Every finding on record at Cascadia of Boise

Based on resident interviews, representative interviews, staff interviews, observations, review of grievances, and review of the three-week nursing schedule, it was determined the facility failed to ensure sufficient staffing was available to meet resident needs according to their plan of care. This failure had the potential to affect all residents residing in the facility if staff were not available to ensure resident needs and safety measures were provided. Findings include: The National Academies of Sciences, Engineering, and Medicine (NASEM) website accessed on 5/13/26, article titled The National Imperative to Improve Nursing Home Quality (2022) documents, inadequate staffing contributes to delayed care, missed care tasks, and reduced resident safety. Staffing must be aligned with resident acuity, not just minimum numbers.A review of facility Grievance Forms, dated 10/3/25 through 5/4/26, showed multiple concerns reported by residents and their representatives related to call light response times, delayed care, untimely medication administration, staff attitude, and unmet care needs. The facility's investigations confirmed the allegations in the majority of grievances reviewed. Examples include: -10/3/25: A resident's representative reported staff were not rounding every two hours and the resident was frequently wet, and anti diarrheal medication was not provided timely. The investigation confirmed residents were not being changed timely. -10/6/25: A resident's representative reported staff were not changing the resident's clothing, not giving medications on time, and not positioning the resident during meals. The investigation confirmed the allegation. -10/23/25: A resident reported long wait times for pain medication. The investigation confirmed the allegation. -10/31/25: A resident's representative reported a call light was activated at 4:54 PM for incontinence care; direct care staff were not able to provide care until 6:22 PM. The grievance did not include an investigation. -10/31/25: A resident's representative reported the resident was not prepared in time for a family function. The investigation confirmed the allegation. -11/11/25: A resident's representative reported long call light response times and staff attitude concerns. The investigation confirmed the allegation; however, the investigation did not address the long call light response time. -11/18/25: A resident reported staff were not checking on her during the night or when family was present. The investigation confirmed the allegation. -12/1/25: A resident's representative reported medication was provided at 6:30 PM and staff tone was inappropriate. The investigation confirmed the allegation. -12/1/25: A resident's representative reported staff were not responding to call lights quickly enough to prevent the resident from soiling himself. The investigation confirmed the allegation. -12/2/25: A resident's representative reported call light response times of 30-40 minutes. The investigation confirmed the allegation. -12/4/25: A resident's family reported staff were not responding to call lights. The investigation confirmed the allegation.-12/16/25: A resident's family reported delayed call light response, staff cell phone use, missed medication coordination, unclean room conditions, and cold meals. The investigation confirmed the allegation. The family transferred the resident to another facility.-12/23/25: A resident's family reported delayed call light response, staff phone usage, and unmet ADL needs. The investigation confirmed the allegation. On 12/26/25, the family requested the resident be transferred.-1/6/26: A resident's physician reported wound maceration and that the resident's incontinence brief was saturated with urine. The investigation confirmed the allegation.-1/14/26: A resident reported long call light wait times. The investigation confirmed the allegation.-1/14/26: A resident reported long call light response times and staff attitude concerns. The investigation confirmed the allegation. The resident was later sent to the emergency room and did not return.-2/20/26: A resident reported staff attitude concerns and delayed call light response. The investigation confirmed the allegation. -3/17/26: A resident reported long call light wait times during morning and night shifts. The investigation confirmed the allegation.-3/18/26: A resident's representative reported staff turned off the resident's call light without providing care and returned an hour later. The investigation confirmed the allegation. -3/23/26: A resident's representative reported long call light wait times. The investigation confirmed the allegation. -4/7/26: A resident reported their call light was on for two hours. The investigation confirmed the allegation.-4/9/26: A resident's representative reported long call light wait times during the day shift. The investigation confirmed the allegation. -4/18/26: A resident reported concerns with call light response. The investigation confirmed the allegation.-4/27/26: A resident and family reported the facility was not answering the doorbell or phones on weekends and call light response was delayed. The investigation confirmed the allegation.-5/1/26: A resident reported long call light response times and lack of follow through on requests. The investigation confirmed the allegation.-5/4/26: A resident's representative reported delayed call light response over the weekend. The investigation confirmed the allegation.A review of Resident Council Meeting minutes dated October 2025 through February 2026 showed residents repeatedly voiced concerns related to call light response times and staff attitude. Examples include:-October 2025: Residents voiced concerns regarding call light wait times and staff attitude.-November 2025: Residents voiced concerns regarding call light wait times.-December 2025: Residents voiced concerns regarding the length of call light response times.-January 2026: Residents voiced concerns regarding call light wait times, particularly during evening hours, and concerns regarding staff attitude.-February 2026: Residents voiced concerns regarding night shift call light response times.-March-May 2026: Resident Council Meeting minutes were not available for review.A review of the three week facility staffing schedule dated 4/19/26 through 5/9/26 documented consistently lower staffing hours on weekends compared to weekdays, as follows:Week 1- 4/19/26 (Sunday): Census 92 - Staffing hours: 297.9- 4/20/26 (Monday): Census 91 - Staffing hours: 343.6- 4/21/26 (Tuesday): Census 92 - Staffing hours: 401- 4/22/26 (Wednesday): Census 94 - Staffing hours: 370- 4/23/26 (Thursday): Census 97 - Staffing hours: 402.8- 4/24/26 (Friday): Census 98 - Staffing hours: 395.1- 4/25/26 (Saturday): Census 99 - Staffing hours: 312.5Week 2- 4/26/26 (Sunday): Census 99 - Staffing hours: 318- 4/27/26 (Monday): Census 96 - Staffing hours: 396- 4/28/26 (Tuesday): Census 97 - Staffing hours: 384.1- 4/29/26 (Wednesday): Census 96 - Staffing hours: 370- 4/30/26 (Thursday): Census 92 - Staffing hours: 367.9- 5/1/26 (Friday): Census 92 - Staffing hours: 367.9- 5/2/26 (Saturday): Census 93 - Staffing hours: 314Week 3- 5/3/26 (Sunday): Census 93 - Staffing hours: 328.6- 5/4/26 (Monday): Census 93 - Staffing hours: 368.6- 5/5/26 (Tuesday): Census 96 - Staffing hours: 399.5- 5/6/26 (Wednesday): Census 94 - Staffing hours: 378.7- 5/7/26 (Thursday): Census 94 - Staffing hours: 385.4- 5/8/26 (Friday): Census 93 - Staffing hours: 379- 5/9/26 (Saturday): Census 91 - Staffing hours: 329.4On 5/12/26 at 4:42 PM, the CEO stated the census on the skilled side was the highest it has ever been and the increase in grievances has gone up.On 5/13/26 at 9:57 AM, Resident #25's representative stated weekends were kind of dead, and the resident reported it was like a ghost town. She stated she keeps a record of concerns and, upon arriving that morning, found Resident #25 soaked in urine, shivering, and wearing only an incontinence brief. She stated, They don't have enough staff.On 5/13/26 at 10:27 AM, CNA #1 stated, Night shift has been a challenge, and reported working multiple shifts until additional staff could be trained and hired. CNA #1 stated they encourage residents to voice concerns during Resident Council meetings if they feel they are not receiving enough help.On 5/13/26 at 10:36 AM, it was observed that a resident's representative asked staff if the resident could receive a shower that day.On 5/13/26 at 10:40 AM, RN #1 stated staffing could be better and reported that recent Medicaid cuts resulted in the facility reducing one nurse position and some CNA positions. RN #1 stated the facility had begun slowly reinstating positions due to workload needs. On 5/13/26 at 11:55 AM, the CEO stated staffing is based on the needs and acuity of the patients and appropriate staff are assigned; however, there are two-unit managers during the week and a wound nurse on Tuesdays whose hours are accounted for during the week. On weekends we have one unit manager.

Based on record review, policy review, and staff interviews, it was determined the facility failed to notify a resident's representative of an accident. This was true for 1 of 3 residents (Resident #20) reviewed for notifications. This deficient practice had the potential to prevent Resident #20 and/or their representative from making timely and informed decisions regarding the resident's medical care. Findings include: The Facility's Fall Response & Management policy, revised 8/21/25, documented facility will notify the provider and resident representative if a resident sustains a fall.Resident #20 was readmitted to the facility on [DATE] with multiple diagnoses including Alzheimer's, dementia, anxiety, kidney disease, and diabetes.The fall report dated 12/16/25, documented Resident #20 was found face down on the floor next to her bed. Upon examination, Resident #20 had a significant bump to the back of the right side of her head and small red mark under her right eye. The I&A report dated 12/16/25, identified Resident #20's representative was not notified. On 5/12/26 at 5:03 PM, the CNO confirmed Resident #20's representative had not been notified of her fall and he should have been.

Based on record review and staff interview, it was determined the facility failed to follow the physician's order to monitor urinary output. This was true for 1 of 3 residents (Resident #4) whose bowel and bladder records were reviewed. This deficient practice had the potential to affect Resident #4's hydration status when physician ordered monitoring was not completed. Findings include:Resident #4 was admitted to the facility on [DATE] with multiple diagnoses including quadriplegia (the partial or total paralysis of all four limbs, both arms and both legs, and the torso), epilepsy, and retention of urine.A physician's order initiated 4/24/25 and revised on 1/20/26, documented to measure and record output for Resident #4's indwelling urinary catheter every shift for hydration management.A review of Resident #4's Medication Administration Record (MAR) and Treatment Administration Record (TAR) for the months of October 2025 through April 2026 showed the physician ordered monitoring of urinary output was not consistently documented. The following missed opportunities were identified:- October 2025: 9 of 58 opportunities were blank- November 2025: 11 of 60 opportunities were blank- December 2025: 6 of 54 opportunities were blank- February 2026: 3 of 54 opportunities were blank- March 2026: 4 of 62 opportunities were blank- April 2026: 6 of 54 opportunities were blankOn 5/12/26 at 4:25 PM, on review of Resident #4's record, the CNO confirmed urinary output was not recorded.

Based on observation, the Food Drug Administration (FDA) Food Code, and staff interview, it was determined the facility failed to ensure ice machines were cleaned, and resident freezers were not contaminated by non-food items, or undated, opened food. These deficiencies had the potential to affect the 70 residents who consumed food prepared by the facility. This placed residents at risk for potential contamination of food and adverse health outcomes, including food-borne illnesses. Findings include: 1. The FDA Food Code Section 3-501.17 Ready-to-Eat, TCS (time/temperature control for safety) food, date marking, states marking the date or day the original container is opened in a food establishment, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded.On 9/26/25 at 12:08 PM, it was observed in the Alpine Resident freezer, undated lemon ices, a frozen yogurt, and a frozen entree meal were not labeled with the resident's name or dated. A therapy ice pack was wrapped in a pillowcase and stored on the top shelf of the freezer.On 9/26/25 at 12:10 PM, RN#2 stated the pillowcase wrapped ice pack should not be in the food freezer. When asked if he was aware the freezer & frozen food was now contaminated, RN #2 stated the freezer food was contaminated and it would get thrown away. On 9/26/2025 at 12:14 PM, the CDM was unaware resident's spouses were storing non-food items in the resident's freezer as there is a resident food policy in all admission packets. She agreed the freezer would need to be clean and sanitized, with the resident's food thrown away. 2. The FDA Food Code Section 4-602.11 Equipment Food-Contact Surfaces and Utensils documented surfaces of utensils and equipment contacting food that is not time/temperature control for food shall be cleaned.On 9/22/25 at 10:50 AM, the ice machine in the kitchen was observed to have a dark residue on the interior portion of the white plastic ice separator.On 9/22/25 at 10:55 AM, the RD identified the same dark residue and stated the ice machines are cleaned quarterly. She was not sure why the machine did not appear to be cleaned.On 9/22/25 at 11:35 PM, it was observed in the Alpine ice room, the ice machine had a dark resident on the interior portion of the white place ice separator.On 9/22/25 at 11:37 PM, RN #2 identified the same dark residue and stated the ice machines are cleaned regularly, but he was not sure when it had last been cleaned.

Based on record review and staff interview, it was determined the facility failed to ensure residents' Minimum Data Set (MDS a standardized assessment tool that measures health status in nursing home residents) Assessments were accurate. This was true for 3 of 6 residents (#5, #16, and #59) whose MDS assessment records were reviewed for accuracy. This deficient practice created the potential for negative outcomes if residents were not assessed and/or monitored due to assessment inaccuracies'. Findings include: 1. Resident #5 was admitted to the facility on [DATE] with multiple diagnoses including chronic respiratory failure, anxiety disorder, panic disorder, and depression. Resident #5's PASRR Level I, dated 6/26/23, documented, in Section I at #1, diagnoses of depressive disorders and anxiety disorders, and at #3, panic disorder. Resident #5's PASRR Level II, dated 7/20/26, documented, in Section IX at #33, Individual has a current diagnosis of sever mental illness per PASRR criteria: Depression, Anxiety, Panic Disorder. Resident #5's Annual MDS assessment dated [DATE], documented under A1500 in Section A, the question, Is the resident currently considered by the state level II PASRR process to have a serious mental illness and/or intellectual disability or a related condition? was answered no. On 9/24/25 at 5:45 PM, the MDS Nurse stated his understanding was if the PASRR level II had box 36 checked and no additional services were recommended then Resident #5 was considered not reviewed for a level II PASRR, on review of Resident #5's Annual MDS dated [DATE] the MDS Nurse stated her assessment was inaccurate. 2. Resident #16 was admitted to the facility on [DATE] with multiple diagnoses including spastic quadriplegic cerebral palsy (paralysis of all four limbs with muscle stiffness due to brain damage at birth or abnormal development), chronic respiratory failure, and epilepsy. Resident #16's PASRR Level I, dated 1/10/25, documented at Section IV, #15, Does the individual have a diagnosis of intellectual disability (ID) - An intellectual disability is evidenced by an IQ of less than 70 based on standardized, reliable tests; onset before age [AGE]? answered yes, at birth cerebral palsy and developmental delay. Resident #16's Admissions MDS assessment dated [DATE], documented under A1500 in Section A, the question, Is the resident currently considered by the state level II PASRR process to have a serious mental illness and/or intellectual disability or a related condition? was answered no. On 9/24/25 at 5:49 PM, the MDS Nurse stated, Resident #16's Admissions MDS assessment was inaccurate due to his diagnosed intellectual disability. 3. Resident #59 was admitted to the facility on [DATE], with multiple diagnoses including quadriplegia (paralysis that affects the ability to voluntarily move the upper and lower body), depression and anxiety. Resident #59's comprehensive MDS assessment dated [DATE], documented under A1500 in Section A, no for the questions, Is the resident currently considered by the state level II PASRR process to have a serious mental illness and/or intellectual disability or a related condition? Resident 59's electronical record included documentation of a PASRR level II dated 9/12/25, documenting Resident #59 was considered to have a severe mental illness. On 9/24/25 at 5:42 PM, the MDS Nurse stated his understanding was if the PASRR level II had box 36 checked and no additional services were recommended then Resident #59 was considered not reviewed for a level II PASRR, on review of Resident #59's Comprehensive MDS dated [DATE] the MDS Nurse acknowledged it was inaccurately completed.

Based on record review and staff interview it was determined the facility failed to ensure residents' care plans were revised according to their post fall needs. This was true for 1 of 22 residents (Resident #33) whose records were reviewed for care plan timing and revision. This deficient practice created the potential for harm when residents' needs were not identified and or met. Findings include:Resident #33 was admitted to the facility on [DATE] with multiple diagnoses including a broken right leg, difficulty walking, muscle weakness, Alzheimer's disease, and dementia.On 9/22/25 at 5:28 PM, Resident #33's representative stated her mom had fallen out of bed a few times as she is a restless sleeper and was on a new mattress. Resident #33's representative stated fall precautions had been put into place. There was a floor pad placed, and Resident #33's bed was in the lowest position while she was in bed.An Incident & Accident (I&A) fall report, dated 8/21/25, documented an unwitnessed fall with Resident #33. She was laying on right side and in noted distress. The report further documented an Interdisciplinary (IDT) review, dated 8/22/25, documented Resident #33 did not have an injury related to her fall and that she would be out of the room when in her wheelchair. The fall report documented a fall assessment was completed, on 8/21/25, where the intervention to prevent a future fall would be a fall mat. A Post Fall Evaluation, dated 8/21/25, documented Resident #3 had an unwitnessed fall and was found on the floor within one (1) foot of her bed. At the time of the fall, Resident #33 had gripper socks on her feet and a fall mat assistive device.A review of Resident #33's care plan documented the following fall risk precautions:Door of room open as resident will allow, initiated 7/25/25. Keep adjustable bed in position for safe transfers. Lock bed brakes initiated 7/25/25. Out of room when up in wheelchair, initiated on 8/22/25. From 9/22/25 through 9/25/25, a fall mat was observed on the floor near Resident #33's bed. When Resident #33 was in bed, the bed was in the lowest position. Resident #33 was in the main dining room area when up in her wheelchair, and her door was open most of the time, except during cares.On 9/25/25 at 3:21 PM, the CRN stated the fall mat was not in Resident #33's care plan. She further stated if the fall mat is in Resident #33's room, it should be on her care plan.

Based on observation, record review, interview and Insulin Lispro website, it was determined the facility failed to ensure residents' medications were administered according to professional standards of practice. This was true for 1 of 2 residents (Resident #36) whose insulin administration was observed. This failed practice created the potential for Resident #36 experience low or high blood sugar if she receives an incorrect amount of insulin. Findings include:Resident #36 was admitted to the facility on [DATE] and readmitted on [DATE], with multiple diagnoses including diabetes.A physician's order, dated 9/2/25 documented Resident #36 was to receive Insulin Lispro 100 unit/ml, inject two units subcutaneously (under the skin) before meals for diabetes management.On 9/24/25 at 11:58 AM, RN #3 took the Insulin Lispro pen, removed the needle, sanitized the tip of the insulin pen, placed a new needle and dialed the pen to two units. RN #1 stated she did not prime the needle because it was an old pen, if it was a new pen then she would prime it. On 9/24/25 at 4:45 PM, the Acting DON stated the insulin pen should be primed before each administration.The Insulin Lispro website, accessed on 9/29/25 stated, priming your insulin pen means removing the air from the needle and cartridge that may collect during normal use and ensures that the pen is working correctly. If you do not prime before each injection, you may get too much or too little insulin.

Based on record review and staff interview it was determined the facility failed to ensure professional standards of practiced were followed. This was true for 3 of 22 residents (#6, #7, and #58) reviewed for following physician's orders. This deficient practice created the potential for harm if the facility failed to follow physician's orders and if resident's experienced complications related to catheter placement and care, and hypoglycemia (a condition in which blood glucose (BG, sugar) falls below normal.) Findings include: 1.Resident #7 was admitted to the facility on [DATE] with multiple diagnoses including diabetes. A physician's order, dated 8/22/25, directed staff to check blood glucose for hypoglycemic (low blood sugar) and/or hyperglycemic (high blood sugar) symptoms. If blood sugar (BG) is less than 70 initiate hypoglycemic protocol and notify MD as indicated. If BG is greater than 400 notify MD and follow directives. A physician's order, dated 8/20/2025, documented staff provide: Gvoke HypoPen 1-Pack Solution Auto-injector 1 mg/0.2 ml (Glucagon; medically used to treat very low blood sugar.) Inject 1 mg subcutaneously as needed for blood sugar less than 70 mg/dl and unable to swallow. Take dose from E-kit .Give 1mg of Gvoke, recheck in 15 minutes. If no improvement, notify the MD immediately. If improving, may repeat. Recheck BG in 15 minutes and Inject 1 mg subcutaneously as needed for blood sugar less than 70 mg/dl and unable to swallow Take dose from E-kit .Give 1 mg of Gvoke, recheck in 15 minutes. If no improvement notify the MD immediately. If improving, may repeat. Recheck BG in 15 minutes Resident #7's medical record documented a BG of 50 mg/dL. A second BG was not taken and recorded as ordered by the physician. On 9/25/25 at 4:29 PM, CRN stated the staff in question did not follow the hypoglycemic protocol to retake a BG 15 minutes later if levels were below 70 mg/dl. 2.Resident #58 was admitted to the facility on [DATE] and readmitted on [DATE] with multiple diagnoses including amyotrophic lateral sclerosis (a progressive neurodegenerative disease that affects nerve cells in the brain and spinal cord, leading to muscle weakness and paralysis), acute and chronic respiratory failure with hypoxia (low levels of oxygen in the body's tissue) and encounter for attention to tracheostomy. On 9/23/25 at 10:56 AM, 9/24/25 at 8:23 AM and 9/25/25 at 10:58 AM, Resident #58 was observed to have a urinary catheter. Review of Resident #58's physician's order did not include an order for urinary catheter. On 9/24/25 at 3:45 PM, when asked about Resident #58's urinary catheter, the Acting DON stated the facility would review physician's order within 24 hours of admission of residents in the facility. The Acting DON stated Resident #58 was readmitted to the facility on [DATE] and his physician's order was not updated due several admissions they had and unforeseen circumstances.

Based on record review and staff interview, it was determined the facility failed to ensure medication orders were clarified. This was true for 1 of 6 residents (Resident #87) whose records were reviewed for unnecessary medications. This failure placed Resident #87 at risk for over medication when her rescue seizure medication orders did not clearly direct their use. Findings include: Resident #87 was admitted the facility on 4/5/23 with multiple diagnoses including spastic quadriplegic cerebral palsy (characterized by stiff muscles and movement difficulties in all four limbs, the trunk, and the face due to early-life brain damage), a seizure disorder, and congenital hydrocephalus (a condition present at birth where excess cerebrospinal fluid (CSF) builds up in the brain, increasing pressure and potentially causing brain injury and developmental problems). Resident #87's medical record contained the following physician orders:Nayzilam Nasal Solution 5 MG/ 0.1 ML, Midazolam (benzodiazepine anticonvulsant), give 1 spray in 1 nostril as needed for seizure that lasts for more than 5 minutes or for more than 3 seizures in 24 hours, dated 7/13/23.Valtoco Nasal Liquid 5 MG/ 0.1 ML, Diazepam (benzodiazepine anticonvulsant), give 15 MG in 1 nostril as needed for seizure lasting 5 minutes or 2 seizures in 24 hours, dated 7/23/25. On 9/26/25 at 10:02 AM, the Acting DON stated, Resident #87's Nayzilam and Valtoco directions were not clear which medication should be given when they had a seizure and needed to be clarified to avoid medication error or over medication.

Based on record review and staff interview it was determined the facility failed to ensure resident's records contained accurate documentation related to their vital signs. This was true for 1of 22 residents (Resident #7) whose record was reviewed for accurate documentation. This deficient practice had the potential for adverse outcomes and harm if Resident #7's blood pressure was taken in an unsafe manner. Findings include:Resident #7 was admitted to the facility on [DATE] with multiple diagnoses including high blood pressure, end stage renal disease (ESRD), and dependence on renal dialysis.A physician's order, dated 8/20/25 and 8/26/25, documented, Check fistula sight to the Left arm for signs and symptoms of infection and if bruit or thrill present, enter = if present and - if not present. Enter NA if not applicable. Every shift for dialysis monitoring. A physician's order, dated 8/20/25, documented, Do NOT take blood pressure on Left arm.A review of blood pressure (BP) measurements documented BP was taken on the Left arm on the following dates: 9/1/25; 9/2/25; 9/6/25; 9/7/25; 9/9/25; 9/10/25; 9/15/25; 9/17/25; 9/22/25 8/20/25; 8/24/25; 8/26/25; 8/29/25; 8/30/25; 8/31/25On 9/25/25 at 10:40 AM RN #2 stated, nurses know not to take BP from a fistula arm. However, they may accidently record taking a BP on the left arm when they meant to document taking the BP on the right arm. This would be inaccurate documentation.

Based on observation, staff interviews, and review of Centers for Disease Control and Prevention (CDC) guidance, it was determined the facility failed to implement infection prevention and control practices to prevent cross-contamination for 2 of 2 Residents (Resident #85 and Resident #59) reviewed for infection control. This failure created the potential for adverse health outcomes, including infection. Findings include:The Centers for Disease Control and Prevention (CDC) web page titled, Clinical Safety: Hand Hygiene for Healthcare Workers, updated 2/27/24, documented hand hygiene should be performed:Immediately before touching a patient.Before performing aseptic task such a placing an indwelling catheter device or handling invasive medical device.Before moving from a soiled body site to a clean body site on the same patient.After touching a patient or patients' surroundings.After contact with blood, body fluids, or contaminated surfaces.Immediately after glove removal.1.Resident #85 was admitted to the facility on [DATE], with multiple diagnoses including respiratory failure, malnutrition, and seizures. On 9/25/25 at 12:03 PM, RT #2 was observed approaching the doorway to Resident #85's room, knocked on the door and entered the room, RT #2 walked up to the supply of personal protective equipment (PPE). She donned her gown, gloves, and mask. No hand hygiene was observed prior to donning her PPE. She then proceeded to approached Resident #85 to assist with cleaning the phlegm off his chest and to suction him. Upon completion of cares RT #2 was observed doffing her gown, gloves, and mask and performing hand hygiene. On 9/25/25 at 12:07 PM, RT #2 stated she should have performed hand hygiene before the application of her PPE. 2.Resident #59 was admitted to the facility on [DATE], with multiple diagnoses including quadriplegia (paralysis that affects the ability to voluntarily move the upper and lower body), depression and anxiety. On 9/24/25 at 10:27 AM, during a wound care observation LPN #1 was observed took one skin prep pad and wiped Resident #59's right heel in a circular motion. She allowed it to dry and proceeds to wipe the left heel with the second skin prep pad in a circular motion. After allowing time for the left heel to dry LN #1 and CNA #1 assisted Resident #59 to reposition in a left lateral position. LN assisted Resident #59 with peri care, discarded the wipes and proceeded to take a gauze socked with normal saline and cleansed the open wound site. No glove change or hand hygiene was observed between peri care and wound care. LN applied venelex and attempted to place a dressing, which fell off. She used a skin prep pad to reattempt placement and later removed the dressing, stating she would return with a larger one. On 9/24/25 at 10:41 AM, LN stated she should have removed her gloves and performed hand hygiene when transitioning between body sites and after peri care. She also stated that a new order had been implemented to leave the wound site uncovered. 3. Resident #58 was admitted to the facility on [DATE] and readmitted on [DATE] with multiple diagnoses including amyotrophic lateral sclerosis (a progressive neurodegenerative disease that affects nerve cells in the brain and spinal cord, leading to muscle weakness and paralysis), acute and chronic respiratory failure with hypoxia (low levels of oxygen in the body's tissue) and encounter for attention to tracheostomy. On 9/22/25 at 3:19 PM. an Enhanced Barrier Precautions signage was observed posted at the entrance of Resident #58's room directing staff to wear gloves and a gown for the following high contact resident activities including device care or use such as tracheostomy (a surgical hole in the windpipe that helps with breathing when the usual way is blocked or reduced). On 9/25/25 at 11:19 AM, RT #1 with a gloved hand was observed suctioning Resident #58's endotracheal tube (a flexible tube inserted into the trachea [windpipe] to maintain an open airway and assist with breathing). RT #1 was not wearing a gown. On 9/25/25 at 11:23, RT #1 stated he should have worn a gown while suctioning Resident #58's endotracheal tube and he did not.

Based on record review, policy review, and staff interview, it was determined the facility failed develop a comprehensive resident-centered care plan. This was true for 1 of 21 residents (Resident #18) whose care plans were reviewed. This failure placed Resident #18 at risk of unmet care needs when he did not have a care plan for pneumonitis. Findings include: Review of the facility's Care Plans policy, dated 10/15/22 revealed, A comprehensive care plan is developed consistent with the residents' specific conditions, risks, needs, behaviors, cultural expectations, preferences and with standards of practice including measurable objectives, interventions/services, and timetables to meet the resident's needs as identified in the resident's assessment or as identified in relation to the resident's response to the interventions or changes in the resident's condition . Resident #18 was admitted to the facility on [DATE], with multiple diagnoses including paraplegia (paralysis of the legs and lower body) and diabetes mellitus. A quarterly MDS assessment, dated 5/24/24, documented Resident #18 was cognitively intact. A physician's order dated 5/23/24 documented the following laboratory request for Resident #18: complete blood count (CBC), comprehensive metabolic panel (CMP), and urinalysis (UA) with culture and sensitivity (C&S) A physician's assistant progress notes dated 5/23/24 documented Resident #18 had a diagnosis of pneumonitis versus urinary tract infection. Resident #18's record documented his UA result was negative for urinary tract infection. A nursing progress notes dated 5/23/23 documented Resident #18 had fever, elevated heart rate, and cough. An order was received for Resident #18 to receive intravenous fluids and Rocephin (antibiotic). Review of Resident #18's care plan revealed no documentation concerning these orders. During an interview on 8/6/24 at 4:12 PM, the MDS Nurse confirmed that a care plan should had been developed to reflect these new orders for Resident #18. During an interview on 8/6/24 at 4:12 PM, the DON confirmed that a care plan should have been updated with the change of condition on 5/23/24 when Resident #18 presented with a fever, cough and elevated heart rate.

Based on record review, policy review and interview, it was determined the facility failed to ensure medication orders were written accurately per current standards of practice. This was true for 2 of 21 residents (#52 and #710) whose physician's orders were reviewed. This failure created the potential for residents to receive the wrong dosage or receive the medication via the wrong route. Findings include: The facility's Eight Rights of Medication Administration policy, undated documented the following: right resident, right medication, right dose (confirm the appropriateness of the dose using a current drug reference), right route (confirm that the resident can take or receive the medication by the ordered route), right time, right documentation, right reason and right response. 1. Resident #71 was admitted to the facility on [DATE] with multiple diagnoses including tracheostomy (a surgically created hole in the windpipe for breathing), dementia, and gastrostomy (presence of surgical opening into the stomach for nutritional support). An admission MDS assessment dated [DATE], documented Resident #71 had a short term and long-term memory problems and severely impaired in decision making. Review of Resident #71's Physician Orders dated [DATE], documented Resident #71 was to received Depakote sprinkles 125 milligrams four capsules by mouth two times a day for seizures. Review of Resident #71's care plan dated [DATE], documented Resident #71 was NPO [nothing by mouth] and medications were administered in liquid or crushed forms and given by gravity as ordered by the physician. During an interview on [DATE] at 4:33 PM, LPN #1 stated, I gave the medication like I do all of his other meds [medicines], per the peg [percutaneous endoscopic gastronomy tube, feeding tube inserted through the skin into the stomach] tube. When asked if LPN #1 clarified the route in which the order stated the medication was to be given, LPN #1 stated, No, I didn't but I should have. During an interview on [DATE] at 4:35 PM, RCM #1 stated, He [Resident #71] doesn't get his meds [medicines] by mouth. The RCM #1 stated the process that was followed once a physician places the order in the computer, the order was flagged as Pending. The nurse would then confirm the order. RCM #1 stated, I check the dosage, time route and what it is used for . When asked if the route was correct for the ordered medication Depakote Sprinkles, RCM #1 stated, No, I will have to fix this right now. During an interview on [DATE] at 4:53 PM, the DON, The nurse is to check the order prior to giving the medication to make sure it is the right drug, the right dose, the right route and the right time. If it is wrong, the nurse is to clarify the order with the doctor. 50981 2a. The facility's policy titled, Oral Medication Administration, dated [DATE], included instructions for staff preparing medications to validate the medication order against the medication packaging and confirm correct dose. Resident #52 was admitted to the facility on [DATE] with multiple diagnoses including fibromyalgia (a disorder characterized by widespread pain accompanied by fatigue, sleep, memory, and mood issues), dysphasia (inability to use or understand language), and had an abnormal gait (a walking abnormality) and problems with mobility. A laboratory result dated [DATE], documented Resident #52 had a low level of Vit D. An order dated [DATE], was received to give Resident #52 cholecalciferol 2,000 mg three times a day for 8 weeks. Resident #52's MAR dated [DATE] through [DATE] documented Resident #52 received cholecalciferol 2,000 mg three times a day. On [DATE] at 8:07 AM, LPN #3 administered one tablet of D3 50mcg/2,000 IU to Resident #52. On [DATE] at 10:26 AM, LPN #3 stated she gave Resident #52 one tablet of Vit D, and it was ordered three times a day. When asked what the order for Resident #52's Vit D was, LPN #3 then reviewed the order and stated it was 2,000 mg TID. LPN #3 then stated she did not give Resident #52 the right amount of Vit D because she only gave one tablet of Vit D 50 mcg. LPN #3 stated, I think it was an entry error. LPN #3 then asked the DON who was just exiting a resident's room. The DON looked at the order and stated, Let me go clarify that. On [DATE] at 10:40 AM, the DON stated Resident #52 received the right dose of Vit D which was 50mcg/2000 IU and not 2000 mg of Vit D. The DON stated the dose was entered wrong in the computer. The DON stated she expect the nurse to contact the physician for clarification if they noticed any discrepancy in the physician's order. On [DATE] at 4:05 PM during a follow-up interview, the DON stated the [DATE] physician's order written for Vit D administration for 8 weeks was expired and Resident #52 should not have continued to receive this order. b. The facility's policy titled, Pharmacist Consultation, dated [DATE], documented the responsibility of the pharmacist to conduct monthly medication regimen review (MRR) for each resident in the facility, including whether the medication dose, frequency, route of administration, and duration are consistent with the resident's condition, manufacturers recommendation, and applicable standards of practice. The May, June and [DATE] MRR, did not include recommendation from the pharmacist regarding Resident #52's medications. On [DATE] at 10:41 AM, during a phone interview, the pharmacist stated he conducted the MRR for the facility once a month and during the review he would check the physician's orders for every resident. The pharmacist stated he should have caught the 2,000 mg dosage of Vit D. He stated it was an oversight.

Based on observations, staff interviews, and record review, it was determined the facility failed to ensure physician's order was followed regarding dressing changes for 1 of 2 residents (Resident #84). This failure created the potential for infection to spread to Resident #84's open areas to his left arm if it was not covered as ordered by the physician. Findings include: Resident #84 was admitted to the facility on [DATE] with multiple diagnoses including stroke, acute respiratory failure with hypoxia (low level of oxygen in the body tissues), and left hemiparesis (weakness) and hemiplegia (paralysis). An admission MDS assessment dated [DATE], documented Resident #84 was severely cognitively impaired. A Physician Order dated 8/6/24, directed staff to cleanse Resident #84's open rash to his left arm with wound cleanser, cover with boarder gauze and change two times a week and as needed. Resident #84's care plan dated 8/7/24, documented Resident #84 had a rash on his left arm. Interventions included: avoid scratching and keep hands and body parts from excessive moisture, monitor skin rashes for increased spread or signs of infection, seek medical attention if skin becomes bloody or infected, and try to identify skin allergies and avoid them. On 8/7/24 at 11:30 AM and 1:49 PM, Resident #84 did not have a dressing on his left arm. At 1:49 PM, RCM #1 accompanied surveyor to Resident #84's room and confirmed Resident #84 had no dressing present to his left arm. During an interview on 8/7/24 at 2:00 PM, LPN # 2 confirmed Resident #84 was to have a dressing to the left arm, and it was to be changed two times a week and as needed. When asked if the dressing came off, was the dressing to be redressed, LPN #2 stated, Yes. LPN #2 then accompanied the surveyor to Resident #84's room and confirmed Resident #84 did not have a dressing on the left arm. During an interview on 8/7/24 at 4:12 PM, the DON stated if Resident #84's dressing to his left arm came off, it was to be redressed.

Based on staff interview, and record review, it was determined the facility failed to obtain physician ordered laboratory testing. This was true for 1 of 21 residents (Resident #18) whose records were reviewed. This failure created the potential for a physician to inaccurately diagnose and/or treat a resident appropriately due to lack of information. Findings include: Resident #18 was admitted to the facility on [DATE] with multiple diagnoses including paraplegia (paralysis of the lower limbs below the navel) and cerebral palsy (CP is caused by abnormal brain development or damage to the developing brain that affects a person's ability to control their muscles). Resident #18 did not have any cognitive deficiencies and could make his own medical decisions. Resident #18's record contained physician orders, dated 5/23/24, for 3 laboratory tests: 1. Complete Blood Count (a CBC examines the number and types of cells in a person's blood); 2. Comprehensive Metabolic Panel (a CMP measures 14 substances in a person's blood to provide information about multiple body systems); 3. Urinalysis with Culture and Sensitivity (a UA with C&S checks for bacteria in a person's urine that could cause infection). Resident #18's record contained laboratory testing results for the ordered CBC and UA with C&S. Results for the CMP were not able to be located in his record. On 8/6/24 at 11:45 AM, the RCM stated the facility used a form to document if laboratory test results were pending, and the form was discussed at their morning clinical meeting. During the discussion, the team would ensure laboratory test results were followed-up on. On 8/6/24 at 2:25 PM, the DON stated she was not aware they had not received results of the CMP laboratory test for Resident #18 and contacted the lab to follow-up. She added, the lab reported the sample of blood for the CMP was collected in the wrong blood sample tube required for this type of blood test and the test was not able to be conducted. The DON stated the facility had not followed-up on ensuring the blood test was completed.

Based on staff interview, record review, and facility policy review, it was determined the facility failed to have accurate and complete clinical records for 2 of 21 residents (Resident's #33 and #84) whose clinical records were reviewed. 1. Resident #33's record did not contain information related to the discontinuation of an antibiotic; and 2. Resident #84's record documented a dressing change had been completed when it had not been. These failures created the potential to cause failures in communication amongst the interdisciplinary team Findings include: 1. Resident #33 was readmitted to the facility on [DATE] with multiple diagnoses including calculus of the ureter (mineral deposits lodged in the tubes that connect the kidneys to the bladder), urosepsis with Methicillin Resistant Staphylococcus Aureus infection (an extreme inflammatory response to a urinary tract infection caused by MRSA that spreads to the kidneys). Resident #33's record contained a physician order from an infectious disease physician, dated 7/25/24, instructing he receive daptomycin 350 mg (an antibiotic), intravenously (IV), for 42 days, through 8/10/24 due to MRSA urosepsis. The order documented instructions to not stop or change the use of daptomycin without consulting the infectious disease physician. On 7/30/24 at 11:41 AM, a progress note written by the DON, documented Resident #33 was diagnosed with pneumonic consolidation (a condition in which lung tissue fills with liquid instead of air) in the base of his right lung. The DON documented the infectious disease physician was consulted and ordered azithromycin (an antibiotic). The progress note did not document information regarding the order for daptomycin. Resident #33's record documented the order for daptomycin was discontinued on 8/3/24. Documentation the infectious disease physician had discontinued the daptomycin could not be located in the record. On 8/6/24 at 4:40 PM, the DON stated, on 7/30/24, when she spoke with the infectious disease physician and they ordered the azithromycin, they gave instructions to discontinue the daptomycin after 48 hours, and that's my error, and she should have documented the order. 28306 2. The facility's policy titled, Documentation of Resident Health Status Needs and Services, dated 10/14/22, documented directions to document services provided after the encounter has concluded and do not document in advance or prior to providing treatments. Resident #84 was admitted to the facility on [DATE] with multiple diagnoses including acute respiratory failure with hypoxia (lack of oxygen in the blood and body tissues), hypertension, heart disease, and stroke. Resident #84 was severely cognitively impaired. Resident #84's record contained a physician order, dated 8/6/24, that directed staff to cleanse the open rash on his left arm with wound cleanser, cover with bordered gauze, and change two times per week and as needed. On 8/7/24 at 11:30 AM, Resident #84 was observed in his room, he did not have a dressing on his left arm. On 8/7/24 at 1:28 PM, LPN #2 documented in a progress note, [Rash on left arm] was cleaned, and foam dressings applied. No other new skin issues noted at this time. On 8/7/24 at 1:49 PM, the Resident Care Manager (RCM) observed Resident #84 and stated he did not have a dressing present on his left arm. On 8/7/24 at 2:20 PM, LPN #2 stated, I got this messed up in my head. I did not do his [dressing] today. On 8/7/24 at 2:24 PM, the RCM stated the nursing notes should reflect the care the nurse gives to the resident. On 8/7/24 at 4:12 PM, the DON stated, she expected the nurses to perform treatments as ordered and to document after the treatment was provided, not prior.

Based on observation, staff interview, record review, and nursing competency review, it was determined the facility failed to observe infection control guidelines during a wound care dressing change for 1 of 2 residents, (Resident #71) whose wound care was observed. This failure placed the resident at increased risk of contracting an infection in their wound. Findings include: Resident #71 was admitted to the facility on [DATE] with multiple diagnoses including acute and chronic respiratory failure with hypoxia (lack of oxygen in the blood and body tissues), dementia, and a stage 4 pressure ulcer (localized damage to the skin and underlying soft tissue, usually over a bony prominence, as a result of intense and prolonged pressure, a stage 4 pressure ulcer has full thickness tissue loss exposing bone, tendon, or muscle) on his sacral region (the area located between the lower back and the tailbone). Resident #71 was dependent on a gastric tube (g-tube) for all of his nutrition, hydration, and medications, and he had a tracheostomy (a surgically created opening in the windpipe that provides an alternative airway for breathing). Resident #71's record contained a physician order from 7/24/24 directing staff to, cleanse and place wet to dry and cover, daily to the wound on his right buttock. Resident #71's care plan, dated 7/15/24, documented he had a stage 4 pressure injury to his right buttock present on admission. His care plan documented he used a pressure relieving mattress and directed staff to administer medications and treatments as ordered, assess/record/monitor wound healing, and report improvements and declines to the medical director. Lippincott's nursing standards of practice for basic wound cleaning, dated 12/2008, directed, For an open wound, such as a pressure ulcer, gently wipe in concentric circles, starting directly over the wound and moving outward. The facility's undated skills competency titled, Clean Dressing Change, documented when cleaning a wound, staff should clean from center of wound to the edge. On 8/7/24 at 8:20 AM, LPN #1 was observed cleaning Resident #71's wound bed by patting the wound with gauze, moving without pattern, patting from areas outside the wound then inside the wound bed, increasing the risk of bringing contaminants from Resident #71's skin into the wound bed. On 8/7/24 at 10:33 AM, LPN #1 stated, The dirty to the cleanest. I don't remember how I cleaned it. On 8/7/24 at 10:45 AM, the DON stated, the nurse should clean the wound from the inside of the wound to the outer region of a wound. On 8/7/24 at 11:01 AM, the Staff Development Coordinator/Infection Preventionist (SDC/IP) stated the nurses were to clean the wound in a circular motion from the inside out of the wound bed to prevent bringing bacteria into the wound.

Based on policy review, record review, observation, and resident and staff interview, it was determined the facility failed to ensure residents were assessed for safety and care-planned to self-administer medication. This was true for 2 of 3 residents (#4 and #7) reviewed for self-administration of medication. This failure created the potential for adverse outcomes if residents self-administered medications inaccurately and received too much or too little of the medication. Findings include: Findings include: The facility's policy, Self-Administration of Medications, dated 11/28/17, states residents may self-administer drugs if the interdisciplinary team has determined that it is safe. The policy states the interdisciplinary team periodically reviews residents' self-administrations of drugs according to the resident's status. lf the medication is to be stored in the resident's room, a method of storing and securing the medication is prearranged and approved for storing medications, such as a locked cabinet. Appropriate notation is included in the resident's care plan and care plan documentation includes: a. Which drugs may be self-administered, b. Who is responsible (resident or nursing staff) for storage and documentation of the drug administration, and c. Location of the drug administration, such as the resident's room or nurses' station. 1. Resident #4 was admitted on [DATE], with multiple diagnoses including respiratory failure (a condition in which the blood does not have enough oxygen). A quarterly MDS Assessment, dated 1/16/24, documented Resident #4 was cognitively intact. On 3/19/24 at 9:39 AM, Resident #4 was in bed with her tracheostomy (surgically created hole in the windpipe that provides an alternative airway for breathing) in place. Resident #4 was observed holding two small medication cups on her overbed table. One cup had four larger pills in it and a second cup had multiple smaller pills in it. Resident #4 was asked about the cups with medications. Resident #4 stated they [the nursing staff] always left her pills with her and provided two cups for her to take them. Resident #4 stated she took her time taking the pills with water. Resident #4 stated she divided her pills herself with one cup holding the smaller pills and the other cup with the larger pills. Resident #4 stated this is how she took her medications all of the time. Resident #4's record did not include an assessment to self-administer medications, care plan to self-administer medications, or a physician's order prior to 3/19/24. 2. Resident #7 was admitted on [DATE], with multiple diagnoses including congestive heart failure (when the heart does not pump blood as effectively as it should). A quarterly MDS Assessment, dated 8/28/23, documented Resident #2 was cognitively intact. A physician's order, dated 1/26/24, documented to administer Flonase Allergy Relief Nasal spray, 2 sprays in both nostrils one time a day for nasal congestion. Resident #7's March 2024 MAR, documented Flonase nasal spray, 2 sprays in both nostrils one time a day for nasal congestion and it was marked as administered in the evenings 3/1/24 through 3/19/24. Resident #7's record did not include an assessment to self-administer medications, care plan to self-administer medications, or a physician's order prior 3/19/24. On 3/18/24 at 10:52 AM, Resident #7 was in her room and a bottle of Flonase nasal spray was observed on Resident #7's overbed table next to her. Resident #7 was asked about the Flonase. Resident #7 stated she had it because she had breathing and allergy issues. During an observation on 3/19/24 at 8:33 AM, Resident #7 was awake in bed and a bottle of Flonase was observed on Resident #7's bedside table. During an interview on 3/21/24 at 3:44 PM, the CNO confirmed that neither Resident #4 or Resident #7 had an order, an assessment completed, or a care plan for self-administration of medications until 3/19/24 when it was brought to the facility's attention that medications for both residents were routinely left at the bedside.

Based on record review, policy review, observation, and staff interview, it was determined the facility failed to ensure a resident's MDS assessment documented his nephrostomy tube (a thin flexible tube surgically placed into a kidney to drain urine). This was true for 1 of 19 residents (Resident #17) reviewed for accuracy of MDS assessments. This failure had the potential for Resident #17 to not receive care and services necessary to prevent infection and damage to her kidney. Findings include Findings include: The facility's policy, Resident Assessment and RAI, revised 10/15/22, documented a comprehensive, accurate, standardized, reproducible assessment of each resident's functional capacity, needs, strengths, goals, life history and preferences using the Resident Assessment Instrument (RAI), was used which directed the care of the resident based on his or her individual needs. Resident #17 was admitted to the facility on [DATE], and readmitted on [DATE], with multiple diagnoses including Hydronephrosis (when one or both kidneys swell) with Renal and Ureteral Calculus Obstruction and Hemorrhage due to Genitourinary Prosthetic Devices. On 3/29/24 at 2:13 PM, Resident #17 was in bed with a nephrostomy tube sutured into her right side connected to a collection bag with urine inside the bag. A quarterly MDS assessment, dated 12/14/23, did not include documentation Resident #17 had a nephrostomy tube in place. On 3/19/24 at 2:13 PM, LPN #1 stated Resident #17 had a nephrostomy tube in her right kidney which drained urine into a collection bag. On 3/21/24 at 10:32 PM, the MDS Coordinator confirmed the section of the quarterly MDS for Resident #17 should have been coded with a yes for a nephrostomy tube and it was not.

Based on record review, policy review, observation, and staff interview, it was determined the facility failed to ensure interventions were in place on a resident's care plan for the care of her nephrostomy tube (a thin flexible tube surgically placed into a kidney to drain urine) and biliary tube (a thin flexible tube surgically placed into the bile duct of the liver to drain bile). This was true for 1 of 19 residents (Resident #17) whose care plans were reviewed. This failure had the potential for Resident #17 to not receive care and services necessary to prevent infection and damage to her kidney and liver. Findings include: The facility's policy for Care Plans, dated 10/15/22, documented A comprehensive care plan is developed consistent with the residents' specific conditions, risks, needs, behaviors, cultural expectations, preferences and with standards of practice including measurable objectives, interventions/services, and timetables to meet the resident's needs as identified in the resident's assessment or as identified in relation to the resident's response to the interventions or changes in the resident's condition. Resident #17's was admitted to the facility on [DATE], and readmitted on [DATE], with multiple diagnoses including Hydronephrosis (when one or both kidneys swell) with Renal and Ureteral Calculus Obstruction and Hemorrhage due to Genitourinary Prosthetic Devices. On 3/29/24 at 2:13 PM, Resident #17 was in bed with a nephrostomy tube sutured into her right side connected to a collection bag with urine inside the bag. A biliary tube was also in place on her right side. A physician order, dated 4/3/23, documented Resident #17 had a right-sided nephrostomy tube and staff were to monitor the nephrostomy output every shift and document the drainage every shift. A physician order, dated 10/11/23, documented staff were to cleanse Resident #17's nephrostomy site as needed with normal saline, and cover the insertion site with split gauze and secure with tape. The order stated to change the dressing every 72 hours and as needed and ensure device was secure and in place. Resident #17's care plan for the nephrostomy tube, dated 4/20/23, did not include interventions for care of her nephrostomy tube. Resident #17 care plan did not include care needed for her biliary tube. On 3/19/24 at 2:13 PM, LPN #1 stated Resident #17 had a nephrostomy tube in her right kidney which drained urine into a collection bag. LPN #1 confirmed Resident #17 had a second biliary tube in her gall bladder that drained bile into a collection bag. On 3/22/24 at 11:00 AM, the RCM stated Resident #17's care plan should include the needed care for her nephrostomy and biliary tubes. On 3/22/24 at 11:05 AM, the CNO confirmed Resident #17 was admitted to the facility with both the biliary and nephrostomy tubes and there should be a plan of care for the care of both tubes on the care plan.

Based on policy review, I&A review, record review, and staff interview, it was determined the facility failed to ensure adequate supervision for residents to prevent falls. This was true for 1 of 3 residents, (Resident #21) whose records were reviewed for falls. This resulted in harm to Resident #21. Findings include: The facility's Accidents and Supervision to Prevent Accidents policy, revised on 10/15/22, stated facilities were obligated to provide adequate supervision to prevent accidents. Adequate supervision was determined by assessing the appropriate level of care and number of staff required, the competency of the staff, and the frequency of supervision needed. This determination was based on the individual resident's assessed needs and identified hazards in the resident's environment. The State Operation Manual, Appendix PP, defined Avoidable Accident as an accident occurred because the facility failed to: Identify environmental hazards and/or assess individual resident risk of an accident, including the need for supervision and/or assistive devices. Resident #21 was admitted to the facility on [DATE], with multiple diagnoses including Alzheimer's disease, cognitive communication deficit, need for assistance with personal care, and generalized muscle weakness. An I&A report, undated, documented Resident #21 had a fall with injury on 8/24/22, while being repositioned in bed by a CNA. The facility's investigation concluded this fall was unavoidable due to the CNA following the plan of care. Resident #21's hospital discharge documents, dated 8/24/22-8/25/22, stated Resident #21 received 3 skin lacerations. Skin laceration #1 was 6 cm deep from the middle of his forehead extending through the middle portion of the left eyebrow. Skin laceration #2 measured 3 cm was a Z-shaped laceration over the frontal scalp. Skin laceration #3 measured 2 cm through the left lateral aspect of the left eyebrow. On 8/1/22, the CNA received the following training: - Gait Belt training - Transfers on Sara Steady - (allows the patient to support themselves by pulling rather than pushing while being transferred in a sitting position.) - Transfers on mechanical /sling lift - Transfers on sit to stand lift The care plan, revised on 11/19/21, documented Resident #21 was a 1-person physical assist to turn and reposition in bed. It also documented Resident #21 was a 2-person physical assist with a Hoyer lift for transfers. The ADL record for bed mobility, dated August 2022, documented Resident #21 required a 2 person assist for bed mobility for 16 of 31 days. Two quarterly MDS assessments, dated 5/24/22 and 8/15/22, documented Resident #21 required the following: -Extensive assist with 2-person assistance for bed mobility. -Dependent to roll in bed onto either side. -Total dependent with transfers and Resident #21 required 2-person physical assistance. On 9/20/23 at 4:52 PM, the CNO stated the care plan did not need to reflect the MDS. She said the facility had the ability to increase care as needed but could not provide lower care than what was documented in the care plan. She also stated the CNAs should have told the nurse if the level of care increased. On 9/21/23 at 9:34 AM, the MDS nurse stated changes identified during the MDS assessment should be reflected on the care plan. She stated the care plan should have reflected Resident #21 required 2-person assistance for bed mobility. 48654

Based on observation, staff interview, policy review, and record review, it was determined the facility failed to ensure professional standards of practice were met related to management of wounds, medication administration, failure to notify the physician of a change in condition, and failure to apply skin protection to prevent skin breakdown. This was true for 4 of 13 residents (#1, #4, #11 and #13) reviewed for treatment and care. Specifically: * Resident #4 was harmed when the facility did not assess, monitor and treat her abdominal wound according to professional standards of practice which resulted in hospitalization . * Resident #11 was at risk for skin breakdown and possible infection when staff failed to follow his care plan to notify the physician of a change of condition when he had drainage and skin irritation at his PEG tube site, and when the facility did not provide him with skin protection for his arms and legs. * Resident #13 was at risk for adverse effects from low or high blood sugar that could result in seizures, coma, brain damage, and sometimes death as a result of not receiving his insulin on time. * Resident #1 was at risk when he did not receive his psoriasis (a skin disease that causes red, itchy scaly patches) creams as ordered by the dermatology clinic, which could result in progression of the psoriasis. Findings include: 1. Resident #4 was admitted to the facility on [DATE], with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #4 had a PEG tube (a tube inserted through the abdomen that delivers nutrition directly to the stomach) placed on 5/19/20. The PEG tube was subsequently removed on 3/17/21. A Medical Appointment note, dated 3/17/21, stated [Resident #4] has persistant [sic] leak around PEG tube, she does not use the tube anymore and wants to have it removed. Consult was for how/if wound site can be closed upon PEG tube removal. Face to face done with physician and PA [Physician Assistant] on 3/16/21. Provider Note/Orders: include [MEDICATION(S)] powder twice a day for [CONDITION(S)] until healed. Will call physician for further imaging of fistula. The [NAME] Medical Center website, accessed on 6/14/21, defines [CONDITION(S)] as a deep infection of the skin caused by bacteria. Symptoms include skin redness and inflammation; untreated [CONDITION(S)] can lead to [CONDITION(S)], shock and death. The website stated diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Treatment includes antibiotics and keeping the area clean and dry. The Drugs.com website, accessed on 6/24/21, stated [MEDICATION(S)] exhibited no appreciable activity against bacteria. Resident #4's physician order, dated 3/17/21, stated she had an open wound site [after removal of her PEG Tube] on her left abdomen which was to be cleansed with skin cleanser and covered with a 4x4 gauze pad. The pad was then to be covered with an abdominal dressing (ABD) using minimal paper tape to hold it in place. This was to occur three times a day and as needed. Resident #4's physician order, also dated 3/17/21, stated [MEDICATION(S)] Powder (an antifungal powder that works by stopping the growth of fungus) was to be applied topically to the affected area of her torso two times a day for [MEDICATION(S)] on her abdomen until healed. A Weekly Skin Alteration report, dated 3/17/21, stated a red rash was noted to Resident #4's abdomen with partial thickness skin loss (loss of skin presenting as a shallow open ulcer with a red/pink wound bed) with no signs or symptoms of infection. The report stated the wound had deteriorated and lacked evidence of healing. The report stated the treatment orders were to cleanse the wound with normal saline (NS), apply [MEDICATION(S)], and cover it with an ABD. The dressing was to be changed 3 times a day and as needed, for saturation. The size of the rash and the wound was not documented. The [NAME] Hopkins Medicine website, accessed 6/24/21, stated An assessment of the wound should be done weekly and be used to drive treatment decisions. Wound assessment includes: location, class/stage, size, base tissues, exudates, odor, edge/perimeter, pain and an evaluation for infection. A nursing note, dated 3/19/21 at 12:05 AM, stated Resident #4's abdominal wound site dressing was changed as the bandage was saturated and the site was oozing blood. A nursing note, dated 3/19/21 at 7:54 PM, stated Resident #4's abdominal wound site dressing was changed twice during the shift due to heavy serosanguinous (thin and clear) drainage and the skin was red and excoriated (damaged). A nursing note, dated 3/20/21 at 2:42 AM, stated Resident #4's wound dressing was changed twice on the shift due to heavy serosanguinous drainage. The note stated Resident #4's skin was red and excoriated at the site. There was no documentation the physician was notified about the heavy drainage or excoriation. A nursing note, dated 3/20/21 at 4:14 AM, stated Resident #4's dressing was changed twice during the shift due to heavy drainage and the skin around the abdominal wound site remained red with some bleeding observed on the surrounding skin area. There was no documentation in the nursing notes the physician was notified of Resident #4's heavy drainage or bleeding from her abdominal wound. A nursing note, dated 3/20/21 at 12:20 PM, stated Resident #4's abdominal wound had a chronic history of inflammation and issues, and was followed by the physician and the wound nurse. A nursing note, dated 3/21/21 at 7:28 PM, stated the dressing to Resident #4's abdominal wound was changed twice during the shift and a heavy amount of dark foul-smelling drainage was noted throughout the day. The note stated the drainage soaked through 4 ABD pads within an hour and the area around the site was red and excoriated. The note stated the physician was notified. There was no documentation new orders were received from the physician. Nursing notes, dated 3/22/2021 at 4:18 AM and 3/23/21 at 2:23 AM, both stated Resident #4's dressing was changed and there were no signs or symptoms of infection to the wound site. A nursing note, dated 3/23/21 at 9:23 PM, stated Resident #4's dressing change was completed and there was drainage of dark, old blood. There was no documentation the physician was notified. A nursing note, dated 3/24/21 at 12:59 AM, stated Resident #4's dressing was changed and there were no signs or symptoms of infection. Resident #4's care plan related to the wound site, dated 3/25/21, stated Resident #4 had a rash at the wound site and the surrounding tissue. The care plan interventions included no harsh detergents, soaps, fragrances, or other irritating substances were to be used and staff were to monitor the rash for increased spread or signs of infection. The care plan stated staff were to seek medical attention if the skin became bloody or infected. The care plan did not include instructions to apply [MEDICATION(S)] to the abdominal wound site or surrounding tissue. The care plan also did not include there was a [MEDICATION(S)] infection at the wound site or surrounding tissue. Resident #4's care plan also stated she had a potential for [MEDICATION(S)] and rashes to her body folds, under her breasts and buttocks. The care plan interventions included assessing and documenting the abdominal wound perimeter, wound bed, the healing progress, and to report improvement and decline to the physician. The care plan interventions also included a wound care consult per physician order. A nursing note, dated 3/25/21 at 2:16 AM, stated Resident #4's dressing was changed, and dark, old bloody drainage was noted. A nursing note, dated 3/25/21 at 5:22 PM, stated Resident #4 had redness and swelling to the abdominal wound site with fluid and blood draining from the site. The note stated the wound was healing. A nursing note, dated 3/26/21 at 3:41 AM, stated Resident #4's dressing was changed and there was dark, old bloody drainage. A nursing note, dated 3/26/21 at 12:55 PM, stated the PA called and the staff reported the redness around Resident #4's abdominal wound had significantly decreased, the drainage had significantly declined and was not as copious or odorous, dressings were changed 3 times a day, and the opening of the wound was half the size of what it was when the PEG tube was originally removed. A nursing note, dated 3/31/21 at 4:03 AM, stated Resident #4's dressing was changed and the area was warm to the touch and bright red. The note stated brown drainage was present and greenish-yellow cloudy thick fluids were observed. The note stated the physician was notified. There was no documentation new orders were received from the physician. The Healthline website, accessed 6/25/21, stated Both surgical and open wounds can have different types of drainage. Purulent drainage is a type of fluid that is released from a wound. Often described as being milky in appearance, it's almost always a sign of infection. The website further stated symptoms of purulent drainage included thick consistency, green, yellow, brown, or white color, and distinct odor. The website stated when the skin is broken the germs then spread into the tissues underneath and cause an infection. The website stated this also means wounds would not heal as quickly or as well, or in some cases at all. A Weekly Skin Alteration report, dated 3/31/21, stated Resident #4's abdomen had a rash with full thickness skin loss (skin loss where subcutaneous fat may be visible but bone, tendon or muscle are not exposed) and adjacent tissue destruction and drainage but no signs or symptoms of infection. The report stated the size of the rash was unable to be measured and the color of the skin was red with epithelization (skin formation). The report stated the treatment was to cleanse with wound cleanser and dry, cover the wound with an ABD and secure the dressing with tape, 3 times per day and as needed. It was unclear why the wound was unable to be measured. Nursing notes, dated 3/31/21 at 5:43 PM to 4/3/21 at 12:21 PM, stated Resident #4 continued to have drainage from the wound site and redness was noted. The note did not describe what kind of drainage was coming from the wound. There was no documentation the physician was notified of the continued drainage. A Skin Inspection Evaluation, dated 4/3/21, stated Resident #4 continued to have a small to moderate amount of serous (clear to pale yellow watery fluid) drainage from the wound site and redness was noted to the left side of the abdomen and mid-region to her side from tape irritation and drainage, and under her left breast. The evaluation stated [MEDICATION(S)] powder was effective to the area. There was no documentation the wound perimeter was measured or the physician was notified about the drainage and redness. A nursing note, dated 4/4/21 at 2:55 AM, stated Resident #4's dressing was changed, and a large amount of drainage was present on the ABD pads. The note stated there was a small area just under the stoma (wound opening) with a visible amount of blood draining, and pads were applied. There was no documentation the physician was notified about the large amount of drainage or blood. A nursing note, dated 4/5/21 at 1:04 AM, stated Resident #4's dressing was changed, and brown granulation (connective tissue and microscopic blood vessels that form on the surfaces of a wound during the healing process) and blood were observed. A nursing note, dated 4/6/21 at 4:41 AM, stated Resident #4's dressing was changed, and brown granular and serous fluid were observed. A nursing note, dated 4/6/21 at 1:15 PM, stated Resident #4's dressing was changed and brown granular and serous fluid were observed, and the skin was red and inflamed. There was no documentation the physician was notified about the drainage or that the skin was red and inflamed. A nursing note, dated 4/7/21 at 6:17 AM, stated Resident #4 refused a dressing change during the shift. A Weekly Skin Alteration report, dated 4/7/21 at 12:00 PM, stated staff were unable to measure Resident #4's rash, the skin was red, and epithelization was occurring, and there were no signs or symptoms of infection. The note stated the wound had full thickness skin loss with adjacent tissue destruction, and serous drainage was present. A nursing note, dated 4/7/21 at 5:21 PM, stated Resident #4's wound site was red but not hot, and drainage was a red/brown color. The note stated there was slight bleeding when cleaned. A physician note, dated 4/7/21, stated the provider removed Resident #4's dressing and noted generalized redness to the left and lower area of the abdomen up to under her left breast. The note stated the redness was not warm to touch and there was some drainage. The note documented that nursing staff reported the area had improved with the application of [MEDICATION(S)]. The note stated the physician discussed wound treatment management with the nursing team and they agreed with the plan. The physician note did not include information specifying the plan for wound treatment management. Nursing notes, dated 4/8/21 at 12:51 AM to 4/8/21 at 5:35 PM, stated Resident #4's dressing changes were completed and brown drainage and redness to the site were observed. Nursing notes, dated 4/9/21 at 5:03 PM to 4/10/21 at 5:34 PM, stated Resident #4's wound site had no signs or symptoms of infection. A Skin Inspection report, dated 4/10/21, stated Resident #4's wound site had blanchable redness (redness of the skin that turns white when pressed with a fingertip, then immediately turns red again when pressure is removed). The Skin Inspection report did not include documentation Resident #4's wound perimeter was measured, whether there was drainage from the abdominal wound, or further description of the site. A nursing note, dated 4/11/21 at 12:11 AM, stated Resident #4 declined a dressing change. A nursing note, dated 4/12/21 at 12:11 AM, stated there was a yeasty smell from Resident #4's wound site and it was blood tinged. There was no documentation the physician was notified. A nursing note, dated 4/12/21 at 2:23 PM, stated Resident #4's dressing was changed and there were no signs or symptoms of infection. A nursing note, dated 4/13/21 at 5:05 AM, stated Resident #4 had a slight panic attack at 3:30 AM and requested her medication from the nurse. The note stated Resident #4 was awake all shift. The note stated at 5:00 AM, Resident #4 was very ill. The note stated Resident #4 vomited, had a high heart rate, low blood pressure, and was very pale. The note stated her breath sounds were diminished (decreased breath sounds which can indicate fluid around the lungs) with coarseness in the bases (low-pitched rattling sounds usually caused by build-up of [MEDICATION(S)] or fluid in the lungs), and she was sent to the hospital. A corresponding nursing note, dated 4/13/21 at 5:55 AM, stated Resident #4 complained of nausea, vomited what looked like a bowel movement, and was pale with cold skin. The note stated Resident #4 stated she was hot and burning up inside. The note stated nursing notified the on-call provider, Resident #4's sister, and Resident #4's daughter. A hospital Patient Death Summary, electronically signed by a physician on 4/17/21 at 6:46 AM, documented Resident #4's date of death was 4/16/21. The summary documented Resident #4's primary diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Merck Manual website, accessed on 6/18/21, defined a necrotizing skin infection, including necrotizing [CONDITION(S)], as a severe form of [CONDITION(S)] characterized by death of infected skin and tissues (necrosis). It is also commonly referred to as a flesh-eating bacteria. The website stated symptoms of necrotizing skin infections include skin that becomes red or bronze and warm to the touch and sometimes swollen. The website stated the person infected usually feels very ill and has a high fever, a rapid heart rate, and mental deterioration ranging from confusion to unconsciousness. It further stated blood pressure may fall because of toxins secreted by the bacteria and the body's response to the infection (septic shock). On 6/11/21 at 11:30 AM, the DON was asked about wound cultures and the use of antibiotics. The DON stated wound cultures were not taken as there was no indication to culture. The DON stated the wound was a fistula (abnormal or surgically made passage between a hollow or tubular organ and the body surface), and fecal matter would be expected in the culture. The DON stated that absent any other symptoms, a wound culture was not indicated. The DON stated antibiotics were not indicated for a fistula or a rash. On 6/11/21 at 2:15 PM, the DON was asked about a wound care consultation from the wound clinic. The DON stated Resident #4's last visit to the wound care clinic was on 11/18/20, Resident #4 was not followed by wound care after that time. The DON stated the physician took over wound care due to the chronic condition of the wound as it was a fistula, and they started gastroenterology (GI) consults. The DON stated a GI consultation occurred on 3/17/21 when the PEG tube was removed. The DON stated Resident #4 was seen by physicians for wound follow-up on 3/4/21, 3/9/21, and 4/7/21. On 6/9/21 at 12:10 PM, Resident #4's physician stated Resident #4 was very ill. The physician stated [MEDICATION(S)] was appropriate and Resident #4 had so many skin issues due to long term and elevated [MEDICATION(S)] (steroid) use. The physician stated they tried everything to get the wound to heal. The physician stated Resident #4 refused to position herself properly and continually leaned over the abdominal wound site, causing increased drainage. The physician stated he could not get the site to heal from the inside, it was a fistula and resistant to closure. The physician stated Resident #4 also suffered off and on, from infections. Resident #4's abdominal wound was not assessed, monitored, and treated following professional standards of practice. 2. Resident #11 was admitted to the facility on [DATE], from a local long-term care facility, with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #11 was non-verbal, used a wheelchair for mobility purposes, and had a [CONDITION(S)] (a hole through the front of the neck and into the windpipe (trachea) creating an air passage to help you breathe when the usual route for breathing is somehow blocked or reduced). Resident #11 used a PEG tube for all food, fluid, and medications. a. On 6/8/21 at 2:26 PM, Resident #12 was observed sitting in his wheelchair, in his room. Resident #11's PEG tube site was covered with a split 4 x 4 gauze dressing. The middle of the gauze contained a dried brown substance and the skin around the stoma site appeared to be red and slightly inflamed. Resident #11's physician order, dated 5/2/21, stated Treatment to PEG site: Cleanse daily with NS [normal saline] and dry. Apply split gauze to PEG site. To be completed daily and PRN [as needed]. every [sic] 12 hours as need for skin integrity. Resident #11's care plan, initiated 5/3/21 and revised 5/19/21, stated he required PEG tube feeding. The care plan stated, Cleanse the skin around the stoma site per MD [medical doctor] orders. Observe the s/s [signs and symptoms] of infection, leakage, and skin irritation. Inspect the tube for inward or outward migration. Notify the MD of any findings. Resident #11's progress notes, dated 4/29/21 - 6/8/21, did not include information related to the discharge or the condition of the skin around the stoma site, and that the physician was notified, as follows: * 4/29/21: .stoma is Dry [sic] clean and intact no redness noticed. * 5/1/21: .PEG tube is present and resident is on feeding via pump, no signs of complications or infections noted. * 5/2/21: .PEG tube is present and resident is on feeding via pump, no signs of complications or infections noted. * Progress notes dated , 5/14/21, 5/21/21, 5/28/21, and 6/4/21, documented Skin Inspection. The documentation did not include a description or results of the skin inspection. On 6/8/21 at 2:26 PM, the Director of Respiratory Therapy was present when Resident #11's stoma site was checked. When asked about the condition of Resident #11's skin, the Director of Respiratory therapy stated it was normal to have drainage and for the skin around the site to be irritated. b. Resident #11's care plan stated he had the potential for alteration in skin/tissue integrity and needed assistance to apply protective garments of Geri-sleeves (a breathable fabric that protects against frictions and skin tears) and Tubigrips (a compression bandage). On 6/8/21 at 9:40 AM and at 2:26 PM, Resident #11 was observed in his room. He was wearing a short sleeve shirt and his arms were bare. On 6/9/21 at 9:38 AM, CNA #4 and #5 were observed transferring Resident #11 to his wheelchair. His was wearing a short-sleeved shirt and shorts. His arms and legs were bare. When asked if Resident #11 had Geri-sleeves and Tubigrips, both CNAs stated they had not seen any and had worked with him since his admission to the facility. On 6/9/21 beginning at 9:59 AM, Unit Manager #1 was asked about Resident #11's use of protective garments for skin integrity. Unit Manger #1 stated they should be applied as stated in the care plan. When asked why staff stated Resident #11 did not have those items available for application, she stated she was not aware of that and would need to check. No additional information was provided. 3. The facility's policy for medication administration, dated 1/1/18, documented residents' routine medications were given close to meals times as AM (breakfast), Noon (lunch) and PM (dinner). The Drugs.com website, accessed on 6/10/21, stated Insulin [MEDICATION(S)] is a long-acting insulin that starts to work several hours after injection [to lower blood glucose] and keeps working evenly for 24 hours. The website stated insulin [MEDICATION(S)] may be given at any time of the day; however, once a time is chosen, it is best to inject it within three hours of that time every day. The website also stated low blood sugar may happen with this medicine and very low blood sugar can lead to seizures, passing out, long [MEDICATION(S)] brain damage, and sometimes death. The Mayo clinic website, accessed on 6/10/21, stated Blood sugar that's either too high or too low for too long may cause various serious conditions, all of which can lead to a diabetic coma. This policy and guidance were not followed. a. Resident #13 was admitted to the facility on [DATE], with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #13's May 2021 and June 2021 Diabetic Administration Record documented she was to receive 10 units of insulin [MEDICATION(S)] subcutaneously one time a day for diabetes mellitus. The Diabetic Administration Record documented Resident #13's insulin [MEDICATION(S)] solution was scheduled to be given at 7:00 PM. Resident #13's insulin was not documented as given at 7:00 PM as follows: * Insulin [MEDICATION(S)] was administered greater than 9 hours from the time it was scheduled on 6/2/21 at 4:24 AM. * Insulin [MEDICATION(S)] was administered greater than 4 hours on 5/11/21 at 11:19 PM. * Insulin [MEDICATION(S)] was administered greater than 3 hours on 5/14/21 at 10:29 PM, on 5/16/21 at 10:20 PM, on 5/19/21 at 10:12 PM, on 5/20/21 at 10:45 PM, on 5/21/21 at 10:32 PM, on 5/24/21 at 10:39 PM, on 5/25/21 at 10:25 PM, on 6/1/21 at 10:40 PM, on 6/3/21 at 10:25 PM, and on 6/4/21 at 10:38 PM. On 6/9/21 at 2:35 PM, the DON reviewed Resident #13's record and stated Resident #13's insulin [MEDICATION(S)] solution was not administered within the time frame as scheduled. The DON stated that Resident #13's insulin [MEDICATION(S)] administered after 10:00 PM was considered late administration of medication. The DON also stated Resident #13's insulin [MEDICATION(S)] solution that was administered on 6/2/21 at 4:24 AM was late documentation. b. Resident #1 was admitted to the facility on [DATE] and readmitted on [DATE], with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #1's May 2021 Diabetic Administration Record, documented he was to receive 28 units of insulin [MEDICATION(S)] subcutaneously at bedtime for diabetes mellitus. The Diabetic Administration Record documented Resident #1's insulin [MEDICATION(S)] solution was scheduled to be given at 7:00 PM. Resident #1's insulin was not documented as given at 7:00 PM as follows: * Insulin [MEDICATION(S)] was administered greater than 5 hours from the time it was scheduled on 5/2/21 at 12:32 AM and on 5/10/21 at 12:13 AM. * Insulin [MEDICATION(S)] was administered greater than 3 hours from the time it was scheduled on 5/5/21 at 10:50 PM, on 5/6/21 at 10:56 PM, and on 5/13/21 at 10:24 PM. On 6/9/21 at 2:35 PM, the DON reviewed Resident #1's record and stated Resident #1's insulin [MEDICATION(S)] solution was not administered within the time frame as scheduled. The DON stated that Resident #1's insulin [MEDICATION(S)] administered after 10:00 PM was considered late administration of medication. 4. Resident #1 did not receive creams to treat his psoriasis (a skin disease that causes red, itchy scaly patches) as ordered by the dermatology clinic. A dermatology clinic progress note, dated 4/28/21, documented Resident #1 was referred to the clinic due to the presence of rashes located on his arms, trunk, legs, and groin which were moderate in severity. Resident #1 was diagnosed with psoriasis and was prescribed the following topical medications: [MEDICAL RECORD OR PHYSICIAN ORDER] * [MEDICATION(S)] 0.1%, apply two times a day, every Monday through Thursday. * [MEDICATION(S)] cream 0.005%, apply two times a day, every Friday through Sunday. A nursing progress note, dated 4/28/21 at 10:24 AM, documented Resident #1 returned from a dermatology (skin) consultation. The progress note documented the driver stated Resident #1 received an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The progress note stated a call was made to the dermatology clinic who stated the physician order would be sent to the facility. A nursing progress note, dated 5/17/21 at 1:26 PM, documented the dermatology clinic was called and the clinic stated the physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The dermatology clinic stated each time they received a voicemail regarding Resident #1's medication, they sent the order to the facility's physician office. Resident #1's Medication Administration Record, [MEDICAL RECORD OR PHYSICIAN ORDER] * Resident #1 received the [MEDICATION(S)] 20 days after it was prescribed to him by the dermatology clinic. The cream was applied from 5/24/21 - 5/27/21 and from 6/1/21 - 6/3/21. * Resident #1 received the [MEDICATION(S)] cream 17 days after it was prescribed to him by the dermatology clinic. The cream was applied from 5/21/21 - 5/23/21, from 5/28/21 - 5/30/21 and from 6/4/21 - 6/6/21. On 6/8/21 at 10:38 AM, Unit Manager #1 stated Resident #1 did not have the physician order with him when he returned from the dermatology clinic on 4/28/21. Unit Manager #1 stated she called the dermatology clinic and asked for the physician order and was told it would be sent to the facility. Unit Manager #1 stated the facility did not receive the physician order so she called the dermatology clinic several times and each time she called, she left a voice mail and requested the physician order be sent to the facility. Unit Manager #1 stated when she was able to talk to somebody at the clinic, she was told the order was sent to the facility's physician office.

Based on record review, staff interview, and policy review, it was determined the facility failed to ensure residents end-of-life pain management needs and preferences were effectively assessed, treated, and integrated into the residents' individualized care plans. This was true for 1 of 12 residents (Resident #2) reviewed for pain management. Resident #2's pain related to his terminal cancer was not effectively managed to maintain his comfort the days prior to, and during, the final hours of his life, resulting in excruciating breakthrough pain. Findings include: The facility's Palliative Care policy, dated 11/20/17, documented palliative care is primarily directed at providing relief to a terminally ill person through symptom management. It stated the number one goal of palliative care symptom management is pain control and staff would assist in pain management as the resident desires. The facility's Pain Management policy, dated, 1/28/17, documented strategies for pain management included identifying and using specific strategies for prevention of pain or pain related symptoms based on the resident's specific assessment and choices using pain medication. It further stated that resident's pain would be monitored for effectiveness of pain management and that some clinical conditions require using several analgesics and/or adjunct medications together and residents should be medicated for pain, as ordered. The facility's Resident Assessment policy, dated 11/28/17, documented assessment of the resident's needs is not limited to the content of the Resident Assessment Instrument (RAI), and documented data included in the assessment may include the effectiveness of treatment, pain symptoms, and response to treatment. These policies were not followed. Resident #2 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . He used a condom catheter, had an [CONDITION(S)] (a surgically created opening in the abdominal wall through which digested food passes), and was on palliative care. Resident #2's admission assessment, dated 2/4/21, documented he had an abdominal incision that required wound dressing changes every 8 hours, was non-weight bearing, and required extensive assistance from one person with all cares. Resident #2's care plan for acute and chronic pain related to his midline surgical incision and terminal cancer, initiated on 2/4/21, documented staff were to administer medications as ordered, evaluate pain using verbal or nonverbal assessments, and offer non-pharmacological interventions for pain relief. Resident #2's care plan did not include documentation of specific goals and interventions related to his palliative care needs. The care plan did not include the level of pain Resident #2 found acceptable on the 0 to 10 pain scale (0 = no pain and 10 = the worst pain Resident #2 had experienced) used by the facility or identify his individualized nonverbal expressions of pain. Resident #2's Idaho Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #2's order summary report included the following medications for pain and anxiety: - On 2/4/21, [MEDICATION(S)] (an opioid [MEDICATION(S)]) was ordered to be given in liquid form, 5 mg every hour as needed for pain and difficulty breathing. - On 2/4/21, Lorazepam (a medication used to manage anxiety) was ordered to be given in liquid form, 0.5 mg every two hours as needed for end of life agitation - On 2/4/21, Acetaminophen (Tylenol), 325 mg 2 tablets by mouth was ordered every 4 hours as needed for pain/fever. - On 2/4/21, a [MEDICATION(S)] Patch 4% was ordered to be applied to Resident #2's chest topically twice a day for pain - On 2/24/21, Acetaminophen (Tylenol), 325 mg 2 tablets were ordered four times a day for pain. - On 2/26/21, [MEDICATION(S)] tablet 7.5 mg was ordered every six hours as needed for pain - On 2/26/21, a one-time order for a [MEDICATION(S)] tablet 10/325 mg (an opioid [MEDICATION(S)] with a combination of 10 mg of [MEDICATION(S)] and 325 mg of acetaminophen) with a repeat [MEDICATION(S)] tablet six hours later. The American Cancer Society website, www.cancer.org, accessed on 6/23/21, documented People with cancer often have pain, and often fear it will get worse. Cancer pain is considered to be chronic pain because it usually lasts longer than pain caused by other problems. While pain can't always be completely relieved, pain can be controlled and managed. Pain does not have to be a part of dying. Resident #2's end-of-life pain was not effectively managed, as follows: * Resident #2's pain summary report, dated 2/4/21, documented his pain level as 4/10 on the 0/10 pain scale at 11:36 PM. The Medication Administration Record (MAR) documented a 4% [MEDICATION(S)] patch was placed on Resident #2 at 11:36 PM. The MAR documented the patch was scheduled to be administered at 8:00 PM. Resident #2 received the [MEDICATION(S)] patch 3 and ½ hours later than scheduled. No other pain medication was administered to Resident #2 at that time. Resident #2's record did not include documentation staff followed up with him to determine if the application of the patch effectively addressed his pain. * From 2/7/21 through 2/19/21, Resident #2's pain level summary report and his MAR pain monitoring sheet documented his pain at a 0/10. There was no documented oral pain medication administered. On 2/21/21, Resident #2's pain level summary report documented he rated his pain as 5/10 at 7:21 AM. His MAR documented he received Acetaminophen at that time. While the Acetaminophen was administered, inconsistent with the pain level summary report, the MAR documented Resident #2 experienced no pain on 2/21/21. Resident #2's pain level summary report documented his last pain assessment on 2/21/21, was at 5:25 PM. Resident #2's MAR documented his next pain assessment was on 2/22/21, at start of day shift at 6:00 AM, 13 hours later. * On 2/24/21 at 3:28 PM, RN #1 documented she spoke to Resident #2 about his pain management. She documented while talking to him, Resident #2 had to stop and breathe through shoulder/neck pain on his right side. She documented she would contact the physician and request for a scheduled dose of acetaminophen for the pain. The MAR pain monitoring sheet documented Resident #2's pain level as 0 out of 10 (no pain) for this 24-hour period. Pain medication was not given at or around 3:28 PM, when it was documented Resident #2 had to stop talking and breathe through right side shoulder and neck pain. Resident #2 had a previous order, dated 2/4/21, for Acetaminophen, 325 mg 2 tablets by mouth every 4 hours as needed for pain/fever. On 2/24/21, Acetaminophen, 325 mg 2 tablets were ordered to be routinely administered four times a day for pain. *On 2/25/21, the pain level summary report documented Resident #2 had varying levels of pain on the 0/10 verbal pain scale throughout the day, as follows: -12:37 AM: He rated his pain a 4/10 -4:45 PM: He rated his pain a 3/10 -7:01 PM: He rated his pain a 7/10 -8:23 PM: He rated his pain a 2/10 -10:25 PM: He rated his pain a 7/10 A progress note documented by RN #1, dated 2/26/21 at 8:39 AM, stated Resident #2's sister called to check on Resident #2. The progress note documented his sister stated Resident #2 was in a lot of pain last night (2/25/21). The progress note documented RN #1 went to Resident #2's room and asked him about his pain. The progress note stated Resident #2 would not talk with RN #1 about how he was feeling and asked to talk with his sister. Resident #2's sister asked RN #1 what pain medications he was on. RN #1 documented she explained to Resident #2's sister that he wanted to talk with her first and transferred the call to Resident #2. There was no further documentation RN #1 spoke with Resident #2's sister. On 6/9/21 at 3:00 PM, Resident #2's family was interviewed by telephone. The family shared Resident #2's biggest concern was pain management. The family stated there was not coordinated communication between the POA and facility staff. The family said Resident #2 was in so much pain he could barely form sentences. The family stated Resident #2's POA for healthcare, his sister, sent an email to the Clinical Liaison for Cascadia Healthcare on 2/26/21 at 8:39 AM. The email was provided by the family. The family stated they did not get a response to the email from Cascadia of Boise. The email stated Resident #2 called his POA around 6:00 PM on 2/25/21 and he stated he was in extreme pain. The POA documented she called Resident #2 that morning (2/26/21) and he continued to be in pain. In the email the POA stated Resident #2 chose the facility because he was concerned about being in pain and you reassured him that he would not be. The Clinical Liaison for Cascadia Healthcare sent a response to the POA on 2/26/21 at 11:46 AM (Mountain Time) stating she had forwarded the email to the social worker at Cascadia of Boise. On 6/9/21 at 10:04 AM, Social Services Assistant #1 was asked about the social services department's interactions with Resident #2. He stated he had only been working at the facility for two weeks and Resident #2 passed away before he was employed at the facility. When asked if there were any social service interactions regarding Resident #2, he stated his supervisor, the Social Services Director would know but she was on vacation. Social Services Assistant #1 stated when he looked for records of Resident #2, he could not find social service notes regarding him, or any conversations regarding Resident #2. He stated he would text the Social Service Director and request any documentation regarding Resident #2. Further information/documentation was not provided. Resident #2's MAR pain monitoring sheet documented Resident #2 had pain levels of 0 out of 10 (no pain) the day of 2/26/21. The MAR conflicted with the data on the pain level summary report which documented his pain level rating as 0, 1, 2, 3, 4, 5, 6, 7, and 9 at various times throughout the day. On 2/26/21 at 4:15 PM, Resident #2's order summary report documented he received an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . On 2/26/21 Resident 2 received the following pain medications -1:38 AM - liquid [MEDICATION(S)] 5 mg for pain 7/10 -4:07 AM - liquid [MEDICATION(S)] 5 mg for pain 6/10 -7:29 AM - liquid [MEDICATION(S)] 5 mg for pain 9/10 -10:20 AM - liquid [MEDICATION(S)] 5 mg for pain 6/10 -12:00 PM - Acetaminophen 650 mg for pain 6/10 -4:00 PM - Acetaminophen 650 mg for pain 3/10 -8:00 PM - Acetaminophen 650 mg pain level 0/10 -8:00 PM - [MEDICATION(S)] 7.5 mg for pain level 5/10 On 2/26/21 at 4:15 PM, Resident #2's order summary report documented he received an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . On 2/26/21 at 10:15 PM, Resident #2's MAR documented a one-time order for a [MEDICATION(S)] tablet 10/325 mg (an opioid [MEDICATION(S)] with a combination of 10 mg of [MEDICATION(S)] and 325 mg of acetaminophen) with a repeat [MEDICATION(S)] tablet six hours later. On 2/26/21 at 9:47 PM, Resident #2's pain level summary report documented his pain level as 5/10. There was no documentation of pain medication offered or administered at or around 9:47 PM. There was no documentation Resident #2 received pain medication after 8:00 PM on 2/26/21. Resident #2's record did not include documentation of a follow-up evaluation of Resident #2's pain level after the medication was administered. Resident #2's record did not include documentation of a pain evaluation completed after 9:47 PM on 2/26/21. A nursing progress note, dated 2/26/21 at 11:22 PM, documented Resident #2 was very agitated about his [MEDICATION(S)] being scheduled every 6 hours and Tylenol being scheduled stating 'he is going to die' if there are no PRN pain medications given between the 8:00 PM and 2:00 AM doses of [MEDICATION(S)] (7.5 mg tablet). The progress note documented Resident #2 then asked if there was anything else he could have. The progress note stated Resident #2 then requested [MEDICATION(S)], however, when he was informed of what it was for (anxiety) he refused the medication, stating he didn't want that, he needed something for pain. The progress note documented the provider was notified and an order was received for a [MEDICATION(S)] tablet 10/325 mg tablet (an opioid [MEDICATION(S)] with a combination of 10 mg of [MEDICATION(S)] and 325 mg of acetaminophen) for breakthrough pain with a repeat [MEDICATION(S)] tablet six hours later. The progress note documented Resident #2 was informed of the [MEDICATION(S)] order and he did not request the [MEDICATION(S)] at that time. Resident #2 had physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Both medications were available at that time and were not offered or administered. * On 2/27/21 at 12:54 PM, Resident #2's pain summary report rated his pain at 5/10 and there was no documentation on the MAR that he received pain medication. At 1:36 PM, the pain summary report documented he rated his pain as 9/10 and there was no documentation on the MAR that he received pain medication. At 2:00 PM, he rated his pain 9/10 and received a scheduled dose of 7.5 mg of [MEDICATION(S)]. At 4:48 PM, he rated his pain at 6/10 and did not receive pain medication. At 8:00 PM, Resident #2 rated his pain at 7/10 and received 650 mg of Acetaminophen. Liquid [MEDICATION(S)] was available to be administered every hour for pain per his physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] On 2/27/21 at 9:10 PM, a nursing progress note documented Resident #2 was unable to swallow medication. It documented he had no complaints of pain and he was aware of a [MEDICATION(S)] tablet he could request if needed. Per nursing assessment, he could not swallow medication at the time the [MEDICATION(S)] was offered. Liquid [MEDICATION(S)] was available to be administered every hour per Resident #2's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . * On 2/28/21 at 2:40 AM, a progress note documented LPN #2 saw Resident #2 at midnight resting with eyes closed and he awoke to stimuli. No pain assessment was completed, and no pain medication was offered at that time. LPN #2 documented at 2:00 AM Resident #2 was found with approximately a cup of coffee ground vomit on his face and bed. He had an oxygen saturation level of 62% on room air (oxygen saturation level is the amount of oxygen in a person's blood. The normal range is 90-100%), was not responding to stimuli, and was grunting. The progress note documented at 2:30 AM, Resident #2 passed away. Resident #2's last documented dose of pain medication was 6 and ½ hours before his death when he was administered Acetaminophen on 2/27/21 at 8:00 PM. On 6/9/21 at 9:33 AM, Unit Manager #2 was asked how she medicated someone on palliative care for pain control. She stated she lets her residents know she will not allow their pain to go above a 3 on the 0/10 pain scale. She stated she would have a discussion with the residents on what she was seeing in her pain assessment and ask them how they were feeling and if what she was seeing was correct regarding their pain. She stated she monitors palliative care resident's pain every 2 hours, more frequently towards end of life. She stated she would medicate anything at a 3 or higher, tried to keep all pain below a 3/10, and would reassess an hour later to make sure the resident's pain was decreasing. On 6/9/21 at 9:50 AM, the DON stated palliative care in the facility was comfort care, keeping the resident comfortable throughout their stay in the facility and pain control was a big part of palliative care. She stated the differences between the MAR and the pain summary report could be a charting discrepancy. When shown Resident #2's liquid [MEDICATION(S)] order for pain she stated she did not know why it was not given. On 6/9/21 at 11:54 AM, Resident #2's physician was interviewed. When asked about liquid [MEDICATION(S)] and liquid Lorazepam, he stated the medications were available to Resident #2 during his stay and could have been administered, as needed.

Based on policy review, record review, and staff interview, it was determined the facility failed to ensure a resident was sufficiently assessed after a fall and failure to notify the physician after a medication error occurred for 2 of 8 residents (Residents #3 and #5) whose records were reviewed. This resulted in the potential for residents to experience adverse effects from a neurological injury and medications. Findings include: 1. The facility's Care Plan policy, revised 11/28/19, stated staff were to implement immediate interventions to prevent falls, determine whether the resident experienced head trauma requiring further diagnostic evaluation to rule out a subdural hematoma, perform neurologic assessments, investigate the fall, revise the plan of care, and document the post-fall evaluation and fall investigation. The facility's Neurological Evaluation policy, revised 11/28/19, stated Neurological vital signs supplement the routine measurement of temperature, pulse rate, and respirations when a resident is suspected to have hit their head (for example, a fall), has hit their head, or has a traumatic brain or spinal cord injury. Direct the staff to begin neurological assessment following the time frames: every fifteen minutes for an hour, then; every hour for four hours, then; every four hours for nineteen hours. These policies were not followed. Resident #3 was admitted to the facility on [DATE] and then readmitted on [DATE], with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #3's fall risk assessment, dated 12/29/20, documented he was at risk for falls. An Incident and Accident report, dated 3/15/21, documented Resident #3 had a witnessed fall on 3/2/21 from his bedside chair to the floor, and hit the right side of his forehead. His physician and a family member were notified on 3/2/21 and 3/3/21, respectively. A nursing progress note, dated 3/3/21 at 2:42 PM, documented Resident #3 had a bump on his forehead and bruising to his right knee from the fall on 3/2/21. Resident #3's record did not include a post-fall assessment or neurological assessments after he had the fall on 3/2/21. On 4/2/21 at 12:16 PM, the Clinical Resource Nurse stated neurological assessments and a post-fall risk assessment should have been completed for the fall on 3/2/21 because Resident #3 hit his right forehead. The Clinical Resource Nurse was not able to provide an updated fall risk assessment. 2. The facility's Medication Errors policy, dated 11/28/17, defined a medication error as an .observed or identified preparation or administration of medications or biological which is not in accordance with prescriber's order. The policy stated staff were to take immediate actions including notifying the prescribing physician, monitoring the resident closely for 24 to 72 hours or as directed by the physician, and complete a medication error report. This policy was not followed. Resident #5 was readmitted to the facility on [DATE], with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #5's physician order, dated 3/18/21, stated he was to receive [MEDICATION(S)] (blood pressure medication) 3.125 mg one time a day for hypertension (high blood pressure). The order stated, Hold for systolic (upper number of blood pressure measurement) blood pressure less than 100 or heart rate less than 60 [beats] per minute. Resident #5's MAR, dated 3/28/21, documented [MEDICATION(S)] was administered when Resident #5's blood pressure was 94/65 and his heart rate was 50 beats per minute. Resident #5's record did not contain documented evidence of physician notification, monitoring of Resident #5, or a completed medication error report. On 4/2/21 at 3:31 PM, the Clinical Resource Nurse stated it was a medication error and the staff should have followed the policy.

Based on observation, record review, policy review, and resident and staff interview, it was determined the facility failed to respect and maintain each residents' dignity. This was true for 6 of 21 residents (#6, #13, #24, #55, #66, and #420) who were reviewed for dignity. Resident #66 was harmed when he experienced emotional distress when he was incontinent of stool and was unable to use his call light to request assistance. These deficient practices also created the potential for residents to experience embarrassment and decreased sense of self-worth. Findings include: 1. Resident #66 was admitted to the facility on [DATE], with multiple [DIAGNOSES REDACTED]. Resident #66's Physical Therapy Evaluation, dated 10/11/19, documented severe weakness of the left and right hands. Resident #66's admission MDS assessment, dated 10/21/19, documented upper extremity impairment (shoulder, elbow, wrist, and hand) on both sides of the body. The assessment also documented Resident #66 required extensive assistance by two or more staff for physical assistance with dressing, bathing, and personal hygiene. The admission assessment documented Resident #66 was always incontinent and required extensive assistance with two staff for toileting. Resident #66's care plan documented he had limited physical mobility related to physical weakness and stroke. There were no interventions included in the care plan for Resident #66's incontinence. A Physical Therapy Progress report, dated 12/1/19 to 12/7/19, documented Resident #66's remaining impairments included body awareness deficits, decreased functional capacity, gross motor coordination deficits, motor control deficits, and sensation and strength impairments. On 12/8/19 at 1:01 PM, Resident #66 shook his head side to side indicating no when asked if he was cleaned up quickly when soiled (incontinent of stool). On 12/10/19 at 9:08 AM, Resident #66 was in his room lying on his back in bed and there was a strong odor of stool. The following was observed: * At 9:08 AM, Activities Assistant #1 went into Resident #66's room and delivered a paper for his roommate to read then left the room. * At 9:14 AM, CNA #9 walked by Resident #66's room, looked in the room then walked away. * At 9:18 AM, CNA#9 again walked by Resident #66's room, looked in the room then walked away. There was a distinct odor of stool in the hallway outside Resident #66's room. CNA #9, RN #5, and RN #8 walked by Resident #66's room without entering from 9:21 AM to 9:37 AM. An alarm sounded from Resident #66's room for his roommate's ventilator. At 9:40 AM, RN #5 entered the room, the alarm was then quiet, and RN #5 exited the room. The odor was still present upon her exit. There continued to be the odor of stool in the hallway outside Resident #66's room. CNA #15 and RN #5 walked by the room without entering from 9:46 AM to 9:56 AM. At 10:24 AM, Resident #66 was observed crying while lying in his bed in his room. When asked if he had a soiled brief he nodded his head up and down indicating yes. When asked if he could reach his call light on his chest he shook his head side to side indicating no. At 11:11 AM, CNA #9 stated incontinent residents were checked every 2 hours. CNA #9 stated she checked Resident #66 one hour ago. At 11:21 AM, Physical Therapist #1 entered Resident #66's room to perform bedside therapy. Physical Therapist #1 attempted to sit Resident #66 up at the side of the bed and Resident #66 was observed shaking his head side to side indicating no. Physical Therapist #1 then laid him back down into bed and left the room. At 11:26 AM, CNA #15 went into the room and performed incontinence care for Resident #66. On 12/10/19, Resident #66 experienced emotional distress when he was incontinent of stool and unable to use his call light, and remained in an adult brief soiled with stool for 2 hours and 18 minutes (9:08 AM to 11:26 AM). On 12/12/19 at 1:46 PM, Resident #66 was in bed with his call light on his chest. The call light was a hard sided, push button type of call light. When asked if he could use his call light, Resident #66 shook his head side to side indicating no. When asked if he could reach his call light, Resident #66 tried to move his left arm to his chest, but his arm could not move off of the bed. When asked if he had ever had a different type of call light, Resident #66 shook his head side to side indicating no. On 12/11/19 at 8:33 AM, Charge Nurse #1 stated they kept a close eye on residents who required incontinence care. He stated residents were to be checked at a minimum of every two hours. 2. Resident #24, whose age was in the mid-30's, was admitted to the facility on [DATE], with multiple [DIAGNOSES REDACTED]., that affects muscle tone, movement, and motor skills, and may also cause sight, hearing, and learning problems) and intellectual disability. Resident #24's care plan, dated 8/6/19 and 11/21/19 respectively, documented she used a mitt for her right hand for skin protection, used a bottle with a nipple with all liquids, and wore a clothing protector to protect clothing and skin from moisture. On 12/8/19 at 11:52 AM, Resident #24 was in the day room in her wheelchair with a baby bottle and an oven mitt in her lap. She had on a small clothing protector with M&M caricatures on it. On 12/8/19 at 12:47 AM, Resident #24 was at the dining room table with a baby bottle with milk in it and her diet meal ticket at the table documented, Baby bottles for beverages. On 12/9/19 at 9:46 AM, Resident #24 was in the day room in her wheelchair with an oven mitt on her right hand with a detachable strap holding the oven mitt in place around her elbow. She had on a small clothing protector with M&M caricatures on it. On 12/10/19 at 8:50 AM, Resident #24 was at the dining room table drinking juice from a baby bottle. She again had on a small clothing protector with M&M caricatures on it and an oven mitt in her lap. On 12/8/19 at 11:59 AM, RN #8 said Resident #24's oven mitt was used to protect her hand from skin breakdown because she chewed and sucked on her hand. RN #8 said the clothing protector was to protect her skin from breakdown due to oral secretions. On 12/11/19 at 3:15 PM, the Director of Therapy said the facility had not been successful in finding a more appropriate adult-like glove or other option for Resident #24 who chewed on her hand. She said the baby bottle had not been assessed for appropriateness. On 12/11/19 at 3:53 PM and 4:19 PM, the Clinical Resource nurse, with the DON present, said Resident #24's family was providing the baby bottles, the clothing protectors, and the oven mitts. She said she could see how the baby bottles and clothing protectors could be viewed as babyish. The DON said she did not expect Resident #24's meal tray ticket to document the use of a baby bottle. 3. Residents were not served their meals at the same time as their tablemates. a. On 12/8/19 from 12:24 PM to 12:33 PM, Residents #6, #13, #24, and #55 were seated at the same dining room table in the Alpine unit. Resident #13 was assisted with his lunch meal by CNA #9. Residents #6, #24, and #55 had not received their meals. At 12:33 PM, Resident #13 was finished with his meal and CNA #9 assisted him from the dining room. At 12:40 PM, Residents #6, #24, and #55 received their meals and were then individually assisted by three CNAs. At 12:50 PM, CNA #9 said there were not enough staff to assist the residents with their meals. On 12/10/19 at 1:28 PM, UM #2 said residents at the assistance table had not received their meals at the same time because the CNAs were not available to assist them at that time. On 12/11/19 at 4:19 PM, the DON said she expected all of the residents at the same table to be served at the same time with staff there to assist them. b. On 12/8/19 at 12:26 PM, Resident #420 and one other resident were sitting at a table in the dining room. At another table, next to them, there were three residents sitting at the table waiting to be served lunch. The four other residents were served lunch and began eating, while Resident #420 was waiting to be served. On 12/8/19 at 12:33 PM, Resident #420 stated he did not know why he did not receive his meal with the other four residents. At 12:44 PM, LPN #2 observed Resident #420 without a plate in front of him and she notified the kitchen server. At 12:47 PM, Resident #420 was served his meal and he began to eat. The four other residents stayed and visited with each other, while Resident #420 ate his meal. On 12/8/19 at 12:52 PM, LPN #2 stated all the residents at a table should be served their meal at the same time. On 12/8/19 at 1:10 PM, UM #2 stated all the residents should have been served at the same time.

Based on observation, record review, staff interview, resident and family interview, and policy review, it was determined the facility failed to ensure appropriate consent was obtained from a resident's Co-Guardians for a laboratory test when the resident did not have the capacity to make their own medical decisions. This was true for 1 of 26 residents (Resident #69) reviewed for resident rights. This deficient practice caused psychosocial harm by causing emotional distress to Resident #69 after he refused to provide urine for a laboratory test which was later obtained by straight catheter after four staff approached him and stated it was physician ordered. Findings include: The facility's policy Resident Rights, with a release date of 11/28/2017, stated Each resident has the right to exercise their rights as a resident of the Facility and as a citizen or resident of the United States without interference, coercion, discrimination, and reprisal and be supported by the facility in the exercise of those rights . Throughout the Resident Rights policies, the term resident also applies to resident or resident and/or a surrogate decision-maker (any person who may, under state law, act on the resident's behalf when the resident is unable to act for himself or herself). Resident Rights include the resident's right to exercise his or her rights . and participate in decisions .To request, refuse, and/or discontinue treatment .In the case of a resident adjudged incompetent under the laws of a State by a court of competent jurisdiction, the rights of the resident devolve to and are exercised by the resident representative appointed under State law . This policy was not followed. Resident #69 was admitted to the facility on [DATE], with multiple [DIAGNOSES REDACTED]. Resident #69's record included a Letter of Co-Guarding which documented two people were duly appointed and qualified as Co-Guardians for Resident #69 on 6/14/18. The letter documented Resident #69 was an incapacitated and protected person. A quarterly MDS assessment, dated 7/19/19, documented Resident #69 was cognitively intact but he had unclear speech. The assessment documented he required two or more staff for bed mobility, transfers, personal hygiene, toilet use, and dressing. The assessment also documented Resident #69 had impairment on one side of his upper and lower extremities. A Care Plan, revised on 8/5/19, identified Resident #69 had impaired cognitive function with impaired thought processes related to impaired decision making due to [MEDICAL CONDITION]. The goals included communicating with family regrading his capabilities and needs. The care plan interventions included for Resident #69 to be able to communicate his basic needs, to remain oriented to person, place, situation, and time, and to maintain his current level of cognitive function. A behavior progress note by the IDT, dated 7/31/19 at 10:40 AM, stated on 7/29/19 Resident #69 was observed acting out of the ordinary from his base line. A CNA asked Resident #69 what was wrong, and he informed the CNA his caregiver, hired by his family for socialization, had given him a marijuana brownie. The physician was informed, and an order was written for a urine drug screen. The note documented Resident #69's family was informed of the situation also. A physician's orders [REDACTED]. One time only for Urine lab for 1 Day. A progress note, dated 8/2/19 at 8:26 PM, documented urine needed to be collected for a drug/toxicity screen on 7/31/19 for Resident #69. The note stated Resident #69 was refusing to use his urinal and was incontinent of urine and this was reported to the nurse practitioner on call and an order was received to use a straight catheter to obtain the urine sample if Resident #69 allowed. The note documented Resident #69 refused the straight catheter and the nurse practitioner was informed. A nurse's progress note, dated 8/3/19 at 5:56 AM, documented two nurses and a CNA approached Resident #69 and asked him if he would consent to a urine laboratory test ordered by a physician. They told him they would obtain the urine by a straight catheter. Resident #69 agreed to obtaining the urine for the laboratory test. Two nurses and two CNAs obtained the urine sample using a straight catheter. On 12/10/19 at 9:50 AM, Co-Guardian #1 stated after telling the facility not to do a laboratory test for Resident #69, the facility went ahead and did the laboratory test anyway without permission from the guardian. The family member stated there was no need for the test and he had told them that. On 12/12/19 at 3:21 PM, the DON was interviewed regarding the urinalysis obtained without the guardian's permission. The DON said the one guardian had returned after the other guardian had left and said it was okay to do the urinalysis. The DON was asked where it was documented the one guardian had given permission. The DON looked in the notes and stated, I guess no one documented it. On 12/12/19 at 3:25 PM, the Administrator was interviewed regarding the court appointed Co-Guardians of the resident. The Administrator was asked if the Co-Guardians were to decide on Resident #69's medical care and treatments. The Administrator said the guardians had been appointed by the court to oversee Resident #69 in everything but his housing. The housing where Resident #69 was placed was the only thing they both had to agree upon.

Based on observation, record review, policy review, and resident and staff interview, it was determined the facility failed to ensure residents received appropriate care to prevent and treat pressure ulcers. This was true for 2 of 4 residents (#52 and #62) reviewed for pressure ulcers. This deficient practice resulted in harm to Resident #52 when he developed an avoidable pressure ulcer and harm to Resident #62 when he developed two avoidable pressure ulcers and he did not receive treatment for [REDACTED]. The National Pressure Ulcer Advisory Panel, (YEAR), defined pressure ulcers as follows: Stage 1- Intact skin with a localized area of non-blanchable [DIAGNOSES REDACTED] (red discoloration of skin as a result of injury) which may appear differently in darkly pigmented skin. Presence of blanchable [DIAGNOSES REDACTED] or changes in sensation, temperature, or firmness may precede visual changes. Color changes do not include purple or maroon discoloration; these may indicate a deep tissue pressure injury. Stage 2 - Partial-thickness skin loss with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough (non-viable yellow, tan, gray, green, or brown tissue) and eschar (dead or weakened tissue that is hard or soft in texture - usually black, brown, or tan in color) are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. Stage 3 - 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 (when the tissue under the wound edges becomes eroded, resulting in a pocket beneath the skin at the wound's edge) and tunneling (channels that extend from a wound into and through the tissue or muscle below) may occur. Fascia, muscle, tendon, ligament, cartilage or bone is not exposed. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. Stage 4 - 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. Epibole (rolled edges), undermining and/or tunneling often occur. Depth varies by anatomical location. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. Unstageable - 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. Stable eschar (i.e. dry, adherent, intact without [DIAGNOSES REDACTED] or fluctuance) on an ischemic limb or the heel(s) should not be softened or removed. Deep tissue pressure injury - Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or [MEDICATION NAME] separation revealing a dark wound bed or blood-filled blister. Pain and temperature change often precede skin color changes. Discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The Lippincott Manual for Nursing Practice, tenth edition, stated measures to prevent pressure ulcer development included repositioning every two hours, using special devices to cushion the specific area, and use an alternating pressure mattress or air fluidized bed for patients who are at high risk. The facility's Prevention and treatment of [REDACTED].unless the individual's clinical condition demonstrates they were unavoidable .'Avoidable' means that the resident developed a pressure ulcer/injury and that the facility did not do one or more of the following: evaluate the resident's clinical condition and risk factors; define and implement interventions that are consistent with the resident needs, resident goals, and professional standard of practice; monitor and evaluate the impact of the interventions; or revise the interventions as appropriate. The facility's policy and procedure stated Procedure Prevention Steps: A risk assessment is completed upon admission and at designated intervals throughout the resident's stay to evaluate the resident's [MEDICATION NAME] risk .that may have an impact on the development, treatment and/or healing of (pressure ulcers/pressure injuries) .Residents at risk for developing pressure ulcers are identified by using the Braden Scale (a tool that predicts the risk for developing a facility acquired pressure injury) .Pressure ulcer and other wound and skin related interventions are created in collaboration with the interdisciplinary team and implemented in order to identify, prevent or reduce the risk of acquiring pressure and/or non-pressure related wounds or skin issues . This policy was not followed. 1. Resident #62 was admitted on [DATE] and readmitted on [DATE], with multiple [DIAGNOSES REDACTED]. to bypass a damaged part of the colon). a. An admission MDS assessment, dated 8/23/19, documented Resident #62 was at high risk for developing pressure ulcers and had one unhealed Stage 1 pressure ulcer on admission. A significant change MDS assessment, dated 10/16/19, documented Resident #62 had three unstageable pressure ulcers with suspected deep tissue injury and two of these unstageable pressure ulcers were present upon admission/reentry. However, his admission MDS assessment, dated 8/23/19, did not include documentation that Resident #62 had two unstageable pressure ulcers upon admission. A nurse's progress note, dated 11/2/19 at 7:08 PM, documented Resident #62 was not feeling well during the afternoon; he had an elevated temperature and his abdomen was round, firm, and tender to touch. The note documented the Medical Director was notified and x-rays were ordered. The note documented Resident #62's family wanted him sent to the Emergency Department for an evaluation and not to wait for the x-rays at the facility. There was no further documentation if Resident #62 was transferred out of the facility. A nurse's progress note, dated 11/12/19 at 3:46 PM, documented Resident #62 was readmitted from a local hospital. The progress note stated Resident #62 had existing pressure ulcers to his coccyx (tailbone), right buttock, and left ankle. The progress note did not include descriptions or measurements of the pressure ulcers. A weekly skin report, dated 11/12/19, documented Resident #62 was readmitted to the facility and had pressure ulcers to his coccyx, right buttock, and left ankle. The report also documented Resident #62 had scabbing to his abdomen and arms and mentioned his neck/[MEDICAL CONDITION] but did not document what skin impairment was present in that area. There was no further descriptions or measurements of the pressure ulcers. The report stated (Resident #62) readmitted to (facility name) with the above-mentioned injuries to skin; some he had prior to discharge. It was unclear in the documentation which skin injuries/wounds Resident #62 had prior to his discharge to the hospital. A care plan, initiated on 11/12/19, identified Resident #62 had skin impairment/pressure ulcers and the interventions included offloading pressure to the back of his head with an occipital ring, Prevalon boots (boots used to minimize pressure, friction and shear on the feet, heels and ankles of non-ambulatory individuals) to both lower extremities at all times, a pressure relieving cushion for his wheelchair, turning and repositioning every 2 to 3 hours as tolerated, a pressure reducing air mattress on his bed, and following wound clinic orders for treatment of [REDACTED]. Resident #62's record documented he developed avoidable pressure ulcers while at the facility, which included a wound to his right ankle and a wound to his right heel, as follows: * A nurse's progress note, dated 11/15/19 at 7:52 PM, documented Resident #62 had a new suspected deep tissue injury to his right ankle (developed within 3 days of his readmission to the facility). The note documented Resident #62 was wearing the Prevalon boots with hard wedges attached to both sides. The note stated there was a linear shaped purple area surrounded swelling with redness which did not blanch. The nurse documented the wedges were removed from the Prevalon boots and the area was cleansed with normal saline, skin prep (a liquid protective film or barrier) was applied, and the wound was covered with a foam dressing. A wound clinic assessment note, dated 11/19/19, documented Resident #62 had four pressure wounds and that the wound on his coccyx was moisture associated skin damage, not a pressure wound. The clinic note documented the pressure wounds as three unstageable pressure wounds (one on his left ankle with an unknown date of origin, one on the back of his left lower leg which was acquired on 9/17/19, and one on his right buttock which was acquired on 11/12/19), and one deep tissue pressure injury (on his right ankle which was acquired on 11/15/19). * On 12/8/19 at 10:33 AM, Resident #62 was lying in his bed, the sheets were not covering his legs and he had a pillow positioned under each leg. In addition to the right and left ankle pressure wounds, Resident #62 was observed to have an 8 cm, dark rusty-brown, blood blister on his right heel. A wound clinic assessment note, dated 12/10/19, documented the wound to Resident #62's right heel as an unhealed pressure ulcer. The assessment note stated Deep Tissue Pressure Injury, persistent non-blanchable deep red, maroon or purple discoloration measuring 4.2 cm x 1.7 cm x 0. The assessment note did not include information related to when the wound was acquired. On 12/11/19 at 8:38 AM, the Wound Nurse stated the left ankle pressure ulcer and the deep tissue pressure injury to Resident #62's right heel developed in the facility. b. Resident #62's record documented treatment orders, which were not implemented and inconsistent healing of Resident #62's wounds. A wound clinic assessment note, dated 11/19/19, documented Resident #62 had four pressure wounds. The clinic note documented the pressure wounds as three unstageable pressure wounds and one deep tissue injury. The wound clinic note documented the status of the wounds as follows: *The left ankle pressure ulcer had an unknown date of origin. It was an unstageable pressure ulcer with full-thickness skin and tissue loss with measurements of 1.5 cm x 1.3 cm x 0.1 cm. *The left back lower leg wound was acquired on 9/17/19. It was an unstageable pressure injury with full-thickness skin and tissue loss with measurements of 0.4 cm x 0.2 cm x 0.1 cm. *The right ischial (buttock) pressure ulcer was acquired on 11/12/19. It was an unstageable pressure injury with full-thickness skin and tissue loss with measurements of 1.3 cm x 0.5 cm x 0.1 cm. *The right ankle pressure ulcer was acquired on 11/15/19. It was described as a deep tissue pressure injury with a small amount of fluid coming from the wound with measurements of 3.5 cm x 1.5 cm x 0.1 cm. Wound clinic treatment orders for the pressure wounds, dated 11/19/19, included the following: * Left ankle: cleanse wound with normal saline or wound spray, apply skin protectant, apply Alginate with silver (absorbent wound dressing that contains silver), cover with a bordered foam dressing, change the dressing three times a week and as needed for soiling, saturation, or accidental removal. * Left lower leg: cleanse wound with normal saline or wound spray, apply skin protectant, apply Alginate with silver, cover with a bordered foam dressing, change the dressing three times a week and as needed for soiling, saturation, or accidental removal. * Right buttock: cleanse wound with normal saline or wound spray, apply zinc oxide-based cream four times a day and as needed with peri-care. * Right ankle: cleanse wound with normal saline or wound spray, apply skin protectant, cover wound with bordered foam dressing, change dressing every other day and as needed for soiling, saturation, or accidental removal. Resident #62's wound clinic assessment note, dated 11/26/19, documented his left lower leg pressure ulcer had healed and his left ankle wound had decreased in size, but his two other wounds increased in size as follows: * The right ischial pressure ulcer advanced to a Stage 3 with a measurement of 1.5 cm x 2.9 cm x 0.1 cm with a scant amount of drainage. * The right ankle pressure ulcer was described as an unstageable pressure injury with full-thickness skin and tissue loss and had increased in size to 5 cm x 1 cm x 0.2 cm. Resident #62's wound clinic assessment did not include documentation regarding why Resident #62's right buttock and right ankle pressure wounds had increased in size. Resident #62's 11/26/19 wound treatment orders, modified the dressing changes and included Santyl (an enzyme used to heal skin ulcers). The orders stated: * Right and left ankles: Cleanse with normal saline or wound spray, apply skin protectant, apply [MEDICATION NAME] (removal of dead or infected skin) agent Santyl (an enzyme used to heal skin ulcers) and cover with slightly moist gauze, then cover with dry gauze securing with a cloth tape, change dressing daily and as needed for soiling, saturation, or accidental removal. * Right buttock: cleanse the wound with normal saline or wound spray and apply skin protectant, it did not include applying a zinc oxide-based cream. Resident #62's wound clinic assessment note, dated 12/3/19, documented his buttocks and right ankle wounds had decreased in size, but his left ankle wound had increased in size from 1.5 cm x 1.3 cm x 0.1 cm on 11/19/19 to 1.8 cm x 1.6 cm x 0 cm. The note also documented the left ankle wound had a scant amount of drainage. Wound clinic treatment orders for Resident #62, dated 12/3/19, stated to continue the previous wound care recommendations. Resident #62's (MONTH) 2019 TAR did not include documentation the 11/26/19 orders were implemented until 12/05/19 (nine days after the 11/26/19 order). The (MONTH) 2019 TAR documented the Santyl start date for the left and right ankles was 12/5/19. The (MONTH) 2019 TAR documented the dressing changes, also started on 12/5/19, that the dressing were to be changed Monday through Friday, which was not consistent with the 11/26/19 order which stated the dressings were to be changed every day and as needed for soiling, saturation, or accidental removal. The (MONTH) 2019 TAR did not include documentation that the wound dressings on Resident #62's left and right ankles were changed on 12/7/19 and 12/8/19. On 12/8/19 at 10:33 AM, Resident #62 was lying in his bed and the sheets were not covering his legs and he had a pillow positioned under each leg, there were no dressings observed on his ankle wounds. On 12/8/19 at 10:56 AM, at 11:28 AM, at 11:40 AM, and at 12:02 PM, Resident #62's feet were touching the footboard of his bed and there were no dressings observed on his ankle wounds. On 12/9/19 at 9:32 AM, Resident #62 was lying in his bed with his heels resting on pillows. There were no dressings observed on his ankle wounds. On 12/11/19 at 8:24 AM, UM #1 was asked about Resident #62 not having any dressing on his pressure ulcers on 12/8/19 and 12/9/19. He stated if the dressings got wet they were changed and Resident #62 was a very [MEDICAL CONDITION] guy so the dressings may have slipped off. The facility failed to ensure Resident #62's treatment orders were followed. c. Resident #62 was not observed to receive preventative measures for his pressure wounds as ordered: On 12/11/19 at 8:38 AM, the Wound Nurse stated the staff were offloading Resident #62's legs to help prevent pressure ulcers. The Wound Nurse stated Resident #62 was wearing Prevalon boots to prevent pressure ulcers from developing. The Wound Nurse also stated Resident #62 was wearing Prevalon boots since admission and was being followed by a wound clinic since admission. Resident #62's wound clinic assessment note, dated 11/26/19, documented interventions which included repositioning Resident #62 every 2 to 3 hours to alleviate pressure and wearing off-loading boots (Prevalon) to both lower extremities. Wound clinic treatment orders for Resident #62, dated 12/3/19, stated to continue the previous wound care recommendations. Resident #62's (MONTH) 2019 TAR did not include documentation the 11/26/19 orders were implemented until 12/8/19 (twelve days after the 11/26/19 order). The (MONTH) 2019 TAR documented Resident #62 was to have bilateral heel protectors while in bed, with a start date of 12/8/19. * On 12/8/19 at 10:33 AM, Resident #62 was lying in his bed and the sheets were not covering his legs and he had a pillow positioned under each leg. He did not have the Prevalon boots on. * On 12/8/19 at 10:56 AM, at 11:28 AM, at 11:40 AM, and at 12:02 PM, Resident #62's feet were touching the footboard of his bed and he did not have the Prevalon boots on. * On 12/9/19 at 9:32 AM, Resident #62 was lying in his bed with his heels resting on pillows. He did not have the Prevalon boots on. On 12/8/19 at 11:28 AM, Resident #62 was repositioned by four staff. On 12/8/19 at 11:06 AM, Resident #62 said staff did not reposition him that much, he said they did it a couple of times a day. On 12/11/19 at 9:56 AM, UM #1 stated for pressure ulcer care the staff floated both hips then rolled Resident #62 from side to side throughout the day. He stated staff did not document position changes in Resident #62's record, but he trusted it was being done by staff. UM #1 stated it was not unexpected Resident #62's Prevalon boots were not on and it was everyone's responsibility to ensure they were. When asked if Prevalon boots were normally on the MAR/TAR UM #1 stated Resident #62 had them as of 11/17/19. When asked why they were not in his orders, UM #1 stated he did not know if it was the facility policy to have them in orders.When asked if he knew Resident #62 had not been wearing the boots, he stated Resident #62 should have Prevalon boots on at all times and there was no reason he would not have them on that he could think of. The facility failed to ensure Resident #62's received preventative measures for his pressure wounds as ordered. 2. Resident #52 was admitted to the facility on [DATE], with multiple [DIAGNOSES REDACTED]. Resident #52's record included a care plan which documented he was at risk for skin impairment related to his impaired mobility. The care plan included interventions, initiated on 2/6/19, for the use of pillows for positioning, keep his skin clean and dry, offload heels while in bed using heel protectors, use of a pressure reducing mattress and wheelchair cushion, and to reposition 2 to 3 times a shift and as needed. A quarterly MDS assessment, dated 9/20/19, documented Resident #52 was at risk for the development of pressure ulcers and had no unhealed pressure ulcers. A Braden Scale for Predicting Pressure Sore Risk, dated 11/4/19, documented Resident #52 was at high risk for the development of pressure ulcers. A significant change MDS assessment, dated 11/15/19, documented Resident #52 had severe cognitive impairment and he was dependent on staff for activities of daily living including bed mobility, transferring, toilet use, personal hygiene, and bathing. The assessment documented he had an indwelling catheter and was always incontinent of bowel. The assessment documented Resident #52 was at risk for developing pressure ulcers and had two Stage 3 pressure ulcers which were not present upon admission. A weekly skin report, dated 10/31/19 at 5:28 PM, documented Resident #52 had a new skin condition or change since the last documented skin check. The report documented Resident #52 had a medical device related pressure injury to his right outer ankle and both of his lower extremities were [MEDICAL CONDITION] (swollen). The report documented this was a new pressure ulcer and the Comments/Summary section documented Resident #52 had an unstageable pressure injury, potentially caused by suprapubic catheter tubing in his pant leg. A Weekly Pressure Ulcer report, dated 11/1/19 at 1:53 PM, documented Resident #52 had a new onset unstageable pressure ulcer to his right outer ankle. The measurements were 5.5 cm x 2.0 cm x 0.2 cm and the report stated it was caused by a medical device. The report documented Resident #52's wound had a small amount of serosanguineous (yellowish fluid with small amounts of blood) drainage and was obscured by necrosis/unstageable/deep tissue injury. Progress notes dated 11/6/19, 11/12/19, 11/19/19, 11/26/19, and 12/4/19 all documented Resident #52's right outer ankle pressure ulcer was decreasing in size. On 12/13/19 at 9:49 AM, the Wound Nurse was observed while changing the dressing for Resident #52's pressure ulcer. The Wound Nurse stated Resident #52's pressure ulcer to his right outer ankle measured approximately 2.0 cm x 0.5 cm x 0 cm. The Wound Nurse stated Resident #52's legs were very swollen at the time the pressure ulcer developed. The Wound Nurse stated Resident #52 was at a higher risk for the development of pressure ulcers due to the [MEDICAL CONDITION] in his bilateral lower extremities. On 12/10/19 at 3:30 PM, the DON stated Resident #52 was at a higher risk for development of pressure ulcers with [MEDICAL CONDITION] in his bilateral lower extremities. The DON stated the development of the pressure ulcer on Resident #52's right outer ankle could have been avoided if the staff had monitored the position of the catheter tubing and the length of time the catheter tubing had been applying pressure to his skin.

Based on observation, Incident and Accident (I&A) report review, policy review, record review, and staff interview, it was determined the facility failed to ensure residents were protected from falls and did not sustain injuries due to incorrect use of sit-to-stand lifts (STS - used to assist people with limited mobility when they are unable to transition from a sitting position to a standing position on their own). This was true for 1 of 3 residents (Resident #55) reviewed for falls and 1 of 5 residents (Resident #10) reviewed for abuse and neglect. Resident #10 was harmed when she sustained extensive bruising and experienced intense fear and anxiety due to dangling from the sling of a STS lift. These failures also placed Resident #55 at risk of bone fractures or other serious injuries from from repeated falls. Findings include: 1. Resident #10 was admitted to the facility on [DATE], with multiple [DIAGNOSES REDACTED]. Resident #10 annual MDS assessment, dated 10/1/19, documented she was severely cognitively impaired and required extensive assistance of 1-2 staff members for her ADLs. Resident #10's physician's orders [REDACTED]. Resident #10's care plan included the following: - She was at risk for abnormal bleeding or hemorrhage due to anticoagulant use related to use of Aspirin and staff were directed to monitor for signs and symptoms of bleeding such as bruising. - She had mood problems related to anxiety and staff were directed to provide 1:1 reassurance, offer two staff members to assist during these times, offer repositioning, offer warm blankets and soothing music. A Nursing Note, dated 1/17/19 at 9:13 AM, documented Resident #10 had an order for [REDACTED]. A PT Evaluation and Plan of Treatment, dated 1/8/19, documented Resident #10 was severely deconditioned and would benefit from increased postural stability for eating and ADLs. The short and long term goals for Resident #10 were for her to safely perform bed mobility, sit at side of bed up to 30 minutes to increase socialization and to improve postural stability, and to safely propel herself in a wheelchair. A Nursing Note, dated 1/27/19 at 5:30 PM, documented the nurse was called by a CNA to check on the bruise found on Resident #10's arm. The bruise measured 11 cm (centimeter) x (by) 9 cm extending down to her right breast measuring 8 cm x 5 cm. Resident #10 denied pain and did not know how it happened. A Weekly Skin Alteration Report, dated 1/30/19, documented Resident #10 had an 11 cm x 9 cm bruise on her right inner arm and an 8 cm x 5 cm bruise on her right lateral breast. A Weekly Skin Check Report, dated 2/5/19, documented Resident #10 had a 15 cm x 4 cm bruise on her right arm and 15 cm x 5 cm bruise on her right breast. An I&A report documented Resident #10's bruise was found on 1/27/19 and her representatives were notified. The I&A documented during witness statement collection Staff A went and looked at Resident #10's bruise and reported to the nurse she thought the bruise could have happened during her therapy session on 1/26/19 with the STS lift. The I&A report documented the Administrator and DON were notified and Staff F was put on suspension pending investigation. Staff A's written statement, dated 1/27/19 at 5:15 PM, documented on 1/26/19 she went to Resident #10's room to provide pericare and Staff F was in the room working with Resident #10 with the STS lift, and told her to wait. Staff A said on her report she left the room and when she came back she saw Resident #10 dangling from the STS lift and was crying. Staff A asked Staff F if she was done with Resident #10 and was told Not yet. Staff A said she left the room to answer another call light. When Staff A came back to Resident #10's room she saw Staff F still trying to get her to stand using the STS lift. Staff A said on her report Resident #10 was dangling and crying and saying she could not breathe. Staff A said Staff F attempted one more time and Resident #10 was saying she could not do it and she could not breathe. Staff F then put Resident #10 down on the bed and Staff A provided pericare to Resident #10. Staff A's report said Staff F assisted her in providing pericare to Resident #10. A Sit to Stand Lift Criteria - Interior Health Website, accessed on 12/19/19, documented the patient should be able to hold onto both handles on the machine to avoid too much pressure in patient's armpit and should be able to keep both feet flat on the footplate of the lift throughout the transfer. An undated and unsigned statement of Staff F, with handwritten note sometime around 9:30-10ish per (Staff F's name) on the right top corner, documented on 1/26/19 she was with Resident #10 and asked if she was ready to stand up. Resident #10 said No as she had with every other treatment they had. Staff F explained to Resident #10 the benefits of getting out of bed and returning to her prior level of function (PLOF), and that they would just practice standing up. Staff F said on her report that she could tell Resident #10 was not comfortable and resisting too much to achieve standing using the STS lift so she returned her back to a sitting position immediately. Staff F's report documented Resident #10 told Staff F she could not breath and Staff F recognized Resident #10's shortness of breath. Staff F documented she asked Resident #10 to take a deep breath, relax and gave her time to calm down. Staff F's report documented she initiated Resident #10 to stand up again using the STS lift but noticed she had quicker resistance and fear with standing and was much quicker to return to sitting position. Staff F's report documented Resident #10 continued to report difficulty of breathing. Staff F told Resident #10 it was perfectly normal to be scared and it was her job to safely show and encourage residents to return to their PLOF. Staff F then put Resident #10 to bed and assisted Staff A with completing pericare to Resident #10. The I&A report further documented the interdisciplinary team (IDT) determined abuse did not occur to Resident #10 and the bruise was caused by the sling from the STS lift. Staff F was working with her scope of practice and with proper plan of treatment. Staff A did not feel Resident #10 was harmed or abused but had questioned in her head why STS lift was being used and it may have gone on too long without stopping the session. Both Staff A and Staff F were given education regarding customer service and abuse training. There was no documentation Staff F was evaluated for proper use of the STS lift or provided additional training related to its use. On 12/10/19 at 9:31 AM, the Director of Therapy said Staff F choose to leave the facility about six weeks ago. On 12/11/19 at 10:25 AM, the Administrator said Resident #10's bruise was caused by the sling from the STS lift. 2. The facility's Fall Response and Management policy, dated 11/28/17, documented staff were to: * Revise the plan of care, as appropriate * Document in the patient medical record: - Review post fall evaluation and fall investigation - Determine causal factors, if possible - Revise the care plan with interventions Resident #55 was admitted to the facility on [DATE], with multiple diagnoses, which included [MEDICAL CONDITION] (a progressive disease of the nervous system that affects movement) and [DIAGNOSES REDACTED] (progressive brain disorder triggered by abnormal deposits of protein in the brain). A quarterly MDS assessment, dated 11/11/19, documented Resident #55 was cognitively intact and was totally dependent on two or more staff members with bathing, bed transfers and bed mobility. The assessment also documented Resident #55 was not steady and required stabilization with assistance when moving from a seated to standing position and walking. A Fall Risk assessment, dated 11/1/19, documented Resident #55 had a prior history of falls within the last 3 months and scored at risk for falls. A Bed Safety Evaluation, dated 11/1/19, documented Resident #55's bed was to be in the low position. Resident #55's care plan did not document an intervention for his bed to be in the low position, until 11/25/19, 24 days after his Bed Safety Evaluation on 11/1/19 assessed his bed was to be in the low position. A Post Fall Investigation documented Resident #55 fell on [DATE] at 12:40 AM. The investigation documented Resident #55 rolled out of bed and fell on to the floor. The investigation documented Resident #55's bed was not in the low position as directed by his Bed Safety Evaluation. Resident #55's care plan documented staff were to use a bedside impact absorbing floor mat next to Resident #55's bed when he was in bed, initiated on 11/15/19. A Post Fall Investigation documented Resident #55 had an unwitnessed fall on 11/22/19 at 7:00 AM. There were no new documented interventions on Resident #55's care plan to prevent further falls. A Post Fall Investigation documented Resident #55 had an unwitnessed fall on 11/24/19 at 7:20 PM, while transferring out of the wheelchair and into the bed. No new interventions were documented on Resident #55's care plan. A physician's orders [REDACTED].#55 was to have a fall mat to the right side of his bed. A physician's orders [REDACTED].#55 was to have his bed in the lowest position. On 12/10/19 at 10:07 AM, Resident #55 was observed lying in bed. There was no fall mat on the floor by his bed and the bed was not in the lowest position as directed by his care plan and physician orders. On 12/10/19 at 10:56 AM, UM #2 stated there was no floor mat in Resident #55's room and he should have one. On 12/10/19 at 10:58 AM, UM #2 stated Resident #55's fall risk score indicated he was a high fall risk. UM #2 stated care plan interventions should be completed after each fall. The facility did not follow its policy to reassess and revise the care plan after each fall. The facility did not follow the interventions that were documented on Resident #55's care plan and subsequently ordered by his physician, for his bed to be in low position and a floor mat next to his bed.

Based on record review, policy review, and staff interview, it was determined the facility failed to ensure residents were free of both significant and non-significant medication errors. This was true for 2 of 5 residents (#70 and #569) whose medications were reviewed. This failure placed residents at risk for harm when symptoms related to adverse side effects from the medications given in error are not recognized and acted upon promptly and if their condition worsened due to not receiving their prescribed medications as ordered by their physician. Findings include: 1. The facility's policy for Medication Errors, dated [DATE], documented the following: * Medications are managed and safely administered to residents with a minimum of medication errors (not 5% or greater) and residents are free of any significant medication errors. * A significant medication error is one which causes the resident discomfort or places the resident's health and safety in jeopardy. * Facility staff monitor the resident for possible medication-related adverse consequences, including mental status and level of consciousness, when the following conditions occur: A clinically significant change in condition/status, unexplained decline in function or cognition, worsening of an existing problem or condition, new or worsening psychiatric manifestation or distressed behavior, acute onset of signs or symptoms or worsening or a chronic problem or condition, .medication error e.g. wrong or expired medication . * ln the event of a significant medication error or adverse drug reaction, immediate action is taken, as necessary, to protect the resident's safety and welfare . The prescriber is notified promptly of any significant error or adverse medication reaction . Any new prescribed orders are implemented, and the resident is monitored closely for 24 to 72 hours or as directed. This policy was not followed. The Nursing 2019 Drug Handbook documented the eight rights of medication administration were: 1. The right drug. 2. The right patient. 3. The right dose. 4. The right time. 5. The right route. 6. The right reason. 7. The right response. 8. The right documentation. Resident #70 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident #70 had two guardians appointed to him through the courts. Resident #70's record included physician orders [REDACTED]. - Apixaban 5 mg twice a day for [MEDICAL CONDITION] - Atorvastatin 40 mg once a day for high cholesterol - [MEDICATION NAME] 62.5 mcg (microgram) once a day for high heart rate - [MEDICATION NAME] 20 mg once a day for [MEDICAL CONDITION] reflux disease (causes heartburn or indigestion) - [MEDICATION NAME] 5 mg once a day for prostate disorder - [MEDICATION NAME] (insulin) 10 units injected before meals for diabetes - [MEDICATION NAME] Insulin 10 units injected before bedtime for diabetes - [MEDICATION NAME] 20 mg one time a day (for water retention) - [MEDICATION NAME] 40 mg once a day for high blood pressure - [MEDICATION NAME] 50 mg twice a day for high blood pressure - Potassium Chloride 10 mEq (milliequivalent) once a day for low potassium - [MEDICATION NAME] 4 mg once a day for enlarged prostrate - [MEDICATION NAME] 1000 unit once a day for supplement - [MEDICATION NAME] 3 mg at bedtime for [MEDICAL CONDITION] A nurse's progress note, dated [DATE] at 5:28 AM, documented Patient is sleeping soundly in bed, no complaints at this time. Water and call light are within reach. At approximately 1900 (7:00 PM), patient was given [MEDICATION NAME] IR, Soma, [MEDICATION NAME], and trazadone (sic). MD (Medical Doctor) notified and orders to monitor patient q (every) 30 min(utes) then to increase to 1 hr (hour) checks of pulse and oxygen. Patient (oxygen saturation) ranged from ,[DATE]% on RA (room air), and pulse of ,[DATE], normal for patients (sic) baseline. The next nurse's progress note was 25 hours later at 6:39 AM on [DATE]. The note documented report was given by the day shift nurse about the medication error and that Resident #70 was being monitored. The nurse documented after receiving report from the day shift nurse she checked on Resident #70 at 6:30 PM on [DATE], and he was sitting up in bed sleeping. The nurse documented she performed a sternal rub (using the knuckles of the hand to rub the chest to elicit a response due to pain) and Resident #70 was aroused from his sleep. The nurse documented Resident #70 was checked on by staff at 10:15 PM and at 12:30 AM. At 2:15 AM on [DATE], the nurse documented Resident #70 stated he was feeling slightly dizzy and she encouraged fluids since .dayshift staff had stated that Res (Resident #70) did not take in any PO (oral) fluids all day. The nurse documented at 4:40 AM on [DATE], staff went to check on Resident #70 and he was found face down on the floor next to his bed and he told a CNA he fell out of bed. The nurse documented she stayed in the room with Resident #70 while the CNA went to get the Hoyer lift (a mechanical lift) and when she attempted to roll him over his face was red and she felt for a pulse and Resident #70 did not have one. The nurse documented the CNA came into the room and she instructed her to call 911 and to call a code (an alert to staff for an emergency to begin cardiopulmonary resuscitation efforts). The nurse documented Emergency Medical Services arrived a short time later and pronounced Resident #70 dead after they attempted resuscitation for 30 minutes. The note stated the police and coroner were called. The medications Resident #70 received had the following significant side effects according to Drugs.com a nationally recognized resource for medication information, website accessed [DATE]: - [MEDICATION NAME]: [MEDICATION NAME] toxicity which may cause tremors, trouble walking, kidney problems, and an altered level of consciousness; confusion, [MEDICAL CONDITION], irregular heartbeat, increased thirst, unusual tiredness or weakness - [MEDICATION NAME] IR: respiratory depression, confusion, dizziness, faintness, lightheadedness, irregular heartbeat, drowsiness - Soma: difficult or troubled breathing, shakiness, unsteady walk - [MEDICATION NAME]: dizziness, fast heartbeat, weakness, drowsiness, confusion - [MEDICATION NAME]: clumsiness, unsteadiness, tiredness or weakness - [MEDICATION NAME]: confusion, dizziness, faintness, tiredness or weakness, irregular heartbeat - [MEDICATION NAME]: dizziness, [MEDICAL CONDITION], irregular heartbeat A Medication Error report, dated [DATE], documented the wrong medication was given to the wrong patient, Resident #70, at 7:15 PM on [DATE]. The report documented the reason for the error was because the medication was pre-poured. Pre-pouring of medication was removing the medication from the packaging and setting it aside for administration at a later time. The report documented the Medical Director was notified at 8:10 PM on [DATE], and the DON was notified at 8:15 PM on [DATE]. The report also documented the Medical Director ordered for Resident #70 to have his oxygen saturation and heart rate monitored every 30 minutes for two hours and then every hour until the end of the shift. The report documented the outcome to Resident #70 was lethargy (abnormal drowsiness) and his vital signs were stable. Resident #70's record did not include documentation of vital signs or assessments after the medication error as ordered by the Medical Director. An untitled document signed by UM #1, dated [DATE], documented he was called to Resident #70's room and when he entered the medication nurse was taking vital signs for Resident #70. UM #1 stated the nurse at the bedside demonstrated Resident #70 was not responsive to painful stimuli. UM #1 stated he observed Resident #70 for two minutes then in a loud voice called Resident #70 by his name and requested he open his eyes. UM #1 stated Resident #70 promptly opened his eyes. UM #1 stated he asked Resident #70 several questions which he answered accurately. UM #1 stated Resident #70 said he was dizzy and stated that someone had given him something. UM #1 stated he was at the bed side for about 10 minutes. UM #1 stated Resident #70 told him it was not necessary for him to go to the Emergency Department. UM #1 stated he requested the medication nurse continue closely monitoring Resident #70, which was put in place earlier that day. An untitled document dated [DATE] and signed by CNA #13 on [DATE], documented Resident #70 was very drowsy during the day and it .took 20 minutes to get up with sternal rubs. CNA #13 documented Resident #70 was lethargic during the times she provided care. An untitled and undated document signed by CNA #2, documented Resident #70 was pretty drowsy during the day and was hard to wake up. CNA #2 also stated Resident #70 was lethargic but was able to be roused. A police report, dated [DATE], documented RN #3 stated Resident #70 was given the wrong medications between 7:00 PM and 8:30 PM on [DATE], he was given his roommate's medications, and stated Resident #70 was lethargic most of the day, was sleeping a lot, and was dizzy. RN #3 stated this was not normal behavior for Resident #70. An untitled document signed by RN #2, dated [DATE], stated it was a late entry for Resident #70. The note documented at 6:00 AM on [DATE] RN #2 received report from the night nurse that a medication error occurred for Resident #70 at 8:00 PM on [DATE]. RN #2 stated the night nurse told her she received orders from the on-call physician to monitor Resident #70 throughout the night and the observation was to end with the day shift. RN #2 stated the night nurse told her the on-call physician told her Resident #70 would sleep it off the next day. RN #2 stated at 7:30 AM she instructed the CNAs to continue hourly monitoring of Resident #70 by taking vital signs hourly and to leave the pulse oximeter (for monitoring oxygen saturation) on him and to report to her if his oxygen level dropped below 92% or his blood pressure dropped below ,[DATE] (Normal oxygen saturation levels are 90 to 100%). RN #2 stated Resident #70 had stable vital signs and was easily roused when spoken to from 8:00 AM to 3:30 PM on [DATE]. RN #2 stated between 3:30 PM and 4:00 PM on [DATE] Resident #70 was more difficult to rouse and mumbled um-hmm when asked questions. RN #2 stated around 4:30 PM to 5:00 PM on [DATE], a CNA informed her Resident #70's oxygen saturation was in the high 70s. RN #2 stated she went into his room to rouse him and he was deep asleep and she repositioned him and took his vital signs and his oxygen saturation went up to 93%. RN #2 stated she radioed for the Unit Manager to come to Resident #70's room for further assessment. RN #2 stated when the Unit Manager entered the room he spoke to Resident #70 in a loud voice asking him to wake up, Resident #70 opened his eyes and sat up and told the Unit Manager he was sleeping and asked what the Unit Manager wanted. RN #2 stated Resident #70 was awake and stable when nursing staff left the room. On [DATE] at 9:28 AM, the case worker from the Veteran's Administration stated they were called by Resident #70's sister to say he had died . The case worker stated they had called Resident #70's daughter to see if there was anything of concern and she told them she was concerned about the medication error. The case worker stated she did not know how Resident #70's daughter and sister found out about the medication error. She stated Resident #70 was doing well at the last visit she had with him. On [DATE] at 1:05 PM, the Medical Director said he generally expected the nurses to call if there were abnormal vital signs or symptoms that were concerning. He said he would rely on the nurse's assessment of these situations. The Medical Director said he reviewed some of the documentation related to this situation, and some words used in the documentation could have been used inappropriately. He said for example, when the resident responded to voice, but did not respond to painful stimuli, he would then question what was meant by painful stimuli. The Medical Director said Resident #70's medication and the medications he was given in error were reviewed. The Medical Director said the medication given to Resident #70 in error was a big dose of a centrally acting medication, and he would have expected him to be sleepy. On [DATE] at 1:52 PM, UM #1 said the incident regarding the medication error for Resident #70 happened at about 5:00 PM. UM #1 said he was getting ready to leave for the day when the nurse asked him to come down and look at Resident #70. UM #1 said the nurse was giving Resident #70 a sternal rub, and after watching the nurse apply the sternal rub he used a low, slow, loud voice and Resident #70 woke right up. UM #1 said the nurse used her knuckles to apply the sternal rub, and he thought the sternal rub was appropriate. UM #1 said, Honestly, I think that conversation was one of the more honest conversation I have had with this resident. He knew where he was and what was going on. I know I wasn't aware of what the doctor had recommended. When we walked out of the room the nurse told me that they were doing enhanced monitoring of the resident. In the conversation that I had with the nurse the vitals we were monitoring were within parameters. She said the blood pressure and pulse were fine she just couldn't get the resident to respond to her. UM #1 said nursing would generally contact the doctor for change of condition, vital signs out of parameter, and any sort of acute condition. UM #1 said he could not remember what Resident #70 said that made him think he was disoriented, but when he attempted to orient him, he responded quickly that he knew where he was and what happened to him. UM #1 said Resident #70 told him he was given something that he should not have been given. UM #1 said he did not have any idea where the vital signs were documented throughout the day. UM #1 said (Resident #70) had a tendency to play possum a lot. On [DATE] at 3:02 PM, the co-guardians for Resident #70 stated they were not notified of the medication error by the facility, it was his sister who informed them. The co-guardians stated the facility notified them of his death but did not mention the medication error. The co-guardians stated they notified his providers, including the Veteran's Administration, about his death. The co-guardians stated a case worker from the Veteran's Administration called them back and stated they were unaware of the medication error also and the case worker told them she was concerned because they oversaw the care of Resident #70 as well. On [DATE] at 4:19 PM, the Clinical Resource Nurse said she found a note that documented nursing would continue to monitor Resident #70 after the medication error, but she did not find documentation they were going to continue taking vital signs. The Clinical Resource Nurse said she was unable to find documented vital signs after the night shift on the evening of the medication error. On [DATE] at 7:23 PM, RN #2 said her shift on [DATE] was from 6:00 AM to 6:00 PM, and The entire situation was very bizarre. RN #2 said when she arrived at the facility and took over for the night shift nurse, she asked whether Resident #70 was transferred to the Emergency Department (ED) and RN #1 told her the Medical Director had given orders which ended with her shift at 6:00 AM. RN #2 said RN #1 told her she talked to the Medical Director at length, and if Resident #70 did not have any trouble by that time, he would be fine. RN #2 said she was not comfortable with not following up with someone who had taken that many medications in error. RN #2 said she told the CNAs they would continue to monitor Resident #70, the vitals machine was in his room all day, and the pulse oximeter was on him continuously. RN #2 said Resident #70 woke up a few times and mumbled a few words, but other than that he slept all day. RN #2 said she told UM #2 that she was not comfortable with that and she thought he needed to be sent to the ED for fluids or the facility could provide IV (intravenous) fluids onsite for him. RN #2 said UM #2 was very confused about what to do, and he asked the other Unit Manager what to do. UM #1 came over and said not to do any more charting on Resident #70 than we usually do, and if he just sleeps just let him sleep it off. RN #2 said UM# 1 said something like don't chart anything out of the usual and he said if everything was stable or fine, the extra monitoring should not be documented and to keep it at a minimum. RN #2 said Resident #70 then just slept for the rest of the day. He had no bowel movement or urine and he just kept sleeping. RN #2 said between lunch and dinner, the aide came to her and said he was unable to rouse Resident #70. The CNA said he tried to rouse Resident #70 and he would moan, but he would not rouse. RN #2 said when Resident #70 could not be roused, the pulse oximeter was on him and vital signs were being taken, but staff could not rouse him. RN #2 said she called for UM #1 on the radio and he came right away. RN #2 said she thought Resident #70 needed to be sent to the ED, and UM #1 yelled out Resident #70's name and wake up in a loud, deep, baritone voice and Resident #70 opened his eyes and was rousable at that point. RN #2 said UM #1 said, It's just like I thought he was playing possum. RN #2 said, I don't think he is playing possum we couldn't rouse him. RN #2 said UM #1 said Resident #70 did not need to be sent to the ED, RN #2 said she kept asking UM #1 if he was sure and he kept saying Resident #70 did not need to go to the ED. She said Resident #70 woke up and made a short/brief comment like What do you want? I'm sleeping. RN #2 said UM #1 said staff were to make sure Resident #70 ate dinner. RN #2 said Resident #70 did not really get up and eat or drink, and later on the aides brought a meal into his room. RN #2 said she was told by UM #1 and UM #2 throughout the day just to follow the order, and the drug half-life (an estimate of the period of time that it takes for the concentration or amount in the body of that drug to be reduced by exactly one half) had passed through his system, and he was just sleeping as the Medical Director said he would. RN #2 said Resident #70's vital signs were stable, so she did not call the physician. RN #2 said she remembered charting the incident on Resident #70, but she stepped away and the note did not get saved. RN #2 said she was contacted the next morning and was told she needed to write a progress note, and she told the facility she did write a progress note. On [DATE] at 8:31 AM, RN #3 said she worked on [DATE] during the 6:00 PM to 6:00 AM shift. RN #3 said the day shift nurse told her that the night nurse had administered several incorrect medications to Resident #70. RN #3 said she went to Resident #70's room first after she received shift report. RN #3 said Resident #70 was awake, still lethargic, groggy, and sitting up. RN #3 said Resident #70's blood sugar and vital signs were checked, his pulse oximeter reading was in the low 90s at the beginning of the shift, and he could answer questions appropriately. RN #3 said staff checked Resident #70 approximately every hour throughout the night. RN #3 said Resident #70 kept saying he was okay, but he was still lethargic. RN #3 said when he fell , he was able to tell her that he rolled out of bed, and when she tried to get him to roll him over he had a red face. RN #3 said she did not receive any instructions regarding documentation of the incident, and she did not think she needed to contact the physician because Resident #70 was up and answering questions appropriately prior to going to bed. RN #3 said she felt Resident #70 was okay, and he was just lethargic. RN #3 said she initially thought he should have been sent out to the ED. RN #3 said when Resident #70 coded, she asked the physician why he was not sent out to the ED. RN #3 said the physician told her he was not informed of all of the medications that were included in the medication error, and she could not remember which medications the physician was aware of. On [DATE] at 10:35 AM, when asked about what should be documented when monitoring and assessing a resident after a significant medication error, UM #1 said I don't know that. He said, All I really know was I wasn't working on that unit, but as I recall they were monitoring his BP (blood pressure) and pulse for that shift, and level of consciousness. UM #1 said he did not know what was ordered regarding documentation for Resident #70. On [DATE] at 8:18 AM, Resident #70's sister said the facility had called her and told her about her brother passing, but she was not aware of the medication error. She said it surprised her that he died because he seemed to be doing really well. Resident #70's sister stated it may have been his daughters that brought the medication error to the attention of his case managers. On [DATE] at 1:12 PM, the DON said there was no documentation of vital signs that were taken after the time frame that was ordered by the Medical Director. She stated the nurse working the day shift on [DATE] did not write a progress note. The DON stated she could not answer why the assessments conducted by the nurse were not documented in Resident #70's record but stated they should have documented the assessments. 2. The facility's policy for Pharmacy Services, dated [DATE], documented the facility provided pharmaceutical services including assuring the accurate acquiring, receiving, dispensing, and administering of drugs and biologicals to meet the needs of each resident. The policy stated the pharmacy worked with the facility to ensure that medications were requested, received, and administered in a timely manner and as ordered by the prescriber. This policy was not followed. Resident #569 was admitted to the facility on [DATE], with multiple [DIAGNOSES REDACTED]. Resident #569's record included physician orders, dated [DATE], for [MEDICATION NAME] (an inhaled medication to treat [MEDICAL CONDITION]),[DATE].5 mcg inhale 2 puffs orally two times a day for [MEDICAL CONDITION], sodium [MEDICATION NAME] (antacid) 650 mg 2 tablets by mouth two times a day for heartburn, [MEDICATION NAME] (a pancreatic enzyme replacement) delayed release particles 6000 Units 1 capsule by mouth three times a day for diarrhea. Resident #569's record included progress notes dated [DATE] at 5:09 PM and 5:17 PM, respectively, which documented the facility was awaiting delivery from the pharmacy to administer the [MEDICATION NAME], sodium [MEDICATION NAME], and Creon. A packing list from the pharmacy documented medications were delivered to the facility on [DATE] at 6:46 PM. The packing list included the 3 medications ordered for administration to Resident #569 that evening. The medications were not administered as ordered. Resident #569's (MONTH) 2019 MAR indicated [REDACTED]. On [DATE] at 1:30 PM, the DON was interviewed regarding Resident #569 not receiving the 3 ordered medications on [DATE]. The DON said she did not know why the LPN did not administer the medications as ordered to Resident #569.