Every finding on record at Cerenity Care Center White Bear Lake

Based on interview and record review, the facility failed to immediately initiate cardiopulmonary resuscitation (CPR) and activate the emergency response system (EMS) when 1 of 1 residents, with a full code status (when a resident's heart stops being (SP) the medical team uses all available lifesaving measures) was found unresponsive. This resulted in an Immediate Jeopardy (IJ) citation when licensed practical nurse, (LPN)-A, was notified by nursing assistant (NA)-A that R1 was unresponsive. LPN-A immediately checked on R1 finding R1 cool to the touch, without pulse and was not breathing. LPN-A failed to assess R1 for irreversible signs of death to determine and if necessary, perform CPR.The immediate jeopardy began on [DATE] when LPN-A failed to assess R1 for irreversible signs of death and did not initiate CPR immediately. The director of nursing (DON) and the Administrator were notified of the immediate jeopardy at 4:35 p.m. on [DATE]. The immediate jeopardy was removed and the deficient practice corrected on [DATE], prior to the start of the survey and was therefore issued at past noncompliance.Findings include: R1's physician order dated [DATE] at 12:23 p.m., indicated R1 was a full code. R1's quarterly Minimal Data Set (MDS) dated [DATE] identified a Brief Inventory Mental Status (BIMS) score of 15 indicating R1 was cognitively intact. R1's pertinent diagnoses were enterocolitis due to Clostridium Difficile (bacteria of the gut), non-pressure ulcer of the left foot and peripheral vascular disease (progressive circulation disorder). R1 required partial to moderate assistance from staff with all grooming and transfer assistance. R1's progress note dated [DATE] at 2:49 a.m. indicated R1 was found unresponsive at 12:05 a.m., writer called another staff nurse for help. At 12:07 a.m., CPR started, and code blue was announced. At 12:20 a.m. 911 was called, emergency services arrived and took over. At 12:49 a.m. emergency services announced R1 had passed away. R1's family was called to inform them. At 2:35 a.m. the family arrived with the priest to view, and the funeral home was called. Upon interview on [DATE] at 10:59 a.m., licensed practical nurse (LPN)-A stated she last saw R1 alive during evening medication pass around 7:00 p.m. At approximately 12:05 a.m. nursing assistant (NA)-A came to LPN-A and stated R1 had passed away. LPN-A went to check on R1 and noticed R1 looked asleep in her bed with the head of her bed raised with her head tilted to the right. LPN-A stated she was unable to locate a radial pulse, and R1's chest was not rising to indicate she was breathing. She touched R1's forehead and R1 felt cool. LPN-A denied pulling the covers back to assess more of R1's body. LPN-A called the charge nurse, LPN-B, to come and assist her stating before we can do anything we need a second nurse. She denied announcing a code blue, checking for R1's code status or giving instructions to NA-A. LPN-A waited for LPN-B to arrive. Approximately five minutes passed until LPN-B arrived at 12:09 a.m. LPN-B noted R1 was not breathing and looked pale. LPN-B found R1's code status, got the crash cart and initiated CPR. LPN-A stated she would have initiated CPR immediately, however she was a new employee and thought NA-A was agency staff and would not know how to call a code blue, so she wanted assistance from another nurse. She stated if she were aware that NA-A was facility staff she would have had her call the code and assist with CPR. Upon interview on [DATE] at 11:19 a.m. nursing assistant (NA)-A stated she was completing her rounds at approximately midnight and noticed R1's chest was not rising up and down when she entered the room. She turned on the light to try to arouse R1 and R1 did not open her eyes and then she noticed R1 was not breathing. She immediately notified LPN-A. LPN-A called downstairs to get LPN-B to assist her. LPN-B came to the second floor as NA-A and LPN-A were in the hallway outside of R1's room. LPN-B entered the room and immediately yelled out to NA-A to call a code blue and grab the Automated External Defibrillator (AED) machine. Upon interview on [DATE] at 2:05 p.m. the DON stated in the morning of [DATE] LPN-B reached out to her stating she was uncomfortable with how the code status went with R1. LPN-B told the DON that she was called by LPN-A with no urgency as a resident was found unresponsive. LPN-A did not complete a thorough assessment on her own and wanted LPN-B's assistance. LPN-B received a call on the house phone from LPN-A who asked to please come to the second-floor unit to look at something. When LPN-B got to the second floor, she assessed R1 was not breathing, however noted her skin was warm, and no rigor mortis had set in, so she initiated CPR and delegated duties to the staff. The DON was not certain exactly what LPN-A had assessed as during her investigative interview with LPN-A, LPN-A only stated she checked a radial pulse and watched for breaths. The DON had to pull information out of LPN-A asking specific questions if she used a stethoscope to auscultate the breath sounds? Did she pull back the covers to assess R1? Did she note her skin temperature and where? LPN-A had difficulty answering her questions as to what assessment she completed and did not have any nursing notes to verify her assessment by. The DON believed LPN-A reached out to LPN-B to verify R1's death not to assist with CPR. LPN-A also stated that she thought NA-A was an agency staff and therefore was not trained on the facilities emergency protocol. The DON verified with LPN-A that NA-A was a facility staff member who had been trained fully by the facility. Upon interview on [DATE] at 3:02 p.m. LPN-B stated around midnight on [DATE] LPN-A called LPN-B and asked her if she could come to the second floor and look at something quickly. LPN-B stated she did not rush as it was not communicated with her that there was an emergency. When LPN-B arrived on the second floor she noticed LPN-A and NA-A were standing outside of R1's room. LPN-B entered R1's room and noticed R1 was not breathing. She asked LPN-A what R1's code status was, and LPN-A was unable to answer. LPN-B quickly checked her code status and assessed R1 to be without breath, no pulse, the body was warm, and no rigor mortis had set in. LPN-B immediately delegated NA-A and LPN-A to call 911, call a code blue, and one of them assisted in getting R1 on the floor to start CPR. LPN-A called the code over the intercom system saying code blue only once without a room number. LPN-B delegated her to go back and to say code blue three times and give the room number. LPN-B and NA-A positioned R1 on the floor and started chest compressions until another nurse arrived and they started the AMBU bag (a handheld, portable, and self-inflating device used to provide positive pressure ventilation when a person is not breathing), in a few minutes EMS arrived and took over until R1 was pronounced dead. Upon interview on [DATE] at 4:14 p.m. the Administrator stated her expectation was that all staff follow the facilities policies and protocols. A facility policy titled Initiation of CPR/AED and BLS Associate Training Expectations dated 2018 indicated: When it is identified that a resident has signs/symptoms requiring CPR/AED (i.e., unresponsive) and meets criteria, EMS will be activated immediately as follows:911 is called.Door access to EMS is ensured.Resuscitation status is verified.If Provider medical order states a Full Code status, then CPR will be initiated.If Provider medical order states DNR Code status, then CPR will not be initiated.If resident Declination of CPR Form is present, then CPR will not be initiated.If the code status is unable to be confirmed or the resident is undecided CPR will be initiated.Once CPR is initiated, lifesaving efforts will continue until directed by dispatch, EMS or provider or effective spontaneous circulation and ventilation have been restored.*Reasons to NOT Initiate CPR/AED upon finding someone pulseless, per CMS, are:Obvious signs of clinical death (e.g., rigor mortis (chemical changes in the muscles after death, causing the limbs of the corpse to become stiff and difficult to move/manipulate), dependent lividity (purplish discoloration of the skin following death due to the settling of blood in the most dependent tissues), decapitation, transection, or decomposition are present.Initiating CPR could cause injury or peril to the rescuer.Family, Director of Nursing and Provider notification occurs as soon as the situation is stabilized.Actions are documented in the resident medical record. The IJ that began on [DATE], was corrected on [DATE]. The IJ was issued at past noncompliance due to the actions the facility implemented prior to survey, including:-The facility identified the error on [DATE] and completed a thorough investigation identifying the facility nurse failed to initiate CPR immediately on a full code resident who was found unresponsive. The root cause identified that LPN-A did not initiate CPR per the facility policy and the delegation of duties during the code situation did not occur. LPN-A was placed on leave pending the investigation on [DATE] and later terminated from employment. -The facility educated staff on the processes and procedures to follow when a resident is found unresponsive.-All residents code statuses were audited and verified correct and facility policies were reviewed.

Based on observation, interview, and document review, the facility failed to ensure a resident's dignity was maintained by not providing a catheter bag cover for 1 of 1 resident (R146) reviewed for catheters. Findings include:R146's admission Minimum Data Set (MDS) dated [DATE], indicated intact cognition, required partial/moderate assistance with mobility and toileting, and had an indwelling catheter. R146's diagnoses included acute kidney failure, unspecified open wound to right hip and abdominal wall, cellulitis. R146's Urinary Incontinence and Indwelling Catheter Care Area Assessment (CAA) dated 12/2/25, indicated R146 required foley catheter care and was at risk for complications and urinary tract infection (UTI). R146's care plan dated 12/10/25, indicated R146 had an activities of daily living (ADL) self-care deficit and required assistance with ambulation, transferring, mobility, and toileting. R146's provider order dated 12/1/25, indicated, Ensure catheter cover or pant leg is in place to cover urine bag, urinary collection bag should not be visible. During observation on 12/8/25, at 2:43 p.m., R146 was in bed sleeping with urine catheter bag half full containing amber colored urine was hanging on the same side of the bed as the door, exposed for anyone who entered to see. During interview on 12/8/25 at 4:58 p.m., R146 stated did not want everyone seeing her urine. R146 further stated the staff that bring my meals in, therapy and others come in here and it is exposed. R146 stated they did not even cover the bag when she left the room with therapy and just hung it on her walker. During observation on 12/9/25 at 11:42 a.m., R146 was sitting up in the wheelchair with catheter bag exposed. During observation on 12/10/25 at 11:59 a.m., R146 was in bed sleeping with catheter bag exposed hanging on same side of bed as the door. During observation on 12/10/25 at 12:42 p.m., catheter bag still exposed, unidentified therapist into R146's room. During interview on 12/10/25 at 12:45 p.m. nursing assistant (NA)-A stated when residents were up during the day they often had a leg bag placed which would be covered by their pants, otherwise they provide little bags to place the catheter bag in so it would not be exposed and protect the resident's dignity. During interview and observation on 12/10/25 at 12:49 p.m. licensed practical nurse (LPN)-A stated all catheters should be covered, even when the resident was in their room since therapy, social services, activities, visitors and other staff would visit and could see the exposed urine bag. LPN-A stated the urine bags should be covered to maintain a resident's dignity. LPN-A confirmed R146's catheter was hanging on the side of the bed, exposed for anyone to see who entered her room. During interview on 12/10/25 at 2:00 p.m., registered nurse (RN)-A stated the facility did have covers for the catheter bags and should be provided to all residents. RN-A stated the urine bag should be covered for dignity. RN-A further stated the urine bag should be covered even if the resident remains in the room since they could have various visitors who enter the room. During interview on 12/11/25 at 9:32 a.m., director of nursing (DON) would expect urine bags to be covered for dignity. Facility policy Resident Rights and Notification of Resident Rights dated 8/28/25, indicated, The facility acts to protect and ensure the rights of residents.

Based on interview and document review, the facility failed to ensure a care conference was provided for 1 of 1 resident (R130) reviewed for care conferences.Findings include:R130's quarterly Minimum Data Set (MDS) dated [DATE], indicated R130 admitted into the facility on 7/30/25, and did not hallucinate or have delusions.R130's social service progress note dated 8/1/25 at 1:32 p.m., indicated R130 was cognitively intact. R130's social service progress note dated 8/6/25 at 2:23 p.m., indicated R130 would like assisted living placement but was still MA pending. A care conference was scheduled for August 8th, to discuss discharge planning and recommendations. R130's social service progress note dated 8/8/25 at 3:30 p.m. and recorded as a late entry on 8/11/25 at 9:42 a.m., indicated R130 had a care conference 8/8/25. R130's nursing progress note dated 8/18/25 at 11:02 a.m., indicated R130 was alert and oriented and had new orders to discharge to long-term care. R130's social service progress note dated 8/18/25 at 1:54 p.m., indicated social services spoke with R130 regarding a discharge plan and R130 planned to discharge to the facilities long-term care until her medical assistance was approved and then would like to transfer to an assisted living facility. R130's social service progress note dated 8/18/25 at 3:30 p.m., indicated a care conference would be held at 1:30 p.m., however a date was not specified.R130's Care Conference form saved on 12/11/25, indicated R130's last care conference was dated 8/8/25, and R130's next care conference date would be 11/9/25. The form lacked information R130 had a care conference after 8/8/25.R130's medical record lacked information R130 had a care conference after 8/8/25. During interview on 12/9/25 at 8:08 a.m., R130 stated she hasn't had a care conference and moved over to the long-term care unit in August. During interview on 12/11/25 at 11:54 a.m., social worker (SW)-A stated she sets a care conference schedule for the following week after the MDS is due. SW-A stated care conferences were documented when they are held and viewed R130's medical record and verified there was one care conference documented on 8/8/25, and there was no additional care conferences documented. SW-A viewed R130's MDS and verified R130 had a quarterly MDS dated [DATE], and stated one week after the MDS is completed, a notice was sent for a care conference, however there were no care conferences documented following the MDS dated [DATE]. SW-A further stated R130 was a reliable historian. SW-A stated the purpose of the care conference was to be able to review a resident's status with them and their family and provide opportunities to ask questions. During interview on 12/11/25 at 12:55 p.m., the director of nursing (DON) the care conference was based on the assessment schedule and the SW coordinates a care conference with the resident and family after the MDS is completed. The DON further stated R130 had a quarterly MDS 9/26/25 and should have had a care conference in October. The DON sent an email on 12/11/25 at 1:59 p.m., that indicated they did not have a policy specific to care conference scheduling but follow the RAI (resident assessment instrument) process for timing and coordination. The DON sent an email on 12/12/25 at 3:32 p.m., that indicated they had no additional information and believed the 10/1/25, MDS changes adjusted their dates in their system and caused care conference dates to be adjusted as well.

REVIEWED LNBased on interview and document review the facility failed to ensure an as needed (PRN) antipsychotic medication (medications to treat psychosis related conditions) was prescribed for only 14 days and failed to ensure staff documented use of nonpharmacological interventions used prior to administration of PRN antipsychotic medication 1 of 2 residents (R117) who received PRN antipsychotic medications. Findings include:R117's admission Minimum Data Set (MDS) dated [DATE], indicated R117 had severe cognitive impairment and diagnoses of dementia with severe anxiety. R117 received antipsychotic medications. R117's nursing and provider orders showed the following:-an order dated 11/24/25, indicated R117 required quetiapine (antipsychotic medication) 50 milligrams(mg) every 6 hours as needed for psychosis, dementia with anxiety. This order lacked an end date. -an order dated 10/23/25, indicated R117 required monitoring for target behaviors related to antipsychotic use that included change in sleep pattern, agitation, delusions and hallucinations. The order further directed staff to document behaviors and non-drug interventions provided when behaviors were observed. R117's medication administration record (MAR) dated 11/2025, indicated R117 received PRN quetiapine on 11/25/25 and 11/27/25 for behavior issues.R117's MAR dated 12/2025, indicated R117 received PRN quetiapine on 12/4/25, 12/5/25, and 12/7/25 for behavior issues. R117's care plan dated 10/29/25, indicated R117 used antipsychotic medications for dementia and severe anxiety. Interventions included monitoring of target behaviors as indicated on the electronic MAR and document each shift. R117's medical record lacked indication non-pharmacological interventions were provided before administration of PRN antipsychotic medication.When interviewed on 12/10/25 at 1:13 p.m., registered nurse (RN)-B stated R117 had anxiety and sometimes panic attacks mostly at nighttime. If anxiety was noted, staff tried to calm her or give her a snack, or something to redirect her. When R117 had behaviors, a progress note should be documented to communicate the behavior and what was done. RN-B verified R117 had a PRN antipsychotic medication order with no end date and had received it several times. RN-B stated a progress note should be written when the PRN medication was given to provide more details. When interviewed on 12/10/25 at 1:29 p.m., RN-C stated when administering a PRN antipsychotic medication, the reason it was given, and any nonpharmacological interventions should be documented. RN-C further stated PRN antipsychotic medication orders needed to be limited to 14 days and then re-evaluated by the provider. RN-C verified R117's quetiapine had no end date and there was no documentation of non-pharmacological interventions tried before giving the quetiapine. When interviewed on 12/11/25 at 10:06 a.m., the Director of Nursing (DON) expected orders for as needed antipsychotic medications to be limited to 14 days. DON further expected documentation to the reason why the PRN medication was used and what interventions were tried prior to administration. When interviewed on 12/11/25 at 1:46 p.m., the clinical pharmacist (CP) expected any PRN antipsychotic medication to be limited to 14 days and document the behaviors and other interventions attempted. A facility policy titled Psychotropic Medication Use revised 9/7/23, directed PRN orders for antipsychotic drugs are limited to 14 days. Furthermore, the policy directed documentation to reflect monitoring of target behavior monitoring and nonpharmacological interventions provided.

R677Based on observation, interview, and document review, the facility failed to ensure routine personal hygiene for nail care was provided for 1 of 1 resident (R6) reviewed for activities of daily living (ADLs) and were dependent on staff for their care. Findings include:R6's quarterly Minimum Data Set (MDS), dated [DATE], identified R6 had diagnosis for Hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side. R6 had moderate cognitive impairment, additionally R6 required partial/moderate assistance with personal hygiene cares.R6's care plan revised dated 10/22/25, identified R6 had and ADL self-care deficit with grooming, required assistance of one by staff.R6's weekly skin checks documentation on 12/8/25 at 2:32 p.m., identified R6 had a shower and nail care was not necessary.During observation and interview on 12/8/25 at 5:42 p.m., R6 stated he asked staff multiple times to cut nails, the staff replied that a nurse or doctor had to cut them. Nails were long and sharp family member (FM)-B had attempted to cut nails, however, fingers on left hand were curled and she was nervous, didn't want to cut the skin.During interview on 12/9/25 at 1:40 p.m., R6 stated nails still had not been cut, they were sharp, long, and did not like it.During observation and interview on 12/10/25 at 9:16 a.m., R6's fingernails on both hands were approximately 1/4 inches long, and jagged with sharp edges. R6's left fingers were curled into palm of hand, extended fingers to observe nails. R6 stated attempted to cut own fingernails, stated asked staff again, they replied a doctor needed to cut fingernails. Fingernail clippers observed on the floor under the television in R6's room.During interview on 12/10/25 at 9:40 a.m., certified nursing assistant (CNA)- B stated finger nails were cut on bath day, sometimes they would be cut on the weekends. There was not a risk to performing cutting R6's fingernails.During interview on 12/10/25 at 11:20 a.m., registered nurse (RN)-C stated with R6 it was not necessary to have a doctor cut nails. Residents should not be clipping own fingernails. She reported she was not aware nail care was not performed, according to the weekly skin assessment documentation, nails were not necessary.During observation on 12/10/25 at 12:06 p.m., RN- C confirmed fingernail clippers were on R6's floor located under television and promptly removed them.During interview on 12/11/25 at 2:40 p.m., Director of Nursing (DON) nails to be checked and completed if needed weekly on bath/shower day. The documentation was under Weekly Skin Check. Nail care was important to reduce injury, for dignity and infection control.A policy titled, Activities of Daily Living (ADL) dated 6/2021, stated residents unable to carry out ADLs independently will receive the services necessary to maintain good nutrition, grooming, personal hygiene, elimination, communication and mobility.

Based on interview and document review, the facility failed to ensure a resident attended a scheduled urology appointment for 1 of 1 residents (R146) reviewed for appointments.Findings include:R146's admission Minimum Data Set (MDS) dated [DATE], indicated intact cognition, required partial/moderate assistance with mobility and toileting, and had an indwelling catheter. R146's diagnoses included acute kidney failure, unspecified open wound to right hip and abdominal wall, cellulitis. R146's Urinary Incontinence and Indwelling Catheter Care Area Assessment (CAA) dated 12/2/25, indicated R146 required foley catheter care and was at risk for complications and urinary tract infection (UTI). R146's care plan dated 12/10/25, indicated R146 had an activities of daily living (ADL) self-care deficit and required assistance with ambulation, transferring, mobility, and toileting. R146's hospital discharge orders dated 11/26/25, indicated, You have an appointment at MN Urology for your follow up on December 2nd at 10:40 am.Your foley catheter should remain in place until you are seen at this appointment. R146's provider order dated 12/4/25, indicated, Patient to reach out [sic] urologist to see if the Foley [catheter] can be removed [Can be removed from Wound Perspective]. During interview on 12/8/25 at 4:58 p.m., R146 stated was not sure how long she was going to need the catheter and that it had been in for over a month. R146 was concerned that she was at risk for another UTI since it had been in for so long and did not want to have to go home with it. During interview on 12/10/25 at 9:04 a.m., R146 stated did not remember seeing a urologist since admission to facility and was not aware of any upcoming appointments to see a urologist. During interview on 12/10/25 at 1:06 p.m., nurse practitioner (NP)-A stated not sure about any urology appointment and that the facility had a scheduler who took care of those things. NP-A further stated triage was notified over the past weekend of R146 experiencing UTI symptoms and that an order was provided for staff to collect a urine sample for lab. P-A further stated the catheter should have been pulled and replaced at that time as well but could not say for sure if that had happened. NP-A stated R146 had been experiencing a lot of drainage and other complications with her wounds and wound vac and not sure it would be appropriate to remove the urine catheter at this point, but would defer to the specialists. During interview on 12/10/25 at 1:08 p.m., health information tech (HIT)-A stated she reviewed orders upon admission and would discuss any referrals for appointments with residents. HIT-A stated she sometimes she would actually schedule the appointment and sometimes the resident would set it up, if it had not already been scheduled prior to admission. HIT-A further stated she would work with family members to see if they would provide transportation or if the resident needed other arrangements which then she would complete. HIT-A further stated she would put a packet together for the resident to take along to the appointment and would receive the packet back upon their return and would scan all documents into the electronic health record (EHR). HIT-A stated if there was nothing scanned into the EHR about R146's urology appointment, then she did not go to it. HIT-A could not explain why R146 missed the urology appointment and could not remember making any arrangements for it. During interview on 12/10/25 at 1:31 p.m., patient services representative (PSR)-A stated R146 was scheduled for MN Urology appointment on 12/2/25 at 10:45 a.m., but could see from the schedule that R146 was a no show. During interview on 12/10/25 at 1:50 p.m., family member (FM)-A stated not being aware of R146 attending any urology appointment and was not contacted for any transportation arrangements. FM-A further stated no aware of any future scheduled appointments. During interview on 12/10/25 at 2:00 p.m., registered nurse (RN)-A stated HIT-A was responsible for managing resident appointments and arranging for transportation to those appointments. RN-A stated could not explain why R146's appointment was missed and there should have been some follow up. During interview on 12/11/25 at 9:32 a.m., director of nursing (DON) stated expectation for residents to attend scheduled appointments with assistance from staff on transportation arrangements. DON stated if a resident chose to cancel an appointment, there should be something documented in the EHR regarding that decision. A facility policy on appointment management was requested but not provided.

Based on observation, interview, and document review the facility failed to ensure a mechanical lift was sanitized between use and furthermore, the facility failed to ensure personal protective equipment (PPE) was donned prior to a transfer for 1 of 1 resident (R5) reviewed for enhanced barrier precautions (EBP).Findings include:R41:R41's admission Minimum Data Set (MDS) dated [DATE], indicated moderate cognitive impairment, had a wheelchair, and was dependent on staff for transferring from R41's chair to the bed and the bed to the chair.R41's care plan dated 11/24/25, indicated R41 had a self-care deficit due to progressive weakness and declining condition and required two staff assistance with a Hoyer lift (a full body mechanical lift) for transfers. R5:R5's quarterly MDS dated [DATE], indicated R5 refused a chair to bed and bed to chair transfer, required substantial assistance with rolling in bed, was at risk of developing pressure ulcers and had two unstageable pressure injuries.R5's Active Orders form undated and saved on 12/10/25 at 10:19 a.m., indicated the following orders:12/8/25, enhanced barrier precautions due to wounds to leg and spine. R5's care plan dated 12/8/25, indicated R5 required enhanced barrier precautions due to active wounds and R5's goal was not to develop signs or symptoms of an acute infection. Interventions indicated to assess resident for EBP need and implement precautions according to facility protocol, post clear signage on the door or wall outside the resident room indicating the type of precautions and required PPE, staff to apply gloves and gowns prior to high-contact care activities, discard PPE in designated location following activities, and sanitize hands after PPE removal. R5's care plan dated 10/29/25, indicated R5 had a self-care deficit and required two assist of staff with a Hoyer lift for transfers. During observation on 12/8/25 at 1:00 p.m., R41 and R5's room had signage on the door that indicated EBP was required.During observation on 12/10/2025 between 9:38 a.m., and 9:57 a.m., nursing assistant (NA)-C entered R41 and R5's room and at 9:43 a.m., NA-D went into the room and left the room at 9:47 and grabbed the mechanical lift that was in the hall. NA-C and NA-D had the lift sling under R41and transferred R41 from her bed into her chair. At 9:51 a.m., NA-C moved the mechanical lift to R5's side of the room. The lift contained a pocket for Super Sani-Cloths (a germicidal disposable wipe used for cleaning and disinfecting surfaces), however neither NA-C nor NA-D wiped down the mechanical lift after use with R41. NA-C and NA-D did not don a gown or gloves. At 9:54 a.m., NA-C and NA-D lifted R5 from her bed with the same mechanical lift to her chair. R5 had a dressing to the right lateral side of her leg. NA-C and NA-D assisted in transferring R5 into her chair. The lift had not been wiped down between R41 and R5's transfer. NA-C verified R5 had two dressings to R5's right leg. At 9:57 a.m., NA-C brought the mechanical lift out of R41 and R5's room and into the hall and re-entered the room without wiping down the mechanical lift. During interview on 12/10/25 at 9:59 a.m., NA-C stated R5 had sores on her legs and thought staff donned a gown when changing R5's dressing. NA-C further stated EBP included residents with wounds and staff had to don gowns and gloves and verified NA-C and NA-D did not wear a gown or gloves when assisting R5 with a transfer and did not clean the mechanical lift between use. NA-C stated they had been instructed to clean the lift after every resident use. During interview and observation on 12/10/25 at 10:03 a.m., NA-D stated R5 was on EBP when staff tend to her wounds. NA-D further stated nurses had to wear gowns, but the NA's did not do anything with the wounds and therefore did not have to adhere to EBP. NA-D verified mechanical lifts should be wiped down between resident use and did not wipe the mechanical lift down. Signage on R41 and R5's door indicated everyone must clean hands before entering and leaving the room and providers must wear gloves and gown in the following high contact resident activities, dressing, bathing, transferring, changing linens, providing hygiene, changing briefs, or assisting with toileting and device care and wound care. During interview on 12/10/25 at 10:28 a.m., registered nurse (RN)-B stated staff should don gloves and gowns during transfers if a resident had a wound. Further, RN-B verified the mechanical lift contained Super Sani-Cloths and expected staff wipe down the mechanical lift between use and stated R5 required EBP because she had wounds and further stated it was important to wipe the lift and follow EBP because they didn't want to spread bacteria to someone. During interview on 12/10/25 at 10:33 a.m., registered nurse (RN)-C stated she planned to ask the director of nursing (DON) about EBP and thought staff should don PPE with transfers but was not sure and expected staff use the Super Sani-Cloths between resident use. During interview on 12/11/25 at 11:16 a.m., the infection preventionist (IP) stated she expected staff don a gown and gloves whenever they are providing cares that are included on the door and expected staff clean lifts between residents and further stated this was stressed during new orientation of staff in order to prevent the spread of infections. During interview on 12/11/25 at 12:55 p.m., the director of nursing (DON) stated she expected staff follow precautions per the EBP signage on the door and further stated she expected mechanical lifts be sanitized between residents. A policy, Standard Precautions for Infection Control, dated 2014 and 2015, indicated staff would use care in handling client care equipment in order to prevent skin and mucus membrane exposure, contamination of clothing, and transfer of microorganisms to other patients or environments. Ensure that reusable equipment and environmental surfaces are appropriately cleaned and reprocessed prior to use on another client. A policy, Enhanced Barrier Precautions, dated 2019, indicated EBP was a strategy in nursing homes to decrease the transmission of CDC targeted and other epidemiologically important multidrug-resistant organisms (MDROs). Residents at risk for MDROs, specifically those with an indwelling medical device and or chronic wounds requiring a dressing will be required to use EBP. EBP refers to the use of gowns and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing. Furthermore, the policy outlined high-contact resident care activities to include dressing, bathing, transferring, hygiene, changing briefs, chronic wound care and with indwelling medical device care or use.

Based on observation, interview, and document review, the facility failed to ensure proper self-administration of insulin for 1 or 1 resident (R87) reviewed for self-administration of medications (SAM). Findings include: R87's quarterly minimum data set (MDS) dated [DATE], indicated R87 was cognitively intact, rejection of care behavior not exhibited, required staff supervision, and set up for bathing and eating, and was independent with all other activities of daily living (ADLs) and mobility. The MDS indicated R87 had impaired vision, and received insulin and opioids. R87's diagnoses included type 2 diabetes, age-related cataract, need for assistance with personal care, depression and anxiety. R87's care plan last revised 11/20/24, indicated R87 was non-compliant with medications, treatments, lab work and typically rejected care on a daily basis. The care plan further indicated, Resident has been assessed by interdisciplinary care plan team to be capable of self-administration. The care plan indicated R87 received high risk medications identified as insulin and opioids and instructed administration of medications per doctor's order. R87's November 2024 medication administration record (MAR) indicated R87's medication orders included the following: -Calcium acetate 667 mg, two tabs three times a day with meals. -Insulin glargine-yfgn insulin pen; 100 unit/ml (3ml)-administer 9 units at Bedtime; subcutaneous (SQ), ok to keep in room and self-administer. -insulin lispro solution; 100 unit/ml; administer per sliding scale (SS) based on blood sugar (BS), SQ, three times a day with meals (ok to keep in room and self-administer): If BS is 70-149, give 0 units If BS is 150-199, give 2 units If BS is 200-249, give 4 units If BS is 250-299, give 6 units If BS is 300-349, give 8 units If BS is 350-399, give 10 units If BS is 400-450, give 12 units If BS greater than 450, call doctor. -Dexcom G7 Sensor (blood-glucose sensor) device, change every 10 days. -Okay to keep in room and self-administer insulins. Has Dexcom for blood sugar checks. R87's Self-Administration of Medication observation assessment dated [DATE], indicated R87 wanted to self-administer insulin glargine 9 units at bedtime and insulin lispro SS three times a day. The SAM assessment further indicated R87 had a history of non-compliance with medications or other treatments and wore a Dexcom monitor. The SAM indicated R87 was provided teaching and was determined safe for insulin administration and in-room storage. During observation and interview on 11/18/24 at 6:10 p.m., R87 had insulin pens, alcohol wipes and a sharps container in her room. R87 stated she stored and administered her own insulin. R87 also had a medicine cup which contained 2 big blue and white pills sitting on her table in front of her and stated she did not know what they were, but she was supposed to take them, but they were hard to swallow. R87 further stated she had visual impairment, could not read small print, and required cataract surgery. R87 stated she monitored her own blood sugar using an app on her phone connected to the Dexcom monitor she wore on her arm. During interview on 11/20/24 at 8:19 a.m., registered nurse (RN)-B stated R87 was supposed to monitor her own BS and administer her own insulin. RN-B stated all other medications were supplied by the nurse but R87 often refused medications when offered by nurses. During observation and interview on 11/20/24 at 8:47 a.m., R87 checked her phone app and showed it indicated her BS was 206. R87 stated per the SS, she needed to administer 4 units of the short acting insulin. R87 picked up the lispro pen, attached a needle, turned the dosage four clicks, used the flashlight on her phone to look at the dial to confirm it was set to 4 units, used an alcohol wipe to prepare her abdomen and administered the insulin. R87 did not prime the insulin pen. R87 stated she was provided education on and then observed self-administration of insulin and that she never primed her pens. R87 stated not thinking priming was necessary with this pen since the nurses don't do it. During interview on 11/21/24 at 8:20 a.m., RN-C stated R87 often declined medications, but she was assessed for safe insulin self-administration. RN-C stated R87 would have been educated and performed a return demonstration when assessed for SAM. RN-C stated expectation that R87 was assessed appropriately and that she would be priming the insulin pen prior to administration. RN-C stated R87 would not be receiving the correct amount of insulin if the pen was not primed. During interview on 11/21/24 at 9:40 a.m., director of nursing (DON) stated residents were educated and assessed with return demonstration for determination of safe SAM. DON stated expectation R87 would be priming the insulin pen prior to admission to ensure she received the proper dosage. Facility policy Self-Administration of Medications dated 8/31/23, indicated residents had the right to SAM if determined to be clinically appropriate and safe to do so. The policy further indicated the resident should have the ability to correctly identify their medications and the indications for their use. Residents would be assessed for ability to swallow without difficulty and any changes in ability to SAM safely would prompt further review. Facility policy on priming insulin pens was requested but not received. Per standard nursing practice and manufactures instructions, insulin pens/needles should be primed with 2 units prior to each injection.

Based on observation, interview, and record review the facility failed to ensure proper nail care for 1 of 1 resident (R95) reviewed for activities of daily living. Findings include: R95's quarterly Minimum Data Set (MDS) dated [DATE], indicated moderately impaired cognition, diagnoses of dementia, need for assistance with personal care, and there were no rejection of care behaviors noted. It further indicated R95 required assistance with personal hygiene. R95's care plan dated 1/25/2024, indicated R95 needed assistance with dressing, personal hygiene, and bathing due to lumbar stenosis. It further indicated an intervention to assist in handing him a soapy wash cloth and cue to wash face, hands, arms, and torso as able during weekly bath. Staff should also wash resident's hair, back, peri area, and legs during weekly bath and trim his nails as needed. R95's progress notes (11/1/24-11/19/24), lacked documentation R95's fingernails had been cut or that he had refused to have them cut. During observation on 11/18/24 at 5:51 p.m., R95 was sitting in his room in his wheelchair watching television (TV). The fingernails on his left hand were approximately 1 inch long and the thumb, middle finger and pinky on his right hand were also approximately 1 inch long. R95 stated he doesn't like his nails long and wanted them cut. During observation on 11/19 24 at 1:00 p.m., R95 was sitting in his room in his wheelchair, watching TV. The fingernails on his left hand were approximately 1 inch long and the thumb, middle finger and pinky on his right hand were also approximately 1 inch long. During interview on 11/19/24 at 2:19 p.m. nursing assistant (NA)-B stated NA's were responsible for cutting the residents nails unless the resident was diabetic. If the resident was diabetic or their nails were too thick, then the nurses were responsible for cutting them. It was completed once a week, usually on bath day. During interview on 11/19/24 at 3:06 p.m. NA-C stated nurses were responsible for cutting residents nails, they do skin assessments on the residents bath day and it's their responsibility to look at their skin and nails. During interview on 11/19/24 at 3:15 p.m. registered nurse (RN)-A stated the nurses were responsible for cutting the residents nails if they are diabetic. NA's can cut the residents nails who are not diabetic but there's more responsibility on the nurse to make sure it get's done. The residents nails are clipped once a week typically on their shower day and it should be documented in a progress note. There was no specific spot to document it unless someone added it on the weekly skin assessment. Refusals should be documented. RN-A also verified R95's nails were long and more then a few weeks growth and stated his nails should've been cut. During interview on 11/21/24 at 10:22 a.m., the director of nursing (DON) stated the NA's were responsible for cutting the residents nails who were not diabetic and the nurse were responsible for cutting the residents nails who were diabetic. She further stated it should be done weekly along with skin checks and usually done on the residents bath day. She would expect it to be documented in the progress notes, including refusals which would prompt it to be care planned. The facility's policy on activities of daily living (ADL) dated June of 2021, indicated residents unable to carry out ADLs independently will receive the services necessary to maintain good nutrition, grooming, personal hygiene, elimination, communication and mobility.

Based on interview and document review, the facility failed to ensure a gradual dose reduction (GDR) was attempted for 1 of 1 resident (R52) reviewed for the use of psychotropic medications. Findings include: R52 ' s Minimum Data Set (MDS) dated [DATE], indicated they had no cognitive impairment and did not reject cares. R52 reported no signs or symptoms of feeling down, depressed, or hopeless. R52 scored a zero on scale for depression or anxiety. R52 stated did not hallucinate or had delusions. R52 ' s physician orders included the following medications for anxiety: -starting on 7/21/23, Bupropion HCL 100 milligrams (mg) tablet daily by mouth -starting on 7/21/23 Duloxetine Hydrochloride 30 mg coated pellets capsules daily by mouth R52 ' s medical record lacked indication R52 had a GDR attempted for bupropion or Duloxetine since R52 ' s admission to the facility in July 2023. During an interview on 11/21/24 at 12:42 p.m., the consultant pharmacist (CP) stated due to an informational technology (IT) glitch, the monthly reviews were incorrectly sent. The facility had not received the recommendations for the months of July-November of 2024. The CP verified R52 ' s pharmacy reviews for the months August 2024 -October 2024 requested a GDR to be completed for R52 ' s prescribed bupropion and duloxetine. During an interview on 11/21/24 at 2:20 p.m., the director of nursing (DON) stated the CP sent any recommendations to the facility to review and send to the providers. DON stated if residents had no recommendations, they were on a list that was also sent. DON verified R52 was not on the list of residents who had no recommendations for August 2024- October 2024. DON stated the monthly reviews requesting R52 ' s GDR had not been received until they were requested by surveyor on 11/21/24 in the afternoon. DON further stated the facility did not keep track of monthly reviews or resident GDRs were sent to the CP monthly directly from the EMR and then it was up to the CP to send the information back. During a follow up interview on 11/22/24 at 9:24 a.m., the consulting pharmacist (CP) stated R52 ' s GDR had not been attempted. It was CP stated within the first year of admission, the process for the GDR had protocols and parameters, and to be attempted twice within one year of admission, attempt a GDR in two separate quarters, one month apart. To ensure the time frame, the CP entered in the current updated documentation electronically, then went to quality assurance performance improvement (QAPI) and confirmed the orders and recommendations. The facility policy Psychotropic Medication Use dated 8/24/2017, directed the facility to begin a GDR within the first year in which a resident is admitted with or is newly prescribed a scheduled psychotropic medication. GDR is attempted in two separate quarters (with at least one month between the attempts), unless clinically contraindicated and documented by the medical provider. 42584 Based on interview and document review, the facility failed to ensure a discussion of risks, benefits and potential side effects occurred and understood by the resident or resident representative for 1 of 1 residents (105) reviewed for unnecessary medications who received Depakote for indication outside the drug classification. Findings include: R105 admission minimum data set (MDS) dated [DATE], indicated R105 had severe cognitive impairment, exhibited physical and verbal behaviors towards others, and received antipsychotic and antidepressant medications. R105's diagnoses included restlessness and agitation, dementia with behavioral disturbance, and Alzheimer's disease. R105's care plan revised 11/18/24, indicated R105 used high risk medications including antipsychotics, hypnotics, and antidepressants for the diagnosis of dementia with behaviors. The care plan further indicated R105 was at risk for falls. The care plan instructed pharmacist medication review for fall risk and medication adjustments and psychiatry visits and medication reviews. The care plan further instructed to monitor for target behaviors and side effects of psychotropic medications as ordered. R105's November 2024 medication administration record (MAR) indicated provider orders including: -Depakote tablet, delayed release; 125 mg; 1 tab; twice a day for restlessness and agitation -Depakote tablet, delayed release; 250 mg; 1 tab; at bedtime for restlessness and agitation R105's admission assessment dated [DATE], indicated R105 had behavioral symptoms and had a history of falls. R105's associated clinic of psychology (ACP) visit note dated 10/30/24, identified Depakote as one of R105's current psychotropic medications. R105's electronic health record (EHR) lacked evidence of a Consent for Use of Psychotropic Medication for Depakote. During interview on 11/21/24 at 10:20 a.m., registered nurse (RN)-C stated a consent for psychotropic medication use should be completed upon admission if the resident was admitted on a psychotropic medication, with any changes in dosages or when started on a new psychotropic. RN-C stated the consent was used to inform residents or family members of the risks, benefits and possible side effects of the medication. RN-C confirmed R105 did not have a consent completed for the Depakote. On 11/21/24 at 10:46 a.m., attempted to contact ACP-NP via phone call with no answer. Voicemail left and email sent. Per email response on 11/22/24 at 5:13 a.m., ACP nurse practitioner (ACP-NP) stated R105 was receiving Depakote (an antiepileptic/or antimanic) for agitation and aggression, but was not an antipsychotic. In any event it is considered a psychotropic medication. ACP-NP further stated expectation for facility to follow policies and procedures regarding the use of psychotropic medications. During interview on 11/21/24 at 2:07 p.m., director of nursing (DON) stated was not aware that Depakote was considered a psychotropic, but if being used out of class would expect a consent for use to be completed. R105's family should be informed of the risks, benefits and potential side effects of the medication and allowed to make an informed decision on its use. Facility policy Psychotropic Medication Use dated 9/7/23, indicated target behaviors and side effects must be identified and monitored when psychotropic medications were ordered and informed consent for the use must be obtained.

Based on observation, interview, and document review the facility failed to ensure insulin was administered in accordance with professional standards of practice for 2 of 3 residents (R100, R51) observed for medication administration. This constituted three (3) errors out of 33 opportunities for a medication error rate of 9.09 % (percent). Findings include: R100's quarterly Minimum Data Set (MDS) dated [DATE], identified she could usually understand others and could be understood. Required partial/moderate assistance with hygiene and diagnoses included diabetes mellitus. R100 received insulin injections seven out of seven days in the lookback period. R100's care plan dated 9/6/24, identified an alteration in nutrition due to type two diabetes mellitus and elevated glucose levels. Interventions included to monitor blood glucose. R100's physician orders included: - 9/19/24, check blood glucose four times a day. - 10/2/24, Lantus (long acting) insulin 24 units subcutaneous (SQ) every morning, hold if blood glucose less than 110. R100's Annual Comprehensive Nursing Home visit dated 10/16/24, identified blood glucose fluctuated between 94 to 371, check blood sugar results four times per day (QID) and continue current insulin orders. During an observation and interview on 11/19/24 at 8:50 a.m., licensed practical nurse (LPN)-B took R100's insulin pen out of the medication cart, attached the needle and dialed up the prescribed dosage of 24 units. LPN-B had not primed the needle and when asked stated she only needed to dial up the prescribed 24 units. LPN-B then administered the insulin without priming the needle, which could potentially have been a subtherapuetic dosage. R51's quarterly MDS dated [DATE], identified intact cognition and was independent with personal hygiene. Diagnoses included type 2 diabetes mellitus with diabetic nephropathy (uncontrolled kidney complications). R51 received insulin injections seven out of seven days in the lookback period. R51's care plan dated 9/10/24, identified an alteration in endocrine function secondary to diagnoses of diabetes mellitus. Interventions included to administer insulin as ordered. R51's physician orders dated 11/15/24, included: - Check blood glucose four times a day via Dexcom (continuous blood sugar monitor). - Lantus insulin 37 units SQ every morning. - Novolog (rapid acting) insulin 12 units SQ three times daily before meals. R51's Annual Comprehensive Nursing Home visit dated 10/16/24, identified blood glucose was elevated in the late afternoons and Lantus was increased to 37 units. During an observation and interview on 11/20/24, at 8:04 a.m., LPN-A took R51's Lantus insulin pen out of the medication cart, attached the needle and dialed up the pescribed 37 units. LPN-A had not primed the needle and insulin was not observed to come out of the tip of the needle. Next LPN-A took the Novolog insulin pen out of the medication cart, attached the needle and dialed up the prescribed 12 units. When asked if the needles needed to be primed, LPN-A stated only needed to dial up the prescribed units. LPN-A stated he did not think the pen needles needed to be primed before each use. LPN-A then administered the insulins without priming the needle, which could potentially have been subtherapuetic dosages. During an interview on 11/20/24 at 8:19 a.m., LPN-C stated with each administration, insulin pen needles needed to be primed first, then dial up the prescribed dosage. During an interview on 11/20/24 at 2:28 p.m., the director of nursing (DON) stated all insulin pens were expected to be primed with insulin prior to the prescribed dosage to ensure the needles worked and the correct dosage was delivered. During an email communication on 11/21/24 at 2:19 p.m., the DON identified the facility lacked a specific insulin pen policy or procedure and would follow manufacturer's instructions. Lantus insulin pen manufacturer's instructions dated 2022, identified step 3 was to perform a safety test: - Dial a test dose of 2 units. - Hold pen with the needle pointing up and lightly tap the insulin reservoir so the air bubbles rise to the top of the needle. This will help get the most accurate dose. - Press the injection button all the way in and check to see that insulin comes out of the needle. The dial will automatically go back to zero as the test is performed. - If no insulin comes out, repeat the test 2 more times. If there is still no insulin coming out, use a new needle and do the safety test again. Novolog insulin pen manufacturer's instructions dated 6/2021, identified to always test the insulin flow: - Select 2 units and press the dose button until the dose counter shows 0. The insulin flow test is complete when you see insulin squirt and there is no longer a gap between the piston rod head and the piston.

Based on observation, interview and document review the facility failed to follow infection control standards of practice for incontinence cares and/or contact precautions for 2 of 2 residents (R40 and R364) reviewed for activities of daily living (ADLs) Findings include: R40's quarterly Minimum Data Set (MDS) dated [DATE], identified intact cognition, dependent on staff for toileting, and was always incontinent of bowel and bladder. Diagnoses included dementia. R40's care plan dated 9/12/24, lacked a history of bladder inflammation, and identified she had incontinence related to impaired mobility, left (L) hemiparesis (paralysis on one side) due to history of CVA (stroke). Interventions included to check resident every two hours and as needed for incontinence and provide assist of one to change brief and provide perineal hygiene. Additionally, keep the call light within reach. R40's admission to the facility orders dated 1/26/24, identified a prescription for Keflex (antibiotic) 500 milligrams twice daily for four days for bladder inflammation (common cause of bladder inflammation is bacteria, such as E. coli, that enters the urethra and multiplies in the bladder). During an interview on 11/18/24 at 12:13 p.m., R40 stated she thought she needed to be changed. She pushed her call light button to alert staff. During an observation on 11/18/24 at 12:36 p.m., nursing assistant (NA)-A entered the room, R40 said she went potty and needed to be changed. NA-A put gloves on, pulled the bed sheet down and unfastened R40's brief. NA-A wiped the front of R40's groin with a wipe, tucked the wipe between R40's legs and instructed R40 to turn on her side. Once R40 was in a side-lying position, NA-A used wipes to clean up a medium soft incontinent bowel movement. With the soiled gloves still on, NA-A grabbed a tube of skin barrier cream and applied the cream to R40's backside, picked up a new brief, tucked the new brief under R40's hips, assisted her to turn on to a back-lying position, cleaned the front of R40's groin with a wipe and applied skin barrier cream, still with the same soiled gloves on, removed the soiled brief, put it in the garbage, picked up R40's call light cord with the same soiled gloves to move it out of the way and assisted R40 to a side-lying position again to finish adjusting the brief. When asked if NA-A could get more gloves, she removed the soiled gloves and applied new ones without performing hand hygiene between glove usage. During a follow up interview on 11/18/24 at 12:50 p.m., when NA-A was asked about education on hand hygiene use and if gloves should be changed immediately after being soiled, she replied she would do that going forward. NA-A agreed she touched the barrier cream bottle, R40's front groin area and call light cord with gloves soiled with bowel movement. 51577 R364's admission Minimum Data Set (MDS) dated [DATE], identified intact cognition, assistance with toileting and dressing, set up for daily hygiene activities. Diagnoses included sepsis (acute system infection) urinary tract infection from extended spectrum beta lactamase (ESBL) resistance (multidrug resistant organism). R364's care plan dated 11/11/24, indicated R364 required contact precautions ESBL and directed staff to implement precautions according to facility protocol. R364's provider and nursing order dated 11/11/24, identified R364 required contact precautions. An observation on 11/18/24, a sign was posted outside R364's room. The sign stated, Contact Precautions and directed anyone who entered the room to perform hand hygiene, don a gown and gloves. A cart was outside of R364's room that contained isolation gowns and gloves. An observation on 11/19/24 at 1:58 p.m., a sign was posted outside R364's room. The sign stated, Contact Precautions and directed anyone who entered the room to perform hand hygiene, don a gown and gloves. A cart was outside of R364's room that contained isolation gowns and gloves. The physical therapist assistant (PTA) knocked on door, introduced self, performed hand hygiene, and foamed hands. PTA did not don a gown or gloves before entering R364's room. The PTA went to the R364 sitting in chair and placed a gait belt (a belt that goes around waist to assist with stability) resident took walker, placed it in front of him and stood. PTA and R364 walked down hallway to rehab area, for therapy. The PTA foamed hands before entering room, did not don gloves or gown before entering R364 room, the PTA assisted R364 to chair. During an interview on 11/19/24 at 2:25 p.m., the PTA verified they did not don a gown or gloves as the indicated. The PTA further stated with contact precautions, gown and gloves should be worn. The rationale for using contact precautions for R364 had EBSL. During interview on 11/21/24 at 12:05 p.m., with infection preventionist (IP) stated the expectation of hand hygiene with personal cares. Staff are expected to clean hands and change gloves between clean and dirty personal cares. The staff are to follow contact precautions per facility policy on wearing gown and gloves when entering resident's room. The facility's Hand Hygiene policy dated 6/2017, identified infection prevention began with basic hand hygiene; proper hand hygiene practices should be followed to reduce the spread of potentially deadly germs and reduce the risk of healthcare provide colonization caused by germs acquired from the residents. Hand hygiene should be performed with soap and water before and after assisting a resident with toileting. The policy lacked instructions for soiled gloves.

Based on observation, interview, and document review, the facility failed to perform comprehensive skin assessments and implement interventions to promote healing and reduce the risk for further pressure ulcer development for 1 of 1 resident (R100) reviewed for pressure ulcers. This resulted in harm for R100. Findings include: A stage one pressure injury is intact skin with a localized area of redness that is non-blanchable (does not turn white when pressed). A stage two pressure ulcer is partial thickness loss of the skin with exposed dermis, presenting as a shallow open ulcer. A stage three pressure ulcer is full thickness loss of the skin in which subcutaneous fat may be visible. Additionally, slough (non-viable yellow, tan, gray, green or brown tissue; usually moist, can be soft, stringy and mucinous in texture) or eschar (dead or devitalized tissue that is hard or soft in texture; usually black, brown, or tan in color, and may appear scab-like) may be visible but does not obscure the depth of the tissue loss. A stage four pressure ulcer is full thickness loss of the 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 on some parts of the wound bed. Undermining and or tunneling often occur. If slough or eschar obscures the wound bed, it is an unstageable pressure ulcer. An unstageable pressure ulcer is obscured full thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough or eschar. If slough or eschar is removed, a stage three or stage four pressure ulcer will be revealed. If the anatomical depth of the tissue damage involved can be determined, then reclassified stage should be assigned. A deep tissue pressure injury (DTPI) is intact skin with localized area of persistent non blanchable deep red, maroon, purple discoloration due to damage of underlying soft tissue. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. This injury results from intense and or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury, or may resolve without tissue loss. If necrotic tissue, subcutaneous tissue (deepest layer of skin), granulation tissue (new connective tissue), fascia (connective tissue), muscle or other underlying structures are visible, this indicates a full thickness pressure ulcer. Once a deep tissue injury opens to an ulcer, reclassify the ulcer into the appropriate stage. R100's admission Minimum Data Set (MDS) dated [DATE], indicated intact cognition, did not reject care, was dependent on staff for toileting, had lower extremity range of motion impairment on one side, required substantial assistance with bathing and showering, was independent with rolling left and right, had an indwelling catheter, was always incontinent of bowel, had a stage one or greater pressure ulcer, was at risk of developing pressure ulcers, had one stage one pressure ulcer, did not have other skin problems which included moisture associated skin damage (MASD), open lesions other than ulcers, rashes, cuts, surgical wounds, burns, and skin tears. Skin treatments indicated R100 had a pressure reducing bed, application of a nonsurgical dressing other than to feet. R100's Face Sheet indicated R100 admitted to the facility on [DATE], and had the following diagnoses: multiple sclerosis (a condition affecting the central nervous system that can cause muscle weakness, vision changes, numbness, and memory issues), adult failure to thrive, major depressive disorder, type 2 diabetes mellitus, and neuromuscular dysfunction of the bladder. R100's care area assessment (CAA) dated 1/12/24 indicated R100 had multiple sclerosis, weakness, failure to thrive and staff assisted R100 with activities of daily living, transfers, mobility, and toileting. The CAA was edited on 1/18/24, and indicated R100 was admitted with redness to her peri area, and had a dressing to her coccyx on admission and 1/10/24 nursing note indicated a stage 1 pressure ulcer to the left heel. R100's care plan dated 1/7/24, indicated a self care deficit and R100 required 1 to 2 assist with bed mobility, bathing, and transfers. R100's care plan dated 1/7/24, indicated R100 was at risk for alteration of skin due to her disease process and her goal indicated she would not develop any skin alterations. R100's interventions were: barrier cream applied to dry areas as needed. The care plan was later revised on 2/14/24, to include the following interventions: Braden skin risk evaluations completed on admission and every week for four weeks, then quarterly, annually, and with any significant change, nursing assistants to observe skin and report any abnormalities to the nurse, air mattress placed on the bed, heel protectors in place to protect heels while in bed, may choose to have the head of bed at the lowest elevation as possible to reduce the pressure on bottom, may refuse treatments and interventions, will allow therapy to see as appropriate to assist in wound healing, will be involved in the treatment process, will be monitored for properly fitting footwear and pressure reduction to heels. Will have a podiatrist as appropriate see me if issues, will be reminded to reposition every 2 hours, will have assistance in repositioning every two hours to offload the pressure areas, will maintain good skin hygiene and skin will be moisturized if I have dry skin as needed, my elimination of waste will be addressed in the toileting section of the care plan, my heels will be floated while in bed, my labs and weight will be monitored as ordered, my pain will be controlled as ordered, pressure redistributing mattress is in place on my bed and I have a cushion for my chair, proper notifications will be made if my wounds change, the staff will provide me with adequate nutrition and hydration. Nutritional supplements and vitamins as ordered, the staff will use a lift sheet to move me in bed as needed. R100's care plan dated 2/13/24, indicated R100 had a nutrition goal R100's skin would improve and or heal and approaches included honoring likes and dislikes, and supplements as ordered. R100's care sheet indicated R100 had an air mattress, report skin findings to the nurse, required assist of 1 for bed mobility, was to be turned and repositioned in bed as tolerated and had a buttocks wound. R100's physician orders indicated the following orders: 1/6/24: Wound care: change dressing every Monday, Wednesday, Friday, and as needed for drainage and saturation. Gently remove previous dressing. Hold skin down as you remove the dressing to prevent further skin tearing and or soak off with NS. Cleanse with wound cleanser; pat skin dry. Protect and treat apply sacral Mepilex silicone foam dressing. Pressure injury prevention: turn and reposition every 2 hours; right and left turns avoid the back. 1/8/24: nystatin powder; 100000 unit/gram; apply topically to groin twice daily 1/9/24: heel pressure relief/floating heels with pillows, boot air fluidized heel aldt std/Z flex heel boot or comparable off loading product. Chair interventions: pressure redistribution seat cushion in place. Keep HOB/Recliner less than 30 degrees, knee [NAME] elevated on bed unless contraindicated by medical condition. Assess skin under all tubes and devices every shift. 1/9/24: Shower day on Friday a.m., assess skin and document in nursing notes. If any skin concerns noted open an event and notify the physician and family per facility protocol. 1/10/24: Wound care left heel stage one: apply skin prep and allow to dry daily. 1/10/24: Braden score 15: assist with turn and repositioning every 2 hours. 1/11/24: Glucerna 8 ounces daily at bedtime 1/26/24: Activity: up in the wheelchair for not more than 2 hours twice a day 1/10/24: blue boots bilateral feet on at all times except cares. 1/26/24: sacral wound care use Medihoney and foam dressing every day. 1/30/24: Measure wound to buttocks weekly and document in the progress notes. R100's telephone order dated 1/26/24 from nurse practitioner (NP)-C indicated orders for an occupational therapy evaluation (OT) for a Roho cushion, change bed to an air mattress, up in the wheelchair not more than 2 hours, sacrum wound care use Medihoney foam dressing daily. R100's Hospital Admission History and Physical form dated 12/27/23, indicated under the heading, Assessment/Plan R100 had a decubitus ulcer that was present on admission. R100's Hospital documents dated 1/6/24 indicated R100's heels were floated off the end of pillows or with heel offloading boots, additionally R100 was out of bed for meals and turned and repositioned every two hours left to right avoiding the back on 1/5/24. Additionally, R100's groin was reddened from a yeast infection. Additionally a note on page (372 of 430) indicated a perineum bilateral pressure injury and surrounding skin was intact, and had a foam dressing, the wound base was open and had a red/pink base. Additionally, on page 373 of 430 had moisture associated dermatitis to skin folds on bilateral legs that were cleansed and a topical product was applied. The progress notes indicated R100 had a bilateral pressure injury to the perineum and bilateral leg moisture associated dermatitis. R100's After Visit Summary 12/27/23, to 1/6/24, indicated care instructions to change coccyx dressing every Monday, Wednesday, and Friday and as needed for drainage saturation. Gently remove previous dressing. Hold skin down as you remove the dressing to prevent further skin tearing and or soak off with normal saline. Cleanse with wound cleanser. Pat skin dry. Protect and treat apply sacral Mepilex silicone foam dressing. Pressure injury interventions included: turn and reposition every 2 hours right/left turns, avoid back, heel pressure relief floating heels with pillows, boot air fluidized heel adlt Std Z flex heel boot or comparable off-loading product, chair interventions; pressure redistribution seat cushion in place, keep head of bed and recliner less than 30 degrees, knee [NAME] elevated on bed unless contraindicated by medical condition, assess skin under all tubes and devices every shift. R100's certified wound ostomy continence nurse (CWOCN) note dated 12/28/23, (page 31 of 430) indicated R100's coccyx was reddened and non blanchable and had shallow ulcers to the right and left buttocks that measured 1 cm each. Further, the note indicated orders for pressure injury prevention, wound and skin care were on the chart, and a sacral Mepilex was ordered for R100. R100's medication administration record (MAR) dated 2/1/24 to 2/13/24 indicated R100 was to have 8 ounces of Glucerna (a nutritional supplement for people with diabetes) daily at bedtime starting on 1/11/24, however, R100 refused the Glucerna 12 times. Additionally, R100 refused the Glucerna 13 times according to the MAR dated 1/11/24 to 1/31/24. R100's dietician progress note dated 2/13/24, indicated R100 was on a consistent carbohydrate diet with intake of 76-100% for 9 of 13 meals monitored since 1/30/24 and R100 received a Glucerna supplement every day at bedtime to provide nutrition in addition to balanced diet including protein at three meals daily to promote healing of open areas and R100's weight, intake, and skin integrity was monitored. R100's breakfast, lunch intake percentages from 1/6/24, to 2/13/24, indicated the breakfast meal was documented 9 times; 6 times R100 ate 76-100%, once R100 ate 51-75%, and R100 ate 26-50% of breakfast twice. The lunch meal was documented 7 times; 6 times R100 ate 76-100%, and once ate 51 to 75%. R100's Skin Risk Observation with Braden Scale form dated 1/6/24, indicated R100 had the following risk factors for developing a pressure injury: an acute condition, chronic incontinence, diabetes, hypothyroidism, multiple sclerosis required assistance for rolling left and right, lying to sitting, sitting to lying, was always incontinent, had lesions and redness to the peri area, had an unhealed pressure injury that was a stage one or higher to the coccyx. The Braden scale score was 15 and indicated R100 was at risk for developing pressure ulcers. Skin and ulcer treatments included a pressure reducing device for the chair and a turning and repositioning program. Additionally, referral that may be appropriate indicated dietary, occupational therapy (OT), and physical therapy (PT). R100's Skin Risk Observation with Braden Scale form dated 2/9/24, indicated R100 had the following risk factors for developing a pressure injury: cardiovascular disease, decreased range of motion, diabetes, multiple sclerosis, catheter/oxygen/wound vac/ tubing, required partial to moderate assistance to roll left and right, dependent for lying to sitting, and sitting to lying, was always incontinent, had redness to the peri area, had limited mobility, unhealed pressure ulcers to the sacrum, and moisture associated skin damage (MASD). The Braden Scale score was 8, indicating R100 was at very high risk for developing a pressure ulcer. Skin and ulcer treatments included turning and repositioning, and pressure ulcer injury care and under the heading Indicate Care Plan Action Taken indicated to continue current care plan. Additionally, referrals that may be appropriate indicated OT and PT. R100's Admission Clinical Documentation note dated 1/6/24, indicated R100 required extensive assistance with bed mobility, was totally dependent on staff for toileting. R100's facility Admission Skin Condition/New Wound Assessment form dated January 7, no year, indicated a diagram with instructions to use the list below to identify (number/letter) on the diagram all skin or body concerns. Further, instructions indicated to document size, depth (in, cms), color and drainage. If an ulcer was present, indicate pressure or non-pressure. The list contained a handwritten circle around the numbers 1, 2, and 8. The number 1 listed Pressure next to number 1, the number 2 listed Reddened next to number 2, and number 8 listed wound next to number 8. The posterior (back) view of the diagram indicated a number 1, and a number 8 next to the coccyx region, and to the left of the coccyx region a circle with a number 1, and 8. On the anterior (front) of the diagram was a circle with the numbers 2, and 3 indicating a reddened bruise. Additionally, there was a circled area with a number 2 indicating a reddened area. Additionally, under a heading, Comments indicated the suprapubic site (below the umbilical region) was reddened, there was a small reddened bruise on the left side groin, and a dressing on coccyx and left buttock. The assessment contained no measurements. R100's Braden Scale for Prediction of Pressure Score Risk form dated 1/24/24, indicated a score of 11. The form included an interpretation of the scores and a score range of 10-12 indicated a high risk for development of a pressure ulcer. Interventions included a pressure reducing device for the chair and a pressure reducing device for the bed. Additionally, referrals that may be appropriate included activities, dietary, nursing rehab, and OT, and the care plan action indicated to continue with the current plan of care. R100's Skin Integrity Events that was recorded on 1/30/24, for 1/6/24, indicated R100 admitted with pressure/moisture associated wound to right and left buttocks. R100's transitional care unit (TCU) follow up note dated 1/15/24, indicated nurse practitioner (NP)-C saw R100 who was sitting up in the wheelchair and had fallen the previous Friday and sustained bruising to her back. The note indicated R100 had incontinence associated dermatitis to her bottom and received topical treatment. R100's TCU follow up note dated 1/18/24, indicated R100 had incontinence associated dermatitis to her bottom, and had fallen with bruising to R100's back. R100's TCU follow up note dated 1/23/24, indicated R100 was sitting up in the wheelchair on this day's visit. The note indicated R100 had bruising to the back, and had incontinence associated dermatitis and planned to continue topical treatment. R100's TCU follow up note dated 1/25/24, indicated R100 was sitting up in the wheelchair and had incontinence associated dermatitis. R100's TCU note dated 1/31/24, indicated incontinence associated dermatitis. R100's TCU note dated 2/1/24, indicated R100 had fallen from a lift at the TCU and x-rays were obtained with no acute injury. Additionally, the note indicated R100 had a coccyx ulcer and per reports had moderate slough and eschar. Additionally, the note indicated R100 had incontinence associated dermatitis. R100's TCU follow up note dated 2/13/24, indicated R100 was sitting up in the wheelchair eating lunch and had an appointment 2/15/24 with vascular service to debride her coccyx wound and continued with the Medihoney dressing changes. During exam, R100 was lying in bed and the wound was documented as a deep tissue injury (DTI) to coccyx that was now unstageable. The note also indicated R100 had admitted to the facility with IAD (incontinence associated dermatitis). The note further indicated R100 slipped in the bathroom that resulted in a DTI to the coccyx and over time the area developed into thick eschar. The note indicated the area measured 7 cm by 6 cm by 2 cm of thick eschar, with no peri wound redness. Additionally, there were four areas to the peri wound with granulation present. R100's emergency department (ED) note dated 2/11/24, indicated R100 was seen for evaluation of a worsening sacral wound and had a CT scan that showed possible cellulitis of the sacral wound, and recommended follow up with the wound clinic. R100's After Visit Summary note dated 2/15/24, indicated new orders to cleanse the buttock wound(s) with normal saline, pat dry with non-sterile gauze, pack wounds with aquacel AG (used for wounds with moderate to heavy drainage) cover with Mepilex. Additionally, the note indicated to offer a supplement three times daily. R100's wound clinic note dated 2/15/24, indicated R100 reported the wound had been present since 10/2023. The note further indicated the wound bed contained necrotic material and the surrounding wound had healthy intact skin. Additionally, the wound had necrotic muscle and was a fairly deep stage four pressure ulcer. The wound pre debridement measurements were 7 cm (centimeters) long by 6.5 cm wide and 1.8 cm deep and total 56 square cm. Further, the note indicated the most important thing to do to support healing was to keep pressure off the wound, R100 should be repositioned every 2 hours around the clock while in bed. Additionally, the physician explained to R100 the importance of protein intake to wound healing and increasing protein intake will speed wound healing and to further speed wound heeling encouraged R100 to take a protein supplement. Further, R100 should only be in the wheelchair for 3 hours a day and R100 needed to reposition themselves every 15-20 minutes while there are in the wheelchair. R100's Wound Management form indicated there were no wound types identified for the resident. R100's nursing progress notes were reviewed from 1/6/24, to 2/14/24, and indicated the following: No progress note was entered on 1/6/24. 1/8/24 perineal care was completed and there was redness noted on R100's sacrum and cream per order and foam dressing endorsed. The documentation lacked any measurement of the reddened area. 1/9/24 perineal cares were completed and nystatin was applied on redness, and [NAME] was applied on the sacrum and the foam dressing was changed. The documentation lacked any measurement of the reddened area to the sacrum. 1/10/24 R100 complained of pain to the left heel which was offloaded with a pillow and blanchable redness was observed on the left heel. Nystatin was applied on the groin. The note indicated negative moisture positive redness and peeling skin was noted on the groin. Additionally R100's sacrum was still red and [NAME] was applied along with a foam dressing. The documentation lacked any measurement of the reddened area to the sacrum. 1/10/24 R100 had a left heel stage 1 ulcer and orders were received to apply skin prep and allow to dry and blue boots both feet at all times except for cares. The documentation lacked a skin assessment of the left heel including measurements. 1/12/24: R100 had a witnessed fall with staff and was lowered to the ground without injuries, the note indicated R100's legs got weak during a transfer with a [NAME] lift and it was recommended to change to a Hoyer for safety. 1/13/24: R100 had a bruise on her right buttocks and the site was red with a closed bruise on the redness. The site was covered with a foam protective dressing. The red site was measured at 13 cm by 10 cm. 1/14/24: R100 had [NAME] on her buttocks, and had bruises on the redness of the sacrum area. Further, the redness on the left heel was prepped and a foam dressing was applied. The heel was not measured. 1/15/24: R100 had bruises on the sacrum with bleeding and peeling skin, and left heel cares were completed. 1/24/24: R100's heel ulcers were documented as assessed and redressed, however there was no documentation of measurements or the assessment. 1/28/24: R100's sacral wound care was completed and slough was noted on the buttocks and was increased in size. The NP was updated who ordered Medihoney and a foam dressing, up in the wheelchair for no more than 2 hours, change bed to an air mattress, and an OT evaluation for a Roho cushion. The note lacked a wound assessment to include any measurements. 1/31/24: R100's total surface area of the sacral wound was 13 by 12 cm and there was no assessment documented on the wound bed. Additionally the left heel pressure wound was red dry and intact, however there were no measurements. 2/1/24: R100's progress note indicated 13.4 cm by 0.1 cm and wound bed was 30% eschar, 30% slough, and 10% superficial tissue loss, 20% non blanchable irregular edges. The periwound was documented as intact and blanchable and the note indicated R100 was admitted with area. The progress note did not identify the location of the wound. 2/3/24: R100's dressing on sacrum was changed and the eschar measured 5 by 6 cm and the total surface of the wound was 12 by 10 cm. The documentation lacked information on R100's left heel. 2/7/24: R100 had eschar that measured 5 by 6 cm and had a total surface area of 11 by 10 cm and the heel wound was documented as intact with no open areas. The documentation lacked a measurement of the left heel wound, and did not identify the location of the wound with eschar. 2/8/24: R100 had an unstageable area on the sacrum and coccyx that measured 13.5 cm by 13.5 cm by 0.1 cm and the wound bed had 30% eschar, 30% clean non granulated tissue, 10% superficial tissue loss, 20% non blanchable irregular edges and the area of eschar measured 6 cm by 6.8 cm and was unable to determine depth of the wound due to the eschar. The documentation indicated that R100 was admitted with the area. Additionally, R100 had a DTI on the left heel that measured 1.5 cm by 1.8 cm in an L shape that was intact and the surrounding wound was intact and pink. Additionally, the note indicated R100 admitted with area. This was the first time R100's left heel wound had been measured. 2/14/24: R100's sacrum wound had a total surface area of 13.3 by 12 cm and the open wound measured 5.4 by 5.6 cm. The wound had varying wound depth with the deepest measuring 0.9 cm. R100 had a 2nd wound documented at the bottom of the first that measured 1.5 cm by 0.9 cm by 0.5 cm in depth, and an open wound at 6 O' clock on the right bottom that measured 3.8 by 0.6 cm, a wound at 9 O' clock 1.6 by 1.1cm, at 8 O' clock 3 by 0.5 cm, and had left buttocks excoriation 0.3 by 0.3 cm. R100's left heel was intact and measured 1.1 cm by 0.4 cm. During interview and observation on 2/12/24 between 4:40 p.m., and 4:48 p.m., R100 was laying on her back in bed towards her right side. A pillow was under the left side of R100 and a family member stated R100's sore was on the right side of her buttocks. At 4:48 p.m., R100 stated the sore on her bottom started in October and didn't become worse until coming to the facility. During continuous observation on 2/13/24 from 1:44 p.m., to 2:07 p.m., R100 was in a wheelchair and there was a Reliant 450 full body lift located in the hallway. At 2:06 p.m., registered nurse (RN)-A brought the full body lift into R100's room and was awaiting assist and at 2:07 p.m., nursing assistant (NA)-B entered the room. RN-A and NA-B positioned R100 in bed on her back. During interview on 2/13/24 at 2:10 p.m., RN-A and NA-B assisted in providing perineal cares and at 2:22 p.m., boosted R100 up in bed, positioned her on her back and provided the call light. RN-A and NA-B did not offer to lie resident on her side. During interview on 2/13/24 at 2:25 p.m., RN-A stated R100 had a bed sore on her bottom and came with incontinence associated dermatitis and it worsened because of incontinence. RN-A stated they use Medihoney for the area because it helped debride the slough and R100 had an appointment on 2/15/24, for vascular to have the wound checked. RN-A stated R100 should be kept repositioned on her left and right side and verified R100 was not positioned on her right or left side and further stated the ulcer was all over her buttocks. Additionally, RN-A stated R100's bed sore could worsen being on her back. Further, RN-A stated wound measurements were documented in the progress notes and was not sure how often they were completed. During observation on 2/13/24 at 3:04 p.m., R100 stated she would be willing to lie side to side. R100 had a pillow under her right side, but was still positioned on her back and the head of the bed was elevated about 30 degrees. R100 had a Journey wheelchair cushion in her wheelchair. During observation on 2/14/24 at 7:20 a.m., R100 was lying in bed on her back, her weight was shifted towards the right side but was mostly on her back and the head of the bed was elevated about 20 to 30 degrees. There was no pillow located under the left side of R100. During interview on 2/14/24 at 8:36 a.m., occupational therapist (OT)-F stated a Roho cushion was a gold standard for true pressure relief because it had air in its cells and were wonderful for wound management. OT-F stated if a resident had trouble with core stability, the cushion would be discouraged and in that case would use a foam cushion which still redistributes pressure, but the foam cushion gave more stability to feel secure in the chair. OT-F further stated the Roho worked well on the TCU. OT-F further stated if an order was to evaluate for a Roho, OT would document the evaluation and do a trial and error. The benefit of the doctor ordering a Roho is if we are not getting enough pressure relief from the redistribution mattress. OT-F stated an evaluation with an order should take place as soon as possible and a TCU patient was very easy to get to right away. OT-F stated R100 was on the TCU side. During interview on 2/14/24 at 9:18 a.m., the rehab director stated their OT was trained in wheelchair positioning and would initiate what they thought was appropriate with or without an order and would document. The rehab director reviewed the OT progress notes and did not locate any documentation of an OT evaluation for a Roho cushion. Further, the rehab director said when there is an order they are notified of the order by nursing staff and the therapist would address the order and would be in their documentation that they looked at the cushion and verified she did not see any documentation R100 was formally assessed for a Roho cushion. The rehab director stated the nurse manager or health unit coordinator would share with therapy anything new to address and stated she got the order and would get it to the appropriate person and was not aware of an order for a Roho cushion and stated she would look through her email. The rehab director also verified physical therapy would not be involved in the Roho cushion and stated if there was an order it would be emailed to her. During observation on 2/14/24 at 9:05 a.m., R100 still had a journey cushion in the wheelchair. RN-G stated R100 had a regular cushion not a Roho cushion. R100 also had a comfort curve cushion and RN-G stated that was not a Roho cushion, but later stated she would have to ask the nurse manager and verified the wheel chair cushion was a Journey wheelchair cushion and the cushion in R100's recliner was a Comfort Curve cushion. During interview on 2/14/24 at 9:11 a.m., OTR stated R100 did not have difficulty with core stability and when asked if R100 had been evaluated for a Roho cushion stated she thought R100 had a pressure relieving cushion on the chair and stated staff elevate the head of the bed for R100 to eat, but patients should not have the head of the bed elevated for a long period of time. During interview on 2/14/24 at 7:13 a.m., NA-B stated she looks on the care sheet to know what cares a resident requires and stated R100 never refused cares. NA-B further stated R100 was incontinent of stool and her dressing sometimes needed to be changed and stated R100 could not reposition herself and stated they reposition R100 off the area a little bit on the left side and right side. NA-B was not aware R100 had any issues with her heels. During interview on 2/14/24 at 9:37 a.m., the dietician (D)-I stated she monitors a appetites and their weights, and proteins, when a resident has a pressure ulcer. D-I stated if a resident had a stage 1 pressure ulcer she encouraged food and ensure and if a resident had a more serious ulcer, she reviews her supplements a resident may be interested in and added, it won't help if a resident refuses and stated she looks at the electronic medication administration record (EMAR). D-I further stated she looked at point of care to see what the NA's documented and stated they couldn't have an expectation that every single meal was documented, but stated the more documentation, the better. R-I stated Glucerna is made by the company that makes Ensure and is for people with diabetes and it was a protein to help with wounds. D-I stated if residents didn't like Glucerna, they had Arginaide which also helped with wound healing. D-I stated the nurses let her know if a resident was refusing supplements and they document in the EMAR. D-I was familiar with R100 and stated she had Glucerna and had a good intake at meals, and had an unstageable pressure ulcer to the coccyx and also had a pressure ulcer to the left heel, but did not know if the heel was unstageable. D-I stated she had just completed a review on R100 the day prior and reviewed R100's EMAR and verified R100 was not taking the Glucerna and stated she would have to follow up with R100. D-I stated the wound nurse gave report every week and so she could look to see if any changes were needed with supplements and stated people need protein for wound healing. During interview on 2/14/24 at 10:36 a.m., the therapy director stated she did not locate any emails regarding a Roho OT evaluation for a wheelchair. During interview and observation between 11:05 a.m., and 12:10 p.m., R100 had a dressing on her left heel and RN-A stated they use an adhesive remover. RN-A stated at 11:10 a.m., that R100's left heel was dark red and was now forming an eschar and stated it was a stage two and measured 1.1 cm long by 0.4 cm wide. At 11:23 a.m., R100 stated she did not like the ensure like supplements. At 11:24 a.m., RN-A stated R100's right foot outer ankle did not have an ulcer, but R100 had redness because her foot tilted to the right so they covered the area with foam. RN-A verified there was an area of redness on the ankle bone that [NAME] [TRUNCATED]

Based on interview and document review, the facility failed to have a method or system in place to ensure the facility offered or provided 3 of 5 residents (R9, R92, R103) updated vaccines to residents per Centers for Disease Control (CDC) vaccination recommendations. This had the ability to affect all 117 residents. Findings include: Review of the current CDC pneumococcal vaccine guidelines located at https://www.cdc.gov/vaccines/vpd/pneumo/hcp/pneumo-vaccine-timing.html, identified for: 1) Adults 19-[AGE] years old with specified immunocompromising conditions, staff were to offer and/or provide: a) the PCV-20 at least 1 year after prior PCV-13, b) the PPSV-23 (dose 1) at least 8 weeks after prior PCV-13 and PPSV-23 (dose 2) at least 5 years after first dose of PPSV-23. Staff were to review the pneumococcal vaccine recommendations again when the resident turns [AGE] years old. 2) Adults [AGE] years of age or older, staff were to offer and/or provide based off previous vaccination status as shown below: a) If NO history of vaccination, offer and/or provide: aa) the PCV-20 OR bb) PCV-15 followed by PPSV-23 at least 1 year later. b) For PPSV-23 vaccine ONLY (at any age): aa) PCV-20 at least 1 year after prior PPSV-23 OR bb) PCV-15 at least 1 year after prior PPSV-23 c) For PCV-13 vaccine ONLY (at any age): aa) PCV-20 at least 1 year after prior PCV13 OR bb) PPSV-23 at least 1 year after prior PCV13 d) For PCV-13 vaccine (at any age) AND PPSV-23 BEFORE [AGE] years: aa) PCV-20 at least 5 years after last pneumococcal vaccine dose OR bb) PPSV-23 at least 5 years after last pneumococcal vaccine dose e) Received PCV-13 at Any Age AND PPSV-23 AFTER Age [AGE] years: aa) Use shared clinical decision-making to decide whether to administer PCV20. If so, the dose of PCV-20 should be administered at least 5 years after the last pneumococcal vaccine. Review of 3 of 5 sampled residents for vaccinations identified: 1) R9 was [AGE] years old and admitted to the facility in June of 2023. R9 had received the PCV-13 on 4/13/15, and the PPSV-23 on 2/13/17 prior to her admission. Per CDC guidelines, the facility failed to initiate a shared clinical decision-making discussion to decide whether to administer one dose of PCV20 at least 5 years after the last pneumococcal vaccine dose. Regardless of whether PCV20 is administered, R9's pneumococcal vaccinations were complete. 2) R92 was [AGE] years old and admitted to the facility in August of 2023. R92 had received the PCV-13 on 8/24/15, and the PPSV-23 on 7/9/17 prior to his admission. Per CDC guidelines, the facility failed to initiate a shared clinical decision-making discussion to decide whether to administer one dose of PCV20 at least 5 years after the last pneumococcal vaccine dose. Regardless of whether PCV20 is administered, R92's pneumococcal vaccinations were complete. 3) R103 was [AGE] years old and admitted to the facility in January of 2024. R103 had received the PCV-13 on 4/2/15, and the PPSV-23 on 10/12/17 prior to his admission. Per CDC guidelines, the facility failed to initiate a shared clinical decision-making discussion to decide whether to administer one dose of PCV20 at least 5 years after the last pneumococcal vaccine dose. Regardless of whether PCV20 is administered, R103's pneumococcal vaccinations were complete. During interview on 2/14/24 at 8:36 a.m., registered nurse (RN)-D explained to keep vaccination statuses updated, a report was run twice weekly on newly admitted residents and vaccine status was reviewed with each resident. If a resident was due for a particular vaccination, RN-D would discuss this the resident, gain consent or declination and update their electronic health record (EHR). RN-D would administer the vaccination if the resident consented and update an internal spreadsheet. RN-D stated the facility used the CDC's 2024 guidelines to determine if a resident was due for a pneumococcal vaccination, and the facility currently implementing a new process of driving the conversation between providers and residents and/or representatives if due for a pneumococcal vaccination. During interview on 2/15/24 at 9:06 a.m., RN-D reiterated the facility was in the process of implementing a new system to identify residents who were eligible for additional doses of the pneumococcal vaccination based on shared clinical decision-making. RN-D reviewed the internal spreadsheet and was able to identify R103 as flagged for review to initiate the shared clinical decision-making discussion. RN-D verified that R9 and R92 were not flagged on the spreadsheet and stated they would be flagged. Facility policy titled Pneumococcal Vaccines for Residents dated 3/18/22, indicated the facility's policy was to provide education and administration of the PPSV23 and PCV13 to the residents of the facility according to CDC recommendations.

Based on observation, interview, and document review, the facility failed to ensure a self-administration of medication assessment (SAM) was completed to allow residents to safely administer their own medications for 2 of 2 residents (R92, R24) observed with medications at the bedside. Findings include: R92 R92's quarterly Minimum Data Set (MDS) dated [DATE], indicated R19 had intact cognition and had diagnosis which included non-Alzheimer's dementia and hypertension (elevated blood pressure. Indicated R92 was independent with bed mobility, toileting and transfers. During an observation on 2/12/24 at 2:08 p.m., there were four bottles of medication sitting on a desk in R92's room. During an observation on 2/13/24 at 8:30 a.m., four bottles of medication remain on a desk in R92's room as R92 was self-administering a medication from one of the bottles. R92 stated these are just my vitamins and I have been taking them myself for years. R 92's self-administration of medication assessment (SAM) dated 9/18/23, indicated R92 had no desire to self-administer medications. Review of R92's care plan dated 1/23/24 lacked any directives for self-medication administration. Review of the four bottles of medication in R92's room revealed the bottles contained Vitamin D 5000 units, whole fruit produce supplement, whole veggie supplement, and Omega XL joint and muscle support. R92's Physician orders dated 2/12/24, were reviewed and lacked an order for any of the above medications. Physician Orders also lacked a self-administration order. During an interview on 2/13/24 at 2:00 p.m., licensed practical nurse (LPN)-A stated was not aware R92 self-administered any medications. LPN-A verified SAM assessment dated [DATE], indicated R92 did not desire to self-administer any medications. During an interview on 2/13/24 at 2:05 p.m., nurse manager (NM) verified the four bottles of medication at R92's bedside and stated she was unaware R92 had any medications at his bedside. NM verified SAM assessment dated [DATE], indicated R92 did not desire to self-administer medications. NM further stated her expectation was that the SAM would have been updated. During an interview on 2/14/24 at 8:42 a.m., director of nursing (DON) stated when a resident wanted to self-administer medications, an assessment was completed to ensure they are safe to self-administer then an order is obtained from the provider. DON stated her expectation was that the SAM would have been updated to reflect R92's desire to self-administer medications. 48299 R24 R24's quarterly Minimum Data Set (MDS) dated [DATE], indicated R24 was cognitively intact and had diagnosis which included heart failure, hypertension, and depression. R24 was independent with bed mobility, toileting, and transfers. During observation and interview on 2/12/24 at 2:10 p.m., R24 was sitting in her wheelchair in her room by herself placing medication from a medication cup into another cup of yogurt and then took medication using a spoon. R24 repeated process of self-administration to take the rest of the medications. A container of Tums and about nine stacked, empty medication cups were observed on R24's nightstand. R24 stated staff usually leave medication for her to take and the nurse knew what medications she was taking. During interview on 2/12/24 at 2:30 p.m., licensed practical nurse (LPN)-B stated R24 usually self-administered medication with yogurt and ice water, and staff recently needed to check-in with R24 since R24 was sometimes forgetting to take the medication. R24 was independent, and LPN-B had left the medications in the medication cup in R24's room around 8 a.m. LPN-B stated the clinical manager completed a self-administration assessment and a note was placed in the computer or care plan. LPN-B thought the Tums were okay to be in R24's room. If staff found medications that were not supposed to be in a room, staff were to take and lock up the medication so others could not take the medication. R24's care plan indicated to administer medication as ordered with start date of 8/9/23 and did not address self-administration of medication. R24's orders indicated okay to self-administer lactaid 3,000 unit 1 tab oral twice a day with start date of 1/3/24 and okay to keep by bedside estradiol cream 0.01% (0.1 mg/gram) onto external vaginal /urethral area with start date of 1/10/24. Other orders did not indicate self-administration. R24's Self-Administration of Medication assessment dated [DATE], indicated R24 could self-administer lactaid and stored in resident's room. R24's Self-Administration of Medication assessment dated [DATE], indicated R24 could self-administer estrogen cream and stored in resident's room. The SAM lacked evidence of other medications. During interview on 2/15/24 at 3:14 p.m., nurse manager (NM)-B stated staff get an order from a doctor and completed a medication observation for residents to self-administer medication. NM-B expected staff to watch residents take their medications if self-administration process was not completed. A self-administration assessment needed to be completed to show the resident knew how to take medication properly at the right times. During interview on 2/15/24 at 4:47 p.m., the director of nursing (DON) stated staff needed to ensure residents had a self-administration assessment completed prior to leaving prescribed medications at residents' bedside. Residents may be at risk for choking, dumping their medication and not taking them, and staff may not know what medication residents take without a completed self-administration assessment. Review of a facility titled Self- Administration of medications reviewed 2/2/19, indicated residents have the right to self-administer medications if the interdisciplinary team has determined it is clinically appropriate and safe. Further stated self- administered medications must be stored in a safe and secure place, which is not accessible by other residents.

Based on interview and document review, the facility failed to ensure resident current wishes for resuscitation status were accurately documented in the medical record for 1 of 2 residents R19 reviewed for advanced directives. Findings include: R19's significant change Minimum Data Set (MDS) dated [DATE], indicated R19 was cognitively intact and had diagnosis which included hypertension (elevated blood pressure), anemia, and gastro esophageal reflux disease. Identified R19 required staff assistance with activities of daily living (ADL's ) which included bed mobility, toileting and transfers. During an interview on 2/12/24 at 5:51 p.m., R19 stated her wishes were to be resuscitated (full code) status. R19's current care plan dated 9/6/23, identified R19's advance directives were for full resuscitation full code status. Review of R19's electronic health record (EHR) identified the following : -R19's physician orders dated 9/29/23, identified R19 had an order for full code status. -R19's banner and face sheet on the computer identified R19's code status was full code. -R 19's Physician Order Life Sustaining Treatment (POLST) dated 4/18/22, identified R19 was a Do Not Resuscitate (DNR). The electronic health record identified a discrepancy of R19's wishes for resuscitation. During an interview on 2/12/24 at 6:51 p.m., licensed practical nurse (LPN)-A stated her usual practice in verifying a resident's code status was to refer to the banner on the computer screen or the physician orders. LPN -A stated there is also a POLST in the computer that is sent to the emergency room with the resident. LPN-A further stated if the banner, physician orders and POLST didn't match She would then follow the physician orders. During an interview on 2/12/24 at 6:54 p.m., registered nurse (RN)-A stated her usual practice in verifying a residents code status was to refer to the banner on the computer screen. RN-A stated however, the POLST in the computer is what is sent to the emergency room when a resident is sent out. During an interview on 2/12/24 at 6:55 p.m., registered nurse RN-B stated her usual practice in verifying a resident's code status was to refer to the banner and the physician orders in the computer. During an interview on 2/12/24 at 6:59 p.m., registered nurse RN-C stated her usual practice for verifying a resident's code status was to refer to the banner. RN-C stated secondly; she would refer to the POLST in the computer. RN-C stated when a resident is transferred to the emergency room the POLST in the chart is sent with the resident to the hospital. RN-C further stated if the banner and the POLST didn't match she would refer to the banner as long as the banner matched the physician orders. During an interview on 2/13/24 at 1:50 p.m., nurse manager (MN) stated her expectation to verify a resident's code status was to refer to the banner and the physician orders in the computer first and that the POLST would be secondary. NM stated if the banner, physician orders, and POLST did not match her expectation was that staff would follow the physician orders. NM verified there was a discrepancy between the banner, physician orders, and the POLST for R19. NM further stated this was a concern because the POLST is sent with a resident to the emergency room and hospital and that there was a chance that R19's wishes may not have been followed. During an interview on 2/14/24 at 8:42 a.m., director of nursing (DON) confirmed there was a discrepancy in R19's medical record related to advance directive wishes. DON stated her expectation in determining a resident's code status was to refer to the banner or the physician orders since not all residents have a POLST. DON stated she was unsure why R19's old POLST was scanned into R19's medical record. DON further stated her expectation was that when a resident was admitted with a POLST that the POLST and the physician orders would match. Review of a facility policy titled Advance Directives reviewed 10/2/23, indicated on admission and at quarterly care conferences thereafter, residents are informed and provided information concerning the right to formulate an advance directive. Further stated the advance directive will be uploaded into the Matrix Care record under resident documents in the Advance Care Planning or Legal Section.

Based on observation, interview, and document review, the facility failed to develop a comprehensive care plan to include assessed risks and interventions with skin care to reduce the risk of complication for 1 of 3 residents (R36) with pressure ulcers reviewed for care planning. In addition, the facility failed to develop a comprehensive person-centered care plan for psychotropic drug use for 1 of 5 residents (R21) reviewed for unnecessary medications. Findings include: R36's admission Minimum Data Set (MDS) dated [DATE], indicate R36 had intact cognition and required staff assistance for most activities of daily living(ADL's). further, MDS indicated R36 was at risk for pressure ulcers and R36 had one stage three pressure ulcer and two unstageable pressure ulcers. R36's most recent Braden Scale dated 2/3/24, identified R36 as being bedfast (confined to bed all or most of the time) and having very limited mobility. Braden scale further identified R36 had two venous ulcers. The scale included a scoring system based on points attached to certain issues which could impact skin, and this identified R36 as being At moderate risk. R36's Care Area Assessment CAA) dated 2/2/24, identified R36 had two unstageable pressure ulcers and one stage three pressure ulcer. CAA stated to proceed to care plan to prevent further skin breakdown and infection. Review of a nursing progress note dated 2/4/24, identified R36 had a sacral wound that measured 2x1.5x2 cm. a left heel wound that measured 2x1cm. and a right heel wound that measured 3x1.5cm. Review of physician orders dated 2/7/23, identified orders for Medi honey to be applied to sacrum wound daily and calcium Arginade with silver to both heels and cover with ABD and wrap with Kerlix twice per day. During an observation on 2/12/24 at 2:10 p.m., R36 was lying in bed wearing a hospital gown on an air mattress on her right side with a pillow behind her back and her feet were elevated off of the mattress with a pillow. Both heels were wrapped with gauze. R36 was not able to respond to any questions. During an interview on 2/13/24 at 1:10 p.m., nursing assistant (NA)-A stated R36 was bedfast, required total staff assist for all cares and had pressure ulcers on her sacrum and on her heels. NA-A stated she knew that staff were supposed to reposition R36 every two hours but was unaware of any other interventions that were in place for R36. NA-A stated she did not recall seeing any pressure ulcers mentioned or any interventions in R36's care plan to prevent further skin breakdown. Review of R36's comprehensive care plan dated 1/25/24, lacked any identified skin problems and stated R36 was at risk for altered skin status with a goal of not developing any skin alterations. Despite R36's medical record identifying that she had pressure ulcers to her sacrum and both heels The only intervention to prevent further skin breakdown was to apply barrier cream to any dry areas. During an interview on 2/13/24 at 1:41 p.m., nurse manager (MN) confirmed R36 was admitted to the facility with pressure ulcers on her sacrum and both heels on 1/23/24. NM further confirmed R36's care plan lacked information regarding R36's pressure ulcers and interventions to prevent further skin breakdown. NM stated her expectation would have been that R36's care plan would have mentioned the pressure ulcers and provided interventions to prevent further skin breakdown so that all staff were aware of how to care for R36. During an interview on 2/14/24 at 8:42 a.m., director of nursing (DON) confirmed R36 was bedfast and had pressure ulcers upon admission to the facility. DON further confirmed R36's care plan lacked any mention of R36's pressure ulcers or interventions to prevent further skin breakdown. DON stated her expectation was that R36's comprehensive care plan would have mentioned R36's pressure ulcers and would have provided interventions to prevent further skin breakdown. 49617 R21's annual Minimum Data Set (MDS) dated [DATE], indicated R21 had severe cognitive impairment with diagnoses of dementia (loss of memory, language, problem-solving and other thinking abilities), depression, and anxiety. R21's MDS also indicated he was receiving an antipsychotic on a routine basis and identified the last gradual dose reduction was on 12/13/23. R21's MDS indicated he had activity preferences that were very important to him, including listening to music he liked, being around animals like pets, doing his favorite activities, and participating in religious services or practices. R21's MDS indicated he had activity practices that were somewhat important to him, including going outside to get fresh air when the weather was nice and doing things with groups of people. R21's Care Area Assessments (CAAs) dated 1/17/24, triggered for psychotropic drug use, psychosocial well-being, cognitive loss and dementia, and behavioral symptoms. The CAAs for psychotropic drug use and psychosocial well-being indicated they would be addressed in R21's care plan. R21's physician's orders for psychotropic medications included the following: - Cymbalta (duloxetine) 60 milligrams (mg) capsule, delayed release/enteric coated (DR/EC), Take 60mg oral once a morning for depression with anxiety, dated 2/9/22. - Seroquel (quetiapine) 25mg tablet, Take 12.5mg oral at bedtime for dementia with psychotic disturbance, dated 12/13/23. R21's care plan dated 7/20/23, was reviewed and lacked resident-centered interventions. The care plan identified that R21 was taking a psychotropic medication, Cymbalta, to assist in regulating his mood. The interventions included administer medication as ordered, ask physician to review medication for possible dose reduction every three months, monitor behavior every shift and document significant occurrences as needed, observe for possible side effects of current psychotropic medication, and report pertinent lab results to physician. The care plan lacked a problem, goal, and interventions for the antipsychotic medication Seroquel R21 was taking. The care plan identified R21 had a cognitive deficit with impaired decision making, forgetfulness and confusion related to dementia and Alzheimer's diagnosis, dated 1/16/24. The interventions were not resident-centered and included allowing ample time to absorb and respond to information, assessing for contributing factors, assessing history if impairment, onset and duration, monitoring for any changes or decline in cognitive status, providing a calm, therapeutic environment and structured routine, and requesting a physician consider a psychiatric evaluation as indicated. During interview on 2/15/24 at 5:10 p.m., the director of nursing (DON) stated for residents taking psychotropic medications, care plans should be developed specific to those types of medications. The DON stated care plans were reviewed quarterly and during care conferences with residents and/or representatives to ensure the care plans were resident-centered and specific. The DON reviewed R21's care plan and verified there was no care plan focus in place for the antipsychotic medication Seroquel. The DON acknowledged that R21's care plan was generic. A facility policy titled Comprehensive Assessments and Care Planning dated 7/2/18, stated the facility's purpose was to provide a comprehensive person-centered care assessment of the resident's condition to develop, review and revise the resident's person-centered comprehensive care plan. Furthermore, the policy indicated all person-centered care plans will incorporate the resident's personal and culture preferences. Additionally, the policy stated all person-centered interventions will be implemented by qualified personnel and may be communicated through the electronic health record, resident profile, assignment sheets, and/or verbal communication.

Based on observation, interview, and document review, the facility failed to ensure a walking program was maintained for 1 of 1 resident (R51) reviewed for ambulation. Findings include: R51's quarterly Minimum Data Set (MDS) dated [DATE], indicated R51 was cognitively intact, independent for wheelchair mobility, and required supervision or touching assistance with ambulation. R51's MDS indicated R51 used a walker and manual wheelchair for mobility and had zero days of training and skill practice in walking during the seven-day look back period. R51's diagnoses included cancer, debility, and cardiorespiratory conditions. R51's care plan dated 2/14/24, indicated R51 was unable to ambulate independently related to unsteady gait and balance. Staff approaches for restorative nursing included documentation of walking program in electronic record and may call family to attempt to encourage resident to participate if refuses. The care plan indicated R51 was at risk for falls and directed staff assist R51 with ambulation program as directed with gait belt and w/c to follow and provide reminders to not ambulate/transfer without assistance. R51's order dated 10/1/23, directed staff to ambulate R51 with walker twice a day to tolerance with gait belt. R51's electronic administration record marked ambulation order as completed every morning and evening shift besides 2/3/24, 2/5/24 and 2/15/24. One of the three times the order was marked as not administered was related to resident refusal. The record did not specify distance or minutes ambulated. R51's nursing care sheet dated 2/9/24, directed staff to encourage R51 to walk to destinations and ambulate R51 twice a day and document in POC (point of care) and indicated R51 used a wheelchair and walker. R51's POC ambulation task dated 2/1/24 to 2/15/24, did not contain documentation for the following dates: 2/2/24, 2/7/24, 2/10/24, 2/11/24, and 2/14/24. On days of documentation, the task was marked as reviewed and did not include distance or minutes. R51's progress notes dated 11/15/23 to 2/15/24, indicated R51 refused ambulation approximately 37 times with last note being 1/27/24, approximately three times family assisted resident with ambulation, and one note which stated ambulation not done without further explanation. During interview on 2/12/24 at 4:49 p.m., family member (FM)-D stated R51 was weaker because he was not getting walked and believed less ambulation caused him to have a harder time transferring and increased risk of falls. FM-D stated family often walked with R51 but not the staff. During observation on 2/13/24 at 3:09 p.m., FM-D assisted R51 to ambulate with walker and gait belt in the hallway. During observation and interview on 2/14/24 at 7:56 a.m., R51 opened his door and was sitting in his wheelchair and dressed without socks or shoes. R51 stated he dressed himself. R51's walker was alongside a wall in his bedroom with the gait belt looped around the front bar of the walker. R51 placed his call light on, and nursing assistant (NA)-H came and applied R51's socks and shoes and asked what R51 wanted for breakfast. During interview on 2/14/24 at 12:32 p.m., R51 stated staff had not assisted him with ambulation yet today. During interview on 2/14/24 at 1:01 p.m., NA-F stated maintenance programs, such as ambulation, was on the team sheets or therapy had instructions in residents' rooms. During interview on 2/14/24 at 1:51 p.m., NA-G stated he did not assist R51 today and thought NA-H assisted R51. During observation on 2/14/24 at 1:54 p.m., R51 was in his recliner and the walker and gait belt were in the same spot. During interview on 2/14/24 at 2:42 p.m., NA-H stated NA-F had R51 on their group. During interview on 2/15/24 at 10:30 a.m., NA-F stated yesterday was busy and would say no one walked with R51. NA-F stated nursing assistants document R51's refusals of ambulation on the computer. During interview on 2/15/24 at 11:24 a.m., NA-G stated he had not seen anyone walk with R51 yesterday. During interview on 2/15/24 at 1:45 p.m., registered nurse (RN)-F stated R51 ambulated when he wanted to and sometimes refused which should be documented. RN-F stated she was not sure if R51 ambulated or not yesterday. RN-F had seen a staff person in R51's room who could have assisted R51 to ambulate around his room but was not sure if R51 was ambulated or not. When asked about nursing documentation yesterday which marked R51's ambulation as complete, RN-F stated she click, click, click[ed] at the end of the day. During interview on 2/15/24 at 3:23 p.m., nurse manager (NM)-B expected staff to ask R51 if he wanted to ambulate on morning and evening shifts. NM-B stated nursing assistants should document the distance and minutes R51 was ambulated, and nurses should indicate if R51 ambulated or refused. NM-B did not know how to look back to review POC documentation. NM-B stated R51 weakens when not ambulated and ambulation was good for R51's strength and endurance, especially since R51 self-transfers. During interview on 2/15/24 at 4:47 p.m., director of nursing (DON) expected staff to follow ambulation programs and offer ambulation. Reduction in current ambulation abilities could result when ambulation programs were not completed or offered. The facility policy Benedictine Restorative Nursing Program dated 6/9/20, indicated registered nurses provided oversight to the program to ensure the restorative interventions were being implemented as planned.

Based on observation, interview, and document review, the facility failed to implement care plan interventions for 1 of 1 resident (R263) reviewed with a history of falls. Findings include: R263's face sheet indicated R263 admitted to the facility on [DATE], and had the following diagnoses: ORIF (open reduction internal fixation a surgical procedure for repairing fractured bone) to right femur, chronic L2 (lumbar) and L3 burst fractures (when a vertebra is crushed in all directions, the condition is called a burst fracture), periprosthetic fracture (a broken bone that occurs around the implants) around other internal prosthetic joint, dementia, Parkinson's disease with dyskinesia (involuntary, erratic, writhing movements of the face, arms, legs, or trunk), age related osteoporosis with current pathological fracture. R263's Clinical Documentation Admission form dated 2/8/24, indicated R263 rarely or never understood under the heading, Ability to express ideas and wants, consider both verbal and non-verbal expression. Additionally, under the heading, Ability to understand others indicated R263 rarely or never understood. The form indicated R263 had adequate vision, had a short-term, and long-term memory problem, had severely impaired cognitive skills for daily decision making. Additionally, R263 required extensive assist for bed mobility, transfers, toileting, and had a history of falling in the last month, 2-6 months, had a fracture related to a fall in the last 6 months prior to admissions, and occasionally had bladder incontinence. The form also indicated R263's prior device used prior to the current illness, exacerbation, or injury included a mechanical lift. A wheelchair and walker were unchecked. R263's physician orders form included the following orders dated 2/8/24: occupational therapy (OT) evaluate and treat continuous, and physical therapy (PT) evaluate and treat. On 2/9/24, R263's physician order included speech therapy (ST) evaluate and treat. R263's physician orders dated 2/8/24, indicated R263 could bear weight as tolerated on the right lower extremity with a walker. R263's care plan dated 2/9/24, indicated R263's goal was to return to the community and interventions included see also therapy plan of care. R263's care plan dated 2/9/24, indicated R263 required therapy services due to a diagnosis of weakness. Interventions included a therapy care plan that included PT, OT, and SLP (speech language pathologist), and the number of days per week was undocumented. R263's care plan dated 2/9/24 indicated R263 was at risk for falls due to weakness, and the goal was R263 would not sustain a fall related injury through the review date. Two interventions were listed on the care plan: grab bar, tab alarm. Interventions were later added on 2/14/24, that included: keep in supervised areas during the day for increased supervision, plan to move patient to room closer to desk for increased supervision as soon as available, PT (physical therapy) OT (occupational therapy) per physician orders, sensor alarm at all times. Nursing assistant care sheets provided on 2/12/24, did not include R263 on the care sheet, however, the director of nursing (DON) provided a care sheet via email on 2/15/24, and indicated the care sheet was from 2/12/24. The care sheet indicated R263 was at high risk for falls and was to be in supervised areas when out of bed, and had an alarm, but did not specify the type of alarm. R263's Occupational Therapy Evaluation and Plan of Treatment form dated 2/9/24, was reviewed and R263's prior level of functioning indicated R263 lived in an assisted living facility and required stand by assist (SBA) with activities of daily living (ADLs) with a walker, and had a front wheeled walker and wheelchair for prior equipment. R263's Occupational Therapy Treatment Encounter Notes forms dated 2/9/24, 2/10/24, 2/13/24, 2/14/24, were reviewed and lacked information regarding the height position of R263's bed, location of the walker, and wheelchair when R263 was in bed. R263's Physical Therapy Evaluation and Plan of Treatment form dated 2/9/24, indicated R263's prior level of functioning indicated R263 lived in an assisted living facility and required stand by assist (SBA) with activities of daily living (ADLs) with a walker, and had a front wheeled walker and wheelchair for prior equipment. Physical Therapy Treatment Encounter Notes forms dated 2/9/24, 2/10/24, 2/11/24, 2/12/24, 2/14/24, were reviewed and lacked information regarding the height position of R263's bed, location of the walker, and wheelchair when R263 was in bed. R263's Physical Therapy Treatment Encounter Note dated 2/12/24, indicated R263 had fallen over the weekend and nursing indicated it was not ok for R263 to be in the room alone anymore and must be in communal areas during the day. R263's Therapy Screen form dated 2/9/24, indicated under a heading, Speech Therapy Areas included swallowing, memory, cognition, and communication and an order was requested for ST due to new admission with a medical history significant for Parkinson's and dementia. R263's Event Report form dated 2/11/24, indicated R263 had a witnessed fall in her room and had walked to get her clothes and was in bed prior to the fall. Immediate actions taken included first aid and an emergency room visit. A bed alarm was in use at the time of the fall. The report indicated R263 had been evaluated by PT/OT/ST for falls. Further, the nurse was notified by the cleaning lady R263 was on the ground and R263 stated she hit her head with a bump on the left side of her head and was sent to the emergency department for an unwitnessed fall. R263 returned around 5:40 p.m., and was situated in bed and her alarm went off at 6:00 p.m., and was found on the floor trying to get her purse. R263's Event Report form dated 2/11/24, indicated R263 fell in her room and was trying to walk just prior to the fall. Additionally, R263 was in bed prior to the fall. Immediate measures taken include a bed alarm and the on call nurse practitioner was updated. The report indicated R263 had not been evaluated by PT/OT/SLP for falls and the event was still open. R263's Emergency Medicine Visit Note dated 2/11/24, indicated R263 was in the emergency department for evaluation of a mechanical fall and the note indicated a new osseous (bone) fragment superior (upper) to the right lesser trochanter (a bony projection from the shaft of the femur), likely new displaced fracture fragment. Orthopedics was consulted and recommended weight bearing as tolerated. During interview on 2/13/24 at 9:51 a.m., family member (FM)-E stated R263 had fallen a couple of times she she had been at the facility. FM-E stated R263 fell at the other facility as well and broke her leg and was at the current facility for rehab. FM-E stated they hadn't stated they were going to do anything different from falling. During interview and observation on 2/14/24 from 7:34 a.m. to 7:47 a.m., R263's door was closed and the call light was on. No staff were in the room upon entrance and resident stated she had to go home and go to the bathroom. R263 was in a gown and the bed was in the low position. R263's walker was across the room. Nursing assistant (NA)-C entered the room at 7:35 a.m. and stated R263 had a bed alarm that sounded when R263 got up. At 7:37 a.m., NA-C took the wheelchair out of the bathroom and placed it next to the bed and locked the brakes and raised the bed up to assist R263 in a transfer. A personal alarm was located in R263's reclining chair and NA-C verified the personal alarm in the chair should be in the chair. At 7:38 a.m., NA-C assisted R263 to stand and the bed alarm began to alarm. At 7:39 a.m., NA-C assisted R263 to the toilet. NA-C stated they have a team sheet to know what cares a resident required. At 7:44 a.m., NA-C locked the wheel chair and assisted resident back into bed and at 7:46 a.m., turned the alarm on again. At 7:47 a.m. NA-C raised the bed from the floor up where the top of the mattress was approximately three feet from the floor. Then at 7:50 a.m., NA-C lowered the bed to the floor and put the wheelchair by the door by the walker which were both out of the resident's reach. At 7:54 a.m. NA-C stated the door should be left open and left the room. At 7:56 a.m., NA-C answered R263's light that was just turned on. During observation on 2/14/24 at 8:01 a.m., R263's call light was on and could hear resident asking about talking to family. During observation on 2/14/24 at 8:10 a.m., an unknown staff person came up the stairs and walked past R263's room and did not answer the light. During observation on 2/14/24 at 8:13 a.m., two staff members were at the end of the hallway but did not answer R263's light. During observation on 2/14/24 at 8:14 a.m., registered nurse (RN)-E entered R263's room and R263 asked her about calling her mother. During interview on 2/14/24 between 8:15 a.m. and 8:36 a.m., RN-E stated R263 came from memory care the end of the week prior and they planned to move R263 to another room because she had a couple of falls and they wanted her closer to the desk. RN-E stated she thought the tab alarm should be on at all times and further stated the team sheets would indicate alarm, but did not always specify which type of alarm. RN-E stated if they identify a resident can remove an alarm independently a sensor alarm is put on the care sheet, but RN-E stated she did not know whether R263 could remove the tab alarm and stated R263 at least had the sensor alarm which should be sufficient. RN-E further stated she hadn't gotten feedback from staff regarding R263's transfers and stated with her cognition, the walker and wheelchair should not be close to her when in bed because sometimes residents will want to pop up and use them. RN-E stated R263 had two falls on the 2/11/24. RN-E further stated staff did not add a lot of information when they entered the care plan. RN-E further stated the minimum data set (MDS) nurses used to update care plans and they dropped MDS nurse hours and the nurse on the floor puts in the initial and then RN-E updates the care sheet and tries to do as much as she can on the care plan. RN-E stated she expected care plans to be updated and stated she would clarify the type of alarm. RN-E further stated R263's bed should be kept in a regular height position, and stated she expected the walker and wheelchair location should be on the care plan so it was individualized per patient and stated it would be important for staff to know. RN-E verified the care plan had not been updated since it was initially added. During interview on 2/14/24 at 1:58 p.m., NA-D stated they had care sheets to know what cares a resident required. When asked if R263's wheelchair or walker should be by her when in bed, NA-D stated she thought the wheelchair should be by her because she knew R263 was at risk for falling. NA-D further stated the beds were always supposed to be in the lowest position. NA-D stated the care sheet didn't always give her that information and added the little bit she worked with R263, she did not know. NA-D stated she thought they discontinued the tab alarm and now had a pad alarm. During interview on 2/14/24 from 2:06 p.m. to 2:19 p.m., licensed practical nurse (LPN)-E stated when a resident falls, they used a cheat sheet so you didn't miss anything. LPN-E stated R263 had confusion, was impulsive and forgetful and didn't remember to use the call light. LPN-E further stated she looked at care plans and stated R263's call light was on from 6:20 to 6:35 and had the light on seven times in a period of 15 minutes and instructed staff R263 needed to come out here for her safety. LPN-E stated the bed is supposed to be in a regular position versus a low position. LPN-E stated she did not think the wheelchair or the walker should be by the bedside. LPN-E stated she expected the alarm types and when to use the alarms be care planned and on the care sheets and the position of the walker and wheelchair whether placed by the bed or pulled away. LPN-E further stated if a resident falls you are supposed to apply an intervention and the care plan should be updated after a fall and verified the care plan had not been updated after the fall at the time of the fall. During interview on 2/14/24 at 2:35 p.m., NA-E stated she was agency staff and stated they looked at the care plan. NA-E would need to see R263's face and thought the bed should be in the lowest position if a resident was a fall risk, and stated she would assume if a resident was at risk for falling the wheelchair and walker would be placed against the wall unless the care plan indicated otherwise. NA-E verified her care sheet did not specify type of alarm, nor the location of the wheelchair and walker when resident was in bed. During interview on 2/14/24 at 2:51 p.m., the director of nursing (DON) stated when a resident falls, the nurses on the floor completes an assessment and an event notification, calls the DON, updates the provider and the nurse management team takes data and does a follow up plan. DON further stated they expected nurses on the floor to do something but they wouldn't add a care plan in the system, but would document interventions. DON further stated she expected the care plan to be updated within 24 hours. Additionally the intervention would go on the nursing assistant care sheets. DON stated if the resident is cognizant and can remove the tab then they would use the pad alarm. DON further stated interventions were determined based on what the resident was attempting to do. DON verified the care plan had not been updated until 2/14/24, and stated she expected interventions to be on the care plan and added R263 was brand new and they would have to learn and additionally nursing hadn't done an assessment on where she should have equipment and therapy would do their assessment and offer insight. A policy, Integrated Fall Management dated 8/24/17, indicated residents were assessed for their risk of falls upon admission, significant change, and quarterly thereafter. Residents with risk for falling will have interventions implemented through the resident centered care plan. When a resident falls, a licensed nurse assesses the residents condition, provides care for, safety and comfort. A fall risk assessment is completed within 48 hours of admission to the community, residents at risk for falls have an individualized resident centered care plan developed. care plan interventions are based on the finding of the fall risk assessment. Additional professionals may be contacted to provide assessment and or interventions regarding fall risk and prevention, including but not limited to the attending physician/provider, pharmacist, physical therapist, occupational therapist, and speech therapist. When a resident falls the environment of the fall is evaluated for possible contributing factors and addressed, the interdisciplinary team reviews the fall and care plan changes and may, if needed, implement additional interventions.

Based on observation, interview, and record review, the facility failed to ensure appropriate collaboration with providers and pharmacy in the transcription of orders for 3 of 3 (R7, R56, and R66) reviewed for medications. Findings include: R7's face sheet printed on 2/15/24, included diagnosis of Alzheimer's disease and dysphagia (difficulty swallowing). During medication administration observation on 2/14/24 at 8:05 a.m., registered nurse (RN)-E prepared R7's medications. Medications included the following: -amlodipine 10 mg tablet -famotidine 20 mg tablet -aspirin 81 mg enteric coated tablet -calcitriol 0.25 mcg capsule -vitamin d 25 mcg capsule (capsule ordered but RN-E gave tablet) -Centrum multivitamin tablet -senna plus tablets RN-E placed all R7's in an envelope and then placed envelope into a pill crusher to crush R7's medications. RN-E placed crushed medications in pudding and administered to R7. R7's physician order review, dated 2/15/24, lacked an order to crush medications. R7's care plan, dated 2/15/24, lacked indication or preference of how R7 takes medications (i.e., whole or crushed). Review of R7's progress notes for period of 8/15/23 to 2/15/24, lacked any notification to pharmacy of R7 taking crushed medication or notification to the provider. Upon further review of EMR, no indications of pharmacy being notified of R7 taking medications crushed. R7's administration notes for the MAR indicate on 2/4/24, medication crush with pudding pureed diet. Entry previously on 12/13/23, indication medication whole. R56's annual Minimum Data Set (MDS), dated [DATE], identified a diagnosis of dementia and had impaired cognition. It further identified that R7 is on a mechanically altered and therapeutic diet. The assessment further identified no signs and symptoms of possible swallowing disorder. R56's face sheet printed on 2/15/24, included diagnosis of dementia and dysphagia. During medication administration observation on 2/14/23 at 7:55 a.m., registered nurse (RN)-E prepared R56's medications. RN-E placed R56's morning medication which included acetaminophen 325 mg two tablets scheduled, senna plus two tablets scheduled, and senna plus two tablets prn (as needed) were crushed together prior to administration and given to R56 in pudding. RN-E indicated the administration notes on the medication administration record indicated to crush medications. R56's physician order report, dated 2/15/24, lacked an order to crush medications. R56's care plan, printed 2/15/24, lacked indication of how R56 takes medications (i.e., whole or crushed). R56's administration notes for the MAR indicate that on 2/4/24 to crush pills. Entry previously was on 3/9/23 indication pills whole with thickened water or juice. R66's quarterly MDS, dated [DATE], identified a diagnosis of dementia and had impaired cognition. It identified R56 is on a mechanically altered diet and identified no signs and symptoms of possible swallowing disorder. Review of R66's progress notes for period of 8/15/23 to 2/15/24, lacked any notification to pharmacy of R66 taking crushed medication or notification to the provider. Upon further review of EMR, no indications of pharmacy being notified of R56 taking medications crushed. R66's physician note, dated 12/27/23, identified R66 current medications as follows: -acetaminophen 325 mg tablet -albuterol 108 microgram/actuation (mcg/act) -albuterol 2.5 mg/3 milliliter (ml) 0.083% neb solution -senna-docusate 8.6-50 mg tablet R66's physician order report, dated 2/15/24, identified the following orders as of 12/27/24: -senna plus 8.6-50 mg take 2 tablets by mouth once a morning start date 11/20/2020 -Tylenol 325 mg take two tablets oral every 4 hours as needed start date 8/19/21 -albuterol sulfate solution for nebulization 2.5 mg/3 ml (0.083%) 1 vial inhalation three times a day as needed start date 10/26/23 -Dulcolax delayed release tablet 10mg by mouth once a day as needed start date 12/1/23 -hyoscyamine sulfate elixir 0.125 mg tablet oral one tablet sublingual every 4 hours for secretions as needed start date 12/1/23 -morphine concentrate solution 100mg/5 mL take 0/.25 mL by mouth every hour as needed start date 12/1/23 -ipratropium-albuterol solution for nebulization 0.5 mg-3 mg (2.5 mg base)/3 ml 1 vial inhalation three times a day start date 12/1/23 Upon review, the medications on the physician order report and the physician progress note do not match. R66's care plan printed 2/15/24, included diagnoses of insomnia. R66's provider note, dated 1/17/24, included an order for trazodone 50 milligrams (mg) tablet take 50 mg by mouth at bedtime and calcium carbonate (TUMS) 500 mg chewable tablet take 200 mg by mouth four times daily. The provider note is electronically signed by provider. R66's physician order report, dated 2/15/24, lacked an order for trazodone 50 mg by mouth at bedtime. The identified an order for calcium carbonate 200 mg one tablet four times a day prn [as needed] for indigestion per SHO [standing house orders]. R66's standing house orders, signed 1/2024, indicate an order for calcium carbonate 500 mg one tablet PO [by mouth] four times a day prn [as needed] for three days. R66's electronic medical record (EMR) included a discontinue order for trazodone 50 mg on 1/10/24. R66's quarterly MDS, dated [DATE], indicated intact cognition. It identified that R66 is on a therapeutic diet and identified no signs and symptoms of possible swallowing disorder. Upon review, the medications on the physician order report and the physician progress note do not match. During an interview on 2/14/24 at 1:05 p.m., nurse manager (NM)-B stated if a resident was having difficulty swallowing then a speech evaluation would be requested. They indicated if a resident takes their medications crushed, an administration note was added to the MAR. They stated they do not put an order in for crushed medications. NM-B stated the physicians are notified some of the time and believes the pharmacy consultant can see the administrant notes. NM-B stated on certain medications, it was indicated not to crush the medications. NM-B stated nurses were expected to know what medications can be crushed. During an interview on 2/14/24 at 1:20 p.m., NM-B provided standing house orders that indicated medications can be crushed unless contraindicated. During an interview on 2/14/24 at 2:22 p.m., RN-C stated floor nurses or the health unit coordinators (HUC)/health information manager (HIM) put physician orders into Matrix (EMR). RN-C stated floor nurses were not responsible to view the provider notes after visits as if there was a change in medication then a new order is written. RN-C stated they do not compare the medication on the physician notes to the medications in the facility EMR. RN-C verified they can use the physician notes for signed orders if needed. During an interview on 2/14/24 at 2:34 p.m., HIM-A indicated part of their role was to enter physician orders. HIM-A stated physician progress notes were used as signed orders and were uploaded after visits. HIM-A stated it was not within their scope to review all the medications on the physician notes as this would be out of their scope. HIM-A indicated they do not review the physician notes for accuracy of medications or compare medications list to what was in facility EMR system as a HIM was not qualified to do this. During an interview on 2/14/24 at 2:42 p.m., NM-A stated physician progress notes were reviewed for accuracy and the providers get the medication from the facility. NM-A stated the providers were not routinely printed a facility medication list during visits. During an interview on 2/15/24 at 9:00 a.m., RN-F stated typically all residents have standing house orders signed by the provider upon admission. They indicated the were in the background meaning they were only to be used when needed and on a temporary basis. RN-F stated if you were using the standing house orders for more than a couple of days, then you must notify the provider. RN-F stated if a resident starts taking their medications crushed, a progress note would be put in and the provider would be updated. RN-F did not say anything about notifying the pharmacy. RN-F stated they know what medications can and cannot be crushed. RN-F stated an order for crushed was not put into the EMR and an administration note was added indicating how the resident takes their medications. During an interview on 2/15/24 at 10:42 a.m., nurse practitioner (NP)-A stated that physician orders were in both matrix [facility EMR] and Epic [provider EMR]. They indicated they do a comparison of medications but primarily use the facility medication list as this was what was being administered. NP-A indicated on the provider notes there was a statement all meds and allergies reviewed in the record at the facility and is the most up-to date. NP-A stated the provider notes were sent over to the facility automatically and believes they were being reviewed as they have heard them being referenced during care conference. NP-A stated the most up to date medication was in the facility EMR. NP-A stated would expect to be notified if a resident was changed to crushed medications due to swallowing concerns. NP-A stated the pharmacy should be reviewing the medications prior to crushing any medication to ensure they can be crushed. If the pharmacy identified an issue with a certain medication being crushed, a new order would be given. During an interview on 2/15/24 at 11:42 a.m., director of nursing (DON) stated if an order was used off the standing house orders, then we would update the provider. It would be on-going communication with the provider as these were used more for a temporary basis. DON stated if medications were being crushed, it would be the expectation to notify the provider as further evaluation would need to be done. DON stated we use the administration notes section to indicate how residents take their medications for example: crushed, or whole in applesauce. DON stated nurses do not get specific training on what medications can or cannot be crushed as it would be expected they know this information, use the drug books available in the nursing office or use online resources. DON stated some medication cards have labels on them that the medications cannot be crushed. DON stated previously had the pharmacist review medication that can be crushed for special cases, but this was not the standard practice. DON was unsure if the pharmacist can see the administration notes on the MAR. DON stated the provider notes were used to sign medication orders. She stated the current process to verify the provider medication list matches the facility list isn't solid at this time. DON stated the process needs to be reviewed. She verified there were medications on the provider notes (were being used as signed orders) were not being administered at the facility. DON stated we need to solidify this process. During an interview on 2/15/24 at 4:00 p.m., consulting pharmacist (CP)-A stated was not notified if a resident takes crushed medications. CP-A stated was not notified when a resident was taking their medications crushed and does not see the medication administration notes on the MAR. CP-A verified would only know if a resident was taking crushed medications was if a physician order was put in. CP-A verified it was important a pharmacist reviews medications prior to the medications being crushed to ensure they can be crushed. Per standing house orders, record indicates on the top All orders initiated from standing orders should be communicated to the provider. A facility policy regarding ensuring accurate collaboration between providers was requested and not received. A facility policy titled Medication Administration, revision date 8/14, was provided. The policy indicates that medications are administered as prescribed. It further indicates that crushing tablets may require a physician's order, per facility policy. No additional facility policy was provided.

Based on observation, interview, and document review, the facility failed to ensure residents were free from abuse for 1 of 3 residents (R1) reviewed for abuse. Nursing assistant (NA)-A mentally and verbally abused R1, was allowed to continue working, and returned to R1's room a second time, mentally and verbally abusing R1 again. This resulted in an immediate jeopardy (IJ). The IJ began on 2/28/22, when NA-A mentally and verbally abused R1. NA-A was allowed to continue working with residents, resulting in a second encounter between NA-A and R1, and NA-A again mentally and verbally abused R1. NA-A was allowed to continue working following both incidents. The administrator and the director of nursing (DON) were notified of the IJ on 3/10/22, at 5:26 p.m. The IJ was removed on 3/11/22, at 1:17 p.m. when it was verified an acceptable removal plan was implemented. Findings include: R1's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's admission MDS dated [DATE], indicated he was cognitively impaired. The admission MDS also indicated R1 required extensive assistance for bed mobility, transfers, and locomotion, and required partial to moderate assist with toileting. The MDS also indicated R1 was cognitively intact. R1's care plan printed on 3/14/22, lacked indication of how R1 required staff assistance with toileting. On 2/28/22, at 12:49 p.m. a facility report to the State Agency (SA) indicated on 2/28/22, at approximately 1:30 a.m. nursing assistant (NA)-A mentally and verbally abused R1. A facility investigation into the incident indicated the following: On 2/28/22, NA-A's written statement indicated she answered R1's call light that night, and he was wet after trying to use the urinal himself. NA-A wrote that she told R1 to cover himself up so she could go and get more help, as he was an assist of two. NA-B wrote she returned from her break, answered R1's call light that was ringing again, and changed him while NA-A was in another room providing cares. On 2/28/22, NA-B's written statement indicated R1's call light was on when she returned from her break on 2/28/22, at 2:10 a.m. NA-B documented all of R1's bedding was soaked with urine. R1 told NA-B earlier he had put his call light on and NA-A had came to his room and he asked her to change him. R1 told NA-B that NA-A told him someone would be down to change him later, after she refused to change him. R1 told NA-B he pressed the call light about 20 minutes after NA-A had left the room, and that is when NA-B arrived. NA-B indicated she had gone into multiple resident rooms where the residents told her NA-B had not helped them when they turned on their call lights. NA-B documented NA-A was just sitting at the nursing station, turning off call lights. NA-B indicated at around 4:00 a.m. she was finishing her charting, and NA-A again turned off a call light, and stated she was tired as she had been working two floors. On 2/28/22, LPN-A's written statement indicated she went to R1's room at 3:03 a.m. and R1 stated he had used his call light, and NA-B answered the call light. R1 stated NA-A had answered his call light and turned it off, after she saw he was wet. R1 stated NA-A then just walked out of his room. LPN-A said R1 stated he wasn't sure if she was coming back or not, so he pressed his call light again and NA-B came to his room and changed him. LPN-A indicated NA-B reported the incident to LPN-A. LPN-A indicated she approached NA-A, and told her there had been a complaint made by R1. LPN-A asked NA-A to write a statement regarding the incident, and NA-A declined stating she did not want to incriminate herself in writing. LPN-A indicated she told NA-A not to return to R1's room. Around 4:10 a.m. R1's light was on, and NA-A was walking down the hall to answer R1's call light. LPN-A told NA-A to stop and not to enter R1's room. LPN-A then went into R1's room and R1 was trembling and asked LPN-A to shut the door as NA-A was standing behind LPN-A in the doorway. R1 told LPN-A he was woken up later by NA-A, and she interrogated him about the earlier incident. R1 stated he had asked NA-A to leave the room twice. LPN-A indicated R1 was crying and told LPN-A he was afraid to use his call light after the incident because he was afraid NA-A would respond to it. R1 stated he felt threatened by NA-A. LPN-A documented she repeatedly apologized to R1 for NA-A's rudeness and behavior. On 3/2/22, the director of nursing (DON)'s written statement indicated education was done with LPN-A specific to removing staff from the schedule after receiving allegations of neglect. The DON discussed the incident with R1 with LPN-A, and told her NA-A should have been sent home immediately after it had been identified NA-A returned to R1's room after being instructed not to. NA-A was not sent home after either incident. On 3/10/22, on 11:53 a.m. R1 was interviewed with family member (FM)-A present. R1 stated the night of 2/28/22, he tried to use his hand-held urinal, but urinated on himself. R1 stated he used his call light and NA-A came to his room, shut off his call light, and threw the sheets and blankets off him. R1 stated when she saw he was wet, NA-A told him she would tell someone to change him, and then left the room. R1 stated after about 20 minutes, he used his call light again, and NA-B came in and changed him. R1 stated he was upset with the situation with NA-A, and wanted to speak to the nurse. R1 stated LPN-A came into his room and took his statement, and he told her he was upset and fearful of NA-A. R1 stated LPN-A told him not to worry, as NA-A would not be working with him anymore. R1 stated later that night, NA-A did returned to his room. R1 stated NA-A said she was there to set the record straight and, I'm going to tell you what happened. R1 stated he was very fearful after the encounter and was afraid to use his call button fearful NA-A would return. R1 stated LPN-A returned to his room after NA-A had left, and he told her he was upset NA-A had returned to his room for a second time. R1 stated the scariest part of the incidents was the intimidation factor used by NA-A. On 3/10/22, at 12:55 p.m. NA-B was interviewed. NA-B stated the night of 2/28/22, she was on break from approximately 1:30 a.m. to 2:00 a.m. NA-B stated she returned from her break, and at approximately 2:10 a.m. she responded to R1's call light. NA-B stated nobody had told her R1 needed help. NA-B stated she changed R1, he was tearful and thankful, and stated NA-A had scared him. NA-B stated she reported this to LPN-A who went and talked to R1. NA-B stated NA-A was asked to write statement about the incident, and was told she was to stay out of R1's room. NA-B stated later in the night, R1's light was on again, and she saw NA-A returning from R1's hallway, and thought NA-A had possibly been in R1's room. NA-B stated NA-A's version of events were not adding up. On 3/10/22, at 1:19 p.m. LPN-A was interviewed and stated she was made aware of the concerns with NA-A by NA-B after R1's first allegation. LPN-A stated R1 told her about the situation, and was very upset. LPN-A stated she spent 30 minutes apologizing and calming R1 down. LPN-A stated she tried to reassure R1 by telling him NA-A would not be returning to his room. LPN-A stated she asked NA-A to write a statement about what had happened, LPN-A stated NA-A only wrote three or four lines, and was extremely aggressively defensive toward her. LPN-A stated she told NA-A not to return to R1's room. LPN-A stated later, she went back to check on R1, and R1 told her NA-A had returned to his room. LPN-A stated R1 told her he was still fearful NA-A would return to his room. LPN-A stated she should have sent NA-A home after the first incident. On 3/10/22, at 2:52 p.m. the DON was interviewed. The DON stated LPN-A should have sent NA-A home after the first incident, because then the second incident wouldn't have happened. The DON stated NA-A absolutely should have been taken off the floor after the second time she returned to R1's room. The DON stated she was informed of the incident at 7:00 a.m. on 2/28/22. R1's progress notes lacked any indication of the incidents on 2/28/22. The facility policy Freedom from Abuse Prevention Plan dated 2017, directed abuse is the willful infliction of injury, reasonable confinement, intimidation, or punishment with resulting in physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain, or mental anguish. This includes verbal abuse, sexual abuse, and mental abuse.

Based on observation, interview, and documentation, the facility failed to determine the need for, and provide needed required supervision and/or assistive devices to prevent further falls for two (R219 and R52) of ten residents reviewed for repeated falls in the facility. R219 was harmed when he fell and sustained a laceration to his head and unstable fractures of his cervical spine; R219 was receiving hospice services and passed away two days after this fall. The failure placed R52 at risk for repeated falls. Findings include: FALLS Review of the facility's Integrated Fall Management policy, reviewed 5/6/21, revealed, Residents are assessed for their risk of falls upon admission, significant change, and quarterly thereafter. Residents with risk for falling will have interventions implemented through the resident centered care plan. When a resident experiences a fall, a licensed nurse assesses the resident's condition, provides care for safety and comfort . Post Fall Procedure . The environment of the fall is evaluated for possible contributing factors and addressed . The interdisciplinary team reviews the fall and care plan changes and may, if needed, implement additional interventions . Fall with Significant Injury: A fall with significant injury is a fall that results in a bone fracture, joint dislocation, closed head injury with altered consciousness, subdural hematoma, or death. 1. Review of R219's Face Sheet, located under the Face Sheet tab of his Electronic Medical Record (EMR) revealed he was admitted to the facility on [DATE], with diagnoses that included alcoholic [CONDITION(S)] of the liver, diabetes mellitus type 2, and [CONDITION(S)]. Further review of the resident's record revealed he was enrolled in hospice services. Review of R219's 11/12/19, Care Plan, located under the Care Plan tab of his EMR, revealed a problem area for risk for falls related to diagnoses of congestive heart failure (CHF), low hemoglobin, [CONDITION(S)], [CONDITION(S)], significant lower extremity [CONDITION(S)], a history of falls, occasional incontinence, and the need for hospice services. Interventions included encouraging the resident to use environmental devices such as grab bars, walker, and electric wheelchair; ensuring his call light was in reach; a nonskid mat at bedside; and the use of gripper (nonskid) socks. No new interventions were added to R219's falls Care Plan after the resident sustained repeated falls, resulting in a fall with significant injury. Review of the paper Event Reports, provided by the facility, revealed R219 had three falls during his stay in the facility: a. The 1/10/20, Event Report revealed the resident had a fall in his room on 1/10/20, wherein he was found in his room laying on the floor next to the door. Further review of the Event Report revealed the resident stated at the time, he had been sitting and had reached for something, causing him to fall. Continued review of the Event Report did not reveal what the resident had been reaching for when he fell . An Interdisciplinary Team (IDT) note, dated 1/13/20, and attached to the 1/10/20, Event Report, revealed R219 agreed to use his reacher device to obtain objects in the future. Review of the resident's Care Plan revealed this intervention was not added. b. The 1/25/20, Event Report revealed R219 had a fall in his room on 1/25/20, at 11:00 p.m., wherein he was found sitting on the floor beside his bed. Further review of the Event Report revealed no more information about the circumstances surrounding R219's fall. An IDT note, dated 1/27/20, and attached to the 1/25/20, Event Report, revealed the resident stated he was reading a book while sitting on the edge of his bed, his buttocks started to slide forward, and he was unable to get his legs under himself to stop sliding, so he slid to the floor. Further review of the IDT note revealed the resident had been noted with a low hemoglobin value of 6.1 grams per deciliter (g/dl) on his most recent lab report (normal range for an adult male is 13.5 to 17.5 g/dl), and did have one other fall from bed where the resident had attempted to sit self on edge of bed and was too close and slid to his buttocks. The IDT note concluded that the 1/25/20, fall was an isolated event, and no new interventions were required to prevent further falls from bed, even though this was a repeat fall from sitting on the edge of the bed. The facility failed to implement appropriate interventions to prevent another fall from the edge of his bed at this time. c. The 3/23/20, Event Report revealed R219 was found on the floor of his room on 3/19/20, at 5:10 p.m., with his head under his electric scooter in a pool of blood. Emergency Medical Services (EMS) were summoned, and the resident was sent to the hospital where he was found to have a laceration to his head requiring 13 sutures, as well as unstable fractures of his cervical spine at vertebrae C5 and C6. Further review of the facility's investigation revealed, had been observed to fall asleep upright despite continual staff reminders and encouragement to ask for assistance for his safety. Further review of the incident report revealed that after the resident was found on the floor with a head laceration and other injuries, R219 stated that he must have fallen asleep while sitting at the edge of his bed. Review of R219's Nursing Progress Notes, located under the Progress Notes tab of his EMR, revealed that R219 returned to the facility from the hospital on 3/20/20, and passed away on 03/21/20. Thus, no observations could be made for this resident during the survey. In an interview with the Director of Nursing (DON) on 9/22/21, at 11:48 a.m., the DON stated in general, it was her expectation that after a resident fell , the IDT would conduct a review of the fall the next business day in the morning meeting. The DON stated that the IDT should determine the factors leading up to the fall, and review and revise a resident's care plan as appropriate. When asked how the IDT determined how R219's fall from 1/25/21 was isolated, the DON stated that the determination was made on historical data and previous falls, but could not elaborate further. The DON stated typical interventions for such a fall would be frequent checks, although the facility had no specific definition of what constituted frequent checks, alarms, cushioned floor mats or other padding, or anything listed on the facility's falls policy. The DON stated R219 had valued his independence, so the facility did not necessarily implement any new fall prevention interventions. When asked to provide the investigative documents outlined in the facility's Integrated Fall Management policy for R219's falls, the DON stated the facility considered those items tools and as such they were not always completed. The DON stated she did not think those tools had been completed for R219, but she would provide them if the facility had them. In an interview with registered nurse (RN)-4 on 9/22/21, at 3:15 p.m. revealed she was the nurse in charge of the unit where R219 resided. RN-4 stated she recalled R219 and was aware he had fallen while in the facility. Regarding the 1/25/20, fall, RN-4 stated she had determined the incident was isolated given R219's desire for independence. After reviewing the Event Report provided by the facility, RN-4 could not determine when R219 had been last seen or assisted by staff prior to the fall. RN-4 stated R219's low hemoglobin level could contribute to increased weakness and/or dizziness, but since the resident was receiving hospice services at the time of this fall, she did not consider whether interventions such as increased supervision or encouraging the resident to rest in a comfortable chair or recline in his bed would benefit him. When asked about R219's fall on 3/19/20, at 5:10 p.m., RN-4 stated she could not determine, from looking at the facility's completed investigation, when the resident had last been attended by staff, or what he was doing before being found by staff. RN-4 stated she has not been aware, until reviewing the facility's completed investigation, that staff had known R219 was falling asleep while sitting on the edge of his bed. RN-4 stated, That's important to know. Had I known that, I definitely would have talked to him about it and encouraged him to sit in a recliner or somewhere other than the edge of his bed. In an interview with the DON on 9/23/22, at 1:46 p.m., the DON stated the facility had not completed any additional documentation regarding R219's falls. In an interview with the administrator on 9/23/21, at 3:30 p.m. revealed the facility had identified falls as a Quality Assurance and Performance Improvement (QAPI) project, and it was his expectation the facility would follow the regulatory requirements for fall prevention while respecting resident's choices for independence. 2. Review of R52's Admission Record, located under the Face Sheet tab of the EMR revealed he was admitted to the facility on [DATE], with diagnoses including: history of falling, [CONDITION(S)] disease, dementia with Lewy bodies, paranoid personality, hallucinations, aftercare joint replacement surgery (left hip), and abnormality with gait and mobility. Review of R52's admission Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 5/22/21, revealed a Brief Interview of Mental Status (BIMS) score of 14 out of 15, indicating cognitively intact mental status. R52 required assistance by one staff member with mobility and was at risk for falls. Review of R52's 6/14/21, Care Plan, located in the EMR under the Care Plan tab, revealed the facility recognized the resident was at risk for falling and had a history of falls with physical and cognitive impairments, [CONDITION(S)] disease with impaired balance and gait instability, and use of [CONDITION(S)] medications. The Care Plan documented, Resident attempts to get up unsafely on his own and turns his alarms on and off. The interventions included providing safety alarms on the bed and chair. Resident has a history of turning off alarms. Staff to check throughout shift to ensure the alarms are on. Additional interventions included: providing an environment free of clutter; keeping personal items and frequently used items within reach of the resident; ensuring the call light was in reach; assuring R52 had proper, well-maintained footwear; and providing verbal reminders not to ambulate or transfer without assistance. Review of paper Event Reports provided by the facility revealed R52 experienced eight falls in the facility between his admission on 5/15/21, and 9/18/21, on: 5/16/21, 5/27/21, 6/6/21, 8/6/21, 8/18/21, 8/29/21, 9/3/21, and 9/18/21. a. The 5/16/21, Event Report revealed R52 fell on [DATE], at 9:03 a.m., where he was found crawling on the floor, alarms turned off, and tab alarm removed from the resident. Further review of the Event Report and R52's EMR revealed no documentation of an IDT discussion on the root cause of the fall or appropriate interventions implemented to address the resident's removal and turning off of the alarms. During an interview with the DON on 9/23/21, at 1:46 p.m. revealed the facility had not conducted a root cause analysis for this fall and had not developed any new interventions for fall prevention, or to address the resident's removal/disarming of the alarms. The DON confirmed the facility continued to use safety alarms as a fall prevention measure after this fall. b. The 5/27/21, Event Report revealed R52 had an unwitnessed fall on 5/27/21, at 2:11 p.m., where R52 slid out of his wheelchair while attempting to pick up his alarm that had fallen off his shirt. Further review of the Event Report and R52's EMR revealed no documentation of an IDT discussion on the root cause of the fall or appropriate interventions implemented to address the resident's removal of the alarms. During an interview with the DON on 9/23/21, at 1:46 p.m. revealed the facility had not conducted a root cause analysis for this fall and had not developed any new interventions for fall prevention, or to address the resident's removal of the alarms. The DON confirmed the facility continued to use safety alarms as a fall prevention measure after this fall. c. The 6/6/21, Event Report revealed R52 had an unwitnessed fall on 6/6/21, at 1:42 p.m., where R52 fell backward when he lost his balance and knees gave out. No injury was noted. The fall alarm was sounding. Further review of the Event Report and R52's EMR revealed no documentation of an IDT discussion on the root cause of the resident's dizziness and subsequent fall, or appropriate interventions implemented to address the resident's loss of balance. During an interview with the DON on 9/23/21, at 1:46 p.m. revealed the facility had not conducted a root cause analysis for this fall and had not developed any new interventions for fall prevention. The DON confirmed the facility continued to use safety alarms as a fall prevention measure after this fall. d. The 8/6/21, Event Report revealed R52 had a witnessed fall in the dining room on 8/6/21 at 7:48 p.m. R52 stood up with the alarm sounding and his legs buckled, and he fell along the edge of the table and landed on his right side on the floor. R52 sustained a quarter-size hematoma on his right eyebrow, two abrasions on his right wrist, and two shallow skin cuts on his upper lip. The section of the report to document a pattern to the falls was left blank. Further review of the Event Report and R52's EMR revealed no documentation of an IDT discussion on the root cause of the fall or appropriate interventions implemented to prevent recurrence. During an interview with the DON on 9/23/21, at 1:46 p.m. revealed the facility had not conducted a root cause analysis for this fall and had not developed any new interventions for fall prevention. The DON confirmed the facility continued to use safety alarms as a fall prevention measure after this fall and stressed the importance of remaining seated to R52. e. The 8/18/21, Event Report revealed R52 had an unwitnessed fall on 8/18/21, at 1:53 p.m., wherein he was found by a visitor sitting on his backside on the floor. R52 stated he was trying to go to the bathroom and slid off his chair. There was no documentation whether the safety alarm was in place or sounding. Further review of the Event Report and R52's EMR revealed no documentation of an IDT discussion on the root cause of the fall or appropriate interventions implemented to prevent recurrence. During an interview with the DON on 9/23/21, at 1:46 p.m. revealed the facility had not conducted a root cause analysis for this fall and had not developed any new interventions for fall prevention. The DON confirmed the facility continued to use safety alarms as a fall prevention measure after this fall. f. The 8/29/21, Event Report revealed R52 had a witnessed fall on 8/29/21, at 4:00 p.m. in the dining room. R52 was seated in his wheelchair and stood up, took two steps, and went down on his right knee. The alarm sounded. Further review of the Event Report and R52's EMR revealed no documentation of an IDT discussion on the root cause of the fall or appropriate interventions implemented to prevent recurrence. During an interview with the DON on 9/23/21, at 1:46 p.m. revealed the facility had not conducted a root cause analysis for this fall and had not developed any new interventions for fall prevention. The DON confirmed the facility continued to use safety alarms as a fall prevention measure after this fall. g. The 9/3/21, Event Report revealed R52 had an unwitnessed fall on 9/3/21, at 5:45 p.m. in his room. The report documented R52 had tried to get up independently. There was no documentation of whether the alarm was sounding. Further review of the Event Report and R52's EMR revealed no documentation of an IDT discussion on the root cause of the fall or appropriate interventions implemented. Review of R52's Care Plan revealed new interventions were implemented on 9/7/21, including: keeping the resident, when awake, in the dayroom or by the nursing unit for close observation; placing R52's at the appropriate height; and encouraging R52 to use the call light for all transfers. During an interview with the DON on 9/23/21, at 1:46 p.m. revealed the facility had not conducted a root cause analysis for this fall but had developed new interventions to increase supervision of R52 and adjust his bed to an appropriate height. The DON confirmed the facility continued to use safety alarms as a fall prevention measure after this fall. h. The 9/18/21, Event Report revealed R52 had an unwitnessed fall on 9/18/21, at 7:00 p.m. in his room, resulting in a laceration to his left eyebrow with profuse bleeding and blood on the floor. R52 complained of pain to his left eyebrow, lower back, and right hip. The report documented the IDT reviewed the fall on 9/21/21, and had the hospice provider review R52's medication regimen for any changes with medication, resulting in new prescriptions for [MEDICATION(S)] (an anti-anxiety medication) and [MEDICATION(S)] (a pain medication) to decrease restlessness and anxiety. During an interview with the DON on 9/23/21, at 1:46 p.m. revealed she was aware R52 would frequently remove/turn off his alarms; however, the facility continued to use alarms as a main intervention for fall prevention. She stated the facility had not done root cause analyses of R52's falls or implemented additional interventions to help prevent falls. The DON added, We didn't have a good system [for addressing falls], but we have a new [unit] manager . and she is much more aggressive on that kind of thing.

Based on interview and record review the facility failed to ensure residents were free of significant medication errors for 2 of 3 residents (R1 and R3) who were reviewed for medication errors. R1 was harmed when she received an antibiotic medication twice a day, instead of the one time a day as ordered, requiring hospitalization with severe nausea and vomiting. Findings include: R1's quarterly minimum data set ((MDS) dated [DATE], identified R1 was cognitively intact and had [DIAGNOSES REDACTED]. R1's care plan revised 2/25/19, identified R1 received medications which placed her at risk for adverse reactions with interventions which included to administer medications per MD (doctor of medicine) orders. R1's Nurse practioner (NP) progress notes dated 3/18/19, indicated seen for follow up of pneumonia. R1's physical exam identified nosocomial (facility acquired) pneumonia. Orders included to given [MEDICATION NAME] (an injectable antibiotic) with [MEDICATION NAME] (a numbing agent) for two doses, to perform some laboratory work on Thursday, and to continue the [MEDICATION NAME] (antibiotic). R1's NP orders dated 3/20/19, included orders to discontinue the [MEDICATION NAME]. R1 was to start [MEDICATION NAME] (an antibiotic) 750 mg (milligrams) PO (by mouth) QD (once a day) X (for) 10 days (for pneumonia). R1's (MONTH) 2019 Medication Administration Record [REDACTED]. [MEDICATION NAME] 750 mg had also been given in the evening on 3/20/19, 3/21/19, 3/22/19, 3/24/19 and 3/25/19. R1's progress note dated 3/25/19, at 3:15 p.m. indicated R1 was being sent to hospital for new onset [MEDICAL CONDITION] recent [MEDICATION NAME] therapy which, makes her sick. R1's progress note dated 3/25/19, at 11:59 p.m. indicated R1 had been admitted to the hospital with [REDACTED]. R1's Emergency Department Encounter dated 3/25/19, included R1 had presented to the emergency department for evaluation of gastric symptoms including, reflux, nausea, vomiting, back pain and shortness of breath. R1 had been given a GI (gastrointestinal) cocktail and vomited it up. R1 was given water and vomited. Other oral attempts were tried and failed. Plan to admit R1. R1 had worsening reflux (back flow of food, stomach acid and digestive enzymes up into the esophagus) after starting on [MEDICATION NAME] and worsening shortness of breath. R1's biggest concern was reflux and vomiting, with no abdominal pain. EKG (electrocardiogram-test to detect [MEDICAL CONDITION] and heart rhythm problems) identified no ischemia (restriction of blood supply), troponin (blood test to check for heart damage) was negative and abdominal x-ray was unremarkable. R1 was given [MEDICATION NAME] (anti-nausea medication) but was unable to tolerate by mouth. R1 was also administered [MEDICATION NAME] (anti-nausea medication) and [MEDICATION NAME] (antacid medication) and was still unable to tolerate anything by mouth. The note included, Certainly could of been related to [MEDICATION NAME], as this was started 5 days ago. She was inappropriately dosed 750 mg twice daily for 10 days. R1 completed 5 days. Given proper dosing is 750 mg once daily for 5 days, I feel this could be stopped. Given she is unable to keep anything by mouth will admit for observation. R1's information obtained included R1 complained of abdominal pain, very bad reflux and stated had been vomiting, 120 times a day which she described as, spitting up a lot, into a tissue. R1's hospital discharge date d 3/27/19, identified R1 was admitted [DATE], with principle problem of nausea and vomiting. R1's discharge summary identified in the Summary Of The Hospital Course that R1 had presented with nausea and vomiting. The summary included, (R1) had recently been treated for [REDACTED]. (R1) had been getting [MEDICATION NAME] 750 mg twice daily for 5 days and likely this was what triggered her nausea. Discharge orders included orders to stop [MEDICATION NAME] 750 mg tablets. Stopping [MEDICATION NAME] as she likely had enough of that and had been getting twice as much as would normally be recommended. R1's event report dated 3/27/19, identified medication error of [MEDICATION NAME] began 3/20/19, ended 3/25/19. Error found by hospital staff 3/26/19, and verified by NP. Order entered wrong by nurse, entered [MEDICATION NAME] 750 mg two times per day rather than the one time a day ordered by the NP on 3/20/19. R1 received wrong dose. Adverse drug reaction was identified as gastrointestinal,[MEDICAL CONDITION] and symptoms, and loss of appetite. R1 was sent to the hospital per NP order. The event report did not include what, if any, actions were taken by the facility to prevent re-occurrence of this type of error. When interviewed on 6/12/19, at 12:55 p.m. registered nurse clinical manager (RN)-A stated R1 had received [MEDICATION NAME] 750 mg twice a day instead of once a day, this resulted in R1 being hospitalized with nausea and vomiting. Staff became aware of the error only once the hospital had notified the facility. The [MEDICATION NAME] order had been entered wrong by a nurse. The transcribing nurse was referred to the staff educator. The order was sent to the pharmacy correctly, and the medication was received at the facility with correct instructions on the label. RN-A stated Staff should have caught the error while reading the directions on the label and clarify the order, but did not. Six different staff administered the Levoquin without catching the error. No further education of all staff who pass medications was conducted. On 6/12/19, at 2:56 p.m. during a phone interview, nurse practitioner (NP)-A indicated she had ordered R1 to receive [MEDICATION NAME] 750 mg everyday for a total of 10 days, but R1 ended up receiving 750 mg twice a day. NP-A stated the error may have contributed to R1's nausea and vomiting. Staff should make sure the orders are correct before giving the medications. NP-A stated she was concerned R1's medication error went through so many people before being discovered at the hospital. When interviewed via phone on 6/14/19, at 12:50 p.m. R1's family member (FM)-A stated R1 had been hospitalized because she had receive too large of a dosage of medication. FM-A stated R1 had not been able to eat or keep food down prior to going to the hospital and had improved once the antibiotic was stopped. R3's quarterly MDS dated [DATE], identified R3 had moderate cognitive impairment and had [DIAGNOSES REDACTED]. R3's cognitive care plan revised 5/10/19, identified R3 had self deficit with ADLs and required extensive assistance of staff. R3's care plan did not include any heart issues, medications received, or associated interventions. R3's event report dated 4/29/19, identified a medication error. On 4/8/19, a health unit coordinator (HUC) had inadvertently added R3 to a list of inactive residents which discontinued all of the medications R3 was prescribed. A nurse had noticed all of the medications had been discontinued for R3 and reported it to a nurse manager. The HUC was notified and re-instated all of the medications, except for [MEDICATION NAME] (a betablocker used for heart failure and hypertension) 6.25 mg BID. The even report indicated the nurse did not verify the medications after the HUC re-instated them. The error was not found until 4/29/19, resulting in 21 days of missed medication. The physician was updated and ordered for blood pressures to be monitored for two weeks. R3's progress note dated 4/29/19, included, IDT follow up medication error identified it was discovered R3 had not received [MEDICATION NAME] as ordered. R3's medications were discontinued then re-instated the same day. HUC had on list to DC (discontinue) as resident not here any more. Writer had verified and discontinued all orders HUC had on list to do so. Discovered by nurse that medications were not in EMAR, so medications were re-instated by the HUC, all except R3's [MEDICATION NAME]. Evening nurse reviewed R3's medication orders, except the [MEDICATION NAME]. Not until 4/29/19 that medication found not to be re-instated and was omitted from being given to R3. NP was updated and ordered R3's blood pressures to be done for 2 weeks. Reviewing R3's blood pressures, there are highs and lows. Error did not affect R3's abilities or physical status. Family updated and aware of error. New orders per NP to discontinue current [MEDICATION NAME] order and new orders for [MEDICATION NAME] 6.25 mg 1 tablet orally twice a day. On Monday check a BMP (basic metabolic panel lab draw) for hypertension and HGB (hemoglobin lab draw) for [MEDICAL CONDITION]. Update NP in 2 weeks regarding R3's blood pressure readings. R3's progress note dated 5/13/19, included, the NP was updated on R3's blood pressures with no new orders. R3's NP progress notes dated 4/29/19, identified R3's current problems included hypertension, with current medications of Losartan (an antihypertensive) 50 mg QD, [MEDICATION NAME] (a water pill) 10 mg QOD (every other day) and [MEDICATION NAME] 6.25 mg a.m. and 12.5 mg p.m., with [MEDICATION NAME] dosage increased by physician on 3/1/19. R3's NP progress notes identified R3's blood pressure was recently 120's-140's/60's-70's. R3's NP progress notes further identified some confusion in [MEDICATION NAME] orders traced back to to a transcription error 4/8/19. Only getting [MEDICATION NAME] 12.5 mg at HS (hour of sleep). Will split dose so she will be getting 6.25 mg BID. Review in 2 weeks. If needed p.m. dosage as ordered 3/1/19. For now blood pressure checks look fine. Repeat BMP next week. When interviewed on 6/12/19, at 12:48 p.m. RN-A stated the HUC had accidentally discontinued R3's medications and when caught, forgot to re-instate the [MEDICATION NAME] order. The nurse coming on duty should have verified all medication orders, but had not. A nurse discovered [MEDICATION NAME] on the medication cart on 4/29/19, and discovered it had not been being given. A voice mail was left for R3's primary care physician on 6/12/19, at 3:17 p.m. No return call was received. When interviewed via phone on 6/13/19, at 10:06 a.m. R3's family member (FM)-B indicated she had been made aware of R3's medication error, and indicated it had been corrected. FM-B indicated she felt the medication error was handled correctly, but the facility had made it seem like R3 had only missed a day or two of the medication. FM-B indicated she had not been informed the medication was not administered for 21 days correctly. On 6/12/19, at 1:54 p.m. director of nursing (DON) indicated the usual facility process for medication order transcriptions included either a HUC (health unit coordinator) completing the order or a nurse. If the HUC completed the order transcription, it was always checked by a nurse, but if a nurse transcribed the medication order, it was not reviewed by another nurse. When a new order was received, a copy of the actual order was sent to the pharmacy. Once a medication error was found, the facility investigates to find out the root cause and what corrective action was necessary. After R1's medication error involving [MEDICATION NAME], they implemented two educational videos to be completed by the person making the error. When interviewed via phone on 6/12/19, at 3:25 p.m. pharmacy consultant (PC)-A stated she was new to the facility. She had not met with the DON yet to discuss medication errors and other processes. PC-A was informed of the significant medication errors of R1 and R3. PC-A indicated she was not aware of the order transcription process at the facility, however, the usual order transcription process was if a HUC completed orders, the orders were double checked by a nurse. It is standard practice for any nurse who administered medication to triple check the order with the medication to assure it was accurate. If the medication order did not match the medication instructions on the card, she would expect them to check the resident's health record to check the actual order. PC-A stated when R3 had not received the [MEDICATION NAME] medication it could have caused potential hospitalization and heart failure. R1's [MEDICATION NAME] medication error resulted in nausea, vomiting and hospitalization . PC-A indicated with excess [MEDICATION NAME] dosing there was also a risk of tendon rupture and change in glucose (blood sugar). When interviewed on 6/12/19, at 4:18 p.m. director of nursing (DON) stated she would expect a nurse to double check orders transcribed by a HUC. However, unless the nurse were to print the original orders out, there was no way to verify the original orders after discontinuation and this was not done for R3. With their current system, the nursing staff give the medications according to the resident's EMARs (computerized medication administration record), and was not sure what a better solution could be to prevent another occurrence of incorrect dosing as in R1's case. A policy on medication administration and order transcriptions was requested, but not provided.