Every finding on record at Carlin Springs Health & Rehabilitation

Based on resident interview, staff interview, facility document review, and clinical record review, the facility staff failed to provide care and services to meet professional standards for four of 52 residents in the survey sample, Residents #154, #145, #173, and #13.The findings include: 1. For Resident #154 (R154), the facility staff failed to administer medications in a timely manner on multiple dates in December 2022. A review of R154's MAR (medication administration record) for December 2022 revealed that on the following dates/times. Omeprazole Delayed Release (1) was administered more than an hour after the time it was scheduled (scheduled time/administered time): 12/20/22 Omeprazole Capsule Delayed Release 40 mg (milligrams) give one capsule two times a day: 5:00 p.m./7:27 p.m.; 12/21/22 Omeprazole 5:00 p.m./7:32 pm.; 12/22/22 Omeprazole 5:00 p.m./7:22 p.m.; 12/23/22 Omeprazole 5:00 p.m./7:48 p.m.; 12/26/22 Omeprazole 5:00 p.m./not given; 12/28/22 Omeprazole 5:00 p.m./11:35 p.m.; 12/28/22 12/31/22 Omeprazole 5:00 p.m./8:48 p.m. On 7/22/26 at 11:45 a.m., RN (registered nurse) #1, a unit manager, was interviewed. She stated that medications should be administered within one hour before or after the medication is scheduled. She stated this is a standard practice for all nurses and that she learned this in nursing school. She added: No one has to tell us this. We have just always known since we were learning to be nurses. She explained that the timing of administration can have an effect on the medication's effectiveness for a resident. On 7/23/26 at 10:36 a.m., the Director of Nursing was interviewed. She stated that the acceptable timeframe for a medication to be administered is one hour before through one hour after the medication is scheduled. She stated that if medications are not administered on time, the resident's condition could change, depending on the severity of the resident's condition. She stated she learned about the one hour before and after timeframe when she was in nursing school. She explained: It is a nursing standard of practice. On 7/23/26 at 4:42 p.m., the Administrator and Director of Nursing were informed of these concerns. A review of the facility policy, Conformity With Laws and Professional Standards, revealed, in part: Our facility operates and provides services in compliance with current federal, state, and local laws, regulations, codes, and professional standards of practice that apply to our facility and types of services provided.Our facility's policies, procedures, and operational practices are developed and maintained in accordance with current commonly accepted health standards. A review of the facility policy, Medication Administration Policy, revealed, in part: This policy establishes the guidelines for the safe and effective administration of medications.All medications administered within the facility are subject to these guidelines.The 5 Rights (right resident, right medication, right dose, right route, right time) must be confirmed.during medication administration. No additional information was provided prior to exit. Reference(1) Prescription omeprazole is used alone or with other medications to treat the symptoms of gastroesophageal reflux disease (GERD), a condition in which backward flow of acid from the stomach causes heartburn and possible injury of the esophagus (the tube between the throat and stomach) in adults. This information is taken from the website https://medlineplus.gov/druginfo/meds/a693050.html. 2. The facility staff failed to meet professional standards by administering fluid restrictions not as ordered for Resident #145. Resident #145 (R145) was admitted to the facility on [DATE] with diagnosis that included but were not limited to metabolic encephalopathy, pulmonary edema, congestive heart failure and ESRD (end stage renal disease) The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 6/18/26, coded the resident as scoring a 13 out of 15 on the BIMS (brief interview for mental status) score indicating the resident is oriented to person, place and time and has unimpaired immediate recall. A review of the MDS Section GG-functional abilities and goals coded the resident as requiring moderate assist with bathing and set up for eating/hygiene and dressing. A review of the comprehensive care plan dated 7/14/26 revealed, FOCUS: the resident has a fluid restriction of (1000) ml's of total fluids per day related to End Stage Renal Disease (ESRD). INTERVENTIONS: Resident to receive (400) ml's fluid per meal tray per day. Nursing to administer (140)ml's with med pass per day. No refillable water cups kept at bedside. Observe and document any instances of extra fluid intake consumed by the resident. A review of the physician's order dated 6/2/26 revealed, Fluid restriction 1 Liter (1000mls), No canned fruit or juice, no fruit cup, no tomato soup, no tomato puree; 360 mL (12 oz) PO TID (three times a day) with meals; 140 mL per shift nursing allowance. An interview was conducted on 7/21/26 at 3:35 PM with LPN (licensed practical nurse) #2, the unit manager. Asked to read and clarify the fluid restriction order for R145, LPN #2 stated, there is an order for fluid restriction of 1000 mls with 360 mL (12 oz) PO TID with meals; 140 mL per shift nursing allowance. Asked to calculate the amount of fluid as written in the order, LPN #2 stated, the resident is getting more fluid than ordered. Asked if the order is clear, LPN #2 stated, it comes to 1500 mls. Asked if the order should have been clarified, LPN #2 stated, yes, it should have been clarified with the provider. Asked if professional standards of practice had been followed, LPN #2 stated, no, since the order was not clarified. On 7/22/26 at 4:30 PM, the Administrator and Director of Nursing were made aware of the findings. No further information was provided prior to exit. 3. For Resident #173 (R173), the facility staff failed to follow professional standards of practice during medication administration. Resident #173 (R173) was admitted to the facility with diagnoses that included but were not limited to hypertension (1), lymphedema (2), generalized muscle weakness, and shortness of breath. On the most recent minimum data set (MDS), quarterly assessment with an assessment reference date (ARD) of 3/6/2024, the resident's BIMS (brief interview for mental status) score was assessed as 14 out of fifteen, indicating the resident was cognitively intact for daily decision making. Review of the physician's orders for R173 document in part, Benazepril (3) HCL tablet 10mg. Give one tablet by mouth one time a day for hypertension. Start Date 1/31/2024 (0900). Discontinued Date 4/27/2024. Review of the April MAR (medication administration report) demonstrated the administration of Benazepril to the resident but failed to code in the MAR that the medication was not administered at the time ordered by the physician as evidence in the medication administration audit report. The medication administration audit report evidence that on 4/1/2024, 4/21/2024 and 4/22/2024, R173's Benazepril was administered over two hours late. On 7/22/2026 at 11:45 AM, an interview was conducted with RN #1, who stated that medications can be administered up to one hour before or one hour after the scheduled time. On 7/23/2026 at 9:55AM, an interview was conducted with LPN #1, who stated that scheduled medications should be administered at the scheduled time or within a one hour range from the time it is ordered. When asked how does a nurse evidence that they have given a medication, LPN #1 stated in the MAR. When asked what is the process for documenting the administration of late medication, LPN #1 stated three attempts should be made to administer the medication, explain to the resident why it is important to take the medication and the benefit of taking the medication, notify the physician and the resident's family and document in the MAR that the medication was late. LPN #1 continued to explain that the MAR will take the nurse to a progress note where they document the reason the medication was late. On 7/24/2026 at 10:43 AM, an interview was conducted with the DON, who stated that scheduled medication should be administered within one hour of the time they are due. When asked why is it important to administer medication as ordered, the DON stated because depending on the medication it could potentially cause a change in a resident's condition. When asked is there a way to know if the medication was not given, the DON stated only if it is documented. A review of the facility's Conformity With Laws and Professional Standards policy, effective 10/01/2021, revealed, Our facility operates and provides services in compliance with.professional standards of practice that apply to our facility and types of services provided. Our facility's policies and procedures. are developed and maintained in accordance with current accepted professional standards and principles as well as current commonly accepted health standards established by national organizations, boards and councils. A review of the facility policy, Medication Administration Policy, revealed, in part: This policy establishes the guidelines for the safe and effective administration of medications.All medications administered within the facility are subject to these guidelines.The 5 Rights (right resident, right medication, right dose, right route, right time) must be confirmed.during medication administration. On 7/23/2026 at 11:30 AM, the Administrator and Director of Nursing were notified of the findings. No further information was provided prior to exit. Reference: Hypertension- High blood pressure, also called hypertension, is when blood puts too much pressure against the walls of your arteries. https://medlineplus.gov/bloodpressuremedicines.html Lymphedema- Lymphedema is the name of a type of swelling. It happens when lymph builds up in your body's soft tissues. Lymph is a fluid that contains white blood cells that defend against germs. It can build up when the lymph system is damaged or blocked. It usually happens in the arms or legs. https://medlineplus.gov/lymphedema.html Benazepril- Benazepril is used alone or in combination with other medications to treat high blood pressure. Benazepril is in a class of medications called angiotensin-converting enzyme (ACE) inhibitors. It works by decreasing certain chemicals that tighten the blood vessels, so blood flows more smoothly. https://medlineplus.gov/druginfo/meds/a692011.html 4. For Resident #13 (R13), the facility staff failed to follow professional standards of practice after a medication error on 1/27/2026. On the most recent minimum data set (MDS), a significant change assessment with an assessment reference date (ARD) of 5/11/2026, the resident was assessed as receiving scheduled and as needed pain medications, having occasional pain, and receiving an opioid medication. The physician orders for R13 documented in part, - Hydromorphone HCl (1) Oral Tablet 8 MG (milligram) (Hydromorphone HCl). Give 1 tablet by mouth every 4 hours for Pain. - Methadone HCl (2) Oral Tablet 10 MG (Methadone HCl). Give 3 tablet by mouth three times a day for chronic pain. The progress notes for R13 documented in part, - 01/27/2026 10:13 (AM) Note Text: At about 0600 (6:00 AM), the nurse was going to administer Methadone 10MG three tablets by mouth to the resident but erroneously gave three tablets of Hydromorphone (Dilaudid) 8MG Tablets by mouth for pain. Resident was informed and advised to call immediately if feels any drowsiness, dizziness, or anything. Resident is stable, alert and oriented X4 (to person, place, time and situation) at this moment, V/S (vital signs) obtained include BP (blood pressure):146/79, P (pulse):68, O2 SAT (oxygen saturation): 98%, T (temperature) 97.9, R (respiration): 18.Staff informed the incoming nurse and Unit Manager about the medication error. NP (nurse practitioner) [Name of NP] was notified via phone at about 0839 (8:39 AM) and ordered to put a hold on the Hydromorphone 8MG tablet for all the three scheduled doses. The daughter [Name of daughter] was also informed via phone at about 0844 (8:44 AM). Monitor is in progress as ordered. - 01/27/2026 12:30 (PM) SNF (skilled nursing facility) follow up [Name of NP] . seen today at the skilled nursing facility for accidental overdose. Per staff, patient was scheduled to receive 3 10mg tablets of methadone (30mg total). Patient instead received 3 8mg tablets of dilaudid (24mg total) at 6 a.m. Staff notified provider of incident at 8:30 a.m. and reported patient remained alert and awake, overall stable. Vital signs remained stable. Narcan PRN (as needed) was ordered but not administered due to patient being stable. Afternoon dose of dilaudid was held. Methadone dose due at 12 p.m (30mg) was held, and one time dose of 20mg was ordered at 2 p.m. Orders were placed to reassess hourly and to assess for appropriate administration of dilaudid dose due at 4 p.m. Continue with frequent monitoring of status and vitals, with orders to monitor patient hourly for any change in condition and monitor vitals closely. Discussed incident with daughter [Name of daughter] over the phone . Plan: Naloxone 4 mg intranasal spray ordered PRN for opioid overdose; not administered as patient remained clinically stable. - Afternoon hydromorphone dose was held. - Scheduled methadone 30 mg dose due at 12 p.m. was held; ordered one-time reduced dose of methadone 20 mg at 2 p.m. - Ordered hourly monitoring of vital signs and clinical status. - Ordered reassessment before next hydromorphone dose due at 4 p.m. to determine appropriateness of administration. - Incident discussed with daughter [Name of daughter] via telephone. - Continue close monitoring for delayed respiratory depression or change in mental status . Review of the medication error report dated 1/27/2026 documented in part, .At about 0600, the nurse was going to administer Methadone 10MG three tablets by mouth to the resident but erroneously gave three tablets of Hydromorphone (Dilaudid) 8MG Tablets by mouth for pain. Resident was informed and advised to call immediately if feels any drowsiness, dizziness, or anything. Resident is stable, alert and oriented X4 at this moment, V/S obtained include BP :146/79, P :68, O2 SAT : 98%, T 97.9, R : 18.Staff informed the incoming nurse and Unit Manager about the medication error. NP [Name of NP] was notified via phone at about 0839 (8:39 AM) and ordered to put an hold on the Hydromorphone 8MG tablet for all the three scheduled doses. The daughter [Name of daughter] was also informed via phone at about 0844 (8:44 AM). Monitor is in progress as ordered. Resident Description: When asked, if feels anything, resident said, I am fine for now . No injuries observed at the time of incident . No injuries post incident . Attached to the medication error report was a telephone order dated 1/27/2026 at 9:11 AM to Monitor vital signs every 4 hours starting 1/27/2026 at 12:00 PM and ending 1/28/2026 at 12:00 AM, a vital sign summary which documented blood pressures on 1/27/2026 at 9:00 AM, 11:45 Am, 5:02 PM, and 8:33 PM, oxygen saturations on 1/27/2026 at 12:30 PM and 10:54 PM, pulses checked on 1/27/2026 at 9:00 AM, 11:45 AM, 5:02 PM, and 8:33 PM and respirations assessed on 1/27/2026 at 11:45 AM, 5:02 PM and 8:33 PM. The clinical record failed to evidence documentation of the hourly monitoring of vital signs and clinical status documented in the NP note, or notification of the provider of the medication error until the night nurse informed the unit manager upon her arrival. On 7/22/2026 at 1:50 PM, an interview was conducted with LPN (licensed practical nurse) #2 who stated that the night shift nurse had reported to her when she arrived around 7:00 AM that he had administered three Dilaudid instead of three Methadone tablets to R13. She stated that she had immediately gone to assess R13, obtained vital signs, contacted the nurse practitioner and R13's daughter. She stated that R13 had told her that she was fine and the vital signs were stable, so she had made sure that they checked on her more often and monitored her more often. She stated that if she had made the medication error she would immediately notify the resident, assess them, check the vital signs, ensure they had the call light in reach, check on them frequently, call the provider to get orders, and notify the family. LPN #2 stated that she would have expected the night nurse to have called the provider prior to her arrival and had interventions in place prior to when she arrived to the facility around 7:00 AM because there was always a provider on call. According to Lippincott Nursing Procedures, 7th Edition, pg. 680, documented in part, .Report all medication errors and adverse effects; this includes preventable ADEs (adverse drug effects), close calls, and hazardous conditions . On 7/27/2026 at 1:20 PM, the Administrator and the Director of Nursing were made aware of the concern. No further information was provided prior to exit. Reference: (1) Hydromorphone is used to relieve severe pain. Hydromorphone is in a class of medications called opiate (narcotic) analgesics. It works by changing the way the brain and nervous system respond to pain . This information was obtained from the website: Hydromorphone: MedlinePlus Drug Information (2) Methadone is used to relieve severe pain. Methadone also is used to treat opioid addiction (physical and psychological reliance on a chemical found in prescription and street drugs). Methadone is in a class of medications called opiate (narcotic) analgesics. Methadone works to treat pain by changing the way the brain and nervous system respond to pain. It works to treat people who were addicted to opiate drugs by producing similar effects and preventing withdrawal symptoms . This information was obtained from the website: Methadone: MedlinePlus Drug Information

Based on staff interview, facility document review, and clinical record review, the facility staff failed to develop and/or implement the comprehensive care plan for three of 52 residents in the survey sample, Residents #9, #13, and #20.The findings include: 1. For Resident #9 (R9), the facility staff failed to monitor the resident for side effects (bleeding) from the anticoagulant (blood thinning) medication Eliquis. R9's comprehensive care plan dated 7/16/25 documented, ANTICOAGULANTS: the resident is at risk for bleeding and bruising related to use of an anticoagulant for diagnosis of Atrial Fibrillation (a heart condition). Observe for s/s (signs and symptoms) of abnormal bleeding or bruising and or black tarry stools and report to MD (Medical Doctor) as indicated. A review of R9's clinical record revealed a physician's order dated 5/15/26 for Eliquis 5mg (milligrams)-one tablet every 12 hours for atrial fibrillation. Further review of R9's clinical record for May 2026 through July 2026 failed to reveal any physician's orders for or documentation that the resident was monitored for anticoagulant side effects (bleeding). On 7/22/26 at 3:17 p.m., an interview was conducted with LPN (Licensed Practical Nurse) #6. LPN #6 stated the care plan demonstrates what staff are doing for the resident and what the resident's goals are moving forward. LPN #6 stated a lot of interventions in residents' care plans are captured in physician's orders and nurses evidence the interventions, such as anticoagulant monitoring, are implemented by signing them off on the medication administration record or treatment administration record. On 7/22/26 at 4:45 p.m., the Administrator and Director of Nursing were made aware of the above concern. The facility policy titled, Care Planning-Comprehensive Person-Centered documented, SPECIFIC PROCEDURES/GUIDANCE- 2. The facility will develop and implement a comprehensive person-centered care plan for each resident, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs as identified throughout the comprehensive Resident Assessment Instrument (RAI) process. No further information was presented prior to exit. 2. For Resident #13 (R13), the facility staff failed to implement the comprehensive care plan to provide pain medication as ordered on 1/27/2026. The comprehensive care plan for R13 dated 5/11/2025 documented in part, OPIOIDS: the resident is at risk for complications related to the use of opioid secondary to arthritis, chronic back pain , chronic pain unrelieved by analgesics, unrelieved joint pain. Under Interventions it documented in part, Administer medications as ordered. The physician orders for R13 documented in part, - Hydromorphone HCl (1) Oral Tablet 8 MG (milligram) (Hydromorphone HCl). Give 1 tablet by mouth every 4 hours for Pain. - Methadone HCl (2) Oral Tablet 10 MG (Methadone HCl). Give 3 tablet by mouth three times a day for chronic pain. The progress notes for R13 documented in part, - 01/27/2026 10:13 (AM) Note Text: At about 0600 (6:00 AM), the nurse was going to administer Methadone 10MG three tablets by mouth to the resident, but erroneously gave three tablets of Hydromorphone (Dilaudid) 8MG Tablets by mouth for pain. Resident was informed and advised to call immediately if feels any drowsiness, dizziness, or any thing. Resident is stable, alert and oriented X4 (to person, place, time and situation) at this moment, V/S (vital signs) obtained include BP (blood pressure):146/79, P (pulse):68, O2 SAT (oxygen saturation): 98%, T (temperature) 97.9, R (respiration): 18.Staff informed the incoming nurse and Unit Manager about the medication error. NP (nurse practitioner) [Name of NP] was notified via phone at about 0839 (8:39 AM) and ordered to put an hold on the Hydromorphone 8MG tablet for all the three scheduled doses. The daughter [Name of daughter] was also informed via phone at about 0844 (8:44 AM). Monitor is in progress as ordered. On 7/22/2026 at 1:50 PM, an interview was conducted with LPN (licensed practical nurse) #2 who stated that the purpose of the care plan was to guide the care of the resident and show the specific needs of each resident. She stated that the interventions should be implemented. LPN #2 stated that the night shift nurse had reported to her when she arrived around 7:00 AM that he had administered three Dilaudid instead of three Methadone tablets to R13. She stated that she had immediately gone to assess R13, obtained vital signs, contacted the nurse practitioner and R13's daughter. She stated that R13 had told her that she was fine and the vital signs were stable, so she had made sure that they checked on her more often and monitored her more often. On 7/27/2026 at 1:20 PM, the Administrator and the Director of Nursing were made aware of the concern. No further information was provided prior to exit. Reference: (1) Hydromorphone is used to relieve severe pain. Hydromorphone is in a class of medications called opiate (narcotic) analgesics. It works by changing the way the brain and nervous system respond to pain . This information was obtained from the website: Hydromorphone: MedlinePlus Drug Information (2) Methadone is used to relieve severe pain. Methadone also is used to treat opioid addiction (physical and psychological reliance on a chemical found in prescription and street drugs). Methadone is in a class of medications called opiate (narcotic) analgesics. Methadone works to treat pain by changing the way the brain and nervous system respond to pain. It works to treat people who were addicted to opiate drugs by producing similar effects and preventing withdrawal symptoms . This information was obtained from the website: Methadone: MedlinePlus Drug Information 3. The facility staff failed to implement the comprehensive care plan for fluid restriction for Resident #20. Resident #20 (R20) was admitted to the facility on [DATE] with diagnosis that included but were not limited to metabolic encephalopathy, cirrhosis of the liver and acute pancreatitis. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 6/28/26, coded the resident as scoring a 15 out of 15 on the BIMS (brief interview for mental status) score indicating the resident is oriented to person, place and time and has unimpaired immediate recall. A review of the MDS Section GG-functional abilities and goals coded the resident as requiring moderate assist with hygiene, bathing/dressing and set up for eating. A review of the comprehensive care plan dated 6/14/26 revealed, FOCUS: Resident has been prescribed a fluid restriction of 1500 total mls (milliliters) per day. INTERVENTIONS: Follow Fluid Restriction per physician order. No Water kept at bedside due to fluid restriction. A review of the physician's order dated 6/5/26 revealed, Fluid restriction (1500 ) BLD and Med Pass per shift, every shift. A review of the MARs (medication administration records) for June 2026 revealed 19 of 26 days and July 2026 16 of 21 days exceeded the Fluid restriction (1500) as ordered. An interview was conducted on 7/21/26 at 3:35 PM with LPN (licensed practical nurse) #2, the unit manager. Asked to read and clarify the fluid restriction order for R20, LPN #2 stated, there is an order for fluid restriction of 1500 mls over breakfast, lunch, dinner and med pass for all 3 shifts. Asked to review R20's MAR for July 2026, LPN #2 stated, the resident is getting more fluid than ordered. Asked if the order is clear, LPN #2 stated, no, it is not. There should be a specific amount per shift, 500 mls per shift to total 1500 mls. That order will be revised now. Asked if the order was followed, LPN #2 stated, no, more fluid was given than ordered. On 7/22/26 at 4:30 PM, the Administrator and Director of Nursing were made aware of the findings. No further information was provided prior to exit.

Based on facility document review and staff interview, it was determined that the facility staff failed to implement their abuse policy for protection of the resident during the investigation of an abuse allegation for one of 52 residents in the survey sample, Resident #162.The findings include:For Resident #162 (R162), the facility staff failed to implement their abuse policy for protection of a resident during the investigation of an abuse allegation reported on 11/11/2025.The facility policy Abuse documented in part, .When specific staff is identified as being allegedly involved in the abuse allegation, the staff may be re-assigned or suspended during the investigation .Review of the facility synopsis of events documented an initial report date of 11/11/2025 for the incident date unknown documenting in part, On November 11, 2025, the administrator received an email from the resident's wife alleging abuse and neglect. Investigation initiated . The facility internal investigation documented a completion date of 11/18/2025. Review of the investigation folder documented Summary of Issues at [Name of facility] which documented in part, .Safety Incidents and Physical Harm . Nurse [Name of LPN (licensed practical nurse) #10] has been verbally abusive and mocking toward [Name of R162], including making fun of him in front of other staff and residents. He cried after several of these incidents and is afraid of her . The final five-day investigation summary documented an abuse investigation with notification of the police and interview of R162 who voiced no concerns regarding nursing staff however failed to evidence re-assignment LPN #10 or suspension during the investigation.Review of the clinical record documented LPN #10 caring for R162 on 11/12/2025, 11/15/2025 and 11/16/2025. On 7/22/2026 at 4:06 PM, an interview was conducted with the Director of Nursing (DON), who stated that the former Administrator had received an email from R162's spouse with concerns regarding care and an abuse allegation so they had reported it and investigated. She stated that she did not think there was any specific staff identified. The DON reviewed the Summary of Issues at [Name of facility] which documented LPN #10 named in the allegation of abuse and stated that normally they would have suspended the employee when they were named in an abuse allegation.On 7/23/2026 at 11:05 AM, the Administrator and the Director of Nursing were made aware of the concern.No further information was provided prior to exit.

Based on clinical record review, staff interview and facility document review, it was determined that the facility staff failed to ensure one of 52 residents were free of a significant medication error, Resident #13. The findings include:For Resident #13 (R13), the facility staff failed to ensure correct dosing of Dialudid (1) and Methadone (2) on 1/27/2026. R13 was admitted to the facility with diagnoses that included but were not limited to Cauda Equina syndrome (3) and chronic pain syndrome (4). On the most recent minimum data set (MDS), a significant change assessment with an assessment reference date (ARD) of 5/11/2026, the resident was assessed as receiving scheduled and as needed pain medications, having occasional pain, and receiving an opioid medication. The physician orders for R13 documented in part, - Hydromorphone HCl Oral Tablet 8 MG (milligram) (Hydromorphone HCl). Give 1 tablet by mouth every 4 hours for Pain.- Methadone HCl Oral Tablet 10 MG (Methadone HCl). Give 3 tablet by mouth three times a day for chronic pain. Review of the eMAR (electronic medication administration record) for R13 dated 1/1-1/31/2026 documented the Hydromorphone HCL 8mg scheduled to be administered at 12:00 AM, 4:00 AM, 8:00 AM, 12:00 PM, 4:00 PM, and 8:00 PM and the Methadone HCL 10mg 3 tablets scheduled to be administered at 7:00 AM, 3:00 PM and 11:00 PM. The comprehensive care plan for R13 dated 5/11/2025 documented in part, OPIOIDS: the resident is at risk for complications related to the use of opioid secondary toarthritis, chronic back pain , chronic pain unrelieved by analgesics, unrelieved joint pain. Under Interventions it documented in part, Administer medications as ordered. The progress notes for R13 documented in part,- 01/27/2026 10:13 (AM) Note Text: At about 0600 (6:00 AM), the nurse was going to administer Methadone 10MG three tablets by mouth to the resident, but erroneously gave three tablets of Hydromorphone (Dilaudid) 8MG Tablets by mouth for pain. Resident was informed and advised to call immediately if feels any drowsiness, dizziness, or any thing. Resident is stable, alert and oriented X4 (to person, place, time and situation) at this moment, V/S (vital signs) obtained include BP (blood pressure):146/79, P (pulse):68, O2 SAT (oxygen saturation): 98%, T (temperature) 97.9, R (respiration): 18.Staff informed the incoming nurse and Unit Manager about the medication error. NP (nurse practitioner) [Name of NP] was notified via phone at about 0839 (8:39 AM) and ordered to put an hold on the Hydromorphone 8MG tablet for all the three scheduled doses. The daughter [Name of daughter] was also informed via phone at about 0844 (8:44 AM). Monitor is in progress as ordered.- 01/27/2026 12:30 (PM) SNF (skilled nursing facility) follow up [Name of NP] . seen today at the skilled nursing facility for accidental overdose. Per staff, patient was scheduled to receive 3 10mg tablets of methadone (30mg total). Patient instead received 3 8mg tablets of dilaudid (24mg total) at 6 a.m. Staff notified provider of incident at 8:30 a.m and reported patient remained alert and awake, overall stable. Vital signs remained stable. Narcan PRN (as needed) was ordered but not administered due to patient being stable. Afternoon dose of dilaudid was held. Methadone dose due at 12 p.m (30mg) was held, and one time dose of 20mg was ordered at 2 p.m. Orders were placed to reassess hourly and to assess for appropriate administration of dilaudid dose due at 4 p.m. Continue with frequent monitoring of status and vitals, with orders to monitor patient hourly for any change in condition and monitor vitals closely. Discussed incident with daughter [Name of daughter] over the phone . Plan: Naloxone 4 mg intranasal spray ordered PRN for opioid overdose; not administered as patient remained clinically stable. - Afternoon hydromorphone dose was held. - Scheduled methadone 30 mg dose due at 12 p.m. was held; ordered one-time reduced dose of methadone 20 mg at 2 p.m. - Ordered hourly monitoring of vital signs and clinical status. - Ordered reassessment before next hydromorphone dose due at 4 p.m. to determine appropriateness of administration. - Incident discussed with daughter [Name of daughter] via telephone. - Continue close monitoring for delayed respiratory depression or change in mental status . Review of the medication error report dated 1/27/2026 documented in part, .At about 0600, the nurse was going to administer Methadone 10MG three tablets by mouth to the resident but erroneously gave three tablets of Hydromorphone (Dilaudid) 8MG Tablets by mouth for pain. Resident was informed and advised to call immediately if feels any drowsiness, dizziness, or any thing. Resident is stable, alert and oriented X4 at this moment, V/S obtained include BP :146/79, P :68, O2 SAT : 98%, T 97.9, R : 18.Staff informed the incoming nurse and Unit Manager about the medication error. NP [Name of NP] was notified via phone at about 0839 (8:39 AM) and ordered to put an hold on the Hydromorphone 8MG tablet for all the three scheduled doses. The daughter [Name of daughter] was also informed via phone at about 0844 (8:44 AM). Monitor is in progress as ordered. Resident Description: When asked, if feels anything, resident said, I am fine for now . No injuries observed at the time of incident . No injuries post incident . Attached to the medication error report was a telephone order dated 1/27/2026 at 9:11 AM to Monitor vital signs every 4 hours starting 1/27/2026 at 12:00 PM and ending 1/28/2026 at 12:00 AM, a vital sign summary which documented blood pressures on 1/27/2026 at 9:00 AM, 11:45 Am, 5:02 PM, and 8:33 PM, oxygen saturations on 1/27/2026 at 12:30 PM and 10:54 PM, pulses checked on 1/27/2026 at 9:00 AM, 11:45 AM, 5:02 PM, and 8:33 PM and respirations assessed on 1/27/2026 at 11:45 AM, 5:02 PM and 8:33 PM. On 7/22/2026 at 1:50 PM, an interview was conducted with LPN (licensed practical nurse) #2 who stated that the night shift nurse had reported to her when she arrived around 7:00 AM that he had administred three Dilaudid instead of three Methadone tablets to R13. She stated that she had immediately gone to assess R13, obtained vital signs, contacted the nurse practitioner and R13's daughter. She stated that R13 had told her that she was fine and the vital signs were stable, so she had made sure that they checked on her more often and monitored her more often. LPN #2 stated that the former assistant director of nursing had educated the nurse directly and observed him passing medications after the incident. She stated that if she had made the medication error she would immediately notify the resident, assess them, check the vital signs, ensure they had the call light in reach, check on them frequently, call the provider to get orders, and notify the family. LPN #2 stated that she would have expected the nurse to have called the provider prior to her arrival and had interventions in place prior to letting her know on her arrival to the facility because there was always a provider on call. On 7/22/2026 at 4:06 PM, an interview was conducted with the Director of Nursing (DON) who stated that she was aware that the medication error had occured and that the staff had monitored R13, completed the incident report, and educated the nurse on the 5 rights of medication administration one to one. She stated that R13 did not have any adverse reaction and the NP had come in to see the resident. On 7/27/2026 at 10:15 AM, an interview was conducted with the Pharmacist who stated that Dilaudid was used to treat pain and a potential side effect of receiving too much was an opiod overdose and Narcan was always kept on hand. She stated that effects of opiod overdosing included low heart rate, respiratory suppression and sedation and required monitoring of blood pressure and breathing if there was a known overdose. She stated that the half-life of the medication was two to three hours and it was normally dosed every four to six hours and if a resident took the medication for an extended period they had probably built up some tolerance to the medication. The facility policy Medication Administration Policy documented in part, . The 5 Rights (right resident, right medication, right dose, right route, right time) must be confirmed at the following stages during medication administration: 1. Before removing the medication package/container from the cart/drawer . 2. Before removing the medication from the container . 3. After preparing the dose and before returning the medication to storage . On 7/27/2026 at 1:20 PM, the Administrator and the Director of Nursing were made aware of the concern. No further information was provided prior to exit. Reference:(1) Hydromorphone is used to relieve severe pain. Hydromorphone is in a class of medications called opiate (narcotic) analgesics. It works by changing the way the brain and nervous system respond to pain . This information was obtained from the website: Hydromorphone: MedlinePlus Drug Information(2) Methadone is used to relieve severe pain. Methadone also is used to treat opioid addiction (physical and psychological reliance on a chemical found in prescription and street drugs). Methadone is in a class of medications called opiate (narcotic) analgesics. Methadone works to treat pain by changing the way the brain and nervous system respond to pain. It works to treat people who were addicted to opiate drugs by producing similar effects and preventing withdrawal symptoms . This information was obtained from the website: Methadone: MedlinePlus Drug Information(3) Although leg and back pain are common and usually go away without surgery, cauda equina syndrome, a rare disorder affecting the bundle of nerve roots (cauda equina) at the lumbar (lower) end of the spinal cord, is a surgical emergency. An extension of the brain, the spinal cord and lumbar nerve roots send and receive messages to and from the pelvic organs and lower limbs. Cauda equina syndrome occurs when the nerve roots in the lumbar spine are compressed (squeezed), cutting off sensation and movement. The nerve roots that control the function of the bladder and bowel are especially vulnerable to damage. Cauda equina syndrome is a surgical emergency. Without immediate treatment to relieve pressure, it can result in a range of problems, including: Permanent paralysis; Impaired bladder and/or bowel control; Loss of sexual sensation; Chronic pain. Even with immediate treatment, some patients may not recover complete function; earlier treatment does, however, offer the best outcomes for cauda equina syndrome . This information was obtained from the website: Cauda Equina Syndrome - OrthoInfo - AAOS(4) Pain might be acute or chronic. The type of pain is based on how long and how often you have pain. Acute pain starts suddenly and goes away when the cause is treated or healed. This pain lets you know that you may be injured or have a problem you need to take care of. Chronic pain lasts longer than three months or the time in which you should have healed. If you have chronic pain, it can occur most days or every day and may last for weeks, months, or even years. It can affect all aspects of daily life, including your mood and relationships. Treatment may not get rid of chronic pain, but it can help with your symptoms . This information was obtained from the website: Chronic Pain | MedlinePlus

Based on clinical record review, staff interview and facility document review, it was determined that the facility staff failed to ensure medications were available for administration for one of 52 residents in the survey sample, Resident #156.The findings include:For Resident #156 (R156), the facility staff failed to ensure Gabapentin (1) was available for two doses on 10/14/2022.Review of the eMAR (electronic medication administration record) for R156 dated 10/1-10/31/2022 documented in part, Gabapentin Capsule 100 MG (milligram). Give 1 capsule by mouth every 8 hours for Neuropathy. On 10/14/2022 the scheduled 6:00 AM dose and 10:00 PM dose were documented as not given saying to see the nurse notes. The 10:00 PM dose on 10/13/2022 and 2:00 PM dose on 10/14/2022 were documented as administered.The nursing notes for R156 documented the 10/14/2022 6:00 AM dose not administered due to it was not delivered from the pharmacy and the 10:00 PM dose not administered due to a prescription needed.On 7/22/2026 at 1:50 PM, an interview was conducted with licensed practical nurse (LPN) #2 who stated that medication orders were faxed to the pharmacy on admission and any medications that they were able to pull from their in house medication stock they pulled out and started them when the pharmacy gave them the code. She stated that there was a new pharmacy and she was not sure if the medications were the same back in 2022 but if the medication was not available they could call the pharmacy to send it over stat.The facility was owned by another company during 2022, and it could not be determined if Gabapentin was kept in house at the time of R156's stay.The facility policy Unavailable Medications dated 8/2020 documented in part, .The nursing staff shall: Notify the attending physician (or on-call physician when applicable) of the situation and explain the circumstances, expected availability, and alternative therapy(ies) available .On 7/27/2026 at 1:20 PM, the Administrator and the Director of Nursing were made aware of the concern.No further information was provided prior to exit.Reference:(1) Gabapentin capsules, tablets, and oral solution are used along with other medications to help control certain types of seizures in people who have epilepsy. Gabapentin capsules, tablets, and oral solution are also used to relieve the pain of postherpetic neuralgia (PHN; the burning, stabbing pain or aches that may last for months or years after an attack of shingles). Gabapentin extended-release tablets (Horizant) are used to treat restless legs syndrome (RLS; a condition that causes discomfort in the legs and a strong urge to move the legs, especially at night and when sitting or lying down). Gabapentin is in a class of medications called anticonvulsants. Gabapentin treats seizures by decreasing abnormal excitement in the brain. Gabapentin relieves the pain of PHN by changing the way the body senses pain. It is not known exactly how gabapentin works to treat restless legs syndrome . This information was obtained from the website: Gabapentin: MedlinePlus Drug Information

Based on observation, resident interview, staff interview, clinical record review and facility document review, it was determined that the facility staff failed to provide a clean and homelike environment for three of 52 residents in the survey sample, Residents #6, #112, and #38.The findings include:1. For Resident #6 (R6), the facility staff failed to provide a clean and homelike environment. On the most recent minimum data set (MDS), an annual assessment with an assessment reference date (ARD) of [DATE], the resident scored 15 out of 15 on the brief interview for mental status (BIMS) assessment, indicating they were cognitively intact for making daily decisions. On [DATE] at 4:46 PM, an observation was made of R6's room. Observation revealed an approximately four feet tall white plastic storage bin to the right side of R6's bed. The plastic storage bin was observed to have a dried brown colored material on the lower right side of the bin. Observation of the privacy curtain revealed two stained areas on the curtain, one area approximately quarter-sized and one approximately six inches long. At that time, an interview was conducted with R6 who stated that someone came in almost every day to mop the floor and clean up but he did not know if they ever changed the curtain. Additional observations were made on [DATE] at 10:30 AM and 4:18 PM. The findings remained the same. On [DATE] at 12:41 PM, an interview was conducted with the Director of Housekeeping who stated that privacy curtains were inspected during daily cleaning and he was notified by his staff if they needed to be changed. He stated that furniture was cleaned as needed and if staff noticed something on the furniture his staff would clean it. At 12:52 PM, the Director observed R6's privacy curtain and the plastic furniture and stated that it needed cleaning and the curtain needed to be changed. The facility policy Homelike Environment, documented in part, Residents will be provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible . On [DATE] at 4:34 PM, the Administrator and the Director of Nursing were made aware of the concern. No further information was provided prior to exit. 2. For Resident #112 (R112), the facility staff failed to provide a clean and homelike environment. On the most recent minimum data set (MDS), a quarterly assessment with an assessment reference date (ARD) of [DATE], the resident scored 15 out of 15 on the brief interview for mental status (BIMS) assessment, indicating they were cognitively intact for making daily decisions. On [DATE] at 2:47 PM, an observation was made of R112's room. During the observation dead roaches were observed on the floor along the headboard of the resident bed and behind the dresser and TV stand. At that time an interview was conducted with R112 who stated that there had been an ongoing roach problem in the room for a while and the room was last treated about two weeks prior. He stated that the dead roaches had been on the floor for awhile and housekeeping had not cleaned them all up. Additional observations were made on [DATE] at 4:45 PM and [DATE] at 4:00 PM. The findings remained the same. Review of the pest control logs documented the most recent pest control treatment to R112's room on [DATE]. On [DATE] at 10:00 AM, an interview was conducted with the maintenance director who stated that after the room was treated housekeeping went in and deep cleaned the rooms to pick up any dead roaches before the resident went back in the room. He stated that nursing was responsible for cleaning the residents belongings prior to putting them back in the residents room after the intensive treatment and housekeeping cleaned the room prior to the resident going back in the room. He observed the dead roaches on the floor in R112's and stated that the room had been treated a couple of weeks ago for roaches and housekeeping must have missed the dead roaches. On [DATE] at 12:41 PM, an interview was conducted with the Director of Housekeeping who stated that when rooms were treated for pests they moved everything out of the room and the furniture was moved away from the walls. He stated that after the pests died the housekeeping staff went in and swept the floor and mopped. The Director stated that housekeeping went back to follow up because the roaches kept dying so they wanted to get them up. He stated that daily floor care also included cleaning behind the bed and under the bed and dressers. The Director stated that residents personal belongings would be cleaned by nursing because housekeeping did not touch personal belongings only furniture. He stated that housekeeping had already cleaned R112's room because maintenance had informed him of the dead roaches on the floor. On [DATE] at approximately 4:34 PM, the Administrator and the Director of Nursing were made aware of the findings. No further information was provided prior to exit. 3. For Resident #38 (R38), the facility staff failed to clean rodent droppings off the resident's floor. On [DATE] at 5:02 p.m., an observation of R38 and the resident's room was conducted. R38 was lying in bed. There was approximately one foot of space (in width) between the resident's bed and the wall. In this area, approximately 25 rodent droppings were observed on the floor. On [DATE] at 8:38 a.m., [DATE] at 3:40 p.m., and [DATE] at 7:45 a.m. R38 was observed lying in bed and the rodent droppings remained on the floor. On [DATE] at 12:52 p.m., an interview was conducted with the Director of Environmental Services. The Director of Environmental Services stated resident room floors should be swept and mopped every day and disinfected if rodent droppings are observed. The Director of Environmental Services stated rodent droppings on the floor are not clean or homelike. On [DATE] at 4:45 p.m., the Administrator and Director of Nursing were made aware of the above concern. No further information was presented prior to exit.

Based on resident interview, staff interview, clinical record review and facility document review, the facility staff failed to assess and implement interventions and/or provide care and treatment for the prevention of pressure ulcers for two of 29 residents in the survey sample (Resident #100 and Resident #115). 1). Resident #100 was admitted to the facility on [DATE], with a brace to the left leg in place and a deep tissue injury to the left lower leg. The facility staff failed to remove the brace for 19 days, failed to assess, monitor, implement interventions and/or treat the resident's skin/deep tissue injury. As a result, the the resident developed a 6 x 3.5 centimeter unstageable pressure ulcer, resulting in actual harm. 2.) The facility failed to ensure Resident #115's specialty mattress for pressure relief was plugged in and operating for the prevention of pressure ulcers. The findings include: 1.) The facility staff failed to remove a left leg brace for Resident #100. The resident was admitted with the brace on 07/06/22. The brace was not removed for daily skin care, skin assessments/inspections and/or treatment for 19 days. On 07/26/22 the resident's leg brace was removed and was found to have an unstageable left lower extremity open wound, measuring 6 cm (centimeters) x 3.5 cm x less than 0.1cm, 90 % necrotic tissue with 10% granulation tissue and scant serosanguinous drainage. Resident #100's diagnoses included, but were not limited to: lung cancer, COPD (chronic obstructive pulmonary disease), anemia, lateral dislocation of left patella, spinal stenosis, high blood pressure, dependence on oxygen, and depression. The most recent MDS was an admission assessment dated [DATE]. This MDS assessed the resident with a cognitive score of 13, indicating the resident was intact for daily decision making skills. The resident was also assessed as requiring extensive assistance from at least one or two staff members for transfers, bed mobility, dressing, toileting and hygiene. The resident was assessed as requiring total assistance for bathing. This MDS documented and assessed the resident as non ambulatory during the look back period. In Section M. of this MDS (Skin Conditions. M0300. Current Number of Unhealed Pressure Ulcers/Injuries at Each Stage) it was documented the resident had one stage I, one stage II, and one stage III pressure ulcer upon admission and that all three were present upon admission. In Section M. (Skin Conditions. M0300. Current Number of Unhealed Pressure Ulcers/Injuries at Each Stage) . G. Unstageable - Deep Tissue injury: 1.) Number of unstageable pressure injuries presenting as deep tissue injury = 0 (zero) 2.) Number of these unstageable pressure injuries that were present upon admission/entry or reentry = 0 (zero). On 07/26/22 at 10:30 AM, Resident #100 was interviewed. The resident was laying in bed. The resident had a sheet partially over her body. A full leg brace was observed on the resident's left leg that was at the top of the resident's thigh and went to down to the resident's ankle. The resident was asked if she had any pressure ulcers/areas anywhere on the resident's body. The resident stated there were current pressure related areas to her sacrum. The resident was asked if she had any other pressure/skin areas of concern. The resident stated that she did not have any other skin issues to her knowledge. The resident was then asked if the staff remove the left leg brace to check the skin and to do do care. The resident stated that no one had taken the brace off since she had arrived at the facility (07/06/22). The resident stated, No one, not even therapy, no one. The resident stated that the brace was put on while she was in the hospital and that she was admitted with it to this facility on 07/06/22. The resident stated that the brace has been in place since her admission and no one has taken it off. On 07/26/22 at approximately 10:50 AM, LPN (Licensed Practical Nurse) #1 stated that the wound nurse RN (Registered Nurse) #3 would be doing the dressing change/wound care for Resident #100 today. On 07/26/22 at 10:55 AM, LPN #1 pre-medicated Resident #100 prior to the dressing change/wound care. At 11:28 AM, RN #3 (wound care nurse) and CNA (certified nursing assistant) #6 washed their hands and prepared for the dressing change/wound care for Resident #100. RN #3 stated that he is the wound care nurse and that he makes weekly rounds with the wound care NP (Nurse Practitioner) #2. RN #3 was asked how many pressure areas/wounds did this resident have. RN #3 stated, Three and counted One, Two, Three as he pointed to each area on the resident's sacral/buttock area. The resident had one pressure area on the right sacral area, one on the left sacral area and one on the left lower buttock (just above the top of the left leg brace). RN #3 completed the treatment and dressing change for the the three wounds. RN #3 was then asked if the resident had any other skin/wound concerns. The RN stated that she did not. The RN was then asked if the resident's left leg brace is removed. RN #3 stated that it (leg brace) comes off daily during care and that staff are doing daily body audits on the resident's entire body everyday. The resident nodded her head back and forth and stated, No one has removed it. RN#3 was asked for clarification, and was asked again if staff were removing the brace everyday and looking at the resident's skin under the brace everyday? RN #3 stated, Yes. RN #3 was then asked when are wound measurements and wound assessments completed. The RN stated that he (RN #3) and NP #2 make wound rounds every Thursday. The RN stated that NP #2 comes every Thursday and they make rounds together, do body audits/skin assessments, take measurements, and complete dressing changes for resident's with wounds. The RN was asked if Resident #100's left leg brace was removed last Thursday, while NP #2 was in the facility during wound rounds. RN #3 stated that he was with NP #2 last Thursday and that they had removed the resident's left leg brace and stated, Yes we took it off last week and looked at her skin. At 11:56 AM, RN #3 again stated that the brace comes off daily during care. RN #3 was asked to remove the brace for a skin observation. RN #3 removed the brace from the resident's left leg. CNA (certified nursing assistant) #6 lifted the resident's left leg to look for any skin break down/impairments. A dressing was observed on the resident's left, lower calf area. This dressing had been hidden by the resident's full leg brace. The dressing was not dated and did not have any initials to indicate when or who applied the dressing. RN #3 stated, What's this? (in regards to the dressing). The dressing was approximately a 4x4, square bordered dressing located on the resident's lower left lateral/outer calf area. RN #3 removed the dressing. The wound was observed with a large amount of black eschar, minimal slough and minimal granulation tissue. RN #3 stated, That's just an abrasion. The RN was asked if he was going to do measurements and stage the wound. The RN measured the wound (6.0 cm x 3.5 cm). RN #3 stated, This is new. The RN was asked, how could it be new if there is a dressing on it, someone must have known about it and put a dressing on it and was aware that something was there. RN #3 agreed and stated, This is the first time I've seen this. The RN was asked if this wound/dressing was present last Thursday when he and NP #2 made rounds and removed the brace. RN #3 stated, No, it was not there. RN #3 was asked what stage is this wound. RN #3 stated he wasn't sure, he would call NP #2 to discuss and he will then stage the wound. The resident's admission assessment dated [DATE], along with the resident's pressure ulcer assessments dated 07/06/22, 07/14/22, and 07/21/22 were all reviewed and did not identify any preexisting deep tissue injury/skin impairment to Resident #100's left lower leg. Resident #100's hospital discharge summary dated 07/06/22 documented, .discharge diagnoses: Active problems: dislocation of left patella .no evidence of acute, displaced fracture .chronically unstable left patella with recurrent dislocation .continue knee immobilizer when out of bed, transferring or ambulating .Ok to WBAT (weight bear as tolerated) with knee immobilizer in place .#left lateral leg: Deep tissue injury: per wound care .Left lateral leg: 6 X 1.5 non blanchable purple hyperpigmentation consistent with medical device related deep tissue pressure injury with intact skin .anticipate this wound will continue to evolve .wound cleansed with saline and covered with mepilex dressing .wound orders .LLL (left lower leg) rinse with saline, pat dry, cover with mepilex. Change Every 72 hours .low air pressure redistribution mattress . The resident's physician's orders were reviewed from admission (07/06/22) through present 07/26/22. A physician's order dated 07/13/22 (one week after admission) documented, .Patellar tracking stabilizer for left knee . There were no physician's orders for the left leg brace prior to this date and there were no orders regarding care and treatment related to donning and doffing the knee stabilizer (per the hospital discharge orders/instructions) or how to manage the immobilizer. The resident's MARs/TARs (medication administration/treatment administration records) were reviewed for the month of July 2022. There was nothing found on the MARs/TARs regarding a wound on the resident's left lower/lateral calf and there was no information regarding the full leg brace that was applied to the resident's left leg. A nursing note dated 07/07/2022 (Thursday) and timed for 3:49 PM documented, .Admission Skin Assessment .Past Medical Hx .Bilateral Knee Pain, L-Patellar Dislocation .Left lateral leg deep tissue Pressure Injury .BRADEN: 15 Patient is at risk for skin breakdown .Alert and Oriented x 3 .Skin is warm to touch and noted as follows .R-Buttock Pressure Injury Stage III .L-Buttock Pressure Injury Stage II .L-Ischium pressure Injury Stage III .multiple bruises noted to Bilateral Upper and Lower extremities .Care Plan in place to promote healing and prevent additional ulceration and infection. Pressure redistribution surface to bed and wheelchair .Assist patient with ADL and transfers .signature of RN #3. A nursing note dated 7/8/2022 and timed for 7:30 AM documented, .Skilled Nursing Note .Alert oriented x 3 .Left patellar dislocation, leg in immobilizer and intact with WBAT . total assistance with ADL care done, resident is in bed .signature of LPN #7. A nursing noted dated 7/14/2022 and timed 4:33 PM documented, .Facility Wound Nurse and Wound Nurse Practitioner saw Resident for weekly skin assessment follow up with skin issues and Tx done .R-Buttock Pressure Injury Stage .L-Buttock Pressure Injury .Stage II .L-Ischium Pressure Injury Stage II .Recommendations: Heel offloading foam/boots .Offloading/turning and re-positioning .signature of RN #3. A progress note by NP #2 dated 7/14/2022 and timed 4:41 PM documented, .Medical Practitioner Note .NP .SNF [skilled nursing facility] rounds with facility Wound Nurse [RN #3] .pressure injury of bilateral buttock, and left ischium noted on admission by facility nurse . Patient sitting up in bed .pressure injury of right buttock .pressure injury of left buttock .pressure injury of left ischium .signature of NP #2. Further review of the resident's clinical records revealed a hospital PT (Physical Therapy) Reassessment Note dated 07/06/22 (date of resident's discharge from hospital to facility) documented, .PT Discharge Recommendations: SNF (skilled nursing facility) .LLE (left lower extremity) weight bearing as tolerated, knee immobilizer .orientation X 4 .Self-care management .education and coaching provided in the following areas .Donning /doffing and maintenance of knee immobilizer .bed mobility .education provided .safety precautions .donning/doffing and maintaining knee immobilizer .reinforce content .patient agreeable to goals and plan of care .PT discharge recommendations: SNF . The resident's current CCP (comprehensive care plan) was reviewed and documented, .alteration in musculoskeletal status .assist .to change position frequently .OT (Occupational Therapy) ADL (activities of daily living) training/adaptive equipment to improve self-care, home management training .safety procedures and/or instructions in use of assistive devices .resident has actual and potential for further skin breakdown .related to immobility .decrease/minimize skin breakdown risks .barrier cream .diet and supplements .reposition as needed .pressure redistributing device on bed/chair .provide preventative skin care routinely and as needed .assist as needed to turn and reposition .pressure ulcer at buttocks .pressure ulcer right buttock .pressure ulcer left buttock .pressure ulcer left ischium .administer treatment per physician's order .body audit daily . The resident's CCP did not identify and/or address any skin condition/impairment to the resident's left lower calf and the CCP did not identify and/or address anything regarding the resident's knee immobilizer/brace. The resident's progress notes were again reviewed. A nursing progress note dated 7/26/2022 and timed 1:15 PM (after the leg brace was removed) documented, .Skin .L-LE (Shin) Pressure Injury Unstageable noted during tx: sustained from Leg Immobilizer which should not be removed .impaired skin integrity measuring 6.0cm x 3.5cm x 0.0cm, 90% necrotic tissue and 10% granulation tissue, scant serous drainage noted .MD (Medical Doctor) notified .signature of RN #3. On 07/26/22 at 2:35 PM, Resident #100 was again observed laying in bed. The resident's brace was under her left leg, the brace was open (not fastened closed). The following day, 07/27/22 at 8:03 AM, Resident #100 was interviewed again. The resident was laying in bed on a specialty mattress. The resident again stated that no one at this facility had taken off the leg brace at anytime prior to yesterday. The resident stated that she did not remember anyone putting a bandage on that area and that must have been done at the hospital. The resident's leg brace was in place and was fastened, while the resident was laying in bed. Another review of the resident's progress notes revealed a progress note written by the wound NP (NP #2) dated 7/26/2022 (date of brace removal) and timed 11:04 PM which documented, .Medical Practitioner Note .chief complaint: left lower extremity (shin) pressure injury noted while in the hospital .Wound care was mepilex foam under a nonremovable splint placed for a left patellar dislocation .Patient was transferred .to the SNF .with the wound covered with a foam dressing and nonremovable splint. Splint was removed to assess wound .left lower extremity open wound (shin) 6cm x 3.5cm x <0.1cm 90% necrotic tissue / 10% granulation tissue scant serosanguinous drainage .Pressure ulcer of left lower extremity, unstageable .signature of NP #2. On 07/27/22 at 11:30 AM, the administrator and DON were made aware of concerns regarding Resident #100's leg brace not being removed for 19 days, the lack of assessment, interventions and/or treatment for the prevention of pressure ulcers and were made aware that the resident's specialty bed mattress had been unplugged for over six hours (the day prior on 07/26/22) without staff intervention to ensure the specialty mattress was on and operating correctly to aid in the prevention of pressure ulcers/skin impairments. The administrator and DON were asked for an interview with MD #1 and NP #2 (the resident's attending physician and NP provider). A policy was also requested at this time on wound care/pressure ulcer prevention and treatment. A policy was presented and reviewed. The policy titled, Skin Management Guidelines documented, .steps required for identification of patients at risk .of skin alterations, identify prevention techniques and interventions to assist with management of pressure injuries and skin alterations .skin alterations and pressure injuries are evaluated and documented by the licensed nurse .head to toe skin evaluation .Body Audits are completed by the licensed nurse daily for patients with pressure injuries and documented on the TAR .new findings documented in the progress note .Treatments as ordered by the medical provider .wound rounds completed weekly on pressure injuries and complex wounds . On 07/27/22 at 11:45 AM, MD #1 was interviewed. The MD stated that she knew the resident had the area on the left lower calf, but was under the impression that the wound nurse (RN #2)and the wound nurse practitioner (NP #2) were aware and taking care of the wound. The MD stated that she was unaware that there were no orders for care instructions for the brace/knee immobilizer care regarding donning/doffing. When asked if there should have been, the MD stated that staff should have taken the leg brace off to look at the resident's skin. The MD was made aware that the resident's leg brace had not been removed for 19 days and when it was (yesterday) the resident was found with a large, necrotic unstageable pressure ulcer. The MD stated that the resident was admitted with the knee immobilizer in place and that the wound care team are supposed to be doing body audits and skin checks daily. The MD was made aware of the serious concerns regarding Resident #100 with the lack of assessment, interventions, care and management of the resident's skin. The MD was made aware that there were no orders found anywhere that documented that the brace/knee immobilizer was not to removed or that it was to be kept in place at all times, and that it was actually documented the opposite. According to the hospital documentation the resident was only to wear the brace/knee immobilizer when out of bed, transferring or ambulating and that it was ok to WBAT (weight bear as tolerated) with the knee immobilizer in place; there was no documentation/orders to leave this brace on at all times or that this was a non removable brace. The MD was asked how would you evaluate a resident's skin if you didn't take off a brace to look at the skin. The MD stated that you would have to take it off to do skin assessments. The MD was made aware that as a result of facility staff not removing the brace (19 days), and not implementing the orders/instructions from the hospital (or obtaining orders) for the leg brace and/or for wound care/treatment and/or prevention that harm had actually occurred for this resident. The MD stated, I fully agree with you. A phone interview was attempted with the wound NP (NP #2) numerous times without success, response and/or comment. On 07/27/22 at 12:00 PM, the administrator and DON (director of nursing) were made aware of the above concerns in a meeting with the survey team. The administrator and DON were made aware of the serious concerns related to Resident #100 regarding the lack of assessment, care, treatment and interventions for the prevention of an unstageable pressure ulcer. The facility staff were made aware of actual harm at this time related to Resident #100. The DON stated that it was a nonremovable brace. The DON and administrator were asked for any additional information and/or documentation to evidence that claim, as the resident's entire clinical records were reviewed and there was no documentation found to evidence that the resident's brace was non removable. On 07/27/22 at 2:15 PM, the DON stated, Regardless it's always going to be there, she's had it for a long time, there was nothing we could do about it. The National Pressure Injury Advisory Panel defines an unstageable pressure injury as, .Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed .(1). No further information and/or documentation was presented prior to the exit conference on 07/27/22 at 5:15 PM to evidence that the facility staff provided the resident with care and necessary treatment services, to promote healing of existing skin impairment and/or prevent new ulcers from developing. (1) NPIAP Pressure Injury Stages. National Pressure Injury Advisory Panel. 7/29/22. https://npiap.com/page/PressureInjuryStages 21875 2. Resident #115 was admitted to the facility with diagnoses that included adult failure to thrive, kidney failure, gastroenteritis, Parkinson's disease, anemia, history of bladder cancer, pancreatitis, gastroesophageal reflux disease, compression fractures, obstructive uropathy and pressure ulcer with MRSA (methicillin resistant staphylococcus aureus) infection. The minimum data set (MDS) dated [DATE] assessed Resident #115 with severely impaired cognitive skills. On 7/26/22 at 11:34 a.m., Resident #115 was observed in bed. There was a control box on the bed footboard for an alternating pressure mattress. The air mattress control box was unplugged and not functioning. On 7/26/22 at 2:00 p.m., Resident #115 was observed in bed. The air mattress control box was observed unplugged and non-functioning. On 7/26/22 at 5:00 p.m., accompanied by registered nurse (RN #4) caring for Resident #115, the air mattress and control box were observed. The air mattress was unplugged and not functioning at the time of this observation. RN #4 was interviewed at this time about the air mattress. RN #4 stated the resident had a pressure ulcer on his buttock RN #4 stated the air mattress was for pressure relief and was supposed to be remain plugged in and functioning. RN #4 stated she did not know why the air mattress was unplugged. On 7/27/22 at 9:49 a.m., the licensed practical nurse unit manager (LPN #4) was interviewed about Resident #115's air mattress not plugged in and functioning on 7/26/22. LPN #4 stated the air mattress was to help with pressure relief and healing of the resident's pressure ulcer. LPN #4 stated nurses were supposed to check the functioning of the air mattress during each shift and observe for function whenever they were in the resident's room. Resident #115's clinical record documented the resident was admitted to the facility with a MRSA infected right buttock pressure ulcer. The most recent wound assessment dated [DATE] and listed the resident had a stage 3 pressure ulcer on the right buttock measuring 5.0 x 2.0 x 0.2 (length by width by depth in centimeters). Resident #115's plan of care (revised 6/30/22) documented the resident had a right buttock pressure ulcer due to impaired mobility. Interventions to promote healing included, .Pressure redistributing support surface . The National Pressure Injury Advisory Panel defines a stage 3 pressure injury as, Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur . (1) This finding was reviewed with the administrator and director of nursing during a meeting on 7/27/22 at 12:10 p.m. (1) NPIAP Pressure Injury Stages. National Pressure Injury Advisory Panel. 7/29/22. https://npiap.com/page/PressureInjuryStages

Based on clinical record review, staff interview, and resident interview, the facility failed for one of 14 residents in the survey sample (Resident # 105) to ensure the resident had physician's orders for the care of a colostomy. Resident # 105 had a colostomy for at least three years without orders for colostomy care. The findings were: Resident # 105 in the survey sample was admitted with diagnoses that included peripheral vascular disease, sleep apnea, diverticulitis, chronic pain syndrome, diabetes mellitus, idiopathic peripheral autonomic neuropathy, gastroesophageal reflux disease, anemia, hyperlipidemia, morbid obesity, osteoarthritis, atherosclerotic heart disease, hypertension, glaucoma, heart failure, depressive disorder, and colostomy status. According to the most recent Minimum Data Set (MDS), a Quarterly Review with an Assessment Reference Date (ARD) of 7/26/2022, the resident was assessed under Section C (Cognitive Patterns) as being cognitively intact, with a Summary Score of 15 out of 15. Under Section H (Bladder and Bowel) at Item H0100 - Appliances, the resident was identified as having a colostomy. Review of the current Order Summary Report in the resident's Electronic Health Record (EHR) failed to reveal any orders for the resident's use of a colostomy, including emptying and changing the collection bag, changing the wafer, checking the area around the stoma for excoriation, and checking the bag attachment at the stoma for leakage. Review of the Electronic Treatment Administration Record (ETAR), in the resident's EHR, failed to reveal any orders for the care of the resident's colostomy. Review of the Electronic Medication Administration Record (EMAR), also in the resident's EHR, failed to reveal any orders for the care of the resident's colostomy. At 8:00 a.m. on 9/28/2022, Resident # 105 was interviewed. Asked about the colostomy, the resident said he has had it for several years. Asked about who provides care for the colostomy, Resident # 105 said, Sometimes the CNA's (Certified Nursing Assistants) do it. A review of previous Minimum Data Sets produced a Quarterly Review MDS with an ARD of 10/9/2019, which identified the resident under Section H (Bladder and Bowel) as having a colostomy. The Quarterly Review MDS of 10/9/2019 was the first MDS that identified the resident as having a colostomy. At 8:10 a.m. on 9/28/2022, RN # 4 (Registered Nurse) was interviewed about colostomy care for Resident # 105. Asked when care is provided, RN # 4 said, He calls us when it needs to be checked. RN # 4 was asked how staff know what to do when caring for the resident's colostomy. When RN # 4 looked in the resident's ETAR for care instructions, she was unable to find any. They aren't any (instructions), RN # 4 said. The findings were discussed during a meeting at 10:00 a.m. on 9/28/2022, that included the Director of Nursing, two administrators from sister facilities, and the survey team. No additional information was provided prior to survey exit.

Based on observation, staff interview, resident interview, and in the course of a complaint investigation, the facility staff failed to serve food that was palatable and per the resident's choice for one of 29 residents. Resident #13's toast was burned, eggs were scorched, and his lunch tray on 07/27/2022 was cold. This is a complaint deficiency. The findings included: Resident #13 had the following diagnoses including but not limited to: Coronary artery disease, heart failure, pressure ulcer, diabetes mellitus, and depression. A quarterly MDS (minimum data set) with an ARD (assessment reference date) of 04/26/2022 assessed Resident #13 as cognitively intact with a summary score of 15. On 07/26/2022 at approximately 9:30 a.m. Resident #13 was observed lying in bed. His breakfast tray was on his bedside table. Three fried eggs were on his plate and two pieces of sausage. He was asked if his food was good. He stated, No, it's not. Look down there in the trash can. Observed in the trash can was two pieces of toast and a piece of sausage. He stated, That toast was browned on one side and black on the other. That sausage was hard as a rock .look at these eggs He picked up the eggs and turned them over. He stated, See that brown crust on them? .that's how they cook things here. It's not fit for a dog, and it's cold. He was asked if he would like anything else. He stated, No, I'm use to it. On 07/26/2022 at approximately 2:00 p.m., Resident #13 was interviewed regarding his lunch. He stated, I wish you could have seen it .it was some kind of beef, stringy, tough, cold .I didn't eat it. He was asked if he would like something else. He stated, Let me save you the time .when you call down to the kitchen you don't get anybody. Nobody answers the phone down there .if they do you get two pieces of bread with a little peanut butter smeared on it and some jelly .who wants that? On 07/27/2022 at approximately 10:20 a.m., the DM (dietary manager) was interviewed regarding the appearance of Resident #13's breakfast tray, and his complaints regarding the inability to get an alternate. She stated, Some of the cooks turn the toaster up to make it hotter and the toast gets darker .I'll talk to them. The above information was discussed with the DON (director of nursing) and the administrator on 07/27/2022 at approximately 12:05 p.m. On 07/27/2022 at approximately 2:00 p.m., Resident #13 was observed lying in bed with his lunch tray on the bedside table. He stated, Look at this. He pointed to his tray, This is fish, look how dry it is .it looks like they cooked it yesterday and heated it in the microwave to dry it out .this broccoli is so hard you can't even cut it and it's so cold it won't even melt the butter would you want this? The RD (registered dietician) and the DM came to the conference room at approximately 4:00 p.m., we met with (Name of Resident #13) we are addressing his concerns. No further information was obtained prior to the exit conference on 07/27/2022. This is a complaint deficiency.

Based on observation, staff interview, and facility document review the facility staff failed to ensure four of 29 residents were provided food substitutions per request and preferences. This is a complaint deficiency. 1. Resident #13's who chose his own menu, was not served the items requested. 2. Resident # 74 - The facility failed to honor Resident # 74's request to not be served fish. 3. Resident # 47 - The facility failed to honor Resident # 47's dislike of dark meat chicken, i.e., legs and backs. 4. Resident #17 was unable to make advanced food choices and request alternates due to no access to posted menus. Findings were: 1. Resident #13 had the following diagnoses including but not limited to: Coronary artery disease, heart failure, pressure ulcer, diabetes mellitus, and depression. A quarterly MDS (minimum data set) with an ARD (assessment reference date) of 04/26/2022 assessed Resident #13 as cognitively intact with a summary score of 15. On 07/26/2022 at approximately 2:00 p.m., Resident #13 was interviewed regarding his lunch. He stated, I wish you could have seen it .it was some kind of beef, stringy, tough, cold .I didn't eat it. He was asked if he would like something else. He stated, Let me save you the time .when you call down to the kitchen you don't get anybody. Nobody answers the phone down there .if they do you get two pieces of bread with a little peanut butter smeared on it and some jelly .who wants that? On 07/27/2022 at approximately 10:20 a.m., the DM (dietary manager) was interviewed regarding the appearance of Resident #13's breakfast tray, and his complaints regarding the inability to get an alternate. She stated, He's right, the phone is here in my office .I don't stay in here so when someone calls I don't always get the message until the next day. I have asked for another phone to be out there at the tray line so when someone calls down we can get the request. She was asked if the additional phone was in place. She stated, Not yet. She was asked about Resident #13's menu and choices/alternates. She stated, He chooses his own menu. She was asked if all residents chose their own menu. She stated, No, but the ones who are more difficult do .we don't have a list of alternates but he knows what the alternates are and he writes them on the menu when he doesn't like any of the choices. At approximately 11:30 a.m., Resident #13 was interviewed about choosing his own menu. He stated, They read it to me and they circle it. A copy of the menu and what he had chosen for lunch was discussed. He stated, Did you say squash casserole? I don't like squash or casseroles, why the h*** would I have chosen that? that's what they circled I didn't pick that. The above information was discussed with the DON (director of nursing) and the administrator on 07/27/2022 at approximately 12:05 p.m. On 07/27/2022 at approximately 2:00 p.m., Resident #13 was observed lying in bed with his lunch tray on the bedside table. He stated, Look at this. He pointed to his tray, This is fish, look how dry it is .it looks like they cooked it yesterday and heated it in the microwave to dry it out .this broccoli is so hard you can't even cut it and it's so cold it won't even melt the butter would you want this? .this isn't even what we talked about earlier .I'm supposed to have country steak and mashed potatoes .they just send you what they want. The above information was discussed with the RD (registered dietician) at approximately 3:00 p.m. She stated, We give them a list of alternates in the admission packet we meet with them and keep their likes and dislikes updated in the dietary kardex, then it is on the tray cards. His tray cards were presented. The RD and the DM came to the conference room at approximately 4:00 p.m. The RD stated, We met with (Name of Resident #13) .he wanted us to tell you that he forgot that he circled the items on his menu .sometimes I do it, but he did this one. Also, what happened today with his lunch, the staff saw that he doesn't like gravy so they substituted the whole entree instead of just leaving off the gravy. The facility policy, FOOD PREFERENCES contained the following: Obtaining and processing information on patient food preferences helps to meet patient food requests, provides more accurate production counts and allows for preparation of alternatives. No further information was obtained prior to the exit conference on 07/27/2022. This is a complaint deficency. 09404 2. Resident # 74 in the survey sample was admitted with diagnoses that included anemia, history of urinary tract infection, history of COVID-19, generalized weakness, history of joint replacement, cirrhosis of the liver, ataxic gait, hypothyroidism, and alcohol abuse. According to the most recent Quarterly Minimum Data Set with an Assessment Reference Date of 6/23/2022, the resident was assessed under Section C (Cognitive Patterns) as being cognitively intact with a Summary Score of 14 out of 15. During the Group Meeting at 2:30 p.m. on 7/26/2022, the discussion turned to food preferences. Resident # 74 said, I don't like fish. They keep serving me fish. I don't eat it, sometimes I just throw it away. Asked if he had told the Dietary Manager or the Dietician he didn't like fish, the resident said, Yes, I've told them several times. At 8:15 a.m. on 7/27/2022, the Dietary Manager and the Dietician were interviewed at the same time about Resident # 74's food preferences. The Dietary Manager pulled up the resident's food preferences on the computer and found that fish was not listed as a dislike. We did not know, the Dietician said. Asked how often residents are asked about their food preferences, the Dietician said residents are asked at admission about their food likes and dislikes. When asked if a resident's food preferences are updated, the Dietician said they usually ask about once a year. 3. Resident # 47 in the survey sample was admitted with diagnoses that included dementia with behavioral disturbances, congestive heart failure, hypertension, peripheral vascular disease, diabetes mellitus, hyperlipidemia, insomnia, non-Alzheimer's dementia, chronic obstructive pulmonary disease, atrial fibrillation, and benign prostatic hyperplasia. According to the most recent Quarterly Minimum Data Set with an Assessment Reference Date of 5/27/2022, the resident was assessed under Section C (Cognitive Patterns) as being moderately cognitively impaired with a Summary Score of 10 out of 15. During the Group Meeting at 2:30 p.m. on 7/26/2022, the resident said, They give me chicken legs. I don't like chicken legs. I'm a diabetic, I shouldn't have fried chicken. Asked if he had told the Dietary Manager or the Dietician he didn't like chicken legs, Resident # 47 said, Yes, and I keep telling them. At approximately 8:15 a.m. on 7/27/2022, the Dietary Manager and the Dietician were interviewed at the same time about Resident # 47's food preferences. The Dietary Manager pulled up the resident's food preferences on the computer and found that chicken legs were not listed as a dislike. We did not know, the Dietician said. Some people do not like dark meat like chicken legs, thighs, and the back. Resident # 74 in the survey sample was admitted with diagnoses that included anemia, history of urinary tract infection, history of COVID-19, generalized weakness, history of joint replacement, cirrhosis of the liver, ataxic gait, hypothyroidism, and alcohol abuse. According to the most recent Quarterly MDS with an ARD of 6/23/2022, the resident was assessed under Section C (Cognitive Patterns) as being cognitively intact with a Summary Score of 14 out of 15. 21875 4. Resident #17 was admitted to the facility with diagnoses that included atherosclerotic heart disease, lymphedema, anxiety, major depressive disorder, obstructive sleep apnea, congestive heart failure, gastroesophageal reflux disease, chronic pain syndrome, history of COVID-19, chronic respiratory failure and history of breast cancer. The minimum data set (MDS) dated [DATE] assessed Resident #17 as cognitively intact. On 7/26/22 at 8:08 a.m., Resident #17 was interviewed about quality of life in the facility. Resident #17 stated she had ongoing issues with meals and food. Resident #17 stated there were standing alternate food items always available but when she requested them she was told there was no answer in the kitchen. Resident #17 stated she requested extra food items for each lunch and dinner because she never knew what was on the menu. The resident stated she added a tuna sandwich or chef's salad for lunch and tuna with cottage cheese or fruit plate for dinner so she would have something she could eat without waiting in case she did not like what was served. Resident #17 described the food as horrible and unappetizing and the meats as always tough. Resident #17 stated the same food items were served over and over. Resident #17 stated she never knew what was to be served because the menus were posted on the unit and she did not get out of bed or out of her room. Resident #17 stated for residents not going out of their rooms, there were no menus provided. Resident #17 stated she had a standing order for the extra food items because she was unable to choose menu items or alternates prior to meals served. On 7/27/22 at 11:06 a.m., the dietary manager (other staff #7) and the registered dietitian (RD - other staff #5) were interviewed about Resident #17's access to menus and food selections. The RD stated a list of always available food items was provided to residents in the admission packets. The RD stated daily menus had two choices each meal and the kitchen honored the likes/dislikes as listed based upon resident preferences. The RD stated the menus were posted on each of the living units. When asked about how residents that stay in bed or in their rooms know the planned menus, the RD stated she had been at the facility a long time and nursing staff could communicate menus verbally to residents. The RD stated they attempted to provide Resident #17 foods that she liked. When asked again about Resident #17's access to menus, the RD stated the menu was posted each day right outside of her [Resident #17's] room. The RD presented a copy of Resident #17's meal ticket information. Extra item options served at breakfast included yogurt, bacon or sausage, bagel or toast, egg with cheese when available or an orange. Extra item options for lunch included yogurt, chef's salad, egg salad, tuna salad or chicken salad on rye, or dinner roll or cornbread. Extra item options for dinner included cottage cheese/fruit plate, tuna salad or rye or dinner roll or cornbread. Resident #17's clinical record documented the resident was prescribed a low sodium cardiac diet with regular texture. Resident #17's plan of care (revised 4/10/21) listed the resident was at risk of anxiety and mood problems. Interventions to minimize anxiety/mood issues included, .Offer choices to enhance sense of control . This finding was reviewed with the administrator and director of nursing during a meeting on 7/27/22 at 12:10 p.m.

Based on observations, clinical record review, resident interview, staff interview, and review of facility documents, the facility failed to serve meals in a timely manner on the East Unit. Breakfast on the East Unit was not served until 9:40 a.m. on 7/26/2022. The findings were: During the orientation tour at 8:00 a.m. on 7/26/2022 on the East Unit, Resident # 15 was interviewed. The resident was her room, seated in a wheelchair. Asked if breakfast had been served, the resident said, No, it is late. It is always late. All the meals are late. Resident # 15 was admitted to the facility with diagnoses that included toxic encephalopathy, cerebrovascular disease, hypertension, diabetes mellitus, hyperlipidemia, non-Alzheimer's dementia, depression, chronic obstructive pulmonary disease, altered mental status, and glaucoma. According to the most recent Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/5/2022, the resident was assessed under Section C (Cognitive Patterns) as being cognitively intact with a Summary Score of 15 out of 15. At 8:30 a.m., 9:00 a.m., and 9:00 a.m., additional observations were made on the East Unit. During all three observations, there was no tray cart on the unit and none of the residents had been served or were eating breakfast. At 9:40 a.m. the tray cart arrived on the East Unit. The first tray off the cart at 9:43 a.m. and was taken to Resident # 15's room. During the Group Meeting at 2:30 p.m. on 7/26/2022, the residents complained of late meal service. Resident # 74, who resides on the East Unit, said meals are always late. Dinner isn't served until 7:30 or 8:00 p.m. The East Unit is the last to be served. The resident went on to say, I don't know if there isn't enough staff or what. There doesn't seem to be any reason. Resident # 74 in the survey sample was admitted with diagnoses that included anemia, history of urinary tract infection, history of COVID-19, generalized weakness, history of joint replacement, cirrhosis of the liver, ataxic gait, hypothyroidism, and alcohol abuse. According to the most recent Quarterly MDS with an ARD of 6/23/2022, the resident was assessed under Section C (Cognitive Patterns) as being cognitively intact with a Summary Score of 14 out of 15. Resident # 71, who also resides on the East Unit, also said the meals are always late and that the East Unit is always the last to be served. Resident # 71 in the survey sample was admitted with diagnoses that included gastroesophageal reflux disease, hyperlipidemia, thyroid disorder, anxiety disorder, depression, and bipolar disease. According to the most recent Annual MDS with an ARD of 6/12/2022, the resident was assessed under Section C (Cognitive Patterns) as being cognitively intact with a Summary Score of 14 out of 15. Resident # 28, who resides on a different floor, said all the meals on that floor are consistently late too. Resident # 28 in the survey sample was admitted with diagnoses that included congestive heart failure, hypertension, diabetes mellitus, hyperlipidemia, Parkinson's Disease, seizure disorder, and bipolar disease. According to the most recent Quarterly MDS with an ARD of 5/12/2022, the resident was assessed under Section C (Cognitive Patterns) as being cognitively intact with a Summary Score of 15 out of 15. At 8:15 a.m. on 7/27/2022, the Dietary Manager and the Dietician were interviewed at the same time about the late meal service. Asked why the meals are late, the Dietary Manager said, It isn't all the time, but could offer no explanation as to why meals were late. When asked if the Kitchen was fully staffed, the Dietary Manager said, We are fully staffed. The Dietary Manager went on to say, Breakfast was a little late yesterday (7/26/2022) because the cook had to stop and take the surveyor around the Kitchen. Regarding the East Unit always being last to be served, the Dietician said, East is not always last. We switch it up. The Dietician had no comment at to the late meal service.

Based on observation, staff interview, and facility document review, the facility staff failed to store, prepare, and served food in a sanitary manner in the main kitchen. Potentially hazardous foods were stored and available for usage past the dates of safe usage, staff food and drinks were stored in refrigerators designated for resident nourishment, temperatures were not recorded for the refrigerators and freezers to ensure they were in working order, and dishwasher was not washing/rinsing dishes at the required temperatures. The findings included: Initial tour of the kitchen was conducted on 07/26/2022 at 7:50 a.m. with OS (other staff) #21. She identified herself as one of the cooks and in charge of the kitchen until the DM (dietary manager) arrived. OS #21 stated the tray line had just been set up. Temps were observed. Two items Sausage patties, temped at 79 degrees and Crumbled bacon temped at 124 degrees were both put back into the steamer to get the temperatures up within range. The three compartment sink was observed to the right of the tray line. The third sink used for sanitizing was filled with pink water., OS #21 explained that the sink had been filled that morning. She was asked to test the sanitation level in the water. She obtained a testing strip which turned a light green. She compared it to the guide on the bottle. The results were 2258 PPM (parts per million) Lactic Acid Range. Per the instructions on the wall above the sink and on the bottle of strips the reading should not be greater than 700 PPM. OS #23 was called to the sink. He stated that he had been taught that the levels could be that high. He removed some of the water from the sink, added more water and retested with a result of 700 PPM. The kitchen had multiple refrigeration areas. The following was observed: The Cook's refrigerator contained a pan of corned beef has that was not dated, a To go type Styrofoam box containing chicken wings that was not dated or labeled with a name , and a black plastic bag with a plastic bowl inside that contained a partially eaten salad, that was not labeled with a date or a name. OS #21 stated, I'm throwing all of this out, it isn't dated or labeled. She was asked if the Styrofoam container or the black bag belonged to a resident or to staff. She stated, I don't know for sure about the chicken but I think the bag is someone's (staff) lunch. The Dinner Leftover fridge contained a pan of gravy dated 07/18, a large pan of white rice not dated, a container of slimy sliced tomatoes not dated, a pan of mushrooms dated 7/22, a large pan of baked beans that were not dated or covered properly as the bean juice had disintegrated the aluminum foil over them, and a container of scrambled eggs dated 7/10. OS #21 removed all the items from the refrigerator and stated, We don't serve or keep anything over three days. All of that needs to go in the trash. Observed in the Walk-in refrigerator was a pickle bucket containing bloody water with something inside the bucket. The plastic wrap over the bucket was dated 7/21. OS #21 identified the bucket and it's contents as fish. She stated, That needs to be thrown away. She removed the bucket from the refrigerator. A rack in the kitchen contained spices and other dry goods. A covered container of puree bread mix was observed on the rack. A scoop was in the container and pointed out to OS #21. She was asked if the scoop was supposed to be stored there. She stated, No. She removed the scoop from the container. The DM arrived at approximately 8:40 a.m., and continued the tour. The Supplemental refrigerator had two plastic bottles of soda that were partially full. The DM stated, I'll throw those away, the staff knows they aren't supposed to put their food or drinks in these refrigerators. The temperature logs for the refrigerators and the walk-in freezer were observed. Per the DM temperatures were to be recorded twice a day, once on morning and once on evening shift. The Walk-in refrigerator and the walk in freezer logs had not had temperatures recorded for the evening shift since 07/07/2022. There were also no temps recorded from 7/09-7/12 for the day shift. The leftover fridge did not have evening temps recorded since 07/20 and the Cooks refrigerator did not have evening temps recorded since 07/21/2022. The Drink refrigerator had not had evening shift temperatures recorded since 07/07/2022, and no temps recorded for 07/09, 07/10, and 07/17 for the day shift. The DM stated, I have told them to record the temperatures. On 07/26/2022 at approximately 11:10 a.m., the dishwasher area was observed while breakfast dishes were being washed. The electronic digital temperature screen was observed. The wash temp was registering 158 degrees, the rinse temp was registering 173 degrees. A message was flashing on the screen Final Rinse Temp Low. OS #8 was pulling trays of dishes out of the machine and putting them away. She was asked if she was watching the temperatures on the machine. She stated, I write what I see at the end of the washing the temperatures change all the time. A dishwasher temperature log for July was observed on a clipboard near the machine. The top of the paper contained the following: Minimum temperature for wash cycle: 150 was handwritten in. Rinse Cycle 180 was handwritten in. The form also contained the following: If temperatures were below standard, the person in charge was notified and dish machine was stopped. OS#8 was asked if she had notified the DM that the machine was flashing a message that the rinse temperature was too low. She stated, No, I write down what I see on that paper, it is up to the manager to look at it and do something if it needs to be done. She was asked again if she had noticed the flashing message on the machine. She stated, No, I did not see that. The staff member who was putting the dishes into the machine stated, When the machine was new the temp was 165 or 160 now it is old and they say 150 it use to take the trays, now we have to push them through .the machine is old. The DM was asked to come to the Dishwashing area. The temperatures were shown to her. She was asked why the wash temperature was listed as 150 degrees. She stated, That is what I was told. The machine was searched for a placard from the manufacturer to determine the required temps. On the side of the machine a silver placard was observed, Minimum wash temperature : 160 .Minimum rinse temperature: 180. This was pointed out to the DM. The temperature log for the dishwasher was observed. The temperatures were to be recorded three times per day. Out of 75 opportunities to record the temperatures, 35 were blank. The remaining 40 recordings of dishwasher temperatures had 8 readings of 160 or greater for the washing temperatures and there were four instances when the rinse temperature was not in range and for three of those both the wash temperature and the rinse temperature had not been within the minimum range. The column Below Min Temp was never checked. There was no indication that the machine had been stopped. The DM stated, I will get maintenance to check it out. The above information was discussed with the DON (director of nursing) and the administrator on 07/27/2022 at approximately 12:05 p.m. On 07/27/2022 at 3;15 p.m., the facility policy, Refrigerator/Freezer Temperature Logs was obtained. Per the policy, Record refrigerator/freezer temperatures in the morning and evening . The DM stated, I inserviced the staff yesterday about this. She was asked who was supposed to review the logs. She stated, I am. Also presented was the policy, Dishwasher Operation, which contained the following: .Sanitizing of the dinnerware is dependent on the concentration of the sanitizer, the water temperature, and the length of time the dinnerware cones in contact with the sanitizing solution .Check and record temperatures of wash and rinse water .Wash temperatures are to be .160 degrees Fe (Fahrenheit) for conveyor type machines. Rinse temperatures must be at least 180 degrees F .temperatures are checked throughout the dishwashing cycle . No further information was obtained prior to the exit conference on 07/27/2022.

Based on observation, staff interview, and facility document review, the facility staff failed to ensure the dishwasher in the main kitchen was in proper working order. Wash temperatures and rinse temperatures were not within the manufacturer's recommended range. Findings were: On 07/26/2022 at approximately 11:10 a.m., the dishwasher area was observed while breakfast dishes were being washed. The electronic digital temperature screen was observed. The wash temp was registering 158 degrees, the rinse temp was registering 173 degrees. A message was flashing on the screen Final Rinse Temp Low. OS #8 was pulling trays of dishes out of the machine and putting them away. She was asked if she was watching the temperatures on the machine. She stated, I write what I see at the end of the washing the temperatures change all the time. A dishwasher temperature log for July was observed on a clipboard near the machine. The top of the paper contained the following: Minimum temperature for wash cycle: 150 was handwritten in. Rinse Cycle 180 was handwritten in. The form also contained the following: If temperatures were below standard, the person in charge was notified and dish machine was stopped. OS#8 was asked if she had notified the DM that the machine was flashing a message that the rinse temperature was too low. She stated, No, I write down what I see on that paper, it is up to the manager to look at it and do something if it needs to be done. She was asked again if she had noticed the flashing message on the machine. She stated, No, I did not see that. The staff member who was putting the dishes into the machine stated, When the machine was new the temp was 165 or 160 now it is old and they say 150 it use to take the trays, now we have to push them through .the machine is old. The DM was asked to come to the Dishwashing area. The temperatures were shown to her. She was asked why the wash temperature was listed as 150 degrees. She stated, That is what I was told. The machine was searched for a placard from the manufacturer to determine the required temps. On the side of the machine a silver placard was observed, Minimum wash temperature : 160 .Minimum rinse temperature: 180. This was pointed out to the DM. The temperature log for the dishwasher was observed. The temperatures were to be recorded three times per day. Out of 75 opportunities to record the temperatures, 35 were blank. The remaining 40 recordings of dishwasher temperatures had 8 readings of 160 or greater for the washing temperatures and there were four instances when the rinse temperature was not in range and for three of those both the wash temperature and the rinse temperature had not been within the minimum range. The column Below Min Temp was never checked. There was no indication that the machine had been stopped. The DM stated, I will get maintenance to check it out. On 07/27/2022 at approximately 9:30 a.m., a representative from the company that serviced the dishwashing machine was onsite. He stated the machine should be run for to get the temperatures up before any dishes were put through the machine. He stated the machine was last serviced in April by his company and they replaced parts, but his company was not contracted to do preventative maintenance. He stated, The curtains that wash the dishes are curled up and should be replaced, the element needs to be descaled. He also stated, The machine has been set to manual mode for trays to go in .it should be automatic where the machine pulls them in .consequently the machine is actually running the wash and rinse cycles at the same time which is dropping the temps. The above information was discussed with the DON (director of nursing) and the administrator on 07/27/2022 at approximately 12:05 p.m. On 07/27/2022 at approximately 2:30 p.m., the DM reported, We are still using disposable dishes .he (the service technician) ordered parts for the machine. He said we need a thermostat and he ordered new parts for the display we won't use the machine until it is fixed. No further information was obtained prior to the exit conference on 07/27/2022.

Based on clinical record review, staff interview, and resident interview, the facility failed for one of 14 residents in the survey sample (Resident # 105) to ensure the resident had physician's orders for the care of a colostomy. Resident # 105 had a colostomy for at least three years without orders for colostomy care. The findings were: Resident # 105 in the survey sample was admitted with diagnoses that included peripheral vascular disease, sleep apnea, diverticulitis, chronic pain syndrome, diabetes mellitus, idiopathic peripheral autonomic neuropathy, gastroesophageal reflux disease, anemia, hyperlipidemia, morbid obesity, osteoarthritis, atherosclerotic heart disease, hypertension, glaucoma, heart failure, depressive disorder, and colostomy status. According to the most recent Minimum Data Set (MDS), a Quarterly Review with an Assessment Reference Date (ARD) of 7/26/2022, the resident was assessed under Section C (Cognitive Patterns) as being cognitively intact, with a Summary Score of 15 out of 15. Under Section H (Bladder and Bowel) at Item H0100 - Appliances, the resident was identified as having a colostomy. Review of the current Order Summary Report in the resident's Electronic Health Record (EHR) failed to reveal any orders for the resident's use of a colostomy, including emptying and changing the collection bag, changing the wafer, checking the area around the stoma for excoriation, and checking the bag attachment at the stoma for leakage. Review of the Electronic Treatment Administration Record (ETAR), in the resident's EHR, failed to reveal any orders for the care of the resident's colostomy. Review of the Electronic Medication Administration Record (EMAR), also in the resident's EHR, failed to reveal any orders for the care of the resident's colostomy. At 8:00 a.m. on 9/28/2022, Resident # 105 was interviewed. Asked about the colostomy, the resident said he has had it for several years. Asked about who provides care for the colostomy, Resident # 105 said, Sometimes the CNA's (Certified Nursing Assistants) do it. A review of previous Minimum Data Sets produced a Quarterly Review MDS with an ARD of 10/9/2019, which identified the resident under Section H (Bladder and Bowel) as having a colostomy. The Quarterly Review MDS of 10/9/2019 was the first MDS that identified the resident as having a colostomy. At 8:10 a.m. on 9/28/2022, RN # 4 (Registered Nurse) was interviewed about colostomy care for Resident # 105. Asked when care is provided, RN # 4 said, He calls us when it needs to be checked. RN # 4 was asked how staff know what to do when caring for the resident's colostomy. When RN # 4 looked in the resident's ETAR for care instructions, she was unable to find any. They aren't any (instructions), RN # 4 said. The findings were discussed during a meeting at 10:00 a.m. on 9/28/2022, that included the Director of Nursing, two administrators from sister facilities, and the survey team. No additional information was provided prior to survey exit.

Based on staff interview, record review, and in the coarse of a complaint investigation, the facility failed for one of 29 resident's to ensure Resident #119 was free of unnecessary medications. Resident #119 was prescribed and given medications that was ordered in error. The Findings Include: Diagnoses for Resident #119 included: fracture of left pelvis, hypertension, anxiety disorder, hyperlipidemia, arthritis, and gastric reflux. The most current MDS (minimum data set) was an admission assessment with an ARD (assessment reference date) of 3/7/22. Resident #119's cognitive score was a 15 indicating cognitively intact. Resident #119 was admitted for therapy on 3/1/22 and discharged on [DATE]. On 7/26/22 while reviewing Resident #119's medical chart specific to a complaint allegation regarding inaccurate medical records of diagnoses and medications ordered, the facilities diagnoses form was reviewed and documentation of a diagnoses of Chronic lymphocytic leukemia of B-cell type in remission and Hypothyroidism did not match the history and physical diagnoses from the hospital, as these diagnoses were not evident in the hospital records. Review of Resident #119's medication orders were then reviewed. Medication orders were placed for the following: Asciminib Tablet 40 MG [milligrams] Give 2 tablet by mouth one time a day for leukemia. Resident did not have a diagnoses of leukemia from hospital Levothyroxine Sodium 75 MCG [ micrograms] Give 1 tablet by mouth in the morning for Hypothyroidism. Resident did not have a diagnoses of hypothyroidism from hospital Enoxaparin Sodium 120 MG inject 120 mg subcutaneous one time a day for DVT [deep vein thrombosis]. Furosemide 20 MG Give 2 tablet by mouth one time a day every other day for hypertension. Prevastatin Sodium give 60 mg by mouth one time a day. Trazadone HCL 50 MG give 1 tablet by mouth at bedtime for insomnia. Resident #119's MAR (Medication Administration Record) was then reviewed. According to documentation of the MAR all medications were started on 3/2/22 and was reviewed through 3/15/22 (discharge of Resident #119). Is as follows: Asciminib 40 Mg, not given due to unavailable medication. Levothyroxine Sodium 75 MCG given 10 doses from 3/2/22 through 3/11/22. Enoxaparin Sodium 120 MG given 10 doses from 3/2/22/ through 3/11/22. Furosemide 20 MG given 5 doses from 3/2/22 through 3/11/22. Prevastatin Sodium give 60 MG given 10 doses from 3/2/22 through 3/11/22. Trazadone HCL 50 MG given 9 doses from 3/2/22 through 3/11/22. The hospital medication discharge summary was then reviewed and did not evidence any of the above prescribed medications as being given while at the hospital or on the hospital discharge instructions. On 7/26/22 at 2:00 PM the director of nursing (DON) was informed a complaint allegation was being looked at for Resident #119 regarding inaccurate records and medications. the DON verbalized there had been a mix up with Resident #119's medications and a investigation had been completed. On 7/27/22 The facilities investigation was reviewed and documented a concern regarding wrong medications being prescribed. A search for the hospitals after care summary (discharge summary to facility) that was transcribed by the nurses at the facility could not be found. The investigation indicated, a current medication list was faxed by Resident #119 community physician and was compared to the medications that were transcribed by the nurse. According to documentation via physician orders, Resident #119's correct medications were ordered using the list of medications from Resident #119's primary care physician, and former medications were discontinued on 3/11/22. On 7/27/22 at 8:47 AM the DON was interviewed. The DON verbalized when Resident #119 was admitted from the hospital the nurses transcribed medications and diagnoses into the electronic medical record. After Resident #119 had refused some medications and Resident #119's daughter was contacted over medications that were not available and the daughter verbalizing Resident #119 was not on the medications in question and an investigation was conducted. The DON said, the investigation was unable to determine if the wrong information was sent by the hospital and transcribed or if the nurse had mistakenly entered another resident's information into the facilities system as the the original diagnoses and medication list were never found. The DON reviewed Resident #119's MAR with the surveyor and pointed out numbers next to nurses initials and verbalized that the number meant that Resident #119 refused medications. Upon further investigation regarding a number next to a nurses initial, the number was actually part of the nurses initial (evidenced on the Staff Administration Legend.). Also progress notes did not evidence that Resident #119 had refused or questioned medications that was being given as stated in the facilities investigation. The facility did do a series of laboratory test to rule out any residual effects of the medications given. The lab results indicated no critical values. On 7/27/22 at 12:45 PM the above information was presented to the administrator and DON. No other information was presented prior to exit conference on 7/27/22. This is a complaint deficiency.

Based on staff interview, clinical record review and facility document review, the facility staff failed to ensure two of three randomly selected residents (Resident #268 and #269), were issued a NOMNC (notice of medicare non coverage) prior to discharge and failed to ensure one of three residents (Resident #270) was issued an ABN (advance beneficiary notice). Findings include: On 07/26/22 at approximately 8:00 a.m., during the entrance conference with the DON (director of nursing), the entrance conference worksheet for beneficiary notices (residents discharged within the last six months) was presented for completion. On 07/26/22 at approximately 1:00 PM, the administrator returned the completed worksheets. Three resident names were then selected randomly. The worksheets were returned to the administrator, along with three separate SNF beneficiary protection notification review forms for the three selected residents. The above information was completed and returned. Upon review, all three randomly selected residents did not have evidence of being issued the required NOMNC/ABN. Resident #268 and #269 should have been issued a NOMNC and Resident #270 should have been issued and ABN. When asked where was the required information/documentation to evidence that the appropriate beneficiary protection notices were issued for the three selected residents, the administrator stated it wasn't done. The DON stated that SW (social work) department completes these. At approximately 12:00 noon, the SW came and stated that these were not done or that she could not locate the information to evidence that they were done and stated she wasn't sure why. On 07/27/22 at approximately 12:30 PM, in a meeting with the survey team, the administrator again stated that they had not been completed for these residents. No further information and/or documentation was presented prior to the exit conference to evidence that that the three randomly selected residents were provided the required NOMNC/ABN beneficiary protection notifications.

Based on observations, clinical record review, and resident interview, the facility failed for one of 14 residents in the survey sample (Resident # 114) to ensure the resident had a clean, comfortable, and homelike environment. The toilet in the resident's room did not flush, the bath tub was dirty, and a paper towel dispenser was dirty. The findings were: Resident # 114 in the survey sample was admitted to the facility with diagnoses that included insomnia, morbid obesity, post-traumatic stress disorder, chronic pain syndrome, chronic atrophic gastritis, epilepsy, major depressive disorder, hypertension, chronic migraine without aura, chronic kidney disease, gastroesophageal reflux disease, adjustment disorder with anxiety, thrombocytosis, delusional disorders, vitamin D deficiency, syncope and collapse. According to an admission nursing assessment, the resident was found to be oriented to situation, person, place, and time. NOTE: At the time of the survey, it was Resident # 114's third day in the facility. At 8:15 a.m. on 9/28/2022, an interview was conducted with the resident. During the interview, the resident stood up, walked to the small bathroom in her room and said, Come look at this. The bathroom consisted of a commode and a bath tub. The lid on the commode water tank was slightly ajar, and there were several rolls of toilet paper on the lid. There was a piece of toilet paper in the toilet bowl. Watch this, the resident said. Resident # 114 pushed the handle on the water tank down to flush the commode, but nothing happened. The resident jiggled the handle several times and attempted to flush the toilet again, but it would not flush. Resident # 114 then said, Look at the bath tub. The bath tub had a large, brown stain on the bottom of the tub. There was also several pieces of black debris on the bottom of the tub. Now look at this, the resident said, pointing to a paper towel dispenser hanging on the wall next to a small handwashing sink in an area adjacent to the bathroom. The paper towel dispenser was covered with splatters of an unknown substance on the side facing the room and on the front of the dispenser. Resident # 114 pointed to the heating/airconditioning unit, which was running and blowing warm air. I asked the nurse to turn it off, but she didn't know how to turn it off. No one knows how to turn it off. The resident then said, I asked for a pair of socks, and this is what they gave me. The resident held up a pair of used, non-skid slipper socks. I wanted a new pair, the resident said. But they told me these were clean, that they came from the laundry. At the time of the interview, the resident was not wearing any socks. The findings were discussed during a meeting at 10:00 a.m. on 9/28/2022, that included the Director of Nursing, two administrators from sister facilities, and the survey team.

Based on resident interview, staff interview and clinical record review, the facility staff failed to ensure one of 29 residents (Resident #100) had physician's orders upon admission, for the immediate care and treatment of a full leg brace and for a deep tissue injury to the resident's left leg. Findings include: Resident #100's diagnoses included, but were not limited to: lung cancer, COPD (chronic obstructive pulmonary disease), anemia, lateral dislocation of left patella, spinal stenosis, high blood pressure, dependence on oxygen, and depression. The most recent MDS was an admission assessment dated [DATE]. This MDS assessed the resident with a cognitive score of 13, indicating the resident was intact for daily decision making skills. The resident was also assessed as requiring extensive assistance from at least one or two staff members for transfers, bed mobility, dressing, toileting and hygiene. The resident was assessed as requiring total assistance for bathing. This MDS documented and assessed the resident as non ambulatory during the look back period. The resident's hospital discharge summary dated 07/06/22 (date of admission to facility) documented, .discharge diagnoses: Active problems: dislocation of left patella .no evidence of acute, displaced fracture .chronically unstable left patella with recurrent dislocation .continue knee immobilizer when out of bed, transferring or ambulating .Ok to WBAT (weight bear as tolerated) with knee immobilizer in place .#left lateral leg: Deep tissue injury: per wound .Left lateral leg: 6 X 1.5 non blanchable purple hyperpigmentation consistent with medical device related deep tissue pressure injury with intact skin .anticipate this wound will continue to evolve .wound cleansed with saline and covered with mepilex dressing .LLL (left lower leg) .rinse with saline, pat dry, cover with mepilex. Change Every 72 hours .low air pressure redistribution mattress . The resident's current physician's orders were reviewed and revealed an order dated 7/13/22, for .Patellar tracking stabilizer for left knee . There were no physician's found for a brace/knee immobilizer on admission (07/06/22) for Resident #100. There were no orders at all regarding care and treatment related to donning and doffing the knee stabilizer for the order written on 07/13/22 and there were no immediate care orders (other than hospital discharge orders/instructions) for the deep tissue injury to the resident's left lower leg. The resident's MARs/TARs (medication administration/treatment administration records) were reviewed for the month of July 2022. There was nothing found on the MARs/TARs regarding the resident's left leg brace/knee immobilizer and/or the resident's deep tissue injury on the left lower leg. The resident's CCP (comprehensive care plan) was reviewed and documented, .alteration in musculoskeletal status .assist .to change position frequently .OT (Occupational Therapy) ADL (activities of daily living) training/adaptive equipment to improve self-care, home management training .safety procedures and/or instructions in use of assistive devices . reposition as needed; use assistive devices as needed .pressure redistributing device on bed/chair .provide preventative skin care routinely and as needed .assist as needed to turn and reposition .body audit daily .pressure redistributing support surface .repositioning during ADL's . The resident's CCP did not identify and/or address any type of brace/knee immobilizer or a deep tissue injury for Resident #100. On 07/26/22 at 10:30 AM, Resident #100 was interviewed. The resident was laying in bed. The resident had a sheet partially over her body. A full leg brace was observed on the resident's left leg (top of thigh down to, just slightly above the resident's ankle). The resident was asked if the facility staff remove the leg brace to check the skin under the brace. The resident stated that no one had taken the brace off since she had arrived at the facility. The resident stated, she came to this facility with the full leg brace on from the hospital and that it has been in place since. At 11:56 AM, RN #3 (wound care nurse) stated that the resident's brace comes off daily during care. RN #3 stated that he and the NP (wound nurse practitioner) #2 do wound assessments/body audits weekly on Thursday and that they had seen the resident last Thursday and removed the brace and checked the residents skin. The RN was made aware that there were no orders for the brace as far as any type of direction/instruction and/or schedule for donning/doffing the resident's left leg brace. The brace was then removed by RN #3 from the resident's left leg. A dressing was observed on the resident's left, lower calf area. This dressing had been hidden by the resident's full leg brace. The dressing was not dated. RN #3 stated, What's this? (in regards to the dressing). The dressing was approximately a 4x4, square bordered dressing located on the resident's lower left lateral/outer calf area. RN #3 removed the dressing. The wound was observed with a large amount of black, minimal slough and minimal granulation tissue. RN #3 stated, That's just an abrasion. The RN was asked if he was going to do measurements and stage the wound. The RN measured the wound (6.0 cm x 3 cm). RN #3 stated, This is new. The RN was asked, how could it be new if there is a dressing on it, someone had to put a dressing on it and knew that something was there. RN #3 agreed and stated, This is the first time I've seen this. The RN was asked if this wound/dressing was present last Thursday when he and NP #2 made rounds and removed the brace. RN #3 stated, No, it was not there. RN #3 was asked what stage is this wound. RN #3 stated he wasn't sure, he would call NP #2 to discuss and he will then stage the wound. A nursing note dated 7/26/2022 and timed 1:15 PM documented, .Skin .L-LE (Shin) Pressure Injury Unstageable noted during tx: sustained from Leg Immobilizer which should not be removed .impaired skin integrity measuring 6.0cm x 3.5cm x 0.0cm, 90% necrotic tissue and 10% granulation tissue, scant serous drainage noted. No c/o of pain and distress during wound care .MD (Medical Doctor) notified and ordered to be cleansed by NSS [normal saline solution], pat dry and apply Optifoam Dressing QD [every day] .signature of RN #3. A progress note by NP #2 dated 7/26/2022 and timed 11:04 PM documented, .Medical Practitioner Note .chief complaint: left lower extremity (shin) pressure injury noted while in the hospital .Wound care was mepilex foam under a nonremovable splint placed for a left patellar dislocation .Patient was transferred .to the SNF [skilled nursing facility] .with the wound covered with a foam dressing and nonremovable splint. Splint was removed to assess wound .left lower extremity open wound (shin) 6cm x 3.5cm x <0.1cm 90% necrotic tissue / 10% granulation tissue Scant serosanguinous drainage .Pressure ulcer of left lower extremity, unstageable .signature of NP #2. On 07/27/22 at 11:30 AM, the administrator and DON were asked for the phone numbers of MD #1 and NP #2 (the resident's attending physician and NP provider). A policy was also requested at this time on wound care/pressure ulcer prevention and treatment. A policy was presented and reviewed. The policy titled, Skin Management Guidelines documented, .steps required for identification of patients at risk .of skin alterations, identify prevention techniques and interventions to assist with management of pressure injuries and skin alterations .skin alterations and pressure injuries are evaluated and documented by the licensed nurse .using the Admission .evaluation .with head to toe skin evaluation .Body Audits are completed by the licensed nurse daily for patients with pressure injuries and documented on the TAR .new findings documented in the progress note .Treatments as ordered by the medical provider .wound rounds completed weekly on pressure injuries and complex wounds . On 07/27/22 at 11:45 AM, MD #1 was interviewed. The MD stated that she knew the resident had the area on the left lower calf (as she had wrote it in her admission note), but was under the impression that the wound nurse (RN #2) and the wound nurse practitioner (NP #2) were aware and taking care of the wound. The MD stated that she was unaware that there was not an order for the brace on admission with instructions for donning/doffing of the knee immobilizer. The MD was made aware that an order was found to order for the brace on 07/13/22. The MD was unsure as to why there were no orders for the deep tissue injury care and treatment (per hospital discharge orders/instructions) and/or why there were no orders regarding the brace/knee immobilizer and/or instructions for donning/doffing. When asked if there should have been, the MD stated there should have been orders and staff should have taken the leg brace off periodically to look at the resident's skin. The MD stated that the resident was admitted with the knee immobilizer and had it upon admission and was not sure about the order on 07/13/22. The MD stated that the wound care team are supposed to be doing body audits and skin checks. The MD was made aware of the serious concerns regarding Resident #100 and the unstageable pressure ulcer found on her left lower calf on 07/26/22 (the day before) that was measured at 6 cm x 3.5cm x <0.1cm 90% necrotic tissue / 10% granulation tissue with scant serosanguinous drainage. The MD was made aware that there were no orders/progress notes, etc. found anywhere that documented that this brace/knee immobilizer for Resident #100 was not supposed to be removed and/or that it was to be kept in place at all times. The MD was asked how would you evaluate a resident's skin if you don't take off a brace. The MD stated that you would have to take it off. The MD was made aware that as a result of facility staff not obtaining physician orders for immediate care and treatment of a resident with a deep tissue injury and brace/knee immobilizer (donning/doffing orders) and/or interventions implemented, the resident suffered actual harm as a result. The MD stated, I fully agree with you. A phone interview was attempted with NP #2 numerous times without success, no response or comment. On 07/27/22 at 12:00 PM, in a meeting with the survey team, the administrator and DON (director of nursing) were made aware of the above information. The administrator and DON were made aware of the serious concerns regarding Resident #100 not having immediate care orders for a brace/knee immobilizer (donning/doffing schedule) and/or not having immediate orders for the care and treatment of a deep tissue injury that subsequently progressed to an unstageable pressure ulcer as a result. The administrator and DON were made aware that the hospital discharge orders/instructions had specific orders in place for the above concerns for Resident #100, but upon admission to this facility the orders were not followed/obtained and no interventions were implemented by the facility and the resident was harmed as a result. On 07/27/22 at 2:15 PM, the DON stated, Regardless it's [pressure area] always going to be there, she's had it for a long time, nothing we could do. The DON was made aware that were no orders found anywhere to evidence that the resident's brace was not to be removed and that the hospital discharge orders/instructions gave specific orders for care upon discharge to the this facility and that this facility failed to provide care and treatment for the prevention/treatment of pressure ulcers. No further information and/or documentation was presented prior to the exit conference on 07/27/22 at 5:15 PM to evidence that the facility staff initiated immediate care orders for Resident #100 regarding the use of a leg brace/knee immobilizer or for the care and treatment of a deep tissue injury.

Based on observations, clinical record review, and resident interview, the facility failed for one of 14 residents in the survey sample (Resident # 114) to ensure the resident had a clean, comfortable, and homelike environment. The toilet in the resident's room did not flush, the bath tub was dirty, and a paper towel dispenser was dirty. The findings were: Resident # 114 in the survey sample was admitted to the facility with diagnoses that included insomnia, morbid obesity, post-traumatic stress disorder, chronic pain syndrome, chronic atrophic gastritis, epilepsy, major depressive disorder, hypertension, chronic migraine without aura, chronic kidney disease, gastroesophageal reflux disease, adjustment disorder with anxiety, thrombocytosis, delusional disorders, vitamin D deficiency, syncope and collapse. According to an admission nursing assessment, the resident was found to be oriented to situation, person, place, and time. NOTE: At the time of the survey, it was Resident # 114's third day in the facility. At 8:15 a.m. on 9/28/2022, an interview was conducted with the resident. During the interview, the resident stood up, walked to the small bathroom in her room and said, Come look at this. The bathroom consisted of a commode and a bath tub. The lid on the commode water tank was slightly ajar, and there were several rolls of toilet paper on the lid. There was a piece of toilet paper in the toilet bowl. Watch this, the resident said. Resident # 114 pushed the handle on the water tank down to flush the commode, but nothing happened. The resident jiggled the handle several times and attempted to flush the toilet again, but it would not flush. Resident # 114 then said, Look at the bath tub. The bath tub had a large, brown stain on the bottom of the tub. There was also several pieces of black debris on the bottom of the tub. Now look at this, the resident said, pointing to a paper towel dispenser hanging on the wall next to a small handwashing sink in an area adjacent to the bathroom. The paper towel dispenser was covered with splatters of an unknown substance on the side facing the room and on the front of the dispenser. Resident # 114 pointed to the heating/airconditioning unit, which was running and blowing warm air. I asked the nurse to turn it off, but she didn't know how to turn it off. No one knows how to turn it off. The resident then said, I asked for a pair of socks, and this is what they gave me. The resident held up a pair of used, non-skid slipper socks. I wanted a new pair, the resident said. But they told me these were clean, that they came from the laundry. At the time of the interview, the resident was not wearing any socks. The findings were discussed during a meeting at 10:00 a.m. on 9/28/2022, that included the Director of Nursing, two administrators from sister facilities, and the survey team.

Based on observation, staff interview and clinical record review, the facility staff failed to promote dignity for one of twenty-nine residents in the survey sample. Resident #115 was left in a soiled gown for over two hours and had no personal clothing to wear. The findings include: Resident #115 was admitted to the facility with diagnoses that included adult failure to thrive, kidney failure, gastroenteritis, Parkinson's disease, anemia, history of bladder cancer, pancreatitis, gastroesophageal reflux disease, compression fractures, obstructive uropathy and pressure ulcer with MRSA (methicillin resistant staphylococcus aureus) infection. The minimum data set (MDS) dated [DATE] assessed Resident #115 with severely impaired cognitive skills and as requiring extensive assistance of one person for dressing and hygiene. On 7/26/22 at 11:34 a.m., Resident #115 was observed in bed feeding himself from a breakfast tray. The resident was wearing a hospital gown with a brown, liquid stain across the entire left chest section of the gown. On 7/26/22 at 2:00 p.m., Resident #115 was observed in bed feeding himself lunch. The resident had on the same hospital gown with a brown liquid stain across the left upper chest section of the gown. On 7/26/22 at 2:10 p.m., the certified nurses' aide (CNA #3) caring for Resident #115 was interviewed about the resident's soiled gown and clothing. CNA #3 stated she had cleaned the resident earlier this morning before breakfast. CNA #3 stated she did not serve the resident his breakfast tray or lunch tray and did not know his gown was soiled. When asked why the resident was wearing a hospital gown, CNA #3 stated the resident had no personal clothing to wear so she dressed the resident with a hospital gown. CNA #3 stated she did not know why the resident had no clothing. On 7/26/22 at 3:18 p.m., the social worker (other staff #3) assigned to Resident #115 was interviewed about the resident's clothing. The social worker stated she was not aware the resident had no personal clothing. On 7/27/22 at 9:00 a.m., the social worker stated she checked the resident's closet and he had only one outfit that included a sweatshirt and one pair of pants. The social worker stated this outfit may have been in the laundry on 7/26/22. The social worker stated she thought the resident had clothes but did not know he had only one outfit. The social worker stated the resident had been in the facility for over a month and there had been a previous care plan meeting but nobody mentioned any issues with clothing. On 7/27/22 at 9:45 a.m., the licensed practical nurse unit manager (LPN #4) was interviewed about Resident #115 left in a soiled gown and with no personal clothing. LPN #4 stated the gown should have been changed when soiled. LPN #4 stated the resident's spouse was involved with his care and he was not aware the resident had no personal clothing. Resident #115's clinical record documented a care plan conference was held on 6/30/22 with attendance by dietary, nursing and social services. The care plan note dated 6/30/22 made no mention of any issues with personal clothing and documented, .No significant changes in activities of daily living at this time . These findings were reviewed with the administrator and director of nursing during a meeting on 7/27/22 at 12:10 p.m.

Based on staff interview, facility document review, clinical record review and complaint investigation, the facility staff failed to assess and implement interventions to prevent a pressure ulcer for one of twenty-one residents in the survey sample, Resident #8. Resident #8 developed a sacral pressure ulcer initially identified at an unstageable status with slough covering 30% of the wound. There was no prior assessment of impaired skin on the sacrum. A nurse with knowledge of redness on the sacrum, failed to document, report and obtain physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Treatment orders for a change in treatment to the pressure ulcer were not implemented. The findings include: Resident #8 was admitted to the facility on [DATE] and was discharged to the hospital on 7/29/21. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The minimum data set (MDS) dated [DATE] assessed Resident #8 with severely impaired cognitive skills and as requiring the extensive assistance of one person for bed mobility, toileting and hygiene. Resident #8's closed clinical record documented a nursing note dated 7/23/21 stating, CNA [certified nurses' aide] call writer to attention asking for dressing to apply on sacrum area. Writer on assessment noted resident sacrum with an open area. Resident in bed sacrum area cleanse with NS [normal saline], measured 4 cm [centimeters] x 3 cm [length x width]. NP [nurse practitioner] .notified, wound nurse notified and treatment orders noted by wound nurse. (Sic) The wound nurse documented a late entry note on 7/23/21 stating, During routine AM care resident was noted to have a pressure injury on coccyx measuring 2.5 cm x 2 cm x <0.1 cm. 70% Granulation and 30% Slough with moderate serosanguinous [serosanguineous] drainage present, No tunneling or undermining present. PUSH tool initiated and Score = 12. Maceration of surrounding skin noted. Braden Scale complete = 11 .RP [responsible party] .notified . (Sic) Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The NP assessed the resident on 7/26/21 and documented, .Very high risk of skin related impairment due to his comorbid conditions .sacral skin impairment . A NP note dated 7/27/21 documented, .Sacrum unstageable pressure injury .Skin - positive for wound pain . The NP documented in the 7/27/21 progress note to change treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . The change in treatment to include Santyl [MEDICATION(S)] agent was not entered or implemented prior to the resident's discharge on 7/29/21. Treatment administration records documented continued treatment with normal saline, Medi-honey, calcium alginate with [MEDICATION(S)] dressing from 7/23/21 through 7/29/21. A follow-up assessment by the wound nurse dated 7/28/21 documented, .Sacral Pressure Injury: 2 cm x 4 cm, 100% slough, surrounding [CONDITION(S)], heavy serosanguinous [serosanguineous] drainage . Resident #8's Pressure Ulcer Healing Chart documenting pressure ulcer scale for healing (PUSH) scored the resident's sacral pressure ulcer on 7/23/21 as 12. The PUSH score on 7/28/21 was 13, indicating worsening of the pressure ulcer due to an increased amount of exudate. Prior to the sacral pressure ulcer found by the CNA on 7/23/21, the clinical record (from 7/1/21 through 7/22/21) made no mention or description of the resident's skin including the sacral area. Nurses had signed off the resident's treatment administration record from 7/1/21 through 7/22/21 indicating that a body audit was performed each evening shift. There were no notes and/or documentation associated with the body audits describing the condition or appearance of the resident's skin when these audits were performed. Audits marked as completed on 7/23/21 through 7/28/21 made no mention of the resident's sacral pressure ulcer or any other skin impairments. Resident #8's plan of care prior to the pressure ulcer acquired on 7/23/21 (initiated 10/3/20) documented the resident had previous redness to the groin area, left/right buttocks redness and was at risk of alterations in skin integrity due to impaired mobility. Interventions to heal redness and prevent skin breakdown included, .Administer treatment per physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] .Report evidence of infection such as purulent drainage, swelling, localized heat, increased pain .Notify physician prn [as needed] .Barrier creams to peri area/buttocks as needed .Observe skin condition with ADL [activities of daily living] care daily; report abnormalities .Provide preventative skin care routinely and prn . On 9/8/21 at 11:50 a.m., the registered nurse responsible for wound care (RN #4) was interviewed about Resident #8's sacral pressure ulcer. RN #4 stated the CNA reported on the morning of 7/23/21 that the resident had an open area on his sacrum. RN #4 stated the pressure ulcer when first observed was partially covered with yellow slough and had a PUSH score of 12. RN #4 stated if using the staging system, the pressure ulcer was unstageable due to slough covering part of the wound. RN #4 stated he notified the NP and got orders for treatment on 7/23/21. RN #4 stated nobody had reported to him any skin impairments for Resident #8 prior to 7/23/21. RN #4 stated an investigation was done about the resident's acquired pressure ulcer. RN #4 stated he did not know why the pressure ulcer was not identified prior to development of slough and drainage. On 9/8/21 at 12:20 p.m., the licensed practical nurse (LPN #2) routinely caring for Resident #8 was interviewed about the pressure ulcer. LPN #2 stated the CNA reported to her on 7/23/21 about an open area on the resident's sacrum. LPN #2 stated she measured the wound and reported the area to the wound nurse (RN #4). LPN #2 stated prior to 7/23/21, the resident's sacral area was red and she had been applying barrier cream to the area. LPN #2 described Resident #8 as total care and as staying mostly in bed. LPN #2 stated the CNAs attempted to reposition the resident but he stayed mostly on his back. LPN #2 stated she did not document anything about the redness and the only treatment prior to 7/23/21 was barrier cream applied after incontinence in addition to repositioning. LPN #2 stated concerning the change in treatment orders that the wound nurse usually entered orders for changes in wound care. On 9/8/21 at 12:45 p.m., the nurse practitioner (other staff #3) that treated Resident #8 was interviewed about the pressure ulcer. The NP stated the resident had an overall, general decline and was at high risk of skin impairment. The NP stated when he assessed the pressure ulcer (7/27/21) the ulcer was, already in bad shape when I saw it. The NP stated the wound was covered with slough and was unstageable. The NP did not know why the change in treatment to Santyl was not implemented. On 9/8/21 at 12:50 p.m., the aide that found the pressure ulcer on 7/23/21 (CNA #1) was interviewed. CNA #1 stated that after she gave the resident a shower on the morning of 7/23/21, she noticed the resident's sacrum was a little bit open. CNA #1 stated she immediately reported the open area to LPN #2. CNA #1 stated LPN #2 told her she was not allowed to put a dressing on the wound without an order and would get the wound nurse. CNA #1 stated she provided total care for Resident #8 that included incontinence care. CNA #1 stated she gave the resident a shower usually twice per week and had not noticed the open area until 7/23/21. On 9/8/21 at 3:40 p.m., LPN #4 that signed off body audits for Resident #8 for the four days prior to 7/23/21 was interviewed. LPN #4 stated each evening he performed a head to toe assessment of Resident #8's skin looking for any open areas. LPN #4 stated he did not document anything about the appearance or condition of the skin unless there was a skin impairment. When asked if he saw any skin impairments on Resident #8's sacral area in the days prior to 7/23/21, LPN #4 stated, I don't remember. LPN #4 stated, If I saw something like that [pressure ulcer], I would put in the notes. On 9/8/21 at 3:50 p.m., the unit manager (RN #2) was interviewed about how Resident #8's pressure ulcer was not identified until an unstageable status and not identified with daily body audits. RN #2 stated the nurses were supposed to do a head to toe inspection and document the assessment in the progress notes. RN #2 stated CNA #1 found the open area during morning care and reported it to LPN #2. RN #2 stated prior to 7/23/21 only barrier cream was applied to the sacrum and the redness mentioned by LPN #2 had not been reported. RN #2 stated the wound nurse usually entered orders for changes in treatment. RN #2 stated she did not know why the change in treatment to Santyl was not entered. On 9/9/21 at 8:20 a.m., the director of nursing (DON) was interviewed about Resident #8's sacrum pressure ulcer. The DON stated Resident #8's pressure ulcer was discovered late and stated, The ball was dropped there. The DON stated the facility had recognized gaps in the skin process and were in the process of educating staff and reviewing the assessment protocols. The DON stated Resident #8's pressure ulcer was investigated. The DON stated their investigation revealed that LPN #2 was aware Resident #8 had sacral redness prior to 7/23/21 and had been applying protective cream. The DON stated LPN #2 did not report the sacral redness or seek treatment orders for the area. The DON stated the wound nurse and unit manager were not aware of the sacrum wound until CNA #1 reported the open area on 7/23/21. The facility's Pressure Ulcer Prevention Pathway (2013) included the following steps to take following a head-to-toe skin assessment for pressure ulcer prevention: Document skin issues including color, temperature, turgor, moisture status, integrity, pressure ulcer, if present or known healed pressure ulcer. This pathway documented, Report any abnormal findings to physician and notify and educate patient and family on findings. For an identified pressure ulcer, the pathway documented to list the location, length, width, depth and PUSH score for each wound and then, Obtain order for treatment from physician and obtain consultations as needed. The National Pressure Injury Advisory Panel (NPIAP) defines a pressure injury as localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear . The NPIAP defines an unstageable pressure injury as, Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible .Depth varies by anatomical location. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. (1) The NPIAP defines the Pressure Ulcer Scale for Healing (PUSH) tool as, a quick, reliable tool to monitor the change in pressure ulcer status over time. (1) These findings were reviewed with the administrator and director of nursing during a meeting on 2/9/21 at 11:25 a.m. (1) NPIAP Pressure Injury Stages. National Pressure Injury Advisory Panel. 9/14/21. www.npiap.org/ This was a complaint deficiency.

Based on observation, resident interview, family interview, staff interview, facility document review, clinical record review and in the course of a complaint investigation, facility staff failed to ensure two of four residents identified as smokers were assessed to determine if they were safe to smoke either independently or were at risk. The residents, one of whom was paraplegic, were observed outside without protective aprons and without direct supervision by facility staff. This was identified as Immediate Jeopardy (IJ) in the area of Quality of Care on 02/05/2019 at 5:01 p.m., with resulting SQC (substandard quality of care). The immediacy was abated on 02/05/2019 at 8:23 p.m. After removal of the immediate jeopardy on 02/07/2019 at 9:30 a.m., the Scope and Severity was lowered to Level III, Isolated. The facility staff also failed to implement interventions and supervision for the prevention of elopement, multiple falls, and falls resulting injury (Harm) for two of 32 residents, and failed to immediately respond and implement safety interventions in response to an emergency door alarm on one of seven units, the 100 unit. 1. Resident #117, a paraplegic, was not assessed to determine her ability to smoke safely and independently. Resident #117 was observed outside smoking cigarettes without a protective apron and without direct staff supervision. This resulted in the identification of Immediate Jeopardy. 2. The facility staff failed to provide adequate supervision to prevent elopement from the facility, multiple falls and falls with injury (harm) for Resident #34. Resident #34 was found in the parking lot on 05/26/2018 requiring evaluation at a local hospital, she had multiple documented falls at the facility including three incidents of harm: a fall with resulting acute proximal humeral shaft fracture on 08/11/2018; a fall on 08/18/2018 with resulting laceration above her right eyebrow requiring 13 sutures; and an acute [MEDICAL CONDITION] phalanx (ring finger) that was identified on 12/02/2018. 3. The facility staff failed to implement interventions and supervision for the prevention of falls for Resident #129, which resulted in harm. Resident #129 had a fall and was sent to the hospital for evaluation, receiving five staples to the back of the head for a laceration. 4. The facility staff failed to accurately assess Resident #60's ability to smoke independently or safely without direct supervision. 5. Facility staff failed to immediately respond and implement safety interventions in response to an emergency door alarm on the 100 unit. The alarm sounded for almost 30 minutes without any response or interventions from staff members present on the unit. A charge nurse interviewed was not knowledgeable about the alarm or what actions were required in response to the alarm. Findings were: 1. Resident #117 was admitted to the facility on [DATE] with the following diagnoses, but not limited to: [MEDICAL CONDITION], acute kidney failure, hypertension, [MEDICAL CONDITION], and neuromuscular dysfunction of the bladder (requiring indwelling catheterization). A significant change MDS (minimum data set) with an ARD (assessment reference date) of 1/14/2019, assessed Resident #117 as cognitively intact, with a summary score of 15. Section J: Health Conditions, J1300 Tobacco Use was checked No. In the course of the survey process a list of residents who smoke was requested from the administrative staff. Resident #117 was identified on the list as a smoker. The clinical record was reviewed on 02/05/2019 at approximately 2:00 p.m. A smoking assessment was not observed on the electronic record. The care plan was reviewed. There were no interventions on the care plan regarding smoking. On 02/05/2019 at approximately 3:30 p.m., Resident #117 was interviewed. She was asked if she was a smoker. She stated, Yes, but I don't smoke everyday, or every smoke break .I usually just go down once a day .I went for so long without smoking because I was so sick, but I've started again . I am going out today at 4:00 (p.m.). Resident #117 was asked where she kept her cigarettes. She stated, They are downstairs with my lighter. During the interview, Resident #117 was asked if she could move her legs or had any feeling in them. She stated, No, they said I have a clot on my spine that is causing it (paralysis) .I don't know if my legs will get better or not. At 4:00 p.m., two surveyors went to the smoking area to observe the residents. The area was located at the end of the facility outside the dining room. OS (Other Staff) #2 was standing in the dining room at the door to the smoking area. She entered a code and allowed the surveyors to walk outside. The smoking area was a covered cement patio with a locked privacy fence in front of it. The dining room door was the only entrance back inside the building and had a narrow, long window above the door knob. The window in the door was the only indoor point of visualization to the smoking area. Three residents were observed smoking. One resident was wearing an apron. OS #2 came outside and offered the other two residents an apron. Both residents declined. OS #2 went back inside the building. Resident #117 was not wearing an apron. She was sitting with her back to the door and her smoking could not be visualized from inside. The residents were talking and Resident #117 stated, My husband brought me some cigarettes, I need to bring them downstairs to the desk, I forgot them in my room. When the observation was complete, OS #2 opened the door for the surveyors to come back into the facility. She was asked what her role was. She stated, I'm here for the smoking time, but I'm not going out there .I don't smoke. A sign was observed beside the door with posted smoking times and the following sentence: Smoking aprons must be worn at all times . A copy of the facility policy was requested at 4:10 p.m. The corporate nurse and the DON (director of nursing) stated that the smoking guidelines were located in the resident admission packet. The Patient Information Handbook was reviewed. Page 3 contained the following information regarding smoking: SMOKING We believe in providing a healthy environment for you. Our center is designated as 'smoke-free.' Smoking is not permitted on the campus or may be permitted in designated area only. Smoking materials, including lighters, matches, cigarettes, and cigars, must be stored at the nurse's station. The DON was again asked if there was a facility policy regarding smoking. She stated, We are looking for it .what we have are called 'guidelines', not a policy. The SMOKING GUIDELINES included the following information: PURPOSE: To determine if a patient is an Independent Smoker or an At Risk Smoker before the patient exercises the privilege to smoke while residing within the center and to establish guidelines for all patients that desire to smoke, as well as non-smokers. GUIDELINES: - Evaluate patients that smoke utilizing the Smoking Evaluation tool either: (a) upon admission; (b) when a previous non-smoking patient takes up smoking; (c) if unsafe smoking practices are observed in a current smoker; or, (d) when a patient that smokes has a significant change in medical condition. -The Smoking Evaluation is generated from the assessment tab in (name of computer system). -Provide education of the Smoking Guidelines to the patient, family members or responsible party and visitors that may supervise patients during smoking. Education is provided when: (a) a new patient is identified as a smoker; (b) a previous non-smoker patient takes up smoking; (c) if unsafe smoking habits are observed in a current smoker; or, (d) a patient that smokes has a significant change in medical condition. The education is documented and saved in the patient's electronic health record utilizing the Patient Education Progress Note or per state requirements -Upon completion of the evaluation, the Interdisciplinary team (IDT), including the attending physician, will make a decision whether the patient is an Independent or an At Risk Smoker. -If the patient is determined to be an Independent Smoker, the patient may smoke without assistance at center designated times. Independent Smokers must still follow smoking guidelines including, but not limited to, keeping smoking accessories in control of the center staff when not in use and smoking only in designated areas at designated times. -If the patient is determined to be an At Risk Smoker, the patient is required to wear a protective smoking vest or apron if needed and is supervised while smoking. -The IDT completes completes a comprehensive patient care plan that reflects the: -smoking evaluation outcome -smoking supervision that is necessary -type of protective smoking equipment that is needed, e.g., smoking apron or vest - education on the Smoking Guidelines and options for smoking cessation activities offered and/or provided to the patient or family members . -Direct personal supervision is provided to At Risk Smokers while smoking. Center administration provides supervision and direction to center staff responsible for providing direct supervision. Other patients cannot, under any circumstances, provide supervision for At Risk Smokers . -Any non-compliance with the smoking guidelines is addressed with the patient and family members as the non-compliant activities occur. Additional education is provided as needed and the plan of care is updated to reflect the patient's current needs . The survey team met to discuss the smoking observations, the lack of smoking assessment, care plan, and supervision for Resident #117, a paraplegic. The team determined that guidelines for Immediate Jeopardy were met. The team supervisor and the State agency were contacted for validation. The office concurred and Immediate Jeopardy was implemented at 5:01 p.m., with subsequent Substandard Quality of Care. On 02/05/2019 at 5:11 p.m., the survey team met with the administrator and the DON (director of nursing). The team leader informed them that the survey team with concurrence from the main office had implemented Immediate Jeopardy at 5:01 p.m., and SQC due to the facility's failure to assess Resident #117, a smoker with [MEDICAL CONDITION] for safe smoking. They were told that Resident #117 was observed outside smoking without a protective apron, without direct supervision, without a care plan or assessment for smoking, and that her MDS did not identify her as a smoker. The administrator was informed that a plan of removal for immediacy would need to be developed and presented to the survey team for approval before the immediacy would be abated. The facility staff presented the following five point plan of correction that was accepted by the survey team on 02/05/2019 at 8:23 p.m.: This serves as Manor Care Health Services Arlington (sic) response to the Immediate Jeopardy Notification that the center received on (MONTH) 5, 2019. The facility Quality Assessment and Performance Improvement (QAPI) Committee met on (MONTH) 5, 2019 to resolve the alleged failure to assess a smoking patient for smoking needs. 1. Resident (initials of Resident #117) was observed smoking without direct supervision. Further investigation also showed that the same resident does not have a smoking assessment on record, there was no care plan completion, and there was no MDS assessment completed. The resident, (initials of Resident #117), has been educated regarding the facility smoking policy. 2. The facility has completed a smoking assessment on (initials of Resident #117) today, 2/5/19. The patient's care plan has been completed to reflect her smoking status. Furthermore, a significant change in status MDS for (initials of Resident #117) has been initiated. The staff responsible for smoking supervision have been educated on direct supervision and use of apron during smoking. 3. The facility would (sic) continue to educate the entire staff on Manor Care's smoking policy. Education has begun today, 2/5/2019, and anticipated to be completed by end of day, 2/7/19. 4. The facility has completed an audit of all residents presently in the facility for smoking. No new smoker was identified above those it currently has on the smoking list. The facility will complete a smoking assessment for all new residents admitted in the facility going forward. 5. This plan of correction has been forwarded to an ad hoc QAPI committee for adoption or further recommendation. Also presented was a Staff Development Program Attendance Record with five staff listed who had received training on DIRECT SUPERVISION FOR SMOKERS. The education attached was: 1. IF ANY RESIDENT IS NOT ON THE CURRENT SMOKERS LIST AND THEY COME OUT TO SMOKE. (sic) YOU MUST STOP THEM AND NOTIFY NURSING FOR RESIDENT TO HAVE SMOKING ASSESSMENT COMPLETED TO DETERMINE THEIR SAFETY. THE SUPERVISOR OF SMOKERS WILL CHECK THE CURRENT LIST TO ENSURE ONLY THOSE RESIDENTS LISTED ARE SMOKIN[NAME] 2. WHILE OBSERVING THE SMOKERS YOU WILL NEED TO MAINTAIN VISUAL CONTACT AND ENSURE RESIDENTS ARE FACING YOU. 3. WHEN INDICATED ENSURE THE RESIDENT HAS SMOKING APRON ON. 4. NURSING/DESIGNEE WILL UPDATE THE SMOKERS LIST FOR NEW ADMISSIONS AND CHANGES OF CONDITIONS AS NEEDED. Resident #117's smoking evaluation was presented and reviewed. Resident #117 was assessed by the facility as an At Risk Smoker, Requires family, friend or staff for physical support or supervision to smoke .Patient able to smoke with apron, and educated on times and need for smoking materials to be secure during non-smoking hours. On 02/07/2019, during the morning, the survey team conducted random interviews throughout the facility to ascertain that staff had received the training outlined on the plan of removal. All interviewees had been trained and were knowledgeable regarding the facility's smoking policy. The facility checklist indicated that all staff had received training as of 9:30 a.m. on 02/07/2019. No further information was obtained prior to the exit conference on 02/07/2019. 2. Resident #34 was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Her admission MDS (minimum data set) with an ARD (assessment reference date) of 05/22/2018 coded Resident #34 as having impairment with both long and short term memory, and severely impaired for daily decision making skills. Resident #34 was also coded as needing limited assistance of one for walking in her room and in the corridor. Under the area Balance During Transitions and Walking (G0300) she was coded as Not steady, only able to stabilize with staff assistance in the areas of Moving from seated to standing position; Walking; turning around; moving on and off toilet; and surface-to-surface transfer. The quarterly MDS with an ARD of 11/22/2018 also coded Resident #34 as impaired with both long and short term memory, and severely impaired for daily decision making skills. She was coded as needing limited assistance of one for walking in her room and in the corridor. Under the area Balance During Transitions and Walking she was coded as Not steady, only able to stabilize with staff assistance in the areas of Moving from seated to standing position; Moving on and off toilet; and surface-to-surface transfer; and coded as Not steady, but able to stabilize without staff assistance in the areas of Walking and turning around. Resident #34's room was located at the end of the the unit on the second floor. Her room was not visible from the nurses station. On 02/05/2019 at approximately 9:15 a.m., Resident #34 was observed in her room eating breakfast. She was sitting in a chair beside her bed. Food was on the floor around her, she got up and down out of the chair and walked to a different chair in her room and then returned to the chair where her breakfast tray was located multiple times. When an interview was attempted Resident #34 spoke no English. No staff was in the vicinity to assist her. On 02/05/2019 from approximate 2:30 p.m. until 2:35 p.m., Resident #34 was observed walking around her room. She was wearing only a wander guard and a sock on her left foot. She walked back and forth from a chair in her room to her bed. She was observed to lay down in the bed, cover up and then immediately get back up. Her clothes and brief were in a pile on the floor. This surveyor walked around the third floor looking for someone to assist Resident #34; a CNA (certified nursing assistant) was located at the far end of the floor and was asked if she was working with Resident #34. She stated, No, I am on the other end. What does she need. When the situation was described the CNA went to the room to assist Resident #34. The clinical record was reviewed on 02/05/2018 at approximately 6:30 p.m. Review of the progress note section indicated that Resident #34 had a history of [REDACTED]. The clinical record included documentation of approximately 17 falls, 2 elopements, two fractures and two lacerations requiring sutures/staples since admission to the facility. Documentation in the progress notes included the following: 05/15/2018 23:47 (11:23 p.m.) Patient present(s) with [DIAGNOSES REDACTED]. 05/16/2018 4:20 (a.m.) she is monitored frequently as she gets up unassisted and gait is unsteady . 05/17/2018 08:51 (a.m.) Resident found lying on the floor at 11:55 p.m no signs of discomfort . 05/29/2018 07:34 (a.m.) Patient is alert, stable and very confused, refuses to stay on the bed or chair, trying to get up but she does not have good gait or good balance, staff have (sic) baby siting (sic) most of the night . 05/17/2018 16:56 (4:56 p.m.) POST FALL NURSES ASSESSMENT; Resident was very combative and refused to stay sitting on her W/C (wheelchair). Resident was put in bed to rest and few minutes later, she got up and began to walk down the hall-way to 2-west unnoticed by staff. She accidentally fell in room (number) @1:30 p.m. today .no new skin impairment . 05/23/2018 00:07 (12:07 a.m.) Patient found on the floor on her right side by 3 [NAME] (east) (not Resident #34's floor) nurses station during shift change. Staff reported she has been wandering around most of the shift .(no injury) 05/26/2018 11:45 (a.m.) Front desk paged writer and stated come down stair (sic) to see resident for Spanish Interpreter, came to front desk and saw resident with fire department, ambulance, stated they found her in Manor Care back of the parking lot .MD gave order to transfer resident to ER for evaluation . 05/26/2018 16:54 (4:54 p.m.) Resident is alert and oriented .Resident up walking independently .writer saw resident around 11:15 a.m. sitting in Longue (sic)with no distress noted .At 11:45 (a.m.) supervisor call writer stated come in front desk (sic), noted resident with fire department, ambulance, they stated they found her in back of Manor Care parking lot .send to ER . 05/26/2018 20:01 (8:01 p.m.) Patient skin reveals bruises to the lower left back, left temple and right arm possible from the reported fall on 5/23/18. She returned from ER for evaluation to rule out dehydration .(physician name) notified for wander guard for safety. 06/11/2018 17:00 (5:00 p.m.) Patient fell out of the facility on her way in for readmission. She was discharged home early at 10:00 AM with her daughter .writer was told that she (Resident #34) refused to stay at (name of facility) and returned to Manor Care .She fell at door entrance and got a cut on the back of her head .911 . 06/11/2018 22:59 (10:59 p.m.) Patient was readmitted from (hospital) .patient has stitches in her head related to fall: wounds noted on the head. One has 4 staples and the other has 1 staple . 06/21/2018 13:08 (1:08 p.m.) Resident is confused, while transferring from bed to w/c lost her balance and sat on floor . 08/11/2018 08:18 (a.m.) Resident was alert with intermittent confusion. Neurocheck was in progress send resident to emergency department to evaluate for acute proximal humeral fracture via 911 .order due to X-ray result shown (sic) fracture on the proximal hum oral shaft .(NOTE: No documentation in clinical record regarding aforementioned x-ray or fall) 08/11/2018 11:32 (a.m.) During AM care this writer was called to resident room by CNA (certified nursing assistant) stating resident right elbow appears swollen. On assessment skin warm to touch, no redness noted in skin, resident alert and verbal, s/s (signs and symptoms) of grimacing noted while touching right elbow .limited ROM (range of motion) on right extremity . 08/11/2018 12:44 (p.m.) .on call MD notified .new order given to do x-ray of shoulder 2 views . 08/11/2018 13:10 (1:10 p.m.) .spoke to RP (responsible party) that she (Resident #34) has an accident and fell from her bed. Neurochecks initiated. 08/11/2018 16:39 (4:39 p.m.) Resident fell in front of her room while ambulating to her room to use the bathroom around 2:00 p.m no apparent injury, redness noted in left side of the head, passive ROM in left upper extremity and both lower extremities within normal limits .right upper extremity has limited ROM . 08/11/2018 18:00 (6:00 p.m.) Mobile tech in X-ray done results pending. 08/11/2018 08:30 (a.m.) (Name) emergency was called to ascertain patient condition and her nurse .indicated that her doctor might discharge her back today. 08/12/2018 16:36 (4:36 p.m.) Resident arrived back from (name) ER at 3:45 p.m noted on her left upper side of the face slightly swollen with redness, right upper shoulder noted swollen, with bruising, and the right lower arm in a cast wrap with ace wrap and in sling .left fifth finger noted with old open area but dry measuring 0.5 cm X 0.5 cm, left knees noted with open area measuring 2.0 cm X 1.0 cm, below left knee noted with scabbed measuring 1.0 cm X 1.0 cm . 08/12/2018 19:58 (7:58 p.m.) .came back with [DIAGNOSES REDACTED].During skin assessment old healing scar with scabbed (sic) noted to the back of the head, right upper shoulder at the back noted with open area measuring 1.0 cm X 1.0 cm, mid back noted with open area measuring 2.0 cm X 0.3 cm and also another tiny open area to mid back measuring 0.3 cm X 0.3 cm and at the right outer back noted with old healed scar resident pulling on her cast and sling . 08/18/2018 10:40 (a.m.) Writer calle (sic) at this time to attention stating resident fell in lunch room on west side and sustained a laceration to upper right eyebrow measured 4 cm X 2 cm with large amount thick red blood from site. Ice pack applies to site .resident transferred to (hospital name) at 10.5 am {sic), report given to ER nurse. 08/18/2018 15:36 (3:36 p.m.) Resident back from the hospital .13 sutures noted intact to facial laceration .Resident in bed at this time but trying to get out of the bed . 08/21/2018 08:23 (a.m.) Patient was found sitting (on) the floor at 7:30 a.m., neurological check done and no change notice (sic) 08/21/2018 16:56 (4:56 p.m.) Loud Portuguese language heard coming from the room and this writer went to check, patient was observed lying on her right side, the right arm on the pillow. No apparent injury noted, skin assessment done, resident noted with right eye lid dark purple color, and stitches in place in right forehead close to right eye, large dark purple discoloration noted in right thigh all those from previous falls .resident was transferred with tow assist to bed, bed was in low position. 08/28/2018 01:54 (a.m.) .very combative with staff going from room to room unsteady on her feet, requires one on one monitoring to prevent falls . 09/05/2018 19:50 (7:50 p.m.) .called writer to room and resident was observed on the floor at 6:20 p.m. lying on her right side beside the entrance door. Based on observation, resident was consuming her dinner meal when she decided to got (sic) up and walk from his (sic) Mw/c and she accidentally fell to the floor at 6:30 p.m. today. Resident assessed head to toe .no new skin impairment .ROM performed .no limitations noticed except little limitation observed on her right fractured humerus from post fall recently . 09/21/2018 15:41 (3:41 p.m.) Resident was observed sitting in wheelchair at the nursing station with other residents at 2:25 p.m. This writer went to assist the aide to transfer another patient from the chair to bed, when she came out of the room this patient was observed sitting on the floor .no apparent injury observed . 09/23/2018 22:35 (10:35 p.m.) .oob to w/c sitting in front of nurses station and as soon as staff goes to attend to other resident, resident will get up from her w/c and ambulate to other resident room and nurse redirected back to her w/c . 10/06/2018 15:26 (3:26 p.m.) Resident was observed at 1:55 PM sitting on the floor in front of her room, bedside table behind her .no apparent injury .resident was last seen lying in her bed resting around 1:40 p.m . 11/17/2018 17:35 (5:35 p.m.) .at 4:10 p.m. sitting in her w/c in front of nurses station, per assign (sic) cna resident wants to stand up, her w/c was locked but the w/c moved a little bit and resident slide (sic) to the floor. Assign (sic) cna said she hold resident on one side and she try to hold resident on the other side but resident slide and sit on floor and resident head, a little bit touch on the wall .no apparent injury .do neurochecks for 24 hours if any change in mental status send resident to ER . 11/28/2018 00:07 (12:07 a.m.) Resident is alert and very confused wander into physical therapy room and lock self up in there the room several attempt patient before patient open room, skin audit done assessment done no acute distress noted . 12/02/2018 16:50 (4:50 p.m.) .resident ambulating in her room when nurse making round at the start of shift at 3:05 PM and no distress noted .staff from activity dept came and wheeled resident to activity upstairs in w/c before 3:30 p.m. Daughter visited and nurse told daughter that resident went upstairs with activity .daughter went upstairs and came down with resident and daughter brought to nurse (sic) attention of resident left 4th finger reddening and swollen. When nurse asked resident what happened resident stated I hit it somewhere 2 days ago and it pain a little .left 4th finger assessed noted swollen and reddening 4th palm noted bruising .daughter requesting x-ray . 12/03/2018 18:26 (6:26 p.m.) .x-ray results positive for acute [MEDICAL CONDITION] phalanx of the ring finger .to schedule appointment with ortho . 12/08/2018 09:57 (a.m.) .resident walking in the hallway all naked. Aide working with this resident was in the shower room given (sic) shower to resident in room (number). Writer took resident in the room, provided ADL care and dress resident . 12/08/2018 16:28 (4:28 p.m.) Writer was called to attention by another staff stating resident is sitting on the floor at west unit station .resident in upright position on floor. Head to toe assessment done, no s/s pain noted . 02/01/2019 15:32 (3:32 p.m.) Resident was observed sitting on the floor in room (number) (NOTE: not Resident #34's room), no apparent injury noted . The care plan was reviewed at approximately 7:00 p.m. and contained the following focus area: Exit seeking/elopement risk multiple attempts to leave facility related to: cognitive impairment, new admission/change of environment. Interventions listed included: Accompany to meals and scheduled activities; ALERT BRACELET; Calmly redirect; Engage in activities/tasks to keep occupied An additional focus area for: At risk for falls due to history of fall, recent fall, non steady gait, not using safe judgement D/T dementia disease process was observed on the care plan. Interventions included: Administer Calcium and Vitamin D per protocol; Administer medication per physician orders; All intervention reviewed and continue with plan of care; Bed in low position; Encourage resident to sit in front of nursing station; have commonly used articles within easy reach; Reinforce w/c safety as needed such as locking brakes; visual monitoring as resident allows; FALL RISK (FYI); Reinforce need to call for assistance. On 02/06/2019 at approximately 7:50 a.m., the DON (director of nursing) was asked for any investigations/incident reports that had been completed on Resident #34 since her admission to the facility in (MONTH) (YEAR). The DON was also asked if the facility used bed or chair alarms. She stated, No. She was asked what the facility did to call attention to residents getting up unassisted who may fall. She stated, We make frequent rounds and care plan them for falls. At approximately 8:00 a.m., RN (registered nurse) #1, the unit manager, RN #6 and LPN (licensed practical nurse) #3 were interviewed regarding Resident #34's wandering, falls, and falls with injury. All three were asked what was done by the facility staff to prevent her falls and injuries. RN #6 stated, On nights we bring her with us. LPN #3 and RN #1 were asked what was done during day shift. LPN #3 stated, We have a care plan that we follow. Concerns were voiced to RN #1 and LPN #3 that while the survey team had been in the building, staff had not been readily available on that end of the hallway. Observations of staff being at the far end of the floor when needed was voiced. Concern over the visualization of Resident #34 were also discussed. Resident #34's room was not visible from the nursing station. LPN #3 and RN #1 were asked how often Resident #34 was observed. RN #1 stated, Yes, I see what you are saying .I am new here, I will see what we can do. At approximately 1:45 p.m., Resident #34 was sitting in her room. Her daughter was at her bedside. The daughter was interviewed regarding Resident #34's care at the facility. The topic of Resident #34's falls were discussed. The daughter stated, They talked to me just now about moving her to a room where they can see her better .my mother needs to be in a private room or she messes with other peoples things .the problem isn't her room, the problem is the staff is never down here where she is .they don't watch her .I always have to look for them when she needs something .the only time she is watched is when I am here .she can't go home with me because my home has steps, and she is less safe there. At approximately 3:20 p.m., after multiple requests, the DON presented incident reports for Resident #34 and they were reviewed. The DON was interviewed regarding staff interventions to supervise Resident #34. The first elopement of Resident #34 on 05/23/2018 when she was found lying in front of the nurse's station on a different floor was discussed. The DON stated, That's when we implemented the wander guard. The DON was informed that the wander guard was not implemented until Resident #34 was found in the back of the facility parking lot on 05/26/2018. She was asked if the wander guard should have been implemented when the resident was found on another floor of the facility after falling She stated, Yes, I would think so. Resident #34's fall with fracture, fall with laceration requiring sutures, and the fracture of her finger were discussed. The DON was asked if she felt the interventions on the care plan were sufficient to supervise and prevent Resident #34 from falling. She stated, We have an opportunity to increase her supervision .the car

Based on staff interview, clinical record and complaint investigation the facility staff failed to perform skin assessments for the prevention of a pressure sore for one of 27 residents in the survey sample. Facility staff failed to provide documented skin assessments for Resident #22 for twelve days following a re-admission to the facility. The resident was then found with a stage III pressure ulcer on her coccyx (harm). The pressure sore developed necrotic tissue, a foul odor and was assessed as a stage IV pressure sore prior to the resident's discharge from the facility. The findings include: The National Pressure Ulcer Advisory Panel (NPUAP) defines a pressure ulcer as localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear. The NPUAP defines a stage III pressure ulcer as, Full thickness skin loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. The depth of a Category/Stage III pressure ulcer varies by anatomical location. Bone/tendon is not visible or directly palpable. The NPUAP defines a stage IV pressure ulcer as, Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present. Often includes undermining and tunneling .Exposed bone/muscle is visible or directly palpable. The NPUAP defines an unstageable pressure ulcer as, Full thickness tissue loss in which actual depth of the ulcer is completely obscured by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Until enough slough and/or eschar are removed to expose the base of the wound, the true depth cannot be determined, but it will be either a Category/Stage III or IV. (1) Resident #22 was admitted to the facility on [DATE], readmitted on [DATE] and was discharged on [DATE]. [DIAGNOSES REDACTED]. The minimum data set ((MDS) dated [DATE] assessed Resident #22 as cognitively intact. This MDS assessed Resident #22 to require the extensive assistance of one person for transfers and bed mobility. Resident #22's closed clinical record was reviewed on 8/5/15. The record documented no skin assessments for Resident #22 from 2/24/15 until 3/9/15 when the resident was assessed with [REDACTED]. Resident #22's treatment record indicated a body audit was completed on 3/2/15 but the record documented no assessment associated with this audit. The resident was at the hospital for almost nine hours on 3/4/15 for a blood transfusion. No skin assessment was conducted upon the resident's return to the facility. Five days later (3/9/15) the resident was assessed with [REDACTED]. The record initially assessed the resident's coccyx wound as a stage III pressure sore. Additional assessments described the wound as unstageable due to the presence of slough. The wound developed necrotic tissue, a foul odor and was later assessed by a physician as a stage IV pressure sore. Resident #22's closed clinical record documented the resident was admitted on [DATE] with non blanchable redness to both of her heels but no other pressure areas. Nursing notes documented the redness to the left heel was resolved on 2/7/15. A readmission nursing assessment dated [DATE] listed the resident had nephrostomy tubes on her right/left side, a suprapubic pubic catheter but no other areas of skin breakdown. A nursing note dated 2/24/15 stated, .patient noted with her skin to be intact, no areas of impaired skin noted .she is on a pressure reducing mattress. Resident #22 was assessed by the facility as a low risk for pressure sore development with use of the Braden Scale for Predicting Pressure Sore Risk form. Resident #22's Braden assessments prior to 3/9/15 documented the following. 2/24/15 - Score of 17 (low risk) - Resident assessed with [REDACTED]. Complete lifting without sliding against sheets is impossible. Frequently slides down in bed or chair, requiring frequent repositioning with maximum assistance . 3/3/15 - Score of 17 (low risk) - Resident assessed with [REDACTED]. During a move skin probably slides to some extent against sheets, chair .occasionally slides down. The resident's plan of care (print date 8/5/15) listed the resident was assessed upon admission to be at risk for skin breakdown. The care plan entry dated 2/3/15 stated, At risk for alteration in skin integrity related to impaired mobility. Interventions listed were, Encourage to reposition as needed; use assistive devices as needed .Observe skin condition with ADL care daily; report abnormalities .Provide preventative skin care routinely and prn (as needed). Other than resolved entries related to the resident's red heels upon admission, there were no updates/revisions regarding pressure sore prevention until the development of the coccyx pressure sore on 3/9/15. The record documented the resident was assessed on 3/9/15 with a stage III pressure sore on her coccyx approximately 2 inches long and 2 inches width with no depth listed. A nursing note dated 3/9/15 stated, Writer was notified by nursing assistant that patient had skin impairment noted during ADL (activities of daily living) care this AM. Upon assessment with RN (registered nurse) manager of 3rd floor patient with stage 3 (III) wound to her coccyx that measures 5 cm (centimeters) x 5 cm with 80% slough present with scant amount of serous drainage present and 20% of [MEDICATION NAME] tissue present. Wound was cleaned with normal saline, pat dry, with Santyl applied to wound bed, skin prep to periwound with Allevyn sacrum dressing applied to wound. M.D .informed of wound with treatment plan in place. Order will be for Santyl twice per day for wound healing .She was changed to a Roho wheelchair cushion from a regular foam cushion .Head to toe assessment completed she is noted with bilateral nephrostomy tubes, suprapubic cath (catheter), coccyx wound, and bilateral lower extremity [MEDICAL CONDITION]. No other impairments noted during the assessment .She spends most of the time in her wheelchair during the day, uses a walker for ambulation transfers . A pressure ulcer record dated 3/9/15 documented, Coccyx wound measure 5 cm x 5 cm with 80% slough present with scant amount of serous drainage with 20% [MEDICATION NAME] tissue present. Periwound skin is intact with blanchable redness present. This record documented Resident #22's risk factors as resident required staff assistance to move, narcotic use, cancer/terminal illness, decreased sensory perception, newly admitted /readmitted and head of bed elevated most of the time. A note documented on this form stated, Patient had appointment .for recent blood transfusion on 3/4/15 she was picked up .at 7:10 a.m. to be transported to hospital via stretcher. She arrived at hospital .at 8:06 am. She returned to facility at 4 pm on 3/4/15 via stretcher. Additional nursing notes listed Resident #22's pressure sore as unstageable and with a foul odor. Pressure ulcer tracking records listed the wound developed necrotic tissue with heavy exudate and was later assessed by a physician as a stage IV pressure sore. The clinical record documented the following regarding the progress of Resident's coccyx pressure sore after 3/9/15. 3/10/15 - Late entry for 3/9/15 for clarification. Wound is unstageable. Wound bed is 80% slough. 3/12/15 - Body audit done no new skin alteration noted continue with treatment on coccyx done as ordered . 3/12/15 - .Body audit done no new skin alteration, continue with treatment on coccyx done as ordered well tolerated Pain management in progress . 3/17/15 - Patient followed up by wound team today, wound to her coccyx measures 3.5 cm x 6 cm with 80% slough present with moderate amount of serosanguineous drainage present and 20% of [MEDICATION NAME] tissue present with edges macerated .braden score is a 17 . Head to toe assessment completed she is noted with bilateral nephrostomy tubes, suprapubic cath, and bilateral lower extremity [MEDICAL CONDITION]. No other impairments noted during the assessment . 3/20/15 - .wound care done it have drainage but no blood noted, it is very hard to touch .no new skin alteration noted. (sic) 3/21/15 - .Body audit done no new skin alteration noted continues with treatment order . 3/24/15 - patient followed up by wound team today, wound to her coccyx measures 7 cm x 10.5 cm x 2 cm depth with 3.5 cm tunnelling (tunneling) at 6 o'clock with 100% slough present with heavy amount of serosanguineous drainage present edges macerated, wound noted with foul odor present. Wound was cleaned with Dakins saline, pat dry, with Santyl applied to wound bed, skin prep to periwound with Allevyn Sacrum dressing applied to wound. Head to toe assessment completed during wound round with increased [MEDICAL CONDITION] noted to her bilateral lower extremities . (sic) Resident #22's pressure ulcer healing chart for the coccyx wound documented the following assessments according to the pressure ulcer scale for healing (PUSH) scoring system. 3/9/14 - slough present with light amount of exudate, length x width > 24.0 square cm 3/17/15 - necrotic tissue with moderate amount of exudate, length x width > 24.0 square cm 3/24/15 - slough present with heavy amount of exudate, length x width > 24.0 square cm A physician's progress note dated 3/17/15 documented the resident had an unstageable wound to the coccyx area with instructions to apply a Santyl wet to dry dressing daily. A physician's progress note dated 3/25/15 stated, Internal Medicine Follow-up .Stage IV large coccyx ulcer: Patient is wheelchair bound with extensive medical hx (history) with advanced Endometrial CA (cancer) - now has a large sacral pressure wound of difficult management due to lack of mobility and nutritional deficits . An undated addendum to this note stated, Pt (patient) very weak at extreme risk for breakdown at any site. Her coccygeal area decubiti was preempted by poor muscle condition .and nine hours of being on a stretcher/gurney while at (hospital) ED (emergency department) . The record documented the resident was out of the facility at a hospital on [DATE] from 7:10 a.m. until 4:00 p.m. getting a blood transfusion. There was no record of a skin assessment upon the resident's return from the blood transfusion on 3/4/15. A note dated 3/4/15 at 7:26 p.m. listed an assessment of the resident's vital signs and general condition but included no assessment of her skin. The note documented, Patient as alert and oriented x 3, returned from blood transfusion this pm in stable condition, no reaction noted at this time. All pm and pain medication administered as ordered well tolerated. One staff assist with ADL care and transferred to bed . Five days later on 3/9/15 the resident was assessed with [REDACTED]. The record documented a physician's orders [REDACTED]. After the readmission assessment dated [DATE] there was no further mention of the resident's skin until 3/9/15 when the resident was assessed with [REDACTED]. A nurse signed off the resident's treatment record on 3/2/15 indicating a body audit was completed but there was no documentation of this assessment in the record. Skin worksheets completed by the certified nurses' aides during ADL care dated 3/2/15 and 3/5/15 identified the resident's skin was Abnormal. Two areas were marked on the sheet's body diagram on the resident's right/left lower back area. The form stated, Check Abnormal if: broken, bruised or reddened areas. There were no nursing assessments regarding either of these skin worksheets identifying or describing the abnormal skin areas. On 8/6/15 at 8:25 a.m. the licensed practical nurse (LPN #4) that cared for Resident #22 during her stay was interviewed about skin assessments. LPN #4 stated she did not remember Resident #22. Concerning skin assessments, LPN #4 stated weekly skin assessments were supposed to be done on all residents. LPN #4 stated, If you see anything wrong you report to wound team and make a note. Concerning skin assessments not showing any impairment, LPN #4 stated, You make a note everything is ok. LPN #4 stated certified nurses' aide (CNAs) filled out shower sheets for each resident on shower days indicating if there were any problem skin areas and these sheets were reviewed by the nurses. On 8/6/15 at 8:30 a.m. CNA #2 that worked on Resident #22's nursing unit during the resident's stay was interviewed. CNA #2 stated she did not remember anything about Resident #22 or her skin. CNA #2 stated, Too many residents. I don't remember. On 8/6/15 at 9:50 a.m. the director of nursing (DON) was interviewed about any skin assessments in the days prior to Resident #22's coccyx pressure sore. When asked if she had any skin assessments for Resident #22 between 2/24/15 until 3/9/15, the DON stated, No. We do not. The DON stated they conducted an investigation after the pressure sore was found on 3/9/15. The DON stated the outcome of their investigation was the resident had lots of co-morbidities and spent a long time on a stretcher when in the hospital on [DATE] for the blood transfusion. The DON stated nurses did not conduct a skin assessment when the resident returned from the hospital on [DATE] until the report of the pressure ulcer on 3/9/15. The DON stated skin assessments were routinely done on readmissions to the facility but they did not consider Resident #22's day at the hospital for the blood transfusion a readmission. The DON stated marked areas of skin impairment on the CNA skin sheets dated 3/2/15 and 3/5/15 were probably the resident's nephrostomy tubes. The DON did not present any nursing assessments related to the CNA shower sheets showing an assessment identifying these areas as the nephrostomy tubes. When asked what could have been done in attempt to prevent/minimize Resident #22's pressure sore, the DON stated, Assessment before and after she (Resident #22) went out. On 8/6/15 at 10:55 a.m. the licensed practical nurse (LPN #3) unit manager was interviewed about Resident #22. LPN #3 stated if skin impairments were found an incident sheet was completed, the physician was contacted for treatment orders and the wound was then tracked weekly by the wound team. When asked if routine skin assessments included a description/assessment of the skin (color, appearance, presence of pain or moisture), LPN #3 stated, We are not doing that. LPN #3 stated nurses initialed the treatment records indicating a skin assessment was done but did not make notes regarding the assessments unless there was impairment. Other than the treatment record initialed by a nurse on 3/2/15, LPN #3 did not present any evidence of a documented skin assessment from 2/24/15 until 3/9/15 when the pressure sore was found. The Prevention and treatment of [REDACTED].Educate health professionals on how to undertake a comprehensive skin assessment that includes the techniques for identifying blanching response, localized heat, [MEDICAL CONDITION], and induration .In individuals at risk of pressure ulcers, conduct a comprehensive skin assessment: as soon as possible but within eight hours of admission, as part of every risk assessment, ongoing based on the clinical setting and the individual's degree of risk and prior to the individual's discharge .Increase the frequency of skin assessment in response to any deterioration in overall condition .Document the findings of all comprehensive skin assessments .Ongoing assessment of the skin is necessary in order to detect early signs of pressure damage, especially over bony prominences .Include the following factors in every skin assessment: skin temperature; [MEDICAL CONDITION]; and change in tissue consistency in relation to surrounding tissue .Assess localized pain as part of every skin assessment. When the individual is able to respond reliably, ask him or her to identify any areas of discomfort or pain that could be attributed to pressure damage . (2) These findings were reviewed with the administrator, director of nursing and assistant administrator during a review meeting on 8/6/15 at 9:50 a.m. This was a complaint deficiency. (1) NPUAP Pressure Ulcer Stages/Categories. National Pressure Ulcer Advisory Panel. 8/8/15. <http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-ulcer-stagescategories/> (2) National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel and Pan Pacific Pressure Injury Alliance. Prevention and treatment of [REDACTED]. Emily Haesler (Ed.). Cambridge Media: Perth, Australia; 2014.