign instructed staff to wear a gown and gloves before entering R24's room. During observation and interview on 3/31/26 at 3:56 p.m., R24 was in bed and observed nursing assistant (NA)-B turning and repositioning R24 using wedge cushions. NA-B was not wearing a gown. NA-B stated he knew there was a contact precaution sign on the door, but he forgot to put on a gown before entering R24's room. During observation and interview on 4/1/26 at 7:52 a.m., observed a nurse entering R24's room with a vital sign rolling stand. RN-A did not put on a gown before entering the room. RN-A obtained vital signs including oxygen levels and blood pressure. RN-A stated he only needed to use a gown if he provided personal cares. RN-A verified a contact precautions sign was taped on R24's room door, which directed staff to wear gloves and a gown before entering the room. RN-A stated R24 was placed in contact precaution because R24 had a skin rash, but he believed it was resolved. R45 R45's quarterly MDS dated [DATE], indicated R45 was unable to talk, and depended on staff for ADLs. MDS indicated diagnoses of chronic respiratory failure, hypertension, intellectual disabilities, dependence on respirator and pharyngeal dysphagia. MDS also indicated R45 had a tube feeding, a tracheostomy, was suctioned and used a ventilator. R45's care plan dated 4/21/26, indicated R45 had a history of an antibiotic-resistant infection. The care plan directed staff to use principles of infection control and universal/standard precautions. In addition, R45 had a tracheostomy care plan which directed staff to use EBP precautions as indicated by facility policy. During observation and interview on 3/30/26 at 5:51 p.m., R45 was in bed, and a nurse was suctioning him. The nurse was not wearing a gown. Registered nurse (RN)-C stated he was supposed to wear a gown when he suctioned residents to prevent infections. RN-C stated he saw R45's call light on because he needed to be suctioned, so he didn't wear a gown. During interview on 4/2/26 at 2:00 p.m., the infection preventionist (IP) stated all staff were educated about EBP, the staff were instructed to use gowns and gloves when they provided hands on care, including suctioning. IP added, if you are going to touch them [residents] then they need to follow EBP. Regarding contact precautions, IP stated any time the staff touched a resident they needed to wear a gown and gloves. IP stated staff needed to use a gown and gloves when turning and repositioning a resident and obtaining vital signs. IP stated she expected the nursing staff to wear personal protective equipment (PPE). The facility's policy titled Enhanced Barrier Precautions dated 3/28/24, indicated it was the policy of the community to protect residents and associates from the transmission of infectious diseases through use of appropriate precautions during resident care. The policy also indicated EBP expanded to the use of PPE beyond situations in which exposure to blood and body fluids was anticipated. It also referred to the use of gown and gloves during high-contact resident care activities that provided opportunities for transfers of multidrug-resistant organisms (MDROs) to staff's hands and clothing. The facility's policy titled Contact Precautions dated 9/2023, indicated It is the policy of [company] to protect residents and associates from the transmission of infectious disease through use of appropriate precautions during resident care. The policy also indicated contact precautions are used, in addition to standard precautions to prevent nosocomial spread of organisms that can be transmitted by direct resident contact or by indirect contact of environmental surfaces of contaminated equipment.

Based on observation, interview and document review, the facility failed to ensure 7 out of 24 residents' (R63, R24, R5, R45, R47, R65, R20) fans were kept clean to provide a safe environment for residents with tracheostomies and/or ventilators.Findings include: R63R63's annual Minimum Data Set (MDS) dated [DATE], indicated R63 was unable to speak, had moderately impaired decision making, and depended on staff members for all activities of daily living (ADLs). MDS indicated diagnoses of cardiorespiratory debility, tracheostomy, had a ventilator, and received oxygen and had a tube feeding. During observation on 3/30/26 at 5:35 p.m., R63 was sleeping in bed with her mouth open. A fan mounted on a wall was blowing air and there was dust accumulated on the grid. The fan was stopped, and dust was present on the fan blades. R63 woke during the visit but she was unable to answer questions. R24R24's quarterly MDS dated [DATE], indicated diagnosis of cardiorespiratory debility, unable to talk, had a tracheostomy, a ventilator and a gastrostomy tube. MDS indicated R24 was dependent on staff members for ADLs. During observation on 3/30/36 at 5:50 p.m., R24 was awake, lying in bed in a supine position. R24 had a tracheostomy tube, a ventilator and a tube feeding. A fan mounted on the wall was on and dust had accumulated on the grid. The fan was stopped, and the fan's blades were dusty. R5R5's quarterly MDS dated [DATE], indicated R5 was cognitively intact, needed moderate assistance with bathing, was dependent to put on footwear, needed set up with personal and oral hygiene. The MDS indicated diagnoses of traumatic brain injury, chronic obstructive pulmonary disease, had a tracheostomy which needed suctioning. During observation and interview on 3/30/26 at 1:42 p.m., R5 stated the fan was dusty and added, the housekeepers clean the fan, but not very often. R45R45's quarterly MDS dated [DATE] indicated R45 was nonverbal, had a diagnosis of cardiorespiratory debility, and was dependent on staff for all his ADLs. R45's face sheet dated 4/3/26, indicated diagnoses of unspecified intellectual disabilities, chronic respiratory failure with hypoxia, epilepsy, dependence on ventilator, tracheostomy, gastrostomy tube, and dysphagia. During observation on 3/30/26 at 5:48 p.m., R45 was in bed, and he had a tracheostomy, a ventilator and a tube feeding. A fan mounted on the wall had dust accumulated on the grid and its blades. R47R47's 5-day MDS dated [DATE], indicated R47 had moderate impaired decision making, was unable to talk, and depended on staff for all ADLs. The MDS indicated diagnoses of progressive neurological condition, chronic respiratory failure, dependence on ventilator, tracheostomy and had a tube feeding. During observation on 3/30/26 at 6 p.m., R47 was in bed, did not respond to questions, and his mouth was wide open. R47 had a tracheostomy, was on a ventilator and a tube feeding. A wall-mounted fan was running and covered with dust. R20R20's quarterly MDS dated [DATE] indicated R20 was cognitively intact, was dependent on bathing, dressing and needed substantial assistance with dressing, and personal hygiene. R20's MDS included diagnoses of cardiorespiratory debility, oropharyngeal dysphagia, dependence on ventilator, and obstructive sleep apnea. MDS also indicated R20 had a tracheostomy, ventilator, received suctioning and had a tube feeding. During observation on 3/30/26 at 6:45 p.m., R20 was in his room, he had a tracheostomy, had a ventilator and had a tube feeding. A fan mounted on a wall was on, and dust was visible on the fan's grid. R20 said yeah it is dirty, I am not sure when or who cleans the fan. R65R65's quarterly MDS dated [DATE], indicated R65 was unable to speak and was dependent on staff for all ADLs. MDS indicated diagnoses of amyotrophic lateral sclerosis, anxiety, depression, respiratory failure, gastrostomy, oropharyngeal dysphagia, dependence on ventilator, and progressive bulbar palsy. MDS also indicated R65 received oxygen, suctioning, tube feeding, and tracheostomy cares. During observation on 4/1/26 at 12:05 p.m., R65 was not in his room. A fan mounted on a wall was on, and the fan's grid was covered with dust. When the fan was turned off there was also dust on the fan's blades. During interview on 4/1/26 at 1:43 p.m., registered nurse (RN)-A verified the fans observed in the residents' room were dusty. RN stated the fans should be cleaned to prevent allergies and/or infections. RN-A added, especially in the rooms with residents with respiratory problems. During interview on 4/1/26 at 1:51 p.m., nursing assistant (NA)-A stated, if the rooms needed to be clean, she would notify the housekeepers. NA-A stated she didn't pay attention to the fans and added my priority is taking care of my patients. During interview on 4/2/26 at 8:31 a.m., housekeeper aid (HA)-A stated he cleaned the fans once a week. During interview on 4/2/26 at 8:34 a.m., the maintenance director (MD) indicated his department had a cleaning schedule. MD stated it was on a template, but he wasn't sure if the fans were included on the template. MD stated he did monthly rounds to check every room, but the fans were usually on, and it's difficult to determine if they were dirty when they are on. MD stated his expectation will be to check the fans every week and at least clean them monthly. During interview on 4/2/26 at 1:34 p.m., RN-D stated the fans in residents' rooms should be cleaned to prevent dust blowing in their room. RN-D added, especially in the rooms of residents with tracheostomies and ventilators to minimize the risk of further respiratory problems. Facility's procedure titled Resident Rooms-Routine Cleaning dated 11/2025, indicated maintaining clean and attractive surroundings without disrupting resident care. The undated Room Survey form included observing the room environment and furniture, including fans to ensure they were cleaned and functional.

Based on interview and document review, the facility failed to ensure a significant medication error was reported to the State Agency (SA) within 24 hours for 1 of 1 resident (R15) reviewed who received 1/10th of the prescribed dose of seizure prevention medication twice daily for 24 of days.Findings include:R15's quarterly Minimum Data Set (MDS) dated [DATE], indicated R15 had severe cognitive impairment, depended on staff for all activities of daily living, and had a diagnosis of hemiplegia and hemiparesis following cerebral infraction affecting the right dominant side. Other diagnoses included hypertension, diabetes, non-Alzheimer's dementia, seizures, and depression.R15's progress notes included:- 10/20/25 note at 4:16 p.m., indicated at 1:00 p.m., a nursing assistant (NA) reported to the nurse on duty R15 was shaking. Nurse indicated R15 was alert, and his right upper and lower extremities were shaking. Vs were obtained. R15's whole body started to shake, 911 was called, and R15 was taken to a local hospital at 1:25 p.m.-10/21/25 note indicated R15 returned at 11:40 p.m., with new order of Keppra 1000 milligrams (mg) twice a day. Order was faxed to pharmacy. R15 was alert, had dinner, denied pain and SOB.-10/21/25 note indicated the facility contacted the pharmacy and were informed the medication would be delivered next day by 9 a.m.R15's October's medication administration record (MAR) included an order dated 10/20/25 for levetiracetam 100 mg/ml, administer 100 mg orally twice a day. R15 received the first dose on 10/21/25.-10/31/25 note indicated R15 had a 60 second, jerking seizure at 9:30 p.m. The note indicated no other seizures were noted for the rest of the shift. A message was left for R15's brother, and the provider was notified.-11/13/25 note indicated at approximately 10:00 a.m., a housekeeper reported R15 was shaking in his room. R15 was sitting in his wheelchair and was experiencing a violent seizures. R15 was unable to articulate but he exhibited signs and symptoms of both pain and discomfort through his facial expressions and verbal cues. The seizures were recurrent, occurring in succession. Facility updated the provider and called R15's daughter. -11/13/25 note indicated at 10:56 a.m., the paramedics took R15 to the ER and his daughter went with them. -11/13/25 note indicated R15 return to the facility at 10:00 p.m. The hospital visit summary indicated lab work was negative for infection, lactate level was elevated, which may be consistent with the possible seizure episode. Daughter stated the EEG did not show definitive evidence of seizure activity. R15 also needed to have a neurologist follow-up appointment.R15's Active Orders dated 4/3/26 indicated an order for levetiracetam (anti-seizure medication) also known as Keppra. The Keppra order dated 11/14/25, indicated: levetiracetam solution 100 milligrams (mg) /milliliter (ml), 1000mg oral twice a day.R15's Customer Concern form dated 11/17/25, indicated a pharmacy concern related to a transcription dosage deviation. The concern form included a findings section which indicated on 10/20/25, R15 experienced severe seizures and was sent to the emergency department (ER). R15 was discharged back to the facility with a new order for Keppra 1000 mg orally twice a day. On 11/13/25, R15 experienced seizures, was evaluated in the ER and returned to the facility the same day. On 11/17/26 the nurse practitioner discovered R15 had been receiving 100 mg of Keppra twice a day instead of 1000 mg twice a day. R15's Event Report dated 11/19/26, identified as a Safety Event-Medication Error indicated the event occurred on 10/20/25. The error began on 10/20/25 and ended on 11/14/25. It was described as a medication error, wrong dose- too little. The report indicated the following adverse extrapyramidal drug reactions- eg.- various combinations of tremors, postural unsteadiness, lack of slowness of movement, cogwheel rigidity, expressionless face, drooling, infrequent blinking, shuffling gate, decreased arm swing, and rigidity of muscles in the limbs, neck, and trunk.- 11/19/25 note indicated R15's brother was informed about Keppra medication error, whereby resident was being given a less dosage than was prescribed. Family did not verbalize any concerns about the low dose. The note indicated on 11/14/25, the nurse practitioner (NP) discovered the Keppra dose needed to be increased to 10 ml, the changes were done immediately, and R15 had not had any seizures since. Lab work was ordered, and medications were faxed over by the NP. R15's November's MAR indicated R15 received 100 mg of Levitra twice a day until 11/13/25. On 11/14/25 R15 started to receive 1000 mg of Levitra twice a day. A provider note dated 11/14/25 indicated, noted that dose was wrong.according to the ED report he [R15] should have been getting 1000 mg twice a day and he is getting the liquid at the facility, but he is only getting 100 mg twice a day so that order was changed -this possibly is why he was having breakthrough seizures. During interview on 4/2/26 at 3:05 p.m., health unit coordinator (HUC) stated the nurses write the orders, then she transcribed them into the computer and gave back the order to the nurse to double check the accuracy of the order. HUC stated all orders were always checked twice. During interview on 4/2/26 at 3:00 p.m., licensed practical nurse (LPN)-A stated when a resident returned from a hospital, the nurse faxed the orders to the pharmacy. RN-E stated the nurses get the orders and the HUC or a nurse entered the orders on the computer. Once the orders were entered into the computer, the orders were checked by two people. During interview on 4/2/26 at 3:10 p.m., RN-E stated the nurses get physician orders, HUC entered the orders in the computer, and nurses verified the orders. RN-E added all orders were double checked. RN-E stated she knew she had to report medications errors and complete paperwork following facility policy. During interview on 4/2/26 at 3:08 p.m., nurse manager RN-B stated on 10/20/25 R15 had seizures and was to the hospital for evaluation. R15 returned to the facility the same day with orders for Keppra 1000 mg twice a day. On 10/20/25 the Keppra order was transcribed by a nurse, but instead of 1000 mg the order was transcribed as 100 mg twice a day. R15 received 100 mg twice a day from 10/21/25 through 11/13/25. RN-B stated, on 11/13/26 R15 had another seizure, he was sent to the hospital for evaluation and returned the same day without new orders. R15 was to remain on 1000 mg of Keppra twice a day. On 11/14/25 RN-B received a call from R15's NP. NP was reviewing R15's 11/13/25 visit to the ER and realized a medication error had been made. RN-B received a verbal order for Keppra 1000 mg twice a day. RN-B stated she reported the medication error to the interim director of nursing and called the family. RN-B stated she didn't know if the medication error was reported to the SA. During interview on 4/2/26 at 3:02 p.m., the administrator and the company's regional nurse indicated the transcription error was not reported because it was not clear this caused harm to R15, so the error was internally fixed and R15 was monitored for further seizure activity.Facility's policy titled Medication Errors dated 8/31/23, indicated when a medication error was made in the preparation or administration of a drug or biological, the licensed staff provides any necessary immediate care, and notifies the attending provider and resident or resident representative.

Based on interview and document review, the facility failed to provide a bed hold notice for 1 of 1 residents (R12) reviewed for hospitalization.Findings include:R12's quarterly Minimum Data Set (MDS) assessment, dated 12/30/25, indicated R12 had moderately impaired cognition with no hallucinations, delusions or behaviors.During an interview and observation on 3/30/26 at 12:49 p.m., R12 was observed lying in bed. R12 responded to questions with yes or no answers.R12's face sheet, dated 4/2/26, indicated R12 had an identified emergency contact and who would also receive statements.R12's census log, printed 4/2/26, indicated R12 was on hospital leave from 2/22/26 and returned on 2/27/26.R12's progress notes, dated 2/15/26 to 2/28/26, were reviewed and identified the following:-2/22/26 at 11:22 p.m.: resident was sent to the hospital for not responding well. Supervisor, resident's spouse, and on-call provider was notified.-2/23/26 at 2:42 a.m.: facility called to follow up with the hospital who continued to determine if resident was going to be admitted or discharged .-2/23/26 at 6:11 a.m.: facility received a call from hospital stating resident will be admitted for continued management and monitoring.-2/24/26 at 4:24 p.m.: facility called to get an update on resident.-2/27/26 at 2:23 p.m.: resident was escorted by two attended via stretcher at 11:50 am, awake and pleasant. Will update incoming shift. The progress notes lacked any indication a bed hold was completed prior to being sent to the hospital, or whether a bed hold was sent to the hospital after resident was transferred.R12's medical record was reviewed and lacked evidence a bed hold notice was provided for 2/22/26 hospitalization either in electronic medical record or in paper chart.During an interview on 4/2/26 at 12:32 p.m., registered nurse (RN)-G stated when a resident transferred to a hospital, the nurse obtained a bed hold which was documented in the electronic medical record. The forms were printed out for the resident to sign, if they were able, and then uploaded once signed. RN-G stated if the resident wasn't able to sign then they talked to the family.During an interview on 4/2/26 on 12:38 p.m., assistant director of nursing (ADON)-B stated the expectation was nurses on the floor would obtain the bed hold when the resident transferred to the hospital. ADON-B stated the form would be signed and uploaded into the electronic medical record. ADON-B could not locate the bed hold for R12's hospitalization for 2/22/26 to 2/27/26, and would have expected it to be done. ADON-B stated she would follow up on the bed hold to see if she could locate it. During an interview on 4/2/26 at 12:48 p.m., ADON/registered nurse (RN)-D stated they would expect nurses to complete the bed holds when a resident transferred to the hospital as if a resident wants their bed held, and it was important to do this. RN-D was unable to locate a completed bed hold for R12's 2/22/26 hospitalization.During an interview on 4/3/26 at 10:05 a.m., administrator stated there was no further documentation for R12's bed hold to provide.A facility policy titled Bed Hold, reviewed 10/23, indicated Prior to or at the time of transfer of a resident for hospitalization or therapeutic leave, a nursing facility must provide to the resident, responsible party, or legal representative written notice which restates and specifies the duration of the bed hold policy. If that is not possible due to extenuating circumstances (i.e. resident has gone to the hospital for an emergency), the Facility must communicate the information by telephone with the resident or responsible party/legal representative, and follow up by mailing the authorization/request form. A signature is not required on the written notice form, as long as the notice is issued to the resident or representative. If the notice is not signed, write the resident's name and how the notice was issued to the resident (e.g., resident unable to sign, or verbal consent by phone given by [name].

Based on interview and document review, the facility failed to accurately code the Minimum Data Set (MDS) for 1 of 1 resident (R88) reviewed for a closed record.Findings include:R88 was admitted to the facility on [DATE] with a diagnosis of aftercare following left knee joint replacement. During R88's stay at the facility, she received therapy services and was discharged from the facility to her home.R88's discharge MDS dated [DATE] indicated, R88 was discharged to a short-term general hospital.R88's electronic medical record (EMR) included a progress note dated 2/9/26 at 3:33 p.m. The progress note indicated R88 was discharged at 11:00 a.m. to her home with her sister. R88's sister provided transportation. Note identified a local home health agency would provide home services. Medication prescriptions were faxed to a local pharmacy, and R88 was discharged with medications as ordered. R88's Discharge Plan of Care indicated R88 returned home on 2/9/26.During interview on 4/2/26 at 9:29 a.m., corporate MDS/registered nurse (CMDS) verified, the R88's discharge MDS indicated R88 was discharged to a hospital. CMDS stated the facility's MDS nurse made a coding error, CMDS added she will make a MDS modification.Requested a MDS policy but was not provided.

Based on observation, interview, and record review the facility failed to ensure residents who were on transmission-based precautions for potential scabies had a documented diagnosis and care plan to ensure staff and any potential future care facilities were aware to help prevent the spread of scabies for 2 of 2 residents (R15 and R73) reviewed who were currently being treated for scabies. In addition, the facility failed to assure a skin care plan was updated to accurately reflect the skin problems for 1 of 1 resident (R24) reviewed for pressure areas.Findings include:R73's annual Minimum Data Set, dated [DATE], indicated R73 was admitted to the care facility on 1/28/22, and dependent on staff for most activities of daily living (ADLs).R73's orders dated 3/28/26, included an order for 2 doses of ivermectin (an antiparasitic medication used in two doses to treat scabies, among other parasitic infections) 15 milligrams (mg) to be given on 3/28/26 and 4/4/26 for dermatitis.R73's care plan, printed 4/1/26, lacked evidence R73 was being treated for possible scabies infection and currently on transmission-based precautions.During observation and interview on 3/30/26 at 1:39 p.m., R73 stated he had been itching for weeks and was just recently started on something to help the itching, a pill he took a few days ago. On his door was a sign that indicated staff were to follow enhanced barrier precautions when in his room providing cares.R15's quarterly MDS, dated [DATE], indicated R15 was admitted to the care facility on 8/15/23, and was dependent on staff for most ADLs.R15's orders, dated 3/30/26, included an order for 2 doses of ivermectin 18 mg to be given on 3/31/26 and 4/7/26.R15's care plan, printed 4/1/26, lacked evidence R73 was being treated for possible scabies infection and currently on transmission-based precautions.During an interview on 3/31/26 at 3:14 p.m., nurse manager and RN-B confirmed R15 and R72 were both being treated for scabies, not dermatitis and was not sure why ivermectin was written for a diagnosis of dermatitis. RN-B also stated R73 should be on contact precautions, not enhanced barrier precautions.During a follow up interview on 4/1/26 at 10:03 a.m., RN-B confirmed R15's and R73's electronic medical record lacked any evidence they were being treated for scabies and should.During an interview on 4/1/26 at 10:57 a.m., Infection Control Assessment and Response (ICAR) stated having a medical record that indicated a resident was being treated for scabies would be an important part of preventing the spread if a symptomatic resident discharged or needed a higher level of care (i.e. hospitalization). A facility policy titled Comprehensive Assessments and Care Planning, dated 2/26/26, indicated a comprehensive, person-centered interdisciplinary care assessment of the residents' condition is used to develop consistent quality care and must accurately reflect the residents' status to include disease diagnosis and health conditions.R24R24's quarterly Minimum Data Set (MDS) dated [DATE], indicated R24 was unable to talk, and was dependent on staff members for all activities of daily living, turning, repositioning, and transfers. MDS indicated R24 was at risk of developing pressure areas, had pressure areas and open lesions, and had pressure-reducing devices for his chair and bed.R24's Face Sheet dated 4/1/26, indicated R24 was admitted to facility on 11/19/24. The face sheet indicated diagnoses of chronic respiratory failure, nontraumatic subdural hemorrhage, dependence on respirator, tracheostomy, gastrostomy, dysarthria following cerebral infarction, moderate protein-calorie malnutrition, pressure areas and iron deficiency anemia.R24's Active Orders report dated 4/1/26, included the following orders related to resident's skin problems:Pro-stat (concentrated, liquid protein medical food designed to manage pressure injuries, wounds and protein-energy malnutrition).Cares for dry blisters with a diagnosis of Bullous Pemphigus (large fluid-filled blisters)Wound care for his left lateral distal leg pressure area.Wound care for his left lateral proximal leg pressure area.Osmolyte 1.2 60 milliliters (ml) per hour for 20 hours via gastric tube.Eucerin cream for dry skin.Wound care for left heelWound care for pressure area on left ear.Wound care for pressure area under the left side where trach ties were secured.Weekly skin checks on bath days.R24's care plan report dated 4/1/25, included a care plan titled Alteration in Skin Integrity related to diagnoses of diabetes and decreased mobility. The care plan had three sections: problem, goal and approach.The Problem section included the following information:Problem dated 11/20/24, indicated R24 had several pressure areas on admission, located on his coccyx, right scapula, right thigh and left thumb.Problem was updated on 4/10/25, and indicated R24 still had a pressure area on his coccyx, left ear and right scapula.The problem section was last updated on 7/8/25, and indicated pressure areas on his coccyx and right scapula.The Goal section dated 11/20/24 indicated resident's skin alteration will heal without infection.The Approach section included the following information:The approach section, dated 11/20/24 directed staff toEncourage adequate nutrition and hydration.Encourage adequate nutritionMonitor for indication of infection, contact MD if present.Physical therapy/occupational therapy for screening as appropriate.Treatment/dressing per MD orders.Turning and repositioning every 2-3 hours and as needed. The approach section dated 9/26/25 directed staff,Use pillows for repositioning him off bony prominences including his coccyx, scapula and other areas prone to breakdown.Use specialty mattress and float his heels or use protectors.Positioning for comfort.The Care Plan report indicated the skin care plan was last reviewed/revised on 11/25/25 at 6:07 pm. The care plan lacked interventions to address R24's ongoing skin changes.R24's Wound Care visit report dated 3/19/26, indicated R24 had a stage 2 pressure area on his left lateral distal leg, a stage 2 left lateral proximal leg, a stage 2 pressure area on his left ear and a right pressure area under the left side of the tracheostomy plastic part.R24's current physician orders included wound care orders for the pressure areas listed above.R24's Skin Assessments dated 3/23/26, and 3/30/26, indicated R24's skin was clean, dry and intact.During interview on 4/1/26 at 7:54 a.m., RN-A stated, R24 had several pressure areas and was seen weekly by the wound care specialist. RN-A stated the nurses were responsible for obtaining or receiving new wound care orders, but the care plan was updated by the nurse manager.During interview on 4/2/26 at 1:34 p.m., RN- B stated the care plans were updated as needed to reflect resident's medical changes. RN-B added the care plans were reviewed and updated when a MDS assessment was completed. RN-B verified the last time R24's approach section of the care plan was updated, was done on 9/26/25. Between 9/26/25 and 4/1/26 R24 wounds and wound care orders were changed but the care plan was not updated. RN-B stated she expected the care plans would be accurate and reflected resident's problems, goals, and interventions.Facility's policy titled Comprehensive assessment and Care Planning dated 2/26/26, indicated a registered nurse must conduct or coordinate each assessment with the appropriate participation of health professionals, and sign and certify that the assessment was completed. The assessment must accurately reflect the residents' status. The policy also indicated the facility should use the results of the assessment to develop, review and revise the residents' person-centered comprehensive care plan.

Based on observation, interview and document review, the facility failed to monitor for signs and symptoms of bleeding and failed to follow up with provider to reinstate an anticoagulant medication for 1 of 1 resident (R31) reviewed for change in condition. In addition, the facility failed to obtain laboratory results and update the primary provider in a timely manner to initiate treatment for a urinary infection for 1 of 1 resident (R31) reviewed for urinary infection.Findings include:F31's comprehensive Minimum Data Set (MDS) dated [DATE], indicated R31 was comatose, depended on staff members for activities of daily living, and received food and medications through a tube feeding. MDS indicated R31 received oxygen, had a tracheostomy, received oral suctioning, and had a gastrostomy tube. MDS indicated diagnoses of stroke, atrial fibrillation, heart failure, hypertension, nontraumatic intracerebral hemorrhage, acute and chronic respiratory failure, persistent vegetative state, autonomic dysreflexia and unspecified convulsions.AnticoagulantR31's March Medication Administration Record (MAR) indicated R31 received 5 mg of Eliquis twice a day from 3/1/26 through the morning dose on 3/9/26.R31's progress notes indicated3/9/26 at 2:02 a.m., R31's urine was dark red. The nurse contacted on-call provider to report R31's status. On-call nurse practitioner (NP) directed staff to continue to monitor and wait until the next day. On-call NP ordered to continue Eliquis as ordered due to risk of clotting.3/9/26 at 3:49 p.m. R31's NP was updated about hematuria (blood in urine), and she held the Eliquis. 3/9/26 at 10:59 p.m. note indicated R31's brief was changed 3 times, still had blood in the urine, and staff were waiting for lab results.3/10/26 at 11:00 p.m. note indicated hematuria was noted again and a urine sample was collected. A fax request was sent to lab to be picked up the next day.3/17/26 at 10:47 a.m. note indicated provider will hold/discontinue Eliquis because of bleeding of the resident.3/24/26 at 3:45 p.m. note indicated daughter wanted Eliquis restarted. NP was contacted and she restarted previous Eliquis order. R31 receive the first dose in the morning.R31's Active Orders report dated 4/1/26 included an order for Eliquis 5 milligrams (mg) twice a day. This order was dated 3/25/26.During interview on 3/31/26 at 11:17 a.m., family member (FM)-A stated on 3/8/26, she noted blood in R31's urine and reported it to the nurse on duty. On 3/9/26 she was informed R31's Eliquis was placed on hold. FM-A stated she visited R31 every day and helped staff to provide cares for her, including changing her brief. FM-A stated after 3/8/26, she did not see any blood in R31's urine, and the staff did not report further bleeding episodes to her. On 3/24/26, FM-A visited R31 while nurse on duty administered the morning medications. R31's Eliquis was not administered. FM-A talked to the nurse and found out the Eliquis had been on hold since 3/9/26. FM-A stated she asked nurse on duty to call the NP and asked her to restart the medication. The nurse contacted the NP, and the medication was restarted on 3/24/26.During interview on 4/2/26 at 12:50 p.m., assistant director of nursing (ADON) stated the Eliquis order on the MAR was written as 'hold/discontinued' because their computer program discontinues any medication placed on 'hold'. ADON verified she contacted the NP and wrote the 3/17/26 progress note. The 3/17/26 indicated provider will hold/discontinue Eliquis because of bleeding of the resident. ADON verified the electronic medical record (EMR) lacked documentation about further bleeding monitoring after 3/10/26. ADON stated the facility failed to clarify the order to hold the Eliquis. ADON stated her expectation was for nursing staff to monitor, document bleeding and update the NP. ADON added, the order also needed to include directions to monitor for bleeding, and when to update the NP on a pre-determined date. Urinary infection, R31's progress notes indicated,3/9/26 at 2:02 a.m., R31's urine was dark red, and a urine sample was collected. Contacted on-call provider to report R31's status. On-call nurse practitioner (NP) directed staff not to send the urine sample to the laboratory, continue to monitor, and wait until the next day. On-call NP ordered to continue Eliquis as ordered due to risk of clotting.3/9/26 at 3:49 p.m. R31's NP was updated about hematuria (blood in urine), and she ordered a urinalysis, and held R31's Eliquis. Sample was sent to the laboratory.3/9/26 at 10:59 p.m. note, indicated R31's brief was changed 3 times, still had blood in the urine, and staff were waiting for lab results.3/10/26 at 12:46 p.m. note indicated the urine sample was cancelled by the laboratory due to wrong spelling of resident's name. Laboratory advised them to send a new sample.3/10/26 at 11:00 p.m. note indicated hematuria was noted again and a urine sample was collected. The staff faxed the lab to request the urine sample to be picked up the next day.3/11/26 at 12:58 p.m. note indicated the urinalysis sample was picked up by the lab.3/11/26 at 3:11 p.m., indicated the staff left a message to NP regarding the urinalysis lab report.3/11/26 at 3:53 p.m. note indicated the NP called back, gave no new orders and instructed staff to wait for urine culture results since the results were negative for nitrate.R31's progress notes lacked documentation about urine culture results or contacting the provider to obtain orders for an antibiotic.R31's laboratory culture results faxed to facility on 3/15/256 indicated growth of >100,000 CFU/ml Escherichia coli and >100,000 CFU/ml Proteus mirabilis.R31's March MAR did not include documentation of resident receiving an antibiotic. During interview on 3/31/27 at 11:17 a.m., FM-A stated one of the symptoms R31 displayed when she had a urinary infection was the presence of blood in the urine. FM-A asked the nurse on duty to call the provider and to request laboratory work to check for a urinary infection. FM-A stated the nurse contacted the primary provider and a urine sample was going to be picked up on 3/9/26. On 3/10/26 FM-A was informed a new urine sample needed to be collected because R31's name was not properly spelled. The second sample was collected on 3/11/26. On 3/12/26 the nurse told her the urinalysis was negative. FM-A stated on 3/13, 3/14, 3/15 and 3/16 she asked the staff for the urine culture results. On 3/17/26, FM-A stated R31 had a thick light brown-amber discharge in her brief. FM-A called the nurse on duty and asked her if the culture results were back from the laboratory. FM-A stated on 3/18/26, the nurse on duty told her R31 was started on an antibiotic for a urinary infection. FM-A stated, apparently the staff contacted the provider on 3/17/26. FM-A stated she was upset because nobody called her to inform her about the new orders. Later, FM-A received a copy of the laboratory reports and noted the culture results were faxed to the facility on 3/15/26. FM-A stated she was unable to understand why the nursing staff waited until she asked about the results to do something. FM-A stated, I am upset thinking she [R31] was uncomfortable with a urinary infection, and she was unable to communicate her discomfort.During interview on 4/2/26 at 8:46 a.m., registered nurse (RN)-H stated, when a urine sample was collected it should be accurately labeled with residents' name, date, time, and resident's medical record number. RN-H stated the laboratory usually collected samples by 3 p.m. on their regular days, and as needed if a lab test needs to be done as soon as possible.During interview on 4/2/26 on 4/2/26 at 8:51 a.m., health unit coordinator (HUC) stated the nurse collected urine samples, completed a lab form and placed it in the laboratory binder. HUC stated the nurses needed to make sure the sample was collected. If a sample was not collected, they needed to contact the lab. HUC stated the laboratory faxed the results to the appropriate nurses' station.During interview on 4/2/26 at 9:06 p.m., nurse manager/RN-B stated after the laboratory collected a urine sample, the expectation was for the nurses to look for the results. If the results were not faxed by the end of their shift, the nurse needed to call the laboratory and request the results. RN-B added if the results were not available, the next shift needed to follow up. Once the results were available, the nurses needed to call the doctors with the results.During interview on 4/2/26 at 12:29 p.m., assistant director of nursing (ADON) stated R31's urine sample was picked up on 3/9/26, but her name was spelled incorrectly. ADON stated on 3/10/26, the family asked about the lab results. A new sample was obtained and was sent to the lab. ADON stated on 3/15/26, the lab faxed the results, but facility staff called the NP on 3/18/26, and obtained orders for an antibiotic. ADON added the results should have been called as soon as they were available. ADON stated the nurses took too long to call the NP, and R31's infection could have worsened.During interview on 4/2/26 on 4/2/26 at 1:34 p.m. RN-D, who was covering for a vacant nurse manager position, stated lab results should be called to the providers as soon as they become available. RN-D stated she didn't see the results, didn't have an explanation for the delay, and had no other information.Facility's policy titled Change in Condition, Resident Examination and Evaluation dated 11/10/25 indicated it was the policy that a resident examination and evaluation was completed upon admission, with a change in physical function, or with an acute change in condition. When a significant change in the resident's physical, mental, or psychosocial status was identified by the licensed nurse, or when there was a need to significantly alter treatment. The licensed nursing associate consulted with attending provider and notified the resident representative.

Based on observation, interview and document review, the facility failed to monitor for orthostasis, a common side effect of antipsychotic medication, for 2 of 5 (R2 and R79) residents reviewed for unnecessary medications who also had a history of falls. Findings include:A National Library of Medicine (NIH) Management of Commons Adverse Effects of Antipsychotic Medication article, dated 9/2018, identified the elderly were at risk of adverse effects (i.e., falls) of antipsychotic medication. The article outlined, All antipsychotics carry some risk of orthostatic hypotension . [which can] lead to dizziness, syncope, falls . it should be evaluated by both history and measurement . Risk factors include systemic diseases causing autonomic instability (e.g., diabetes, alcohol dependence, Parkinson's disease), dehydration, drug-drug interactions, and age.R79R79's annual Minimum Data Set (MDS), dated [DATE], indicated R79 was cognitively intact and independent with most activities of daily living (ADLs). The MDS further indicated R79 had taken antipsychotic medications during the look-back period. R79'd orders indicated an order for lurasidone (an atypical antipsychotic medication), dated 3/12/25, 40 milligrams (mg) once a day for schizophrenia, and risperidone (an atypical antipsychotic medication), dated 3/31/26, 5mg twice a day for bipolar. R79's electronic medical record (EMR) lacked any evidence orthostatic blood pressure was being monitored. R79's progress notes, dated 3/24/26, directed staff to provide R79 with a water pitcher at the beginning of each shift to help manage her blood pressure. R79's progress note, dated 3/17/26, indicated staff found R79 sitting on the bathroom floor, stating she lowered herself to the floor after she felt dizzy. R79's progress note, dated 2/5/26 indicated staff met with R79 related to a recent fall. R79's progress note, dated 1/22/26, R79 was found on the floor outside the smoking area. R79's progress note, dated 1/1/26, R79 fell coming inside from the smoking area. During an interview on 4/2/26 at 9:12 a.m., R79 stated she feels dizzy at times which causes her to fall. During an interview on 4/2/26 at 9:20 a.m., stated R79 had falls once and awhile and was able to ambulate independently around the facility and would call staff for help if she felt unsafe. R2 R2's significant change MDS, dated [DATE], indicated R2 was cognitively intact and dependent on staff for most ADLs. The MDS further indicated R2 took antipsychotic medications during the look-back period. R2's orders, dated 2/5/26, indicated an order for clozapine (an atypical antipsychotic medication) 300 mg at bedtime for paranoid schizophrenia. R2's electronic medical record (EMR) lacked any evidence orthostatic blood pressure was being monitored. During an interview on 4/2/26 at 11:10 a.m., clinical manager and registered nurse (RN)-B stated R2 had a fall with major injury and was currently only walking with physical therapy and was pivot transferring with staff. RN-B further stated R79 would fall if her blood pressure dropped, causing her to get dizzy. RN-B confirmed that neither R2 nor R79 had care planned or ordered interventions to monitor orthostatic blood pressure, stating it would be a good idea for R79 with her history of falls and dizziness. During an interview on 4/2/26 at 2:10 p.m., the regional director stated it was expected that orthostatic blood pressure be monitored monthly for residents on antipsychotic medications. A facility policy titled Psychotropic Medication use, dated 9/7/23, indicated medication side effects to be monitored (i.e. orthostatic blood pressure.)

Based on observation, interview, and document review, the facility failed to ensure resident identifiable personal health information (PHI) was kept secured and out of public view. This had potential to affect all 73 residents of the second, third and fourth floors whose personal information was listed on exposed care sheets. Findings include: Document titled 3rd Floor Nursing Care Work Sheet downloaded 1/14/25, indicated, Carry this care worksheet with you during your shift; do not leave out for others to see (HIPAA/PHI) [Health Insurance Portability and Accountability Act - federal standards to protect PHI - Personal Health Information]. During observation on 1/15/25 at 8:37 a.m., on the third-floor transitional care unit (TCU), an alcove in the middle of the hallway across from room [ROOM NUMBER] contained two large plastic rolling containers with lids, a linen cart that was covered, and a tall office type chair. On top of the covered linen cart was an unattended, 3rd Floor Nursing Care Work Sheet containing twenty five resident room numbers, names, and information on each resident such as assistance needed for dressing, grooming, oral cares, continence, toileting, bed mobility, transfer, ambulation safety devices, eating, bathing, infection control precautions status, and comments to include information on hearing, positioning needs, keeping bed in low position, fall risk, elopement risk, refusals of care, smoking status, bedrail positioning, and tracheostomy and gastric tube presence. Two staff members walked past the unattended care sheet. During interview on 1/15/25 at 8:39 a.m., nursing assistant (NA)-A pointed to the third-floor unattended care sheet and stated, Care sheets should not be left unattended. During interview on 1/15/25 at 8:42 a.m., NA-B verified the third-floor unattended care sheet was his responsibility and stated, I forgot about it and left it there [pointing to the alcove]. There is private information on this sheet and should not be visible to anyone. During observation and interview on 1/15/25 at 9:39 a.m., on the fourth-floor of the facility, an unattended, 4th floor Nursing Care Work Sheet containing twenty five resident room numbers, names, and information on each resident such as assistance needed for dressing, grooming, oral cares, continence, toileting, bed mobility, transfer, ambulation safety devices, eating, bathing, infection control precautions status and comments to include information on hearing, positioning needs, keeping bed in low position, fall risk, elopement risk, refusals of care, smoking status, bedrail positioning, and tracheostomy and gastric tube presence was left face up on an unattended medication cart located in the common area directly across from the nursing station. During interview with assistant director of nursing (ADON) at 9:43 a.m., the ADON verified the unattended fourth-floor care sheet contained, patient identifying information. The ADON stated, This could be visible to people who shouldn't see it. During interview with RN-B on 1/15/25 at 10:27 a.m., RN-B stated, unattended care sheets [sic] should not happen. [contains] Private information that others should not see. During observation on 1/16/25 at 8:48 a.m., on second-floor across from room [ROOM NUMBER], the alcove contained an unattended care sheet titled, 2nd Floor NAR WORKSHEET. The worksheet contained twenty three resident room numbers, names, and information on each resident such as assistance needed for dressing, grooming, oral cares, continence, toileting, bed mobility, transfer, ambulation safety devices, eating, bathing, infection control precautions status and comments to include information on hearing, positioning needs, keeping bed in low position, fall risk, elopement risk, refusals of care, smoking status, bedrail positioning, and tracheostomy and gastric tube presence. During interview with trained medication aide (TMA)-A on 1/16/25 at 8:49 a.m., TMA-A pointed to the second-floor unattended care sheet and stated, [that] has patient information and [it is a] violation of HIPAA. During interview on 1/16/25 at 8:50 a.m., NA-D pointed to second-floor unattended care sheet and stated, should not be left open. Violation of HIPAA. [contains] patient information. [staff] should have this in their pocket and not out in the open. During interview with director of nursing (DON) on 1/16/25 at 11:15 a.m., DON stated, care sheets should always be out of sight. It is a privacy concern. 49339

Based on interview and document review, the facility failed to ensure the resident and/or resident representative participated in care conferences for the planning process and development of interventions for 1 of 1 residents (R36) reviewed for participation of care planning. Findings include: According to the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual dated October 2023, the RAI is used to, assist staff with evaluating goal achievement and revising care plans accordingly by enabling the nurse home to track changes in the resident's status. The RAI, establishes a course of action with input from the resident (resident's family and/or guardian or other legally authorized representative), resident's physician and interdisciplinary team that moves a resident toward resident-specific goals utilizing individual resident strengths and interdisciplinary expertise. The Assessment Reference Date (ARD) refers to the specific endpoint for the observation period in the MDS assessment process and is federally mandated to be completed on admission, quarterly (every 92 days), annually, with a significant change in status (SCSA), and on discharge. R36's quarterly Minimum Data Set (MDS) dated [DATE] identified R36 with severe cognitive impairment, was dependent on staff for personal hygiene, toileting, showers/bathes, dressing upper and lower body and turning in bed. In addition, R36 with diagnoses of Alzheimer's, dementia, hemiplegia affecting right dominant side, and malnutrition. R36's electronic medical record (EMR) indicated the MDS assessments were documented and submitted on the following dates: - 1/3/24 - quarterly - 3/27/24- quarterly - 6/26/24- quarterly - 7/21/24 - SCSA (significant change) - 10/16/24- quarterly Care Conferences were documented on 1/17/24, 4/9/24, and 7/17/24 following discharge from hospice services. The EMR lacked evidence of a care conference being done after 7/21/24. During interview with the registered nurse/infection control preventionist (ICPC) on 1/14/25 at 12:10 p.m., ICPC stated, we do it [care conferences] when the ARD is due or as needed. [Social Worker] takes care of the care conferences. During interview with facility's director of social services (SS)-A on 1/15/25 at 2:23 p.m., SS-A stated she was responsible for scheduling and conducting the care conferences for all residents of the facility. SS-A stated R36 is due for one and, should be done every three months. In addition, SS-A stated [R36] is one to two months late. It should be done with every MDS cycle, but it was not done. SS-A unable to state why R36's October 2024 care conference was not done. During interview with family member (FM)-A on 1/16/25 at 7:25 a.m., FM-A stated she was R36's primary emergency contact. FM-A stated she was invited to R36's care conferences and was last invited, Last Summer [2024] and not since then. During interview with director of nursing (DON) on 1/16/25 at 10:40 a.m., DON stated expectation of care conferences to coincide with the MDS assessments. Facility policy titled Comprehensive Assessments and Care Planning dated 11/2017 state, Residents and resident representative will be involved in the comprehensive person-centered care planning. Facility policy titled Resident/Family Participation in Care Planning dated 11/28/2017 state, Care conference documentation includes that[sic] staff, resident and others that participate. And, Responsible for Implementation: Social Services, Nursing.

Based on observation, interview and document review the facility failed to revise and update a comprehensive care plan for 1 of 1 resident (R23) who had a foley catheter, psychology provider anxiety interventions, and refusals of care not identified in the care plan. Findings include: R23's annual Minimal Data Set (MDS), dated [DATE], indicated R23 was admitted to the care facility on 12/18/19, had moderate cognitive impairment and was dependent on staff for toileting and bathing and required touching assistance with personal hygiene. R23's Hospital Discharge Summary, dated 12/31/24, indicated R23 was hospitalized on [DATE] and discharged back to the care facility on 12/31/24. A foley catheter was placed at the hospital on 12/28/24. R23's Orders indicated a nursing order, dated 1/11/25, for staff to monitor urine output every shift. R23's Active Orders, printed 1/16/25, lacked any other order related to R23's foley catheter. R23's Associated Clinic of Psychology (ACP) note, dated 12/13/24, indicated several interventions for R23's generalized anxiety disorder and major depressive disorder including milieu (a person's social environment) management/positive focus/socializing by tidy up R23's space and engaging in a blinds open program everyday to increase natural daylight exposure. R23's ACP note, dated 1/3/25, indicated several new and similar interventions for R23's generalized anxiety disorder and major depressive disorder including ensuring important items such as the TV remote and eyeglasses were left within reach for R23's sense of agency and control, continue to encourage staff to assist with cleaning up and organizing R23's room, use a non-judgmental, patient centered approach to encourage R23 to get up, out of bed with phrases such as I've heard you say you get so tired of being this bed. I'd be happy to get you up after lunch to get you get a soda and change it up for a while, and continue to engage in an open blinds program every day where curtains are opened in the morning and closed at night. R23's care plan, printed 1/16/24, indicated R23 was fully incontinent of bladder and for staff to check and change resident every 2-3 hours and prn [as needed]. Continue to offer commode, though I decline toileting. R23's care plan further indicated R23 had a foley catheter removed 3/29/21, and to encourage patient to void when urge is noted. The care plan lacked any updates on R23's current catheter use to ensure proper monitoring and catheter cares, and lacked any updates from R23's ACP notes to help R23 with a sense of control and to help reduce his anxiety and depression. R23's Care Work Sheet, printed 1/14/25, lacked any interventions for R23's foley catheter use and further lacked any ACP interventions for staff to use when approaching and providing cares for R23. During observation on 1/14/25 at 8:58 a.m., R23 was laying in bed with the blinds closed, a foley catheter bag hooked onto the side of his bed. During an interview on 1/15/25 at 10:20 a.m., R23's nurse practitioner (NP) stated R23 had his foley catheter placed during his most recent hospitalization . The NP further stated urology, who placed the catheter, would usually remove it and she believed it would be temporary, stating she will have to make a plan for R23's catheter. During an interview on 1/15/25 at 10:35 a.m., registered nurse (RN)-C stated, as a nurse she would be expected to review the residents' care plans and orders prior to providing care to the residents to gain an understanding of what care, treatment, and medications to administer during her shift. RN-C confirmed the electronic medical record (EMR) lacked indication of and direction for R23's catheter. During an interview on 1/15/25 at 10:49 a.m., nursing assistant (NA)-B stated he worked with R23 about once a week, and this day was the first time he had noticed R23 had a catheter. NA-B stated the aides were expected to use the care work sheets to know what cares to provide a resident. During an interview on 1/16/25 at 9:33 a.m., clinical manager and RN-I stated it would be expected for the nurses and nursing assistants to use the residents care plans and care work sheets everyday while working with the residents. RN-I stated the nursing aides should report to the nurses if something was missing or different on the resident care sheets for updates. RN-I stated it was her and the MDS nurse's responsibility to update the care plans. The MDS nurse would generally review the resident's hospital discharge paperwork to review for any necessary care plan changes, confirming R23's foley catheter use should be care planned. RN-I stated ACP notes should be reviewed with social services and herself and discussed at IDT to ensure any new recommendations or updates are on the residents' care plans. RN-I stated keeping care plans up to date with the residents' current status is important to ensure nurses and nursing assistants are providing accurate care to the residents. During an interview on 1/16/24 at 10:55 a.m., the MDS nurse stated she reviewed the resident's hospital discharge summaries and generally updated them during an MDS cycle, though the nurse managers also reviewed them to try to catch changes in real time. The assistant director of nursing also confirmed that care plans should be updated in real time and that it was a work in progress to ensure care plans were updated and accurate.

Based on observation, interview, and document review, the facility failed to ensure routine personal hygiene and self-care was completed to promote a dignified appearance and reduce the risk of complication (i.e., scratches) for 3 of 4 residents (R23, R36, and R53) reviewed for activities of daily living (ADLs) and whom were dependent on staff for their care. Findings include: R53 R53's quarterly Minimum Data Set (MDS), dated [DATE], identified R53 had severe cognitive impairment, demonstrated no speech, and was unable or rarely able to be understood. Further, the MDS identified R53 was dependent on staff for nearly all self-care. R53's care plan, dated 11/22/24, identified R53 needed assistance with dressing and personal hygiene due to a history of stroke and hemiplegia (paralysis of one side). The care plan listed a goal which read, All my ADL needs will be anticipated and met by staff through the review date, and multiple interventions including assist of one with personal hygiene and, Staff to trim Resident's finger and toe nails as needed following weekly bath. The care plan lacked any identified nail length preferences. On 1/14/25 at 9:15 a.m., R53 was observed lying in bed while in his room. R53's eyes were closed and adjacent ventilator equipment was present at the bedside. R53 did not open his eyes or respond verbally with interaction. However, a few moments later, R53 picked up his left hand without being asked or commanded, and he shook it several times in the air with his eyes seeming to squint down or grimace with the motion. R53's hands were visible and had no braces or splints present. R53's fingers on both hands were clenched into his palms, however, multiple fingernails were visible and long in length with the nail being several millimeters (mm) long and, at times, pressing into the palm skin. Further, multiple nails had visible dark-colored substance underneath of them. Later on 1/14/25 at 11:38 a.m., R53's family member (FM)-B was interviewed. FM-B stated R53 getting bathed and personal hygiene care was another gray area of care and expressed R53, in general, wasn't being cleaned up well adding, Not as often as we'd like them to be [doing it]. FM-B stated R53 was often found unshaven and, at times, with long fingernails adding concern, He will just scratch himself. FM-B reiterated they wanted basic cares completed for R53 but often It's just not happening. The following day, on 1/15/25 at 8:45 a.m., R53 was again observed lying in bed with his eyes closed. R53 remained non-verbal with interaction and was connected to an external tube feeding pump. R53's fingernails remained long with several nails having dark-colored debris present under them as had been observed the day prior. R53's progress note, dated 12/23/24, identified R53 had a brace applied to his right hand. The note continued, Finger nails clipped. No discomfort . R53's subsequent Weekly Skin Check(s), dated 12/26/24 to 1/9/25, identified a total of three bed baths were completed on 12/26/24, 1/2/25, and, 1/9/25, respectively. These completed checks all listed a question to be answered by the staff which read, Was nail care completed?[,] which was answered, Not Necessary, on each of the completed evaluations. On 1/15/25 at 8:55 a.m., nursing assistant (NA)-E was interviewed. NA-E explained R53 was total care with everything and spent most of his time in bed due to being non-verbal and having a ventilator. NA-E stated nail care would be completed by the NA since R53 was not diabetic, and it should be completed as often as we need to. NA-E stated R53's nails and hands were, at times, hard to clean or trim as he would pull his hands away but reiterated staff have to make an effort. NA-E observed R53's nails at this time and expressed aloud, They could probably use a clipping, adding further, [They're] start digging into his skin. NA-E stated two people usually help to trim the nails due to R53's behavior but expressed it could be done. Further, NA-E stated any attempts or refusal of nail care wouldn't likely be documented by the NA as they just tell the nurse. R53's medical record was reviewed and lacked evidence nail care had been attempted or refused since 12/24/24, despite R53 having long, soiled nails present and needing total assistance with personal hygiene. When interviewed on 1/15/25 at 9:29 a.m., registered nurse (RN)-D stated R53 was total help with cares but would, at times, fight you a lot with some of them. RN-D stated two people usually were needed to get R53's nails clip and, at times, R53's family member would help them. RN-D stated they last helped R53 with nail care couple weeks ago but verified they should be clipped on bath day. RN-D stated nail care was charted using the Weekly Skin Check and any attempt or refusal should be charted in the record. On 1/15/25 at 12:49 p.m., registered nurse manager (RN)-E was interviewed. RN-E stated nail care should be address every time they have a shower [bath]. RN-E explained R53 could be a little difficult to get it completed on as, at times, the left arm goes everywhere but acknowledged the charting reflected such care was 'not necessary' adding they were unsure why it had been marked as such. RN-E stated R53's nails should have been clipped and kept clean adding they just updated his orders to include nail care and a nurse sign-off. RN-E stated they did this order update for everyone adding, If he's missed, who else is missed? RN-E stated it was important to ensure nail care was completed as his nails could penetrate the skin or he could scratch himself. RN-E verified the medical record lacked evidence nail care was attempted or provided since 12/24/24 adding aloud, no, no, no [none]. 44656 R36 R36's quarterly MDS, dated [DATE], identified R36 with significant cognitive impairment, did not reject care, dependent on staff for toileting, baths, upper and lower body dressing, personal hygiene, transfers, and bed mobility. In addition, R36 with diagnoses of Alzheimer's, dementia, hemiplegia (paralysis on one side of the body), stroke, and malnutrition. Review of document titled 3rd Floor Nursing Care Work Sheet scanned 1/14/25, identified all residents of third floor with column identifying 25 resident room numbers, names, and information on each resident such as assistance needed for dressing, grooming, oral cares, continence, toileting, bed mobility, transfer, ambulation safety devices, eating, bathing, infection control precautions status, and comments to include information on hearing, positioning needs, keeping bed in low position, fall risk, elopement risk, refusals of care, smoking status, bedrail positioning, and tracheostomy and gastric tube presence. This document identified: Facial hair and nail care (men and women) occur on bath days, Report off to your nurse; make sure you've brought any change in condition or concerns to the nurses attention, and Refusals of care/treatment or inability to complete identified cares for your residents must be reported to nurse. 3rd Floor Nursing Care Work Sheet scanned 1/14/25, identified R36 with a column titled, Bathing and identified, Aide trim nails. R36 care plan (CP) revised 9/16/24 identified, Resident is dependent on staff for grooming cares, which consists of bath/shower, shampoo, nail care shave and full skin assessment. Resident with diagnoses of CVA [cerebral vascular accident], dementia. During observation on 1/14/25 at 2:14 p.m., R36 was in bed with head of bed elevated and meal tray in front of her on rolling bedside table. R36 had both feet resting on pillow with heels positioned off mattress. The left foot middle toenail was half an inch long while rest of toenails on both feet were thick, jagged, and extending beyond the toe rubbing against the sheet and covers. All fingernails were half an inch to three quarters of an inch long, with dark matter noted, and their left hand was clenched in a fist with nails pressing into palm of hand. During interview with nursing assistant (NA)-A on 1/15/25 at 10:13 a.m., NA-A stated she was familiar with R36 and worked with her many times. NA-A stated, nail care is done the activities [department], they put fingernail polish and stuff like that. No, I do not do nail care on [R36]. NA-A stated, no nail for [R36] after showers by the [nursing] aides. NA-A stated, if nails are long on other residents, I would tell [nurse]. NA-A looked at R36's fingernails and toenails and stated, [R36's] fingernails are half inch to one inch long. NA-A verified dark matter under right thumbnail and, yes, toenails are long .half inch long. NA-A stated, [R36] don't want them trimmed. I haven't noticed or told anyone about them because she always refuses. I let nurses deal with that. During interview with NA-C and NA-D on 1/15/25 at 10:50 a.m., NA-C stated, nail care was done by nursing assistants, unless [resident] is diabetic. NA-D stated nail care involved clipping and file [nails]. During interview with infection control preventionist and nurse manager (ICPC) on 1/15/25 at 10:55 a.m., ICPC stated they expected nail trimming and maintaining nails to be done on shower day and prn mainly nurses and aides. ICPC stated she was aware of R36's refusals, but facility had nothing to address the R36's refusals for nail care. ICPC stated, [R36] has the right to refuse. During interview with activities director (AD) on 1/15/25 at 12:04 p.m., AD stated she had worked at facility for three years and the activities department painted the nails, but did not file, clip, or trim them. R36's Weekly Skin checks documented by nurses for week of 1/9/25, 12/23/24, and 11/18/24, all indicated, Refused nail care. The record lacked documentation for the weeks of 1/13/25, 12/30/24, 12/16/24, 12/9/24, 12/2/24, and 11/25/24. During observation and interview with RN-C on 1/16/25 at 7:59 a.m., RN-C stated she was very familiar with R36 and stated, nail care[sic] cut them by nurses when needed on shower days. RN-C stated if very long we try to talk to the nurse after refusals and go to nurse manager and let the MD [provider] know. We are to document on weekly skin check in chart. RN-C stated, [R36] don't allow us to cut her nails. She needs a team of people to work together to go in and approach her and try to convince her to let us trim them. We should involve the family in the conversations. It takes a team to get her to allow us to cut her nails. RN-C stated she had not received report from aides regarding R36's nails and did not know of any communication or plan by facility to ensure nail care was being done for R36. RN-C looked at R36's fingernails and stated, they definitely need [sic] to be cut. Both feet [nails] are too long. During interview with family member (FM)-A on 1/16/25 at 7:30 a.m., FM-A stated she was R36's primary emergency contact. FM-A stated R36 required help with all hygiene, [R36] does nothing for herself. Also, [R36] scratches herself and cuts herself [with long nails]. But they [facility] got to keep them cut. Those nails on both [fingernails and toenails]. RM-A stated, it is ok if they [facility] knock her out if they have to to cut them off. I want them off. FM-A stated facility never contacted her to discuss nail care approaches. 47495 R23 R23's annual Minimal Data Set (MDS), dated [DATE], indicated R23 had moderate cognitive impairment and was dependent on staff for toileting and bathing and required touching assistance with personal hygiene. R23's Care Plan, revised 9/17/24, indicated R23 was dependent on staff for grooming cares, which consists of bath /shower, shampoo, nail care, shave, and full skin assessment. Resident with diagnosis of left side hemiplegia [inability to move] and CVA with an intervention to bathe R23 on Monday evenings. R23's care plan also included R23 was limited in ability to maintain grooming/personal hygiene R/T [related to] hemiplegia and hemiparesis following cerebral infarction to left side, generalized muscle weakness with an intervention to shave R23 on bath day with his electric shaver. R23's Nursing Care Work Sheet, dated 1/14/25, indicated, under the bathing category, the nursing assistants were to shave R23's facial hair. During interview and observation on 1/14/25 at 8:58 a.m., R23 was laying in bed, hair disheveled with approximately half inch long facial hair. R23 stated he preferred to be clean shaven but staff did not have time to assist him. On a shelf in R23's room was an electric shaver plug into an outlet. During interview and observation on 1/15/25 at 8:42 a.m., R23 was up in his wheelchair and had not been shaved. When asked again if he would like to be shaved, R23 shook his head yes. During an interview on 1/15/25 at 10:35 a.m., registered nurse (RN)-C stated she usually saw R23 clean shaven and that he had been readmitted to the facility on Friday, 1/10/25 after hospitalization with facial hair. RN-C was unsure why R23 had not been shaved with his bath day on Monday. During an interview on 1/15/25 at 10:49 a.m., nursing assistant (NA)-B stated the nursing assistants used the care work sheets to know how to care for each resident, including when their bath day is. NA-B further stated it was expected that all residents were offered to be shaved on bath days. During an interview on 1/16/25 at 9:33 a.m., nurse manager RN-I stated it was expected that the nursing assistants use the care work sheets every shift to know what cares to provide the resident. RN-I stated when a resident was readmitted after hospitalization it was expected they receive at least a bed bath, and residents should always be offered to be shaved during bathing. The Activities of Daily Living policy dated 2021, indicated care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with hygiene (bathing, dressing, grooming, and oral care).

Based on observation, interview, and document review, the facility failed to ensure care-planned interventions for activities of interest were provided or offered for 1 of 2 residents (R53) reviewed for activities and whom was non-verbal and unable to be understood. Findings include: R53's quarterly Minimum Data Set (MDS), dated [DATE], identified R53 had severe cognitive impairment, demonstrated no speech, and was unable or rarely able to be understood. Further, the MDS identified R53 was dependent on staff for nearly all self-care. R53's most recent Activity Assessment, dated 11/25/24, identified R53 was a Christian and listed a section labeled, Specific Leisure Interests, which marked R53 as having a preference for card games, active sports, classical and jazz music, television and movie interests, and social visits adding, Res. will have 1:1 [one to one] visits. A section labeled, Programming Information, outlined R53 preferred 1:1 visits and was unable to participate with passive participation marked. Further, the evaluation concluded, Updated Care Plan on - 11/25/2024. R53's activities care plan, dated 11/25/24, identified a problem statement which read, Per family, res. enjoyment is listening to music, TV/movie shows and social visits with staff/family. The care plan outlined a goal which read, Per family, res. will listen to background classic, jazz, oldies, 50's & [NAME] music, TV/movie shows old time, science fiction and comedy and social visits with staff/family, along with multiple interventions including not listening to the news, staff setting up music on the radio or I-Pad, and tuning the TV to old time, science fiction or comedy shows. On 1/14/25 at 9:15 a.m., R53 was observed lying in bed while in his room. R53's eyes were closed and adjacent ventilator equipment was present at the bedside. R53 did not open his eyes or respond verbally with interaction. However, a few moments later, R53 picked up his left hand without being asked or commanded, and he shook it several times in the air with his eyes seeming to squint down or grimace with the motion. The room had a television mounted on the wall with a white-colored paper underneath which listed R53's favorite activities and television channels. The room also contained a CD player on the shelf. However, neither of these were activated or turned on and the room was silent. Later, on 1/14/25 at 11:29 a.m., R53's family member (FM)-B was interviewed and stated they were unsure if R53 would be able to enjoy activities or not adding he (R53) was kind of limited. FM-B stated R53 spent a majority, if not all, of his day in his room and expressed a few months ago someone had asked them about R53's activities but could not recall the specifics of the conversation. The following day, on 1/15/25 at 8:45 a.m., R53 was again observed in bed while in his room. R53's eyes remain closed and, again, he demonstrated no obvious response to verbal communication. R53 had a visible tracheotomy and was attached to an external tube feeding pump. However, again, the room was silent with no TV or radio or music being played in the room. When interviewed on 1/15/25 at 8:55 a.m., nursing assistant (NA)-E stated they had worked with R53 multiple times and described him as needing total care with everything. NA-E stated R53 did, at times, get up to a wheelchair but it was not every day. NA-E stated they had rarely, if ever, seen activities personnel in the room with him or doing one-to-one activities adding, Not to my knowledge, I haven't seen any. NA-E stated staff, at most, seemed to maybe peek in but that was it. NA-E stated nobody had ever told them to play music or have the television on for R53 adding aloud, Nope. NA-E stated the nursing staff and activities staff don't interact very well unless the NAs are told to get certain people up to some activities adding, They [activities] don't really communicate with us very much. NA-E stated they had, at times, seen R53 with his television set turned on and expressed there was a listing of channels taped to the wall to their recall which R53 enjoyed. NA-E showed this listing to the surveyor and verified it was posted in the room along with an activity calendar for the building. However, NA-E verified R53 did not attend any of the listed or advertised activities adding aloud, No. NA-E stated it was due to R53 using a ventilator and being unable to take it with him. Further, NA-E stated R53's wife visited and would, at times, turn on the TV or radio for R53 but added, I haven't seen her lately. On 1/15/25 at 9:29 a.m., registered nurse (RN)-D was interviewed and verified they were assigned to R53's care that day. RN-D explained R53 was total help with cares and expressed the wife would, at times, come and play music for him using the CD player in his room. RN-D stated themselves and staff didn't turn it on as the wife comes everyday, then adding aloud, But I don't know about Winter [if she visits]. When questioned on what, if any, activities were provided or done with R53, RN-D stated aloud, You'd have to ask activities. When interviewed on 1/15/25 at 10:15 a.m., therapeutic recreation director (TRD) explained R53 was supposed to have the television turned on for him adding such was care-planned and should be on. TRD explained the floor staff should be doing that or playing music for him and those items were basically it for his activities outside of some one-to-ones. TRD verified R53 did not attend group-based activities but explained there were some scheduled for his floor which could be attended, such as music, but getting him to those would be basically up to the nurse. TRD stated they had told staff R53 could attend the music groups on the floor if they brought him adding, I have told them. TRD stated the activities staff did complete one-to-ones with R53 and tracked those on the flowsheet which they would provide. However, TRD reiterated all staff should be turning on the television for R53 adding there was no specific schedule or times for that but rather should have it on throughout the day. TRD stated it was important to ensure the television was on so R53 had some type of stimulation. Later on 1/15/25, at 10:42 a.m., TRD provided R53's one-to-one tracking form. R53's One on One Visits Form, dated 9/2024 to 1/2025, identified all recorded one-to-one visits completed with R53 during the period. This recorded a total of five (5) visits since 12/1/24, and included: 12/1/24 Staff updated residents calendar. 12/16/24 Staff played [NAME] in Ipad and had social visit. 12/19/24 Staff had social visit with resident and made sure resident was comfortable . made sure TV was tuned. 1/1/25 Staff updated resident calendar to January. 1/10/25 Staff played [NAME] on Ipad and organized residents room. TRD verified the provided one-to-one tracking and reiterated all staff members, including nurse, should be playing music or turning on R53's radio. A provided Wellness & Life Enrichment policy, dated 3/2024, identified a facility' policy to involve residents in an ongoing program of activities designed to appeal to their interests and enhance their psychosocial well-being.

Based on observation, interview, and document review, the facility failed to ensure gastrostomy tube water flushes were provided per physician orders for 1 of 1 residents (R75) reviewed for tube feedings. Findings include: R75's quarterly Minimum Data Set (MDS) dated , 12/3/24 identified R75 was severely cognitively impaired, dependent on staff for all oral, toileting, personal hygiene, and mobility. In addition, R75 had diagnoses of a stroke (poor blood flow to a part of the brain causing cell death resulting in parts of the brain to function properly), diabetes, chronic obstructive pulmonary disease, respiratory failure, convulsions, gastrostomy (feeding tube inserted into the stomach), and a tracheostomy (surgical opening in the neck to allow a machine called a ventilator to help with breathing). R75's physician orders (PO) dated 11/2/24 stated, Tube Feeding: H2O (water) 150 milliliters[ml] per feeding tube q4hrs (every four hours). R75's care plan goal, dated 9/12/24 stated, Approach: Water flushes via GT [gastrostomy tube] per MD [physician]. During observation and interview on 1/14/25 at 8:58 a.m., registered nurse (RN)-A entered R75's room to administer medications through GT. R75 was lying in bed with the feeding tube not attached to her. RN-A set up area on rolling bedside table with liquid and crushed medications in three small medication cups, and two larger plastic drinking cups. RN-A obtained an unopened bottle of water from resident room stating it was for mixing R75's medications prior to administering them through the GT. RN-A opened the 500ml water bottle, sanitized her hands and applied gloves. She then used a large piston syringe, attached it to R75's GT port and pulled back on the syringe to assess for residual (amount of liquid drained from the stomach following administration of tube feeding). RN-A removed the piston syringe from R75's GT port and used the bottled water to dilute and mix the liquid and crushed medications. RN-A withdrew the medication into the syringe and re-attached the syringe to R75's GT port and administered the medications. RN-A repeated the process until all the medication cups were emptied leaving visible residue in each of the cups. RN-A poured water into each of the medication cups and administered the mixtures into R75's GT port. When this was completed, RN-A capped R75's GT port and moved on to changing R75's tracheostomy in-line suctioning apparatus. RN-A did not measure out water to flush R75's GT port completely to ensure the entire GT was clear of residual medications. During interview at 9:18 a.m., RN-A stated, I flushed with water in each of the med cups. RN-A agreed she did not measure out 150ml of water after administering R75's medications. During interview with RN/infection control preventionist (ICPC) on 1/16/25 at 10:18 a.m., ICPC stated expectation of nursing staff to flush [GT] with water after administering all of the medications. ICPC stated it was likely the medications administered to R75 by RN-A were not flushed adequately which could cause complications with GT flow. During interview with director of nursing (DON) on 1/16/25 at 11:06 a.m., DON stated, the water should be used to flush the tube after administration and not mixed in with the bottom of all the med cups. There could easily be residual thick medications in those cups, and it not considered clean water. That practice is likely to plug the GT. Facility policy for flushing gastrostomy tube prior to and following medication administration was requested and not received.

Based on observation, interview, and document review, the facility failed to comprehensively assess and, if needed, develop interventions or implement appropriate pain monitoring to ensure comfort for 1 of 2 residents (R53) reviewed for pain management and whom was non-verbal and unable to communicate their needs. In addition, the facility failed to assess for and implement, if requested, non-pharmacological pain interventions for 1 of 2 residents (R70) reviewed for pain management. Findings include: R53 R53's quarterly Minimum Data Set (MDS), dated [DATE], identified R53 had severe cognitive impairment, demonstrated no speech, and was unable or rarely able to be understood. The MDS identified R53 was dependent on staff for nearly all self-care and outlined R53 consumed no scheduled medication or non-pharmacological interventions for pain management. However, the completed staff evaluation for pain on the MDS, located under Section J - Pain, identified staff had recorded, C. Facial expressions (grimaces, winces, .), during the review period. On 1/14/25 at 9:15 a.m., R53 was observed lying in bed while in his room. R53's eyes were closed and adjacent ventilator equipment was present at the bedside. R53 did not open his eyes or respond verbally with interaction. However, a few moments later, R53 picked up his left hand without being asked or commanded, and shook it several times in the air with his eyes seeming to squint down or grimace with the motion. Later, on 1/14/25 at 11:43 a.m., R53's family member (FM)-B was interviewed and stated R53 not being in pain was very important to me and a concern for them. FM-B stated R53 was hard to read given his lack of verbal communication and post-stroke deficits adding, It's not easy to read his face. FM-B stated they were unsure if R53 was absolutely free of pain but expressed, in the past, some physicians had communicated they didn't believe R53 to have pain, however, FM-B reiterated aloud, I don't want him to be suffering. R53's most recent Pain Interview, dated 11/26/24, identified R53 consumed no scheduled pain medication or non-pharmacological interventions for pain; however, had received a PRN (as-needed) medication within the past five days. The evaluation identified the pain interview with R53 should not be completed as he was rarely or never understood. As a result, a Staff Assessment For Pain was completed which, again, identified R53 demonstrated facial expressions of potential pain within the past five day period. The frequency was marked, Indicators of pain or possible pain observed 1 to 2 days, and the evaluation identified a non-pharmacological intervention listed as, Rest, and scheduled Tylenol recorded for symptom management. The completed evaluation lacked any detail on how R53's pain would be monitored to ensure comfort despite R53 being recorded as unable to be understood, nor evidence what, if any, assessment had been completed to determine if the identified symptom management techniques (i.e., rest, Tylenol) were adequate or not despite R53 having physical symptoms of possible pain. R53's pain management care plan, dated 9/5/24, identified R53 was at risk for pain due to a history of stroke with hemiparesis (paralysis on one side of the body) and . no ability to communicate to staff. Observation of non-verbal signs of pain is needed. The care plan listed a goal, [R53] will appear comfortable and rest well, without signs of pain or discomfort through the review date, along with multiple interventions including medications as ordered, assessing pain prior and post medication administration, completing pain assessments quarterly and as-needed, and rating his pain via a facial expression scale. All the listed interventions were created in 3/2023 and lacked documented revision or edit. When interviewed on 1/15/25 at 8:55 a.m., nursing assistant (NA)-E stated they had worked with R53 multiple times over the past months and described him as total care with everything. NA-E stated they had noticed, at times, R53 would raise his hand up in a ball while staff did cares and place it by his face adding, He put his hand up there. NA-E stated they had noticed R53 also, at times, seemed to squinch his eyes with facial washing, however, felt it was just random movement and not pain. NA-E stated R53 seemed not really in pain. R53's Medication Administration History, dated 1/2025, identified R53's medications and nursing treatments for the month period. This identified R53 was receiving baclofen (muscle relaxant) three times daily for spasms, and had an order for Tylenol 650 milligrams (mg) every six hours as needed for mild pain or temperature. The MAR identified Tylenol as being administered once on 1/11/25 at 5:52 p.m. for pain with results listed, SE [somewhat effective]. However, the MAR lacked what specific symptoms were observed which indicated pain and warranted medication, nor did the MAR have any ongoing pain monitoring to demonstrate what, if any, symptoms were being tracked or observed to ensure R53 remained comfortable despite floor staff seeing him make movements with cares which could be pain related (i.e., hand to face, squinted eyes) and now having Tylenol provided with only somewhat effective results. On 1/15/25 at 9:29 a.m., registered nurse (RN)-D was interviewed. RN-D verified they were assigned care for R53 and expressed he was total help with care. RN-D stated they felt R53 had no pain but voiced grimacing would be considered a sign of pain for him as he was non-verbal. RN-D reiterated, I've never seen [R53] in pain. RN-D stated they had observed R53 raise his clenched fists up before but felt he didn't appear uncomfortable with it adding, I've never associated that [movement] with pain. RN-D stated pain assessments would be done by the floor nurse in the moment when they determine whether or not to give pain medication, adding, a progress note would be completed. RN-D reviewed R53's MAR and verified PRN Tylenol was given on 1/11/25 and stated such administration must be new as they had never given him any before to their recall. RN-D reviewed R53's medical record and the corresponding progress note, dated 1/11/25, which merely recorded R53 as being uncomfortable and lacking what specific symptoms were displayed. RN-D then directed the surveyor to the unit manager for further discussion on pain monitoring and evaluation. R53's medical record was reviewed and lacked evidence R53 had been recently comprehensively assessed for his pain management needs despite having ongoing physical symptoms of pain (i.e., squinted eyes) and staff providing as-needed medication for pain. Further, the record lacked evidence of ongoing, comprehensive monitoring of pain (i.e., every shift, consistent manner) to ensure R53 was kept comfortable and ensure appropriate care-planning was completed for pain. On 1/15/25 at 12:49 p.m., registered nurse manager (RN)-E was interviewed. RN-E reviewed R53's medical record and verified it lacked ongoing pain monitoring adding aloud, We should be monitoring it too. RN-E verified the completed Pain Interview (dated 11/26/24) identified physical symptoms were identified, however, lacked what, if any, interventions were done or placed despite them. RN-E stated they had not reviewed the evaluation prior as those were mainly done for the MDS. RN-E stated nobody had reported potential pain symptoms to them and, had they, then monitoring would have been placed in the order set. RN-E stated they recalled reading R53's note, dated 1/11/25, about being uncomfortable but didn't put two and two together with it being a pain issue. RN-E verified R53's demonstrated physical symptoms had not been comprehensively evaluated for what, if any, pain management was needed for them and expressed doing such would be important as we [staff] need to get to the bottom of what his pain is and help it. A provided Pain Management policy, dated 9/2023, identified the staff would evaluate residents for verbal and non-verbal symptoms of pain including the resident and responsible party in the development of pain management interventions. The policy directed, Reevaluate pain and document . [bullet] At regular intervals according to the needs of the resident . [bullet] With each new report of pain . [bullet] At appropriate intervals after pharmacological on [sic] non-pharmacological interventions. However, the policy lacked specific information on how a non-verbal resident would have their pain assessed or monitored. 49339 R70 R70's admission Minimum Data Set (MDS) assessment dated [DATE], indicated R70 had intact cognition with no hallucinations or delusions. Assessment indicated in section J-Health Conditions section J0100 pain medication section A: been on a schedule pain medication regimen marked yes, section B: received PRN (as needed) pain medication marked yes, section C: received non-medication interventions for pain marked no. Further the form indicated R70 frequently has pain which occasionally effects sleep and rated pain with a verbal descriptor scale of moderate pain. R70's face sheet, printed 1/16/25, included the following diagnoses: hip stress fracture (crack or break of the hip), fracture of the left lower leg, fracture of the right femur (crack or break of the right upper leg bone), upper abdominal pain, rheumatoid arthritis with rheumatoid factor of multiple sights (a chronic inflammatory disorder usually causing painful swelling of joint linings), muscle weakness and fibromyalgia (a long term condition that involves widespread body pain and tiredness). R70's care plan, printed 1/16/25, indicated R70 experienced pain related to broken hip/ankle as evidenced by reports of pain with the following approaches: -Administer my pain medications as ordered -Assess for psychological pain & document interventions used to address. -Assess the characteristics of my pain: location, severity based off pain scale appropriate to me, type, frequency. -Consult with physician for pain management, notify physician of any changes in level or frequency of pain, any increase in use of PRN pain medications, and any noted side effects of pain medications. -Discuss with me the factors that precipitate pain and what may reduce it. -Discuss with me the importance of requesting PRN pain medications before pain becomes severe. -Educate me and my family about pain care and pain medications. -Offer alternative comfort measures: Acupressure, Acupuncture, Biofeedback, Brace, Cold, Comfort food, Decreased stimulation, Distraction, Guided imagery, Heat, Massage, Music, Prayer, Psychotherapy, Relaxation, Repositioning, Rest, Sleep, Television, TENS Unit, Whirlpool bath. -Reassess intervention with any changes in response to pain or pain medications and routinely per facility protocol. The care plan lacked evidence of what non-pharmacological interventions have been tried, what had been effective and not effective and what non-pharmacological interventions should be used. Furthermore, the care plan lacked identification of what pain scale would be appropriate/resident's preference to use. R70's January 2025 Medication Administration Record (MAR/TAR), printed 1/16/25, included the following orders and administrations: -acetaminophen [Tylenol] (pain reliever) tablet 500 milligrams (mg) tablet administer 1000 mg oral [by mouth] every 6 hours PRN [as needed] for pain. MAX DOSE 4000 MG daily. Started 12/13/24. The MAR indicated it was administered 21 times in the month of January. Of those administrations, 2/21 had a numeric pain scale and 5/21 had a location of pain listed. The remaining administrations, 19/21 administrations, did not have a pain scale listed and 16/21 administrations did not have a location of pain listed. -oxycodone (narcotic pain medication) 5 mg tablet administer daily as needed. Discontinued 1/2/25. The MAR indicated it had been administered 2 times in the month of January. Of those administered, 0/2 had a numeric pain scale and 0/2 had a location of pain listed. -oxycodone 5 mg tablet administer twice a day as needed. Started 1/3/25. The MAR indicated it was administered two times a day for the month of January starting on 1/3/25. Of those administrations, 4/26 had a numeric pain scale and 4/26 had a location of pain. The remaining administrations, 18/26 administrations, did not have a pain scale and 18/26 administrations did not have a location of pain listed. The MAR/TAR lacked orders or administrations of any non-pharmacological interventions offered, declined, or accepted prior to administration of pain medications. R70's progress notes, dated 1/1/25 to 1/15/25, were reviewed. The progress notes lacked evidence of pain scales being used prior to or after administration of pain medications. Furthermore, lacking evidence of any nonpharmacological interventions being offered, accepted, or declined. R70's Pain Interview completed 12/12/24 revealed the following: Pain Interview: questions are answered with radio-button answers: Pain: received scheduled pain med regimen at any time in the last 5 days: yes Received PRN pain medications OR was offered and declined in the last 5 days: yes Received non-medication intervention for pain: No Should Pain Assessment interview be conducted: yes Presence of pain: yes Pain frequency: frequently Pain effect on sleep: frequently Pain interference with therapy activities: does not apply. Pain interference with day-to-day activities: Not assessed/no information Verbal scale rating: severe On 1/16/25 at 11:00 a.m., R70 indicated the pain can get pretty intense. R70 indicated the facility had her try distraction once for pain reduction. R70 indicated they were open to trying other nonpharmacological interventions and added the facility had not talked to them about this before. R70 indicated their pain level was typically at a 6/7 and their goal was a 3/10. On 1/16/25 at 11:11 a.m., registered nurse (RN)-F stated when a resident reported pain then a pain assessment was completed which included: location, what is the pain, frequency, quality of the pain and have them rate the pain. RN-F indicated this would be documented in the progress notes or on the MAR. RN-F stated nonpharmacologic interventions are offered to residents such as repositing, distraction and music and stated this would be documented on the MAR. RN-F verified R70 did not have any nonpharmacological interventions on their MAR/TAR. On 1/16/25 at 11:39 a.m., RN-G stated that pain assessments for a resident reporting pain was documented in the progress notes which would include the pain level (either numeric scale or face scale), how long they have had the pain (chronic or new), location of pain and to check the site. RN-G stated a pain level was not always assessed for scheduled pain medications. RN-G indicated the pain level for new pain was assessed prior to giving PRN pain medications which would be documented on the MAR or possibly in the progress note. RN-G stated any non-pharmacological interventions would be documented in the progress notes. RN-G reviewed recent administrations of PRN acetaminophen and oxycodone and stated the pain scale was not completed as it is not new pain. On 1/16/25 at 11:56 a.m., assistant director of nursing (ADON) indicated the location of documentation of nonpharmacological interventions prior to PRN medication use, along with pain scales with pain medication adminsitration, would depend on what floor the resident was on and the manager on the floor. During a follow up interview at 1:25 p.m., ADON verified a pain scale was not used (except for what was listed above) for the administration of acetaminophen and oxycodone. ADON verified the location of R70's pain was not documented (except for listed above) during the administration of PRN pain medication. ADON did indicate she had a follow up conversation with R70 about nonpharmacological interventions and preferred pain scale. On 1/16/25 at 12:50 p.m., director of nursing (DON) indicated the expectation would be nursing to do an assessment prior to administering PRN pain medication which would include assessing a pain level and location along with offering nonpharmacological interventions. A facility policy titled Pain Management reviewed 9/7/23 indicated the facility will evaluate the resident for verbal and nonverbal signs and symptoms of pain and reevaluate pain and document: at regular intervals according to the needs of the resident; with each new report of pain; at appropriate intervals after pharmacological and non-pharmacological interventions.

Based on observation, interview, and document review, the facility failed to attempt alternatives and ensure ongoing assessments for safety and appropriate use of side rails were completed for 1 of 1 resident (R18) who was observed to have side rails affixed to the bed. Findings include: R18's annual Minimum Data Set (MDS) dated [DATE], indicated R18 had moderately impaired cognition. R18's significant change MDS dated [DATE], indicated R18 had moderately impaired cognition. R18's quarterly MDS dated [DATE], indicated R18 had severely impaired cognition. R18's Restraint/Adaptive Equipment Use Observation was completed on 3/12/20 and 9/08/22. Both reports included assessments of R18 for side rail entrapment risk factors such as falls and medication use. The assessments indicated R18 had half side rails for bed mobility and assistance with transfers. R18's medical record was reviewed and lacked indication R18 was assessed for safety and appropriate use of side rails and alternatives were attempted since the assessment on 9/22. R18's Physical Therapy Discharge Summary dated 12/14/22, indicated R18 needed stand by assistance from staff for bed mobility. R18's Physical Therapy Discharge Summary dated 9/11/24, indicated R18 required maximum assistance with all bed mobility tasks on the baseline assessment completed on 8/21/24. At the time of discharge from physical therapy, on 9/11/24, R18 required assistance with bed mobility related to knee and hip pain. R18's care plan dated 12/16/24, indicated staff were to ensure R18's upper side rails were in the upright position and were to provide cues to use rails for bed mobility. During an observation on 1/14/25 at 12:45 p.m., R18 was observed sitting in a chair next to her bed. R18's bed was observed with half side rails in the fully upright position on both sides of the bed. During an interview on 1/15/25 at 12:20 p.m., LPN-A stated she thought all residents should have been assessed before bed rails were installed and have an order for bed rails. LPN-A stated she was unaware what further assessments or reassessments were required for bed rail use and referred further questions to the Director of Nursing (DON). On 1/16/25 at 10:47 a.m., LPN-A stated she had worked with R18 since her admission in 2018 and was her primary day shift nurse. LPN-A stated R18 had side rails on her bed that she could use while turning. LPN-A stated staff had to help R18 turn in bed as she had been declining over the last year and had been required more assistance. LPN-A stated R18 used to be able to use her walker with only stand by assistance but had not been able to recently. During an interview on 1/15/25 at 1:05 p.m., the Director of Nursing (DON) stated bed rails should be assessed when they are installed but admitted that the facility did not have a process to ensure ongoing bed rail monitoring or reassessment of resident's risk related to side rail use. On 1/16/25 at 12:02 p.m., the DON stated she expected a resident to be assessed for the risk of entrapment and the safe use of bed rails anytime the resident had a change of condition but especially if it required a significant change such as the one R18 had in 6/24. The DON stated she would otherwise expect these resident specific entrapment risk assessments to be completed annually. The DON stated it was important that residents were reassessed for the continued need for bed rails as well as the potentially elevated risk of entrapment with resident changes of condition to minimize entrapment and potential resident injury. The DON confirmed the facility had reviewed the medical record and was unable to find an updated assessment of R18's potential risk and use of bed rails. The facility's Bed Safety and Bed Rails policy dated 8/22, indicated side rails and mattresses were checked for entrapment concerns annually. The facility policy did not indicate when or if ongoing resident assessments for safety and appropriate use of side rails were to be completed.

Based on observation, interview, and document review, the facility failed to complete comprehensive and ongoing behavioral monitoring (i.e., symptom or target behavior) for an administered antipsychotic medication to ensure efficacy of the medication for 1 of 5 residents (R62) reviewed for unnecessary medication use. Findings include: R62's quarterly Minimum Data Set, dated dated [DATE], identified R62 had severe cognitive impairment but demonstrated no delusional thinking, hallucinations, or other behaviors (i.e., physical, verbal, other) during the review period. Further, the MDS identified R62's consumed medications for the period which included both antipsychotic and antidepressant medication. On 1/14/25 at 9:05 a.m., R62 was observed while seated in a reclined high-back wheelchair in the commons area. R62 had multiple, red-colored scrapes on the left side of her face but was unable to verbally respond to questions when asked. R62 did not appear in distress at this time. Immediately following, at 9:09 a.m., registered nurse (RN)-D was interviewed. RN-D expressed R62's facial scrapes were due to a fall over the past few days. RN-D stated staff had heard a boom and found her on the floor adding, I'm assuming she tried to get up [from her wheelchair]. R62's Medication Administration Record (MAR), dated 1/2025, identified R62's current physician-ordered medications along with their corresponding administration or refusals. The MAR outlined an order for clonazepam (anti-anxiety medication) three times a day along with an order for Seroquel (antipsychotic medication) 50 milligrams (mg) once daily. The Seroquel had listed start date which read, 12/30/2024 - Open Ended, and listed a diagnosis for the medication as, Psychosis, MDD [major depression]. The MAR recorded the medication as being administered, as ordered, every day for the month period thus far. R62's corresponding Nursing Orders Flowsheet Administration History (i.e., TAR), dated 1/2025, identified an order which outlined, Resident on: Seroquel for Major depressive disorder [sic] with psychosis. Target behaviors [blank space], with a frequency recorded , Three times a day. This order listed a start date which read, 10/10/2023 - Open Ended, and was recorded by staff, as ordered, three times a day with a negative response (i.e., no, N/A). However, the documentation lacked evidence what symptoms or specific target behaviors were being tracked or monitored to ensure the medications' efficacy. R62's care plan, dated 12/2024, included R62 was identified as being at risk of adverse consequences due to antipsychotic medication use. A goal was listed which read, Resident will not exhibit signs of drug related side effects or adverse drug reaction, along with multiple interventions including, Monitor resident's behavior and response to medication, and, Resident on: Seroquel for Major depressive disorder [sic] with psychosis. Target behaviors [blank space]. The care plan lacked what specific symptoms or target behaviors (i.e., agitation, hallucinations, etc.) had been identified as R62's behavior warranting the medication, nor how such behaviors would be monitored. When interviewed on 1/16/25 at 8:15 a.m., nursing assistant (NA)-D stated they had worked with R62 multiple times and described R62 as needing total care adding, We do everything for her. NA-D explained R62 was mostly non-verbal but could, when seated in her wheelchair, still propel herself around the unit and, at times, even try to board the elevator by herself. NA-D stated they had noticed when R62's significant other leaves, then R62 does seem, at times, to become upset adding, It triggers a lot of mental [issues]. NA-D stated they had never seen or heard of R62 having other behavioral issues such as hitting out, verbal behaviors, or hallucinations adding, I haven't noticed none. NA-D stated it wasn't possible to determine what, if any, depression symptoms R62 had, either, as R62 was non-verbal adding, We can't tell. However, NA-D stated they had noticed R62 to have periods of crying before and reiterated it seemed more frequent when the significant other leaves or doesn't visit as planned. Further, NA-D stated the NA(s) didn't complete routine charting on behaviors but rather, if noticed, would do an incident report form and then it was routed to the nurse. R62's progress notes, dated 9/2024 to 1/2025, were reviewed. These notes identified only two recorded episodes of potential behavior including: On 12/9/24, R62 was recorded as crying and being distressed while attempting to pull out her feeding tube. The note concluded, The patient's condition will continue to be monitored closely. On 12/24/24, R62 was recorded as falling from her bed twice with both falls being unwitnessed. The note recorded, Res noted to be quite agitative [sic] for the most part of the shift. However, the note lacked what specific symptoms or observations were happening to detail 'agitative'. When interviewed on 1/16/25 at 10:04 a.m., registered nurse (RN)-D stated they were currently assigned care for R62 and had worked with R62 before. RN-D described her as aggressive but not hitting people, explaining R62 seemed aggressive when attempting to roll her wheelchair at times, but reiterated she had never physical hit anyone or had other behaviors to their recall. RN-D stated they were unsure if R62 had any delusional thinking or hallucinations as she's not talking, she might but we don't know. RN-D stated they were unsure what, if any, target behaviors were identified or tracked for R62 adding, I'm not sure. RN-D stated R62 had been falling a lot lately and attributed this to periods when R62 gets agitated. RN-D stated usually behaviors or symptoms were listed in the MAR or TAR and answered like a question but added they were unsure where in the medical record any recorded target behaviors or symptoms for the Seroquel use would be. RN-D stated, I'm not sure specifically for her. R62's most recent Extended Care Nursing Home Visit note, dated 12/10/24 and authored by the medical provider, identified R62 was seen at nursing' request for increased agitation during the day with some falls. The note outlined, [R62] is on Seroquel at night which has worked for her agitation when she was pulling on her trach she has been very upset and agitated after her significant other calls her or says that he is coming in [and] does not show up, most of these episodes as of cursed [sic] in the evening . However, R62's medical record was reviewed, including the recorded progress notes, and lacked evidence of ongoing, consistent monitoring of any identified target symptoms or behaviors despite being on a scheduled antipsychotic medication and staff reporting potential behaviors (i.e., upset, crying when significant other leaves) as being observed. On 1/16/25 at 11:12 a.m., registered nurse unit manager (RN)-E was interviewed. RN-E verified they had reviewed R62's medical record and it lacked any specific target behaviors or symptoms for the Seroquel use adding, It wasn't in there. RN-E stated they had just updated the TAR to include the symptoms of wandering, anxiousness and refusing cares. RN-E verified behaviors, if happening, should be documented in the progress notes and tracked so they placed the new order for monitoring to be done every shift adding R62 was, at times, different on the nights versus the waking hours. RN-E stated it was important to ensure behaviors were tracked and monitored adding, We gotta make sure the medication is working, and, Make sure it's effective. A provided Psychotropic Medication Use policy, dated 9/2023, identified when a resident exhibited signs of distress which interfered with daily living, the nurse or interdisciplinary team (IDT) would identify target behaviors and non-pharmacological interventions for them. The policy outlined, Psychotropic medications are ordered by the medical provider to treat a specific condition as diagnosed and documented in the medical record. The policy directed, The IDT team monitors the resident condition and target behaviors for efficacy of the medications and any clinically significant adverse consequences, adding further, Documentation will reflect implementation of the above.

Based on interview and document review, the facility failed to assess and notify provider for change in condition for 1 of 1 resident (R1) reviewed. This resulted in an immediate jeopardy (IJ) situation for R1 when his heart rate (HR) was identified to be 156 bpm (beats per minute), was later found unresponsive with no pulse, CPR (cardiac pulmonary resuscitation) was performed, and he subsequently died at the facility. The immediate jeopardy began on [DATE], when at 1:30 a.m. R1's HR was 156 bpm, and no action taken by registered nurse (RN)-A. Then at 3:40 a.m. R1 was found unresponsive with no pulse, CPR was performed, paramedics arrived at 4:20 a.m., and took over CPR until R1 was pronounced dead at 4:47 a.m. at the facility. The director of nursing (DON) and administrator were notified of the IJ on [DATE], at 4:20 p.m. The IJ was removed on [DATE], following verification of an acceptable removal plan however, noncompliance remained at the lower scope and severity level D, which indicated no actual harm with potential for more than minimal harm that is not immediate jeopardy. R1's admission Minimum Data Set (MDS) dated [DATE], indicated R1 unable to be interviewed for mental/cognition status due to unable to express ideas and wants, rarely or never understood, unable to respond, and had highly impaired vision. MDS indicated R1's diagnoses included respiratory failure, fracture, septicemia (bacteria in the blood stream) and multi-drug resistant organism (MDRO) (a germ that is resistant to any antibiotic). R1 prognosis identified he did not have a chronic condition identified that may have resulted in less than six-month life expectancy. R1 had a tracheostomy (a surgical opening made through the front of the neck and into the windpipe/trachea kept open for breathing) and suctioning, he was dependent on a ventilator (a machine that helped lungs work then unable to breath on your own properly), and oxygen. R1's Baseline Care Plan dated [DATE], identified cognition as nonresponsive, non-verbal, and questionable impaired hearing. Staff were expected to suction R1 as needed and oxygen saturation (SaO2) (measures how much oxygen is in your blood) levels to be maintained over 90%. Plan of care directed staff for total resident care: Management of ventilator, tracheostomy, suctioning, cervical collar, nutrition, and tube feeding. Facility Standing Orders dated [DATE], identified Respiratory distress: O2 (oxygen) at 2 to 4 L liters/minute via cannula for up to 30 minutes. Notify physician. Hospital discharge summary and orders dated [DATE], identified: -Diagnoses: acute (sudden onset) failure of the respiratory system with lack of oxygen [DATE] to [DATE]. -Call provider for: difficulty breathing, headache or visual disturbances. -Call provider for temperature over 100.4. F -Code status: full R1's progress notes (PN) dated from [DATE], through [DATE], identified: -[DATE], at 11:00 p.m. R1's SaO2 95% on room air, and no heart rate identified. -[DATE], at 6:56 a.m. R1's vital signs at 1:00 a.m. BP (blood pressure) ,d+[DATE], T (temperature) 97.9 F (Fahrenheit), SaO2 87%, HR (heart rate/pulse) 107, on room air (RA), R (respirations)16. R1 was started on oxygen 2 L (Liters) per nasal cannula. R1's SaO2 improved to 94%. Second vitals were checked to be BP ,d+[DATE], HR 107, T 97.5 F and remained unresponsive throughout to verbal nor sensory stimuli. No sign of pain or distress were observed. -[DATE], at 11:03 p.m. remained unresponsive throughout shift, no body movement, no respiratory distress, or signs/symptoms of pain. Vitals: BP ,d+[DATE], HR 113, T 97.5 F, SaO2 95% on 2 L of oxygen. Second set of vitals: BP ,d+[DATE], HR 114, T 98.6 F, R 15, SaO2 94 to 95% on 2 L oxygen. Suctioned four times with moderate white secretion. -[DATE], at 12:00 p.m. HR 120, R 17 and SaO2 91% on 2 L of oxygen. Breath sounds slightly course, diminished throughout, post suction times three small/pale/thin secretions. -[DATE], at 4:19 p.m. resident restless and vent was alerting for about 30 minutes, but stable now. Vitals: BP ,d+[DATE], 98.1 F, HR 120, R 18, SaO2 93% on 2 L oxygen. Nurse Practitioner (NP)-B was notified day four of no bowel movement, onetime house order for MOM (milk of magnesia) 30 cc and prune juice order for constipation. -[DATE], at 10:59 p.m. no signs of restlessness on shift. Vital signs: BP ,d+[DATE], 98.2 F, HR 111, R 20, SaO2 95% on 2 L oxygen. Resident was being monitored for any changes in status. -[DATE], at 7:36 a.m. vital signs at 12:30 a.m. 98.1 F, HR 111, R 14, BP ,d+[DATE]. Suctioned four times with small to moderate whitish secretions each time. -No progress notes or vital signs documented on [DATE], from 3:06 p.m. to [DATE], at 3:04 p.m. (almost 24 hours). -[DATE], at 3:06 p.m. resident alert and smiled to his mom when communicating with him. Vital signs: BP ,d+[DATE], HR 109, 98.1 F, SaO2 94%, and R 14. Vent dependent and on oxygen at 2 L with no shortness of breath. -[DATE], at 3:04 p.m. remained unresponsive through shift and ventilator dependent. Temperature 100.5 F. Modified the room and wet towel over forehead and under arm placed, non-pharmacology intervention was not effective. Tylenol administered and fever went down to 98.9 F tympanic (ear probe), BP ,d+[DATE], HR 114, SaO2 96% on 2 L oxygen, and R 17. -[DATE], at 6:23 a.m. at about 3:40 a.m. to 3:45 a.m. resident was found unresponsive by writer (RN-A), R1 pulse was checked electronically and manually. Shouted for help and other nurses came in right away, CPR started, and 911 was called. Paramedics arrived about 4:20 a.m. and took over, and at 4:47 a.m. R1 was pronounced dead by the emergency team. At beginning of shift vital signs were T 97.5 F, SaO2 90% with 4 L of O2, HR 156, and observed with bilateral chest rise and fall, breathing unlabored, on ventilator, in bed. Suctioned periodically per need. R1's medical record lacked documentation of vital signs on [DATE], from 3:06 p.m. through [DATE], in progress notes. Additionally, no progress notes were documented since 8:55 a.m. on [DATE], until [DATE], at 6:23 a.m. (almost three days). R1's physician communication/order document dated [DATE], at 3:15 p.m. completed by RN-B identified R1 had no BP [sic] (bowel movement) day four. NP-B ordered and signed on [DATE], at 3:15 p.m. warm MOM (milk of magnesia) 30 cc (cubic centimeters) with one glass of prune juice if no BM on day two. One time order. The communication document did not identify R1 had tachycardia (exceeds the normal resting rate) HR of 120 beats per minute identified in the progress notes. A facility document titled Configure Vital Alerts, printed [DATE], at 12:44 p.m. identified acceptable vital sign ranges (minimum/maximum) set in R1's HER to alert staff when vital signs were out of range: - Pulse 55 to 110 per minute - Respirations 10 to 26 per minute - Temperature 96.0 F to 100.0 F - O2 Saturation 90% to 100% R1's HR readings located in EHR vitals and progress notes from [DATE]-[DATE], identified: [DATE], HR 89, 98, and 98 (EHR vitals) [DATE], HR 107, 107, 112, 98, 113, and 114 (EHR vitals) [DATE], HR 120, 120, and 111 (PN) [DATE], HR 111, and 109 (PN) [DATE], HR 114 (PN) [DATE], through [DATE] HR was not documented. [DATE], HR 99, 111, and 156 (EHR vitals). R1's medical record's (PN and EHR) indicated HR was identified to be out of acceptable range 10 times between [DATE]-[DATE] with no action taken by the facility or contact made with the Provider for direction. During an interview on [DATE] at 1:15 p.m., registered nurse (RN)-B stated she worked with R1 on [DATE] and verified R1's HR was 120 and the ventilator was alarming a lot, so she had to trouble shoot. RN-B stated R1 was also constipated, and the provider was contacted regarding that concern. RN-B stated the provider was unaware of the 120 HR, and ventilator alarming, and really should have been updated right away. RN-B stated if R1's condition had changed, especially respiratory and vitals abnormal, a provider would have been contacted right away. During an interview on [DATE] at 1:30 p.m., respiratory therapist (RT) stated he noted on [DATE], R1's HR was considered elevated at 120 beats per minute (bpm), and he reported to the nurse on duty. RT stated when a pattern was noted of R1's elevated HR a provider should have been contacted for further direction. During a follow up interview on [DATE] at 10:11 a.m., RT stated on [DATE], R1 was placed on 2 L of oxygen, and on [DATE], R1 was bumped up to 4 L of oxygen by RN-A. RT indicated R1's 156 HR would be the key related to an indicator something was wrong for R1 as he had seen residents go into sepsis with HR 120 to 130, and most likely there was a problem with R1's heart. During an interview on [DATE] at 2:10 p.m., RN-C stated they worked [DATE], when R1's temperature was 100.5 F and HR was 114. RN-C indicated acceptable HR range was identified in the EHR vitals section as 55 to 110 bpm. RN-C administered R1 Tylenol and temperature went down. RN-C indicated they were focused on the temperature and not on his HR. RN-C verified a provider was not contacted since temperature when down. During an interview on [DATE] at 2:53 p.m., admissions nurse RN-H stated nursing staff were expected to contact a provider with any change in condition such as temperature/fever, elevated HR, change in BP, and respiratory/oxygen status, and RN-H verified she would have expected staff to contact the provider when the HR was elevated especially up to 156. RN-H indicated a problem was identified prior to R1's death, and the provider was not notified of R1's elevated HR. RN-H stated she believed if a provider would been contacted for direction/orders it could have changed the outcome for R1. RN-H also stated the nurse would be expected to reach out to the provider for tighter parameters when they started to elevate outside of the norm, no matter what time of day, the provider should have been called and parameters would have helped. During a telephone interview on [DATE] at 4:10 p.m., primary medical provider (PMD) stated no notifications were made to her regarding R1's change in status. PMD verified staff were expected to contact provider for any significant change in clinical status such as a HR outside parameters and had a sense the resident was not doing well. PMD indicated R1 was non-responsive and had a head injury which would affect the range of vitals collected. PMD stated vitals were important when you had to rely more heavily on other data for a resident who is non-responsive. During a telephone interview on [DATE] at 5:17 p.m., RN-A stated they worked the night shift on 2nd floor which started at 11:00 p.m. RN-A stated he received report at 11:30 p.m., organized things, then counted medications with previous shift. Then at approximately 12:00 a.m. RN-A stated he saw four residents prior to entering R1's room at about 1:30 a.m. RN-A stated he was in R1's room for approximately 20 minutes total, adding R1's oxygen level was low at 88% on 2 L O2 and HR was 156, that was when he noted the oxygen tank registered zero/empty. He was unsure how long it had been empty, and he replaced it with a full one. RN-A stated he increased oxygen up to 4 L and oxygen level improved but was unable to indicate how much it improved during interview. RN-A stated he completed R1's water flush through feeding tube, dressing change, and HR went down somewhat, to 122 to 140 per minute (not recorded in EHR or PN). RN-A stated R1's vitals fluctuated so he monitored them for a short time, felt R1 was stable, then left the room to check on four other residents. RN-A stated around 2:40 a.m. he entered R1's room again and HR was 118 (not recorded in EHR or PN) and SaO2 had gone back down again to 88%. RN-A stated seemed like something was wrong and called RN-E into the room. RN-A stated along with RN-E checked a HR manually and unable to find one. RN-A stated R1's was warm to the touch when he called out his name, rubbed his shoulders, completed a sternal rub (a firm rub on the flat bone in the middle of the chest to provoke pain or stimulus meant to provoke a response), and no reaction noted, then started CPR. RN-A called for another nurse, RN-D, who called 911 and a code in the facility. RN-A indicted during CPR they checked for HR and noted to be 98 to 110 and SaO2 up to 100%. RN-A stated at 4:20 a.m. emergency personnel arrived and took over CPR for approximately 20 minutes, R1 was pronounced dead at 4:40 a.m. RN-A stated the HR of 156 was not normal for R1, after the water flush was given via feeding tube the HR came down somewhat, believed he was stable, so no need to call a provider. RN-A stated he had concerns about the elevated HR and that was the reason why he went back to R1's room and checked on him after he saw the other four residents. RN-A stated when he realized R1's SaO2 level had dropped back down to 88%, he called another nurse for assistance. RN-A indicated R1's baseline vitals could have been figured out through time but was unsure as to what they should have been. RN-A verified there was no need to notify a doctor right away and the outcome most likely would have not changed. RN-A verified he was educated on change of condition and importance of notification to provider. During an interview on [DATE] at 10:35 a.m., floor manager RN-F stated when R1 was admitted with HR 89 and tried establishing a baseline but struggled because his HR was overworking and something was going on with him. RN-F stated staff were expected to have documented in EHR nurses progress notes and vitals section, and contact the provider when HR started to elevate. RN-F also stated R1's temperature was elevated over 100.4 F while at the facility and provider should have been notified at that time also. RN-F verified R1's transfer order from the hospital to facility: call provider for temperature over 100.4 F, was not entered into his orders. During an interview on [DATE] at 12:24 p.m., director of nursing (DON) stated on [DATE], she reviewed R1's medical records and noted the elevated heart rate. The following morning, she spoke with the administrator about a concern related to the registered nurse (RN)-A not acting or when R1's heart was elevated. DON verified she had filed an incident report with the state on Tuesday morning [DATE]. DON stated parameters for vitals are the same for all residents and pre-set up in the EHR and determined by the facility's health system. DON indicated we had the ability to obtain specific and separate ranges for each resident. DON verified she had given that task to the floor manager and planned on obtaining parameters in the future from the providers. DON stated on [DATE], met with RN-A, completed interview, requested a written document that indicated understanding of what happened on the night shift [DATE], through [DATE]. DON stated she flat out told RN-A he was wrong with what he chose to do that night and expected him to respond and act to the situation, contact the provider, and take responsibility for his actions. DON stated R1's elevated HR could have potentially been an indication of infection and possibly sepsis due to an alteration in condition. DON stated the nurse would have been expected to monitor the HR frequently especially since it became elevated. DON verified R1 was non-responsive and therefore the vital signs would have been pretty important information used to assess him, he was unable to verbally respond and unable to show signs of pain or discomfort. DON verified the transfer order from the hospital to the facility on [DATE], call provider if temp was over 100.4 F. was not entered into R1's EHR and should have been. DON also verified there was lack of documentation by the nursing staff for R1 in the EHR. DON stated RN-A should have responded and contacted the provider services with a change in condition. During a telephone interview on [DATE] at 2:38 p.m., medical director (MD) stated R1's HR 156 was considered a very abnormal vital sign and should have urgently been called in to a provider that evening. MD stated this incident was identified as a change in condition. MD also stated this group of residents, about 13 to 14 (tracheotomy's and some on ventilators) with various needs, were terribly sick, and occasionally became tachycardiac (a HR over 100 beats per minute). MD stated residents with tachycardia may not cause any symptoms but sometimes a warning of a medical condition that required medical attention. MD stated residents on ventilators showed signs of anxiousness and respiratory infections, and in this case RN-A was unable to recognize it was a change in condition. MD indicated RN-A did not meet the nursing standards of care. MD stated nursing was expected to notify and provider when the temperature became two points above the baseline, HR above 110, and respirations above 20 per minute. MD also indicated when a resident was on supplemental oxygen, SaO2 was below 90% along with a rapid heart rate and did not return to normal range, RN-A would have been expected to document findings, and provider should have been contacted. MD stated RN-A's documentation was considered incomplete/inadequate, did not reflect his thought process, and lacked insight as to what happened that night. MD verified a change noted in R1's vitals required a provider be called to diagnose, intervene, and revise the treatment plan. MD stated R1's situation was out of the nurse's scope of practice and was not the facility policy for an individual nurse to have made those decisions. During a telephone interview on [DATE] at 1:15 a.m., RN-E verified she had worked the night shift on [DATE], through [DATE]. RN-E stated around 3:00 a.m. RN-A had informed her he was unable to get R1's SaO2 reading and knew something was wrong. RN-E stated we entered R1's room together and R1 was very pale, checked manually for a pulse, no pulse felt, and immediately started CPR. RN-E verified was not informed prior to this incident about a change in condition or elevated HR by RN-A. RN-E stated we are expected to go by the resident's normal ranges and if out of the normal range, check orders for interventions, then contact the provider no matter what time of day or night it was. RN-E stated R1 had a tachycardia (abnormal high HR), would have suspected sepsis, provider should have been notified, and most likely sent out via ambulance. During a telephone interview on [DATE] at 2:22 p.m., RN-D stated they worked the night shift on [DATE] through morning of [DATE]. RN-D stated they were not assigned to R1 however around 3:00 am to 3:30 a.m. RN-E came running down the hallway and said something was wrong with R1. RN-D and RN-E both entered R1's room together and RN-D noticed his face was grayish in color, and where the plates used to be in his head, was more sunk in, and he did not really look like himself. RN-D along with RN-A manually checked for HR together, no HR, then started CPR immediately. RN-D verified RN-A had not informed him any time prior to his death about abnormal vitals or concerns about a change in condition. RN-D stated nursing would be expected to call provider when a change was noted in condition such as elevated HR, especially in the 150's, a decision would be made by the provider as to new orders and/or whether to send him in by ambulance to ED. Facility policy titled Nursing Services undated, identified thorough resident examination and assessment will capture any abnormalities in health status, physical function, or an acute change of condition. Notify the provider of any abnormalities such as, but not limited to abnormal vital signs, labored breathing, breath sounds that are not clear, or cough, productive or nonproductive. Document physical exam in the HER. Facility policy titled Change in Condition last reviewed [DATE], identified care and services was to be provided based upon the current needs of the resident under the direction of the attending provider. When a significant change in the resident's physical, mental, or psychosocial status is identified by the licensed nurse, or when there is need to alter treatment significantly, consult with the attending provider, implement orders for treatment and appropriate monitoring as directed. The licensed nurse was expected to assess for significant change in the resident's condition noted through direct observation, interview, or report from other staff. Obtain a set of vital signs and repeat as needed or ordered. Document symptoms, assessment, observations, resident/resident representative, and medical provider notification. If unable to contact physician, contact the medical director as appropriate. The IJ which began on [DATE], was removed on [DATE], when the facility successfully implemented a removal plan which included: All nursing staff on duty including agency/contract nursing staff will be re-educated by DON or designee beginning on [DATE] in relation to: change in condition definitions and what to do when a change in condition occurs, documentation of change in conditions including vital signs, out of range vital signs, what parameters cause alerts in the EHR, and recheck and notify provider if outside of parameters. Nursing staff will be educated prior to beginning their next scheduled shift, time clock notifications in place, education emailed out to staff not currently present, and charge of building notified to verify completion of staff during their shift. This education will continue until completed with current nursing staff including agency/contract. Validation of understanding of education will be verified by random interviews of staff members conducted by DON or designee. Further 1:1 education will be provided as needed to reinforce understanding of education provided. The policy and procedure for change in condition and documentation of out of range vital signs and follow up with provider all have been reviewed. On [DATE], between 8:30 a.m. and 3:30 p.m. interviews with DON, nursing staff, and management verified the facility had a plan in place and check off system to assure all staff would be educated prior to working their next shift.

Based on interview and document review, the facility failed to comprehensively assess pressure ulcers and provide necessary treatment and services to prevent and/or mitigate the risk of new ulcer development or deterioration resulting in actual harm with the development of a new pressure injury for 1 of 3 residents (R1) reviewed for pressure ulcers. Findings include: Definitions of pressure ulcer types Stage 2 Pressure Ulcer: Partial-thickness loss of skin with exposed dermis (middle layer of skin), presenting as a shallow open ulcer. The wound bed is viable, pink or red, moist, and may also present as an intact or open/ruptured blister. Fat is not visible and deeper tissues are not visible. Stage 3 Pressure Ulcer: Full-thickness loss of skin, in which subcutaneous fat may be visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough (non-viable usually moist tissue than can be soft and stringy in texture) and/or eschar (dead or devitalized tissue that is usually black and may appear scab-like) may be visible but does not obscure the depth of tissue loss. Undermining and tunneling may occur. Fascia (connective tissues), muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the wound bed, it is an Unstageable pressure ulcer. Unstageable Pressure Ulcer: Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough or eschar. If the slough or eschar is removed, a Stage 3 or Stage 4 pressure ulcer will be revealed. Deep Tissue Pressure Injury (DTPI): Intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration due to damage of underlying soft tissue. This area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury, or may resolve without tissue loss. R1's Minimum Data Set (MDS) dated [DATE], indicated R1 admitted to the facility on [DATE] from a hospital and had diagnoses including unspecified displaced fracture of first cervical vertebra (broken neck), anemia (lack of healthy red blood cells), septicemia (sepsis), stroke, quadriplegia, respiratory failure, stage 2 pressure ulcer of right buttock, unspecified convulsions, and dependence on ventilator status. R1 was rarely/never understood and rarely/never understood others, had severely impaired cognitive skills for daily decision making, had range of motion limitations in all extremities, and was fully dependent on staff for cares such a mobility in bed, transferring, and hygiene. R1 had an indwelling urinary catheter, was always incontinent of bowel, got 51% or more of total calories through a feeding tube, utilized supplemental oxygen, was on an invasive mechanical ventilator, and needed tracheostomy care. R1's MDS identified him as at risk for developing pressure ulcers and noted one stage 2 pressure ulcer present on admission with treatments of a pressure reducing device for chair and bed, pressure ulcer care, and the application of nonsurgical dressings other than to feet. R1's post-discharge instructions from the discharging facility dated 4/10/24, included Miami J collar [a cervical collar/brace to stabilize cervical neck injuries] in place due to diagnosis of C1-C4 [cervical vertebra one through four] fracture incomplete quadriplegia. It did not include orders or instructions regarding management of the collar, note any active wounds, or include orders for wound care. A progress note dated 4/12/24, indicated R1 arrived at the facility the previous evening at 7:38 p.m. and had a cervical collar on as well as wound on both buttock/coccyx, with left buttock wound measuring 3 centimeters (cm) long by 0.7 cm wide and right buttock wound measuring 2.5 cm long by 1 cm wide. The note included clean[ed] with NS [normal saline] and foam dressing applied. It lacked comprehensive assessment of both wounds that identified risk factors including decreased mobility, medication that impaired healing, co-morbities, refusals/rejection of care and treatment, cognitive status, incontinence status, nutrition, hydration, pressure points for turning and reposition needs, wound bed characteristics, drainage and pain. R1's Skin Risk Observation with Braden Scale dated 4/12/24, indicated R1 had one of more unhealed pressure injuries at stage 1 or higher. The location(s) of the observed pressure injuries was buttock R/L [right/left]. R1's Braden Scale for Prediction of Pressure Sore Risk indicated he was at a high risk level. It lacked further assessment of the identified wounds. A provider note by nurse practitioner (NP)-A dated 4/12/24 and 4/16/24, both noted no skin breakdown. They also noted Incomplete quadriplegia since 11/2023. Has a collar in place. Plan: will need neuro[logy] follow up with xrays [sic]. R1's provider orders included an order dated 4/16/24, noting resident has a Miami [NAME] [sic] collar. Special instructions: NP will address after review of chart. R1's provider orders included an order dated 4/16/24, for wound care: sacral area foam dressing every shift until wound nurse assessment. R1's electronic health record (EHR) lacked wound care orders for the sacral wound prior to 4/16/24. R1's Treatment Administration Record (TAR) dated 4/1/24 to 4/30/24, indicated the sacral wound care treatment was first documented as complete on the first shift of the day on 4/16/24. R1's TAR lacked documentation of wound care treatments for the sacral wound prior to 4/16/24. R1's Wound Management Detail Report by the facility's wound nurse dated 4/17/24, included a pressure ulcer right of coccyx present on admission with date identified of 4/17/24. The wound was 2.8 cm long, 2.5 cm wide, and 0.1 cm deep with no exudate (drainage) or odor, was a stage 2, had no undermining or tunneling, irregular wound edges, 100% epithelial tissue, blanchable redness of the skin surrounding the wound, and wound healing status was stable. Comments noted peri-wound skin fragile. The wound report did not address the pressure ulcer on the left buttock previously identified on left buttock. R1's Care Area Assessment (CAA) for pressure ulcer/injury dated 4/22/24, identified R1's risk factors for pressure ulcer/injury. Extrinsic risk factors included: requires staff assistance to move sufficiently to relive pressure over any one site, confined to a bed or chair all or most of the time, needs special mattress or seat cushion to reduce or relieve pressure, slides down in the bed, and persistently wet (especially from fecal incontinent, wound drainage, or perspiration). Intrinsic risk factors included: immobility, cognitive loss, incontinence, and poor nutrition. Medication risk factors included opioid medications. Diagnoses or conditions that presented complications or increased risk included: cerebrovascular accident (stroke), paraplegia/quadriplegia, edema, sepsis, pain, and recent decline in functional abilities. Treatments and other factors that caused complications or increased risk included: newly admitted or readmitted , history of healed pressure ulcer/injury, ventilator or respirator, functional limitation in range of motion, head of bed elevated most or all of the time, and devices that can cause pressure (such a oxygen or indwelling catheter tubing, TED (compression) hose, casts, or splints). The analysis of findings noted admitted [with] pressure ulcer and pressure ulcer risk with contributing factors above. At risk for further clinical declines, increased burden of care, discomfort if this does not heal or further breakdown occurs. R1's Wound Management Detail Report by the facility's wound nurse dated 4/24/24, included a pressure ulcer right of coccyx present on admission with date identified of 4/17/24. The wound was 2.3 cm long, 2 cm wide, and 0.1 cm deep with a light amount of bloody (bright red, thin) exudate, no odor, was a stage 2, had no undermining or tunneling, had wound edges epithelializing flush with the wound base, 100% epithelial tissue, blanchable redness of the skin surrounding the wound that was dry and thin, and wound healing status was improving. Comments noted Smaller. Peri-wound skin has fragile areas. Hydrocolloid covers [a type of dressing for wounds]. R1's care plan for pressure ulcer/injury dated 4/26/24, noted I have a current pressure ulcer (admitted with) located buttock/sacral area. I am at risk for increased skin integrity issues due to incontinence, immobility, use of equipment and medications, anemia. Goal dated 4/29/24, noted my pressure ulcer will continue to show sings of healing and no new areas will develop through the review date with interventions dated 4/26/24 including assisting with repositioning every two to three hours with use of an air mattress for pressure relief and need for head of bed elevated for tube feeding and ease of breathing, nursing assistants (NA's) observing skin and reporting any abnormalities to the nurse, having good skin hygiene and skin to be moisturized as needed if dry, elimination of waste to be addressed in the toileting section of the care plan, monitoring of labs and weight as ordered, pressure redistributing mattress on bed and cushion in chair, proper notifications to be made if wounds change, staff providing adequate nutrition and hydration with nutritional supplements and vitamins as ordered, using pillows between knees and bony prominences to avoid direct contact, and treatments as ordered (see TAR). A provider note by nurse practitioner NP-A dated 4/26/24, noted no skin breakdown. It also noted Incomplete quadriplegia since 11/2023. Has a collar in place (wife reports C2 [second cervical vertebra] was not healing and that is why collar was left in place in Arizona [R2 admitted to facility from a hospital in Arizona]). Plan: will need neuro[logy] follow up with xrays [sic] and referral to [local hospital] neurosurgery. A neurosurgery clinic provider note dated 4/30/24, noted R1 was seen for consideration of weaning of collar and noted due to the complexity of the patient's recent hospital course, would like to review chart in more detail prior to discontinuing collar. Instructions included follow-up on Thursday at 8:30 a.m. and orders placed at the visit were for a computed tomography (CT) scan. R1's Wound Management Detail Report by the facility's wound nurse dated 5/1/24, included a pressure ulcer right of coccyx present on admission with date identified of 4/17/24. The wound was 3 cm long, 6 cm wide, and the depth could not be measured with a moderate amount of serosanguineous (pale red to pink, thin and watery) exudate, no odor, was a stage 3, no undermining or tunneling, had irregular wound edges, was 60% covered by epithelial tissue and 40% covered by slough tissue (dead tissue usually cream or yellow in color), skin surrounding the wound had blanchable redness, and the wound healing status was declining. Comments noted Larger area of denuded [exposed, damaged] skin. R1's wound was identified as a stage 3 pressure ulcer whereas previous Wound Management Detail Reports from 4/17/24 and 4/24/24 had identified this wound as stage 2. R1's Wound Management Detail Report by the facility's wound nurse dated 5/1/24, included a pressure ulcer with location of coccyx center; superior not present on admission with date identified of 5/1/24. The wound was 2.7 cm long, 1.1 cm wide, with depth that could not be measured, no odor or exudate, was a stage 3, had no undermining or tunneling, the wound was 90% covered by slough tissue and 10% covered by epithelization tissue, had well defined wound edges with pink/normal surrounding skin, and the wound healing status was stable. Comments noted covered with hydrocolloid along with other open area. R1's skin care plan did not include any revisions upon identification of the worsening pressure ulcer of the right coccyx. Further R1's record did not include a comprehensive assessment of the center superior coccyx wound identified on 5/1/24 that included risk factors including decreased mobility, medication that impaired healing, co-morbities, refusals/rejection of care and treatment, cognitive status, incontinence status, nutrition, hydration, pressure points for turning and reposition needs, and pain. During an interview on 5/23/24 at 1:10 p.m., the assistant director of nursing (ADON) confirmed R1's admission progress note dated 4/12/24 identified sacral pressure ulcers on both the left and right sides with placement of a foam dressing and wound care orders that started on the 16th with the order for a sacral area foam dressing every shift. The ADON stated she did not see any evidence of wound care between 4/12/24 and 4/16/24. She noted that if a resident arrived with wounds but no wound care orders, staff should request orders from the provider and this did not meet her expectation for wound care nor was it in line with standards of care. The ADON identified that a pressure ulcer not being treated had the potential to worsen. The ADON stated comprehensive assessment of wounds were completed by the facility's wound nurse who rounds weekly on Wednesdays. She confirmed that the wound nurse saw R1 on 4/17/24 and documented the right coccyx pressure wound but did not document the second wound previously identified in the 4/12/24 progress note until a visit on 5/1/24 when it was first comprehensively assessed. The ADON stated the wound should have been assessed as soon as it was identified and by the wound nurse when she saw R1 on 4/17/24. The ADON confirmed documentation indicated R1's right coccyx pressure ulcer progressed from a stage 2 wound on 4/24/24 to a stage 3 wound on 5/1/24 and she would want a resident's care plan, orders, and interventions to be updated for a worsening wound and did not have any evidence that interventions were re-assessed for effectiveness when staff identified the wound was worsening. A provider note by nurse practitioner NP-A dated 5/2/24, indicated R1 had a change in condition and NP-A recommended sending him to the hospital for further evaluation and diagnosis. A progress noted dated 5/2/24, indicated R1 was transported to the emergency department via emergency services at approximately 11:30 a.m. A hospital patient care image (photograph) in R1's EHR dated 5/2/24 at 1:42 p.m., depicted a large open wound on the back of the head with description of mechanical pressure ulcer back of head from c collar [cervical collar]. Additional photographs depicted a foam border dressing with the date 3/18 visible on the front in marker and the back of the dressing with a large amount of bloody drainage, hair, and skin attached after removal from R1's head. A hospital intensive care unit admission note dated 5/2/24 at 1:44 p.m., included open wounds on his occipital area and coccyx (pictures in chart). A hospital progress note dated 5/2/24 at 2:03 p.m., noted patient malodorous, has foam bandage to back of head that is grossly bloody with layers of skin, wound under occiput in same shape and depth of dressing dated 3/18 as in March 18. Today's date is May 2nd. Unable to currently visualize skin under Miami J. Wound nurse consult placed stat as well. A hospital wound nurse consultation note dated 5/3/24 at 8:10 a.m., identified a pressure injury on the posterior head noted to be unstageable and a pressure injury located on the sacrum with poorly defined/irregular margins noted to be a deep tissue injury. Review of R1's record throughout his admission to the facility prior to transfer to the hospital lacks any documentation of a wound on the posterior head. Nursing Home Incident Report #356410 submitted to the State Agency by the facility dated 5/4/24, noted resident [R1] was sent to the hospital for evaluation. At the hospital resident was noted having a pressure related ulcer at the back of his head. Nursing Home Incident Report Investigation Report Summary #356410 submitted to the State Agency by the facility dated 5/10/24, noted staff did not have orders for management of Miami J Collar, and were waiting for [physician]/NP to decide on management. In an interview on 5/23/24 at 7:26 a.m., registered nurse (RN)-D stated R1 had a cervical collar secured with Velcro and they would undo the Velcro to change his tracheostomy ties (a strip of material that goes around someone's neck to assist with securing a tracheostomy tube on the front of the neck). RN-D noted staff did not have an order for the collar and it said in the computer that it would be evaluated by the provider to determine how to manage it. RN-D stated nurses needed an order to remove the collar to clean the skin underneath and because she saw that the collar was to be evaluated by the provider she thought they would come and do something. RN-D stated she did not know what the manufacturer recommended for management of the Miami J cervical collar. In an interview on 5/23/24 at 8:21 a.m., RN-B stated residents with neck braces admit to the facility with instructions from the doctor about the brace that staff followed. She noted if someone had a brace sometimes they might get a wound, like if the brace is not ever released, if it is tight, or if there is already a wound underneath that needs to be dressed, so you have to always assess . you have to see if it is making a wound from the pressure, you have to check the skin. RN-B stated to check the skin nurses could remove the brace if there was an order to do so but, if not, could look and feel inside the space between the back of the head and the brace to assess the skin. RN-B noted that if someone had a brace but no orders she would call the provider to request orders, if someone had a pressure ulcer but no wound care orders she would assess the wound and call the provider to request orders. In an interview on 5/23/24 at 8:53 a.m., RN-C stated for a resident with a cervical neck brace the first thing is you need to assess the skin under the collar and see what's going on . you remove it and then put it back on when you're done and check to see if the collar is clean on the inside too. RN-C further stated if a resident with a collar comes in, it doesn't matter if there is an order or not, you have to assess the skin. If you think it's not safe to remove the collar and do the assessment then you need to let the provider know that you need an order so you can assess. RN-C states if a resident had a pressure ulcer but no wound care orders nurses have to assess it and tell the provider, it was not okay to just leave it, nurses had to ask for orders. In an interview on 5/23/24 at 11:01 a.m., the administrator stated R1 was admitted on [DATE] with a Miami J collar and staff immediately realized they did not have orders for the management of the collar. The administrator noted staff contacted the discharging facility and requested orders the next day but did not receive them. He stated R1 had a provider visit on 4/12/24 and nursing requested orders from NP-A, but NP-A and the doctor said they could not give the orders and R1 needed to be referred to neurology for this. He noted a referral was made and appointment scheduled for 4/30/24. The administrator stated that after the referral was made the question arose of whether we should take the collar off and see the skin under, but the family said that we should not touch the collar because his C2 hadn't healed and it was very dangerous. He stated they waited and at NP at the neurology clinic saw him on 4/30/24 but was not comfortable giving any orders for management of the collar. The administrator noted that the facility had access to the hospital's medical record system and became aware after R1 was transferred to the hospital that hospital staff identified a wound under the Miami J collar. The administrator stated nurses need to do a thorough job in assessing skin and although they did not have orders to move the collar, maybe they should have sent R1 in faster for evaluation of the collar, maybe to the emergency department rather than wait for a neurology appointment. He noted attempts were made to get orders for management of the collar, but doctors were not willing to provide them and the mistake initially happened when R1 was admitted without complete orders. The administrator stated that accepting a resident for admission with complete orders was a mistake because once the facility accepted the resident they became the facility's responsibility. In an interview on 5/23/24 at 1:10 p.m., the assistant director of nursing (ADON)stated she was not aware during his admission that R1 had a wound on the back of his head. She noted head to toe skin assessments are done on admission but R1's did not identify a head wound. The ADON noted for someone like R1 with skin underneath a medical device she would expect to have orders for management of the device and would expect staff to have an order to remove a cervical collar. She further noted that staff could have at least felt behind the collar to check R1's skin in the absence of orders to remove the collar for skin assessment. In an interview on 5/23/24 at 2:00 p.m., the director of nursing (DON) stated the facility lacked orders for R1's cervical collar she wouldn't dare remove it without having direction which is why NP-A referred R1 to neurosurgery. The DON noted she expected comprehensive skin assessments and getting needed orders to be done within 24 hours of admission. She stated comprehensive assessments of wounds and documentation of all the wound characteristics were needed to track wound healing and should be done within the first couple days after a wound was identified. She confirmed that a wound identified on a Thursday (4/11/24) that was not comprehensively assessed until the following Wednesday (4/17/24) was not in line with her expectations or professional standards of practice. The DON noted that the facility had been informed in R1's pre-admission assessment that he did not have any wounds but if someone had a wound and no wound care orders staff should initiate wound care per facility protocol and contact the provider for further orders. In an interview on 5/23/24 at 2:39 p.m., NP-A stated for someone with a cervical collar typical standards of care are that the facility would have some orders for it from the discharging facility. She stated typically the facility would have orders directing to leave a collar on for a specific amount of time or to remove it and clean underneath it, but they didn't have a lot of data from the discharging facility about R1 and his collar. NP-A noted she referred R1 to neurosurgery to et an x-ray and orders for the collar for specialist to make a recommendation about what to do. She stated expectations for skin assessment with R1 were tough, if staff had asked her if it was okay to remove to collar and look at the skin underneath she probably would have deferred to the physician because the facility did not have good records and they were going off of what family said. NP-A stated staff probably wanted me to say let's take off the collar and look at the skin, but we never had that specific conversation about looking at the skin. The question was what do we do with the collar and my answer was send him to neurosurgery. I think we all own a piece of this . I'm a wound care nurse and I turned him over and looked at his bottom but I didn't take the collar off, didn't see the back of his head . I was aware that we weren't taking the collar off because we agreed neurosurgery needs to evaluate him. NP-A noted that she first saw R1 on 4/12/24 and did not note any skin issues but knew he had a little area on his bottom and states I recall seeing small areas on his bottom, one comes to mind, but I can't say for sure. They were like superficial. In an interview on 5/29/24 at 11:50 a.m., the facility's medical director (MD) stated, if a resident admitted with a cervical collar it would always be left on until staff could obtain orders for its management because staff needed doctor's orders to remove a cervical collar. The MD noted R1 did not have orders for management of his Miami J collar on arrival so staff attempted to get orders from the referring hospital, the primary care team, and the neurology clinic. The MD stated the facility did not receive complete information about R1's care needs and somebody had previously put a dressing on a wound underneath the collar but never recorded it for facility staff to see, so they had no knowledge there was an open area or that there was a dressing in place. The MD identified this as a bad outcome and noted nursing staff are responsible for skin care once a resident arrives at the facility. The MD stated he did not have a clear timeline for how long a resident could go without orders for a cervical collar before he would expect alternative interventions, like sending the resident to the emergency department. The MD stated he did not have an answer regarding if he would expect nursing staff to consult manufacturer guidelines for a cervical collar. Miami J Patient Care Handbook from manufacturer Ossur copyrighted 2010, includes C-Spine Precautions: you must be lying flat to remove the collar unless your doctor gives you permission to do this in a sitting position. You will need a second person to help you in order to maintain the proper head, neck, and airway alignment. Position patient with arms to the side, shoulders down and head aligned centrally. Unless otherwise specified by your doctor: do not remove the collar except to wash under it and change the pads. Keeping your Miami J and the skin beneath clean is an important part of your treatment. Daily cleaning will help to prevent skin irritation. Facility policy titled Prevention and Treatment of Skin Breakdown dated 2018, included Policy: Resident skin integrity is assessed upon admission and weekly thereafter. A skin risk assessment is completed upon admission and weekly for 4 weeks upon significant change, and quarterly thereafter. Those residents at an increased risk for impaired skin integrity are provided preventative measures to reduce the potential for skin breakdown. Those residents' who experience a break in skin integrity or wounds are provided care and service to heal the skin according to professional standards of care. Treatment of impaired pressure injury and lower extremity ulcers (arterial, venous, neuropathy/diabetic, mixed) If a resident is admitted with impaired skin integrity or a new pressure injury or lower extremity wound developed the licensed nurse implements the following items: 1.) Documentation of the skin impairment is completed in the medical record. Staging of pressure injury is completed as necessary by trained licensed associated. Other lower extremity wounds with [sic] be described a partial thickness loss or full thickness loss. 2.) Standing orders/protocol for skin wound are initiated. 3.) Notify attending provider, resident and resident representative. Attending provider determines wound type and may provide additional orders. 4.) Notify supervisor/designee. 5.) Evaluate current pressure reduction interventions and revise resident centered care plan. Facility policies an admission orders and skin protocol were requested but not received.

Based on interview and document review, the facility failed to ensure the head of bed was elevated for 1 of 3 residents (R1) who utilized a tube feeding to meet their nutritional needs. This resulted in an immediate jeopardy (IJ) situation for R1 who had an emesis when left flat in bed, while their tube feeding was running, which lead to aspiration and subsequent hospitalization . The IJ began on 1/15/22, at 3:10 p.m. while R1 was found laying flat in bed and covered in emesis when her tube feeding was actively running and was subsequently hospitalized due to an aspiration pneumonia. The administrator and director of nursing (DON) were notified of the IJ for R1 on 1/21/22, at 12:15 p.m. The IJ was removed on 1/21/22, after the facility had implemented an acceptable removal plan; however, non-compliance remained at D - isolated, scope and severity level, which indicated no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: R1's quarterly Minimum Data Set (MDS), dated [DATE], identified R1 was in a persistent vegetative state (chronic state of [CONDITION(S)] in which a person shows no signs of awareness), demonstrated no chronic pulmonary diseases (i.e., asthma, [CONDITION(S)]) or [CONDITION(S)], and required total assistance from staff to complete her activities of daily living (ADLs). Further, the MDS outlined R1 received her daily nutritional calories and fluids via a feeding. R1's Nutrition Assessment, dated 12/2/21, identified R1 was to receive nothing by mouth (NPO) and received a tube feeding of [MEDICATION(S)] (the brand of feeding) 70 milliliters (mL) an hour for 18 hours a day, along with scheduled water flushes, through a gastrostomy tube (g-tube; a tube inserted through the belly which provides nutrition directly to the stomach). R1's care plan, dated 12/16/21, directed staff to provide R1's tube feeding as ordered along with keeping the head of bed elevated as close to 30 degrees as possible; avoid elevation of greater than 30 degrees. Further, the care plan directed staff to assess R1 for signs of intolerance to the tube feeding which included abdominal distention, decreased bowel sounds, vomiting, diarrhea, and constipation. A Nestle Health Science (the manufacturer of R1's feeding formula) Tube Feeding with A Pump guideline, dated 2014, identified general guidelines to be completed while using their formula with a pump. The section labeled, Administration, directed, Sit or lie with head elevated at least 30 degrees (about the height of two pillows) and remain in this position for 30 to 60 minutes after each feeding. However, R1's progress notes were reviewed and identified: On 1/15/22, at 10:42 p.m. R1 was discovered by licensed practical nurse (LPN)-A lying in bed with the head of bed (HOB) not elevated and flat. R1 had visible vomit on her person when discovered by LPN-A and was recorded as using her accessory muscles to breathe and had wheezing (high-pitched whistling sound made while breathing) and crackles (discontinuous adventitious lung sound) present on auscultation (using a stethoscope) of her lungs. On 1/16/22, at 4:10 a.m. a subsequent note identified R1 had a heart rate of 145 (normal range 60 - 100) and oxygen saturation of 88 percent on room air (normal range 95 percent or higher). R1 had continued wheezing and difficulty breathing. R1 was sent to the emergency room . R1's corresponding Emergency Department Stabilization Note, dated 1/16/22, identified R1 presented with worsening respiratory compromise and was found to have gurgling respirations with oxygen saturations in the low 90 (%) range while on room air. R1's temperature was recorded as 100.6 degrees (F), her oxygen saturation was 94 percent (while on oxygen), and she had a heart rate of 132. The note outlined R1 was intubated, placed on a ventilator, and started on IV antibiotics. Further, R1's Intensive Care Unit (ICU) Transfer Note, dated 1/19/22, indicated R1 had been diagnosed with acute hypoxic (low blood oxygen) [CONDITION(S)] and [CONDITION(S)] (severe infection). R1 had not returned to the facility at the time of the abbreviated survey. On 1/20/22, at 9:00 a.m. the DON verified facility staff failed to elevate the head of R1's bed while she received a tube feeding (1/15/22) and had vomited. R1 was subsequently hospitalized . The DON further stated staff still needed to be educated on the position of the bed for residents who had tube feedings. When interviewed on 1/20/22, at 12:11 p.m. hospital registered nurse (RN)-B verified R1 was admitted to the hospital for [CONDITION(S)] related to aspiration. R1 remained intubated due to [CONDITION(S)] and received IV antibiotics. During an interview on 1/20/22, at 1:00 p.m. LPN-B stated R1 received a tube feeding and was always to have the head of the bed elevated at least 30-degrees; however, LPN-B stated she became aware R1 had an emesis, and was flat in bed, at the end of her shift on 1/15/22. LPN-B described R1's head as being turned to the side and her clothing was soiled with a lot of emesis on her person. LPN-B stated she thought all staff needed to have education on proper positioning of a resident who received a tube feeding and confirmed she had not received education since the incident occurred on 1/15/22. During an interview on 1/20/22, at 3:00 p.m. LPN-A stated on 1/15/22, when doing rounds at 3:10 p.m., he found R1 lying flat in bed, with her head positioned to the right side, and was covered in vomit. The vomit was on R1's clothing and bedding to R1's right side. LPN-A stated R1's tube feeding was running and R1 did not have any additional emesis during his shift. R1 was monitored throughout the shift and did have wheezing and crackles heard in her lungs. During an interview on 1/20/22, at 3:30 p.m. RN-A stated when she arrived for her shift on 1/15/22, at 11:00 p.m. R1, did not look good. R1 was noted to be breathing heavier (outside of baseline), her mouth was open, she had facial grimacing, and appeared to be having difficulty breathing. R1 also appeared to be using her accessory muscles in her chest and abdomen to breathe. R1 was wheezing, had audible crackles, and also had a distended abdomen. RN-A stated she notified the on-call nurse practitioner (NP) and received an order to send R1 to the hospital. During an interview on 1/20/22, at 1:37 p.m. nursing assistant (NA)-A stated R1 was able to open her eyes, but she was unable to communicate or move her own body. R1 was completely dependent on staff for all her cares and had a sign above her head which directed staff to always keep the head of R1's bed up at a 30-degree angle. NA-A stated she last checked on R1 around 1:30 p.m. on 1/15/22, when she checked and changed the resident. NA-A did not observe any episodes of vomiting. During an interview on 1/22/22, at 10:02 a.m. the facility medical director stated it appeared very clear R1's [CONDITION(S)] was caused by aspiration after emesis which caused her to require intubation, pulmonary toileting (clearing airway), and treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . The medical director further stated for most people, aspiration can be cleared by a resident, but when a resident was in a vegetative state it was difficult for a resident to do this. R1 was in a vegetative state and could not communicate concerns and could quickly go get worse. During an interview on 1/21/22, at 11:15 a.m. the hospital medical doctor stated R1 could have had a quick change related to aspiration. R1's [CONDITION(S)] was caused by aspiration which required intubation. R1 remained hypoxic and would need to remain intubated for a few days. During an interview on 1/21/22, at 10:40 a.m. the DON confirmed the facility failed to provide proper positioning for R1 who was on a tube feeding. R1 was found in bed in the flat position, had a emesis, and required hospitalization . All direct care staff needed to have education on positioning of residents with tube feedings and keeping residents head of bed up at a 30-degree angle. The facility's policy titled Enteral Feeding dated 12/02, indicated staff would leave the resident in a safe and comfortable semi-fowlers position (bed angle 30 to 45-degrees). A systemic removal plan was approved on 1/24/22, however, the IJ which began on 1/15/22, at 3:10 p.m. was removed on 1/21/22, after survey entrance, when the facility implemented appropriate corrective actions which included: - Nursing assistant care guides were updated to reflect appropriate bed placement for residents with tube feedings on 1/21/22. - The facility educated direct nursing staff, currently working at the facility, on the proper placement of a resident's bed during a tube feeding on 1/21/22. Four RN's and four NA's were interviewed and verified they received an understood education related to resident positioning who were administered tube feedings. - Staff were not working were notified education must be completed prior to their next scheduled shift on 1/21/22. - The facility reviewed policies and procedures related to tube feedings on 1/21/22.

Based on interview and document review, the facility failed to ensure staff were trained and competent to provide [MEDICAL CONDITION] cares for one of 30 residents (R1) reviewed who required [MEDICAL CONDITION] cares. A nurse left R1's [MEDICAL CONDITION] cuff inflated and capped the [MEDICAL CONDITION], blocking R1's airway and ability to breathe. R1 was harmed when he was unable to breathe and died . The failure of the nurse to deflate the [MEDICAL CONDITION] cuff before capping the [MEDICAL CONDITION] placed 30 residents with tracheostomies at risk of Immediate Jeopardy. The facility was not in compliance on (MONTH) 14, (YEAR) when the facility failed to ensure staff were trained and competent to provide [MEDICAL CONDITION] cares for one of 30 residents (R1) reviewed who required [MEDICAL CONDITION] cares and died after a nurse left R1's [MEDICAL CONDITION] cuff inflated and capped the [MEDICAL CONDITION]. The facility corrected the non-compliance on (MONTH) 26, (YEAR), when it was verified during an on-site investigation that the facility implemented a systemic plan that included the following actions: the completion of education to all nurses on the topics of [MEDICAL CONDITION] care by way of video, exchange of questions and answers, written step-by-step instructions and the nurses provided a return demonstration. The facility also added a printed reminder to always deflate the [MEDICAL CONDITION] cuff in the residents' treatment administration records (TARS). Findings include: R1's medical record was reviewed. R1 admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. R1 had a Brief Interview for Mental Status (BIMS) score of five, which indicated severe cognitive impairment. R1's care plan, dated [DATE], indicated R1 had a [MEDICAL CONDITION] for protection of airways and to help manage secretions, with a goal of R1 having a patent airway. R1's care plan indicated staff to provide [MEDICAL CONDITION] cares every shift and [MEDICAL CONDITION] and keep set to minimum occlusion. R1's care plan indicated he had aphonia post surgery and [MEDICAL CONDITION] placement and could not speak; R1 required a passy-muir valve (PMV) for speaking and it was ok to deflate cuff for verbalization. R1's respiratory administration records (RARs) for June, July, (MONTH) and (MONTH) (YEAR) indicated licensed practical nurse (LPN)-K had performed R1's [MEDICAL CONDITION] cares per physician's orders [REDACTED]. R1's physician's orders [REDACTED]. R1's physician's orders [REDACTED]. A nursing progress note dated [DATE] at 10:08 a.m. indicated R1 was able to use a PMV as tolerated during the day but not to be used at night. R1's language was not improving per speech therapy. Facility video surveillance (no audio) dated [DATE], showed at 10:51:04 a.m. LPN-K talked to the respiratory therapist (RT)-A at the second floor nursing station. LPN-K held a PMV and showed it to RT-A. RT-A looked at the PMV, said something to LPN-K and she turned away and walked down the hall directly in front of the nursing station. LPN-K stopped and turned back towards RT-A and then went down the hall to R1's room. At 10:52:04 a.m. LPN-K entered R1's room. At 10:53:11a.m. LPN-K exited R1's room and entered another room in the same hallway. At 11:38:16 a.m. LPN-K entered R1's room At 11:38:50 a.m. a nursing assistant entered R1's room and exited at 11:39:00 a.m.and ran toward the nursing station waving her arms. RT-A followed the nursing assistant into R1's room at 11:39:12 a.m. More staff followed RT-A. At 11:40:14 a.m. LPN-K got the crash cart and went back to R1's room. At 11:42:06 a.m. LPN-K was at the nursing station desk with the health unit coordinator (HUC). LPN-K called 911 Staff paged a code. At 11:46:11 a.m. MD-J and other staff arrived on second floor in response to the code. At 11:48:48 a.m. emergency medical services (EMS) arrived but remained outside of R1's room. At 11:50:00 a.m. more EMS staff arrived. At 11:52:14 a.m. EMS left without R1. An undated Internal Investigation Incident # 6 indicated that facility administration could not confirm LPN-K reviewed the [DATE], order to cap R1's [MEDICAL CONDITION] in the electronic medical record (EMR) before performing the procedure, or that LPN-K obtained an oxygen saturation reading on R1 after capping his [MEDICAL CONDITION]. R1 was pronounced dead at 11:50 a.m.by MD-J. A nursing progress note dated [DATE] at 1:58 p.m., indicated a nursing assistant called for help for the nurse from the hallway outside R1's room. RT-A proceeded to go to R1's room at 11:40 a.m. and saw R1 slouched in his wheelchair and unresponsive. LPN-K had the cap off R1's [MEDICAL CONDITION] and was using the heated humidity circuit with in line suction on him. RT-A moved R1 to the bed and assessed for breathing and a pulse. R1 was not breathing and had no pulse. RT-A said he saw the [MEDICAL CONDITION] cuff and pilot balloon were still inflated. RT-A told staff to call 911 and he started cardiopulmonary resuscitation (CPR) while a registered nurse (RN)-B administered oxygen by ambu-bag via R1's [MEDICAL CONDITION]. Staff continued CPR for approximately 10 minutes until R1's chart was reviewed and Do Not Resuscitate (DNR) orders were confirmed. MD-J was present and confirmed R1 had no pulse or respirations and stopped CPR at 11:50 a.m. and pronounced R1 dead. When interviewed on [DATE] at 10:31 a.m., RT-A said LPN-K came to him on the morning of [DATE] with a passy muir valve (PMV) in her hand and asked him if she needed to use the PMV on R1. RT-A said he told LPN-K no, R1 had a new order to have his [MEDICAL CONDITION] capped so she could put the PMV away in his drawer and just use a red cap on his trach. RT-A said LPN-K said ok and walked away from the second floor nursing station to R1's room. RT-A said R1 was working with speech therapy to move beyond using a PMV and speak independently with a capped [MEDICAL CONDITION]. The cap is a red cap that fits onto the front hub on the [MEDICAL CONDITION] and allows the resident to breathe through the nose and mouth. RT-A stated he provides a hands on class training on trachs, PMV's, and caps to show how use the equipment, but in the past did not consitently keep attendance training records. When interviewed on [DATE] at 10:02 a.m., registered nurse staff coordinator (RN)-C said she is responsible for coordinating annual training needs for the facility staff. RN-C said she participated in the reeducation of the nurses for [MEDICAL CONDITION] cares with a return demonstration and completed audits by completing a checklist to ensure the care provided was done correctly. When interviewed on [DATE] at 11:40 a.m., RN-D said the capping process requires nursing staff to deflate the cuff, cap the [MEDICAL CONDITION], make the resident cough, and see if they have difficulty breathing and how they are doing; the entire process should take about five minutes if there are no difficulties. RN-D said after R1's death the nurses were retrained on [MEDICAL CONDITION] cares, the PMV and [MEDICAL CONDITION] cap and performed a return demonstration. When interviewed on [DATE] at 1:39 p.m., director of nursing (DON)-G said LPN-K had taken off an extended leave of absence for approximately eight months. When LPN-K returned from the extended leave of absence she had to reapply for the position and complete new hire training. DON-G stated she was not sure of any competency retesting on LPN-K when she returned to work at the facility. DON-G said all nurses have been reeducated on [MEDICAL CONDITION] education for deflating the cuff, the PMV, and the trachesotomy cap. When interviewed on [DATE] at 2:26 p.m. assistant director of nursing (ADON)-I said the morning of R1's death was busy but not unusually so for a Wednesday, there was a lot of activity because physicians round and there was an inservice for infection control with the medical director in the lower level classroom some of the staff were attending but they were fully staffed. ADON-I stated she participates in the annual retraining for the nurses for [MEDICAL CONDITION] and ventilator residents. When interviewed on [DATE] at 10:13 a.m., MD-J said he had written an order about two weeks earlier to have R1 start using a PMV and then move to a capped [MEDICAL CONDITION]. On the morning of [DATE], MD-J said he saw R1 for an earwax and ear ache issue and R1 was overall doing well. MD-J said he'd talked with RT-A that morning and wrote a new order to cap R1's [MEDICAL CONDITION] as tolerated. MD-J said both the PMV and the cap require a resident's [MEDICAL CONDITION] cuff be deflated; if it is not deflated, there is no air flow to the lungs and it is a fatal condition. MD-J said his expectation is staff are trained and competent. When interviewed on [DATE] at 9:56 a.m., LPN-K said on the day of the incident she administered R1's medication and monitored his humidified in-line suction. LPN-K said she went to care for another resident and an unnamed nursing assistant notified LPN-K that R1 wanted his PMV. LPN-K said she looked in R1's chart to check what type of PMV R1 used and did not see the information so she went to find RT-A for help. LPN-K said RT-A was at the second floor nursing station talking to the HUC and she asked him about R1's PMV and was told to do the cap just like on fourth floor.LPN-K said she entered R1's room and R1 was seated in his wheelchair alert. LPN-K said she placed the red cap onto his [MEDICAL CONDITION] hub but did not deflate the cuff. LPN-K said she did an oxygen saturation check on him and recalled it read 97% but did not document the level. LPN-K asked R1 if he was ok and R1 smiled. LPN-K said she placed the call light within reach and left the room and went to care for five or six other residents. LPN-K went to check back on R1 and found him slumped over in his wheelchair. She touched his arm and said his name a few times and then yelled for help. LPN-K said there was no alarm or call light activated from R1's room. LPN-K said she did not realize what happened until RT-A told her R1's cuff had not been deflated. LPN-K said she worked at the facility from 2005 to (YEAR). She had taken several months off in (YEAR) and came back to work at the facility in April, (YEAR). LPN-K said she had nursing refresher skills for two days, one day on 3rd floor and one day on 4th floor but did not have to complete a return demonstration. A facility policy titled Departmental Supervision, revised ,[DATE] indicated the Director of Nursing Services and or the Nurse Supervisor/ Charge Nurse as a minimum, is responsible for: arranging schedule to allow time for supervision and evaluation of performance of nursing personnel. A facility policy titled Daily Work Assignments, revised ,[DATE] indicated all nursing service personnel shall follow daily work assignments and perform assigned duties in accordance with professional standards of practice and facility policy. A facility policy titled Director of Nursing Services, revised ,[DATE], indicated the Director is responsible for but no necessarily limited to: developing standards of nursing practice; developing and maintaining nursing policy and procedure manuals; developing staff training programs for nursing service personnel; assuring the nursing care personnel are administering care and services in accordance with the resident's assessment and care plan. A facility policy titled Capping of Trach, dated [DATE] indicated the purpose was to allow a [MEDICAL CONDITION] resident to use their upper airway. The procedure instructed staff to: have a physician's orders [REDACTED].; make sure call light is with them for any immediate issues. An undated facility document titled Nurse Rehire Orientation indicated staff watch education videos required annually and have eight hours of orientation to each floor that they will be assigned to. A staff schedule dated [DATE] indicated LPN-K oriented on 4th floor 7:00 a.m. to 3:30 p.m. The Abuse Prevention Plan, dated (YEAR), defined neglect as the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. The past non-compliance that began on (MONTH) 14, (YEAR) was verified to be corrected on (MONTH) 26, (YEAR) during an on-site visit. Verification of corrective action confirmed with review of documentation and interviews. No other residents with tracheostomies passed away. Forty five nurses were retrained on [MEDICAL CONDITION] cares and three on-call nurses were scheduled to retrain by the RT-A and RN-C. Training encompassed watching a [MEDICAL CONDITION] video detailing [MEDICAL CONDITION] cares including the differences between PMV and a cap, a question and answer segment, and a documented skills demonstration check. Reminders to deflate cuffs were added to residents charts. Interviews were attempted with four of the residents with orders for PMVs and caps. Only one resident had the PMV on and she said the staff took good care of her [MEDICAL CONDITION].

Based on observation, interview, and document review, the facility failed to adequately assess and implement interventions to alleviate pain during wound care for 1 of 2 residents (R98) which resulted in actual harm. Findings include: R98 was admitted to the facility 2/22/14, with a complicated past medical history that included chronic [MEDICAL CONDITION] status [REDACTED]. In addition, R98 had a Stage 4 pressure ulcer (Full thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures e.g., tendon, joint capsule. Undermining and sinus tracts also may be associated with Stage 4 pressure ulcers) on his coccyx. R98 was observed during a dressing change on 4/23/14, at 10:45 a.m. to the Stage 4 pressure ulcer on the coccyx. There were two nursing assistants (NAs) NA-E and NA-F in the resident's room who had just completed morning cares. The dressing change was done by registered nurse (RN)-G. RN-G came into R98's room, took gloves from the bedside stand that had dressing materials. RN-G explained to R98 that she was going to change the dressing on his wound. NA-E assisted RN-G to turn and position the resident onto his left side. NA-E supported the resident on his left side while RN-G removed the old dressing. RN-G indicated the resident would let them know when he was having pain. RN-G did not inquire the pain status of the resident before starting the dressing change. RN-G donned gloves, and put saline (salt water) wound wash on a 4 x 4 gauge dressing and dabbed the wound and repeated the procedure one more time. R98 was observed grimacing and was then asked by the surveyor if he was having pain and R98 confirmed that he was having pain. R98 was asked if he had pain with other dressing changes and he replied that he had pain with all dressing changes. RN-G acknowledged she heard the resident state he was having pain. RN-G indicated she would get him something for pain after she finished with the dressing change. RN-G then put on a fresh pair of gloves and packed the wound with SoloSite (a wound dressing gel that creates a moist wound environment) on a 4 x 4 gauge dressing and used a Q-Tip to place the dressing in the wound. The resident continued to grimace in pain. Following the procedure, RN-G went out to the med cart and got a [MEDICATION NAME] (pain medication) for R98 at 11:00 a.m. RN-G was interviewed after she gave the pain medication to R98 and confirmed she did not assess the resident for pain before starting the dressing change and the resident had not received anything for pain before the dressing change. RN-G then discussed with RN-D and both agreed they should check with the resident the status of his pain before doing a dressing change. RN-G confirmed the resident did not have a scheduled pain medication(s) before the dressing change but there was an order for [REDACTED]. R98 had pain assessments completed on 2/4/14 and 2/7/14. Each assessment indicated he was having pain daily in the buttocks area. Both pain assessments indicated the resident's pain was located in the coccyx area where there was a wound and a check mark was by distressing/miserable (moderate pain). Both of the pain assessments indicated the resident was on [MEDICATION NAME] 2 tabs per the [DEVICE] every 4 hours for pain. Another pain assessment was completed on 2/22/14, and indicated R98 had pain in the buttock area and the pain was uncomfortable /annoying (mild pain) and the pain was less than daily and the Tylenol (a mild [MEDICATION NAME]) 650 mg was effective and he could have the Tylenol as needed for pain. On 2/25/14, a 4th pain assessment was completed and the pain was once again noted to be in the buttocks area and the pain was distressing/miserable (moderate pain). The resident could have Tylenol through the [DEVICE] every 4 hours for pain and it was noted to be effective. The pain assessments did not have a time when the assessments were completed and it could not be determined if the pain assessments were only completed by interview or in conjunction with cares and wound care treatments. The Care Area Assessment (CAA) done for cognition loss/dementia was done on 2/11/14, and indicated that area triggered because the Brief Interview for Mental Status (BIMS) score showed impaired cognition. The conclusion that was drawn under Analysis of Findings indicated the following: "Resident is alert and oriented. Understand communication and is able to follow instructions. Resident is on ventilator full time. He is able to mouth words and is understood when cuff is deflated. Resident is able to write some. Hearing is adequate, resident feels he can't hear well." Received a fax dated 4/25/14, and the note on 4/7/14, indicated, "Resident knows pain medication is available and documentation exists in record that he does request it." The CAA for pain was done on 2/17/14, and indicated, "Per resident report during pain interview he has continuous pain that can range from 7 to 10. States it is usually the coccyx area that hurts. Reports that pain medication helps. Was started on QID (four times a day) [MEDICATION NAME] with PRN (as needed) [MEDICATION NAME] for breakthrough pain." R98's care plan dated 3/5/14, indicated R98 had pain/potential for pain. -- Pain: alteration in comfort level pain due to immobility and pressure area -- Resident will verbalize good pain control and /or will have minimal visible indicators of pain -- Assist with developing coping mechanism -- Attempt non-pharmacological methods of pain interventions: imagery, distraction techniques, relaxation exercises, massage therapy hot or cold compress. Rest periods to facilitate comfort sleep, and relaxation. Eliminate additional stressors or sources of discomfort, sleep and relaxation. Eliminate additional stressors or sources of discomfort whenever possible -- Complete pain assessment: annually, quarterly, significant change and PRN -- Medications as per MD (physician) orders -- Monitor for SE (side effects) of pain medication: sedation, respiratory depression, N/V (nausea and vomiting) itching, increased confusion, Educate resident and family -- Nursing to observe and record effectiveness of scheduled and PRN medications and update MD as indicated -- Observe for any objective signs of pain: moaning, groaning, grimacing -- Resident uses Tylenol PRN for pain -- Staff to evaluate resident's rate pain on a 1-10 scale if resident states he/she was experiencing pain, or point to faces of pain on a scale. The plan of care was not followed as the staff did not monitor R98 for signs of pain during the dressing change nor did the staff offer pain medication prior to the dressing change. Progress notes were reviewed for R98. - On 3/12/14, at 3:50 p.m. the resident settled in to his room and transferred to facility ventilator. (Resident returned from the hospital). Stated he had some pain to back side. "Dressing change done to Stage IV coccyx ulcer and wound measurements done." - On 3/17/14, at 4:21 p.m. Resident stated he had pain to coccyx. "Resident does have stage IV pressure to coccyx upon re-admission. Resident was on [MEDICATION NAME] prn for pain." - On 3/20/14, at 7:01 p.m. Resident stated he had pain in his butt which he rated 6/10." "PRN (as needed) [MEDICATION NAME] administered via [DEVICE] at 0515 (5:15 a.m.) with somewhat effective results. Resident now rates pain at 5/10." - On 3/26/14, at 2:44 p.m. resident requested pain medication for back ache at 2:00 p.m. - On 3/28/14, at 3:02 p.m. resident requested pain medication for back ache at 1320 (1:20 p.m.) and [MEDICATION NAME] for anxiety. - On 4/7/14, at 7:05 a.m. requested pain med for pain in low back and cough medicine at 0630 (6:30 a.m.). - On 4/7/14, at 8:11 a.m. stated that when pain occurs pain medication ([MEDICATION NAME]) was good to relieve it. R98 had a physician's orders [REDACTED]. The order was to do the dressing change as follows: "1. Cleanse coccyx daily with normal saline 2. Pack with gauze loosely moistened with SoloSite 3. Skin protectant to wound edges 4. Cover with ABD." R98 had a physician's orders [REDACTED]. A pain assessment interview was completed on 4/7/14, at 8:05 a.m. (30 day assessment) and indicated the resident had not received any scheduled pain medication in the last five days. However, R98 had received PRN pain medications in the last five days. The next question was, "at any time in the last 5 days, has the resident received any non-medication intervention for pain?" The answer was "Yes" but the area for description of the pain was left blank. When the resident was asked "Have you had pain or hurting at any time in the last 5 days?" the answer was "Yes." The resident indicated he had pain occasionally and the pain was moderate. The indicators for pain was blank. R98's Minimum Data Set ((MDS) dated [DATE], indicated R98 was severely cognitively impaired and had an unhealed pressure ulcer at Stage 4. The MDS indicated R98 had occasional pain. R98's physician note dated 4/23/14, indicated a nurse had informed him about identified pain during dressing changes and R98 would be pre-medicated with [MEDICATION NAME] in the future. R98 also had a chronic Stage 4 stage pressure ulcer related in part to his debilitated condition poor cardiac output and prolonged bed rest. A progress note dated 4/24/14, at 3:26 p.m. indicated the following: "Resident received PRN (as needed) [MEDICATION NAME] at 0950 (9:50 a.m.) this shift prior to coccyx dressing change. The resident later stated that this medication made the dressing change more comfortable for him." The Medication Administration Record [REDACTED]. R98 received pain medication PRN: - On 4/11/14, at 3:43 p.m. - On 4/12/14, at 6:27 p.m. - On 4/13/14, at 6:40 p.m. - On 4/15/14, at 6:30 a.m. and again at 12:36 p.m. - On 4/16/14, at 9:00 a.m. - On 4/17/14, at 12:45 a.m., 6:57 a.m. and 5:18 p.m. - On 4/19/14, at 9:32 a.m. - On 4/21/14, at 8:39 p.m., 12:52 p.m., and 4:45 p.m. The MAR indicated [REDACTED]. Also the MAR indicated [REDACTED]. R98's physician was interviewed on 4/23/14, at 2:10 p.m. and it was brought to the attention of the physician that R98 was having pain during dressing changes on his Stage 4 pressure ulcer. R98's physician agreed to talk to the resident and addressed the pain during the dressing changes. The physician would evaluate if R98 should have a scheduled pain medication. RN-D was interviewed on 4/24/14, at 8:45 a.m. and confirmed R98's physician saw the resident yesterday, (4/23/14) and assessed R98 for pain during dressing changes. R98's physician wrote a doctor's order on 4/23/14, for [MEDICATION NAME] one before each dressing change. R98 was interviewed on 4/24/14, at 8:55 a.m. R98 stated he always experienced pain during the dressing changes and on 4/23/14, the pain was at least a "7, maybe higher" when he had the dressing change (the resident was aware that on a scale of 1 to 10, 10 would be the highest). The director of nursing (DON) was interviewed on 4/24/14, at 11:40 a.m. was questioned about pain management, her response was, "I will have to get the policy and read it and get back to you." The DON declined comment on additional questions relating to pain assessments prior to treatments saying she had not read R98's chart and was not familiar with his cares. RN-D was interviewed on 4/24/14, at 11:50 a.m. and confirmed R98 "can tell us when he is having pain and can ask for pain medication, he knows he has pain medication available." RN-D added they do pain assessments on admission, 14 days, 30 days, and at 60 days, and R98's answers were mostly reliable. RN-D confirmed the resident should have been asked before the dressing change if he had pain. "We do not routinely do pain assessments before treatments." The pain management policy dated 12/2002, indicated that the standard was, "All residents who are experiencing pain, or may have conditions that may result in pain, will have a comprehensive assessment of pain symptoms and will have a treatment plan established to treat pain symptoms." The policy indicated the following, "1. Each resident will be provided with a consistent, accurate and timely comprehensive assessment of resident's comfort level as related to acute, chronic or suspected pain. 2. Each resident who experiences pain will have a pain prevention/intervention plan established and implemented. 3. A licensed nurse will complete a comprehensive pain assessment that will address a resident's pain origin, location, severity, alleviating and exacerbating factors, current treatment, and resident response to treatment."