Every finding on record at Cerenity Care Center on Humboldt

Based on observation, interview and document review, the facility failed to maintain a clean, homelike environment for 2 of 2 residents (R45, R2) who received nutrition via tube feeding.Findings include: R45 R45's admission Minimum Data Set (MDS) dated [DATE], indicated R45's cognition could not be assessed, was dependent on staff for all activities of daily living (ADLs), and required nutrition through a feeding tube. R45's diagnosis included traumatic brain injury (a condition resulting from an injury to the head causing disruption of normal brain function and can affect cognition, speech, and physical abilities). R45's care plan dated 10/3/25, indicated potential for altered nutritional/hydration status related to tube feeding. R45's care plan instructed staff to administer tube feeding with water flushes per provider order. R45's care plan further indicated R45 also received an oral diet with modified textures for pleasure or comfort. R45's provider order dated 3/2/26, indicated, Tube Feeding: Continue with EN [enteral nutrition] support via PEG [percutaneous endoscopic gastrostomy – a tube through the abdomen into the stomach]. Current EN prescription is Osmolite 1.2 at 55 milliliters (ml)l/hour. Water flush of 65 ml/hr. Tube feeding administered continuously using enteral pump. During observation on 3/2/26 at 6:44 p.m., R44 had a tube feeding formula hanging. The tube feeding was attached to R45 via a PEG tube and running. The base of the pole that held the bag of tube feeding formula and water flush, as well as the enteral feeding pump had numerous spots of a dried beige substance which appeared to be tube feeding formula spillage. During observation on 3/3/26 at 10:06 a.m., R44 was in bed with his tube feeding attached and running and still had numerous spots of a dried, beige colored substance on the base of the tube feeding pole. During observation on 3/3/26 at 10:45 a.m., housekeeper (H)-A was in R45's room cleaning. During interview on 3/3/26 at 10:48 a.m., H-A stated she had finished cleaning R45's room. H-A reentered R45's room and confirmed R45's tube feeding pole had a copious amount of tube feeding formula spilled on the base. H-A stated they did not think the tube feeding poles that were in use were her responsibility to clean. H-A stated she would move the pole and clean the floor under the pole, when necessary, but would not touch the pole otherwise while the feeding was running and attached to the resident. H-A further stated, I don't know who is supposed to clean it. R2 R2's quarterly MDS dated [DATE], indicated R2 had severe cognitive impairment, impairment of upper and lower extremities, and was dependent on staff for bed mobility, and transfers. It also indicated R2 required EN and had diagnoses of stroke with hemiplegia (paralysis to one side of the body) and severe protein-calorie malnutrition. R2's care plan dated 2/1/26, indicated potential for altered nutritional/hydration status related to tube feeding. R2's care plan instructed staff to administer tube feeding with water flushes per provider order. R2's care plan further indicated R2 also received an oral diet with modified textures for pleasure or comfort. R2's physician order dated 2/27/26, indicated, Tube feeding continue with EN support via G- tube. Current EN prescription was Isosource 1.5, 45ml/hr. Water flush of 25ml/hr. Tube feeding administered continuously using enteral pump. During observation on 3/2/26 at 4:49 p.m., R2 had tube feeding formula hanging, attached to R2 via G-tube and running. The base and the pole that held the bag of tube feeding formula and water flush, as well as the enteral feeding pump had copious amount of light brown drips and large brown spots of dried liquid on it. During observation on 3/3/26 at 11:20 a.m., R2 was in bed with his tube feeding attached and running and still had copious amounts of dried beige colored substance on the base of the tube feeding pole. During interview on 3/3/26 at 11:39 a.m., housekeeper (H)-B stated they cleaned R2 room, however, housekeeping was not responsible for cleaning R2's tube feed pole or machine. H-B verified there was a lot of brown dried liquid all over the pole and the base of the pole. The housekeeping cleaning list did not have tube feeding pole listed to clean it. During interview on 3/3/26 at 11:53 a.m., registered nurse (RN)-F stated there was a large amount of dried formula on the machine, pole and base. Furthermore, RN-F had administered R2's medication this am, however, did not clean the pole or machine. During interview on 3/3/26 at 11:35 a.m., RN-A stated they would expect nursing to wipe up any formula at the time of the spill and that housekeeping could also share the responsibility if a dirty pole was seen when cleaning the resident room. RN-A further stated they would expect residents to have a clean, homelike environment. During interview on 3/3/26 at 3:37 p.m., director of nursing (DON) stated nursing should clean the tube feeding poles when a spill occurs, and that housekeeping could also clean the poles as needed. DON stated would expect residents' dignity to be considered and should and a clean homelike environment provided. Facility policy titled Monitoring Residents Receiving Enteral Feedings dated August 2019, directed the nursing staff to be responsible for the administration of enteral feedings and all feeding equipment. Facility policy titled Resident Care Equipment dated 1/2024, directed staff to ensure IV poles were cleaned when soiled by either housekeeping or nursing.

Based on interview and document review, the facility failed to ensure an antipsychotic medication (medication that works by changing the effects of chemicals in the brain) had a qualifying diagnosis to support its use for 1 of 5 residents (R8) reviewed who required antipsychotic medicationsFindings include:R8's quarterly Minimum Data Set (MDS) dated [DATE], identified moderate cognitive impairment. R8 did not hallucinate, have delusions, behaviors, wander or reject care during the assessment period. R8 took an antipsychotic medication in the last seven days, and an indication was noted.R8's psychotropic drug use care plan dated 2/27/26, identified psychotropic medication was in use, to administer medications per MD (medical doctor) order, monthly medication record review by pharmacist, and monitor for target behaviors daily.R8's provider orders dated 9/17/25, identified Risperdal (risperidone, an antipsychotic medication) two milligrams (mg) tablets by mouth at bedtime for a diagnosis of major depressive disorder, single episode, mild.R8's available Associated Clinic of Psychiatry (ACP) visits dated 10/28/25, 10/31/25, 11/20/25, 12/1/25, 1/9/26, and 1/23/26, lacked a diagnosis associated with Risperdal use.R8's Consultant Pharmacist (CP) recommendation to physician dated 8/23/25, and 1/19/26, identified R8 received an antipsychotic medication Risperdal 2 mg at bedtime for MDD (major depressive disorder, mild) and a qualifying diagnosis to support its use was not documented. Per CMS (Center for Medicaid and Medicare Services) guidelines and DSM-5 (Diagnostic and Statistical Manual of Mental Disorder) diagnostic criteria, antipsychotic medications are generally appropriate only when used to treat the following conditions:Schizophrenia spectrum disorders (e.g. schizophrenia, schizoaffective disorder, schizophreniform disorder, delusional disorder)Bipolar I or II disorders with manic, mixed or psychotic features.Major depressive disorder with psychotic featuresRefractory major depressionBrief psychotic disorderPsychotic disorder due to another medical condition (e.g. delirium with psychotic features)Other specified or unspecified schizophrenia spectrum and psychotic disorders.During an interview on 3/5/26 at 12:15 p.m., the director of nursing (DON) stated R8's diagnosis should come from ACP psychiatry and not the primary care provider. The DON stated the facility policy was to print the recommendation and follow up right away by giving the recommendation to the provider. The DON stated there was no documentation the facility followed up with the ACP provider to obtain a qualifying diagnosis. The DON did not identify what types of qualifying diagnoses applied to antipsychotic medications. During an email on 3/5/26 at 1:09 p.m., the CP identified she was not available for phone calls. The CP's email response identified R8's' psychiatric services were managed by ACP. In situations where outside psychiatric providers oversee psychotropic management, the facility appropriately forwards consultant pharmacist recommendations to the prescribing provider by fax for review. The facility's Psychotropic Medication Use policy dated 9/7/23, directed the DON to implement the policy to ensure psychotropic medications were ordered by the medical provider to treat a specific condition as diagnosed and documented in the medical record. Additionally, the nursing associates would collaborate with the medical providers to ensure the lowest possible dosage was given for the shortest period. The policy lacked the process to review qualifying diagnoses for antipsychotic medications.

Based on observation, interview and document review the facility failed to ensure the manufacturer's recommended sling size was used for 1 of 1 resident (R79) reviewed for mechanical lift transfers. Findings include: R79's quarterly Minimum Data Set (MDS) dated [DATE], identified severely impaired cognition and no behaviors. R79 had impairment to upper and lower extremities, was dependent staff for bed to chair transfers and had a diagnosis of traumatic brain dysfunction. R79 had no falls since the prior assessment.R79's admission Activities of Daily Living (ADL) Care Area Assessment (CAA) dated 9/17/25, identified the CAA triggered due to assistance required in ADLs, impaired balance and transition during transfers and functional impairment in activity. Contributing factors included generalized weakness.R79's ADL care plan dated 9/11/25, identified two staff assist was required with full body mechanical lift with a sling size of medium.R79's Safe Lifting and Movement assessment dated [DATE], identified he could not stand for eight seconds without any devices, had unpredictable behavior changes frequently and was unable to follow simple commands. R79 required two person transfers with full body mechanical lift and R79's height was five feet seven inches and most recent weight was 155 pounds. During an observation and interview on 3/2/26 at 3:24 p.m., nursing assistant (NA)-A positioned an EZ Lift brand full body sling with maroon straps under R79 while he sat in his wheelchair. NA-A had not looked at the sling label for size, and positioned the sling behind R79's back, brought the leg straps under R79's legs, crossed the straps, connected the sling to EZ Lift model 798 (full body mechanical lift) and connected the longer lower loop to the EZ Lift hooks. NA-B connected the upper loops using the lower strap to the EZ lift hooks. NA-A raised R79 in the sling out of R79's wheelchair, pushed the lift over to the bed, lowered R79 to the bed and NA-A and NA-B lowered the sling to the bed and removed the sling from under R79. During the transfer R79's body was tilted to the right, instead of straight up and down, and his left hip and buttocks hung down through the sling seat opening area. When asked what sling size was used, NA-A picked up the sling that was removed and read the label which read size large. NA-A stated he should have checked the sling size before completing the transfer. NA-A removed the sling from R79's room as it was soiled.During a follow up interview on 3/2/26 at 5:38 p.m., NA-B stated staff should reference the care card for mechanical lift sling sizes. NA-B presented the care card which specified a medium sling should have been used. NA-B stated sometimes if a resident had a shower and the sling got wet, staff would have to use what was available. NA-B confirmed she was with Na-A during the transfer, and the sling size was not checked.During an interview on 3/2/26 at 5:43 p.m., registered nurse (RN)-B stated mechanical lift sling size was the responsibility of the managers and the staff should reference the resident care cards. RN-B presented R79's care card which identified he needed a medium body sling. RN-B stated she would look for a medium sling, since NA-A brought the sling to the laundry and no sling was currently available.During an interview on 3/4/26 at 2:38 p.m., the director of nursing (DON) stated therapy would establish sling size for residents and communicate with the managers so the care cards could be updated. The purpose of appropriately sizing a sling was to prevent accidents due to unsafe equipment.During an interview on 3/5/26 at 11:53 a.m., the physical therapist (PT) verified R79 should use a medium size sling to ensure transfers are stable.The EZ Way Sling Size Chart (form #2-150) dated 9/13/24, identified a large sling (burgundy straps) should be used for resident weight of 190 to 330 pounds and maximum distance from tailbone to base of neck of 26 inches, and medium sling size (beige straps) should be used for resident weight of 90 to 220 pounds and maximum distance from tailbone to base of neck 24 inches.The facility's undated policy titled Using a Mechanical Lift, identified a resident needed to be measured for proper sling size and purpose according to manufacturer's instructions and to double check the sling and machine's weight limit against the resident's weight. After placing the sling under the resident, visually check the size to ensure it is not too large or too small.

Based on observation, interview, and document review, the facility failed to ensure administration of tube feeding formula according to provider orders for 1 of 1 resident (R45) reviewed for tube feeding. Findings include:R45's admission Minimum Data Set (MDS) dated [DATE], indicated R45's cognition could not be assessed, was dependent on staff for all activities of daily living (ADLs), and required nutrition through a feeding tube. R45's diagnosis included traumatic brain injury (a condition resulting from an injury to the head causing disruption of normal brain function and can affect cognition, speech, and physical abilities). R45's care plan dated 10/3/25, indicated potential for altered nutritional/hydration status related to tube feeding. R45's care plan instructed staff to administer tube feeding with water flushes per provider order. R45's care plan further indicated R45 also received an oral diet with modified textures for pleasure or comfort.R45's nutrition progress note by registered dietician (RD) dated 3/2/26 at 2:54 p.m., indicated R45 experienced a weight gain since admission of 15 pounds which was contributed to good oral intake combined with tube feeding formula running at 75 milliliters an hour (ml/hr) continuously for 24 hours with water flushes of 65 ml/hr over 24 hours. R45's progress note indicated RD ordered a reduction in the tube feeding rate to 55 ml/hr and continued the water flushes as previously ordered.R45's provider order dated 3/2/26, indicated, Tube Feeding: Continue with EN [enteral nutrition] support via PEG [percutaneous endoscopic gastrostomy - a tube through the abdomen into the stomach]. Current EN prescription is Osmolite 1.2 at 55 ml/hour. Water flush of 65 ml/hr. Tube feeding administered continuously using enteral pump.R45's March 2026, medication administration record (MAR) printed on 3/3/26 at 10:20 a.m., indicated R45's tube feeding of 55 ml/hr with water flushes at 65 ml/hr was signed off as completed on 3/2/26 shift 2 (evenings) and shift 3 (nights), and 3/3/26 shift 1 (days). R45's MAR further indicated the tube feeding at 70 ml/hr with 65 ml/hr water flush was not given on 3/2/26 at 3:40 p.m., due to being discontinued.During observation on 3/2/26 at 6:44 p.m., R45's tube feeding was running at 70 ml/hr.During observation 3/3/26 at 10:06 a.m., R45's tube feeding was running at 70 ml/hr. The tube feeding formula was labelled 3/3/26 1:30 a.m.During interview on 3/3/26 at 10:32 a.m., licensed practical nurse (LPN)-A stated when a resident received continuous tube feeding and water flushes, the formula and water bags were changed when they ran out. LPN-A stated R45's tube feeding was running at 70 ml/hr as it had been for quite some time. LPN-A stated they just replaced the bags as needed and did not adjust the rate since the rate never changed. LPN-A looked in R45's electronic medical record (EMAR) and verbally verified R45 had a new order for his tube feeding to run at 55 ml/hr instead of 70 ml/hr. LPN-A entered R45's room and confirmed R45's tube feeding was running at 70 ml/hr and it was not running as ordered. LPN-A stated when a new order was placed, a second nurse had to verify the order in the EMAR prior to the first administration of the new order. During interview on 3/3/26 at 2:40 p.m., LPN-B stated he verified R45's new order of 55 ml/hr in the EMAR on 3/2/26 at the start of the evening shift but did not hang a new bag on his shift. LPN-B stated he signed off the tube feeding in the EMAR for his shift to indicate the rate had been confirmed but stated he did not visually confirm the rate at which R45's tube feeding was running. LPN-B could not explain why he was not aware of the new rate even though he had verified the new order in the EMAR.During interview on 3/3/26 at 2:47 p.m., registered nurse (RN)-A expected nurses to follow orders as written and would not expect nurses to sign off medication administration or treatments if not actually completed. RN-A stated orders should be verified by a second nurse. The nurse who verified the order would sign off the order as verified prior to any administration or treatment.During interview on 3/3/26 at 3:37 p.m., director of nursing (DON) expected nursing staff to follow provider orders as written and not sign off items on the MAR or TAR if not actually completed. During interview on 3/4/26 at 1:54 p.m., RD stated would expect orders to be followed as entered. RD stated R45's tube feeding rate had been changed on 3/2/26, to a lower rate due to his weight gain and would expect nurses to have changed the rate with the most recent administration.A facility policy titled Monitoring Residents Receiving Enteral Feedings dated August 2019, indicated residents who receive enteral feeding will receive appropriate treatment.

Based on observation, interview and document review, the facility failed to ensure respiratory equipment was properly maintained for 1 of 1 resident (R44) reviewed for respiratory care. Findings include:R44's admission Minimum Data Set (MDS) dated [DATE], indicated R44 had intact cognition, required partial/moderate assistance with most activities of daily living (ADLs), and required oxygen therapy while a resident. R44's diagnoses included chronic respiratory failure, congestive heart failure (CHF) and dependence on supplemental oxygen. R44's care plan dated 1/15/26, indicated R44 required special treatments including oxygen therapy. R44's treatment administration record (TAR) dated 2/15/26 through 3/2/26, indicated, Change humidifying jar [bubbler] weekly.once a day on Sun. The TAR indicated the task was signed off as completed on 2/15/26, 2/22/26, and 3/1/26. During observation on 3/2/26 at 1:35 p.m., R44 was in her room in a wheelchair with oxygen administered via nasal canula at 2 liters per minute. The undated oxygen tubing was attached and running through a bubbler. The bubbler was labeled, 2/15 JMD. During interview on 3/2/26 at 1:51 p.m., licensed practical nurse (LPN)-C stated oxygen tubing and bubbler were changed once a week by the nurse. LPN-C stated she forgot to change R44's bubbler yesterday (3/1/26). Further, she verified she should not have signed it off as being completed since she did not complete the task outlined on the TAR. LPN-C confirmed R44's oxygen tubing was not dated, and the bubbler was dated 2/15. LPN-C could not confirm when the tubing had last been changed and could not explain why the bubbler was signed off as changed on 2/22/26 and still had the 2/15 date on it. During interview on 3/3/26 at 2:47 p.m., registered nurse (RN)-A expected nurses to follow orders as written and would not expect nurses to sign off medication administrations or treatments if they were not actually completed. RN-A further stated R44's oxygen tubing and bubbler should be changed weekly to prevent any respiratory infections. During interview on 3/3/26 at 3:37 p.m., director of nursing (DON) stated staff were expected to follow provider orders as written and not sign off items on the medication administration record (MAR) or TAR if not actually completed. Facility policy Cleaning of Oxygen Equipment dated June 2017, identified purpose to reduce the risk of infections and directed staff to replace oxygen tubing and humidifier bottle once a week and to use tape to place date and initials on tubing and bottle when replaced.

The facility failed to ensure new medication orders were transcribed correctly to ensure accurate medication administration for 1 of 1 resident (R79) who was reviewed for recent medication changes. Findings include:R79's quarterly Minimum Data Set (MDS) dated [DATE], identified severely impaired cognition and no behaviors. R79 had impairment to upper and lower extremities, was dependent on staff for bed to chair transfers and had a diagnosis of traumatic brain dysfunction.R79's Cognitive loss/Dementia care plan dated 1/20/26, identified a diagnosis of cognitive loss from a traumatic brain dysfunction. R79 would receive services and assistance needed specific to his cognitive function. R79's family member assisted with decision making.R79's hospital After Visit Summary (AVS) dated 2/27/26 at 9:53 p.m., identified he was seen due to redness of skin, seizure like activity and fever. Instructions included to stop taking lacosamide which is an anti-seizure medication, and to start taking levetiracetam (Keppra) which is a different antiseizure medication; take 500 milligrams (mg) by mouth two times a day for 14 days.R79's undated active orders included:-Start date of 2/25/25, lacosamide 100 mg tablet by mouth two times a day.-Start date of 2/28/26, levetiracetam 500 mg tablet by mouth two times a day for 14 days.R79's medication administration record dated 2/25/26 through 3/2/26, identified lacosamide 100 mg by mouth twice daily was documented as held due to R79's emergency department (ED) visit on the evening of 2/27/26, refused the morning of 2/28/26, on hold per report the evening of 2/28/26, refused the morning of 3/1/26, and on hold the evening of 3/1/26. The medication was administered the morning of 3/2/26. The medication was not discontinued from R79's medical record on 2/27/26, as ordered in the AVS.During an interview on 3/2/26 at 12:16 p.m., R79's family member (FM)-A stated last week R79 had what looked like a seizure, went to the hospital to be evaluated and was started on lacosamide (an antiseizure medication). A couple of days later R79 went to the hospital again with a suspected reaction to the lacosamide which included a new rash and lip swelling. The hospital doctor discontinued the lacosamide and started a new anti-seizure medication and R79 returned to the facility.During an observation and interview on 3/2/26 at 3:45 p.m., licensed practical nurse (LPN)-G and registered nurse (RN)-E entered R79's room with one yellow shaped pill and stated it was R79's lacosamide. FM-A stated the lacosamide was discontinued and showed R79's AVS dated 2/27/26, which identified the medication was discontinued. LPN-G and RN-E left R79's room and went to the nurse's cart. At the cart, the lacosamide 100 mg was verified as the pill brought into R79's room. FM-A brought the AVS up to the nurse's cart and LPN-G and RN-E verified the AVS FM-A had, matched the AVS which was uploaded in R79's electronic medical record (EMR). FM-A stated there were no signs of current allergy.During a follow up interview on 3/2/26 at 3:55 p.m., registered nurse (RN)-E verified lacosamide was an active order and the previous nurse should have discontinued the medication from the system and not documented as refused or held. RN-E stated he called R79's primary care provider and was awaiting a return call.During an interview on 3/2/26 at 4:12 p.m., RN-B stated after hours, and on weekends, new orders were to be transcribed into the medical record by a nurse and verified by another nurse. RN-B reviewed R79's AVS and stated the order should have been discontinued from R79's EMR. RN-B stated the interdisciplinary team reviewed R79's emergency room visit but had not looked to see if the new orders had been implemented correctly.During an interview on 3/3/26 at 2:58 p.m., LPN-E stated she worked with R79 on the weekend. On weekends and after hours the nurse on duty would update orders into the EMR and a second nurse would verify the orders. LPN-E stated she held the medication on the weekend due to family request. LPN-E stated the medication should have been discontinued from the EMR once the new orders were received. During an interview on 3/4/26 at 9:19 a.m., the nurse practitioner (NP) stated she was updated on 3/2/26, about the medication transcription error and that R79 received an extra dose after the lacosamide was discontinued. The NP would have expected the medication to be transcribed as ordered. Additionally, the transcription error was not serious because after the medication was discontinued, only one extra dose was administered. NP-A stated she was unsure of lacosamide being a true allergy at this time. During an interview on 3/4/26 at 2:58 p.m., RN-C stated she worked on 2/27/26, in the evening when R79 returned from the emergency department. RN-C stated she entered the new order for Keppra into R79's EMR, however did not see the new order to stop the lacosamide.During an interview on 3/5/26 at 12:22 p.m., the director of nursing (DON) stated he expected two nurses to verify new medication orders for accuracy. New orders for a resident should be reviewed and implemented as soon as possible. The DON stated the order was missed on the AVS at the time of R79's return, and subsequent nurses had not reviewed the original AVS.A medication transcription policy was not obtained on survey.

Based on interview and document review, the facility failed to ensure consultant pharmacist recommendations were followed up timely for 1 of 5 residents (R8) reviewed for unnecessary medications.Findings include:R8's quarterly Minimum Data Set (MDS) dated [DATE], identified moderate cognitive impairment. R8 did not hallucinate, have delusions, behaviors, wander or reject care during the assessment period. R8 took an antipsychotic medication (medication that works by changing the effects of chemicals in the brain) in the last seven days, and an indication was noted.R8's psychotropic drug use care plan dated 2/27/26, identified psychotropic medication was in use, to administer medications per MD (medical doctor) order, monthly medication record review by pharmacist, and monitor for target behaviors daily.R8's prescription orders dated 9/17/25, identified Risperdal (risperidone. antipsychotic medication) two milligrams (mg) tablets by mouth at bedtime for a diagnosis of major depressive disorder, single episode, mild.R8's available Associated Clinic of Psychiatry (ACP) visits dated 10/28/25, 10/31/25, 11/20/25, 12/1/25, 1/9/26, and 1/23/26 lacked a diagnosis for Risperdal.R8's Consultant Pharmacist (CP) Recommendation to Physician dated 8/23/25, and 1/19/26, identified R8 received an antipsychotic medication Risperdal (risperidone) 2 mg at bedtime (HS), for MDD (major depressive disorder, mild) and a qualifying diagnosis to support its use was not documented. Per CMS (Centers for Medicaid and Medicare Services) guidelines and DSM-5 (Diagnostic and Statistical Manual of Mental Disorder) diagnostic criteria, antipsychotic medications are generally appropriate only when used to treat the following conditions:Schizophrenia spectrum disorders (e.g. schizophrenia, schizoaffective disorder, schizophreniform disorder, delusional disorder)Bipolar I or II disorders with manic, mixed or psychotic features.Major depressive disorder with psychotic featuresRefractory major depressionBrief psychotic disorderPsychotic disorder due to another medical condition (e.g. delirium with psychotic features)Other specified or unspecified schizophrenia spectrum and psychotic disorders.R8's electronic medical record lacked indication the facility had followed up on the CP recommendations from 8/23/25 or 1/19/26. Follow up for R8's CP recommendations for 8/23/25 and 1/19/26 were requested, however were not received.The CP issued the recommendations first on 8/23/25, and again on 1/19/26, and it was still not addressed 3/5/26, which was 6 months and 10 days after the initial recommendation.During an interview on 3/5/26 at 12:15 p.m., the director of nursing (DON) stated R8's diagnosis should come from ACP psychiatry and not the primary care provider. Additionally, CP recommendations should be followed upon monthly unless otherwise indicated by the CP. The DON stated the facility policy was to print the recommendation and follow up right away by giving the recommendation to the provider. The DON stated there was no documentation the facility attempted to follow up with the ACP provider to obtain a qualifying diagnosis. During an email on 3/4/26 at 2:33 p.m., the CP identified she was not available for phone calls. The expectation was that clinical staff respond in a timely manner either accepting the recommendation or providing patient specific clinical rationale as to why the recommendation was declined.Communication via email on 3/5/26 at 1:09 p.m., the CP identified she was not available for phone calls. The email response identified timely follow-up and resolution of CP recommendations were routinely emphasized through ongoing collaboration with facility leadership. During Quality Assurance and Performance Improvement (QAPI) meetings and routine discussions with the DON, the importance of reviewing and responding to recommendations in a timely manner was reinforced. For R8, the initial recommendation was made in August. Follow-up communication was provided via email to the DON in October, and the recommendation was re-sent in January to ensure continued review. The residents' psychiatric services were managed by ACP. In situations where outside psychiatric providers oversaw psychotropic management, the facility was expected to forward the recommendations to the prescribing provider by fax for review. When monitoring response timelines, the CP took these additional communication steps and the involvement of outside specialty providers into consideration, while continuing to follow up as needed to support appropriate medication management.The facility's Psychotropic Medication Use policy dated 9/7/23, identified the DON was responsible for implementation of this policy. Psychotropic medications were ordered by the medical provider to treat a specific condition as diagnosed and documented in the medical record. Additionally, the nursing associates would collaborate with the medical providers to ensure the lowest possible dosage was given for the shortest period. The policy lacked the process to review qualifying diagnoses for antipsychotic medications.The facility's Consultant Pharmacist Services Provider Requirements dated 12/17, indicated a written or electronic report of findings and recommendations would be completed monthly and the facility had a process to ensure the findings were acted upon.

Based on observation, interview and document review the facility failed to implement enhanced barrier precautions (EBP) for 2 of 2 residents (R19 and R2) observed for EBP.Findings include: R19 R19's comprehensive Minimum Data Set (MDS) dated [DATE], identified moderately impaired cognition, no behaviors or rejection of care. R19 required substantial/maximal assistance with eating, bathing and dressing. Diagnoses included orthopedic aftercare. R19 had two unhealed pressure ulcers classified as unstageable (wounds where the extent of tissue damage cannot be identified) and present upon admission. R19's admission pressure ulcer Care Area Assessment (CAA) dated 12/17/25, triggered due to actual pressure ulcers. Care plan interventions would be initiated to improve current activities of daily living status and functional ability. R19's care plan dated 2/14/26, identified he was on EBP for osteomyelitis (bone infection) and presence of a wound. Interventions included implement EBP according to facility protocol. Clear signage would be posted on the door to indicate the presence of personal protective equipment (PPE) requirements. Staff were directed to apply gloves and gown prior to high-contact care activities. R19's medication orders dated 3/2/26 through 3/29/26, identified give one-gram meropenem (antibiotic medication) intravenous (IV) solution twice daily for a diagnosis of osteomyelitis. During an observation and interview on 3/4/26 at 8:29 a.m., licensed practical nurse (LPN)-H prepared R19's 8:00 a.m., dosage of IV meropenem while LPN-C observed. LPN-H stated R19 had a peripherally inserted central catheter (PICC); a type of central line which delivers medication via IV. During an observation and interview on 3/4/26 at 8:45 a.m., R19's room door had a sign directing EBP were in place. The EBP door sign identified: Wear gloves and a gown for high-contact resident care activities such as device care or use of a central line. A PPE bin was located outside the door containing gloves and gowns. LPN-H donned (put on) gloves from the PPE bin, but no gown, and entered R19's room. LPN-H raised R19's head of bed, set a pill cup on the bedside table, administered pills and then the inhaler. LPN-H then doffed (removed) the used gloves and donned new gloves, cleaned R19's PICC line port with an alcohol wipe, and flushed the PICC line with 10 milliliters(mL) of normal saline. LPN-B was present in the room observing. At 8:56 a.m., LPN-H hung R19's meropenem on the IV pole, and the surveyor stopped the procedure. When asked if any other PPE was required for PICC line care, LPN-B and LPN-H reviewed the sign on the room door which identified a gown and gloves should be worn during PICC line care. LPN-B asked LPN-H to don PPE. LPN-H removed his gloves, exited the room, used an alcohol-based hand rub, donned a gown and gloves and reentered the room to administer R19's IV antibiotic as ordered. At 9:05 a.m., LPN-H doffed his PPE, used an alcohol-based hand rub and exited R19's room. LPN-H stated he did not notice the sign on the door with the PPE requirements but had received training upon hire on the process. R2 R2's quarterly MDS dated [DATE], indicated R2 had severe cognitive impairment, impairment of upper and lower extremities, and was dependent on staff for total body care, bed mobility, and transfers. It also indicated R2 had enteral feeding (administer liquid nutrition and medication in a tube in abdomen), diagnoses of stroke with hemiplegia (paralysis to one side of the body) and severe protein-calorie malnutrition. R2's physician orders dated 8/4/25, indicated R2 required care for feeding tube: wash around tube daily and as needed, with warm water and cloth, apply sterile split gauze around site, and secure in place as needed. R2 further required EBP to be implemented for cares of R2. R2's care plan dated 8/10/25, indicated R2 had an enteral nutrition via a feeding tube. Interventions included EBP according to facility protocol. Post clear signage on the door or wall outside of resident room and required personal protective equipment. During observation on 3/4/26 at 7:55 a.m., R2's door sign stated enhanced barrier precautions and directed staff to use gown and gloves during high contact cares. Outside of R2's room was a cart with PPE that included gowns and gloves. Registered nurse (RN)-D completed hand hygiene, donned gloves and entered R2's room without donning a gown. RN-D disconnected R2's tube feeding, administered medications and flushes and reconnected R2's tube feeding. RN-D then took off the old dressing from the feeding tube site, cleaned the tube site and placed a new dressing. During observation and interview on 3/4/26 at 8:13 a.m., nursing assistant (NA)-D and NA-F had entered R2's room to assist R2 with personal cares. Without gowns on, NA-D and NA-F rolled R2 side to side and proceeded to change R2's linen and soiled brief. NA-D stated it was not necessary to wear EBP such as a gown during personal cares with R2. After cares were completed, NA-D verified R2 had a EBP sign on door with PPE equipment cart outside of the room directing them to wear gown and gloves with close contact cares. During interview on 3/4/26 at 1:43 p.m., NA-F stated EBP not necessary unless touching or doing direct cares with R2's feeding tube. A gown wasn't necessary to wear, but gloves were when providing personal cares with R2. During interview on 3/4/26 at 1:58 p.m., RN-D stated PPE was to be worn according to the signage on residents' door. EBP could include a mask, gown and gloves. EBP was used in cares that included dressing changes, tube feedings and personal care. RN-D verified she did not wear a gown when completing R2's tube feeding cares and medication administration. Furthermore, EBP was used to decrease risk of infections. During interview on 3/5/26 at 11:33a.m., infection preventionist (IP) stated they expected staff to don gown and gloves for any cares/contact with residents who required EBP. This included IV medication administration, personal cares and tube feeding cares. During interview on 3/5/26 at 1:31 p.m., director of nursing (DON) stated staff were expected to wear proper PPE when doing personal or direct cares with residents on EBP. They were to wear gloves, gown and mask. The information was on the sign on the residents' door. EBP was to be utilized to prevent cross contamination and prevent infections from spreading. A policy titled Enhanced Barrier Precautions dated 4/1/24, directed staff to use EBP in situations in which exposure to blood and body fluids is anticipated and refers to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing. EBP were also used for residents with indwelling medical devices, central lines, hemodialysis catheters, feeding tubes and indwelling urinary catheters. High-contact resident care activities included transfers, dressing, assisting during bathing, providing hygiene, changing briefs or assisting with toileting, changing linens, indwelling urinary catheter, and wound care. EBP were intended to be used for the duration of a resident's stay.

Based on interview and record review, the facility failed to report allegations of maltreatment to the state agency within two hours after the allegation was made for 1 of 1 resident (R2) reviewed for reporting of alleged violations of maltreatment. R2 reported the allegations of maltreatment to dietary aide (DA)-A on 11/11/2025 and the facility did not report the allegations to the state agency.Findings include: R2's face sheet printed on 11/18/25, indicated R2 was admitted to the facility on [DATE], with a primary diagnosis of repeated falls. R2's additional diagnoses included type 2 diabetes mellitus without complications, unspecified dementia with unspecified severity and other behavioral disturbance, adult failure to thrive, psychotic disorder with delusions due to known physiological condition, major depressive disorder, restlessness and agitation, violent behavior-aggression, vascular dementia that is severe with agitation, and anxiety disorder. R2 had two admissions to the facility prior to her current admission; one from 5/15/19 to 9/4/19 and the other admission was from 5/2/21 to 4/22/23. R2's care plan dated 5/15/19, indicated staff would report and investigate any allegations of suspected abuse, neglect, or exploitation. R2's brief interview for mental status (BIMS) dated 10/24/25, indicated R2 had a score of six, which indicated R2 had severely impaired cognition. Surveyor attempted to contact DA-A on 11/18/25 at 8:53 a.m. but had to leave a voicemail. DA-A did not return surveyor's call. During an interview on 11/18/25 at 11:43 a.m., the administrator stated she received an email on 11/12/25, reporting R2 had alleged maltreatment when the nurses at the facility would hit her. The administrator stated the facility did not report the allegations to the state agency because R2 had a history of allegations in her care plan and the bruises that R2 showed when she reported the allegations were documented prior to these allegations occurring. During an interview on 11/18/25 at 1:39 p.m., social services (SS)-A stated she was made aware of the maltreatment allegations at an interdisciplinary team meeting on 11/12/25 by the administrator. SS-A stated she did not report the maltreatment allegations to the state agency because it wasn't in her scope of practice. SS-A stated she is mandated reporter and would report any type of abuse made aware to her by a resident or about a resident. During an interview on 11/18/25 at 2:01 p.m., licensed practical nurse (LPN)-C stated the director of nursing (DON) told her about R2's allegations of maltreatment on 11/12/25. LPN-C stated she did not report the allegations to the state agency because she didn't think she needed to report it to the state agency. LPN-C stated she was a mandated reporter and she would be required to report any allegations of physical, sexual, or financial abuse. During an interview on 11/18/25 at 3:20 p.m., SS-B stated she received an email on 11/12/25 regarding the maltreatment allegations from R2. SS-B stated she did not report the allegations to the state agency because they looked in R2's progress notes and saw that R2 was more combative and she saw the documentation on the bruises prior to R2's allegations. The facility's Abuse Prevention Plan policy dated 7/21/22 indicated if an event involved maltreatment, the facility was required to report the suspicion immediately, but no later than two hours after the allegations were made.

Based on observation, interview, and document review, the facility failed to ensure a resident received adequate supervision and assistance to prevent accidents for 1 of 3 residents (R4) reviewed for falls. This resulted in actual harm when R4 fell and suffered a femur fracture. The facility implemented immediate corrective action, so the deficient practice was issued at past non-compliance. Findings include: R4's face sheet dated 5/16/25, identified diagnoses of Parkinson's disease (a disease of the central nervous system that affects movement), depression (persistent sadness), and anxiety (a common human emotion involving feelings of worry, nervousness, or unease). R4's Physical Therapy (PT) evaluation dated 4/22/25, identified that R4 was admitted the facility due to weakness and without further PT she would be at increased risk for falls and functional decline. R4 was modified independence with contact guard assistance (one or two hands on body to support balance or steady body) for transfers. R4's admission Minimum Data Set (MDS) dated [DATE], identified R4 needed supervision or touching assistance for transfers and had moderate cognitive impairment. R4's fall care plan focus dated 4/22/25, identified R4 was at risk for falls due to Parkinson's disease. Goal of will not sustain a fall related injury through review date. With interventions of education on prevention, reduction precautions per facility protocol. R4's care plan did not identify what level of transfer assistance R4 required as per the PT evaluation dated 4/22/25 nor the level of assistance that was identified on the MDS dated [DATE]. R4's nursing assistant care sheet dated 4/22/25, identified R4 was assist x1 with gait belt and walker for transfers. R4's physician note dated 5/1/25, identified R4 was still working with therapy and is not back to her baseline strength or balance and does not feel ready to go home. R4's fall safety event dated 5/10/25 at 1:45 p.m , identified R4 had a witnessed fall in her room during a transfer without assistance. During the transfer R4's feet became entangled in the nightstand, which caused her to lose her balance, fall, and landed on her right hip. R4 had pain in right femur area and was sent to emergency department (ED) for evaluation. R4's emergency department (ED) note dated 5/10/25, identified R4 had been seen in ED following a fall in the nursing home and had subsequent hip pain and unable to bear weight. Imaging showed moderately displaced intertrochanteric fracture of the proximal right femur. R4's hospital operative note dated 5/11/25, identified R4 underwent insertion of intramedullary nail of right femur following a fall in the nursing home. R4's interdisciplinary team (IDT) progress note dated 5/12/25 at 10:12 a.m., identified review of fall on 5/10/25 that R4 was ambulating in room with a staff member present with a gait belt on, however he stepped back as resident was attempting to brush her hair near the nightstand. Staff visualized R4's feet got tangled up in the nightstand when attempting to turn, causing her to lose balance and fall. Staff member was not within close reach to catch R4 from falling. Staff interviews reveal that R4 had a history of ambulating in her room without assistance. R4 was an assist of one with a walker for transfers and ambulation prior to the fall. R4's activities of daily living care plan dated 5/12/25 was revised after her fall on 5/10/25, to include the level of staff assistance R4 required which was, limited assist of one for transfers with a gait belt and walker. R4's progress note dated 5/14/25, identified R4 returned from the hospital and was substantial/maximum assistance for all transfers. During an interview on 5/15/25 at 1:38 p.m., nursing assistant (NA)-B referenced the nursing assistant care sheets as the care plan that gives them direction on how to care for a resident. During an interview on 5/15/25 at 3:55 p.m., nursing assistant (NA)-D stated he was assisting R4 in her room at the time of her fall on 5/10/25. NA-D placed a gait belt on R4 and ambulated her next to the nightstand so she could brush her hair, he then left her at the nightstand and went to get her walker when she must have turned and got her feet tangled on the nightstand and fell to the ground. NA-D stated he was not standing near R4 at that time, and when she lost her balance, he was not able to catch her. During an interview on 5/15/25 at 12:40 p.m., licensed practical nurse (LPN)-C stated R4's nursing assistant care sheet identified R4's transfer status of assist of one staff on admission, however R4's care plan did not identify how she was transferred until 5/12/25 after it was reviewed after the fall. During an interview on 5/15/25 at 4:36 p.m., registered nurse regional director (RNRD) stated her expectation would be for staff to transfer resident per plan of care and ensure adequate supervision is provided during the transfers to maintain safety and that any resident would have their care plans updated in a timely manner. Review of the facility's Integrated Fall Management Policy dated 9/23, identified residents with risk for falling will have interventions implemented through their resident centered plan of care. Additional professionals may be contacted to provide assessment and/or interventions regarding fall risk and prevention, including but not limited to, attending physician/provider, pharmacist, physical therapist, occupational therapist, and speech therapist. The following corrective actions were verified as implemented prior to the survey: 1. A four-point plan of correction was initiated on 5/12/25: a. Specific action taken for identified resident. b. Resident sent to ED for treatment. c. NA suspended pending investigation. d. Updated provider and family. e. Report filed with state agency. f. Interview of NA involved. g. Interviewed therapy. h. Interviewed like residents with no concerns identified. 2. Root cause of R4's fall identified that NA was not following the plan of care and that R4 should have been assist of one with a gait belt. 3. Identified all residents that ambulate with staff assistance may be at risk for the same deficient practice. 4. Educated the NA involved in the incident regarding following plan of care for ambulation status. Education provided to all NA and nurses regarding following plan of care for residents. 5. Ensured all residents had the correct ambulation status on care plan and nursing assistant care sheets. 6. Education of all staff regarding abuse and neglect, reporting policy, expectations including timeframe. 7. Monitoring will be done via audits of direct audit of staff during resident ambulation five times per week x 4 weeks, three times per week x 4 weeks, one time per week for 4 weeks x 4 weeks. Audits will be brought to quality assurance performance improvement (QAPI) to determine ongoing audits. 8. Director of Nursing of designee will be responsible for the compliance of the action plan. 51576

Based on observation, interview, and document review, the facility failed to provide sufficient staffing to ensure residents received the care and assistance they needed in a timely manner for 4 of 5 residents (R5, R1, R3, & R6) reviewed for call lights. This caused actual harm to R5 when she waited nearly three hours for her call light to be answered causing her to experience increased anxiety, distress, fear, and feelings of worthlessness and helplessness. Findings include: R5 R5's Minimum Data Set (MDS) assessment dated [DATE], indicated she had intact cognition and no behaviors or rejections of care. R5 had diagnoses including multiple sclerosis (chronic disease affecting the central nervous system), anxiety disorder, major depressive disorder, and morbid obesity. R5 was frequently incontinent of bowel and bladder and required substantial staff assistance with toileting hygiene, bathing, dressing, and mobility in bed. R5 was dependent on staff for transfers and used a motorized wheelchair independently. R5's urinary incontinence care plan interventions dated 2/11/25, included keep call light within reach, provide incontinence care after each incontinent episode, toilet per request, and staff to toilet every two hours and as needed with extensive assistance. R5's activities of daily living (ADL) care plan included intervention dated 2/11/25, to discuss with staff how to honor R5's preferences and provide care in a timely manner. R5's psychosocial well-being care plan dated 1/15/25, identified potential for trauma related to history of sexual abuse, physical abuse, and mental abuse. Interventions dated 1/15/25 included observe for signs of adjustment difficulties such as inability to pursue interests or activities or sad or anxious mood. R5's mood state care plan dated 5/26/22 identified R5 was at increased risk for mood issues related to anxiety disorder, suicidal ideations in the setting of delirium, toxic encephalopathy, new an unfamiliar environment, and legal blindness. Intervention dated 5/16/24, noted psychology was to evaluate and treat as needed. R5's psychology provider note by licensed independent clinical social worker (LICSW)-A dated 1/31/25, indicated R5 had diagnoses including major depressive disorder and anxiety disorder. R5's mental status exam noted dysthymic (mild long-lasting depressed) mood, ruminating (persistent negative) thoughts, tearful affect, and tearful behavior. R5 reported an incident of waiting for her brief to be changed after a bowel movement (BM), which she believes contributed to current UTI [urinary tract infection]. Treatment recommendations included it remains of benefit for [R5] to have brief changes after BM's as soon as possible, to reduce risk of developing UTI's which she seems to be prone to. This would aid in decreasing anxiety levels. R5's psychology provider note by LICSW-A dated 2/21/25, indicated R5 presented with anxious and depressed mood of sadness, overwhelmed, grief, stress, difficulty concentrating, and fatigue. R5 reported she had another UTI and endorsed anxiety around this. R5's Long Term Care Social Service assessment dated [DATE], indicated she had mood appropriate to circumstance and mood was affected by diagnoses. She did not have mood symptoms of depression, crying, or withdrawal from activities and her mood was not restless, anxious, or inclusive of complaints. R5 was identified as expressing her feelings openly and coping well. She did not distort or misrepresent events, worry/deny/cry, or display ineffective coping skills such as distancing self, anger, or withdrawal from life at facility. The facility's Grievances Log included a grievance entry dated 4/26/25 voiced by R5. The concern section noted R5 reported on Saturday 4/26/25 around 3:00 p.m. she put on her call light for assistance transferring from chair to commode and waited an hour for a nurse to come in. The nurse said she was going to turn the call light off and then back on and let a nursing assistant (NA) know she was waiting. R5 requested the call light not be turned off as she hadn't been assisted yet. Nurse left call light on and informed a NA who then assisted. The findings section of the log noted The resident's call light was not answered for approximately one hour after activation on Saturday, 4/26, around 3:00 PM. When a nurse eventually responded, she did not provide direct assistance but informed an aide, who later assisted the resident. The nurse initially planned to reset the call light before notifying staff, but the resident requested it remain on until assistance was received. The action section noted Staff were reminded of the importance of promptly responding to call lights to ensure residents receive timely assistance. Nursing staff were specifically instructed not to reset a call light until the resident's needs have been fully addressed. The situation was reviewed with the care team to reinforce effective communication practices and appropriate procedures for escalating any delays in care. The resident was informed of the concern and the steps being taken to address it. R5's Device Activity Report (call light log) dated 4/12/25 through 5/14/25, included but was not limited to the following reset times (time from when light is activated to when it is cleared): - 4/12/25 at 7:27 p.m., 20 minutes and 46 seconds - 4/12/25 at 10:40 p.m., 25 minutes and 48 seconds - 4/13/25 at 7:57 a.m., 100 minutes and 22 seconds - 4/15/25 at 2:09 p.m., 21 minutes and 35 seconds - 4/16/25 at 5:05 p.m., 29 minutes and 19 seconds - 4/17/25 at 3:37 p.m., 24 minutes and 32 seconds - 4/19/25 at 7:57 a.m., 23 minutes and 7 seconds - 4/20/25 at 8:50 a.m., 43 minutes and 48 seconds - 4/20/25 at 12:58 p.m., 61 minutes and 51 seconds - 4/20/25 at 9:45 p.m., 22 minutes and 36 seconds - 4/22/25 at 7:38 a.m., 34 minutes and 54 seconds - 4/22/25 at 1:18 p.m., 49 minutes and 30 seconds - 4/22/25 at 9:54 p.m., 28 minutes and 3 seconds - 4/25/25 at 1:16 p.m., 26 minutes and 8 seconds - 4/26/25 at 7:13 a.m., 202 minutes and 18 seconds - 4/26/25 at 3:38 p.m., 64 minutes and 31 seconds - 4/26/25 at 5:50 p.m., 20 minutes and 30 seconds - 4/27/25 at 5:40 p.m., 30 minutes and 14 seconds - 4/28/25 at 6:01 p.m., 32 minutes and 32 seconds - 5/3/25 at 1:03 p.m., 22 minutes and 52 seconds - 5/6/25 at 7:41 a.m., 57 minutes and 32 seconds - 5/6/25 at 1:00 p.m., 43 minutes and 42 seconds - 5/6/25 at 5:20 p.m., 26 minutes and 2 seconds - 5/7/25 at 7:34 a.m., 24 minutes and 35 seconds - 5/7/25 at 5:57 p.m., 31 minutes and 49 seconds - 5/10/25 at 12:12 p.m., 174 minutes and 8 seconds - 5/11/25 at 12:58 a.m., 20 minutes and 55 seconds - 5/11/25 at 2:12 p.m., 59 minutes and 19 seconds - 5/11/25 at 7:17 p.m., 26 minutes and 51 seconds - 5/12/25 at 3:16 p.m., 31 minutes and 41 seconds - 5/13/25 at 3:24 p.m., 18 minutes and 14 seconds - 5/13/25 at 5:52 p.m., 29 minutes and 34 seconds During an interview on 5/14/25 at 2:19 p.m., R5 stated there are huge issues with call lights. R5 stated at night sometimes nobody would answer her call light so she would have to use a telephone to call the nursing station on her unit and another unit to request assistance. R5 explained on a good day call lights are answered in 15 minutes, on a bad day anytime between half an hour and 45 minutes, and on a real bad day a lot longer. R5 noted there were occasions she had to wait marathon times with the most recent incident on Saturday 5/10/25. R5 stated a nursing assistant (NA) got her up and dressed in the morning and told her the NA assigned to her had left sick an hour into the day shift. The NA who had helped her was then pulled and put on a medication cart to work as a medication aide because they were short a nurse, leaving one NA working the whole floor. R5 stated around 12:15 p.m. she turned her call light on because she needed to have her brief changed. She was sitting in her recliner, it was nice out, and she wanted to go outside. She turned on the light to have her brief changed and transfer to her electric wheelchair to go outside. R5 stated, no one came until 3:15 in the afternoon, nobody came, not one person to check on me. Review of R5's call light log identified her call light was activated on 5/10/25 at 12:12 p.m. and was not reset for 2 hours 54 minutes and 8 seconds. R5 stated the evening shift NA stopped in her room while orienting another NA who was agency staff and they were not aware her light was on when they came by, but R5 told them what she needed. R5 stated she was a [NAME] of a [NAME] [sic] by this point, I was angry at being ignored, I was terrified that here I am again, and grateful I wasn't in serious physical danger. R5 noted this could have been fatal to somebody so yeah, I'm grateful for that, but I'm afraid, it makes me afraid about being here. I'm never safe here. After she was assisted to the commode she had NAs put her in bed. R5 was afraid by that time, she didn't know who was going to be working that night. She didn't feel comfortable enough to be in her wheelchair and go outside. I thought just put me in my bed so I can be as safe as possible. R5 noted the facility had been staggering nurses and instead of two nurses starting at 3:00 p.m. they had one start at 3:00 p.m. and one start at 5:00 p.m. which made R5 not feel secure and safe. R5 stated I don't think emotionally I have recovered R5 did not feel safe in the late afternoon or early morning because staff don't help. R5 explained another recent instance where she waited an extended time for assistance. R5 had a large BM and had BM all over herself. She informed an NA that she needed assistance because I know I needed to be changed, and I needed to be changed fast because I didn't want to have another UTI. R5 indicated the NA told her he needed to finish passing out lunch trays and collecting them and would then get to her. R5 then went to the nursing station and informed staff she needed to be changed now, went back to her room, and turned on her call light. After 15 to 20 minutes, she left her room in her wheelchair to find the NA, told him she needed to be changed now, he stated he had to do something else first, and she returned to her room. After waiting another 15 to 20 minutes she went looking for him again, and he again said he had to go do something in another room. After 15 to 20 more minutes, she found him again and he did it again a third time. R5 stated she lost it and went back to my room and she wept and wailed. After about five minutes, the NA arrived and asked why she was crying and she said because you won't change me. The NA got a second NA and the two then assisted with cleaning her up. R5 stated she was very upset by this incident. During an interview on 5/15/25 at 12:05 p.m., trained medication aide (TMA)-A stated aides answer call lights and other staff don't answer call lights, but they should. TMA-A noted it was hard to answer call lights with three aides and sometimes two working. TMA-A stated ten minutes was too long to take to answer a call light and if somebody needs to go to the bathroom they can't wait, we don't have enough staff to do that. TMA-A stated with two aides it is a struggle. If we had more staff it would be helpful with call lights. TMA-A noted R5 used the call light when she needed to use the commode or wanted to come out of her room and staff did not have time because two people were needed to transfer R5. TMA-A stated, R5 did get upset about the call light after waiting, her face changes, she is mad. During an interview on 5/15/25 at 12:26 p.m., registered nurse (RN)-C stated there were not enough staff to do what needed to be done for the residents and answer call lights like we should. RN-C stated she thought the recent instance when R5 had to wait approximately three hours for her call light to be answered was sad and it's obvious how you would feel, neglected, afraid. RN-C explained there should be three aides at all times and noted call lights were more of a problem when there were less than three NA's working on the unit. During an interview on 5/15/25 at 9:50 a.m., staffing coordinator (SC) reviewed the schedule from Saturday 5/10/25 for R5's unit. She noted the day shift had two nurses, an RN from 6:30 a.m. to 1:00 p.m. and an LPN from 6:30 a.m. to 3:00 p.m. The day shift had three NA's working, with two scheduled from 6:30 a.m. to 2:45 p.m. and one scheduled from 6:30 a.m. to 3:00 p.m. The NA scheduled to work until 3:00 p.m. came in for about an hour in the morning, became sick and left, and another NA came in to replace her. The evening shift had two nurses and two NA's. One LPN was scheduled from 3:00 p.m. to 8:00 p.m. and the second LPN scheduled from 4:00 to 11:00 p.m. called out and was replaced by an RN pulled from a different unit. Three NA's were scheduled to work: one from 2:30 p.m. to 11:00 p.m., one from 3:00 p.m. to 11:00 p.m., and one from 3:00 p.m. to 9:00 p.m. Two NA's worked the evening shift as the third was pulled to a different unit to work as a TMA. The SC stated one of the aides from another unit was probably floating between their assigned unit and R5's unit. During an interview on 5/15/25 at 4:33 p.m., the nurse manager for R5's unit, RN-D, stated she didn't know what was going on with call lights, we need to work on getting those lights. Call lights should be answered in no more than five minutes. If a light was not answered timely a resident would may not feel good about it or disappointed, RN-D noted she wouldn't be happy. RN-D recalled the instance on 4/26/25 when R5 had to wait an hour for her call light to be answered and thought it was because an aide had been sick and left early. RN-D stated she talked to R5 about this and she was not happy. Whoever saw the light should have answered right away and it was unacceptable. RN-D had also spoken with R5 about the instance on 5/10/25 when she waited approximately three hours for her call light to be answered and R5 wasn't happy. Long call lights had a negative effect on residents when they had to wait that long for assistance and it was definitely something we need to work on with the call lights, whether it is a weekend or not. Regarding how long call light times affected R5, RN-D stated she knew for sure R5 did get anxious and worried because R5 had told as much. RN-D stated she had not looked into how call light logs compared to staffing and hadn't heard from her staff that they were related. During an interview on 5/15/25 at 4:00 p.m., the director of social services (DSS) stated long call light wait times are negative towards people's psychosocial well-being and could make residents not trust our staff, could impact how people feel about being safe here. The DSS noted some residents could get a lot more anxious if their call lights were not being answered, especially if they already have anxiety. An increase in anxiety would be considered a negative impact to psychosocial well-being. The DSS reviewed her concerns (grievances) database and noted a concern from R5 on 5/10/25 that her call light was on for three hours and noted staff were still looking into this with nurse manager RN-D assigned to investigate. She identified an additional concern from R5 dated 4/26/25 when she waited for over an hour for her light to be answered which was confirmed when staff reviewed call light logs. The DSS assumed this impacted R5 negatively, could be harmful, and probably increased her anxiety levels. The DSS noted waiting one or three hours for a call light to be answered could impact a resident's sense of dignity or self-worth. She expected call lights to be answered no later than 20 minutes and long call light wait times wouldn't feel good. During a return phone call interview on 5/19/25 at 4:45 p.m., licensed independent clinical social worker (LICSW)-A stated she had been seeing R5 since she admitted to the facility and saw R5 for her depression, chronic adjustment distress, anxiety, and post-traumatic stress symptoms. LICSW-A was aware of R5's long call light times, including the one that took staff three hours to answer. LICSW-A noted in response to the long call light times it made R5 feel helpless, a lack of control, and like her needs don't matter. R5 was reliant on staff to use the bathroom or get transferred. Long call light wait times certainly impacts her [R5's] anxiety levels. R5's reported three-hour wait time was a long wait time, I would expect that most people would feel pretty distressed by that. LICSW-A felt R5's distress level and response is completely understandable and appropriate to the situation. LICSW-A also noted R5 had brought up call light wait times with her previously. LICSW-A believed it did impact R5's mood and feeling of lack of being in control of her situation. Additionally, feeling of helplessness that R5 requested help and not only has it not arrived, but then she has had to wait for that long amount of time. LICSW-A stated for R5 it kind of filters into her thought of do my needs matter?' and when her call light was not answered timely she feels depressed. R5 was angry and tearful when talking about this experience. LICSW-A stated for her to wait that long, that is harmful to her. R5 had filed multiple complaints and grievances and spoken with facility staff and the ombudsman, but there has not been any improvement so she worries. LICSW-A noted R5 had expressed fears about what could happen to her in the time frame while she was waiting for a call light to be answered, and the worry had been kind of steady. LICSW-A noted adjusting to the facility has been very difficult for her [R5] and long call light wait times doesn't help. LICSW-A noted R5 had been better adjusted over the last year and a half but then if a circumstance like this comes up it brings her back to some of those feelings. R1 R1's MDS assessment dated [DATE], indicated she had intact cognition and no behaviors or rejections of care. R1 had diagnoses including Parkinson's disease, acute pain due to trauma, back pain, and abnormalities of gait and mobility. She was occasionally incontinent of urine, and required substantial staff assistance with toileting, bathing, bed mobility, and transfers. R1's mobility care plan dated 3/1/25, identified she needed staff assistance with bed mobility, transfers, ambulation, and locomotion due to immobility. Intervention dated 5/12/25, directed staff to ensure the call light was in reach and encourage R1 to use it to make needs known. R1's urinary care plan with interventions dated 2/11/25, directed staff to keep call light in reach, toilet every two to three hours and as needed, and toilet per request. Her communication care plan dated 2/11/25, identified R1 preferred to have her call light on the table in her room and would also like to have a bell to ring if she needed assistance. Intervention dated 2/11/25, directed to discuss with staff how to honor preferences and provide care in a timely manner. R1's call light log dated 4/12/25 through 5/14/25, included but was not limited to the following reset times: - 4/12/25 at 11:05 a.m., 28 minutes and 46 seconds - 4/12/25 at 5:32 p.m., 33 minutes and 39 seconds - 4/12/25 at 8:24 p.m., 26 minutes and 58 seconds - 4/13/25 at 8:27 a.m., 25 minutes and 25 seconds - 4/13/25 at 9:17 a.m., 32 minutes and 59 seconds - 4/13/25 at 12:37 p.m., 34 minutes and 42 seconds - 4/15/25 at 12:21 p.m., 21 minutes and 39 seconds - 4/16/25 at 10:57 a.m., 18 minutes and 41 seconds - 4/16/25 at 12:20 p.m., 31 minutes and 20 seconds - 4/16/25 at 5:20 p.m., 24 minutes and 22 seconds - 4/16/25 at 7:32 p.m., 32 minutes and 38 seconds - 4/19/25 at 1:38 a.m., 26 minutes and 51 seconds - 4/20/25 at 11:12 a.m., 29 minutes and 16 seconds - 4/20/25 at 3:56 p.m., 23 minutes and 32 seconds - 4/20/25 at 7:41 p.m., 36 minutes and 34 seconds - 4/21/25 at 10:01 a.m., 36 minutes and 51 seconds - 4/22/25 at 12:28 p.m., 24 minutes and 18 seconds - 4/24/25 at 9:13 a.m., 265 minutes and 5 seconds - 4/24/25 at 1:40 p.m., 29 minutes and 14 seconds - 4/20/25 at 10:38 a.m., 22 minutes and 34 seconds - 5/3/25 at 10:52 a.m., 46 minutes and 44 seconds - 5/4/25 at 1:54 p.m., 53 minutes and 24 seconds - 5/5/25 at 6:09 p.m., 19 minutes and 12 seconds - 5/6/25 at 11:47 a.m., 24 minutes and 4 seconds - 5/6/25 at 5:39 p.m., 31 minutes and 19 seconds - 5/7/25 at 9:56 a.m., 22 minutes at 24 seconds - 5/7/25 at 5:56 p.m., 26 minutes and 44 seconds - 5/7/25 at 9:46 p.m., 49 minutes and 43 seconds - 5/10/25 at 8:06 a.m., 67 minutes and 58 seconds - 5/10/25 at 9:40 a.m., 21 minutes and 56 seconds - 5/10/25 at 5:27 p.m., 31 minutes and 21 seconds - 5/10/25 at 6:03 p.m., 21 minutes and 49 seconds - 5/11/25 at 10:22 a.m., 24 minutes and 52 seconds - 5/11/25 at 1:32 p.m., 30 minutes and 56 seconds - 5/12/25 at 7:56 p.m., 27 minutes and 33 seconds During an interview on 5/12/25 at 3:08 p.m., R1 stated things aren't going well. Staff would not answer the light. R1 had a bell that one of the nurses gave him and directed R1 that if staff did not answer the call light in a reasonable time, to use the bell. R1 stated I do scream and staff would tell R1 to quit it. Staff would not answer the bell either, so R1 gave it away. R1 stated she would press her call light and wait so long that she turned it off because staff didn't answer. R1 stated she had fallen recently while trying to organize laundry in her room and staff told her to use her call light for assistance, but that was a joke because staff don't answer her light and have said they are shorthanded. R1 stated she used her call light when she needed to use the bathroom but staff don't answer, so I end up going in my pull-ups because she couldn't hold it for that long. R1 stated she felt helpless, and it sometimes took one or two hours for her call light to be answered. She stated, I am bitter because I had to mess myself because she could not get staff to come help her. On 5/12/25 at 5:18 p.m., a call light digital alarm board in the hallway displayed displayed alarm [R1's room number] 15 minutes and was flashing. NA-C entered R1's room. R1's call light log indicated her light was activated on 5/12/25 at 5:00 p.m. and was not cleared for 17 minutes and 58 seconds. Upon exiting, NA-C stated R1 wanted to go to the bathroom and usually if her call light is on it is because she wanted water or to go to the bathroom. NA-C stated she had taken R1 to the bathroom and cleaned her up after toileting. During an interview on 5/13/25 at 9:23 a.m., R1's friend and power of attorney (POA)-A stated R1 had called her crying before, stating she's uncomfortable, needed to get up, needed to go to the bathroom, and needed pain medication. POA-A told R1 to ring her bell while still on the phone to see if staff come in and she's ringing the bell, and nothing happens. POA-A stated this was not okay. R3 R3's MDS assessment dated [DATE], indicated she had intact cognition and no behaviors or rejections of care. R3 had diagnoses including stage four pressure ulcer of the sacral region (wound with full thickness tissue loss and exposed bone, tendon, or muscle over the tailbone area), low back pain, heart failure, non-Alzheimer's dementia, and depression. She was occasionally incontinent of bowel and bladder and required supervisory staff assistance with toileting hygiene and bathing, and partial assistance with footwear and walking. R3's urinary care plan included interventions dated 2/13/25, including keep call light within reach, staff to toilet every two to three hours and as needed with assist of one staff, and toilet per request. R3's routines care plan included intervention dated 2/13/25, directing discuss with staff how to honor my preferences and provide care in a timely manner. R3's activities of daily living care plan included interventions dated 8/9/24, I can verbally ask for assistance, I need assistance to help me remain free from skin breakdown and respect my dignity. Her pain care plan included a goal dated 5/3/25, to be comfortable. Intervention dated 9/5/24, noted interventions for pain included prescribed medications, relaxation, and distraction. R3's call light log dated 4/12/25 through 5/14/25, included the following reset times: - 4/12/25 at 5:20 p.m., 40 minutes and 21 seconds - 4/20/25 at 12:21 p.m., 26 minutes and 36 seconds - 4/21/25 at 12:11 p.m., 49 minutes and 11 seconds - 4/21/25 at 3:45 p.m., 36 minutes and 22 seconds - 4/26/25 at 8:53 a.m., 106 minutes and 54 seconds - 4/28/25 at 7:04 p.m., 44 minutes and 12 seconds - 4/30/25 at 8:41 a.m., 17 minutes and 2 seconds - 5/1/25 at 8:46 a.m., 51 minutes and 35 seconds - 5/4/25 at 12:21 p.m., 17 minutes and 43 seconds - 5/5/25 at 9:10 a.m., 124 minutes and 52 seconds - 5/5/25 at 12:52 p.m., 45 minutes and 40 seconds - 5/5/25 at 2:54 p.m., 33 minutes and 14 seconds - 5/7/25 at 7:36 a.m., 114 minutes and 47 seconds - 5/7/25 at 12:56 p.m., 32 minutes and 41 seconds - 5/8/25 at 1:15 p.m., 56 minutes and 11 seconds - 5/10/25 at 9:47 a.m., 105 minutes and 27 seconds - 5/10/25 at 6:34 p.m., 75 minutes at 14 seconds - 5/11/24 at 9:02 a.m., 119 minutes and 15 seconds - 5/13/25 at 11:01 a.m., 24 minutes 35 seconds - 5/14/25 at 8:38 p.m., 38 minutes and 14 seconds On 5/13/25 at 11:04 a.m., NA-A stated staffing was short sometimes, and they could use a little help. NA-A noted call lights should be answered in either eight to 10 minutes or five to eight minutes, she couldn't remember. NA-A noted she would usually turn call lights off right away and then go look for someone to help her if she was unable to provide the needed assistance. She stated answering call lights can be a challenge and lights were usually on for thirty minutes plus which was pretty bad and a long time. NA-A noted she wouldn't like this if it was her family member. At 11:24 a.m., a call light digital alarm board in the hallway displayed alarm [R3's room number] 20 minutes and was flashing. NA-A entered R3's room and stated she was there because R3's call light was on and confirmed it had been on for 20 minutes. During an interview on 5/13/25 at 11:24 a.m., R3 stated it had been a while since she pressed her call light. R3 asked NA-A for as needed pain medication for back pain rated six out of 10. R3 thought nursing staff all went on break every hour because it sometimes took a long time for call lights to be answered. R3 noted call light wait times were not timely around mealtimes, as staff were busy preparing and serving meals and passing trays. R3 stated she realized staff were busy and she just had to be patient, but sometimes staff got mad and then they ignore you. R6 R6's MDS assessment dated [DATE], indicated she had intact cognition and no behaviors or rejections of care. R6 had diagnoses including encephalopathy (disturbance in brain's function), sclerosis, anxiety, depression, and functional quadriplegia (complete inability to move all four limbs due to extreme debility or frailty). She was frequently incontinent of bowel and had an indwelling urinary catheter. R2 was dependent on staff for assistance with all cares, activities of daily living, and mobility. R6's mobility care plan dated 2/13/25, identified she needed assistance due to functional quadriplegia. Intervention dated 5/7/26, directed staff to ensure call light is in resident's reach while in room and encourage to use it to make needs known. R6's communication care plan dated 4/24/25, noted she used a specialized call light she accessed with her face/chin. R6's urinary care plan included interventions dated 2/13/25, including keep call light within reach, staff to toilet every two to three hours and as needed, and toilet per request. R6's call light log dated 4/12/25 through 5/14/25, included the following reset times: - 4/13/25 at 8:56 a.m., 58 minutes and 55 seconds - 4/18/25 at 2:38 p.m., 18 minutes and 4 seconds - 4/20/25 at 5:10 a.m., 28 minutes and 8 seconds - 4/20/25 at 7:04 a.m., 37 minutes and 0 seconds - 4/20/25 at 9:26 a.m., 30 minutes and 55 seconds - 4/20/25 at 11:00 a.m., 55 minutes and 37 seconds - 4/20/25 at 12:56 p.m., 51 minutes and 14 seconds - 4/21/25 at 9:20 a.m., 22 minutes and 45 seconds - 4/21/25 at 10:10 a.m., 43 minutes and 0 seconds - 4/21/25 at 1:31 p.m., 25 minutes and 3 seconds - 4/21/25 at 7:13 p.m., 23 minutes and 59 seconds - 4/22/25 at 5:22 a.m., 20 minutes and 4 seconds - 4/22/25 at 7:39 a.m., 30 minutes and 28 seconds - 4/22/25 at 9:16 a.m., 36 minutes and 43 seconds - 4/22/25 at 10:02 a.m., 20 minutes and 31 seconds - 4/24/25 at 11:22 a.m., 20 minutes and 36 seconds - 4/24/25 at 5:01 p.m., 18 minutes and 47 seconds - 4/25/25 at 2:08 p.m., 19 minutes and 55 seconds - 4/25/25 at 2:35 p.m., 18 minutes and 50 seconds - 4/26/25 at 5:11 a.m., 60 minutes and 40 seconds - 4/26/25 at 6:41 a.m., 96 minutes and 29 seconds - 4/26/25 at 9:32 a.m., 55 minutes and 11 seconds - 4/26/25 at 10:54 a.m., 61 minutes and 9 seconds - 4/26/25 at 12:21 p.m., 34 minutes and 50 seconds - 4/26/25 at 2:26 p.m., 18 minutes and 4 seconds - 4/26/25 at 3:27 p.m., 31 minutes and 45 seconds - 4/27/25 at 2:34 p.m., 18 minutes and 50 seconds - 4/27/25 at 3:36 p.m., 36 minutes and 5 seconds - 4/27/25 at 5:30 p.m., 22 minutes and 24 seconds - 4/27/25 at 10:07 p.m., 50 minutes and 2 seconds - 4/28.25 at 5:25 a.m., 19 minutes and 3 seconds - 4/28/25 at 10:46 a.m., 48 minutes and 21 seconds - 4/29/25 at 7:50 a.m., 21 minutes and 13 seconds - 4/30/25 at 2:24 p.m., 23 minutes and 32 seconds - 5/1/25 at 10:56 a.m., 18 minutes and 32 seconds - 5/2/25 at 6:30 a.m., 28 minutes and 24 seconds - 5/2/25 at 7:09 a.m., 51 minutes and 11 seconds - 5/2/25 at 11:41 a.m., 36 minutes and 59 seconds - 5/4/25 at 5:40 a.m., 37 minutes and 11 seconds - 5/4/25 at 12:08 p.m., 29 minutes and 32 seconds - 5/4/25 at 1:49 p.m., 27 minutes and 39 seconds - 5/4/25 at 1:18 p.m., 21 minutes and 34 seconds - 5/5/25 at 5:28 a.m., 29 minutes and 18 seconds - 5/5/25 at 8:37 a.m., 28 minutes and 18 seconds - 5/5/25 at 10:43 a.m., 20 minutes and 1 second - 5/5/25 at 1:49 p.m., 22 minutes and 15 seconds - 5/5/25 at 2:38 p.m., 54 minutes and 56 seconds - 5/5/25 at 6:58 p.m., 71 minutes and 0 seconds - 5/6/25 at 12:04 p.m., 26 minutes and 50 seconds - 5/7/25 at 4:17 p.m., 25 minutes and 59 seconds - 5/10/25 at 7:28 a.m., 45 minutes and 41 seconds - 5/10/25 at 9:53 a.m., 63 minutes and 46 seconds - 5/10/25 at 12:58 p.m., 106 minutes and 44 seconds - 5/10/25 at 2:46 p.m., 81 minutes and 29 seconds - 5/10/25 at 5:43 p.m., 72 minutes and 11 seconds - 5/10/25 at 7:26 p.m., 29 minutes and 53 seconds - 5/10/25 at 10:18 p.m., 32 minutes and 12 seconds - 5/11/25 at 3:47 a.m., 27 minutes and 26 seconds - 5/11/25 at 9:19 a.m., 92 minutes and 53 seconds - 5/11/25 at 7:13 p.m., 19 minutes and 51 seconds - 5/11/25 at 7:40 p.m., 20 minutes and 37 seconds - 5/11/25 at 10:00 p.m., 43 minutes and 56 seconds - 5/12/25 at 12:13 p.m., 36 minutes and 55 seconds - 5/12/25 at 3:23 p.m., 26 minutes and 10 seconds - 5/13/25 at 7:33 a.m., 44 minutes and 6 seconds - 5/14/25 at 9:32 a.m., 37 minutes and 47 seconds During an interview on 5/14/25 at 3:05 p.m., R6 stated she used her chin to press her specialized call light. R6 stated that when she used her call light staff sometimes came right away and sometimes who knows when they would come. R6 stated it pissed her off when staff didn't answer her call light in a timely manner and it doesn't feel very good. She noted some staff would turn her call light off and leave without helping and she sometimes had to wait a really long time for assistance. R6 noted she had limited mobility and that's why she used the call light for staff assistance, such as when she wanted a sip of water. During an interview on 5/14/25 at

Based on interview and record review, the facility failed to ensure the Quality Assurance and Performance Improvement (QAPI) committee identified, investigated, analyzed, and responded to excessively long call light response times by developing and implementing action plans for process improvement identified to be a current concern with past identified non compliancy. This had the potential to affect all 81 residents who resided in the facility. Findings include: The facility's QAPI Program Plan dated September 2024, identified the purpose of the quality program was to provide quality and performance excellence in care and service delivery. The plan included various areas of care and service with an ongoing process to select and monitor data. Quality focus areas identified by both the facility and community included regulatory compliance and customer concerns. Data was collected for regulatory compliance from CMS-2567 forms as it occurred and the threshold (level of performance that requires a reaction) was identified as compliance. Customer concern data was collected monthly from residents/families/guests with threshold of 90% or lower resolved in five days. The program's systematic analysis and systemic action included systematically analyzing underlying causes of systemic quality issues, developing/implementing quality improvement activities, and monitoring the effectiveness of actions. The Quality Council was noted to fulfill the role of the community's quality assessment and assurance committee and assumed responsibility for identifying and responding to quality deficiencies throughout the community. Additionally, the council developed and implemented corrective actions, monitored to ensure performance goals or targets were achieved, and revised corrective action when necessary. The facility's Quality Council meeting PowerPoint for March 2025 with corresponding meeting minute notes identified the council met on 3/25/25 to review data from February 2025. The PowerPoint included a slide titled MDH-Survey Plan of Correction/Audits which identified citation from annual survey with plan of correction dated 1/15/25 including F725 sufficient nursing staff. A slide titled Concerns identified there were zero concerns for the month related to call light issues. The PowerPoint and meeting notes lacked further information about the audits and did not identify the details of the data collected. There was no investigation or causal analysis of the data, specific related goal, identified action plan, or monitoring of effectiveness of the facility's related actions. The facility's Quality Council meeting PowerPoint for April 2025 with corresponding meeting minute notes identified the council met on 4/22/25 to review data from March 2025. The PowerPoint included a slide titled MDH-Survey Plan of Correction/Audits which identified citation from annual survey with plan of correction dated 1/15/25 including F725 sufficient nursing staff. A slide titled Concerns identified there were 19 total concerns for the month including 3 related to call light issues. The PowerPoint and meeting notes lacked further information about the audits or call light and did not identify the details of the data collected (audits completed and 3 concerns). There was no investigation or causal analysis of the data, specific related goal, identified action plan, or monitoring of effectiveness of the facility's related actions. The facility's grievance log dated 2/20/25 through 5/12/25, included call light grievances related to staff response times. Grievances included: - On 3/25/25, a resident expressed concern that he put his call light on, waited 30 minutes with no response, and then went to the nursing station to ask staff for assistance. - On 4/1/25, a resident stated at night she had to wait over an hour for someone to answer her call light. - On 4/14/25, a resident stated when she put her call light on for toileting it was not answered fast enough, and she had to go in her brief. - On 4/14/25, a resident stated he put his call light on at 2:00 am and a staff member answered the light, turned the light off, left the room, and did not address his needs. - On 4/26/25, a resident reported she put her call light on and waited over an hour for staff to respond. Facility audit sheets titled F725 Sufficient Nursing Staff: Call Light Times included columns titled date, resident, shift being audited, were call lights answered timely, does resident have any concerns with call light times, and comments. Completed audit sheets were dated from 2/25/25 through 5/7/25. During an interview on 5/14/25 at 5:22 p.m., the administrator stated each nurse manager had been completing audits each week on a variety of shift. The administrator stated currently one resident and one shift was being audited each week, and the resident and shift had been picked at random. The administrator stated she had not heard of any concerns identified on the audits but had reviewed call light logs requested by surveyors and the data reflected in the call light logs did not align with what was recorded on the audit sheets. The administrator stated no specific direction was given to nurse managers when completing the audits, such as what constituted answering a call light timely, and they just followed the prompts in the column titles. She noted the QAPI committee met monthly and reviewed reportable incidents from the prior month, current plans of correction being worked though, admission data, quality improvement program data, return to hospital data, medication errors, skin issues, falls, behavior management, concerns from the prior month, nutrition and weight data, human resources data, and anything else relevant at the time. The administrator stated call light logs have not been included in QAPI and noted they were listed under the current audits the facility was doing and there hasn't been concerns in the actual audits. The administrator stated call lights had not been identified as on ongoing concern. During an interview on 5/15/25 at 8:15 a.m., the director of nursing (DON) stated she was aware call lights were an ongoing problem because of concerns and reports from residents. The DON stated data regarding call light times was monitored through the audits and resident concerns, like grievances filed. The DON reviewed the facility's call light logs dated 2/25/25 through 5/7/25. She identified some audits were marked see attached and did not specify if the light was answered timely or the resident had concerns, some audits stated lights were answered timely but included call light logs with times that did not meet her expectations for timeliness, and some audits were not completed fully. The DON stated the audits were not complete or accurate, did not specify what constituted timeliness, and did not include analysis of the data. The DON was unable to articulate how the facility was analyzing data and monitoring the call light times when the data collected was not complete or accurate and stated we weren't doing that effectively. She noted call light data came from audits and grievances and would be analyzed prior to and reviewed at QAPI meetings. She confirmed the QAPI meeting slide for plans of correction did not include data. After reviewing the call light audit sheets, she stated the data in the audits identified ongoing concerns and noted I don't see inclusion or analysis of the data or development of an improvement plan in the QAPI committee meetings. She further noted there was no analysis of the causal factor of action plan that I'm aware of and identified the administrator as the person who had been more involved and would know more. During and interview on 5/15/25 at 3:39 p.m., the administrator stated call lights were identified as an issue and the facility was cited for this in January. The plan to monitor and ensure compliance was nurse managers completing call light audits weekly, though she stated the audits were not complete or accurate. The administrator stated audits were analyzed by the nurse managers completing them, the DON, and herself and they did not identify the call light times as continued issue through the audits but they should have. She stated call light time data had not been analyzed in QAPI and a causal analysis had not been completed. The administrator stated the QAPI committee meeting showed the audits were being done and identified the number of related grievances, but we need to do more a deep dive into the why's behind them. She confirmed there was no action plan for process improvement based on the data and no measurable goal for call light times. She stated, the goal was 15 minutes, but it is not identified. Facility policy titled Call Lights - Call System Activation and Response dated 5/28/24, included Call light response times are reviewed as part of the QAPI program. Facility policy titled Quality Council (Quality Assessment and Assurance Committee) undated, indicated the facility had a Quality Council. The Quality Council assumes responsibility and oversight for services related to resident safety, health outcomes, resident autonomy, choice, quality of care, as well as customer satisfaction, regulatory compliance, and related performance improvement. The community will develop a plan to promote excellence in quality of care, quality of life, resident choice and person directed care. To accomplish this all employees are empowered to participate in ongoing QAPI efforts which support our mission. The Quality Council will collect and utilize data related to the unique characteristics and needs of the patients, focusing on high risk, problem prone, and high-volume areas to develop their annual QAPI plan. The Quality Council serves as the Community's Quality Assessment and Assurance (QAA) Committee with oversight of the Quality Assurance and Process Improvement (QAPI) program. Procedure included, The Quality Assessment and Assurance committee Plan describes the process for identifying and correcting quality deficiencies and includes: a) Tracking and measuring performance; b) Establishing goals and thresholds for performance improvement; c) Evaluation of the care and services provided; d) Identifying and prioritizing quality deficiencies and opportunities for improvement; e) Systematically analyzing underlying causes of systemic quality deficiencies; f) Developing and implementing corrective action or performance improvement activities; g) Monitoring and/or evaluating the effectiveness of corrective action and performance improvement activities and revising as indicated; h) The QAA plan will be reviewed annually and with any significant change to the community.

Based on interview and document review, the facility failed to maintain a complete, accurately documented, and readily accessible medical record in accordance with accepted professional standards and practices for 2 of 3 residents (R2, R3) reviewed for documentation. Findings include: R2 R2's facesheet indicated he admitted to the facility on [DATE]. R2's electronic health record (EHR) was reviewed on 5/15/25. The EHR lacked any primary care provider (medical doctor, nurse practitioner, or physician assistant) visit notes from R2's current admission starting 12/3/24. During an interview on 5/15/25 at 10:46 a.m., the director of nursing (DON) confirmed there were no primary care provider visit notes in R2's EHR. R2's primary care provider visit notes were retrieved from the primary care provider's external medical records system by facility staff. Visit notes provided to surveyors absent from the facility's EHR included eight total visits from dates: 12/4/24, 12/17/24, 12/24/24, 1/7/25, 2/19/25, 3/25/25, 4/2/25, and 5/13/25. R3 R3's facesheet indicated she admitted to the facility on [DATE]. R3's EHR was reviewed on 5/14/25. The EHR lacked any primary care provider visit notes from R3's current admission starting 8/29/24. During an interview on 5/14/25 at 4:45 p.m., the DON confirmed there were no primary care provider visit notes in R2's EHR. R3's primary care provider visit notes were retrieved from the primary care provider's external medical records system by facility staff. Visit notes provided to surveyors absent from the facility's EHR included 17 total visits from dates: 9/3/24, 9/4/24, 9/10/24, 9/17/24, 9/24/24, 9/25/24, 10/8/24, 11/20/24, 11/26/24, 12/10/24, 12/24/24, 1/14/25, 1/29/25, 2/25/25, 3/5/25, 4/8/25, and 5/3/25. During an interview on 5/14/25 at 4:45 p.m., the DON stated primary care provider notes were handled by medical records who uploaded visit notes into resident EHRs. The DON stated she would expect to see provider notes uploaded in the EHR and it was important to have complete and accurate information about a resident. She would not consider a medical record complete and accurate without primary provider visit notes and this did not meet her expectations. The DON was not aware of a specific time frame within which notes should be uploaded but would guess within a month. During an interview on 5/14/25 at 5:22 p.m., the administrator stated she would expect provider notes to be in resident EHRs. The administrator noted this mattered because staff needed access to reference them and they were needed in case of an emergency. The administrator was not aware there were resident EHRs that contained no primary care provider notes. She would expect notes to be uploaded into EHRs as soon as they were received by the facility. Facility policy titled Charting and Documentation in the Medical Record dated 10/4/23, indicated the purpose was to ensure objective, accurate, timely and clinically complete information in the individual resident medical record. Information to be documented in the resident medical record included: Objective observations; Medications administered; Treatments or services performed; Changes in the resident's condition; Events, incidents or accidents involving the resident; Progress toward the care plan goals; other communication with resident representative. The policy indicated documentation in the medical record would be objective, complete, and accurate.

Based on observation, interview, and document review the facility failed to provide adaptive eating utensils according to the care plan for 1 of 1 resident (R7) reviewed for nutrition. Findings include R7's face sheet dated 5/16/25, identified diagnosis of rheumatoid arthritis (a chronic inflammatory disorder affecting joints in hands or feet). R7's Minimum Data Set (MDS) dated [DATE], identified R7 was independent in eating and had intact cognition. R7's nutritional status focus care plan dated 5/7/25, identified a potential for altered nutrition related to rheumatoid arthritis, with an intervention of built-up utensils with all meals and culinary to provide. R7's nursing assistant care sheet dated 5/15/25, identified that R7 needed built-up utensils provided by the kitchen. R7's daily meal cards dated 5/15/25, identified R7 was to have built up utensils for all meals. R7's registered dietician progress note dated 3/6/25, identified R7 has continued to need built-up silverware to help with self-feeding related to rheumatoid arthritis. R7's grievance dated 3/21/25, identified R7 was not getting her built-up silverware with meals as ordered. An undated action identified culinary staff were educated on need to include built up silverware on meal tray. During an observation and interview on 5/15/25 at 12:54 p.m., R7 was in her room eating her meal of a pizza slice with a lettuce salad. R7 stated, How am I supposed to eat my salad without my built-up silverware. R7 was supposed to get them with all her meals, however had not received them in a long time. R7 stated her right hand did not work very well due to her rheumatoid arthritis and she had difficulty holding onto a regular utensils. R7 explained without having built up silverware she just uses her fingers to eat her salad. During an interview on 5/15/25 at 1:27 p.m., licensed practical nurse (LPN)-C confirmed R7 did not receive built-up silverware for her noon meal and was supposed to be having them placed on her tray for each meal. LPN-C further stated the dietary department has been educated on making sure they are place; however, it continues to be a problem. During an interview on 5/15/25 at 4:36 p.m., registered nurse regional director (RNRD) stated her expectation would be for dietary staff to follow the directions on the menu card and supply residents with the adaptive silverware if listed on the tray card for all meals. Review of the facility's Scope of Meal Service Policy undated, identified all culinary services personnel are responsible for the accuracy of tray assembly and all utensils are placed on the resident's tray. 51576

Based on observation, interview and document review, the facility failed to ensure medications were administered in accordance with physician orders and failed to identify and report medication errors for 2 of 3 (R1, R2) residents reviewed for medication administration. Findings include: R1 R1's Minimum Data Set (MDS) assessment dated [DATE], indicated she admitted to the facility on [DATE] with diagnoses including acute pain due to trauma and dorsalgia (pain in the upper back). R1 was on a scheduled pain medication regimen and received as needed (PRN) pain medications. R1's care plan revised 2/6/25, identified R1 experienced pain and discomfort. Interventions included administration of scheduled and PRN pain medication. R1's care plan also identified risk for alteration of skin status. Interventions included ensuring protective skin measures (barrier cream to dry areas and wheelchair cushion) were in place. R1's physician orders included an order for miconazole nitrate 2% topical cream (antifungal cream used to treat fungal or yeast infections) with start date 10/29/24 and discontinue date 5/15/25. Instructions were to apply to affected area topically twice daily scheduled for administration once between 7:00 a.m. and 3:00 p.m. (day) and again between 3:00 p.m. and 11:00 p.m. (evening). R1's physician orders included an order for tramadol oral tablet (an opioid pain medication used to treat moderate to moderately severe pain) 50 milligrams (mg) strength with start date 1/30/25. Instructions were to administer 25 mg orally four times a day for pain scheduled for administration at 8:00 a.m., 12:00 p.m., 4:00 p.m., and 8:00 p.m. R1's medication administration record (MAR) dated 3/1/25 through 5/13/25, included the scheduled twice daily administrations of miconazole. Documentation of the miconazole as not administered included: - 3/1/25 day and evening doses with notes drug/item unavailable - 3/3/25 evening dose with comment on order - 3/6/25 evening dose with note drug/item unavailable - 3/7/25 day and evening doses with notes drug/item unavailable - 3/8/25 day dose with note drug/item unavailable - 3/15/25 day dose with note drug/item unavailable - 4/4/25 evening dose with note drug/item unavailable - 4/5/25 day and evening doses with notes drug/item unavailable - 4/6/25 day and evening doses with notes drug/item unavailable - 4/7/25 day dose with note drug/item unavailable - 4/24/25 evening dose with note drug/item unavailable - 4/25/25 day and evening doses with notes drug/item unavailable - 4/26/25 day and evening doses with notes drug/item unavailable - 5/2/25 day and evening doses with notes drug/item unavailable - 5/4/25 day dose with note drug/item unavailable - 5/7/25 day dose with note drug/item unavailable R1's medication administration record (MAR) dated 3/1/25 through 5/13/25, included the scheduled four daily administrations of tramadol. Documentation of the tramadol as not administered included: - 4/11/25 at 4:00 p.m. with note drug/item unavailable - 4/24/25 at 8:00 p.m. with note med[ication] not here called pharmacy - 4/25/25 at 8:00 a.m., 12:00 p.m., 4:00 p.m., and 8:00 p.m. with notes drug/item unavailable - 4/26/25 at 8:00 a.m., 12:00 p.m., and 4:00 p.m. with notes drug/item unavailable R1's progress notes dated 4/24/25 at 6:45 p.m. and 6:55 p.m., indicated insurance would not cover the current dose of tramadol and wanted to change the dose. The pharmacy sent a fax to the facility to change the tramadol orders, R1 had no more tramadol available, and the on-call provider was notified. The on-call provider approved the pharmacy changing the tramadol order with new order for 50 mg tablets, give half tablet four times daily and once daily as needed for pain. Per pharmacy, insurance would cover this dose. Review of R1's progress notes did not identify further documentation regarding availability of the tramadol or miconazole, missed administrations, or related provider notifications. On 5/15/25 at 11:53 a.m., licensed practical nurse (LPN)-A stated on 4/24/25, R1 only had one remaining tramadol tablet. She contacted the pharmacy to re-order, was told R1's insurance would no longer cover this tablet, and contacted the on-call provider for approval to change from 25 mg tablets to 50 mg tablets cut in half. LPN-A stated she notified the provider to get approval, but did not notify the provider of the missed dose at 8:00 p.m. when the medication was unavailable because she assumed the medication would arrive later that night after her shift ended. LPN-A stated if a medication was not administered, the physician should be notified and missed doses of medications without a provider order to hold were medication errors. LPN-A noted R1's miconazole had been discontinued earlier that morning because she did not use it and would say she didn't want it at times. LPN-A stated she would document medications as not administered with note that drug/item was unavailable when a medication was not available and would then call the pharmacy. LPN-A confirmed she was R1's nurse and in charge of the medication cart with R1's medications. During observation, LPN-A searched R1's medications in the cart, house stock medications in the cart, R1's room, and the medication room for R1's miconazole cream. LPN-A confirmed she had not removed it from the cart for disposal and was not able to locate the medication. LPN-A confirmed this was a physician ordered medication and should be available, thought noted there had been a lack of supply previously. During an interview on 5/15/25 at 8:15 a.m., the director of nursing (DON) stated medications should be available for administration as ordered. If a medication was not available, the provider should be notified. If a medication was not available and staff failed to obtain a provider order to hold (not give) the medication, it would be a medication error. The DON stated she was not aware of R1's missed administrations of miconazole and tramadol. The DON stated if the tramadol was not given and the provider did not give an order to hold it, it would be considered a medication error. She stated she would expect R1's miconazole cream to be in stock and available for administration, would expect the provider to be notified if it was not, and would consider the missed administrations to be medication errors. The DON reviewed facility medication administration error reports and confirmed there were no medication errors reported for R1 between 3/1/25 and 5/13/25. During an interview on 5/15/25 at 10:46 a.m., the DON stated on 4/24/25 at 4:00 p.m. R1 received the last dose of her available tramadol, which was in 25 mg tablet form. On 4/24/25, staff were informed by the pharmacy that the 25 mg tablets would no longer be covered by insurance and got provider approval to change the prescription to half of a 50 mg tablet. R1 did not receive the medication again until 4/26/25 at 8:00 p.m. The DON stated she saw no indication the provider was notified of the ongoing lack of medication supply or missed administrations and would be processing this as a medication error. R2 R2's MDS dated [DATE], indicated he admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD). R2's care plan revised 2/6/25, identified R2's goal of care was comfort focused. Interventions included medications, treatments, and cares as ordered by primary physician and nurse practitioner. R2's physician orders included an order for albuterol sulfate aerosol inhaler 90 micrograms (mcg) per actuation with start date 12/3/24. Instructions were to inhale two puffs four times a day for COPD scheduled for administration at 8:00 a.m., 12:00 p.m., 4:00 p.m. and 8:00 p.m. R2's provider visit note dated 5/13/25, indicated he had a history of COPD with previous hospitalization s for pneumonia and COPD exacerbation. The note indicated R2's COPD was managed with medications including two puffs of an albuterol inhaler four times a day. R2's medication administration record (MAR) dated 3/1/25 through 5/13/25, included the scheduled four daily administrations of albuterol. Documentation of the albuterol as not administered included: 4/2/25 at 4:00 p.m. and 8:00 p.m. with note drug/item unavailable Review of R2's progress notes did not identify documentation regarding availability of the albuterol inhaler, missed administrations, or related provider notifications. During an interview on 5/15/25 at 2:20 p.m., the DON confirmed documentation reflected two missed doses of albuterol on 4/2/25 with notes that it was unavailable. The DON stated she was not informed of this and did not see it in the facility's medication error reports. The DON stated she would expect it to be identified as a medication error and to be reported to the provider. The DON noted the medication was not administered in accordance with physician orders. Facility policy titled Administering Medications dated 8/31/23, included 2.) Medications are administered in accordance with the orders. 3.) Medications are administered within their prescribed time. 4.) The person preparing or administering the medication will contact the provider if there are questions or concerns regarding medication. 5.) With any irregularities, appropriate notifications will be completed for clarification. Facility policy titled Medication Error/Occurrence dated 8/31/23, included definition of a medication error as the preparation or administration of drugs or biologicals which is not in accordance with the attending providers' orders, manufacturer's specification or accepted standards and principles of the professional providing the services. Examples of medication errors included omissions. The policy included When an error is made in the preparation or administration of a drug or biological, the licensed nurse provides any necessary immediate care and notifies the attending provider and resident or resident representative when nursing or medical intervention, observation or treatment is indicated. Medication errors are tracked and trended for quality improvement purposes . Insignificant medication errors such as a missed vitamin C will be internally investigated and may not be reported as nursing or medical treatment is not necessary. Frequent nonsignificant errors will require additional process investigation and performance improvement interventions including notification to the medical director. The licensed nurse and/or nurse supervisor may notify the attending physician and resident/resident representative of medication errors as deemed appropriate . Documentation includes the date, time of the error or discovery of error, the resident's condition, including vital signs, notification of provider, medical orders and notification of the resident/resident representative.

Based on observation, interview, and record review the facility failed to ensure expired food items were removed from service, food items were labeled and dated, and food was stored in a manner to prevent cross contamination from resident care items. Furthermore, the facility failed to ensure follow up and maintenance of a leaking refrigerator, routine maintenance of the dishwasher and overall cleanliness of the kitchen was maintained. Findings include: A facility kitchen/kitchenette cleaning log was requested however was not received. An email recieved [DATE], at 2:50 p.m., the administrator stated the last work order for the 4th floor refirdgerator was on [DATE]. A new order was placed and contractors have been notified to remedy the issue. Kitchenettes An observation on [DATE] at 8:56 a.m., the 4th floor kitchenette was reviewed. The refrigerator contained a container of opened Molly's Kitchen premade egg salad with a use by date was [DATE]. An opened bottle of [NAME] prune juice had a best by date of [DATE]. The bottom shelf of the fridge contained food crumbs or debris. In the back of the lower shelf was a box that appeared to be frozen onto the shelf. There were several butter packets stuck to the bottom of the box and the box stuck. The freezer contained a loaf of bread that was set upon a frozen white one time use ice pack. On the counter of the kitchenette was a bottle of opened Smucker's grape jelly that indicated it required refrigeration after opening. The counter also contained an open pump bottle of Simply Thick easy mix instant food thickener with a best use by date of [DATE]. When interviewed on [DATE] at 9:11 a.m., licensed practical nurse (LPN)-C verified the egg salad, prune juice, jelly, and food thickener. LPN-C stated all those items should be discarded and the jelly should be refrigerated. LPN-C stated kitchen staff would bring food items up weekly and ensure they were not out of date. LPN-C stated the ice pack was a one-time use and should be thrown away and for infection control purposes, not stored with the food. LPN-C verified the food debris and box that was stuck on the bottom shelf and was not able to remove it. An observation on [DATE] at 9:15 a.m., the 3rd floor kitchenette was reviewed. The refrigerator contained a container of opened Molly's Kitchen premade egg salad with a use by date was [DATE]. The freezer contained two instant once time use ice packs on the shelf and one in the door of the freezer. The freezer contained a few ice cream containers. The bottom shelf of the freezer and the back of the freezer contained spilled red sticky substance. On the counter of the kitchenette contained two opened bottles of Smucker's grape jelly that indicated it required refrigeration after opening. When interviewed on [DATE] at 9:39 a.m., LPN-A verified the egg salad, ice packs and red sticky substance in the freezer. LPN-A wasn't sure who stocked the refrigerator or monitors for items that are expired. He wasn't sure if nursing staff or dietary staff were responsible for cleaning the in the kitchenette. LPN-A further stated ice packs should not be stored in the kitchenette freezers and were either one time use or there was a freezer in the medication room. An observation on [DATE] at 9:42 a. m., the 2nd floor kitchenette was reviewed. The freezer contained two one time use ice packs. The freezer also contained a ball of dough like substance wrapped in plastic wrap. There was no label or date on it. When interviewed on [DATE] at 9:47 a.m., nursing assistant (NA)-B verified the ice packs and the dough like substance. NA-B was not sure what the process for ice pack storage was as she normally did not work on 2nd floor. NA-B was not sure what the dough was and what it was for, however verified there was no label or date. When interviewed on [DATE] at 1:30 p.m., registered nurse (RN)- F stated the culinary staff usually take care of the kitchenettes. This included checking dates on food items and cleaning. Nursing doesn't look at dates on any routine basis but can always double check when using an item. RN-F stated icepacks were one time use only and should not be stored in the freezers. Having them in the freezer could cause contamination or become an infection control issue. Main kitchen An observation on [DATE] at 11:26 a.m., the main kitchen was reviewed. In a stand-up refrigerator a tray of salad items was noted. The tray consisted of cut up meats, cheese, vegetables for salad building. The tray was covered in plastic wrap, however, was not labeled or dated. This was verified by the Culinary Director (CD). At 12:02 p.m., The dishwasher was reviewed, there was grime and dirt on the floors, under shelves and the dishwasher countertop. The Ecolab dishwasher had grime on top and the sides of the machine and had white flaky scale substance on the counter where clean dishes exited the machine and around the bottom of the lift door. CD wasn't sure when the machine was last de-limed and stated the bigger concerns was to ensure temperatures were in range. When interviewed on [DATE] at 11:26 p.m., the CD expected all food items to have a label and date, so staff know what it is and how long it is good for. CD stated the kitchen staff delivered snacks and cold salads to the floor weekly. CD stated that was when the dates of those items were checked. CD stated the egg salad dated from [DATE] should be tossed out. Kitchen staff reviewed only the fridge and freezer items and nursing staff were responsible for the rest of the kitchenette. CD stated all staff using the kitchen should be ensuring the dates of items if pulling to use. CD verified the 4th floor refrigerator had been leaking down the back causing the box of butter to be frozen. CD stated he had placed multiple work orders for this to get fixed and wasn't sure why it was not done. When interviewed on [DATE] at 1:11 p.m., the Director of Nursing (DON) expected ice packs to be stored separately from any food or kitchen items. DON further stated it is a group effort between the kitchen staff and nursing staff to ensure kitchen items were not expired and still ok for resident use. When interviewed on [DATE] at 3:06 p.m., the administrator verified there was not a cleaning schedule for the kitchen or kitchenettes and this was being worked on. The administrator further expected any expired items to be removed from service and expected the kitchen staff to be managing both the main kitchen and kitchenettes. A facility policy titled Food Storage revised ,d+[DATE], directed staff to ensure all storage areas in refrigerated and freezer will be maintained in a clean and sanitary condition and spills should be wiped up immediately. All prepared food items should be covered labeled and dated. A facility policy titled Equipment Operation Safety revised ,d+[DATE], directed staff to make provisions for regular inspection and assure equipment is in good working order and protected by safeguards as needed.

Based on observation, interview and document review, the facility failed to provide sufficient staffing to ensure residents received care and assistance they needed (R127, R35, R281, R11, R25, R59) for 6 of 7 residents reviewed for staffing needs. This had the potential to affect all 85 residents who reside in the facility. Findings include: The facility's payroll-based journal (PBJ) Staffing Data Report dated 7/1/24 through 9/30/24, identified excessively low weekend staffing as an area of concern. R127's significant change Minimum Data Set (MDS) dated [DATE], indicated intact cognition and diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting right dominant side and abnormalities of gait and mobility. It further indicated R127 was frequently incontinent of bowel, bladder and required assistance with toileting. R127's care plan dated 2/1/24, indicated R127 will have less than 2 episodes of bowel incontinence per day, will be continent of bowel at all times, and will be continent of bowel during the daytime with an intervention to observe his level of incontinence and initiate toileting schedule if indicated; check and change every two hours with incontinence pad. R127's Point of Care history report for bowel/bladder dated 6/7/24, indicate R127 hadn't been assisted with toileting from 8:46 a.m. until 9:15 p.m. During interview on 1/16/24 at 8:33 a.m., (NA)-T stated she changed R127 and he had dried bowel movement (BM) and it appeared he had been sitting in it for awhile. R127's call light log dated 6/7/24, showed the following delayed call light response times: -11:30 a.m. 41 minutes and 46 seconds -12:26 p.m. 50 minutes and 30 seconds -1:56 p.m. 93 minutes and 33 seconds -3:31 p.m. 78 minutes and 56 seconds 44647 R35 R35's annual MDS dated [DATE], identified moderately impaired cognition, no rejection of care; and diagnoses of kidney insufficiency, high blood pressure, osteoporosis and respiratory failure. R35 used a manual wheelchair for mobility and was dependent on staff for toileting, bathing, dressing, and hygiene. R35's call light log dated 1/15/25, showed the following delayed call light response times: 12/19/24 9:19 a.m., 31 minutes and 48 seconds 12/21/24 at 9:28 a.m., 56 minutes and 41 seconds 12/24/24 at 9:46 a.m., 102 minutes and 9 seconds 12/27/24 at 9:50 a.m., 40 minutes and 48 seconds 1/3/25 at 10:37 a.m., 45 minutes and 1 second 1/9/25 at 10:45 p.m., 39 minutes and 5 seconds 1/23/25 at 8:46 p.m., 44 minutes and 54 seconds 1/13/25 at 8:25 p.m., 37 minutes and 29 seconds 1/14/25 at 9:49 a.m., 37 minutes and 31 seconds. During an interview on 1/15/24 at 11:10 a.m., R35 stated call lights were absolutely not answered in 15 minutes. Staff had a habit of coming in and turning the call light off and say they would be back in when they are able to, but they never come back. R281 R281's quarterly MDS dated [DATE], identified intact cognition, no rejection of care and diagnoses of Multiple Sclerosis, heart failure and high blood pressure. R281 used a motorized wheelchair for mobility and needed substantial assistance with toileting, upper body dressing and was dependent on staff for lower body dressing and hygiene. During an interview on 1/15/24 at 11:10 a.m., R281 stated nurses will answer call lights sometimes, however they will turn it off and say, I will let your aide know. Medications were often late and sometimes a nurse from another floor will come and help, but just at the beginning of the shift. 46885 R11's admission Minimum Data Set (MDS) dated [DATE], indicated intact cognition, did not have behaviors, and did not reject cares. Further, R11 required substantial to maximal assistance with toileting hygiene, and transfers, did not have a catheter or ostomy, was frequently incontinent of urine and bowel and a toileting program trial had not been attempted. Additionally, R11 had diagnoses of noninfective gastroenteritis and colitis, nausea and vomiting, The MDS indicated R11 was at risk for developing pressure ulcers and application of ointments and medications were completed other than to feet. R11's Facesheet form undated, indicated the following diagnoses: noninfective gastroenteritis and colitis, diarrhea, and other sites of candidiasis (a fungal infection) to the groin. R11's care plan dated 1/13/25, indicated R11 had a self care deficit with bathing, grooming, oral cares, ambulation, transferring, mobility, vision, bowel and bladder and was continent of bowel and bladder. Additionally, R11 had a bowel and bladder plan that included offering toileting every two to three hours at 12:00 a.m., 3:00 a.m., 6:00 a.m., 9:00 a.m., 12:00 p.m., 3:00 p.m., 6:00 p.m., and 9:00 p.m. R11 required assist of one for toileting and used the toilet. R11's care sheet dated 1/13/25, indicated R11 was continent of bowel and bladder and required assist of one with most activities of daily living (ADLs). R11's Bowel Assessment form dated 1/4/25, indicated R11 was occasionally incontinent and risk factors for incontinence included frequency of diarrhea. During interview on 1/13/25 at 9:28 a.m., R11 stated she was in a room that was far away from the nurse's station and experienced problems with diarrhea and sat in diarrhea for 45 minutes before a staff person came. R11 stated the diarrhea breaks down her skin and further stated she should be seen faster than 45 minutes. R11's call light logs were reviewed and included the following reset times: 12/31/24 at 2:08 p.m., 19 minutes, 36 seconds. 1/2/25 at 4:50 a.m., 20 minutes, 36 seconds. 1/2/25 at 3:59 p.m., 23 minutes, 30 seconds. 1/3/25 at 8:39 a.m., 21 minutes, 44 seconds. 1/3/25 at 10:58 a.m., 26 minutes, 13 seconds. 1/3/25 at 7:34 p.m., 19 minutes, 25 seconds. 1/4/25 at 5:17 a.m., 50 minutes, 2 seconds. 1/6/25 at 4:52 a.m., 25 minutes, 5 seconds. 1/6/25 at 9:13 a.m., 23 minutes, 33 seconds. 1/6/25 at 2:56 p.m., 29 minutes, 43 seconds. 1/7/25 at 8:18 a.m., 63 minutes, 42 seconds. 1/7/25 at 10:09 p.m., 25 minutes, 44 seconds. 1/8/25 at 7:47 a.m., 24 minutes, 50 seconds. 1/8/25 at 8:48 a.m., 27 minutes, 34 seconds. 1/8/25 at 1:12 p.m., 20 minutes, 43 seconds. 1/10/25 at 8:34 a.m., 48 minutes, 51 seconds. 1/11/25 at 1:36 a.m., 27 minutes, 39 seconds. 1/11/25 at 7:37 a.m., 28 minutes, 47 seconds. 1/11/25 at 8:14 a.m., 43 minutes, 27 seconds. 1/12/25 at 1:36 p.m., 27 minutes, 15 seconds. 1/15/25 at 12:47 p.m., 21 minutes, 48 seconds. 51379 R25's face sheet dated 1/15/25, indicated R25 had diagnoses of generalize pain disorder, generalized muscle weakness, sciatica, morbid obesity, presbyopia, and a right fibula fracture. R25's care plan dated 11/29/24, indicated scheduled pain medications to be administered per physician order. R25 has visual dysfunction and self-care deficit requiring additional help for activities of daily living (ADL). R25's medication administration record (MAR) dated 1/1/25 through 1/15/25 indicated R25 received late medication 10 out of the 15 days. R25's call light logs were reviewed and included the following reset times: 1/4/25 at 5:13 a.m., 21 minutes, 13 seconds 1/4/25 at 12:54 p.m., 33 minutes, 36 seconds 1/4/25 at 1:37 p.m., 91 minutes, 49 seconds 1/5/25 at 10:23 a.m., 67 minutes, 32 seconds 1/8/25 at 8:37 a.m., 23 minutes, 27 seconds 1/8/25 at 8:38 p.m., 26 minutes, 15 seconds 1/9/25 at 5:00 p.m., 19 minutes, 19 seconds 1/9/25 at 10:46 p.m., 39 minutes, 31 seconds During interview on 1/13/25 10:14 a.m., R25 stated she has difficulty getting her scheduled pain medications on time; sometimes additional pain medication could often take an additional 2-3 hours due to low staffing, especially overnight. R59's face sheet printed 1/16/24 8:56 a.m., indicated R59 had recently been admitted with a diagnosis of cellulitis of left lower limb, methicillin resistant staphylococcus aureus infection (MRSA), Type 2 diabetes mellitus, morbid obesity, chronic heart failure, and partial traumatic amputation of the left foot. R59's care plan dated 12/10/24, indicated a high risk for infections, administering intravenous medications as ordered by physician. R59 had ADL deficits requiring nursing assistance of one. R59's provider order dated 12/30/24 to 1/23/24, indicated R59 required ceftriaxone 2 grams (G) intravenous (IV) once per day and vancomycin 1000 milligrams (mg) IV two times per day. R59's MAR dated 1/1/25 through 1/6/25 indicated R59 received late medication 10 out of 15 days. When interviewed on 1/13/25 at 12:55 p.m., R59 stated he often disconnected his peripherally inserted central catheter (PICC) line; he stated the reason he does his own flush was staff just don't have time. An observation on 1/15/24 at 1:28 p.m., R59 was observed disconnecting the vancomycin IV medication from his PICC line and flushing the PICC line with the saline flush. R59 did not wash his hands or perform hand hygiene prior to disconnecting the medication and flushing the PICC line. During an interview on 1/16/25 at 9:55 a.m., licensed practical nurse (LPN)-D stated she feels like they can't answer call lights fast enough. LPN-D stated they are understaffed because it can take longer to answer call lights and medications can be late. During an interview on 1/16/25 at 10:00 a.m., nursing assistant (NA)-B stated staffing could be better. NA-B stated the residents complain to her call lights take a long time to get answered; in the mornings when she comes on, the residents say they took so long to get things over night. NA-B stated some residents have yelled at her for not helping them even though she is already helping another resident. NA-B stated most days just fly by because she never sits down. During interview on 1/16/25 at 10:05 a.m., registered nurse (RN)-A stated they very rarely have enough staff. Nights and weekends have high call ins; this staff may not get replaced. RN-A stated it has been difficult to get all the meds passed on time and give the residents the attention they deserve. RN-A stated it is very difficult to get everything done in a shift if someone calls in. Residents tell her they need to hire more staff, but nothing seems to change. RN-A stated she just wishes there were more staff so things could get done on time. During an interview on 1/16/25 at 11:15 a.m., staffing Coordinator (SC) stated the staffing coordinator and administrator handle most things with staffing. SC stated daily staffing is completed using the daily census and daily budget allowances for each day. SC stated staffing is done daily for the next day to make sure the right number of staff are scheduled for the number of residents. SC stated staff are required to call them as soon as they know they won't make a shift; staff who call in on weekends can be difficult to replace. SC stated all workload concerns (too many meds to pass, call lights, resident cares, etc.) are submitted to the director of nursing (DON). During interview on 1/16/25 at 12:15 p.m., administrator confirmed staffing numbers are based solely on census and budgeted hours not resident acuity or diagnosis. Administrator stated the facility does use temporary staffing; most days temporary staff make up 1-5 people of the daily staff. Administrator confirmed the facility does not perform care plan audits or task completion audits. Administrator confirmed the facility does not track late medication administration. Administrator confirmed the expected call light response time is less than or equal to 15 minutes. Administrator confirmed the facility does not routinely perform call light response time audits.

Based on observation, interview and record review the facility failed to ensure transmission-based precautions (TBP) were followed for 1 of 1 resident (R38) who required TPB during medication administration and failed to ensure a glucose meter was disinfected per manufacturer's guidelines after resident use for 1 of 1 residents (R31) observed for glucose monitoring. Furthermore, the facility failed to ensure resident clothing was transported in a manner to ensure cleanliness and protect from dust and soil during transport. This had the potential to impact all residents residing on the 3rd floor and who the facility provides laundry services for. Findings include: R31's quarterly MDS dated [DATE], indicated R1 was cognitively intact and had diagnoses of diabetes. R31's provider order dated 12/17/24, indicated R31 required a blood glucose check on Sun, Tue, Thu, Sat, at 5:00 p.m. R38's admission Minimum Data Set (MDS) dated [DATE], indicated R38 was cognitively intact and had diagnoses of cellulitis (skin infection) of left lower limb and Methicillin resistant Staphylococcus aureus (multidrug resistant bacteria, (MRSA) infection to left extremity wound. R38's provider dated 12/10/24, indicated R38 required ceftriaxone 2grams intravenous (IV) daily for cellulitis. R38's provider and nursing orders lacked indication R38 required contact precautions. R38's care plan revised 12/23/24, indicated R38 required contact precautions related to MRSA and presence of open wounds. Interventions included to post clear signage on the door outside the resident room to indicate precautions and personal protective equipment (PPE) needed and to assure residents are encouraged to be restricted to their rooms or limited participation in group activities. Cleaning and disinfecting the Assure Platinum blood glucose monitoring system revised 9/2024, recommended cleaning and disinfecting with the following products; Clorox germicidal wipes, Dispatch hospital cleaner disinfectant towels with bleach, super Sani-cloth germicidal wipes, Cavi wipes, or microdot bleach wipes. A continuous observation on 1/24/25 at 4:42 p.m., LPN-F approached R31 who was seated at the dining room table with a white basket that contained an Assure Platinum glucometer, test strips, lancets, and alcohol wipes. LPN-F obtained R31's blood glucose and wrote 166 down on a piece of paper. LPN-F removed the test strip and then placed the glucometer back in the white basket, removed gloves and folded the used test strip up in the gloves, and returned to the medication cart. LPN-F removed gloves and performed hand hygiene. The white basket was placed on top of the medication cart. No sanitizing wipes were observed to be on the medication cart. Without cleaning the glucometer, LPN-F continued with medication administration. At 4:59 p.m., LPN-F obtained R38's medications to administer. R38's door was open and outside the door was a sign that stated Contact Precautions and instructed staff to perform hand hygiene, gown, and glove before entering the room. LPN-F performed hand hygiene and gloves before realizing R38 was in the dining room waiting for dinner. LPN-F stated they needed to get some supplies to administer R38's antibiotic. LPN-F still having gloves donned entered R38's room without placing a gown. LPN-F opened R38's nightstand table that was located towards the end of the bed and obtained a normal saline (NS) flush (medication used to access an IV before administering medication). LPN-F then closed the dresser drawer and left the room without removing gloves or performing hand hygiene and went back to R38 still in the dining room. With the same gloves, LPN-F opened the saline flush and prepared it to administer. LPN-F then removed their gloves and without hand hygiene placed new gloves. R38 removed the cap from his IV and LPN-F then cleaned the port and gave the NS flush medication. LPN-F then primed and connected R38's ceftriaxone medication. LPN-F removed gloves and without hand hygiene, administered the remaining pills to R38. LPN-F then verified there were no other residents who required blood glucose checks or medications to be administered. When interviewed on 1/24/25 at 5:22 p.m., LPN-F verified the glucometer was used for multiple residents. LPN-F was only helping with medications and wasn't sure how many residents used the glucometer. LPN-F further stated the glucometer had to be cleaned with the purple top super-Sani-cloth disinfectant wipes and wasn't sure where they were at. LPN-F was not able to find any on either medication cart or at the nurse's desk. LPN-F then donned gloves and started to clean glucometer with an alcohol wipe as the other Sani-cloth wipes were not available. LPN-F verified R38 was on contact precautions for MRSA and acknowledged the signage directing staff to wear a gown and gloves when entering the room. LPN-F stated a gown was needed if completing cares, but it was ok to enter to obtain supplies or when not providing wound or close contact care. LPN-F acknowledged R38 should have returned to their room for the antibiotic, or a gown should have been worn when accessing it. LPN-F further stated hand hygiene should be done in-between glove changes and at when done working with the IV site. When interviewed on 1/15/25 at 1:13 p.m., the Director of Nursing (DON) thought most residents had their own glucometers and those should be used. If residents shared one, the super-Sani cloth (purple top) wipes needed to be used after each use. DON was unsure of the use of alcohol wipes and would need to review policy/procedure. DON stated staff would be able to enter the room for residents on contact precautions if they were not providing cares for the resident. DON expected staff to have a gown and gloves in place when working with an IV site and to perform hand hygiene after each glove removal and upon exiting resident rooms. When interviewed on 1/15/25 at 1:23 p.m., the covering infection preventionist (IP) expected staff to follow the signs for contact precautions and should be gowning and gloving whenever entering the resident environment. Upon exit of any rooms, gloves should be removed, and hand hygiene performed. Furthermore, staff should wear gown and gloves when working with an IV of a resident and after any glove exchange hand hygiene should be completed. IP stated some of the residents have their own glucometers, however if using one for multiple residents the super-Sani cloth (purple top) wipes or an alcohol swab should be used to sanitize after each resident use. Laundry An observation on 1/14/25 at 11:45 p.m., nursing assistant (NA)-N was pushing a rack of clothing through the hallway on 2nd floor. The clothing contained resident items that were coming back from laundry. The items were hung up with hangers and uncovered. Other staff were observed to be walking down same hallway, delivering meals to residents. Several staff and residents had walked by the rack of clothing. When interviewed on 1/24/25 at 11:50 a.m., NA-N stated they had just picked up shifts to help in laundry and didn't work there regularly. NA-N stated she had training and was told only sheets and linens needed to be covered when transported, and it was ok for residents clothing to be uncovered. When interviewed on 1/15/25 at 3:02 p.m., the Director of Maintenance (DM) stated resident linen should be covered during transport. Residents clean clothing was transported on an open rack and were not covered. DM further stated currently, there was not a housekeeping supervisor and he thought covering laundry during transport was intended for linens and not resident clothing. A Facility policy titled Infection Control; Hand Hygiene revised 2009, directed staff to perform hand hygiene before and after direct contact with residents, before and after handling an invasive device such as an IV, after glove removal and before and after entering isolation precaution settings. A facility policy titled Contact Precautions revised 9/2023, directed staff to use contact precautions in addition to standard precautions to prevent spread of organisms that can be transmitted by direct resident contact or by indirect contact of environmental surfaces. This includes acute infection with MRSA. A facility policy titled Environmental Cleaning, Disinfection and Sterilization revised 8/2023, directed staff to clean semi-critical devises such as glucometers with a disinfectant that claims to inactivate HIV, TB, HBV, and HCV or household bleach (1 part bleach and 9 parts water). A facility policy titled Linen and Laundry revised 5/15/24, directed staff to transport linens by methods to ensure cleanliness and protection from dust and soil during transportation.

Based on observation, interview and document review, the facility failed to ensure the resident's ability to self-administration of medications (SAM) was assessed prior to leaving medications with the resident for 3 of 3 residents (R10, R278, R59) reviewed who had medications in their rooms. Findings include: R10's annual Minimum Data Set (MDS) dated [DATE], identified diagnoses of Parkinsonism (neurological condition which makes body movements difficult), mild cognitive impairment, personality disorder, bipolar disorder, depression, and arthritis. High risk medications included antidepressant, antipsychotic, anticoagulant, antibiotic, hypoglycemic and anticonvulsant medications. R10 required supervision with eating meals. R10's Cognition Care Area Assessment (CAA) dated 10/22/24, was triggered and identified staff were to monitor for changes in cognition and assist with decisions. R10's Care Plan dated 10/22/24, identified she was a vulnerable adult and needed assistance to remain safe within the community. Vulnerabilities included: negative impacts of mental and physical health related to diagnoses of personality disorder, bipolar 1, fibromyalgia, hypothyroidism, DM2 (diabetes mellitus type II), ADHD (attention deficit hyperactivity disorder), history of drug and alcohol use. R10's care plan lacked a SAM assessment. R10's observations and orders dated 1/13/25 through 1/13/25, lacked a SAM assessment or orders to SAM. R10's undated Physician's Orders report included the following start dates for morning and noon medications: 1. 10/15/23, acetaminophen 1,000 milligrams (mg); oral tablet at morning, noon and bedtime. 2. 10/15/23, duloxetine (antidepressant) 60 mg oral capsule in the morning. 3. 10/15/23, gabapentin (pain medicine) 300 mg oral tablet at 8:00 a.m., 12:00 p.m., and 4:00 p.m. 4. 10/15/23, vitamin D3 25 mcg (micrograms) take 2 oral tablets at 8:00 a.m. 5. 11/9/23, ferrous gluconate (supplement) 324 mg oral tablet at 8:00 a.m. 6. 3/28/24, coenzyme Q10 (supplement); 100 mg oral tablet at 8:00 a.m. 7. 8/19/24, Eliquis (anticoagulant) 5 mg oral tablet; take 2.5 mg in the morning and evening. 8. 8/20/24, lisinopril (blood pressure medication) 5 mg oral tablet at 8:00 a.m. 9. 8/29/24, metformin (lowers blood sugars) 750 mg oral tablet at 8:00 a.m., and 4:00 p.m. 10. 10/15/24, cyanocobalamin (vitamin)1,000 mcg oral tablet at 8:00 a.m. 11. 11/1/24, fexofenadine (antihistamine) 60 mg oral tablet at 8:00 a.m. and 4:00 p.m. During an observation and interview on 1/13/25 at 9:19 a.m., R10 had a pill cup with several medications inside. R10 stated she did not know specifically what the medications were for and the nurse brought them in the morning. R10 also stated technically the nurses were supposed to watch her take them but sometimes they do not. During an observation and interview on 1/13/25 at 10:04 a.m., nursing assistant (NA)-A answered R10's call light, confirmed she saw the medications in the cup on the bedside table after the nurse left the room, and R10 took the medications with breakfast. NA-A stated usually the nurse would watch R10 take the medications. During an observation and interview on 1/13/25 at 12:59 p.m., R10's pill cup on her bedside table contained two large white medications. R10 stated she was unsure if those were her noon medications. During an interview and observation on 1/13/25 at 1:02 p.m., licensed practical nurse (LPN)-A stated he recently brought R10 her medications. LPN-A stated R10 said she would take them, then LPN-A said he left the room without confirming they were taken as ordered. LPN-A re-entered R10's room with surveyor and confirmed the pill cup contained two large white pills acetaminophen and one capsule of gabapentin at the bedside table. LPN-A stated in order to safely leave medications in a resident's room there should be an assessment and physician order to SAM. LPN-A reviewed R10's orders, care plans and observations; and agreed SAM had not been assessed and he should not have left the room before confirming R10 had taken her medications. 44647 R278's face sheet printed 1/13/25, indicated R278 had recently admitted to the facility and had diagnoses of kidney failure, prostate cancer, and low back pain. R278's provider order dated 1/6/25, indicated R278 required a lidocaine adhesive patch 4% applied in the morning and removed at bedtime. R278's provider orders lacked indication R278 could self-administer medications. R278's self-administration observation dated 1/10/25, indicated R278 did not want to self-administer medications. An observation on 1/13/25 at 8:26 p.m., registered nurse (RN)-E entered R278's room to administer morning medications. R278 stated he wanted to wait for the lidocaine patch as he was to painful to turn at this time. RN-E left the opened lidocaine patch on R278's tray table and left the room. When interviewed on 1/13/25 at 8:56 a.m., RN-E verified R278's lidocaine was ok to leave at the bedside as he wanted it later. RN-E further stated it was just lidocaine and that medication was ok to leave with residents. 51379 R59's face sheet 1/16/24, indicated R59 had recently been admitted with a diagnosis of cellulitis of left lower limb, methicillin resistant staphylococcus aureus infection (MRSA), Type 2 diabetes mellitus, morbid obesity, chronic heart failure, and partial traumatic amputation of the left foot. R59's provider order dated 12/30/24 to 1/23/24, indicated R59 required ceftriaxone 2 grams (G) intravenous (IV) once per day and vancomycin 1000 milligrams (mg) IV two times per day. R59's provider orders lacked indication R59 could self-administer IV medications. When interviewed on 01/13/25 12:55 p.m., R59 stated he has a heel injury from home, this injury has been debrided multiple times requiring IV antibiotics. R59 stated he often must disconnect his peripherally inserted central catheter (PICC) line himself; staff leave a saline flush for him. He stated the reason he does his own flush was staff just don't have time. He doesn't mind helping them with this task. Saline flush observed on R59's bedside table. An observation on 1/15/24 at 10:27 a.m., registered nurse (RN)-F entered R59's room to administer the morning dose of vancomycin IV to infuse over 2-3 hours in his PICC line. An observation on 1/15/24 at 1:28 p.m., R59 was observed disconnecting the vancomycin IV medication from his PICC line and flushing the PICC line with the saline flush. R59 did not wash his hands or perform hand hygiene prior to disconnecting the medication and flushing the PICC line. When interviewed on 01/15/25 01:25 p.m., trained medication aide (TMA)-A stated if the resident does not have a self-administration of medications (SAM), then she has to stay in the room and watch the resident take the medication; she states the same policy is required for IV medications. TMA-A verified R59 did not have a SAM for IV medications. When interviewed on 01/15/25 01:31 p.m., RN-A stated if a resident doesn't have a SAM order completed, then they can't administer their own medications; this also applies to disconnecting medications and flushing PICC lines. RN-A verified R59 did not have a SAM for IV medications. When interviewed on 01/15/25 01:42 p.m., director of nursing (DON) stated the facility policy is all residents who self-administer medication including IV medications would need an active SAM. DON verified R59 did not have a SAM for IV medications. Facility policy dated 2/2019, stated each resident must be evaluated and a SAM order placed in the electronic medical record. R59 did not have a SAM order to administer, discontinue, or flush the PICC line.

Based on observation, interview, and document review, the facility failed to ensure dignity was maintained for 2 of 4 residents (R11, R277) reviewed for dignity. Findings include: R11's Optional State Assessment (OSA) dated 1/6/25, indicated intact cognition, and did not have behaviors or reject care. R11's face sheet form in the electronic medical record indicated R11's given name, name A, along with quotations around another name, name B. R11's care plan was reviewed and lacked information R11 had a preferred name. R11's care sheet dated 1/13/25 at 9:08 a.m., included R11's given name A. Name B was listed in quotations. R11's physician progress notes dated 1/7/25, indicated R11 wanted to be called by name B. During interview and observation on 1/13/25 between 9:28 a.m., and 9:48 a.m., R11 had signage on her door that indicated R11's given name A. Name B was listed in quotations. R11 stated the staff were calling her name A and not her preferred name, which was name B. R11 stated it got tiring having to tell them the same thing. During interview on 1/15/25 at 11:35 a.m., nursing assistant (NA)-F stated he followed the care plan to know what cares a resident required and further stated R11 had intact cognition and called when she needed help. Further, NA-F stated R11 wanted to be called name A when asked if R11 had any preferences on what she wanted to be called. During interview on 1/15/25 at 2:52 p.m., the director of nursing (DON) reviewed R11's electronic medical record and stated R11's name B was in quotations and further stated obviously admissions knew R11 wanted to be called name B and stated it went along with dignity and staff should call someone the name the person preferred. During observation on 1/16/25 at 8:44 a.m., R11 still had the signage located on her door indicating name A. Name B was also identified on the sign in quotations. During interview on 1/16/25 at 8:54 a.m., registered nurse (RN)-C stated R11's real name was name A, but R11 never wanted to be called name A and and further stated the quotations around name B in the computer indicated R11 wanted to be called name B. R277: R277's face sheet indicated R277 admitted to the facility on Friday, 1/10/25 at 11:53 a.m., and had the following diagnoses: unspecified fall, paranoid schizophrenia, depression, urinary incontinence, and type two diabetes. R277's Functional Abilities form dated 1/14/25, indicated R277 required partial to moderate assist with toileting, showering and bathing, lower body dressing, and required supervision or touching assistance with personal hygiene which included shaving. R277's Orders form indicated the following orders: 1/10/25 bath conduct a full body audit weekly skin check observation, 2., obtain a complete set of vital signs and ensure the nails are trimmed and filed (nurse if there was a diagnosis of diabetes) and complete a progress note on concerns and follow the protocol for refused baths and showers; update the CM with refusal. Once a day on Mondays 7:00 a.m., to 3:00 p.m. 1/10/25 bath, conduct a full body audit weekly skin check observation, obtain a complete set of vital signs and ensure nails are trimmed and filed (Nurse if there was a diagnosis of diabetes) and complete a progress note on concerns and follow the protocol for refused baths and showers and update the CM with refusal. Once a day on Fridays 3:00 p.m., to 11:00 p.m. The orders were reviewed and lacked information regarding who should complete shaving when a resident had diabetes. R277's medication administration record (MAR) and treatment administration record (TAR) printed 1/15/25 at 8:00 a.m., indicated R277 received a bath or shower on 1/10/25, and lacked documentation on 1/13/25, that R277 received a shower or bath. R277's care plan dated 1/10/25, indicated R277 had a self care deficit with bathing, grooming, oral cares, ambulation, transferring, mobility, vision, bowel and bladder. The care plan indicated R277 could not verbally ask for assistance. The care plan lacked information regarding who should complete shaving. R277's care sheet dated 1/13/25, was reviewed and lacked information regarding shaving, but indicated R277 required assist of one with dressing, washing, oral and hair care. Further, the care sheet indicated R277 was to receive a bath on Monday a.m., and Friday p.m. R277's Point of Care history notes dated 1/1/25, through 1/15/25, lacked information for how R277 showered or bathed. R277's Weekly Skin Check form dated 1/10/25, indicated under the section, Did the resident receive the following included an option for marking bath, shower, or other. The circle indicated Other and next to Other indicated New pt. The form further indicated R277 had diabetes, but lacked information whether R277 was shaved. R277's Weekly Skin Check form dated 1/13/25, indicated R277 received a bed bath, had diabetes, and nail care was not necessary. The form lacked information whether R277 was shaved. R277's progress notes were reviewed and lacked information R277 refused to be shaved. During interview and observation on 1/13/25 at 9:00 a.m., R277 had a patch of chin hairs measuring approximately 1/2 inch in length and wanted someone to help her shave the chin hairs. During observation on 1/13/25 at 1:30 p.m., R277 still had the chin hairs. During observation on 1/14/25 at 1:08 p.m., R277 was going down the hallway in her wheelchair and still had the chin hairs located on her face measuring approximately 1/2 inch in length. During interview on 1/15/25 at 7:36 a.m., nursing assistant (NA)-E stated she looked at the care plan to know what cares a resident required and stated shaving was completed daily or every other day and female residents were shaved usually once a week and stated they provide razors for residents and further stated some residents come with their own razor. During interview and observation on 1/15/25 at 7:31 a.m., occupational therapist (OTR)-A entered R277's room and was going to bring R277 to the shower room. R277 still had the patch of chin hairs and verified R277 had the chin hairs and stated he did not know whether the facility had razors. During interview on 1/15/25 at 7:42 a.m., registered nurse (RN)-D stated the aides knew what cares a resident required because they had flow sheets that summed everything up and further stated residents were shaved on their shower days and refusals were documented in the body audit. RN-D stated R277 was very cooperative and checked the progress notes and verified no refusals were documented. RN-D stated he expected staff shave R277 on her bath day and stated they would take care of it but did not know whether they provided shavers. RN-D viewed the shower list which indicated R277 was supposed to receive a bath on Monday a.m., and Friday p.m., and stated he assumed R277 received a shower, but was not shaved and stated it would be important for R277 to look presentable. During interview on 1/15/25 at 9:32 a.m., RN-C stated R277 came to the facility on Friday, 1/10/25, at around 11:53 a.m., and stated the nurse shaves a resident who is diabetic and R277 was supposed to receive baths on Friday evenings and Monday a.m.'s. RN-C further stated they provided razors and refusals were documented in progress notes and stated it was a dignity issue for a female resident to have chin hairs and added she noticed R277 had chin hairs the night before when she was in the hallway, but did not notice when she completed a skin check on 1/10/25. During interview on 1/15/25 at 11:20 a.m., OTR-A stated he located a razor and R277 could do some shaving but required supervision and assist. During interview on 1/15/25 at 2:45 p.m., the director of nursing (DON) stated she expected staff shave residents and refusals should be documented. Further, the DON stated nurses shaved diabetic residents and stated it was a dignity issue. A policy, Resident Rights and Notification of Resident Rights, revised 1/16/24, indicated the facility acts to protect and ensure the rights of residents. Resident's rights include respect and dignity.

Based on interview and document review, the facility failed to implement physician prescribed treatment orders for wound care, notify the physician of signs and symptoms of infection and labs results for 1 of 3 residents (R1) reviewed for wound care. This resulted in a delay of treatment for R1 when R1's right great toe trauma injury wound and left second toe trauma injury developed osteomyelitis (bone infection) and required amputation of both toes. The IJ began on 11/30/24, when R1's right great toe and left second toe were amputated. The administrator and director of nursing (DON) were informed of the IJ on 12/5/24 at 5:17 p.m. The facility had implemented corrective action on 12/3/24, prior to the start of the survey, and was therefore past noncompliance. Findings include: R1's Face Sheet dated 7/23/24, indicated R1 had diagnoses of type 2 diabetes with diabetic neuropathy (nerve damage which can cause pain or numbness to feet, hands, and legs), peripheral vascular disease (circulation disorder that affects blood vessels outside of the heart), and end stage renal disease (ESRD) with renal dialysis. R1's care plan dated 10/7/24, indicated R1 had impaired skin integrity. Interventions included R1's wounds would be monitored for changes, and for signs and symptoms of infection. If indicated, the medical provider would be updated, and labs would be monitored as ordered. On 10/23/24, medical doctor (MD)-A did wound care rounds at the facility, and saw R1. MD-A's Wound Physicians summary orders directed Xeroform gauze (sterile wound dressing) and gauze dressing with border to left second toe trauma injury, change daily. Non-pressure full thickness wound (wounds that extend beyond the two layers of skin [dermis and epidermis] and go into the subcutaneous tissue [innermost layer of skin]) of left second toe caused by bumping toe during transfer measuring 0.5 centimeter (cm) x 1.1 cm x 0.1 cm with light serous (clear liquid part of blood) drainage. Date of injury to the left second toe was not identified. Right great toe was not identified to have any injuries. On 10/30/24, MD-A did wound care rounds at the facility, and saw R1. MD-A's Wound Physicians summary orders directed Xeroform gauze and gauze dressing with border to left second toe trauma injury, and right great toe trauma injury to be changed daily. Non-pressure full thickness wound of left second toe measuring 0.8 cm x 1 cm x 0.1 cm. Non-pressure full thickness wound of right great toe measuring 1 cm x 0.3 cm x 0.1 cm with light serous drainage. R1's Treatment Administration Record (TAR) lacked identification of dressing change orders or treatment orders for R1's left second toe for the month of October 2024. Treatment orders for R1's left second toe were not placed in the TAR until 11/13/24, 21 days after the physician's initial dressing change order. On 11/13/24, MD-A did wound care rounds at the facility, and saw R1. MD-A's Wound Physicians summary orders directed to discontinue previous orders, and to start Alginate Calcium (highly absorbent wound dressing for wounds with moderate to high drainage) and gauze dressing with border to left second toe trauma injury, and right great toe to be changed daily. Non-pressure full thickness wound of left second toe measuring 1.5 cm x 1.8cm x 0.1 cm. Non-pressure full thickness wound of right great toe measuring 1 cm x 1.5 cm x 0.1 cm. MD-A ordered the following labs: erythrocyte sedimentation rate (ESR) and c-reactive protein (CRP. Both labs are indicators of inflammatory conditions, such as infections). The facility implemented the 11/13/24 dressing changes as prescribed to R1's toes, and completed these daily as prescribed. On 11/16/24, R1's lab results indicated ESR was 52 millimeters/hour (mm/hr. Normal range was 0-20 mm/hr), and CRP inflammation was 34.20 milligrams/Liter (mg/L. Normal range was under 5 mg/L). These lab results were not communicated to MD-A (the ordering physician). On 11/20/24, the facility completed wound care rounds and identified R1's left second toe measured 1.5 cm x 1.7 cm. R1's right great toe measured 0.5 cm x 1.5 cm. Both wounds were documented as, Improving. On 11/27/24, the facility completed wound care rounds and identified R1's left second toe measured 1.4 cm x 1.7 cm. The right great toe measured 0.5 cm x 0.5 cm. Both wounds were documented as, Stable. On 11/27/24 at 8:35 p.m., licensed practical nurse (LPN)-A wrote a progress note that indicated R1's right great toe wound had darkish drainage, swelling, and a foul-smelling odor. On 11/28/24 at 5:55 p.m., a progress note indicated R1 was sent to the hospital due to an unrelated incident. On 11/29/14, R1's hospital records indicated R1 had osteomyelitis (infection in the bone) in his right great toe, and a concern for infection of his left foot. On 11/30/24, R1's hospital records indicated R1 had osteomyelitis to his right great toe and his left second toe. R1's right great toe and left second toe were both amputated as a result of the osteomyelitis. On 12/4/24 at 12:41 p.m., registered nurse (RN)-A stated he changed R1's the dressings on 11/14/24, and R1's right great toe had a foul odor and yellow colored drainage. He did not update MD-A or family about the change in the wound, because MD-A would see him the following Wednesday, 11/20/24 (six days later). On 12/4/24 at 12:57 p.m., licensed practical nurse (LPN)-A stated on 11/27/24, R1's right great toe had a dark drainage, foul odor, and swelling. He didn't update anyone as he didn't know if the foul odor and swelling was normal. He did document his findings in a progress note. On 12/5/24 at 9:57 a.m., the director of nursing (DON) stated the nurse managers do wound care rounds with MD-A. When MD-A had treatment orders for wounds, she would write them down and give them to the nurse manager. The nurse manager would put the new orders into the resident's electronic medical record (EMR), so staff would follow the dressing changes. There was no treatment orders in R1's TAR or EMR until 11/13/24 when LPN-B identified there were no orders for R1's right great toe and left second toe wounds. The facility did find orders from MD-A on 10/23/24 and 10/30/24 but they were not placed into the TAR or EMR. If there were a decline in a wound, the provider should be updated. On 12/5/24 at 10:22 a.m., the medical director (MD-B) stated there was a probability the lack of following orders and doing treatments to R1 wounds caused the infection, which resulted in the amputation of the toes. On 12/5/24 at 11:54 a.m., MD-A stated she hand wrote treatment orders for the facility, and had her visit summary completed before she left the facility. The facility did not communicate to her they did not complete R1's wound care orders for his toes until 11/13/24. There was a potential for amputations when the wound treatments were not completed for several weeks. She also never received the results of the ESR and CRP she ordered for R1, as they were sent to R1's primary MD, even though she was the ordering MD. If she would have received the lab results, she would have started R1 on oral antibiotics. The facility policy Change in Condition reviewed 10/2/23, directed staff to notify the attending provider if a change in condition, implement orders for treatment, and monitoring as directed. The past noncompliance immediate jeopardy began on 11/30/24. The immediate jeopardy was removed, and the deficient practice was corrected by 12/3/24, after the facility implemented a systemic plan which included the following actions: All residents with wounds were reviewed for accuracy of orders. All wounds were monitored daily in morning meeting. The facility re-educated all licensed nurses on the expectation of wound care, and what to do if a wound has changed. The facility completed weekly audits to monitor wound orders and progress notes to ensure providers were updated with signs of infection for twelve weeks, and will bring these results to the Quality Assurance and Performance Improvement (QAPI) committee. Verification of corrective action was confirmed by observation, interview, and document review on 12/4/24 and 12/5/24.

Based on interview and record review the facility failed to comprehensively assess and follow the hospital discharge orders to keep a cast completely dry for 1 of 3 residents (R1) reviewed for orders. R1 was harmed when he was admitted to the facility with a post-surgical cast covering his right leg with orders that the cast must remain dry, and the facility failed to keep the cast dry. R1 was sent to the hospital where the cast was found to be soiled with urine and feces, contributing to continuous infections. Findings include: R1's hospital discharge information to the facility dated 6/25/24 indicated R1 was medically complicated. R1 had a right knee open reduction dislocated hinged total knee arthroplasty revision on 6/20/24 with confirmation of infectious bacteria: staphylococcus aureus and pseudomonas aeruginosa. Following the lab results R1 underwent placement of a peripherally inserted central catheter (PICC) line to directly treat the bacteria infections with antibiotics. R1 had a history chronic and multiple episodes of bacteremia: methicillin-susceptible staphylococcus aureus (MSSA), group B strep, pseudomonas aeruginosa, corynebacterium, and s. epidermidis. of the right infected total knee prosthesis dating back to 2020. R1's active problem list also included atrial fibrillation, cardiomyopathy ischemic, coronary artery disease, chronic kidney disease stage 4, obesity, presence of automatic cardiac defibrillator with pacemaker, declined functional status, delirium, history of right fractured ankle with open reduction and internal fixation (ORIF) 2021 and left knee arthroplasty total knee replacement 2021, history of left shoulder arthroscopy date unknown with a current views on 6/19/24 indicating the surgical components appeared intact. R1 had history of falling, deep vein thrombosis, anemia, anxiety, obstructive sleep apnea. R1's hospital after visit summary dated 6/26/24 indicated R1's knee incision was covered by a long leg cast. Do not put anything under the cast. Keep the cast completely dry. R1 was to maintain the long leg cast until a return appointment on 7/9/24. Do not let cast get wet, if does get wet, notify the orthopedic surgeon immediately. R1's skin assessment dated [DATE] at 7:10 p.m. indicated R1 was always continent of bowel. No intervention of bowel care was initiated on the care plan. R1's admission nursing progress note dated 6/26/24 at 10:37 p.m. indicated R1 arrived from the hospital and had knee replacement surgery. R1 had a cast on his right leg. R1 had a PICC line on his upper left chest area. R1 had some IV bruises on his right arm and wounds on his left foot 2nd and 3rd toe. R1 had a slight rash on his bottom and some blood. He had a spot near top of his cast. [sic] R1's care plan dated 6/27/24 indicated R1 had an infection in his right knee wound culture results were Staphylococcus Aureus and Pseudomonas. R1's risk factors were a history of Pseudomonas in wounds and inadequate fluid intake. R1 admitted with an infection, abnormal wound drainage, abnormal labs, and abnormal x-ray results. R1's goal was to resolve the infection without signs or symptoms of complications of antibiotics. R1's approaches were: -Antibiotics per medical provider, monitor for effectiveness and side effects -Assess for pain: nature, intensity, location, and duration -Encourage periods of rest -Encourage high protein/high carbohydrate foods/fluids when indicated -Encourage oral fluid intake -Explore with resident potential etiological factors, which potentiate infection and include appropriate health teaching. -Isolation precautions per policy - Enhanced barrier precautions -IV as ordered, IV dressing change and site care as ordered -Labs as ordered -Meds as ordered -Monitor for signs and symptoms of worsening infection -Monitor vital signs every shift for duration of antibiotic therapy -Observe for any complications with IV therapy: signs of infection around site, infiltration -Update family and medical provider as needed. -Wound team to follow on weekly rounds. R1's care plan failed to document problem, goals, and an approach for R1's toileting, transferring, and what assistance was required for activities of daily living. R1's care plan failed to assess whether R1 was to wear an incontinent pad or not or if he were to use the urinal by himself. In addition, R1's care plan did not identify that R1's cast was to kept dry and methods to keep it dry. R1's admission Minimum Data Set (MDS) dated [DATE] indicated R1 had a Brief Interview for Mental Status (BIMs) score of 15 indicating R1 was cognitively intact. R1 required extensive assistant for bed mobility, transferring, eating and toilet use. The MDS indicated R1 had no unhealed pressure ulcers or injuries. R1 was occasionally incontinent of urine and frequently incontinent of bowel. R1 had a surgical wound. His skin treatments were pressure reducing device for chair and bed and applications of ointments. The MDS did not indicate turning/repositioning program, nutrition or hydration interventions or pressure ulcer care. R1's pertinent diagnoses were Methicillin susceptible Staphylococcus aureus infection, Pseudomonas, presence of right artificial knee joint, lymphedema (swelling caused by lymphatic blockage), atopic dermatitis (itchy inflammation of the skin), pain in right knee, infection, and inflammatory reaction due to internal right knee prosthesis. Progress note dated 7/5/24 at 8:58 a.m. indicated: R1 had a covered cast on his right knee, no drainage noted. R1 had dull pain of his right knee. R1's toileting was dependent. R1's skin condition was not assessed. emergency room encounter 7/7/24 at 8:51 p.m. indicated R1 was an [AGE] year-old male with multiple medical problems from a facility with failure to thrive, decreased mental status and fatigue. Recently R1 was discharged from another hospital after he was found to have an infected right total knee replacement. R1's groin was red and irritated with no signs of Fournier's gangrene. His cast was soaked in the upper and half due to urine. His left lower extremity was all bandaged and specifically a dorsal wound of the third toe which appears to be infected. Posteriorly R1 had Stage II (partial loss of skin, but no deeper than the dermis) pressure ulceration on his essentially backside from the mid-thigh through the mid lumbosacral (five large vertebrae that make-up the lumbar portion of the spine) region. R1 will be sent to larger hospital where he had surgery for further care as well as treatment. emergency room nursing note dated 7/7/24 at 11:48 p.m. R1 came in looking red, flush, and complaining of pain. Upon skin assessment staff noticed the following: -Red, swollen skin to the scrotum, penis and peri-area, penis had a large amount of smegma (thick cheesy secretion around genital that collects when not washed regularly). -Skin around R1's cast on the right leg was excoriated, red and non-blanchable and cast was noted to have a strong odor to it along with being saturated with urine and stool. -Left arm had a cast stocking on it from the hand to midway past the elbow, damp and visually soiled. Hospital admission note dated 07/08/24 at 12:00 p.m. indicated R1 presented with septic shock secondary from infected right knee on 7/8/24. His dressing was removed by orthopedics and noted significant soiling of the dressing with concern for infection of the knee. R1 was transferred to the intensive care unit (ICU) for continuing care on 7/9/24. Orthopedic surgeon was planning a washout vs. amputation of R1's right leg. Infectious disease summary 7/8/24 indicated on admission R1 was found to have fecal and urine contamination of his right knee incisions under the cast. His incisions were noted to be macerated (a softening and breaking down of skin resulting from prolonged exposure to moisture) and dehiscence (separation of wound edges). He was also noted to have foul smelling drainage. Upon interview on 7/10/24 at 10:41 a.m. nursing assistant, (NA)-A stated, stated R1 was incontinent of bowel and bladder and often had diarrhea. R1's urinal would spill under him because he would leave I between his legs and fall asleep. Staff checked on him every two hours, but when he was finished using the urinal, he would not press the call light when he was finished with the urinal. NA-A stated no other means of toileting was attempted. Upon interview on 7/10/24 at 3:23 p.m. Family member (FM)-A stated R1 arrived at the large regional hospital and was awaiting amputation of his right leg. She stated at the emergency room (ER) R1's cast was cut off due to the odor and then staff found the entire cast was seeping with urine and feces. FM-A stated the ER noticed the infected surgical knee sight and immediately notified the hospital where he had surgery and wanted him sent back due to their ability to handle infections of that level. FM-A stated she noted the smell of urine and feces in his room and noticed the top cloth portion of the cast was yellow with urine. She stated the facility did not speak with her about interventions other than a urinal to keep him dry. The facility did not drape anything over the cast, discuss a catheter or make an attempt to stop his diarrhea. Upon interview on 7/10/24 at 4:01 p.m. occupation therapist, (OT)-A stated she was only saw R1 on one occasion and that was the day after his admission when she completed her assessment. She stated she attempted to sit R1 at the edge of his bed and he became incontinent of very runny stool. Cleaning him required the assistance of the nursing assistants. She stated she does not recall the stool getting on his cast, but did not see how it could not, as he had to be laid down in bed and rolled to be cleaned. She stated she was aware that R1 used a urinal for urination and stated it was right of the family to choose the method they prefer. She stated occupation therapist assistant (OTA)-A told her R1 frequently had his urinal between his legs, and it would spill. OT-A stated she did not do another assessment on R1's safe use of a urinal. She stated nursing would be more likely to do that as they do the bowel and bladder assessment. OT-A stated R1 had been incontinent of bowel and bladder since his day of admission to the facility. Upon interview on 7/10/24 at 4:41 p.m. R1's orthopedic surgeon stated, in a few moments R1 was going to have his right leg amputated above his knee. He stated, I can't say 100% that the urine and feces filled cast caused the infection requiring amputation, but it certainly had a contributing factor. Upon interview on 7/11/24 at 10:43 a.m. R1's nurse practitioner (NP) stated she did not notice any odor or urine on R1's cast. She stated that the facility did not reach out to her and ask for a catheter or any other invention, such as a barrier cover. She stated having R1 use a urinal with a cast within inches of R1's right groin and a dislocated left shoulder was not a good plan for a cast needing to stay dry. She stated she was not aware R1 was having diarrhea therefor no interventions were ordered. Upon interview on 7/11/24 at 11:10 a.m. R1's occupation therapy aide (OTA)-A stated she did notice frequently when she went to work with R1 that he had a urinal between his legs and his bedding was soiled. She stated she did not notice the cast was soiled. She stated on the 7/7/24 she assisted the nursing assistants with cleaning R1 after an episode of diarrhea. She stated that the feces did get on the cast and cast was yellow tingled from urine. Upon interview on 7/11/24 at 11:53 a.m. RN-A the unit manager stated that she was aware that R1 used a urinal, she was not aware of any spillage from the use. She denied staff ever reporting that the cast had gotten soiled if it did the surgeon would have been called immediately. Upon interview on 7/11/24 at 3:42 p.m. the director of nursing, (DON) stated her expectation of staff would be for the NAs to report any skin concerns to the nurses. She stated she expected nursing staff who are assessing and treating the residents to follow the resident's orders. Upon interview on 7/11/24 at 3:55 p.m. the Administrator stated her expectation would be for the resident assessment instrument (RAI) tool to be accurate, leading to an accurate care plan for the residents and finally proper care being implemented for the residents. A facility policy titled Abuse Prevention Plan Prevention dated 2017 indicated neglect is the failure of the facility, its employees, or services providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress.

Based on interview and record review the facility failed to ensure 1 of 3 residents (R1) reviewed for pressure ulcers received care consistent with professional standards of practice to prevent pressure or worsening of pre-admission pressure ulcers. R1 was harmed when the facility failed to promote healing of current pressure ulcers and prevent new ulcers from developing. R1 was admitted with two pressure ulcers, and a shearing wound on 6/26/26. R1 discharged from the facility on 7/7/14 with three pressure ulcers and the shearing wound turned into stage II pressure ulcers in multiple areas from his thigh to his mid-dorsal back. R1's hospital discharge information to the facility dated 6/25/24 indicated R1 was medically complicated. R1 had a right knee open reduction dislocated hinged total knee arthroplasty revision on 6/20/24 with confirmation of infectious bacteria: staphylococcus aureus and pseudomonas aeruginosa. Following the lab results R1 underwent placement of a peripherally inserted central catheter (PICC) line to directly treat the bacteria infections with antibiotics. R1 had a history chronic and multiple episodes of bacteremia: methicillin-susceptible staphylococcus aureus (MSSA), group B strep, pseudomonas aeruginosa, corynebacterium, and s. epidermidis. of the right infected total knee prosthesis dating back to 2020. R1's active problem list also included atrial fibrillation, cardiomyopathy ischemic, coronary artery disease, chronic kidney disease stage 4, obesity, presence of automatic cardiac defibrillator with pacemaker, declined functional status, delirium, history of right fractured ankle with open reduction and internal fixation (ORIF) 2021 and left knee arthroplasty total knee replacement 2021, history of left shoulder arthroscopy date unknown with a current views on 6/19/24 indicating the surgical components appeared intact. R1 had history of falling, deep vein thrombosis, anemia, anxiety, obstructive sleep apnea. R1's hospital discharge orders dated 6/25/24 indicated R1 had: -A Stage 3 (an injury that extends through the skin into deeper skin and fat but does not reach muscle tendon or bone) pressure ulcer on the dorsum (upper surface) of his second right toe. R1 had this pressure injury since 1/6/23. -A dermatologic condition of his right foot since 1/6/23 -Incision on the anterior portion of his right knee since 6/20/24 -A Stage 4 (an injury that extends to the muscle, tendon, and bone) pressure injury on the dorsum of his third right toe since 6/21/24. -A dermatologic condition of generalized rash and pruritis since 6/21/24 -A Shearing wound to his buttocks bilaterally from friction and adhesive from sacral Mepilex (a wound dressing) since 6/21/24. -A deep tissue pressure injury (when there is not an open wound, but the tissues beneath surface have been damaged the skin may appear purple or dark red) to R1's right thigh since 6/24/24. -A Peripheral inserted central catheter (PICC) single lumen permanent tunneled and implanted to his left chest placement 6/25/25. R1's after visit summary dated 6/26/24 indicated on 10/27/22 - present for R1's dermatitis perianal was to include acetic acid soaks for 15 minutes followed by zinc oxide keeping the area open and dry. R1's skin assessment dated [DATE] at 7:10 p.m. indicated R1 was always continent of bowel. R1 had a rash in his peri-care, no description documented. The assessment indicated R1 did not have one more unhealed pressure injuries at a Stage 1 or higher. R1 did have an open lesion on his foot and a surgical wound, no description documented. R1's admission nursing progress note dated 6/26/24 at 10:37 p.m. indicated R1 arrived from the hospital and had knee replacement surgery. R1 had a cast on his right leg. R1 had a PICC line on his upper left chest area. R1 had some IV bruises on his right arm and wounds on his left foot 2nd and 3rd toe. R1 had a slight rash on his bottom and some blood. He had a spot near top of his cast. [sic] R1's care plan dated 6/27/24 indicated R1 had an infection in his right knee wound culture results were Staphylococcus Aureus and Pseudomonas. R1's risk factors were a history of Pseudomonas in wounds and inadequate fluid intake. R1 admitted with an infection, abnormal wound drainage, abnormal labs, and abnormal x-ray results. R1's goal was to resolve the infection without signs or symptoms of complications of antibiotics. R1's approaches were: -Antibiotics per medical provider, monitor for effectiveness and side effects -Assess for pain: nature, intensity, location, and duration -Encourage periods of rest -Encourage high protein/high carbohydrate foods/fluids when indicated -Encourage oral fluid intake -Explore with resident potential etiological factors, which potentiate infection and include appropriate health teaching. -Isolation precautions per policy - Enhanced barrier precautions -IV as ordered, IV dressing change and site care as ordered -Labs as ordered -Meds as ordered -Monitor for signs and symptoms of worsening infection -Monitor vital signs every shift for duration of antibiotic therapy -Observe for any complications with IV therapy: signs of infection around site, infiltration -Update family and medical provider as needed. -Wound team to follow on weekly rounds. R1's care plan dated 6/27/24 did not indicate R1 had any pressure ulcers. In addition, R1's care plan failed to document problem, goals, and an approach for R1's pressure ulcers of the toes, potential for pressure ulcers per Braden assessment, turning and reposition and how R1 was to toilet, transfer, and what assistance was required for activities of daily living. R1's care plan failed to assess whether R1 was to wear an incontinent pad or not or if he were to use the urinal by himself. R1's Braden Scale for Prediction of Pressure Sore Risk dated 7/1/24 indicated: -R1's sensory perception was completely limited, R1 was unresponsive to painful stimuli. -R1 was constantly moist - skin is kept moist constantly by perspiration, urine etc. Dampness is detected every time resident is moved or turned. -R1 was chairfast. -R1 was completely immobile - does not make slight changes in body or extremity position without assistance. -R1's nutrition was probably inadequate. -R1 had a problem with friction and shearing - He required moderate to maximum assistance in moving. R1's Braden score was eight. Indicated very high risk for pressure ulcers. R1's interventions were: -Pressure reducing device for chair and bed. -Turning/repositioning program. -Nutrition for hydration intervention to manage skin problems. The assessment failed to provide interventions for pressure ulcer care, application of nonsurgical dressings, application of ointments or applications of dressing. No other measures were taken, and the care plan was not updated. R1's admission Minimum Data Set (MDS) dated [DATE] indicated R1 had a Brief Interview for Mental Status (BIMs) score of 15 indicating R1 was cognitively intact. R1 required extensive assistant for bed mobility, transferring, eating and toilet use. The MDS indicated R1 had no unhealed pressure ulcers or injuries. R1 was occasionally incontinent of urine and frequently incontinent of bowel. R1 had a surgical wound. His skin treatments were pressure reducing device for chair and bed and applications of ointments. The MDS did not indicate turning/repositioning program, nutrition or hydration interventions or pressure ulcer care. R1's pertinent diagnoses were Methicillin susceptible Staphylococcus aureus infection, Pseudomonas, presence of right artificial knee joint, lymphedema (swelling caused by lymphatic blockage), atopic dermatitis (itchy inflammation of the skin), pain in right knee, infection, and inflammatory reaction due to internal right knee prosthesis. Progress note dated 7/5/24 at 8:58 a.m. indicated: R1 had a covered cast on his right knee, no drainage noted. R1 had dull pain of his right knee. R1's toileting was dependent. R1's skin condition was not assessed. R1's nursing progress note dated 7/5/25 at 10:17 a.m. R1's family member (FM)-A was in the facility taking pictures of R1's skin. FM-A started placing acetic acid to skin on R1's buttocks and told the NA she was going to leave it on for 1 hour. FM-A stated this was the order that the hospital was performing. LPN-A attempted to education FM-A that an hour was too long. FM-A stated this is the only way the redness will improved. FM-A stated that R1's bottom was very red, sore, and bleeding in areas where the skin is excoriated or split open. LPN-A observed the skin the prior day and the skin was red and intact. FM-A also asked when R1 had his last oxycodone (a narcotic pain medication) as FM-A felt R1 was too sedated. R1 had not received any oxycodone since 7/2/24 at 2:00 p.m. FM-A did not want R1 to receive any more oxycodone, but also stated R1 was in so much pain because of his bottom hurt him. LPN-A explained R1 will not lay in bed on his side, he sits in a chair or lies on his back and the skin does not get any relief. FM-A stated that the staff are not making him lie on his side. LPN-A stated the staff cannot make him change position. LPN-A called the primary care clinic triage and left a message for the NP regarding pain management and informed her that FM-A was doing acetic acid treatments and leaving on the skin for a longer period that was order. The progress note did not indicate a description of R1's skin on 7/5/25 just the prior day observation or what the facility was doing for the R1's skin. emergency room encounter 7/7/24 at 8:51 p.m. indicated R1 was an [AGE] year-old male with multiple medical problems from a facility with failure to thrive, decreased mental status and fatigue. Recently R1 was discharged from a regional hospital after he was found to have an infected right total knee replacement. R1's groin was red and irritated with no signs of Fournier's gangrene. His cast was soaked in the upper and half due to urine. His left lower extremity was all bandaged and specifically a dorsal wound of the third toe which appears to be infected. Posteriorly R1 had Stage II (partial loss of skin, but no deeper than the dermis) pressure ulceration on his essentially backside from the mid-thigh through the mid lumbosacral (five large vertebrae that make-up the lumbar portion of the spine) region. R1 will be sent back to the [NAME] larger hospital where he had surgery for further care as well as treatment. emergency room nursing note dated 7/7/24 at 11:48 p.m. R1 came in looking red, flush, and complaining of pain. Upon skin assessment staff noticed the following: -Red, non-blanchable, grossly excoriated, bleeding skin of the gluteus maximus, gluteus Medius, and gluteus minimus. -Red, swollen skin to the scrotum, penis and peri-area, penis had a large amount of smegma (thick cheesy secretion around genital that collects when not washed regularly). -Red excoriated skin to the right abdominal folds and right axillary. -Skin around R1's cast on the right leg was excoriated, red and non-blanchable and cast was noted to have a strong odor to it along with being saturated with urine and stool. -Left thigh, knee and shin aberrations from leg rubbing on the cast. -Left arm had a cast stocking on it from the hand to midway past the elbow, damp and visually soiled. -Left top of foot had an open sore weeping serosanguinous drainage. Hospital admission note dated 07/08/24 at 12:00 p.m. indicated: #1 Wound 07/08/24 Incontinence Associated Dermatitis Buttocks and posterior thighs. Date First Assessed: 07/08/24 Present on Original Admission: Yes, Primary Wound Type: Incontinence Associated Dermatitis Location: Buttocks Wound Description (Comments): and posterior thighs Shape Irregular *Wound Bed Open; Red; Shiny Tissue Exposed None Odor None Exudate Amount Small Drainage Description Serosanguineous Peri-wound Assessment Fragile ;Friable; Painful; Rash #2 Wound 07/08/24 Incontinence Associated Dermatitis Groin Bilateral and thighs. Date First Assessed: 07/08/24 Present on Original Admission: Yes, Primary Wound Type: Incontinence Associated Dermatitis Location: Groin Wound Location Orientation: Bilateral Wound Description: and thighs Shape Irregular *Wound Bed Closed; Red; Shiny Odor None Exudate Amount Scant Drainage Description Serous Peri-wound Assessment Friable; Painful; Red; Rash #3 Wound 07/08/24 Intertriginous Dermatitis Pannus Right Date First Assessed: 07/08/24 Present on Original Admission: Yes, Primary Wound Type: Intertriginous Dermatitis Location: Pannus Wound Location Orientation: Right Shape Irregular *Wound Bed Closed; Red; Shiny Odor None Exudate Amount Scant Drainage Description Serous Peri-wound Assessment Fragile; Red; Rash #4 Wound 07/08/24 Intertriginous Dermatitis Axilla Bilateral Date First Assessed: 07/08/24 Present on Original Admission: Yes, Primary Wound Type: Intertriginous Dermatitis Location: Axilla Wound Location Orientation: Bilateral Shape Irregular *Wound Bed Closed; Red; Shiny Exudate Amount Scant Drainage Description Serous Peri-wound Assessment Maceration; Rash #5 Wound 06/21/24 Pressure Injury Stage 4 Toe Third Left; Dorsum Date First Assessed/Time First Assessed: 06/21/24 1020 Primary Wound Type: Pressure Injury Pressure Injury Staging: Stage 4 Location: Toe Third Wound Location Orientation: Left; Dorsum Shape Round / oval *Wound Bed Full thickness; Red; Yellow Tissue Exposed Bone Odor None Exudate Amount Small Drainage Description Sanguineous Peri-wound Assessment Intact #6 Wound 01/06/23 Pressure Injury Stage 3 Toe 2nd Right; Dorsum Date First Assessed/Time First Assessed: 01/06/23 1315 Primary Wound Type: Pressure Injury Pressure Injury Staging: Stage 3 Location: Toe 2nd Wound Location Orientation: Right; Dorsum Shape Irregular *Wound Bed Red; Pink; Open Odor None Exudate Amount Scant Drainage Description Serosanguineous Peri-wound Assessment Maceration Wound 07/08/24 Pressure Injury Deep Tissue Heel Right #7 wound Date First Assessed: 07/08/24 Present on Original Admission: Yes, Primary Wound Type: Pressure Injury Pressure Injury Staging: Deep tissue Location: Heel Wound Location Orientation: Right Shape Round / oval *Wound Bed Black; Brown; Pink (mixed wound bed, evolving purple discoloration with sloughing edges revealing pink tissue) Tissue Exposed None Odor None Exudate Amount Scant Drainage Description Serosanguineous Peri-wound Assessment Fragile Upon interview on 7/10/24 at 10:41 a.m. nursing assistant, (NA)-A stated, his skin was not good. She stated R1 was incontinent of bowel and bladder and often had diarrhea, making R1's skin red, raw, and bleeding on his buttocks. Sometimes he would have an incontinence pad on and sometimes he would not, if he were having frequent diarrhea, staff would put an incontinent pad on and if not, staff would let him sit without an incontinence pad. She stated she believed the nursing staff was aware of R1's skin concerns because he had a zinc treatment the nursing assistants were applying to his back and buttocks. NA-A stated she recalled R1 had some kind of dressing on his toes but was not aware whether nursing was doing a treatment or not. R1 used the urinal on his own and with staff assistance. The urinal would spill under R1 as he would leave the urinal between his legs and fall asleep. The urine would spill on his skin and his cast. Staff checked on him every two hours, but when he was finished using the urinal, he would not press the call light for assistance. Upon interview on 7/10/24 at 3:23 p.m. FM-A stated she visited R1 almost daily and she would find him incontinent of urine or stool. She stated R1 was not to have an incontinent pad on because his skin was to be open to air and she would often find him wearing one. She stated she left notes all over R1's room for what staff was to do for his skin care. She stated the staff was supposed to be doing an acetic acid treatment on his buttock and back. The facility told FM-A they did not have an order. FM-A called the nurse practitioner (NP) and told her R1's skin was getting worse, and she wanted the staff to follow the hospital recommendations. FM-A did not receive a response from the NP. She stated she took the acetic acid that he that hospital staff had used and started doing the cares herself. FM-A stated R1 was difficult to reposition, because of the dislocation to his left shoulder. She stated she would perform his repositioning by shifting him slightly with a pillow under one side of his buttocks to relieve pressure. She stated she asked staff to reposition him that way multiple times with no avail. FM-A asked an unidentified nursing assistant why R1 was wearing a pad and to please remove it and clean him as the pad was wet. The response FM-A received was, if he is wet, he did not need to be changed until the line on the pad turned blue. FM-A removed the pad herself and cleaned R1. Upon interview on 7/10/24 at 4:15 p.m. NA-C stated R1 had diarrhea often and his bottom and back had rashes all over that were bleeding from multiple open areas. She stated that the nursing department was aware because they would assist NA-C to change R1 and clean him when he was incontinent. R1 would cry whenever the skin on his back was touched. NA-C would sometimes find R1 in an incontinent brief and sometimes not she stated there were not specific instructions on that. She stated if staff did not put an incontinent brief on R1 they would have entire bed changes due to either urine or feces. Upon interview on 7/10/24 at 4:41 p.m. R1's orthopedic surgeon stated, the condition of R1's skin when he returned to the hospital from the facility was neglect. He stated please read all the hospital wound notes from his hospital discharge summary on 6/26/24 to his re-admission note on 7/8/24. Upon interview on 7/11/24 at 10:43 a.m. R1's nurse practitioner (NP) stated she was not aware R1 had any wounds. She stated the nursing manager had mentioned R1 had some yeast in his groin and asked for Nystatin powder and the order was given. She stated R1's family member, (FM)-A had called her and spoke with her about the groin rash and about his back. FM-A was asking if an acetic acid treatment that the hospital did, with good results, could be implemented for the rash and sores on R1's back. The NP told FM-A she would investigate that treatment. FM-A also inquired with the NP about using a hydrocortisone cream on his skin. The NP stated that the daughter wanted hydrocortisone applied to his entire body for itching. The NP ordered hydrocortisone to be used on itching areas, she was not aware where R1's itchy areas were. The NP denied ever observing R1's skin stating the facility staff makes observations and reports concerns to her or refers the residents directly to the wound care. Upon interview on 7/11/24 at 11:53 a.m. RN-A the unit manager stated R1 did not admit with any wounds. She stated a few days after admission R1's daughter was asking about using acetic acid on his back however he did not have any rash or redness. RN-C stated she was not aware of the documented wounds on the hospital discharge. Acetic acid was listed on the discharge medication list and RN-A stated she thought that was maybe from a catheter he may have had. RN-A did not find out exactly what the acetic acid was recommended for. She stated the wounds were more than likely overlooked because there were no orders attached to them. RN-C was uncertain why R1's care plan indicated wound care to see R1 weekly since he did not have wounds. RN-A stated he was not seen by wound care because the provider was on vacation on 7/3/24 and the provider the agency sent out, did not seen R1 on that date and R1 was discharged on [DATE]. RN-A did not observe R1's skin directly during his stay. Upon interview on 7/11/24 at 3:30 p.m. RN-C stated he completed R1's admission skin assessment. He stated he recalled R1 had what appeared to be a couple of open blisters that had popped on two of R1's toes. He stated due to shoulder pain and inability to turn RN-C was unable to assess R1's backside to assess. Upon interview on 7/11/24 at 3:42 p.m. the director of nursing, (DON) stated her expectation of staff would be for the NAs to report any skin concerns to the nurses. She stated she expected nursing staff who are assessing to observe the patient and if a nurse can assess a resident fully to notify the manager so the staff can get an accurate assessment later. Upon interview on 7/11/24 at 3:55 p.m. the Administrator stated her expectation would be for the RAI tool to be accurate, leading to an accurate care plan for the residents and finally proper care being implemented for the residents. A facility policy titled Prevention and treatment of skin breakdown dated 2018 indicated resident skin integrity is assessed upon admission and weekly thereafter. A skin risk assessment is completed upon admission and weekly for 4 weeks upon significant change, and quarterly thereafter. Those residents at an increased risk for impaired skin integrity are provided preventative measures to reduce the potential for skin breakdown. Those residents' who experience a break in skin integrity or wounds are provided care and service to heal the skin according to professional standards of care.

Based on observation, interview and document review, the facility failed to comprehensively assess and implement pressure ulcer interventions for 3 of 5 residents (R59, R43, R73) identified at risk for pressure ulcers. This resulted in actual harm when R59 developed three unstageable pressure areas, one stage III pressure area and one stage IV pressure area after admission and actual harm when R43 developed a stage III pressure ulcer after admission. 47790 Findings include: Stage II pressure ulcer: partial-thickness loss of skin 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 and eschar are not present. Stage III pressure ulcer: full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. Stage IV pressure ulcer: 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. Unstageable pressure injury: obscured 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 III or Stage IV pressure injury will be revealed. R59's significant change Minimum Data Set (MDS) dated [DATE], identified R59 had severe cognitive impairment and required extensive assistance for bed mobility, transfers, dressing, eating, and personal hygiene. R59 had not walked. R59 required total assistance with toileting. R59 had diagnoses of dementia and diabetes. Further, the MDS outlined R59 was at risk for developing pressure ulcers, however, had no current pressure ulcers or injury. R59's care plan reviewed/revised 2/14/23, indicated R59 was at risk for pressure ulcer due to friction, shear, nutrition, bedfast/ mobility and impaired sensory perception. The interventions included elevate heels off bed or use heel protectors, encourage family to bring in favorite food, monitor for infection, nutritional consult, offer small frequent meals, provide nutritional supplement as ordered, teach patient to do frequent small shifts of body weight if able, treatment as ordered, weekly wound rounds scheduled, wound vac to sacrum in place as ordered, air mattress in place, repositioning patient every 2-3 hours, minimum of two people plus draw sheet to lift resident while in bed, and skin inspection every incontinence care with close attention to heels and other pressure areas. R59's Skin Risk Assessment with Braden Scale dated 10/19/22, indicated R59 was at risk due to diabetes, incontinence of bowel and bladder, slightly limited sensory perception, chairfast, slightly limited mobility, and friction and shearing being a potential problem. The assessment lacked any interventions. On 11/28/22 R59's Braden score was 13 the interventions were to apply barrier cream and to turn and reposition. With a Braden score of 13 and the interventions to apply barrier cream and to turn and reposition the facility increased the risk for R59 to develop pressure areas. R59's Admission Body Audit: Skin Condition dated 10/19/22, indicated all skin was intact. R59's Weekly Bath Day Body Audit Form dated 10/25/22, indicated all skin was intact. R59's Weekly Bath Day Body Audit Form dated 11/16/22, indicated all skin was intact. R59's Weekly Bath Day Body Audit Form dated 1/11/23, indicated no new skin issues, had non-verbal pain indicators, cause was from R59's buttocks. R59's Weekly Bath Day Body Audit Form dated 1/31/23, indicated a scar on right ankle measuring 2 centimeters (cm) x 2 cm, a scab on left ankle measuring 2 cm x 1.5 cm, a pressure ulcer on left heel measuring 3 cm x 3.5 cm, and a pressure ulcer on sacrum measuring 10 cm x 9 cm. R59's Weekly Bath Day Body Audit Form dated 2/15/23, indicated no new skin issues noted except dry skin on her lower extremities. There was no evidence in R59's electronic medical record (EMR) that weekly skin audits had been completed between 11/17/22 through 1/10/23. R59's progress note dated 12/20/22, indicated purplish blister on her left heel measuring 4.5 cm x 4 cm, with necrotic (death of body tissue) wound on left ankle measuring 2 cm x 2 cm and on left outer foot which is 1 cm x 1 cm. Wound on right ankle is 1.5 cm x 1.5 cm. R59's progress note dated 1/1/23, indicated an open area on the sacrum measuring 3 cm x 2 cm. R59's Physician Order Report dated 2/16/23, included the following orders: - 1/31/23, zosyn in dextrose 3.375 milligram/50 milliliter intravenously every 6 hours. - 1/31/23, wound vac to sacrum: Negative pressure on the pump is 125 millimeters of mercury continuous. Supplies needed for wound vac dressing change are medium black granuform. The pump must be delivering this amount of negative pressure for at least 22 out of 24 hours. If the pump alarms that pressure is not correct the warning LEAK DETECTED will show on the pump. If this occurs, please try to locate the leak by listening, and patch the air leak with clear tegaderm. If the seal cannot maintain for two hours, then the wound vac dressing will need to be removed and replaced with normal saline wet to moist dressing and notify medical director MD. - 2/2/23, Wound care (bilateral lateral ankles and left foot): Cleanse wound with normal saline and pat dry, skin prep to scabs, no dressing needed. - 2/2/23, Wound care (left heel): Cleanse wound with normal saline and pat dry, apply xeroform, cover with 4x4 mepilex. R59's Wound Evaluation and Management Summary physician notes identified the following: - 1/4/23, Right lateral ankle stage II pressure area measuring 1.5 cm x 2 cm, scabbed over, duration greater than 18 days. Unstageable deep tissue injury to left ankle measuring 2 cm x 1.7 cm, duration greater than 18 days. Unstageable deep tissue injury to left lateral foot measuring 1 cm x 0.9 cm, duration greater than 18 days. Unstageable due to necrosis of left heel pressure area measuring 5 cm x 3.2 cm, duration greater than 18 days. Stage III pressure wound to sacrum measuring 1.8 cm x 1.3 cm x 0.1 cm, duration greater than 10 days. Recommendations for all wounds was to off-load wounds, reposition per facility protocol, float heels in bed, sponge boot. - 1/18/23, Right lateral ankle pressure area unstageable due to necrosis measuring 1.8 cm x 1.8 cm eschar/scab is dry with no signs of infection. Left ankle unstageable pressure area due to necrosis measuring 2.2 cm x 2 cm scab/eschar (dead tissue) is dry and intact. Left lateral foot unstageable deep tissue injury measuring 1 cm x 0.8 cm with intact skin. Left heel unstageable pressure area due to necrosis measuring 3.5 cm x 3.7 cm. Sacrum unstageable pressure area due to necrosis measuring 6 cm x 8.2 cm, given the increase in size and new odor, recommended transfer to emergency department. - 2/1/23, Right lateral ankle pressure area unstageable due to necrosis measuring 1.8 cm x 2 cm scab. Left ankle unstageable pressure area due to necrosis measuring 2.6 cm x 2 cm. Left lateral foot unstageable deep tissue injury measuring 0.8 cm x 1 cm with intact skin. Left heel unstageable pressure area due to necrosis measuring 3.2 cm x 3.7 cm x 0.2 cm. Sacrum stage IV pressure ulcer measuring 10 cm x 6.5 cm x 1 cm. - 2/8/23, Right lateral ankle pressure area unstageable due to necrosis measuring 1.2 cm x 1.2 cm scab. Left ankle unstageable pressure area due to necrosis measuring 0.4 cm x 0.3 cm. Left lateral foot unstageable deep tissue injury measuring 1 cm x 1 cm with intact skin. Left heel stage III pressure area measuring 3.2 cm x 3 cm x 0.2 cm. Sacrum stage IV pressure ulcer measuring 8.1 cm x 7.5 cm x 1.3 cm. During an observation on 2/14/23, at 03:55p.m. R59 was noted to have heel boots in place on bilateral feet. R59 had a pillow wedge under her right side. Wound vac noted to be intact with no soiling on wound vac. R59 was noted to have an air mattress. During an interview on 2/15/23, at 12:42p.m. the medical doctor (MD)-A stated the facility could have caught the pressure ulcers earlier if they would have been doing skin inspections weekly but would not have prevented the pressure areas from occurring. On 2/16/23, at 8:58a.m. RN-D stated the facility staff does body audits twice a week and then they are uploaded in the system. If staff find any skin concerns, they would call the on-call for the facility and they would direct us on what to do. The nurse manager is the one who puts interventions into place. On 2/16/23, at 9:09a.m. registered nurse (RN)-B stated the facility staff do body audits on the fourth floor twice a week and then they are uploaded into the system. RN-B stated she was unable to find any other body audits for R59 other then what was already in the EMR. On 2/16/23, at 10:08a.m. the director of nursing (DON) stated the staff are expected to complete a skin assessment upon admission and once or twice weekly for each resident. The DON stated the facility changed the process this week as the paper body audits were not being completed. R59's wounds might have been caught sooner if staff were doing body audits but it is hard to say. The DON confirmed the expectation for nurses is to do weekly skin assessments on all residents. On 2/16/23, at 3:04p.m. the Medical Director stated he felt the preventable and avoidable pressure injuries to the bilateral lower extremities and the sacrum developed between 12/7/22 and 12/20/22. 42579 R43's quarterly MDS dated [DATE], identified R43 had moderately impaired cognition and no rejection of care assessed. R43 was totally dependent on staff for bed mobility and transfers and had not walked. R43 required extensive assistance with dressing. R43 had no functional limitation in range of motion to his upper extremities and impairment on both sides of lower extremities. R43 had diagnoses of encephalopathy (altered mental state and confusion), diabetes, malnutrition and schizophrenia. R43 was at risk for pressure ulcer or pressure injury, however did not have a pressure ulcer or injury at the time of the assessment. Interventions included pressure relieving device for chair and bed and a turning and repositioning schedule. R43's Pressure Ulcer Significant Change Care Area Assessment (CAA) dated 5/12/22, identified R43 was admitted with no major skin concerns but was at risk for skin breakdown related to reduced mobility, reduced skin integrity, reduced strength, incontinence, and risk for shearing during transfers or repositioning. Resident had a pressure reducing device for chair and bed, and turning/repositioning program. R43 completed therapies with no new referrals and to continue care plan. R43's care plan dated 7/5/22, identified R43 was at risk for pressure ulcers due to a fracture of right patella, staphylococcus arthritis, schizophrenia, cognitive impairment, type two diabetes, encephalopathy, incontinence, catheter and dependence on mechanical lift for transfers. Interventions included monitor skin daily with cares and conduct systematic skin inspection weekly, remove immobilizer from knee and perform skin check twice daily. The care plan lacked intervention to address proper foot wear or other protective and preventative measures for R43's feet. R43's Skin Risk Assessment with Braden Scale dated 1/23/23, identified he was at moderate risk due to cardiovascular disease, contractures, diabetes, hemiplegia, and catheter. History of or refusal of care was not checked on the assessment form. R43 had no pressure ulcers at the time of the assessment. R43 had a cast/brace/splint checked and elevated head of bed due to medical necessity. R43 had slightly limited sensory perception that would affect his ability to respond meaningfully to pressure related discomfort, pressure relieving device for chair, bed and was on a turning and repositioning schedule. The assessment lacked intervention to address proper foot wear or other protective and preventative measures for R43's feet. R43's Physician Order Report dated 1/16/23 - 2/16/23, included the following orders: -1/24/23: occupational therapy (OT) to eval and treat due to wound on the right sole of foot, cushion may be needed for the foot rest -1/25/23: right foot cleanse wound daily with wound cleanser and pat dry. Apply calcium alginate to open wound bed, wrap with kerlix and tape. R43's care plan dated 1/25/23, identified R43 had a stage II pressure ulcer located on the bottom of his right foot plantar (bottom of foot) region. R43 was at risk for increased skin integrity as indicated by the Braden score and comorbidities. Interventions included to wear heel protectors to protect heels while in bed and would be monitored for properly fitting footwear and pressure reduction to the heels. R43's OT Evaluation and Plan of Treatment dated 1/26/23, identified R43's right lower extremity hung off the foot rest at each arch point of foot where there was now a wound. R43 required a different wheelchair and adaptive equipment to prevent skin breakdown to his lower extremeties. R43's Wound Evaluation and Management Summary physician notes identified the following: -1/11/23, treatment to a post surgical wound of the right knee and other wound to the leg was provided. There were no pressure sores identified on R43's foot -1/25/23, a stage II pressure wound of the right plantar foot was identified which measured 4.5 x 2.3 x 0.2 cm and treatments provided. Recommendations included offload the wound and sponge boots -2/1/23, the stage II pressure wound of the right plantar foot had deteriorated to a stage III pressure wound measuring 5 x 4.5 x 0.2 cm, the wound was debrided (removal of dead skin) and treatments provided -2/8/23, the stage III pressure wound of the right plantar foot had deteriorated and measured 5.5 x 6 x 0.4 cm and treatments provided. Redness was noted and antibiotics were ordered. During observations on 2/13/23, at 1:00 p.m., 2/14/23, at 9:00 a.m. and 2/15/23, at 9:00 a.m. R43 was observed to be able to self propel in his wheelchair using his hands. R43's legs were elevated on foot rests attached to the wheelchair. R43 had foam boots on both feet. During an interview on 2/14/23, at 3:07 p.m. NA-B stated she had worked with R43 frequently. R43 relied on staff to dress him. R43 had not worn shoes before he developed this current pressure ulcer on the bottom of his foot. NA-B was unsure if R43 had shoes. NA-B stated R43 would self propel his wheel chair with his unprotected feet pushing on the foot rests. NA-B also stated R43's right foot curved over the foot rest so more pressure was on the foot rest. NA-B stated R43's knee immobilizer was discontinued after the wound developed so he could move his leg more. During an interview on 2/15/23, at 1:04 p.m. NA-A stated she worked regularly on the unit R43 resided on. NA-A stated R43 had not worn shoes probably due to a personal preference, she had not asked why R43 didn't have shoes on. NA-A stated R43 would self propel in his wheelchair with his legs up on the foot rests. NA-A stated the knee immobilizer made it harder for R43 to move his right leg and the pressure from the wheelchair foot rest lined up with the new pressure sore on the bottom of his foot. NA-A stated the knee immobilizer was now discontinued. During an observation on 2/15/23, at 2:08 p.m. with RN-A, RN-B, and MD-A wound treatment was provided to the right plantar pressure sore. MD-A measured the wound to be 5.5 x 4.7 x 0.4 cm which was slightly improved from the previous week. MD-A told R43 she wanted to remove more dead tissue but R43 declined and said yes when MD-A asked if the wound hurt while she worked on it. MD-A stated she would order a pain medication to be given prior to the treatment the next time she came and R43 agreed to reschedule the dead tissue removal next week. During an interview on 2/15/23, at 2:13 p.m. with RN-A, RN-B and MD-A together after wound care was provided, RN-A stated the cause of the pressure sore was R43's foot putting pressure on his wheelchair foot rest and that R43 was at higher risk for pressure sores to the way his right foot dropped (weak in the front of the foot). Next, RN-B stated R43 had a diagnosis of being malnourished and this could contribute to R43's risk for pressure ulcers. MD-A then stated the wound was caught early, however she was unsure why the wound had deteriorated. MD-A stated a wound like this on R43 could develop in as little as two hours, and less than a day. MD-A stated pressure on R43's unprotected foot from the wheelchair foot rests while he self-propelled was the likely cause of the pressure sore. MD-A stated protection of the foot such as a shoe, something more than socks, could have prevented the pressure sore. During an interview on 2/15/23, at 2:20 p.m. RN-A stated R43 was at risk for pressure ulcers and his skin was monitored, however, the bottoms of his feet were not identified as a high risk area even though R43 had not worn shoes, had limited mobility to offload due to the knee immobilizer, his feet rested often on the wheelchair foot rests and R43 lacked protection to the bottom of his feet. During an interview on 2/16/23, at 9:14 a.m. the OT-A stated she had worked with R43 prior to and after the development of the pressure ulcer on the bottom of his foot. OT-A stated the wound developed on the arch of R43's foot which lined up with the wheelchair foot rests. Once the wound developed and then the leg brace was discontinued R43 could move his foot more to offload pressure. OT-A stated R43 only wore socks and was not able to move his foot off the wheelchair foot rest. OT-A stated they were now trying to find a new wheelchair so he could self-propel and protect his feet. OT-A stated the pressure from the foot rest on R43's unprotected foot was the cause of the pressure ulcer and could have been prevented. During an interview on 2/16/23, at 10:24 a.m. the DON reviewed R43's record and agreed with the Braden assessment that he was at moderate risk for developing pressure ulcers. The DON reviewed R43's care plan and agreed foot wear or foot protection was not addressed in the care plan prior to the development of the pressure ulcer on the bottom of his foot. The DON agreed that the pressure sore on the bottom of R43's foot could have been prevented if the foot had been identified as a higher risk area. 42586 R73's quarterly MDS dated [DATE], indicated R73 had intact cognition and diagnoses of fracture of unspecified part of neck of left femur, pressure ulcer of sacral region (stage IV), muscle weakness, and need for asssitance with personal care. It further indicated R73 required extensive assistance with bed mobility (2 staff) and transfers and ambulation did not occur. R73 was at risk for developing a pressure ulcer, had (1) stage IV pressure ulcer (sacral region), and had an intervention of a turning/repositioning program. R73's care plan dated 9/5/22, include R73 was at risk for alteration of skin status due to fracture of unspecified part of neck of left femur with routine healing, cognitive communication deficit, diabetes mellitus type II, unspecified severe protein- calorie malnutrition, metabolic encephalopathy (neurological disorder resulted from systemic illness such as diabetes or organ failure and which can be reversed if treated), and pressure ulcer of sacral region, with an intervention of a turning and positioning program due to decreased mobility with assist of two. R73 prefers to be repositioned every three hours and requires special attention when positioning related to pressure ulcer of sacral region. R73's nursing assistant care sheet (undated), indicated R73 should be repositioned every 2-3 hours. During continuous observation on 2/14/23, from 1:40 p.m. to 4:47 p.m. R73 was not repositioned timely. R73 was laying in bed on her back and remained in that position throughout the entire observation. At 3:08 p.m. NA-C entered R73's room with a vital signs machine and exited at 3:09 p.m. NA-C stated she took R73's vital signs and did not re-position her or offer to do so. No other staff entered R73's room. During interview on 2/14/23, at 4:45 p.m. NA-C stated R73 should be repositioned every two hours and the last time R73 was repositioned was at 2:30 p.m. by the girl who worked the day shift. NA-C did not know the name of the staff. R73's medical record lacked any documentation R73 had been repositioned, offered to be repositioned, or refused to be repositioned. During interview on 2/16/23, at 2:50 p.m. the director of nursing (DON) stated staff should be repositioning R73 according to her care plan and even if R73 refused, staff should still be offering. The DON also stated staff should be documenting refusals. The facility policy titled Prevention and Treatment of Skin Breakdown/Pressure Injury undated, indicated weekly skin audits would be performed by a licensed nurse. The policy also indicated the treatment for a pressure injury would include a weekly measurement, exam, and staging of the area.

Based on interview and document review, the facility failed to ensure coordination of hospice services was implemented to treat a resident's reported excruciating pain for 1 of 3 residents (R3) reviewed for end of life services. The lack of the facility's coordination with hospice services resulted in R3 experiencing excruciating pain, which resulted in actual harm. Findings include: R3's medication and treatment administration record, dated (MONTH) 2019, revealed the following orders for pain management: TOPICAL [MEDICATION NAME] sodium gel 1% amount to administer: 2 grams topical twice a day 5/1/19 to 5/31/19. R3's last administration date was 8:00 a.m. on 5/31/19. [MEDICATION NAME] sodium gel 1% amount to administer: 2 grams topical twice a day apply 2 grams to R (right) knee/back bid dx (diagnosis) pain; 5/28/19 to open ended. R3 received all scheduled doses on 5/30/19 and 5/31/19. ORAL [MEDICATION NAME] 10mg (milligrams)/ml (milliliter) liquid 10mg/ml Amount to administer: 2 mg (0.2 ml) oral every four hours 5/30/19 to 6/4/19. R3 did not receive any doses on 5/30/19 at 4:00 p.m. the Medication Administration Record [REDACTED]. [MEDICATION NAME] 10mg/ml liquid; 10mg/ml; amount to administer 2 mg/(0.2 ml); oral every hour prn (as needed) for pain 5/30/19 to 6/4/19. R3 did not receive any doses in May. [MEDICATION NAME] liquid 1 mg/ml; amount to administer: 2 mg; oral every 4 hours; take 2 mg every 4 hours dx: SOB (shortness of breath) /pain 5/28/19 to 5/30/19. R3's last dose was administered at noon on 5/30/19. [MEDICATION NAME] 10 mg/ml liquid; 10mg/ml; amount to administer: 5 mg; oral at bedtime 5/30/19 to open ended. R3 did not receive the medication on 5/30/19 at 8:00 p.m. with a note, Due to condition and comment: unable to swallow did not respond to attempts to give [MEDICATION NAME]. [MEDICATION NAME] liquid 1 mg/ml; amount to administer: 2 mg; oral every hour-prn; Take 2 mg ever hour as needed Dx: SOB/pain from 5/28/19 to 5/30/19. R3 was not administered any doses on 5/30/19 or 5/31/19. R3's 5/30/19 progress note for 2:39 p.m., included, Hospice nurse visit (R3) up in w/c (wheelchair) restless, resistive to cares. Per staff he is either sleeping or restless when asked if having pain he stated responded excruciating in my lower back and my knees when asked what about your knees he states they hurt very very bad was able to tell me the pain was in his left knee. P (pulse) 68, R (respirations per minute) 20, BP (blood pressure) 150/84, 02 sats (oxygen saturation) 93% on room air. Ate 50% of lunch fed self, updated NP (nurse practitioner) and OK to start [MEDICATION NAME]. Call to (physician) will start [MEDICATION NAME] 5 mg at bedtime. Call to (family member), (FM-A) updated on changes in meds, she stated any thinking you can do to make him comfortable, added he has no quality of life and we are not looking at extending his life, just want him comfortable. Continue comfort cares. R3's progress note dated 5/31/19, at 12:49 p.m. included, Hospice nurse visit (R3) up in w/c restless, had been leaning forward in chair earlier, as trouble sitting up, broad chair ordered. c/o (complaints of) pain in back and knees when asked, [MEDICATION NAME] not started yesterday as ordered. P (pulse) 64, R (respirations per minute) 16' BP (blood pressure) 110/76, 02 sats (oxygen saturations) 79% on room air. R3's medication incident/error report, dated 5/31/19, included, Medication as ordered (include name of medication, dose, route and frequency): [MEDICATION NAME] 10 mg/ml 5 mg oral, and, Description of error (include name of medication, dose, route and time(s) administered: Medication not given at HS (hour of sleep), and, Care provided and outcome to resident: poor managed pain-Resident other pain medications given. R3's progress note, marked as a late entry on 6/5/19, 10:33 a.m. indicated on 5/30/19, at 10:32 a.m. On Thursday HS (hour of sleep) hours resident was not swallowing and writer was unable to give [MEDICATION NAME]. Reported to night nurse who came at shift change. Noc nurse reported she would try to give it. There was no indication the hospice nurse was contacted to assist in direction of what medication R3 could have instead of the [MEDICATION NAME] to assist in pain relief. On 6/5/19, at 9:00 a.m. the hospice nurse case manager, (RN)-A, reported she observed R3 with, excruciating back pain and failed knee issues, on 5/30/19. RN-A reported when she visited the next day, 5/31/19, R3 was in the same pain. RN-A described that R3 was grimacing, was requiring more assistance with transfers and reported excruciating pain. RN-A noted she saw the [MEDICATION NAME] was noted as not given due to resident being unavailable. RN-A reported this did not make sense as R3 was a terminally ill patient with dementia. RN-A reported she would expect the facility to offer the medication multiple times and contact hospice with any difficulties. RN-A reported she checked the delivery receipts and the [MEDICATION NAME] was delivered at 7:30 p.m., in time for hour of sleep. RN-A reported facility nursing staff should ensure a dying patient was kept comfortable. On 6/5/19, at 12:08 p.m., the nurse manager (RN)-B reported she was not aware what the MAR meant by noting the resident was unavailable at 8:00 p.m. on 5/30/18, as R3 had terminal [DIAGNOSES REDACTED]. RN-B reviewed the medications and noted R3 had his last dose of oral medication pain relief for 5/30/19, at noon. R3 had his [MEDICATION NAME] sodium gel 1% topically on 5/30/19, at 4:00 p.m., but no oral medications for pain relief at the 4:00 p.m. or 8:00 p.m. medications, as normally scheduled, and no prn oral pain medications. The medications were changed on 5/30/19, after R3 reported excruciating pain to the hospice nurse on 5/30/19, at 12:49 p.m. The new medications ([MEDICATION NAME] 10mg/ml liquid; 10mg/ml; amount to administer 2 mg/(0.2 ml); oral every hour prn for pain 5/30/19 to 6/4/19; [MEDICATION NAME] 10mg (milligrams)/ml (milliliter) liquid 10mg/ml Amount to administer: 2 mg (0.2 ml) oral every four hours 5/30/19 to 6/4/19, and [MEDICATION NAME] 10 mg/ml liquid; 10mg/ml; amount to administer: 5 mg; oral at bedtime 5/30/19 to open ended) were not available at 4:00 p.m. and the prior medications ([MEDICATION NAME] liquid 1 mg/ml; amount to administer: 2 mg; oral every 4 hours; take 2 mg every 4 hours dx: SOB /pain 5/28/19 to 5/30/19 and [MEDICATION NAME] liquid 1 mg/ml; amount to administer: 2 mg; oral every hour-prn; Take 2 mg every hour as needed Dx: SOB/pain 5/28/19 to 5/30/19, were discontinued and not available as an order in the MAR indicated [REDACTED]. RN-B reported she was made aware of the medication error on 5/31/19, during the morning. RN-B reported she would expect the nursing staff to coordinate with hospice staff if pain medications were not available for a resident who had reported excruciating pain earlier in the day. RN-B reported pain control and dignity is the first priority for hospice patients. On 6/5/19, at 1:28 p.m. the director of nursing reported nursing staff should have consulted with hospice if there was difficulty, or delays in administering pain medications for R3, since he had reported excruciating pain earlier in the day. On 6/5/19, at 1:45 p.m. RN-C, reported she did not administer any oral pain medications to R3 on the evening of 5/30/19, as the medications were not available at 4:00 p.m. and R3 was sleeping, and therefore, unavailable at 8:00 p.m. RN-C reported she received the new medications at 7:30 p.m. from the pharmacy. RN-C reported she did not consult with the hospice to determine a pain management plan for R3, who reported excruciating pain earlier in the day, when he did not awake to swallow the 8:00 p.m. pain medications. RN-C reported she did notify the night shift nurse.

Based on observation, interview and document review the facility failed to provide the necessary care and services to prevent skin breakdown, and pain, for 1 of 1 resident (R29) in the sample identified for skin breakdown and pain. The failure of the facility to provide care resulted in harm for R29 who sustained skin breakdown and severe pain associated with the skin breakdown. Findings include: R29 did not receive underarm care and services for 5 to 6 days which resulted in bilateral 22 centimeter (cm) flame red, moist, raw excoriated (to tear or wear off the skin) axilla (underarm/armpit) with a pain rating of 10 when care was provided. During an observation on 10/16/17, at 5:27 p.m. R29 was in bed lying supine (on backside) wearing a patient gown and there was a pungent odor detected that permeated the room. During continuous observation on 10/18/17, from 6:56 a.m. to 11:00 a.m., the following observations were made: R29 was observed to lay on back in bed sleeping until 8:30 a.m., when medications and continental breakfast were brought to the room. Licensed practical nurse (LPN)-B gave medications to R29 and R29 informed LPN-B that morning cares could be completed after brunch. At that time, there was no offer to provide any cares or education regarding the importance of cares to be conducted at specified times. The pungent odor that was detected in the room earlier, remained. At 11:00 a.m., the surveyor intervened and sought staff assistance for R29. When interviewed on 10/18/17, at 11:00 a.m., nursing assistant (NA)-E verified that no morning cares had been performed for R29 that day, acknowledging there had been no turning or repositioning. NA-E stated this was because (R29) refused. When questioned about the process for reporting resident refusals to the nurse, NA-E replied that the nurse should have been informed right away. At this time, NA-E walked over to the medication cart where licensed practical nurse (LPN)-B was setting up medications and informed LPN-B that R29 had refused all cares so far today. At 11:02 a.m. LPN-B went into R29's room and asked R29 if it would be acceptable for cares to be provided now and R29 responded yes. LPN-B left the room and NA-E started to gather supplies. R29 was interviewed on 10/18/17, at 11:05 a.m. and stated cares had not been offered this morning, Staff will say I refuse care, adding sometimes I do, but not all the time, most of the time they don't offer the care or I don't understand them. R29 was adamant that personal cares and repositioning had not been offered yet today. Following conversation with the resident, observation of morning cares was observed with NA-E and NA-G removing R29's gown. At that time, both underarms were observed to be excoriated, with a flame red, moist, burn like appearance. The areas were approximately the size of an 8 inch plate and when the arms were lifted, a strong pungent odor was detected. Using water and a wash cloth NA-E started to wash under the resident's right underarm. R29 cried out in pain stating, Stop that, you are hurting me! NA-E reached into the bedside drawer and retrieved a container of [MEDICATION NAME] (an anti-fungal) powder to apply to the underarm areas. When the surveyor questioned the nursing assistants about whether the areas were new, and/or whether the nurse had or should look at the raw areas prior to application of the powder, NA-G left the room to get the nurse. LPN-B came to the room, observed the underarms, and asked R29 about pain, using a 1-10 level pain scale (10 being the worst pain), to which R29 responded the pain was at level 10 when staff tried to wash the area. LPN-B asked R29 how long the armpit areas had been painful and R29 responded five to six days. At that time, LPN-B acknowledged to the surveyor that these excoriated, flame red burn like areas under R29's arms were new. R29 stated the facility gowns were too small and did not fit under the arms, and indicated the skin became irritated from rubbing against it. NA-E and NA-G verified the gown was not large enough which caused friction and shearing of the skin (mechanical force exerted on skin that is dragged across any surface, and the interaction of both gravity and friction against the surface of the skin. Shear occurs when layers of skin rub against each other or when the skin remains stationary and the underlying tissue moves and stretches and angulates or tears the underlying capillaries and blood vessels causing tissue damage, and rubbing of the skin). The director of nursing viewed the new excoriated areas under the arms and when interviewed on 10/18/17, between 11:05 am to 11:30 a.m. NA-E, NA-G, LPN-B and the director of nursing (DON), verified the pungent odor in the room. LPN-B and the DON said the pungent odor could be associated with the excoriated areas under R29's arms. R29 stated, I wondered what that smell was and acknowledged having noticed the odor the other day but was not able to be more specific. The DON verified the patient gown was not large enough and verified the excoriated red, raw areas to both underarms appeared to be from friction and or shearing. When interviewed on 10/18/17, at 11:50 a.m. R29 stated, I feel so helpless, I just feel like crying, I would get up in the chair more but they will not guarantee to put me back to bed if I get dizzy and it is so much work to get me up. R29 reiterated the underarms had been painful for five to six days, but rated the pain at a level 10 when staff were providing care. Review of a skin assessment completed by the DON on 10/18/17, at 12:20 p.m. indentified, R29 now had large areas of excoriation under axilla area (measured at 22 cm bilaterally) and under breast folds. Review of R29's, The Brief Interview, for mental status document revealed a change from cognitively intact to moderately impaired on the 4/16/17 assessment with inability to report the year, month and day. Document review of the facility form titled, Resident Face Sheet, indicated a [DIAGNOSES REDACTED]. Document review of R29 weights noted on admission 4/15/16, weight 305# with current weight 10/5/17, to be 346#. Review of the plan of care dated 7/10/17, included a problem area related to pain: At risk for alteration in comfort r/t (related to) immobility, h/o (history of) fall,functional status obesity per resident report, {aeb} chronic bilat (bilateral) shoulder pain, complaints of back/coccyx pain with sitting, complaints of R groin and underarm pain. In addition, the plan of care dated 7/10/17, also addressed the resident's non-compliance with care (i.e. ADL's incontinent pad changing, bathing, etc.; eating and taking medications, etc.) The approaches included: Actively involve the resident in care. Express willingness to adjust regimen. Assess resident's resistance to care (e.g., incongruence with expectations, cognitive status, attitude, motivation, lack of understanding, pain/intolerance, fear of financial burdens, etc.). Explain the disease process and consequences of refusal of therapy, Have consistent expectations for resident amongst caregivers. Reiterate the purpose and advantages of treatment for [REDACTED]. Plan of care concerns initiated 4/8/17, indicated R29 required extensive staff assistance with dressing, grooming and bathing and addressed actively involving the resident in care, including to express a willingness to adjust the resident's care regimen. Under the communication plan of care, approaches included to ask one question or give one piece of information at a time. Face resident when speaking and remove background distractions as able. Repeat/rephrase prn (whenever necessary) and to observe for R29's understanding. The October 2017 Medication Administration Record [REDACTED]. A facility form titled, Weekly Bath Day Body Audit Form dated 9/29/17, noted; a shower was performed and the only open areas were to the lower legs. A request to see the bath body audits for October 6th and October 13th, however, no bath or body audits had been completed for these dates. There were no documented offers for any other day to receive the bath and body audit in October for R29. There were no refusals documented for the October baths and body audits. The October 2017 Medication Administration document read, Weekly Bath: 1) Conduct Full body audit 2) Ensure NAR bath sheet filled out completely and sign. Frequency Once a Day on Friday. Special Instructions *Not optional, follow protocol for refused baths/showers* Progress notes reviewed for September and October 2017, with only the following refusals of care noted. 10/15/17, at 4:10 p.m. Resident refused to get out of bed during the a.m. shift. On 10/14/17, at 3:29 p.m. Resident refused to get out of bed during the a.m. shift. On 10/10/17, at 4:10 p.m. NP (nurse practitioner) wants documentation of when resident gets up in (R29) chair Q (every) day. Resident refused to get out of bed during the day shift per usual. On 10/5/17 Resident continues to refuse to get out of bed and at times refuses care. There was no documentation as to why R29 had refused to get out of bed, no assessment or alternative measures implemented to promote R29 to be out of bed. Document review of the facility policy titled Refusal of Treatment dated May 2013, read, Our facility shall honor a resident's request not to receive medical treatment as prescribed by his or her physician, as well as care routines outlined on the resident's assessment and plan of care. Under Interpretation and Implementation, #6. Should the resident refuse to accept treatment, detailed information relating to the refusal must be entered into the resident's medical record. #7. Documentation pertaining to a resident's refusal of treatment shall include at least the following: a. The date and time the staff tried to give a medication or treatment was attempted; b. The medication or treatment refused; c. The resident' response and reason(s) for refusal; d. The name of the person attempting to administer the treatment; e. That the resident was informed (to the extent of their ability to understand) of the purpose of the treatment and the consequences of not receiving the medication/or treatment; f. The resident's condition and any adverse effects due to such refusal; g. The date and time the physician was notified as well as the physician's response; h. All other pertinent observations; and i. The signature of the person recording the data. During an interview on 10/19/17, at 1:54 p.m. the DON explained the facility expectation would be for staff to provide AM and PM care everyday including washing the underarms, to ensure proper skin care, and to prevent skin breakdown. The DON verified R29's axilla areas bilaterally were flame red, raw and moist. The DON said immediate interventions to prevent friction/sheering, and to provide pain control for R29, would need to be implemented immediately.

Based on observation, interview and document review, the facility failed to ensure a resident identified at risk for pressure ulcers received timely repositioning for 2 of 3 residents (R29, R71) in the sample identified at risk for skin breakdown. The failure of the facility to consistently implement a turning and positioning program, resulted in harm, when R29 aquired two new, stage II, open areas. Findings include: R29 did not receive a position change on 10/16/17, for over four hours, and on 10/18/17 for over four hours, and acquired two new, stage II, open areas .05 centimeter (cm) by 1.0 c size to the left mid buttock. Observations were made of R29 on 10/16/17, at 3:00 p.m., 5:00 p.m. and 7:00 p.m. R29 was positioned in bed, lying on her back (supine) at 3:00 and 7:00 p.m., and at 5:00 p.m. R29 was positioned supine lying with the head of the bed elevated 20 degrees and had finished feeding self while in bed. During interview, on 10/16/17, at 5:18 p.m. R29 stated she was unable to change own position in bed and required staff assistance to turn and reposition. R29 stated it was typical to remain on backside when lying in bed. At 7:00 p.m., when asked whether staff had assisted with turning and positioning, R29 stated,not today. Review of a facility form titled Brief Interview for Mental Status (BIMS) revealed a change from cognitively intact to moderately impaired as of the 4/16/17 assessment with inability to report the year, month and day. Review of the facility form titled, Resident Face Sheet, identified R29 had [DIAGNOSES REDACTED]. Resident weights identified in the record indicated R29's weight on admission 4/15/16 to be 305# , and a weight from 10/5/17, to be 346#. The Care Area Assessment (CAA) form dated 4/12/17, included: pressure ulcer risk due to total assist with transfers and extensive assist with bed mobility, always incontinent, non-ambulatory, and a mechanical lift with all transfers. The skin assessment titled, Turning and Repositioning Observation, dated 4/6/17, indicated the resident will be turned and repositioned while lying and sitting every two hours. The nursing assistant assignment sheet titled, Care Card and dated 9/28/17, included: repositioning every 2 hours. Review of the plan of care edited 4/8/17 for Pressure Ulcer included; At risk for pressure ulcer d/t (due to) needing assistance with ADL's (activities of daily living), incontinence of bladder and bowel, non ambulatory, and the approaches directed: keep linens clean, dry and wrinkle free, Provide extensive staff assist with repositioning O2H (every 2 hours) 2 staff needed to boost up in bed. Staff monitor skin daily with cares. Licensed staff assess QWK (every week) with bath body audit. The facility form titled, Weekly Bath Day Body Audit Form dated 9/29/17, indicated a shower was performed and the only open areas were to the lower legs. The bath day body audits for 10/6 and 10/7/17 had not been completed and were not available. There was no documention of a bath and body audit for any other days in October for R29. There was no indication that R29 had refused a bath or body audit in October. The October 2017 Medication Administration document read, Weekly Bath: 1) Conduct Full body audit 2) Ensure NAR bath sheet filled out completely and sign. Frequency Once a Day on Friday. Special Instructions *Not optional, follow protocol for refused baths/showers* R29's plan of care dated 5/4/16, for activities of daily living (ADL's) had a self care deficit in bed mobility, transfers and locomotion d/t (due to) needing assistance with ADLs, incontinent of bladder and bowel, non-ambulatory and [MEDICAL CONDITION]. The approach was for extensive staff assistance with bed mobility, check and change incontinent product Q2H (every 2 hours) and prn (whenever necessary), extensive staff assistance with dressing, grooming, and bathing, and set up for oral care. provide physical assistance prn. Resident has a significant history or non-compliance with allowing ADLs. and the approach directed when resident declines cares to NAR (nursing assistant registered) nurse to reapproach, When resident refuses/declines cares, nurse to provide extensive education on skin integrity, pressure ulcer and what the consequences of that can lead to up to including death and document. Monitor and document non-compliance with ADLs. Staff to offer support, kindness, patience and reminders that {R29) is well liked and respected. Encourage resident to verbalize feelings, concerns, fears, etc. Clarify misconceptions. A revised plan of care dated 7/10/17, addressed: Resident is non-compliant with care (i.e. ADL's incontinent pad changing, bathing, etc.; eating and taking medications, etc.) The approaches read, Actively involve the resident in care. Express willingness to adjust regimen. Assess resident's resistance to care (e.g., incongruence with expectations, cognitive status, attitude, motivation, lack of understanding, pain/intolerance, fear of financial burdens, etc.). Explain the disease process and consequences of refusal of therapy, Have consistent expectations for resident amongst caregivers. Reiterate the purpose and advantages of treatment for [REDACTED]. During continuous observation on 10/18/17, from 6:56 a.m. to 11:00 a.m., the following observations were made: R29 was observed to lay on backside in bed sleeping until 8:30 a.m., when medications and continental breakfast were brought to the room. Licensed practical nurse (LPN)-B gave medications to R29 and R29 informed LPN-B that morning cares could be completed after brunch. At that time, there was no offer to provide any care, including repositioning, nor education regarding the importance of cares to be conducted at specified times. At 11:00 a.m., R29 had not yet been turned and repositioned (greater than 4 hours) when the surveyor sought staff assistance. When interviewed on 10/18/17, at 11:00 a.m., nursing assistant (NA)-E verified that no morning cares had been performed for R29 that day, acknowledging there had been no turning or repositioning. NA-E stated this was because (R29) refused. When questioned about the process for reporting resident refusals to the nurse, NA-E replied that the nurse should have been informed right away. At this time, NA-E walked over to the medication cart where licensed practical nurse (LPN)-B was setting up medications and informed LPN-B that R29 had refused all cares so far today. At 11:02 a.m. LPN-B went into R29's room and asked R29 if it would be acceptable for cares to be provided now and R29 responded yes. LPN-B left the room and NA-E started to gather supplies. R29 was interviewed on 10/18/17, at 11:05 a.m. and stated cares had not been offered this morning, Staff will say I refuse care, adding sometimes I do, but not all the time, most of the time they don't offer the care or I don't understand them. R29 was adamant that the personal cares and repositioning had not been offered yet today. R29 reported having been laying on backside all night and all morning because staff were not able to position her to the side, due to her weight and the size of the bed. R29 explained that staff will turn R29 to perform incontinence care but is then positioned on backside again. R29 stated being generally changed for incontinence once on the night shift and otherwise remains on backside when in bed. A pillow was observed for R29's head, however, no other pillows were observed to be used for positioning. Observations continued on 10/18/17, and at 11:30 a.m. NA-E and NA-G, who verified multiple bruise areas to the bilateral thighs of R29, associating the bruising occurred when staff pulled R29's legs apart to provide perineal cleansing. At this time, NA-E and NA-G turned R29 to the side to complete incontinence care. Two red open areas were visualized to the posterior mid left buttocks, with a red streak approximately 1 centimeter (cm) by 4 cm in length. There were multiple red creases/craters and wrinkling of the skin to the buttocks and posterior thigh areas on R29. The bottom sheet was not a fitted sheet and there was bunching up of the linen to the buttocks and posterior thigh area. The director of nursing (DON) came to the room to check on the two new stage II open areas to the mid left buttock. When interviewed on 10/18/17, at 11:45 a.m. the DON acknowledged R29 would benefit from a larger bed to accommodate turning and positioning, and that a fitted bottom sheet would be obtained to help prevent wrinkling of the linen under R29. A referral would be made to physical therapy for consideration of a trapeze overhead to aide in positioning. When interviewed on 10/18/17, at 11:50 a.m. R29 stated, I feel so helpless, I just feel like crying, I would get up in the chair more but they will not guarantee to put me back to bed if I get dizzy and it is so much work to get me up. Document review of a skin assessment completed by the DON on 10/18/17, at 12:20 p.m. that identified new stage 2 denuding (loss of [MEDICATION NAME] associated with urine and feces) excoriation of the left buttock. Size 1 centimeter (c) in length and 0.5 c in width. Although the DON, with surveyor present, had observered and acknowledged the two new stage II areas, when documention was completed, the DON had only identified one new area, on 10/18/17 at 12:20 p.m. The facility policy titled Repositioning, dated May 2013, indicated: The purpose of this procedure is to provide guidelines for the evaluation of resident repositioning needs to aid in the development of a individualized care plan for repositioning, to promote comfort for all bed or chair bound residents and to prevent skin breakdown, promote circulation and provide pressure relief for residents. Repositioning documentation read, The following information should be recorded in the resident's medical record: 1. The position in which the resident was placed. This may be on a flow sheet. 2. The name and title of the individual who gave the care. 3. Any change in the resident's condition. 4. Any problems or complaints made by the resident related to the procedure. 5. If the resident refused the care and the reason(s) why. 6. Observation of anything unusual exhibited by the resident. 7. The signature and title of the person recording the data. R29 did not have any documentation available to indicate repositioning was monitored as directed. Under the section Reporting directed, 1. Notify the supervisor if the resident refuses the procedure. 2. If the resident refuses care an evaluation of the basis for refusal, and the identification and evaluation of potential alternatives is indicated. 3. Report other information in accordance with facility policy and professional standards of practice. R29 did not have any documentation available to indicate repositioning was refused. Progress notes reviewed for September and October 2017, with only the following refusals noted: 10/15/17, at 4:10 p.m. Resident refused to get out of bed during the a.m. shift. On 10/14/17, at 3:29 p.m. Resident refused to get out of bed during the a.m. shift. On 10/10/17, at 4:10 p.m. NP (nurse practitioner) wants documentation of when resident gets up in (R29) chair Q (every) day. Resident refused to get out of bed during the day shift per usual. On 10/5/17 Resident continues to refuse to get out of bed and at times refuses care. There were no other refusals documented. There was no indication on the reason for refusal was assessed or interventions provided to increase compliance with cares. The facility's policy titled Refusal of Treatment dated May 2013, included: . Our facility shall honor a resident's request not to receive medical treatment as prescribed by his or her physician, as well as care routines outlined on the resident's assessment and plan of care. Under Interpretation and Implementation, #6. Should the resident refuse to accept treatment, detailed information relating to the refusal must be entered into the resident's medical record. #7. Documentation pertaining to a resident's refusal of treatment shall include at least the following: a. The date and time the staff tried to give a medication or treatment was attempted; b. The medication or treatment refused; c. The resident' response and reason(s) for refusal; d. The name of the person attempting to administer the treatment; e. That the resident was informed (to the extent of their ability to understand) of the purpose of the treatment and the consequences of not receiving the medication/or treatment; f. The resident's condition and any adverse effects due to such refusal; g. The date and time the physician was notified as well as the physician's response; h. All other pertinent observations; and i. The signature of the person recording the data. During an interview on 10/19/17, at 1:54 p.m. the DON verified the facility expectation would be to reposition R29 every two hours, according to the assessment, and to inform the nurse immediately if the resident refused and to follow the protocol for the nurse to reapproach right away to ensure proper repositioning and to prevent skin breakdown. R 71 did not recieve care and services to prevent pressure ulcers. R71's care area assessment, dated 3/14/17, was reviewed and revealed (R71) triggers pressure ulcers D/T (due to) (R71) requiring extensive assist with bed mobility and total assist with transfers. (R71) is always incontinent of bladder and bowel. R71's nursing assistant care guide, dated 9/(blank)/17, directed staff Reposition: EA1 (extensive assist of 1) 2 staff to boost up Q2 (every 2 hours). R71's care plan, last updated 9/21/17, directed staff Resident is at risk for pressure ulcers and EA2 to reposition q 2 hrs and prn. Attempt to position off back/coccyx as (R71) allows. During continuous observations on 10/18/17 from 7:45 a.m. to 12:32 p.m., R71 was observed sitting in a high back wheelchair in the dining room without being repositioned. From 7:45 a.m. until 11:06 a.m., R71 was observed eating donuts, drinking coffee and nodding off. At 11:06 a.m., R71 was served brunch and fed by a nursing assistant (NA)-C. At 12:05 p.m., NA-C was asked when R71 was last repositioned. NA-C reported not being R71's aide and did not know. NA-A reported not being R71's aide and was not aware of the last time R71 was repositioned. The floor nurse, (RN)-A reported not being R71's nurse and was unable to answer questions because it was time for a break. RN-A reported LPN-B was R71's nurse and LPN-B was on break. At 12:21 p.m., NA-G reported she was R71's aide, however was unaware of the last time R71 was repositioned. NA-G reported R71 was in the high back wheelchair when her shift at 6:53 a.m. NA-G reported she had not provided R71 any repositioning since she started her shift. NA-G reported she was not used to working the day shift. NA-G offered to take R71 to the room for incontinence cares and repositioning. R71 reported R71 would be ready in 15 minutes as R71 was still drinking pop from brunch. At 12:32 p.m., NA-G wheeled R71 into R71's bedroom. NA-G and NA-C used the full mechanical lift to transfer R71 from high back wheelchair to bed. R71's skin was observed and was dry and intact, with no reddened areas. On 10/18/17 at 2:29 p.m., the director of nursing (DON) reported she would expect staff to reposition R71 at least every two hours. DON explained it may not always be reasonable to reposition R71 every two hours on the dot. When asked about R71 not being repositioned from 6:53 a.m. until 12:32 p.m., DON reported that is not acceptable.

Based on interview and document review, the facility failed to provide care according to each resident's care plan for 2 of 7 residents reviewed, Resident #1 (R1) and R2, when staff members failed to transfer those residents with transfer belts, in accordance with their care plans, and the residents fell . R1 experienced harm when his shoulder was injured in the fall. Findings include:Medical record review revealed R1 was admitted to the facility on [DATE] following rotator cuff repair surgery. R1's [DIAGNOSES REDACTED]. A progress note, dated 8/17/2016, revealed R1's Brief Interview for Mental Status (BIMS) score was 15/15 indicating no cognitive impairment. R1's Nursing Assistant Care Card Key dated 8/19/2016 revealed the resident was to be transferred with the extensive assist of staff, and was to have no range of motion (ROM) to his right shoulder due to recent right rotator cuff repair surgery. R1's care plan, dated 8/14/2016, revealed that R1 was at risk for falls and R1 was to have the extensive assist of staff for transfers. R1's nursing notes dated 8/18/2016 revealed R1 experienced a witnessed fall in the tub room. R1's nursing notes dated 8/19/2016 revealed the resident fell in the tub room on 8/18/2016 just after he had finished with a shower. The gait belt was not on the resident at the time of the fall. The resident's care plan and care card were updated to include the extensive assist of staff and gait belt for all transfers. R1's MRI results dated 8/29/2016 revealed a full thickness re-tear of the repaired supra spinatus tendon. During an interview on 9/19/2016 at 4:30 p.m., Nursing Assistant (NA)-E stated she gave R1 a shower and she was assisting R1 to get dressed. The resident had no gait belt on. NA-E asked R1 to stand to pull up his pants. The resident stood up and held onto the 1/2 wall that was in front of him. As NA-E was pulling up his pants, R1 started to shake and was not able to continue standing. NA-E stated she helped the resident to the ground holding onto his pants. NA-E stated she did not use a gait belt because he was not transferring, just standing up, so she did not think a gait belt was necessary. NA-E stated she did not recall R1 bumping his shoulder and did not recall touching his shoulder during the fall. During an interview on 9/20/2016 at 1:00 p.m., R1 stated at about 7:00 p.m. on 8/18/2016 NA-E was giving him a shower. R1 stated he stood for a transfer after the shower and he lost his balance. NA-E grabbed his right shoulder on reflex and helped him to the ground. R1 stated NA-E did not use a transfer/gait belt when she stood him up. R1 stated the staff members who assisted him off the floor did not use a transfer/gait belt either. After this fall, the pain in his right shoulder became much worse and now he may need another surgical procedure to repair the shoulder again, or have a joint replacement. During an interview on 9/21/2016 at 2:15 p.m., Licensed Practical Nurse (LPN) - H stated she assisted R1 after his fall in the tub room on 8/18/2016. LPN-H stated she assessed R1 for injury at the time of the fall and none was observed. R1's vital signs, pain and neurological status were within normal limits. LPN-H stated she assisted NA-E to get R1 off the floor after he was checked for injury. LPN-H stated she thought she and NA-E used R1's pants to assist him off the floor, and did not recall using a transfer/gait belt. During an interview on 9/21/2016 at 2:45 p.m., Staff Development Registered Nurse (RN)-L stated she provides the training to all new Nursing Assistant staff. All new NAs are given a gait belt, and it must be on their person at all times. Every time a resident is transferred, a gait belt should be used, even when standing, unless the resident's care plan indicates one should not be used. RN-L stated that although she trains all new staff, she had not trained NA-E on the use of gait belts, because NA-E started before this training program was initiated. NA-E was on the list for this training in the future, but this training had not been completed yet. Medical Record review revealed R2 was admitted to the facility in 2015 with [DIAGNOSES REDACTED]. R2's care plan with a start date of 12/30/2013 re-evaluated R2 was at risk for falls and required the extensive assist of staff for all transfers. Nursing notes, dated 4/5/2016, revealed that R2 was standing on the scale and attempted to get off the scale and fell , hitting her head on the wall and falling to the ground. R2 was not wearing a gait belt at the time. R2 complained of left foot and right toe pain after the fall. R2 had X-rays, but no fractures were identified. The policy titled Gait/Transfer Belt Policy, dated 4/1/2011, and provided by facility staff stated: Nursing staff are trained during orientation on transfers with a transfer belt. Any resident that is not independent or stand by assist; or uses a lift machine (i.e. stand lift or hoyer lift) is to be transferred utilizing a transfer belt for all transfers, unless otherwise documented.

Based on medical records review, staff interviews, and the facility's policies and procedures review, the facility failed to ensure that 1 of 6 residents (Resident #1) was free of significant medication errors, when Resident #1 received one dose of Regular insulin that was discontinued. Resident #1 required hospitalization for [DIAGNOSES REDACTED] and altered mental status. Review of Resident #1's medical records revealed she was admitted to the facility in 2003 with [DIAGNOSES REDACTED]. Resident #1 had scheduled [MEDICATION NAME] Regular insulin solution; 100 units/ML. Resident #1 also had accu checks to check her blood sugars, four times a day; with a sliding scale coverage of Regular insulin for the first three accu checks. Additionally, Resident #1 received [MEDICATION NAME] 100 units/ML; every bedtime. Documentation on 1/08/2011, revealed that at 3:30 p.m., Resident #1 was found diaphoretic and unresponsive. Resident #1's blood sugar was 44, and she was given intermuscular [MEDICATION NAME]. Documentation revealed Resident #1's on call nurse practioner was notified when her blood sugar dropped to 24, and Resident #1's 4:00 p.m. insulin was held. Documentation on 1/09/2011, at 1:00 p.m., noted Resident #1 had a blood sugar of 56. Resident #1 was seen by the nurse practioner on 1/10/2011, who prescribed new insulin orders. The orders included discontinuing Resident #1's scheduled Regular insulin. Based on Resident #1's blood sugar results, staff were to use a sliding scale to administer Resident #1's insulin before her brunch and supper only. Staff interviews established the orders from the nurse practioner on 1/10/2011, were written after 12:00 p.m. Documentation on 1/10/2011, revealed Resident #1's Regular scheduled insulin was not discontinued. Employee (F), nurse, was interviewed on 1/18/2011, at 9:00 a.m. Employee (F) stated she received report from Employee (E), nurse, but was not told of any new insulin orders for Resident #1. Employee (F) stated Resident #1's blood sugar at 4:30 p.m. was 367 and she gave Resident #1, 10 units Regular insulin per sliding scale. Employee (F) stated she also gave 10 units of the scheduled Regular insulin, that was still on the MAR. Employee (F) stated she was alerted by staff at 5:00 p.m., that Resident #1 was sleepy and did not eat her supper. Employee (F) stated although Resident #1 did consume 100% of her house supplement, her blood sugar around 8:15 p.m. was 69. Employee (F) stated Resident #1's was drowsy, her skin was clammy and she did not talk. Employee (F) stated she attempted to give Resident #1 glucose, but she spit it out. Employee (F) stated she checked Resident #1's blood sugar 15 minutes later and the meter read low. Documentation on 1/10/2011, at 9:00 p.m., noted Resident #1 was non responsive, her skin was cool, clammy, and she was diaphoretic, with a blood sugar of 29. Resident #1 was transferred to the hospital where she was diagnosed with [REDACTED]. Review of the facility's Policy and Procedure on Transcription of Physician Orders, revised 8/09, states: Procedure: 5. If a HUC transcribes the order they will sign off the order and make a progress note. The nurse must review, cosign the order, ensure the orders are complete and verify all orders. 6. Use transcription stamp to ensure all orders are completely transcribed. Stamp into left side of Physician order [REDACTED].