Every finding on record at Colonial Heights Rehabilitation and Nursing Center

Based on observation, interview, clinical record review and facility documentation the facility staff failed to ensure the residents right to be free from abuse for two residents (R111 and R 110) in a suvey sample of 18 residents. 1. For R111 the facility staff failed to protect R111 from physical assault by R 118. Resident 111 was admitted to the facility on [DATE] with diagnoses that included but were not limited to acute respiratory failure, anxiety disorder, anemia, underweight, poisoning by unspecified medicaments and biological substance, hypotension (low blood pressure), psychoactive substance dependence with psychoactive substance induced persisting dementia, seizures, anoxic brain damage, cognitive communication deficit. R111's most recent MDS (Minimum Data Set) with an ARD (Assessment Reference Date ) of 6/5/26 coded R111 as having a BIMS (Brief Interview of Mental Status) score of zero out of a possible 15, indicating severe cognitive impairment. R111 was also coded as requiring maximum assistance of 1-person physical assistance with all activities of daily living. A review of the clinical record revealed the following note: 6/4/26 2:15 pm -Spoke with [R111's emergency contact name redacted] via telephone. Informed her that resident entered another residents' room and that resident subsequently hit her in the chest. No pain, bruising, or bleeding at this time. [emergency contact name redacted] states she's very familiar with [R111's name redacted] wandering, and that she was here with [R111 name redacted] in the dining room recently and [R111 name redacted] physically attacked her after attempting redirecting her from touching other residents' food in the dining room. [Emergency contact name redacted] also states that she'll be returning to Atlanta this weekend so she'll be in to see [R111 name redacted]. A review of the incident file revealed that the incident was witnessed by employees; LPN 2 (Licensed Practical Nurse) and OE 1 (Other Employee) both employees provided statements that describe R111 walking up to R118 and reaching to take some crackers from him and in return R118 punched R111 in the chest. On 8/4/26 an interview with the Administrator was conducted and she stated that she reported to all parties, the nurse notified md and emergency contacts. She further stated that the facility staff separated the two residents, assessed R111 for injuries (none were found) and notified the md, the emergency contact for the resident, and began the incident report. According to documentation provided by the facility, Adult protective services, the OLC (Office of Licensure and Certification) and the ombudsman were all informed of the incident. The initial incident was reported to the OLC on 6/4/26 and the follow up was sent on 6/10/24. The Administrator stated the care plan was updated and R111 was immediately put on 1:1 and has continued to be on 1:1 supervision. A review of the policy Abuse/Neglect/Misappropriation/Crime – Patient Protection, dated 10/17/23, revealed, in part, that the facility maintains zero tolerance for mistreatment, abuse, neglect, misappropriation of property, or crimes against a patient. The policy further stated that all employees are responsible for immediately reporting allegations to the Administrator, or in the Administrator's absence, the Director of Nursing (DON) or immediate supervisor, no later than two hours if the allegation involves abuse or bodily injury, or no later than 24 hours if the allegation does not involve abuse or bodily injury. On 08/05/26 at 1:26 p.m., the Director of Nursing (DON) was interviewed. The DON stated that abuse may be physical, verbal, or mental and is not tolerated in the facility. The DON stated that any witnessed abuse should be reported immediately and that facility staff are responsible for protecting residents and preventing all forms of abuse. On 8/6/26 during the end of day meeting the Administrator was made aware of the concerns and no further information was provided. 2. Resident #110 was originally admitted to the facility on [DATE] following an acute care hospital stay. Current diagnoses included, but were not limited to, dementia, Alzheimer's disease, and chronic kidney disease. Resident #110's most recent Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 06/16/26, was coded as a Quarterly Assessment. The Brief Interview for Mental Status (BIMS) was coded as 3 out of 15, indicating moderate to severe cognitive impairment. A review of the facility's Synopsis of Events, dated 06/18/26, revealed that on 06/12/26, facility staff reported that Resident #109 struck Resident #110. The residents were immediately separated and redirected. Upon receiving this information, the facility initiated an internal investigation. A review of the facility's investigation report revealed the following: Resident #109 and Resident #110 were observed arguing in the hallway. While staff intervened and attempted to separate the residents, Resident #109 punched Resident #110. The residents were immediately separated and redirected. A head-to-toe skin assessment and pain assessment were completed for Resident #110, and no injuries were identified. Social Services interviewed Resident #109 following the incident; Resident #109 denied the observed altercation with Resident #110. The investigation concluded that the incident was substantiated. Both residents were separated and redirected. Social Services would continue to monitor both residents for behavioral concerns and psychosocial needs. Care plans were reviewed and updated, and the physician and resident representative were notified. Further investigation indicated that no additional interactions between the two residents had occurred following the incident. A review of the facility policy titled Abuse/Neglect/Misappropriation/Crime – Patient Protection, dated 10/17/23, revealed, in part, that the facility maintains zero tolerance for mistreatment, abuse, neglect, misappropriation of property, or crimes against a patient. The policy further stated that all employees are responsible for immediately reporting allegations to the Administrator, or in the Administrator's absence, the Director of Nursing (DON) or immediate supervisor, no later than two hours if the allegation involves abuse or bodily injury, or no later than 24 hours if the allegation does not involve abuse or bodily injury. On 08/05/26 at 1:26 p.m., the Director of Nursing (DON) was interviewed. The DON stated that abuse may be physical, verbal, or mental and is not tolerated in the facility. The DON stated that any witnessed abuse should be reported immediately and that facility staff are responsible for protecting residents and preventing all forms of abuse. On 08/06/26 at approximately 2:00 p.m., the Administrator, Regional Director of Clinical Services (RDCS), and DON were informed of the survey findings and concerns. No additional information was provided prior to exit.

Based on resident interview, staff interview, facility document review, and clinical record review, the facility staff failed to provide food that accommodated a resident's food allergies, resulting in harm for one of 35 residents in the survey sample, Resident #5, and failed to provide food that accommodated a resident's food preferences for one of 35 residents in the survey sample, Resident #51. The findings include: 1. For Resident #5 (R5), the facility staff provided fish, a food the resident was allergic to, resulting in the resident's tongue swelling and requiring the use of emergent allergy medications. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 5/15/26, the resident scored 15 out of 15 on the BIMS (brief interview for mental status), indicating the resident was cognitively intact for making daily decisions. A review of R5's clinical record revealed a documented allergy to fish. A nurse practitioner's note dated 5/18/26 documented, notified by nursing that patient received fish on lunch tray and took a bite despite fish allergy. Patient now complaining of tongue swelling. Evaluated at bedside. Vital signs stable. Patient awake and alert, no respiratory distress noted at this time. EpiPen (medication used to treat an allergic reaction) administered. Solu-Medrol (medication used to treat an allergic reaction) 40 mg (milligrams) IM (intramuscularly) x1 now. Start oral prednisone (medication used to treat an allergic reaction) taper. Continue close monitoring for worsening allergic reaction, airway compromise, wheezing, or respiratory distress. Monitor vital signs closely. A nurse's note dated 5/18/26 documented, Notified by aid that resident mistakenly ate fish on her lunch tray. Resident realized it was fish after first few bites. Writer immediately notified provider. Received order for epinephrine 0.3 mg. Pulled from omni cell (an automated medication dispensing system) and administered. Monitored vitals q (every)15 minutes for one hour and documented. Resident c/o (complained of) of tongue swelling. Notified provider. 40 mg Solu Medrol removed from omni cell and administered. Order received to monitor vitals every four hours for 24 hours. Care is ongoing. Will continue to monitor. On 6/16/26 at 8:31 a.m., an interview was conducted with R5. R5 stated the facility staff knew she was allergic to fish because it was documented on her meal tray ticket. R5 stated that when the incident occurred, she thought the food on her plate was a chicken tender. R5 stated that after eating some of it, she realized the food was fish. R5 stated her tongue automatically began to swell so she told the nurse. R5 stated the nurse immediately administered epinephrine. On 6/16/26 at 8:57 a.m., an interview was conducted with the Food Service Director. The Food Service Director stated that on 5/18/26, the cook made a regular meal tray for another resident and an alternative meal tray for R5 at the same time and mixed up the meal trays. On 6/16/26 at 2:05 p.m., an interview was conducted with RN (Registered Nurse) #2. RN #2 stated on 5/18/26, an aide came to her and said R5 mentioned she was served fish and ate bits of it. RN #2 stated she immediately assessed R5 and R5's tongue had begun to swell to the point that her voice changed and her speech was affected. RN #2 stated she immediately obtained R5's vital signs, notified the nurse practitioner, and administered epinephrine per the nurse practitioner's orders. R5 stated she thought solumedrol was also administered to R5. RN #2 stated staff closely monitored R5, and the swelling was gone after two to three hours. On 6/16/26 at 3:58 p.m., the Administrator and Regional Director of Clinical Services were made aware of the above concern. The facility policy titled, Food Allergies documented, Individuals with food allergies will be provided with safe foods and fluids, and appropriate substitutions to maintain health. 2. For Resident #51 the facility staff failed to document Resident food preferences and dislikes as a guide for the preparation of her meal trays. Resident #51 was originally admitted to the facility on [DATE]. Diagnoses included but were not limited to subdural hemorrhage and multiple fractures after violent physical family abuse, protein calorie malnutrition, pre-diabetes mellitus, hypertension, and pneumonia. Resident #51's most recent MDS (Minimum Data Set Assessment) with an ARD (Assessment Reference Date of 3-18-26 was a quarterly assessment which coded the resident as able to make her needs known, she understood others, and was able to be understood. On 6-15-26 at 11:30 AM, Resident #51 was interviewed during initial tour of the facility. Resident #51 was found to be alert, oriented to person, place and time, was pleasant and jovial, laughing with the surveyor appropriately while conversing. She expressed displeasure that kitchen staff failed to ensure that her meal preferences were honored. Resident #51 said, The food is terrible. I have told them a hundred times what I like but they never get it for me. I have told them I love cabbage, potatoes, fried chicken, collards, biscuits, pork chops, macaroni and cheese, I'm not picky, but I hate brussels sprouts, and fish but they still bring it. I don't want eggs every day, and I don't want rice or noodles with every meal. The Resident was asked if she was offered a substitute when those meals that she disliked arrived and she stated yeah, if I want a peanut butter jelly sandwich, but I am sick of them. On 6-15-26 an interview was conducted with the Dietary Services Manager [DSM] and her assistant. The DSM stated she had trouble with the computer system, and her assistant put all of the Resident's preferences in the computer for her. The Dietary Assistant stated she had not put all of the preferences in my notebook with everyone's preferences in it but somebody spilled a drink all over it about 4-6 months ago and the ink bled together and it was unreadable. She then stated that I couldn't put it in the computer because of that. She was asked if the preferences were being redone, and she stated, I am going to do that. The DSM and her assistant were asked for a copy of the Residents tray ticket, and it was supplied. The ticket revealed under instructions nothing documented, under dislikes nothing documented, [and there was no area] for preferences, or likes. In only one area, tray notes for the breakfast meal appeared Bacon or sausage, bananas. The facility policy for admission Resident Preferences was requested and received. The document revealed that Residents would be visited and food preferences obtained within 48 hours of admission, the preferences would be documented on the preference intake form, entered into the resident profile system, appear on the Residents meal ticket [tray ticket], and would be updated as needed. On 6-16-26 at 1:00 PM at the end of day debriefing the facility Administrator and her staff were made aware of findings. On 6-16-26 at 1:30 PM prior to exit a staff member delivered a Registered Dietician progress note dated 1-2-25 which documented spoke with Resident about her food preferences. Resident states she does not like the fish or the cabbage. The note was documented 1.5 years ago and it was wrong. The Resident did not like fish and brussels sprouts, and loved cabbage. None of that information was documented on the [meal] tray ticket which was derived to guide the Resident's food tray preparation for every meal in the kitchen by tray line staff. On 6-16-26 at 2:00 PM at the exit conference the facility Administrator and her staff were made aware of findings. They stated they had nothing further to provide.

Based on staff interviews, facility document review and clinical record review, it was determined that the facility staff failed to provide RN (registered nurse) coverage for eight hours per day, seven days a week for two of 30 days reviewed, which had the potential to affect all residents. The findings include:The facility staff failed to provide RN (registered nurse) coverage for eight hours per day, seven days a week for two of 30 days reviewed, May 17, 2026 and May 22, 2026.During the facility task Sufficient and Competent Staffing and review of the 30 days as worked schedule, it was noted that two dates 5/17/26 and 5/22/26 had no RN coverage.On 6/16/26 at approximately 3:00 PM the Regional Director of Clinical Services was asked to provide timecard detail of RN coverage for those three dates.On 6/16/26 at approximately 4:00 PM, the Regional Director of Clinical Services provided timecard for the 5/30/26 evidencing RN coverage and stated, was trying to find the information for the other two dates.On 6/17/26 at approximately 10:15 AM, an interview was conducted with OSM (other staff member) #1, the scheduler. When asked to provide evidence of RN presence on 5/17/26 and 5/22/26, OSM #1 stated, let's see. There is no RN on either date. When asked the process for RN coverage, OSM #2 stated, there are two agencies that are called to fill any vacancies. Currently there are only have two full time RNs on staff. On 6/17/26 at 1:20 PM, the Administrator, the Director of Nursing and the Regional Director of Clinical Services were informed of the above concerns.A review of the Facility Assessment Nursing Services which revealed, Registered Nurses must use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week.No further information was provided prior to exit.

Based on observation, staff interview, and facility document review, the facility staff failed to maintain the area surrounding the facility's three dumpsters in a sanitary manner.The findings include:On 6/15/26 at 11:20 AM, went on a Kitchen tour with the Food Services ManagerOn 6/15/26 at approximately 11:40 AM, an observation was made on the way out of the building, trash outside of kitchen door a ball of paper, cigarette butts and lime peel. Two of the Three dumpsters-left and middle were filled above top of dumpster with two flaps on both dumpsters open. Right dumpster top closed, is for cardboard boxes. walking up to all Three dumpsters there were pieces of trash and food debris(sausage, eggs, bread, pieces of plastic and cardboard). Behind the middle dumpster was a trash bag with diapers and other trash on ground. Multiple lids on the ground, a juice container, a syrup container and bits of paper, and spoons. after taking a closer look in the right dumpster (cardboard dumpster) there was plastic bags, plastic gloves, and an unidentified shinny object. To the right of all 3 dumpsters there was a broken wooden dresser.On 6/15/26 at approximately 11:50, an Interview was conducted with the Food Services Manager, who stated, the trash is usually picked up by this time. They come on Monday's and Thursdays, not sure why they are late today. We have three departments that use the dumpsters, housekeeping, kitchen and laundry.On 6/17/26 at 1:20PM, the Administrator and the Director Of Nursing were made aware of concerns. A review of the facility's Waste disposal policy revealed Garbage will be disposed of as needed throughout the day and at the end of each day.No further information was provided prior to exit

Based on staff interview, facility document review, and clinical record review, the facility staff failed to provide care and services for a Foley indwelling catheter for one of 35 residents in the survey sample, Resident #164. The findings include:1.a. For Resident #164, the facility staff failed to obtain a urology consult regarding the resident's Foley catheter (1). A nurse practitioner's note dated 3/2/26 documented, Chief Complaint / Nature of Presenting Problem: Follow-up for recent hospital admission with left femoral neck fracture status post ground-level fall, and for advanced dementia .The resident had urinary retention post surgery and a Foley catheter was placed. Recommendations for voiding trials after discharge from the hospital. A nurse practitioner's note dated 3/5/26 documented in part, The plan of care has been discussed with the nursing staff. The resident has been seen and examined. The resident's medications have been reviewed. The nursing staff will monitor her for decreased urine output, hematuria (bloody urine), and dysuria (painful urination). She will continue with an indwelling Foley catheter for now and will follow-up with her urologist. Further review of R164's clinical record failed to reveal a scheduled appointment with the resident's urologist. On 6/16/26 at 2:05 p.m., an interview was conducted with RN (Registered Nurse) #2. RN #2 stated that outside appointments are documented in the unit appointment book and taken to the scheduler for the appointment to be made. On 6/16/26 at 3:58 p.m., the Administrator and Regional Director of Clinical Services were made aware of the above concern. The facility policy titled, Transportation and Appointments documented, 1. The center will schedule a provider appointment when a consult recommendation is received. No further information was presented prior to exit. Reference:(1) A Foley catheter is a tube placed in the bladder to drain urine. This information was obtained from the website: https://medlineplus.gov/ency/article/003981.htm 1.b. For Resident #164 (R164), the facility staff failed to provide Foley catheter care per physician's order. A review of R164's clinical record revealed a physician's order dated 2/27/26 that documented, Foley care q (every) shift. R164's February 2026 and March 2026 TARs (treatment administration records) revealed the same physician's order but failed to reveal the treatments were done (as evidenced by X marks and no nurses' checks/initials). On 6/16/26 at 2:05 p.m., an interview was conducted with RN (Registered Nurse) #2. RN #2 stated Foley catheter care consists of cleaning the catheter tubing with chlorhexidine wipes and most residents have a physician's order for Foley catheter care every shift. RN #2 stated nurses evidence Foley catheter care is done by clicking and signing off their initials on the TAR. On 6/16/26 at 3:58 p.m., the Administrator and Regional Director of Clinical Services were made aware of the above concern. No further information was presented prior to exit.

Based on observations, staff interview, and facility document review, it was determined that the facility staff failed to maintain the kitchen in a sanitary manner. The findings include:On 6/15/26 at 11:20 AM, an observation was conducted in the kitchen with the following findings: in the walk-in refrigerator, observation of a one half full mocha Frappuccino bottle on the second shelf. Asked if the Frappuccino was for the residents and to be stored in the walk-in refrigerator, the Food Services Manager stated, no, it is not the residents and it should not be there. It will dispose of immediately.On 6/17/26 at 1:20 PM, the Administrator and the Director of Nursing were informed of the above concerns.A review of the facility's Food Storage policy revealed, Food will be stored in an area that is clean, dry and free from contaminants. Food will be stored, at appropriate temperatures and by methods designed to prevent contamination or cross contamination.No further information was provided prior to exit.

Based on staff interview, and clinical record review, the facility staff failed to act on pharmacy recommendations of two of 35 residents in the survey sample, Residents #17, and #74. The findings include: 1.For Resident #17, the facility staff failed to act on pharmacy recommendations dated 9/29/25 and 12/15/25. A review of R17's clinical record revealed the following physician's orders: -3/28/25-Paxil 40mg (milligrams). One tablet at bedtime for major depressive disorder. -6/11/25-Trazadone 50mg. Two tablets at bedtime for major depressive disorder. A pharmacy recommendation dated 9/29/25 documented, Federal guidelines state antidepressant drugs should have an attempt at a gradual dose reduction (GDR) twice per year for the first year in 2 different quarters with 1 month between attempts, then annually thereafter, when used to manager behavior, stabilize mood or treat psych disorder. This resident has been taking PAXIL 40 MG QD (every day) since (3/2025) without a GDR. Could we attempt a dose reduction at this time to 30 MG QD to verify this resident is on the lowest possible dose? If not, please indicate response below. Further review of the pharmacy recommendation or R17's clinical record failed to reveal the facility staff addressed (accepted or declined and documented a rationale) for the above pharmacy recommendation. A pharmacy recommendation dated 12/15/25 documented, Federal guidelines state antidepressant drugs should have an attempt at a gradual dose reduction (GDR) twice per year for the first year in 2 different quarters with 1 month between attempts, then annually thereafter, when used to manager behavior, stabilize mood or treat psych disorder. This resident has been taking TRAZADONE 100 MG QD (every day) HS (at bedtime) since (6/2025) without a GDR. Could we attempt a dose reduction at this time to 75 MG HS to verify this resident is on the lowest possible dose? If not, please indicate response below. Further review of the pharmacy recommendation or R17's clinical record failed to reveal the facility staff addressed (accepted or declined and documented a rationale) for the above pharmacy recommendation. On 6/17/26 at 7:57 a.m., an interview was conducted with the Director of Nursing. The Director of Nursing stated the pharmacist sends recommendations to her email then she prints the recommendations out and consults with the physicians. The Director of Nursing stated either the physicians agree with the recommendations and change the orders, or they do not agree with the recommendations and document why. On 6/17/26 at 10:28 a.m., the Administrator, Director of Nursing, and the Regional Director of Clinical Services were made aware of the above findings. The facility staff failed to provide a specific policy regarding pharmacy recommendations. No further information was presented prior to exit. 2. The facility staff failed to act on a pharmacy recommendation dated 4/30/26 for Resident #74. Diagnoses for R74 included; dementia, peripheral vascular disease, diabetes and anxiety disorder. The most current MDS (minimum data set) was a quarterly assessment with an ARD (assessment reference date) of 6/10/26. R was assessed with a cognitive score of zero indicating severely cognitively impaired. An unnecessary medication review was conducted for R74. Active physician orders were reviewed and documented, Alprazolam [Xanax] Oral Tablet 0.25 MG (Alprazolam) Give 1 tablet by mouth every 12 hours for Agitation and Behavior [.]. The order was dated 10/31/2025. Review of the pharmacist monthly medication review dated 4/30/26 indicated a recommendation had been initiated but did not state what the recommendation was for. On 6/16/2026 at 2:28 p.m. the director of nursing (DON) was asked about the location of the pharmacy recommendation. The DON verbalized that she would look into where the recommendation is at. On 6/16/2026 at 4:24 p.m. the regional division director presented the pharmacy recommendation and verbalized the recommendation was for a GDR for Xanax but had not followed. Review of the pharmacy recommendation dated 4/30/2026, recommended a GDR attempt for Xanax from being given twice daily to once daily. The recommendation indicated that the same dose had been given since October 2025. The pharmacy recommendation form did not evidence documentation from the physician responding to the recommendation. R74's clinical record also did not indicate a response to the recommendation from the physician. On 6/17/26 at 7:57 a.m., an interview was conducted with the DON. The Director of Nursing stated the pharmacist sends recommendations to her email then she prints the recommendations out and consults with the physicians. The DON stated either the physicians agree with the recommendations and change the orders, or they do not agree with the recommendations and document why. On 6/17/2026 at 11:45 a.m. the DON presented a physician's progress note and system assessment dated [DATE] (ten days prior to the pharmacy recommendation) and verbalized that according to the assessment, the physician did address the pharmacy recommendation and wanted to continue R74 on the same dose of Xanax. The physician assessment of systems progress note was reviewed and did not show evidence of a rational that contraindicated the attempt for a dose reduction for Xanax. On 6/17/26 at 1:20 p.m. the above finding was presented to the director of nursing, administrator, and regional director of clinical services. A facility policy titled Medication Management read in part 2. If a medication seems unnecessary or harmful to the resident, the Director of Nursing or consultant pharmacist requests that the prescriber evaluate the continued need for the medication and/or consider reducing the dosage of the medication. If the provider deems the medication necessary, a documented clinical rationale for the benefit of or necessity for the medication is included in the resident's active record. No other information was presented prior to exiting the facility.

Based on resident interview, staff interview, clinical record review, and facility document review, the facility staff failed to assess for self-administration of a wound treatment for one of 35 residents, Resident #111. The findings include:The facility did not document an assessment or evaluation for self-administering treatment of a wound for Resident #111 (R111). Diagnoses for R111 included; unspecified injury to abdominal wall, umbilical hernia, and diabetes. The most current MDS (minimum data set) was a significant change assessment with an ARD (assessment reference date) of 5/12/26. R111 was assessed with a cognitive score of twelve indicating cognitively intact. Review of R111's active physician orders documented abdomen: cleanse with NS [normal saline], apply alginate to wound bed and Greers goo to peri wound and cover with dry dressing. change every day shift every Mon, Wed, Fri for old peg site.On 6/16/2026 at 3:45 p.m. R111 was interviewed regarding the wound to the abdominal area. R111 explained that the wound is from an old feeding tube site and mentioned the nurses supply the items for the dressing change and R111 performs the dressing changes. On 6/16/26 at 4:00 p.m. registered nurse (RN #1, nurse that was assigned to R111) was interviewed regarding R111 doing self-wound care. RN #1 said that R111 is very independent and prefers to perform his own dressing changes so the nurses give R111 the supplies needed.Review of R111 clinical record did not evidence an assessment or evaluation to self-administer wound care.On 6/17/2026 at 10:24 a.m. the assistant director of nursing (ADON) was interviewed and verbalized unawareness of R111 doing self-wound treatments and said that an assessment should be in place to ensure that R111 is competent to perform wound care.The facilities policy titled Self-Administration of Medication at Bedside2. read in part: Complete Medication Self-Administration Safety Screen assessment. 3. The Interdisciplinary Team will review the assessment and together, use clinical judgement to determine if the patient is eligible.On 6/17/26 at 1:20 p.m. the above finding was presented to the director of nursing, administrator, and nurse consultant. No other information was presented prior to exiting the facility.

Based on staff interview, facility document review, and clinical record review, the facility staff failed to notify a resident representative of a need to alter treatment for one of 35 residents in the survey sample, Resident #164. The findings include:For Resident #164 (R164), the facility staff failed to notify the resident's representative regarding physician's orders and the administration of intravenous sodium chloride on 3/6/26 and 3/11/26. A review of R164's clinical record revealed physician's orders for one liter of intravenous sodium chloride to be infused at 50 milliliters per hour on 3/6/26 for dehydration and 3/11/26 for hydration. A review of R164's March 2026 medication administration records revealed the above orders were completed. Further review of R164's clinical record (including progress notes) failed to reveal the resident's representative was made aware of the above orders and the administration of intravenous sodium chloride on 3/6/26 and 3/11/26. On 6/16/26 at 2:05 p.m., an interview was conducted with RN (Registered Nurse) #2. RN #2 stated residents' representatives should be notified of any change in condition or physician's orders. RN #2 stated the notification should be documented in a progress note. On 6/16/26 at 3:58 p.m., the Administrator and Regional Director of Clinical Services were made aware of the above findings. The facility policy titled, Significant Change of Condition documented, 3. Responsible Party will be notified of a change of condition. No further information was presented prior to exit.

Based on observation, interview, clinical record review and facility document review, the facility staff failed to ensure the resident's right to be free from abuse for 2 residents (R111 and R 110) in a survey sample of 18 residents. For R111 the facility staff failed to protect R111 from physical assault by R 118. Resident 111 was admitted to the facility on [DATE] with diagnoses that included but were not limited to acute respiratory failure, anxiety disorder, anemia, underweight, poisoning by unspecified medications and biological substance, hypotension (low blood pressure), psychoactive substance dependence with psychoactive substance induced persisting dementia, seizures, anoxic brain damage, cognitive communication deficit. R111's most recent MDS (Minimum Data Set) with an ARD (Assessment Reference Date ) of 6/5/26 coded R111 as having a BIMS (Brief Interview of Mental Status) score of zero out of a possible 15, indicating severe cognitive impairment. R111 was also coded as requiring maximum assistance of 1-person physical assistance with all activities of daily living. A review of the clinical record revealed the following note: 6/4/26 2:15 pm -Spoke with [R111's emergency contact name redacted] via telephone. Informed her that resident entered another residents' room and that resident subsequently hit her in the chest. No pain, bruising, or bleeding at this time. [emergency contact name redacted] states she's very familiar with [R111's name redacted] wandering, and that she was here with [R111 name redacted] in the dining room recently and [R111 name redacted] physically attacked her after attempting redirecting her from touching other residents' food in the dining room. [Emergency contact name redacted] also states that she'll be returning to Atlanta this weekend so she'll be in to see [R111 name redacted]. A review of the incident file revealed that the incident was witnessed by employees; LPN 2 (Licensed Practical Nurse) and OE 1 (Other Employee) both employees provided statements that describe R111 walking up to R118 and reaching to take some crackers from him and in return R118 punched R111 in the chest. On 8/4/26 an interview with the Administrator was conducted and she stated that she reported to all parties, the nurse notified provider and emergency contacts. She further stated that the facility staff separated the two residents, assessed R111 for injuries (none were found) and notified the provider, the emergency contact for the resident, and began the incident report. According to documentation provided by the facility, Adult protective services, the OLC (Office of Licensure and Certification) and the ombudsman were all informed of the incident. The initial incident was reported to the OLC on 6/4/26 and the follow up was sent on 6/10/24. The Administrator stated the care plan was updated and R111 was immediately put on 1:1 and has continued to be on 1:1 supervision. A review of the policy Abuse/Neglect/Misappropriation/Crime – Patient Protection, dated 10/17/23, revealed, in part, that the facility maintains zero tolerance for mistreatment, abuse, neglect, misappropriation of property, or crimes against a patient. The policy further stated that all employees are responsible for immediately reporting allegations to the Administrator, or in the Administrator's absence, the Director of Nursing (DON) or immediate supervisor, no later than two hours if the allegation involves abuse or bodily injury, or no later than 24 hours if the allegation does not involve abuse or bodily injury. On 08/05/26 at 1:26 p.m., the Director of Nursing (DON) was interviewed. The DON stated that abuse may be physical, verbal, or mental and is not tolerated in the facility. The DON stated that any witnessed abuse should be reported immediately and that facility staff are responsible for protecting residents and preventing all forms of abuse. On 8/6/26 during the end of day meeting the Administrator was made aware of the concerns and no further information was provided. 2. Resident #110 was originally admitted to the facility on [DATE] following an acute care hospital stay. Current diagnoses included, but were not limited to, dementia, Alzheimer's disease, and chronic kidney disease. Resident #110's most recent Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 06/16/26, was coded as a Quarterly Assessment. The Brief Interview for Mental Status (BIMS) was coded as 3 out of 15, indicating moderate to severe cognitive impairment. A review of the facility's Synopsis of Events, dated 06/18/26, revealed that on 06/12/26, facility staff reported that Resident #109 struck Resident #110. The residents were immediately separated and redirected. Upon receiving this information, the facility initiated an internal investigation. A review of the facility's investigation report revealed the following: Resident #109 and Resident #110 were observed arguing in the hallway. While staff intervened and attempted to separate the residents, Resident #109 punched Resident #110. The residents were immediately separated and redirected. A head-to-toe skin assessment and pain assessment were completed for Resident #110, and no injuries were identified. Social Services interviewed Resident #109 following the incident; Resident #109 denied the observed altercation with Resident #110. The investigation concluded that the incident was substantiated. Both residents were separated and redirected. Social Services would continue to monitor both residents for behavioral concerns and psychosocial needs. Care plans were reviewed and updated, and the physician and resident representative were notified. Further investigation indicated that no additional interactions between the two residents had occurred following the incident. A review of the facility policy titled Abuse/Neglect/Misappropriation/Crime – Patient Protection, dated 10/17/23, revealed, in part, that the facility maintains zero tolerance for mistreatment, abuse, neglect, misappropriation of property, or crimes against a patient. The policy further stated that all employees are responsible for immediately reporting allegations to the Administrator, or in the Administrator's absence, the Director of Nursing (DON) or immediate supervisor, no later than two hours if the allegation involves abuse or bodily injury, or no later than 24 hours if the allegation does not involve abuse or bodily injury. On 08/05/26 at 1:26 p.m., the Director of Nursing (DON) was interviewed. The DON stated that abuse may be physical, verbal, or mental and is not tolerated in the facility. The DON stated that any witnessed abuse should be reported immediately and that facility staff are responsible for protecting residents and preventing all forms of abuse. On 08/06/26 at approximately 2:00 p.m., the Administrator, Regional Director of Clinical Services (RDCS), and DON were informed of the survey findings and concerns. No additional information was provided prior to exit.

Based on staff interview, facility document review, and clinical record review, the facility staff failed to ensure residents were free from unnecessary psychotropic medications for two of 35 residents in the survey sample, Residents #17, and #74. The findings include: 1. For Resident #17 (R17), the facility staff failed to address a GDR (Gradual Dose Reduction) for the antidepressant medication Paxil and the antidepressant medication Trazadone. A review of R17's clinical record revealed the following physician's orders: -3/28/25-Paxil 40mg (milligrams). One tablet at bedtime for major depressive disorder. -6/11/25-Trazadone 50mg. Two tablets at bedtime for major depressive disorder. A review of R17's MARs (medication administration records) for March 2025 through June 2026 revealed the resident was administered Paxil and Trazadone per physician's order since the original prescribed dates. A pharmacy recommendation dated 9/29/25 documented, Federal guidelines state antidepressant drugs should have an attempt at a gradual dose reduction (GDR) twice per year for the first year in 2 different quarters with 1 month between attempts, then annually thereafter, when used to manager behavior, stabilize mood or treat psych disorder. This resident has been taking PAXIL 40 MG QD (every day) since (3/2025) without a GDR. Could we attempt a dose reduction at this time to 30 MG QD to verify this resident is on the lowest possible dose? If not, please indicate response below. Further review of the pharmacy recommendation or R17's clinical record failed to reveal the facility staff addressed, accepted or declined, and documented a rationale for the above pharmacy recommendation. A pharmacy recommendation dated 12/15/25 documented, Federal guidelines state antidepressant drugs should have an attempt at a gradual dose reduction (GDR) twice per year for the first year in 2 different quarters with 1 month between attempts, then annually thereafter, when used to manager behavior, stabilize mood or treat psych disorder. This resident has been taking TRAZADONE 100 MG QD (every day) HS (at bedtime) since (6/2025) without a GDR. Could we attempt a dose reduction at this time to 75 MG HS to verify this resident is on the lowest possible dose? If not, please indicate response below. Further review of the pharmacy recommendation or R17's clinical record failed to reveal the facility staff addressed, accepted or declined, and documented a rationale for the above pharmacy recommendation. On 6/17/26 at 8:46 a.m., an interview was conducted with the Director of Nursing. The Director of Nursing stated the staff uses pharmacy recommendations to determine when GDRs should be attempted. The Director of Nursing stated that if the pharmacist recommends a GDR, staff should meet with the psychologist or physician and either attempt a GDR or document a rationale if a GDR if not attempted. On 6/17/26 at 10:28 a.m., the Administrator, Director of Nursing, and the Regional Director of Clinical Services were made aware of the above findings. The facility policy titled, Chemical Restraints documented, 5. The patient will be evaluated for possible dosage reductions. No further information was presented prior to exit. 2. The findings include: The facility failed to address a gradual dose reduction (GDR) for Xanax (a psychotropic antianxiety medication) for Resident #74 (R74). Diagnoses for R74 included; dementia, peripheral vascular disease, diabetes and anxiety disorder. The most current MDS (minimum data set) was a quarterly assessment with an ARD (assessment reference date) of 6/10/26. R was assessed with a cognitive score of zero indicating severely cognitively impaired. An unnecessary medication review was conducted for R74. Active physician orders were reviewed and documented, Alprazolam [Xanax] Oral Tablet 0.25 MG (Alprazolam) Give 1 tablet by mouth every 12 hours for Agitation and Behavior [.]. The order was dated 10/31/2025. Review of the pharmacist monthly medication review dated 4/30/26 indicated a recommendation had been initiated but did not state what the recommendation was for. On 6/16/2026 at 2:28 p.m. the director of nursing (DON) was asked about the location of the pharmacy recommendation. The DON verbalized that she would look into where the recommendation is at. On 6/16/2026 at 4:24 p.m. the regional division director presented the pharmacy recommendation and verbalized the recommendation was for a GDR for Xanax but had not followed. Review of the pharmacy recommendation dated 4/30/2026, recommended a GDR attempt for Xanax from being given twice daily to once daily. The recommendation indicated that the same dose had been given since October 2025. The pharmacy recommendation form did not evidence documentation from the physician responding to the recommendation. R74's clinical record also did not indicate a response to the recommendation from the physician. On 6/17/26 at 7:57 a.m., an interview was conducted with the DON. The Director of Nursing stated the pharmacist sends recommendations to her email then she prints the recommendations out and consults with the physicians. The DON stated either the physicians agree with the recommendations and change the orders, or they do not agree with the recommendations and document why. On 6/17/2026 at 11:45 a.m. the DON presented a physician's progress note and system assessment dated [DATE] (ten days prior to the pharmacy recommendation) and verbalized that according to the assessment, the physician did address the pharmacy recommendation and wanted to continue R74 on the same dose of Xanax. The physician assessment of systems progress note was reviewed and did not show evidence of a rational that contraindicated the attempt for a dose reduction for Xanax. Observations of R74 throughout the survey process did not evidence oversedation or body function impairment. On 6/17/26 at 1:20 p.m. the above finding was presented to the director of nursing, administrator, and regional director of clinical services. A facility policy titled Medication Management read in part 2. If a medication seems unnecessary or harmful to the resident, the Director of Nursing or consultant pharmacist requests that the prescriber evaluate the continued need for the medication and/or consider reducing the dosage of the medication. If the provider deems the medication necessary, a documented clinical rationale for the benefit of or necessity for the medication is included in the resident's active record. No other information was presented prior to exiting the facility.

Based on staff interview, clinical record review and facility document review, it was determined the facility staff failed to evidence an accurate PASARR (preadmission screening and resident review) screening for one of 35 residents in the survey sample, Resident #15.The findings include: The facility failed to ensure a PASARR II was completed upon admission for Resident #15. Resident #15 (R15) was admitted to the facility on [DATE] with diagnosis that included but were not limited to dysphagia, traumatic subdural hemorrhage, bipolar disorder, schizophrenia and diabetes mellitus. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 4/14/26, coded the resident as scoring a 05 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was severely cognitively impaired. A review of the MDS Section GG-functional abilities and goals coded the resident as being dependent for bed mobility, transfer, hygiene, toileting, bathing and eating. A review of the comprehensive care plan dated 12/5/25 revealed, FOCUS: Resident is at risk is at risk for adverse reactions related to the use of antipsychotics secondary to diagnosis of bipolar disorder. INTERVENTIONS: AIMS (abnormal involuntary movement scale) assessment as needed. PHQ9 (Patient Health Questionnaire 9) mood screening as indicated Psych services as needed.There was no evidence of a PASARR II in R15's medical record. A request was made to the facility adminsitration to provide it to the survey team on 6/15/26 at 4:25 PM.On 6/16/26 at 2:45 PM an interview was conducted with the Director of Social Services, who stated the PASARR II should be done when there is serious mental illness. When asked if a resident with diagnosis of bipolar disorder and schizophrenia are serious mental illnesses, the Director of Social Services stated, yes and resident meets criteria for PASARR II; will check on this resident and get back to you.On 6/16/26 at 4:10 PM, the Director of Social Services stated, for this resident, it was an oversight. An audit was done and for R15 has been submitted and it is done. On 6/17/26 at 1:20 PM, the Administrator and the Director of Nursing were informed of the above concerns.A review of the facility's Level II PASRR policy revealed, If a Level II PASRR was triggered, by the Level I PASRR provided by the transferring hospital and the patient was admitted without a completed Level II PASRR, the center Social Work and Discharge Planner will initiate the discharging planning process by contacting the PASRR contractor.No further information was provided prior to exit.

Based on staff interview and clinical record review, the facility staff failed to develop a base-line care plan for one of thirty-five residents in a survey sample, Resident #162. The Findings Include: Resident #162 (R162) did not have a complete base-line care plan for a Foley catheter. Diagnoses for R162 included; urinary retention, traumatic subdural hemorrhage, dysphagia, and diabetes. An MDS (minimum data set) had not been completed due to R162 being newly admitted . R162's admission assessment was completed and indicated R162 was assessed as having cognitive impairment. On 6/15/2026 at 12:44 p.m. R162 was observed in bed with a Foley catheter attached and family members visiting. During a family interview a family member verbalized the Foley catheter was placed at the hospital prior to being admitted to the facility. Review of R162's clinical record indicated the base-line care plan was part of the admission assessment and indicated a Foley catheter had been triggered for a care plan, however no interventions were put in place for the Foley catheter. A comprehensive care plan had also been started for R162 but also did not indicate a care plan for a Foley catheter. On 6/17/2026 at 9:15 a.m. the MDS coordinator was asked to review R162's base-line care plan for a Foley catheter. After reviewing the care plan the MDS coordinator verbalized interventions for the Foley catheter should have been put in place to complete the care plan. On 6/17/26 at 1:20 p.m. the above finding was presented to the director of nursing, administrator, and nurse consultant. No other information was presented prior to exiting the facility.

Based on staff interview, facility document review, and clinical record review, the facility staff failed to implement the comprehensive care plan for two of 35 residents in the survey sample, Resident #164, and #39. The findings include: 1.a. For Resident #164 (R164), the facility staff failed to implement the resident's comprehensive care plan for Foley catheter (1) care. A review of R164's clinical record revealed a physician's order dated 2/27/26 that documented, Foley care q (every) shift. R164's comprehensive care plan dated 3/9/26 documented, (R164) requires an urinary indwelling catheter related to: urinary retention .provide catheter care Q (every) shift. R164's March 2026 TAR (treatment administration record) documented the above physician's order but failed to reveal the treatments were done (as evidenced by X marks and no nurses' checks/initials). On 6/16/26 at 2:05 p.m., an interview was conducted with RN (Registered Nurse) #2. RN #2 stated the purpose of the care plan is to, just to make sure we are doing everything we can to improve that patient outcome for that resident because everybody is different. RN #2 stated nurses can access residents' care plans in the computer system. RN #2 stated Foley catheter care consists of cleaning the catheter tubing with chlorhexidine wipes and most residents have a physician's order for Foley catheter care every shift. RN #2 stated nurses evidence Foley catheter care is done by clicking and signing off their initials on the TAR. On 6/16/26 at 3:58 p.m., the Administrator and Regional Director of Clinical Services were made aware of the above concern. The facility policy titled, Care Planning documented, A licensed nurse, in coordination with the interdisciplinary team , develops and implements an individualized care plan for each patient in order to provide effective, person-centered care, and the necessary health-related care and services to attain or maintain the highest practical physical, mental, and psychosocial well-being of the patient. No further information was presented prior to exit. Reference: (1) A Foley catheter is a tube placed in the bladder to drain urine. This information was obtained from the website: https://medlineplus.gov/ency/article/003981.htm 1.b. For Resident #164 (R164), the facility staff failed to implement the resident's comprehensive care plan for wound care. A review of R164's clinical record revealed the resident was admitted to the facility on [DATE] with a left hip surgical wound and a left forearm abrasion. Further review of R164's clinical record revealed the following physician's orders dated 2/27/26: -cleanse left hip with normal saline and apply dry dressing daily. -cleanse open areas to left forearm with normal saline, bacitracin, and dry dressing daily. R164's comprehensive care plan dated 2/27/26 documented, (R164) has a skin impairment: skin tear to left arm and surgical incision to left hip .Treatment as ordered. R164's February TAR (treatment administration record) documented the above orders but failed to reveal the treatments were done on 2/28/26 (as evidenced by blank spaces and no nurses' checks/initials). On 6/16/26 at 2:05 p.m., an interview was conducted with RN (Registered Nurse) #2. RN #2 stated the purpose of the care plan is to, just to make sure we are doing everything we can to improve that patient outcome for that resident because everybody is different. RN #2 stated nurses can access residents' care plans in the computer system. RN #2 stated nurses evidence wound care is done by clicking and signing off their initials on the TAR. On 6/16/26 at 3:58 p.m., the Administrator and Regional Director of Clinical Services were made aware of the above concern. No further information was presented prior to exit. 2. For Resident #39 (R39), the facility failed to develop and revise the resident's comprehensive care plan to address the resident's history of aggressive behaviors and individualized behavioral interventions. A review of R39's clinical record revealed diagnoses including traumatic brain injury without loss of consciousness. Review of the most recent Minimum Data Set (MDS) assessment identified a Brief Interview for Mental Status (BIMS) score of 9. A review of the facility investigation dated 3/9/26 revealed R39 pushed Resident #64 (R64) in a wheelchair toward R64's room. Upon entering the room, Resident #149 (R149) instructed R39 not to enter. R39 approached R149, struck R149 twice on the head, and briefly placed R149 in a headlock. Staff immediately intervened and separated both residents. R149 was assessed following the incident. No injuries were identified. The physician and responsible party were notified, neurological checks were initiated, and R149 declined transfer to the hospital. A review of Facility Reportable Incidents (FRIs) dated 1/18/26, 1/29/26, and 3/9/26 revealed R39 had a history of resident-to-resident verbal altercations requiring staff intervention. A review of R39's comprehensive care plan dated 6/15/26 revealed a focus stating, R39 used inappropriate language towards another resident. Interventions included separating residents, psychosocial follow-up, and referral to psychiatry. The comprehensive care plan failed to reveal individualized interventions addressing R39's documented history of aggressive resident-to-resident behaviors, identified behavioral triggers, or interventions routinely utilized by staff to de-escalate the resident. On 6/17/26 at approximately 9:50 a.m., an interview was conducted with Social Worker (SW). SW stated staff were familiar with R39's behavioral triggers and interventions used to calm and redirect the resident. Ms. [NAME] stated there should have been a behavior care plan in place for R39 and stated one would be added immediately. A review of R39's revised comprehensive care plan dated 6/17/26 revealed no behavior-focused care plan addressing aggressive behaviors, triggers, nor individualized interventions. The facility policy titled Care Planning (Policy #1801, effective 11/1/19) stated, A licensed nurse, in coordination with the interdisciplinary team, develops and implements an individualized care plan for each patient in order to provide effective, person-centered care, and the necessary health-related care and services to attain or maintain the highest practical physical, mental, and psychosocial well-being of the patient. The policy further stated, Care plans will be updated on an ongoing basis as changes in the patient occur. Based on record review and interview, the facility failed to revise R39's comprehensive care plan to include individualized behavioral interventions despite multiple documented resident-to-resident verbal altercations and staff knowledge of the resident's behavioral triggers and effective interventions. No further information was presented prior to exit.

Based on observation, staff interview, facility document review, and clinical record review, the facility staff failed to review and revise the comprehensive care plan for one of 35 residents in the survey sample, Resident #14. The findings include:For Resident #14 (R14), the facility staff failed to review and revise the resident's comprehensive care plan for the use of bed rails. A review of R14's clinical record failed to reveal a physician's order for bed rails. R14's comprehensive care plan created on 4/14/26 failed to document information regarding bed rails. On 6/15/26 at 11:34 a.m., and 6/16/26 at 8:20 a.m., R14 was observed lying in bed with bilateral grab bars in the upright position. On 6/16/26 at 2:05 p.m., an interview was conducted with RN (Registered Nurse) #2. RN #2 stated residents' care plans should be reviewed and revised to include the use of bed rails because that is something that is being used for their care. On 6/16/26 at 3:58 p.m., the Administrator and Regional Director of Clinical Services were made aware of the above concern. The facility policy titled, Care Planning documented, 5. Care plans will be updated on an ongoing basis as changes in the patient occur and reviewed quarterly with the quarterly assessment. No further information was presented prior to exit.

Based on staff interview, facility document review, and clinical record review, the facility staff failed to provide care and services to maintain a resident's highest level of well-being for one of 35 residents in the survey sample, Resident #164. The findings include:For Resident #164 (R164), the facility staff failed to provide physician ordered wound care on 2/28/26. A review of R164's clinical record revealed the resident was admitted to the facility on [DATE] with a left hip surgical wound and a left forearm abrasion. Further review of R164's clinical record revealed the following physician's orders dated 2/27/26:-cleanse left hip with normal saline and apply dry dressing daily.-cleanse open areas to left forearm with normal saline, bacitracin, and dry dressing daily. R164's February TAR (treatment administration record) documented the above orders but failed to reveal the treatments were done on 2/28/26 (as evidenced by blank spaces and no nurses' checks/initials). On 6/16/26 at 2:05 p.m., an interview was conducted with RN (Registered Nurse) #2. RN #2 stated nurses evidence wound care is done by clicking and signing off their initials on the TAR. On 6/16/26 at 3:58 p.m., the Administrator and Regional Director of Clinical Services were made aware of the above concern. The facility policy titled, Wounds/Skin Impairments documented, 5. Provide treatments as ordered. No further information was presented prior to exit.

Based on observation, staff interview, and clinical record review, the facility staff failed to implement bed rail requirements for three of 35 residents in the survey sample, Residents #14, #17, and #5. The findings include:1. For Resident #14 (R14), the facility staff failed to attempt appropriate alternatives prior to the resident's use of bed rails (grab bars) and failed to review the risks and benefits/obtain informed consent for the use of bed rails. A review of R14's clinical record failed to reveal a physician's order for bed rails. Further review of R14's clinical record failed to reveal appropriate alternatives were attempted prior to the resident's use of bed rails, failed to reveal the risks and benefits of bed rails were reviewed with R14 (or the resident's representative), and failed to reveal informed consent for the use of bed rails was obtained. A bed side rail tool dated 4/16/26 documented, 2a. What other alternatives were trialed prior to placing bed railsa. bolstersb. concave mattressc. wedgesd. low [NAME]. other.None of the alternatives were selected.The bed side rail tool further documented, 4. Risk verses benefits and consent obtained for side rails from:a. Patient/Residentb. Patient/Resident Representative.Neither option was selected. On 6/15/26 at 11:34 a.m., and 6/16/26 at 8:20 a.m., R14 was observed lying in bed with bilateral grab bars in the upright position. On 6/16/26 at 2:05 p.m., an interview was conducted with RN (Registered Nurse) #2. RN #2 stated alternatives should be attempted prior to a resident's use of bed rails. RN #2 stated the facility utilizes wedges, pillows, and she has seen a resident with a trapeze bar. RN #2 further stated nurses should explain the risks and benefits of bed rails to residents/resident representatives, and obtain informed consent. On 6/16/26 at 3:58 p.m., the Administrator and Regional Director of Clinical Services were made aware of the above concern. The facility did not provide a specific policy regarding bed rails. No further information was presented prior to exit. 2. For Resident #17 (R17), the facility staff failed to attempt appropriate alternatives prior to the resident's use of bed rails (grab bars) and failed to review the risks and benefits/obtain informed consent for the use of bed rails. A review of R17's clinical record revealed a physician's order dated 6/2/25 for bilateral 1/4 side rails while in bed to enable mobility. Further review of R17's clinical record failed to reveal appropriate alternatives were attempted prior to the resident's use of bed rails, failed to reveal the risks and benefits of bed rails were reviewed with R17 (or the resident's representative), and failed to reveal informed consent for the use of bed rails was obtained. A bed side rail tool dated 7/22/25 documented, 2a. What other alternatives were trialed prior to placing bed railsa. bolstersb. concave mattressc. wedgesd. low [NAME]. other.None of the alternatives were selected.The bed side rail tool further documented, 4. Risk verses benefits and consent obtained for side rails from:a. Patient/Residentb. Patient/Resident Representative.Neither option was selected. On 6/15/26 at 11:39 a.m., and 6/16/26 at 7:50 a.m., R17 was observed lying in bed with bilateral grab bars in the upright position. On 6/16/26 at 2:05 p.m., an interview was conducted with RN (Registered Nurse) #2. RN #2 stated alternatives should be attempted prior to a resident's use of bed rails. RN #2 stated the facility utilizes wedges and pillows, and she has seen a resident with a trapeze bar. RN #2 further stated nurses should explain the risks and benefits of bed rails to residents/resident representatives and obtain informed consent. On 6/16/26 at 3:58 p.m., the Administrator and Regional Director of Clinical Services were made aware of the above concern. No further information was presented prior to exit. 3. For Resident #5 (R5), the facility staff failed to attempt appropriate alternatives prior to the resident's use of bed rails (grab bars). A review of R5's clinical record failed to reveal a physician's order for bed rails. Further review of R5's clinical record failed to reveal appropriate alternatives were attempted prior to the resident's use of bed rails. A bed side rail tool dated 5/11/26 documented, 2a. What other alternatives were trialed prior to placing bed railsa. bolstersb. concave mattressc. wedgesd. low [NAME]. otherNone of the alternatives were selected. On 6/15/26 at 2:43 p.m., and 6/16/23 at 8:31 a.m., R5 was observed lying in bed with bilateral grab bars in the upright position. On 6/16/26 at 2:05 p.m., an interview was conducted with RN (Registered Nurse) #2. RN #2 stated alternatives should be attempted prior to a resident's use of bed rails. RN #2 stated the facility utilizes wedges and pillows, and she has seen a resident with a trapeze bar. On 6/16/26 at 3:58 p.m., the Administrator and Regional Director of Clinical Services were made aware of the above concern. No further information was presented prior to exit.

Based on staff interviews, clinical record review and facility document review, it was determined the facility staff failed to provide complete and accurate documentation for one of 35 Residents in the survey sample, Resident #15.The findings include:The facility failed to obtain and document Barium (BA) swallow results for Resident #15.Resident #15 (R15) was admitted to the facility on [DATE] with diagnosis that included but were not limited to dysphagia, traumatic subdural hemorrhage, bipolar disorder, schizophrenia and diabetes mellitus. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 4/14/26, coded the resident as scoring a 05 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was severely cognitively impaired. A review of the MDS Section GG-functional abilities and goals coded the resident as being dependent for bed mobility, transfer, hygiene, toileting, bathing and eating. A review of the comprehensive care plan dated 10/10/25 revealed, FOCUS: Resident is at risk for gastrointestinal secondary to indigestion GERD (gastrointestinal reflux disease). INTERVENTIONS: diagnostics as ordered.A review of the physician orders dated 12/1/25 revealed, Modified barium swallow study one time only.A review of the physician orders dated 6/9/26 revealed, MBSS (modified barium swallow study) requested to formally assess swallowing function.A review of the NP (nurse practitioner's) note dated 12/1/25 revealed, . The nursing staff will monitor him for GI upset and complaints of body aches beyond his baseline. He will continue to receive cholecalciferol 2000 units daily. Resident will continue to be monitored for nausea, vomiting, heartburn, indigestion, epigastric pain, and coffee-ground emesis. He will continue to receive famotidine 20 mg nightly at bedtime.A review of the NP note dated 1/13/26 at 12:00 AM revealed, The resident went for a modified barium swallow study. We are currently awaiting the results to be faxed to the facility for review and recommendations. The resident has been seen by the in-house speech therapist who recommended he have a modified barium swallow study performed. The resident tolerates his medications. Unit manager has requested the modified barium swallow study results to be faxed to the facility for review.Unable to locate 1/12/26 BA swallow test results in PCC (point click care). Request was made on 6/15/26 at 4:25 PM for results of R15's test results. On 6/16/26 at approximately 8:00 AM the Administrator and the Director of Nursing stated medical records faxed the hospital to obtain the results of the barium swallow, updates will follow. Asked the process for obtaining results, the Director of Nursing stated, the resident is sent with a facility consult sheet, the hospital is to complete it and send it back with the resident. Nursing then informs the physician of results/plan and awaits orders. Medical Records scans it into the resident's medical record.On 6/16/26 at 11:40 AM, the Director of Nursing stated there is no reply to the request for barium swallow results for R15.On 6/16/26 at 2:50 PM, the Medical Services Director stated, the hospital was faxed again today, and it was escalated to the head of the hospital's medical records. The first time the request was faxed was the day you came in (6/15/26), yesterday.On 6/17/26 ay 9:25 AM, faxed results for the 1/12/26 test, were received which revealed, The patient ingested thin barium, nectar thick barium, honey thick barium, barium pudding and a barium coated cracker in the lateral position with continuous fluoroscopy. The exam is limited by patient position and cooperation. Within these limitations, there is no penetration or aspiration with any consistency.On 6/17/26 at 1:20 PM, the Administrator and the Director of Nursing were informed of the above concerns.A review of the facility's reference from [NAME], [NAME], [NAME], [NAME] 11th edition, page 57, Complete Documentation contains appropriate and essential information. Current documentation includes making timely entries in a patient's record, which avoids omissions and delay in patient care.No further information was provided prior to exit.

Based on staff interview, clinical record review, and facility documentation review, the facility staff failed to have five medications available for administration for one resident (Resident #8-R8) in a survey sample of ten residents.The findings included:For R8 the facility failed to have give medications available to administer in accordance with physician orders on 5/4/25. On 1/6/26, during a closed record review of R8's clinical record it was noted on the census tab that R8 had discharged from the facility on 10/15/25. Review of the medication administration record (MAR) for May 2025 revealed that on 5/4/25, the following medications had a code 9- entered on the MAR. According to the chart codes (legend) at the bottom of the MAR, code 9 indicated other/see nurse notes. The medications with that code were: Fluticasone Propionate Nasal Suspension (Flonase nasal spray- used for allergic rhinitis), Vitron-C (a vitamin with Vitamin C and iron), Budesonide-Formoterol Fumarate inhaler (a corticosteroid used to treat inflammation in the lungs), Buspirone HCL (Buspar- used to treat anxiety) for two doses, and Hydralazine HCL (used to treat blood pressure). According to the MAR, R8's blood pressure on 5/4/25 was recorded as 197/103, which was elevated and the medication used to treat elevated blood pressure was not administered. According to R8's physician orders, each of the above noted medications had an active physician order on 5/4/25. According to the nursing progress note entries dated 5/4/25 regarding each of the medications not given, the entry read, medication not available. On 1/7/26 at 3:28 PM, an interview was conducted with licensed practical nurse #3 (LPN #3). LPN #3 explained the protocol when medications are not available for administration. LPN #3 stated that she checks to see if the medication has been ordered, if it had not been ordered, she would order it. LPN #3 went on to report she would check the Omnicell [medication dispensing/storage machine/supply maintained on-site]. When asked what LPN #3 would do if the medication is not available in the Omnicell, LPN #3 said, I would call the pharmacy, if it is not STAT [medical term meaning immediately/without delay] you don't have to get it, you just wait for it to come in through the pharmacy. I make a note in the chart and let the nurse coming in to relieve me know and the administrator. When asked why it is important for residents to receive their medications, LPN #3 said, A lot of the medications they receive help with different co-morbidities they have. On 1/7/26 at 3:52 PM, an additional nurse was interviewed, LPN #4. LPN #4 explained when medications are not available how she responds. LPN #4 said, First I check the Omnicell and then I call the provider if it is not available and document the intervention the provider suggests. When asked why it is important for residents to receive their medications, LPN #4 said, for the continuation of care, medication compliance and to maintain therapeutic levels. On 1/7/26 at 3:57 PM, an interview was conducted with the assistant director of nursing (ADON), who was a registered nurse (RN #1). RN #1 explained that if a medication is not available, the staff let us know and let the doctor know. We get an order to actually put it on hold until we get the medication, we call the pharmacy to see when we will get it, if it is not in the Omnicell. We don't have a big problem, usually we have the medications in the Omnicell. Review of the Omnicell contents listing provided by the facility revealed that of the five medications not administered to R8 on 5/4/25, only one was available in the Omnicell, which was Hydralazine 25 mg tablet. On 1/7/26 at 4:55 PM, during an end of day meeting with the facility's administrator, director of nursing (DON), and regional director of clinical services (RDCS), the above findings were discussed. The DON explained that during medication administration if a medication is not available, they [the staff] are to check the Omnicell and if it is not available contact the provider to initiate an alternative medication. Review of the facility policy titled, General Guidelines for Medication Administration with an effective date of 09-2018, was conducted. The policy read in part, . 11. If a medication with a current, active order cannot be located in the medication cart/drawer, other areas of the medication cart, medication room, and facility (e.g. other units) are searched, if possible. If the medication cannot be located after further investigation, the pharmacy is contacted or medication removed from the emergency kit. No further information was provided.

Based on staff interview, clinical record review, and facility documentation review, the facility staff failed to implement their abuse policy with regards to allegations of abuse involving one resident (Resident #1-R1) in a sample of ten residents.The findings included:For R1, who was involved in several resident-to-resident altercations, the facility staff failed to report the incidents of/allegations of abuse to the Ombudsman in accordance with their abuse policy. On 1/7/26-1/8/26 a clinical record review was conducted of R1's chart. This review revealed a progress note dated 11/2/25 that read, Resident was witnessed telling another resident to move from in front of his door holding a butter knife. Resident yelled, 'move her from in front of my door.' Removed resident and attempted to take butterknife and resident refused to give to write [sic]. On 1/7/26, a review of facility documentation revealed that the facility failed to send the investigation summary to the ombudsman and Adult protective services. Further review of facility documentation revealed a facility investigation summary dated 9/12/25 that described an incident where R1 was . struck from behind and that he responded by striking her back. The facility had no credible evidence that the incident was reported to the Ombudsman in accordance with their abuse policy. On 1/7/26 at 4:12 PM, an interview was conducted with R1. R1 was difficult to keep focused on the questions asked when the surveyor inquired about the above incidents. R1 did report that he gets along with everyone and wasn't able to give any details about the incidents. The facility's policy titled, Reporting Requirements/Investigations with an effective date of 02/05/2023, was reviewed. The policy read in part, 1. Immediately upon notification of any alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, the Administrator will immediately report to the State Agency, but not later than 2 hours after the allegation is made, if the events that caused the allegation involves abuse or results in serious bodily injury, or not later than 24 hours if the events that caused the allegation do not involve abuse and do not result in serious bodily injury. A. Notify the Adult Protective Services Agency, the local Ombudsman, and the appropriate local law enforcement authorities (police, sheriff's office, and/or medical examiner as deemed appropriate) for any incident of patient abuse, mistreatment, neglect, or misappropriation of personal property or other reasonable suspicion of a crime. On 1/7/26 at 4:55 PM, during an end of day meeting with the facility administrator, director of nursing, and regional director of clinical services the above findings were reviewed. On 1/8/26 at 8:23 AM, the facility administrator met with the surveyor and reported that she had come to the facility from another state and was not aware that incidents of abuse were reported to/sent to the Ombudsman. The administrator went on to state that she had received communication recently from the Ombudsman's office and was made aware of this requirement. The administrator stated she is now aware and would be reporting as required going forward. On 1/8/26 at 12:04 PM, during another meeting with the facility administrator, director of nursing and regional director of clinical services, the above findings were again reviewed.

2. For Resident #27 (R27), the facility staff failed to check placement and function of a wander guard (1) as ordered on multiple dates in October, November and December of 2024. On the most recent MDS (minimum data set), an annual assessment with an ARD (assessment reference date) of 10/20/24, the resident scored eight out of 15 on the BIMS (brief interview for mental status) assessment, indicating the resident was moderately impaired for making daily decisions. Section E documented no wandering behaviors. The assessment documented the use of a wander/elopement alarm used daily. The physician orders for R27 documented in part, Wander guard - Check placement, function and skin integrity every shift every shift for elopement. Order date: 05/01/2024. An elopement risk assessment dated [DATE] for R27 documented a high risk for elopement/exit seeking. The comprehensive care plan for R27 documented in part, The resident is at risk for elopement related to Dementia. Created on: 04/18/2023. Revision on: 10/19/2023. Under Interventions it documented in part, .Wander guard to left ankle check placement every shift. Date Initiated: 10/10/2023. Created on: 10/10/2023. Revision on: 10/10/2023. The eTAR (electronic treatment administration record) for R27 dated 10/1/24-10/31/24 failed to evidence ordered wander guard checks completed on evening shift of 10/5/24, 10/10/24 and 10/11/24. The eTAR for R27 dated 11/1/24-11/30/24 failed to evidence ordered wander guard checks completed on day shift of 11/19/24 and night shift on 11/24/24. The eTAR for R27 dated 12/1/24-12/31/24 failed to evidence ordered wander guard checks completed on day shift of 12/12/24, 12/16/24, 12/23/24 and evening shift on 12/3/24 and 12/9/24. On 1/2/25 at 10:10 a.m., an interview was conducted with LPN (licensed practical nurse) #1 who stated that treatments were evidenced as completed by signing off on the eTAR. On 1/2/25 at 4:18 p.m., an interview was conducted with LPN #2 who stated that wander guards were checked every shift. She stated that they checked placement and function and documented it on the eTAR to evidence that it was done. On 1/3/25 at 8:21 a.m., an interview was conducted with OSM (other staff member) #9, the director of maintenance. OSM #9 stated that the nurses applied the wander guards and checked them. He stated that once a month he checked the door alarms to ensure that the sensors worked. He stated that only the outside exterior doors had the alarms, and all the doors were checked daily Monday through Friday. On 1/3/25 at approximately 9:20 a.m. an observation was made of all facility doors, wander guard sensors were observed to be on the main entrance door, side administration door, rehab entrance and courtyard entrance. Other facility doors were observed to have emergency exit alarms and keypad locks. All doors were functioning at that time. The facility policy Elopement/Exit-Seeking Behaviors effective 1/29/24 failed to evidence guidance on checking the wander guard. On 1/3/25 at 12:09 p.m., ASM (administrative staff member) #1, interim administrator, ASM #2, assistant administrator, ASM #3, director of nursing, ASM #4, regional vice president of operations, and ASM #5, regional director of clinical services were made aware of the findings. No further information was provided prior to exit. Reference: (1) A WanderGuard system relies on three components: bracelets that residents wear, sensors that monitor doors and a technology platform that sends safety alerts in real time. When a resident with a bracelet approaches a monitored door, the system alerts your caregivers. Even more important, when paired with optional magnetic door locks, the door automatically locks. When a caregiver needs to escort a wander-prone resident outside the safe area, the caregiver can use a secure code to bypass the system. The system also works in areas without physical doors. These virtual boundaries help a community feel welcoming without compromising safety. This information was obtained from the website: https://www.securitashealthcare.com/blog/3-reasons-you-need-wanderguard-system 3. For Resident #8 (R8), the facility staff failed to ensure fall mats were in place when in bed as care planned for fall risk. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 9/14/24, the resident was assessed as being severely impaired for making daily decisions. The assessment documented no falls since the prior assessment. On 12/19/24 at 8:16 a.m., an observation was made of R8 in bed asleep. R8 was observed with the bed in the low position with no fall mats on either side of the bed. The comprehensive care plan for R8 documented in part, Resident has had actual falls & is at risk for falls related to cognitive impairment, muscle weakness, poor balance, unsteady gait recent, poor safety awareness, dementia, Prostate CA, incontinence, impaired mobility, cognitive impairment, dementia, communication impairment, metabolic encephalopathy, OA (osteoarthritis), nonambulatory, psychotropic med use, depression, malnutrition, HTN (hypertension). Created on: 04/05/2023. Revision on: 03/19/2024. Under Interventions it documented in part, .falls mats to side of bed (bilateral) while in bed. Date Initiated: 06/02/2023. Created on: 06/02/2023. Revision on: 09/06/2023 . A post fall risk assessment dated [DATE] for R8 documented a low risk for falls. On 12/20/24 at 11:50 a.m., an interview was conducted with LPN (licensed practical nurse) #27 who stated that fall mats were interventions to prevent falls. She stated that the nurses had access to the care plan and could see if a resident required fall mats when in bed and the CNAs (certified nursing assistants) had access to the Kardex. On 12/20/24 at approximately 12:15 p.m., an observation was made of R8's room where LPN #27 stated that she was not sure where the fall mat was for R8, but they should have one if it was on the care plan. The facility policy Falls Management Program effective 1/29/24 documented in part, .The center utilizes a systematic approach to a falls management program that facilitates an interdisciplinary approach with evidence-based interventions to develop individual care strategies . On 12/20/24 at 4:00 p.m., ASM (administrative staff member) #14, interim administrator, ASM #3, director of nursing, ASM #4, regional vice president of operations, ASM #5, regional director of clinical services, ASM #11, regional vice president of operations, ASM #15, regional director of clinical services, and ASM #12, administrator from sister facility were made aware of the findings. No further information was provided prior to exit. 4. For Resident #24 (R24), the facility staff failed to check placement and function of a wander guard (1) as ordered on multiple dates in June, July, and August of 2024. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 6/15/24, the resident scored three out of 15 on the BIMS (brief interview for mental status) assessment, indicating the resident was severely impaired for making daily decisions. Section E documented no wandering behaviors. The assessment documented the use of a wander/elopement alarm used daily. The physician orders for R24 documented in part, Check Wander Prevention patient Band every shift. every shift for Monitoring. Order date: 04/29/2024. An elopement risk assessment dated [DATE] for R24 documented at risk for elopement/exit seeking. The comprehensive care plan for R24 documented in part, The resident is at risk for elopement related to cognitive impaired, resident removes wanderguard. Created on: 04/17/2023. Revision on: 08/20/2024. Under Interventions it documented in part, Continue to check placement to right ankle every shift. Date Initiated: 04/17/2023. Created on: 04/17/2023. Revision on: 08/20/2024 . The eTAR (electronic treatment administration record) for R24 dated 6/1/24-6/30/24 failed to evidence ordered wander guard checks completed on day shift on 6/3/24 and on evening shift of 6/24/24. The eTAR for R24 dated 7/1/24-7/31/24 failed to evidence ordered wander guard checks completed on day shift of 7/21/24 and evening shift on 7/21/24. The eTAR for R24 dated 8/1/24-8/31/24 failed to evidence ordered wander guard checks completed on day shift of 8/4/24. The progress notes for R24 documented in part, - 01/07/2024 16:41 (4:41 p.m.) Note Text: This nurse was notified by Kitchen staff that the resident was outside lying on the ground. Resident was lying on in the grass on his left side. There were obvious abrasions to the left side of the face and eye. Residents mouth was actively bleeding. Staff immediately called 911 as well as contacted the MD and residents POA (power of attorney). Emergency services arrived and assisted staff with placing resident on the stretcher and resident was transferred to [Name of hospital]. - 01/07/2024 17:30 (5:30 p.m.) Note Text: This nurse communicated with the residents POA. POA was concerned about resident wearing his wander guard. POA was told that resident was seen walking down the hall with a bag of clothing at the start of the shift and this nurse and a CNA (certified nursing assistant) redirected the resident back to his room and checked to make sure that the wander guard was intact and it was. POA stated that she has known him to cut the wander guard off in the past. - 01/07/2024 22:52 (10:52 p.m.) Note Text: Resident returned to the facility via ambulance on a stretcher, resident was alert with confusion. Resident cleaned up and put clean dry clothes on. Evening medications were administered also PRN (as needed) Tramadol for complaints 7/10 all over pain. Resident continues to walk around the nurses station with redirection for safety reasons. Will continue to monitor. - 07/07/2024 17:20 (5:20 p.m.) Situation: Resident was walking around the facility and another resident's family member went outside and let [Name of R24] out. Activities employee spotted him and flagged down a CNA to redirect the resident back inside. Resident proceeded to walk to the back of the building when this nurse escorted the resident back inside the building without difficulty. Background: Resident has a histor [sic] of exit seeking behaviors. Assessment (RN)/Appearance (LPN): Resident unharmed in any wat [sic] alert and oriented VS (vital signs) WNL (within normal limits) NP (nurse practitioner) and Emergency contact aware . - 07/31/2024 19:15 (7:15 p.m.) Situation: Staff member was in dinner break and observed [Name of R24] outside in the parking lot. Staff was able to redirect resident back into the facility without difficulty into the door that is closest to his room. Background: Resident has a history of exit seeking and wears a wander guard per MD order that tested functional before and after this incident. Assessment (RN)/Appearance (LPN): Resident alert and oriented at baseline. Did not say where he was going or how he exit the building. No visible injuries were noted. VS 143\64 97.3 70 18 97% ORA (on room air) Resident denies any pain. Assessment: Residents's [sic] daughter was called at 2135 (9:35 p.m.) but this caller got no response. NP has been notified as well. Recommendation: Resident currently in TV room watching TV and staff is making frequent rounds . A high-risk note dated 7/12/24 documented a high-risk meeting with the IDT (interdisciplinary team) reviewing the elopement on 7/7/24 with R24's photo updated in the elopement book and the resident encouraged to attend activities. Facility elopement incident reports dated 7/7/24 and 7/31/24 were reviewed. A facility synopsis of events for R24 dated 1/7/24 documented in the final investigation, .On January 7, 2024, at about 1630 (4:30 p.m.), [Name of R24] removed his wander guard and exited the facility's front door. He walked on facility grounds and had a ground level fall with injury near an entrance on the left side. He was found by dietary staff who alerted nursing. Emergency first aid was provided, and he was sent out to the emergency department . Review of the documented door monitor and patient wandering system checks evidenced the doors checked Monday through Friday and functioning on Friday 1/5/24, Monday 1/8/24, Friday 7/5/24, Monday 7/8/24, and Wednesday 7/31/24. On 1/2/25 at 1:53 p.m., an interview was conducted with OSM (other staff member) #33, social worker who stated that they remembered R24 walking the hallways in the facility. She stated that she never saw R24 leave the facility, and he was easily redirectable. On 1/2/25 at 4:18 p.m., an interview was conducted with LPN (licensed practical nurse) #2 who stated that wander guards were checked every shift. She stated that they checked placement and function and documented it on the eTAR to evidence that it was done. She stated that R24 exited the building a couple of times following visitors out of the front door. She stated that one time the front desk person did not recognize him as a resident, and they found him in the parking lot and another time he followed someone out. She stated that she was unsure how the wander guards worked because she did not recall the door alarms going off when R24 was found in the parking lot however the wander guard was in place and functioning when he came back inside. She stated that she never witnessed R24 taking or cutting the wander guard off. On 1/2/25 at 4:56 p.m., an interview was conducted with LPN #29 who stated that wander guards were checked by holding a wand up to the device on the resident and it beeped green if working correctly or red if not working properly or the battery was getting low. He stated that they were checked at least once a day that he knew of and documented on the eTAR. He stated that he recalled R24 having a wander guard and the resident going out in the parking lot on one occasion and falling but he was not working that day. On 1/3/25 at 8:21 a.m., an interview was conducted with OSM (other staff member) #9, the director of maintenance. OSM #9 stated that the nurses applied the wander guards and checked them. He stated that once a month he checked the door alarms to ensure that the sensors worked. He stated that only the outside exterior doors had the alarms, and all the doors were checked daily Monday through Friday. On 1/3/25 at approximately 9:20 a.m. an observation was made of all facility doors, wander guard sensors were observed to be on the main entrance door, side administration door, rehab entrance and courtyard entrance. Other facility doors were observed to have emergency exit alarms and keypad locks. All doors were functioning at that time. On 1/3/25 at 12:09 p.m., ASM (administrative staff member) #1, interim administrator, ASM #2, assistant administrator, ASM #3, director of nursing, ASM #4, regional vice president of operations, and ASM #5, regional director of clinical services were made aware of the findings. No further information was provided prior to exit. Reference: (1) A WanderGuard system relies on three components: bracelets that residents wear, sensors that monitor doors and a technology platform that sends safety alerts in real time. When a resident with a bracelet approaches a monitored door, the system alerts your caregivers. Even more important, when paired with optional magnetic door locks, the door automatically locks. When a caregiver needs to escort a wander-prone resident outside the safe area, the caregiver can use a secure code to bypass the system. The system also works in areas without physical doors. These virtual boundaries help a community feel welcoming without compromising safety. This information was obtained from the website: https://www.securitashealthcare.com/blog/3-reasons-you-need-wanderguard-system 5. For R2, facility staff failed to complete a fall investigation following a fall on 06/11/2023. R2 was admitted to the facility with diagnoses that included but were not limited to hemiplegia (1) and muscle weakness. On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 05/11/2023, R2 scored 11 out of 15 on the BIMS (brief interview for mental status), indicating R2 was moderately impaired of cognition for making daily decisions. The comprehensive care plan for R2 documented, Focus: the resident has had actual fall & (and) is at risk for falls/injuries related to impaired mobility, psychotropic medication use, pain medication use/c/o pain, incontinence of B&B (bowel and bladder), brain tumor, left sided weakness, neuropathy, malnutrition, RA (rheumatoid arthritis), difficulty walking, glaucoma, eyeglasses Created on: 05/05/2023. Under Interventions it documented, administer medications as ordered. Date Initiated: 01/02/2025 Created on: 05/16/2023 Revision on: 01/02/2025; encourage the resident to wear their glasses when out of bed. Date Initiated: 01/02/2025 Created on: 05/16/2023 Revision on: 01/02/2025; ensure proper positioning in bed. Date Initiated: 01/02/2025 Created on: 06/09/2023 Revision on: 01/02/2025; ensure the resident wears shoes when ambulating. Date Initiated: 01/02/2025 Created on: 05/16/2023 Revision on: 01/02/2025; falls mats to sides of bed Date Initiated: 01/02/2025 Created on: 06/09/2023 Revision on: 01/02/2025; non-skid socks while out of bed. Date Initiated: 01/02/2025 Created on: 05/16/2023 Revision on: 01/02/2025; place bed in lowest position while resident is in bed. Date Initiated: 01/02/2025 Created on: 06/09/2023 Revision on: 01/02/2025; place common items within reach of the resident Date Initiated: 01/02/2025 Created on: 05/05/2023 Revision on: 01/02/2025; remind the resident to use their call light to ask for assistance with ADLS. Date Initiated: 01/02/2025 Created on: 05/05/2023 Revision on: 01/02/2025; Therapy referral as indicated. Date Initiated: 01/02/2025 Created on: 05/16/2023 Revision on: 01/02/2025; use of wedges for bed positioning. Date Initiated: 01/02/2025 Created on: 06/09/2023 Revision on: 01/02/2025; wheelchair for ambulation and transfers Date Initiated: 01/02/2025. The facility's Fall Risk Evaluation for R2 dated 06/09/2023 documented in part, Mental Status: intermittent confusion. History of falling (in the last 3 months])? No. Category: No fall or fracture. Further review of the fall assessment indicated R2 was at moderate risk for falls. The facility's nurse's note dated 06/11/2023 documented, Description of the fall/V (vitals)/S (situation)/injuries if any: VS (vital signs) 98.4 (temperature), 144/80 (blood pressure) 88 (pulse) 20 (respiration). unwitnessed fall lying on floor left side of bed on back. What Interventions were in place at the time of the fall? : fall mat. What are the risk factors that could have contributed to the fall?: pain, anxiety preexisting health hx (history). What new Interventions were implemented in response to the fall?: na (not applicable). Was the Provider/resident and RP (responsible party) notified at the time of the fall?: yes MD (medical doctor)/POA (power of attorney) Additional Comments: Resident sent to ER (emergency room) for evaluation. The facility's nurse's note dated 06/12/2023 documented, Note Text: LOA (leave of absence) to Hospital. On 01/02/2025 at approximately 10:15 a.m., an interview was conducted with ASM (administrative staff member) #23 and ASM #5, regional director of clinical services. ASM #5 stated that the facility did not have evidence of a fall investigation for R2's fall on 06/11/2023. On 01/03/2025 at approximately 9:05 a.m., an interview was conducted with ASM #3 regarding the procedure following a resident's unwitnessed fall. She stated that residents should be assessed for injury, a skin assessment should be conducted, notification to the physician and responsible party as well as the administrator and director of nursing. According to ASM #3, a post-fall evaluation and neurological checks should be completed. If the resident demonstrates anything abnormal, notify the physician to send the resident to the hospital and obtain a staff statement. ASM #3 further stated if the resident sustained a serious or immediate injury such as a fracture, 911 would be called immediately. On 01/02/2025 at 11:16 a.m., a request was made to obtain hospital records related to R2's fall and admission to the hospital's emergency room. By the time of this writing, 01/08/2025 at 12:06 p.m., the requested hospital records regarding R2's fall and admission to the hospital on [DATE] were not received. On 01/03/2025 at approximately 12:09 p.m., ASM (administrative staff member) #1, interim administrator, ASM #2, assistant administrator, ASM #3, director of nursing, ASM #4, regional vice president of operations, and ASM #5, regional director of clinical services, were made aware of the above findings. No further information was provided prior to exit. References: (1) The loss of muscle function in part of your body. Paralysis can be complete or partial. It can occur on one or both sides of your body. It can also occur in just one area, or it can be widespread. This information was obtained from the website: https://medlineplus.gov/paralysis.html. Based on staff interview, facility document review and clinical review, it was determined the facility staff failed to provide supervision and to implement safety procedures to prevent injuries for five (5) of 33 residents in the survey sample, Resident #1, #27, #8, #24, and #2. For Resident #1, the facility staff failed to ensure a resident was transferred in a manner to prevent a fracture of the distal fibula (lower end, near the ankle, of the small bone in the lower leg) that resulted in harm. The findings include: 1. For Resident #1(R1), the facility staff failed to ensure the resident was transferred in a manner to prevent a fracture of the distal fibula in April 2024 that resulted in harm. The most recent MDS (minimum data set) assessment, prior to the fracture in April 2024, with an assessment reference date of 3/28/24, the resident scored a 14 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired for making daily decisions. In Section GG, Functional Abilities and Goals, the resident was coded as being dependent for sit to standing and for chair/bed-to chair transfers. In Section GG0115 - Functional Limitation in Range of Motion, R1 was coded as having limitations in range of motion on one upper extremity (arms) and both lower extremities (legs). The comprehensive care plan dated 2/2/2018 and revised on 1/4/24, documented in part, Focus: At risk for falls due to impaired balance/poor coordination. She uses a motorized w/c (wheelchair) for transportation. She is able to release seat belt on command, peripheral neuropathy, OA (osteoarthritis) HTN (high blood pressure), RA (rheumatoid arthritis), poor musculoskeletal control, muscle weakness, other lack of coordination, incontinence, neuropathy, CP (cerebral palsy), visual impairment. The Interventions revised on 9/8/22, documented in part, Provide assistance to transfer as needed (assist of two as needed). Focus: ADL (activity of daily living) Self-care deficit related to physical limitations. She has a dx (diagnosis) of Cerebral Palsy, R (right) hand contracture. The Interventions revised on 9/8/22, documented in part, Assist of (1 person/2 person) with ADL's as needed. The nurse practitioner note dated, 4/17/24 at 3:39 p.m. documented in part, Pt (patient) seen today for c/o (complaint of) left ankle pain and swelling x 1-2 weeks. Would like some Tylenol. Wears TED (anti-embolism stockings) hose daily for support. Ankle feels stiff. Denies numbness and tingling. The nurses' note dated, 4/18/24 at 5:43 p.m. documented, Received call from (name of radiology company), reporting that she (R1) has a fractured distal fibular (sic). Left message for NP (nurse practitioner). Resident denied pain when asked. The nurse's note dated 4/18/24 at 6:31 p.m. documented, Received fax report of resident's results for x-ray taken earlier today. Report indicates fracture to left distal fibular. Updated NP with results. Spoke with resident and asked if she experienced a fall recently. Resident stated that she has not fallen, but approximately two weeks ago there were two aids getting her up to her power chair, her foot somehow got caught on or beneath the power chair at the moment the aids pulled her upward to sit her in the chair. She remembers this because she states this particular incident hurt left ankle and this is the only incident that has occurred that caused significant pain to that body part. Resident did not recall the names of the aides that were assisting her but stated that they are not the regular staff that works with her. The x-ray report dated, 4/18/24 documented in part, Findings: A fracture of the distal fibula is identified. The fracture does not involve the articular surface (1). No callus formation is noted. The ankle mortise (2) is intact. The surrounding soft tissues are normal. The facility synopsis of event dated, 4/19/24, documented, This is the final for Injury of Unknown Origin related to (R1) reported April 18, 2024. (R1) stated that two weeks ago, two CNAs (certified nursing assistants) were getting her up to her power chair and her left foot got hung on the chair. MD (medical doctor) and RP (responsible party) made aware. (R1) is a [AGE] year-old female with medical diagnoses not limited to Cerebral Palsy, Type 2 diabetes mellitus, COPD (chronic obstructive pulmonary disease), glaucoma, GERD (gastroesophageal reflux disease), BIMS (brief interview for mental status) score is 14. Resident interviewed; medical records reviewed. On April 18, 2024, (R1) complained of pain in her left foot. Upon observation, (R1) foot was swollen. When asked if she had fallen, (R1) stated that two weeks ago, two CNAs were getting her up to her power wheelchair and her foot got hung as they were trying to position her in the chair. (R1) said she did not say anything at the time it happened because she was not in any pain. An x-ray was ordered and done in which the results showed a fracture of the left distal fibular. (R1) denies any abuse from staff. (R1) as an ortho (orthopedic) appointment on April 22nd at 1425 (2:15 p.m.). Resident and staff interviewed; medical records reviewed. The allegation of abuse was unsubstantiated. Staff will have an in-service on safe transfers. The file with the above synopsis had no other documents in the file folder. There was no documented evidence of interviews with staff and further information regarding a complete investigation into the fracture. The folder containing the investigation into the fractured ankle was reviewed with ASM (administrative staff member) #4, the regional vice president of operations. He stated there should be more documents, staff interviews, x-ray reports, in the folder. ASM #4 returned at 2:44 p.m. returned and stated he couldn't find any further documentation related to the fracture of R1. An interview was conducted with CNA (certified nursing assistant) #4 on 1/2/25 at 11:38 a.m. CNA #4 was normally assigned to provide care and transfers to R1. CNA #4 explained and demonstrated, R1 was transferred in two different ways. Some days two staff members would lift under her arms, grab the back of her pants, put her (CNA) foot in front of the resident's feet and lift. CNA #4 said, The resident could pivot a little, she could not stand or bear weight, just put her feet on the floor. Other days, when the resident couldn't help, we lifted her with one CNA on each side of the resident, lifting her under the arms and under her knees, a full lift. The CNA said a gait belt was not used, but sometimes they grabbed the resident's pants and waistband to facilitate transfers. CNA #4 said she was not involved with the transfer of R1 when the resident's left foot was caught on or beneath the power chair. The facility policy provided, in part, Bed to Chair or Wheelchair Transfers documented in part, The following stand and pivot transfers are used if: the person's legs are strong enough to bear some or all of his or her weight. The person is cooperative and can follow directions. The person can assist with the transfer .Safety: The chair, wheelchair, or other device must support the person's weight. The number of staff members needed for a transfer depends on the person' abilities, condition and size. For some persons, you will use mechanical assist devices. The person must not put his or her arms around your neck. Otherwise, the person can pull you forward or cause you to lose your balance. Neck, back and other injuries from falls are possible. If not using a mechanical device, using a gait/transfer belt is the preferred method for chair or wheelchair transfers. It is safer for the person and you. Putting your arms around the person and grasping the shoulder blades is the other method. It can cause the person discomfort. And it can be stressful for you. Use this method only if instructed to do so by the nurse and the care plan .16. Apply the transfer belt. a. Stand in front of the person. b. Have the person hold on to the mattress. c. Make sure the person's feet are flat on the floor. d. Have the person lean forward. e. Grasp the transfer belt at each side. Grasp the handles or grasp the belt from underneath. f. Prevent the person from sliding or falling by doing one of the following: 1. Brace your knees against the person's knees. Block his or her feet with your feet. 2. Use the knee and foot of one leg to black the person's weak leg or foot. Place your other foot slightly behind you for balance. 3. Straddle your legs around the person's weak leg. ASM #2, the assistant administrator, ASM #3, the director of nursing, ASM #5, the regional director of clinical services, ASM #1, the interim administrator, and ASM #4, the regional vice president of operations, were made aware of the above concern for harm on 1/2/25 at 5:36 p.m. No further information was provided prior to exit. (1) Articular Surface - any surface of a skeletal formation (bone, cartilage) that makes normal direct contact with another skeletal structure as part of a synovial joint; bony articular surfaces are usually covered with articular cartilage. This information was obtained from the following website: https://medical-dictionary.thefreedictionary.com/articular+surface. (2) The ankle mortise is the socket formed by the tibia and fibula bones of the lower leg. This socket holds the talus bone of the foot, creating the ankle joint. The alignment and interaction between these bones allow for smooth and stable movement of the foot. This information was obtained from the following website: https://radiologyinplainenglish.com/ankle-mortise

Based on staff interview, clinical record review, and facility documentation the facility failed to ensure Residents were free from accidents and hazards for 2 Residents (#212 and #72) in a survey sample of 59 Residents resulting in harm for Resident #212. 1. For Resident #212 the facility failed to adequately supervise and monitor closely for pulling at [MEDICAL TREATMENT] port resulting in Resident pulling off the caps of the port and subsequently bleeding out which resulted in death. This is harm. 2. For Resident #72, the facility staff failed to follow physician's orders [REDACTED]. Resident #72 was observed drinking water at bedside, unsupervised, through a straw. Also, the discharge diet recommendation from occupational therapy dated [DATE] included supervision. The findings include: 1. For Resident #212 the facility failed to adequately supervise and monitor closely for pulling at [MEDICAL TREATMENT] port resulting in Resident pulling off the caps of the port and subsequently bleeding out which resulted in death. This is harm. Resident #212 an [AGE] year old woman admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #212's most recent (Minimum Data Set) MDS (screening tool) was a quarterly completed on [DATE] and coded Resident as having a (Brief Interview of Mental Status) score of 99 meaning Severe Cognitive Impairment she was also coded under G 0110 as #3 Extensive Assistance- Resident involved in activity, staff provide wt. bearing support and Support was coded as #2 One person physical assist. On [DATE] a clinical record review was conducted. Resident #212's Care Plan showed the following: F[NAME]US: Resistive/noncompliant with treatment /care/pulling at [MEDICAL TREATMENT] port while at [MEDICAL TREATMENT]/LTCF, removing oxygen related to cognitive impairment and anxiety (initiated [DATE]). (Dated [DATE] no revision until [DATE] after resident expired) INTERVENTIONS: Allow for flexibility in ADL routine to accommodate mood preferences and customary routine Ask physician to explain the need for treatment Elicit family input for best compliance Provide education about Risks of not complying with therapeutic regimen Provide non care related conversation proactively before attempting ADL's Psych consult as needed. (Dated [DATE] no revision until [DATE] after resident expired) On page 23 of the care plan the following was entered on [DATE]: F[NAME]US: At risk for behavior symptoms related to [MEDICAL CONDITION]. Resident has a history of pulling at port, Scratches self. INTERVENTIONS: Administer medication per physician order Attempt [MEDICAL CONDITION] drug reduction per physician order Observe for mental status/behavioral changes when new medication is started or with change in dosage Psych referral as needed Use consistent approaches when giving care Wander guard bracelet (canceled on [DATE]) According to a progress note dated [DATE] @ 11:45 AM the [MEDICAL TREATMENT] Center phoned the facility at 6:20 AM to inform them that Resident #212 was confused and pulled her bandage off. According to progress notes, a care plan meeting was held on [DATE] at 6:27 AM. The note stated the following departments were present. Social Services, Nursing Case Manager, and it stated the Patient Representative was invited but did not attend. The note goes on to say the topics discussed were Discharge Goal, Advanced Directives, Cognition/Orientation Mood and Behavior, Social Service needs, Medications and Treatments, Continence/ Elimination, Risk for skin breakdown, Communication, Pain management, Nutrition,, ADL function, Risk for Falls,/safety activities. The summary stated (Interdisciplinary Care Plan) IDCP team met to review plan of care. Care plans updated as needed. Team to remain available as needed. On [DATE] during clinical record review it was noted that no changes were made to the care plan on [DATE] as a result of the care plan meeting or thereafter. A progress notes dated [DATE] at 10:50 AM stated: Change in condition noted related to removing top from shunt port bleed out and remove scab from upper left leg above knee. This change in condition started on [DATE]. Since this started she has stayed the same. Other relevant information RP (Responsible Party) RP N states She has a History of doing this it's not the first time at home you walk in her bedroom and blood would be everywhere. According to note, the Nurse Practitioner was informed on [DATE] at 11:00 AM and gave orders only to clean and redress the right upper chest (port site) and dress (as needed) PRN. Also to clean area to knee and redress daily. The Behavioral Tracking Sheets for ,[DATE] code Resident and #7 Pulling enteral feeding tube she is coded as O (indicating number of times pulling at tube) every shift for entire month. For (MONTH) and (MONTH) the behavior tracking sheets do not list #7 pulling tubes as a behavior problem in spite of the incident on [DATE]. A progress notes on [DATE] at 05:30 am stated: Resident last rounded on at 4:05 AM. Dressing to [MEDICAL TREATMENT] port dry and intact. Resident acknowledged staff presence by opening eyes while site being checked. Progress note on [DATE] at 05:30 am stated: Change in condition noted related to Resident noted laying in a pool of blood at 0530 when phlebotomist entered to draw blood. Writer entered room noted resident 911 without respirations or pulse. This change in condition started on [DATE]. Since this started it has stayed the same. Other relevant information 911 called. According to Facility Reported Incident (FRI) dated [DATE] Resident #212 had a BIMS of 99 and requires minimal assistance with care. The FRI also stated: Upon investigation and based on the findings per family, [MEDICAL TREATMENT] center, and the staff at (Facility Name) the resident had a history of [REDACTED]. (Resident name) removed her [MEDICAL TREATMENT] dressing and port caps causing her to bleed excessively. We do not feel evidence supports any other cause that contributed to this unfortunate event of (Resident Name). On [DATE] at 5:00pm, an interview with the DON was conducted. The DON stated she was not in the facility when the Resident was there The DON was asked what the expectation for nurses and CNA's for a Cognitively Impaired Resident with a known history of pulling at her [MEDICAL TREATMENT] port. The DON stated she wound expect frequent rounding, a bandage might cause her to pick at it more. When asked what is frequent, the DON stated every 2 hours. On [DATE] at 5:10 pm an interview was conducted with the Administrator. The administrator stated that they do not have any other cognitively impaired residents that pull at the [MEDICAL TREATMENT] port. She stated she was aware the staff made routine rounds every two hours on all Residents. On [DATE] 520 pm, an interview was conducted with RN A. When asked what the facility did about the Resident pulling at the [MEDICAL TREATMENT] port, RN A stated, we used to wrap it in gauze and tape it. When asked if it was a deterrent to the Resident, RN A stated, Not really it slowed her down but didn't really stop her from doing it. When asked is resident education an appropriate intervention for a Resident with a BIMS of 99, RN A answered, no we could tell her but she wouldn't understand. On [DATE] the Administrator was made aware of the issue and no further information was provided. 2. For Resident #72, the facility staff failed to follow physician's orders [REDACTED]. Resident #72 was observed drinking water at bedside, unsupervised, through a straw. Also, the discharge diet recommendation from occupational therapy dated [DATE] included supervision. Resident #72, a [AGE] year old female, had an initial admission date of [DATE]. [DIAGNOSES REDACTED]. Resident #72's most recent Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE] was coded as an annual assessment. Resident #72's Brief Interview for Mental Status (BIMS) was coded as 9 out of possible 15 indicative of moderate cognitive impairment. Functional status for eating was coded as requiring limited assistance from staff. Functional status for dressing, toileting, and personal hygiene were coded as requiring extensive assistance from staff. On [DATE] at 8:13 AM, Resident #72 was observed seated in front of her tray table in her room. Her breakfast tray and water pitcher (with a straw inserted through the top of it) was on the tray table. A spoon was on the plate and the plate was empty except for some small bits of scrambled eggs and sausage. The milk carton was open and empty on the tray. The apple juice was unopened. Resident #72 was observed picking up her water pitcher and sipping water from it through the straw. There was no staff in the room. The tray card had Resident #72's name on it and under Texture, it was documented, Mech (mechanically) Altered (NDD2)(National Dysphagia Diet, Level 2) Bread Allowed. Under Special Diets, it was documented, HCC/CCHO (high calorie consistent carbohydrate). Under Adaptive Equipment, it was documented, No straws. On [DATE] at 8:32 AM, Resident #72 was observed sleeping in her bed, lying on her right side. She was wearing a pink shirt and covered with her blankets. The tray table had her water pitcher on it with a rigid plastic straw inserted through the top of the pitcher. On [DATE] at 8:35 AM, the physician's orders [REDACTED]. On [DATE] at 8:44 AM, CNA B was asked where she finds information about what Resident #72 needs for eating and she stated, The kardex. Looking at the Kardex together, we saw it was documented, No straws. When CNA B was asked why Resident #72 could not have straws, she stated, Because she could aspirate. On [DATE] at 9:40 AM, Resident #72 was observed sitting up in front of her tray table. There was bits of French toast and sausage left on the plate. The water pitcher with a straw was also on the tray and the end of the straw had a lipstick stain on the end. There was no staff in the room. An aide entered the room to take the tray away and placed the water pitcher (with the straw inserted through the top) in front of Resident #72. On [DATE] at 12:47 PM, RN A and this surveyor reviewed the current physician's diet order (including no straws) together. RN A and this surveyor then entered Resident #72's room. The water pitcher with a straw was on Resident #72's tray table. When asked about the water pitcher, RN A picked up the water pitcher and placed it back on the table and stated, She can have thin liquids. When asked about the straw, she stated, oh, the straw. RN A removed it from the water pitcher, and threw it in the trash. The speech therapy notes were reviewed. The resident was seen in (MONTH) (YEAR) by speech therapy. The referral stated to see if the resident was on the least restrictive diet. At the time the resident was on mechanically altered diet. At the end of speech therapy that ranged from [DATE] to [DATE], the discharge plan dated [DATE] documented, Discharge planned for this patient. Recommendations discussed with patient and/or caregivers include Regular textured solids and thin liquids. Swallow strategies to include alternate solids/liquids and take small bites/sips. For speech therapy services with a range of [DATE] through [DATE], a speech therapy note dated [DATE] documented in the 'Reason for Referral' section, The LTC (long-term care) resident was recently hospitalized for [REDACTED]. readmitted on mechanically altered diet and thin liquids. Skilled Speech Therapy evaluation is indicated to assess swallowing function and ensure patient is on safest and least restrictive diet. Under Prior hospitalization , the dates listed were [DATE] to [DATE]. In the 'Underlying Impairments' section, it was documented, MBS (modified [MEDICATION NAME] swallow) completed inpatient on [DATE]: flash penetration of thin liquid trial by straw, no penetration/aspiration of other trials, thin, nectar, puree, or solid; Rec'd (recommended) mechanically altered diet with thin liquids and no straws. Limited natural dentition. A speech therapy note dated [DATE] documented under 'Discharge Plans & Instructions', Discharge planned for this patient. Recommendations discussed with patient and/or caregivers include NDD2 mechanically altered solids and thin liquids with supervision for carryover of compensatory swallow strategies. On [DATE] at approximately 10:15 AM, an interview with Employee F, a speech therapist, was conducted. As Employee F looked at Resident #72's electronic medical record, she stated that Resident #72 was seen by speech therapy beginning [DATE] to evaluate if Resident #72 was on the least restrictive diet. Employee F stated that Resident #72 was on a mechanically altered diet at the time. Employee F stated that upon discharge from speech therapy services on [DATE], it was recommended that Resident #72 advance to a diet of regular textured solids and thin liquids. When asked about the physician's diet order that included no straws, Employee F stated that must be based on the recommendation from the results of the modified [MEDICATION NAME] swallow when (Resident #72) was an inpatient. She also verified that the speech therapy diet recommendation on [DATE] was mechanically altered diet with supervision. The current physician's orders [REDACTED]. The care plan was reviewed. For the focus of Imbalanced nutrition and fluid imbalance, an intervention initiated on [DATE] and revised on [DATE] documented, Provide diet as ordered NDD2/bread allowed HCC/CCHO, thin, NO STRAWS. An intervention initiated on [DATE] documented, Encourage and assist as needed to consume foods and/or supplements and fluids offered at and between meals. On [DATE] at approximately 6:30 PM, the Administrator and DON were notified of findings and offered no further information or documentation.

Based on staff interview, facility documentation review, clinical record review, hospital record review, and in the course of a complaint investigation, the facility staff failed to ensure the highest practicable well being for 4 Residents (Residents #76, #78, #260, and #210), resulting in harm for Resident #76 in a survey sample of 59 residents. 1. For Resident #76, the facility staff failed to provide care and treatment for [REDACTED]. This is harm. 2. Resident #78 had two episodes of impaction without timely treatment, resulting in nausea and vomiting and admissions to the hospital. 3. Resident #260 did not receive his antifungal for complaints of thrush timely. 4. The facility staff failed to assess and implement bowel protocol for Resident #210. The finding included: 1. For Resident #76, the facility staff failed to provide care and treatment for [REDACTED]. This is harm. Resident #76, a [AGE] year old female, was initially admitted to the facility on [DATE] with a recent readmission on 1/14/18. Her [DIAGNOSES REDACTED]. disease, acquired absence of left leg below knee. Resident #76's most recent MDS with an ARD (assessment reference date) of 12/20/18 was coded as a quarterly assessment. Resident #76 was coded as having a BIMS (Brief Interview for Memory Status) score of 15 indicating no cognitive impairment. She was also coded as requiring supervision with her activities of daily living except coded as requiring limited assistance of one staff member for dressing. She is coded as being occasionally incontinent of bladder and frequently incontinent of bowel. On 2/21/19 at 4:31 PM, during interview with Resident #76, she was observed with two small cups on her over bed table. One with a cream and a powder in the other. When the resident was asked about it she stated the powder is [MEDICATION NAME] and I don't know the name of the cream but the nurses bring it to me several times a day to put on my rash. Resident #76 stated, I have rashes due to my pull ups and I can't put any clothes on, it gets really red and bloody. They said there was nothing else they can do for me because the company doesn't make anything else due to the size. I've talked to (Employee H) but she said she can't find any other big ones. This has gone on for quite some time, Dr. has put me on antibiotics and some cream before. I'm getting depressed because I don't know what to do, do I stay in my room in my housecoat all the time? Resident #76 has not been assessed, nor found to be safe to self administer medications. On 2/22/19 at 10:03am, during an interview with Resident #76, she stated I have tried underwear with the pad but I soak right through them. I can't live in my housecoat and gown all the time. I can't go in a gown with no pants on. I feel isolation and depressed, I loved to go to activities and now I can't. (Employee H) tells me there is nothing else. A record review on 2/22/19 revealed Resident #76 is on [MEDICATION NAME] tab 5mg 1 tablet by mouth twice daily for overactive bladder. She is also on [MEDICATION NAME] tab 25 mg 2 tablets (50mg) by mouth twice daily for urinary frequency. Her MDS with an ARD of 12/20/18 was coded that she needs supervision, set-up help only with toileting. It was also coded that she is occasionally incontinent of bladder and frequently incontinent of bowel. Nursing Notes dated 12/20/18 state resident offered briefs and mesh liners. Resident is able to use bathroom for toileting but chooses not to. During an observation of Resident #76's groin by another surveyor on 2/22/19 at 10:07am with LPN A present, the surveyor stated; it is bleeding with red open weeping areas, and looks like moisture, it doesn't look like yeast, LPN A stated yeah, it's moisture. LPN A asked the resident what kind of soap are you using? Resident #76 states she went 2 weeks without wearing clothes and it got better. LPN A stated this has been a concern of hers, she has voiced her concern about her briefs, they have been trying to see if the company has anything else. Employee H talked to me two weeks ago or about a month ago. She has talked to the Nurse Practitioner. On 2/22/19 at 10:19am during interview with Employee H, she stated I've talked to her several times and have offered the best solution, she has the largest pullup the manufacturer offers. I have offered mesh underwear with pads but she doesn't want to do that, says she tried it in the past and it didn't work. She said they are too tight in the leg area and I told her we don't offer a different brand. When asked how long Resident #76 has been complaining, Employee H said its been going on for the last month but she spoke with me about it before about four months ago, I wish I could help her, I really do. When asked , if they had considered cloth options employee H said I would have to see, its not on my formulary, I may have to call and get them to add it. On 2/22/19 at 10:57am Employee H returned and stated I called my manufacturer and they don't offer it, my representative said they had never heard of them but she's not going to go for this. She told me it was too tight, not that it was breaking her out, she said it was rubbing her legs, today y'all are the first ones to tell me it was a rash. Review of weekly skin assessment reports for Resident #76 showed her groin area was pink on 12/10/18. Weekly skin assessments dated 1/7/19, 1/21/19, and 1/28/19 noted treatment to groin area. The assessment dated [DATE] indicated there was redness with treatment. The 2/11/19 assessment indicated treatment to groin, and the 2/18/19 assessment indicated redness with treatment. A review of progress notes on 2/22/19 showed Resident #76 reported to the nurse practitioner on 12/19/18 that she had chronic groin discomfort. On 12/20/18, the resident reported to the Nurse Practitioner that her groin discomfort improved and the Nurse Practitioner wrote to continue with warm compresses and epson salt. There was no further evidence in the clinical record review that the warm compresses were being administered. On 1/3/19 nursing note read, patient does not have a possible or active infection. A note dated 1/8/19 read, patient does not have a possible or active infection. A review of Resident #76's treatment record dated 12/1/18-12/31/18 had the following orders to the groin: [MEDICATION NAME] Cream apply topically to affected area twice daily. However, this was not signed off as being completed on two occasions on 12/14, 12/21, 12/26, and 12/27. Epsom Salt Gra (sic) Topical soaks to bilateral groin and ABD (Abdominal) folds q (every) shift. This was started on 12/19/18. However, the treatment record showed this treatment was not provided on: 12/28, two omissions on 12/29, two omissions on 12/30, and 12/31. [MEDICATION NAME] ointment 0.05% apply thin layer topically to affected area twice daily. However this was not signed off as being administered any for the month of Dec. [MEDICATION NAME] Ointment 500/gm cleanse right side groin area with normal saline and apply [MEDICATION NAME] to affected area topically every shift. However, this was not signed off on 7a-3pm shift on 12/12, 12/13, 12/14, 12/17, 12/18, 12/19, 12/20, 12/21, 12/22, 12/23, 12/24, 12/26, 12/27, 12/28, 12/31; and was not signed off as being administered on 3p-11p shift on 12/14, 12/23, 12/24, 12/27. 12/31; and was not signed off as being administered on 11p-7a shift on 12/12, 12/17. Review of Resident #76's treatment record dated 1/1/19-1/31/19 had the following orders to the groin: [MEDICATION NAME] Cream apply topically to affected area twice daily. However, this was not signed off as being completed on 1/28, 1/29, 1/30, 1/31. Epsom Salt Gra (sic) Topical soaks to bilateral groin and ABD (Abdominal) folds q (every) shift. However, the treatment record showed this treatment was not provided on: 1/1, 1/28, 1/29, 1/30, 1/31 . [MEDICATION NAME] Ointment 500/gm cleanse right side groin area with normal saline and apply [MEDICATION NAME] to affected area topically every shift. However, this order was not administered on the following dates: 1/6, 1/9, 1/10, 1/11, 1/13, 1/14, 1/15, 1/25, two omissions on 1/28, 1/19, 1/30 and two omissions on 1/31. Review of Resident #76's treatment record dated 2/1/19-2/28/19 has the following orders to the groin: [MEDICATION NAME] Cream apply topically to affected area twice daily. Epsom Salt Gra (sic) Topical soaks to bilateral groin and ABD (Abdominal) folds q (every) shift. The order was discontinued on 2/5/19. However, the treatment record indicates this treatment was not provided on: three omissions on 2/2, two omissions on 2/3, 2/4. [MEDICATION NAME] Ointment 500/gm cleanse right side groin area with normal saline and apply [MEDICATION NAME] to affected area topically every shift. However, this order was not administered on 2/15, 2/20. Review a physician's orders [REDACTED]. Another physician order [REDACTED]. Although the [MEDICATION NAME] cream was ordered 2/11/19, it was not on the treatment record for February. During an interview with Resident #76 on 2/21/19 at 04:31 PM, it was observed on her overbed table two small cups with a cream in one and a powder in the other. When the resident was asked about it she stated the powder is [MEDICATION NAME] and I don't know the name of the cream but the nurses bring it to me several times a day to put on my rash. She indicates that staff bring it to her for her to apply herself. A review of Resident #76's most recent MDS with an ARD of 12/20/18 which was a quarterly assessment indicated she scored 00 for mood interview indicating she has no sign or symptoms of depression. During resident interviews on 2/21/19, 2/22/19 and 2/25/19 she verbalized being depressed and became tearful, which she relates to the rash on her groin. On 02/25/19 at 11:45 AM, during follow up interview with resident in her room, Resident #76 was asked if anyone followed up with her about her incontinence supplies she says I haven't seen anyone. I don't know what they are going to do. The nurse practitioner is here and asked how I was doing, so I told her not good (RN A) kept asking about the soap I am using. Resident #76 became tearful and said I just want to wear clothes and be out there with everyone else. On 02/25/19 at 11:56 AM, an interview was conducted with Employee D, the Activity Director. When Employee D was asked about her activity participation she stated Resident #76 is very independent, likes Bingo, parties, crafts, goes on Lunch Bunch. Employee D further stated when Resident #76 attends group activities she wears regular clothes, sometimes shorts. Employee D acknowledged that her participation has decreased slightly, she told the assistant she doesn't feel well. A review of activity progress notes from 11/1/16-1/2/19 showed that she participates in at least 3 OOR (out of room) activities each week, was happy to resume activities and the socialization with others, attends activities of choice 5-7 times per week, Participates in activities of choice daily both in room and out of room, resident continues to participate in activities of choice both independently and OOR groups on a daily basis. The review of her activity attendance indicated the Resident #76 attended 22 group activities in December, attended 17 in (MONTH) and has attended 9 from (MONTH) 1st until 2/24/19. The administrator and DON were made aware of the findings on 2/25/19. No further information was provided. 2. Resident #78 had two episodes of impaction without timely treatment, resulting in nausea and vomiting and admissions to the hospital. Resident #78, was admitted to the facility on [DATE] and was readmitted on [DATE]. Diagnoses included; stroke, anxiety, history of small bowel obstruction and [MEDICAL CONDITION]. Resident #78's most recent MDS (minimum data set) with an ARD (assessment reference date) of 1-8-19 was coded as a significant change in status assessment. Resident #78 was coded as having no memory deficits, did not refuse care, and was able to make own daily life decisions. The Resident was also coded as needing extensive assistance of one to staff members to perform his activities of daily living, except for independent locomotion, both on and off the units. On 2/20/19 at 1:30 PM: An interview was conducted with Resident #78. He stated he had weight loss due to recent problems with intestines. Review of the resident's bowel movements (BM) from 9-20-18 to 9-23-18 (4 days), showed Resident #78 had no BM during this time. A laxative protocol was not initiated, usually consisting of milk of magnesia, [MEDICATION NAME] suppository, and then enemas. On 9-24-18, nurse's notes documented noted with nausea and vomiting three times that day. Senna 8.6 mg (milligrams) 1 tablet was ordered, which was not given. A KUB (x-ray of kidneys, ureters and bladder) revealed an early or incomplete small bowel obstruction, with small bowel maximum diameter measuring 4.5 cm (centimeters), minimal stool. [MEDICATION NAME] of Magnesia was ordered the same day and was given. On 9-25-18 at the 6:33 AM, nurse's note recorded: Resident continues with nausea but no vomiting. Unable to hear bowel sounds times 4 quadrants. On 9-25-18 at 3:00 PM, the nurse's notes read: Monitoring continue (sic) related to bowel obstruction and nausea and vomiting resident has bowel sounds times 4 quads sluggish noted, nausea and vomiting times 2, clear liquid diet in place . alert and verbal denies abdominal pain states its tender there remains in bed. On 9-25-18 at 4:44 PM, the nurse's notes read: Resident continues nausea and vomiting noted, vomitus brown in color about 200 cc (cubic centimeters) without sediment. Nurse Practitioner (name) updated. New orders to send resident to emergency room , sent to ER at 5:30 PM. The resident was admitted to the hospital at 9:10 PM with a small bowel obstruction. Review of the hospital records for the admitted d 9-25-18 revealed the [DIAGNOSES REDACTED]. came to emergency room after having nausea vomiting and abdominal pain for the last 3 days, workups done in the ER shows small bowel obstruction. The history and physical notes, NG (nasal gastric tube) with low suction, patient has copious amount of bloody drainage. Review of the resident's care plan dated 5-11-15 revealed: Potential for constipation related to decreased mobility and medications (antipsychotic). The goal was Will have a BM at least every 3 days. Interventions included: Enemas per physician order, record bowel movements and report abnormalities. Report signs and symptoms of constipation such as abdominal cramping, diarrhea, nausea and vomiting, no bowel movement for 3 days. On 12/25/18, review of the resident's BM from 12/25/18 to 12/28/18 (4 days), the BM record revealed no bowel movements during this time period. 12/29/18 nurse's notes documented: Writer unable to obtain urine specimen via straight (Catheter). During procedure resistance met. NP made aware, new orders to monitor output for 8 hours, if no results, send to ER. There was no documentation that the constipation was reported or treated. Documentation from 12/24-18 through 12-29-18 revealed the resident was refusing his Senna (laxative). There was no rationale provided why the resident was refusing this medication (nausea, vomiting, etc). 12/30/18 nurse's notes documented Clysis (intravenous fluids into the tissues). A KUB was ordered and showed a small bowel obstruction. The resident was readmitted to the hospital 12-31-18 for a small bowel obstruction. There was no documentation his constipation was recognized or treated until 12/30/18. Review of the hospital records for this admission date of [DATE], the discharge [DIAGNOSES REDACTED]. The final report read: Patient had a poor appetite last 4 days, abdominal swelling has gotten worse, is nauseated he threw up once as well. On 2/22/19 at 11:05 AM an interview with an LPN (licensed practical nurse) was conducted . She stated the resident had problems with his bowels and had been diagnosed with [REDACTED]. She went on to state there is a flow sheet that the unit manager checks every day to see who is flagging for no BM for three days. On 2/22/19 at 11:10 AM an interview with the unit manager a registered nurse about the BM monitoring was conducted. She stated it will flag on the dash board, and she would know who is flagging. She stated the system will flag due to no BM's for 3 days. On 2/22/19 at 11:44 AM Review of the policy for bowel protocol read as followed: Assessment and Recognition: As part of the initial assessment, the staff and physician will help identify individuals with previously identified lower gastrointestinal tract conditions and symptoms. This should include a review of gastrointestinal problems during any recent hospitalization s, results of previous [MEDICATION NAME] studies, endoscopies, etc. There was no laxative protocol for no BM for 3 days. On 2/25/19 at 3:10 PM The Administrator, DON (director of nursing) and corporate nurse were informed of the concerns. 3. Resident #260 did not receive his antifungal for complaints of thrush timely. On 2/20/19 at 2:26 PM: During the initial interview, the resident stated, I haven't gotten my swish/swallow for days. Resident stated he had thrush; he opened his mouth and the tongue has cracks on it. He stated it was making it hard for him to eat. On 2-20/19 at 3:29 PM Review of the clinical record (SBAR- situation, background, assessment, review) dated 2-16-19 addressed: Change in condition noted to resident had complaints of certain areas in his mouth bothers him when he is eating anything . mouth has areas of redness and signs of irritation. No recommendations were obtained. On 2-18-19, there was a physician's orders [REDACTED]. The swish and swallow was noted on the MAR (medication administration record) but had not been given. On the back of the MAR, it was noted the medication was not available for 6 doses. Later on 2-20-19 Resident #260 was observed at the nurse's station, asking for the swish and swallow. On 2-20-19 (No time on order) a physician's orders [REDACTED]. On 2-21-19 at approximately 9:15 AM, Resident #260 was observed receiving the [MEDICATION NAME] for treatment of [REDACTED]. 4. The facility staff failed to assess and implement bowel protocol for Resident #210. Resident #210 was admitted to the hospital on 11-16-18, and discharged to the facility on [DATE]. Resident #210 stayed in the facility until 11-26-18, and was discharged back to the hospital on 11-26-18. Diagnoses for Resident #210 at the time of hospitalization on [DATE] included, bruising of the thorax from one fall in the last 3 months at home, urinary tract infection, spinal stenosis and cervical [MEDICAL CONDITION] disk disease, high cholesterol, hypertension, arthritis, history of kidney stones, and depression. Review of the nursing and physician progress notes [REDACTED]. Her respiratory status was without difficulty and 98% oxygen perfusion on room air. The Resident was continent of bowel and bladder, with normal bowel sounds in all 4 quadrants. The Resident required only 1 staff assistance with activities of daily living such as ambulation (walking), bed mobility, bathing, dressing, eating, toileting, and transfers. The Resident was coded as having no weight loss during her stay. Resident #210's Minimum Data Set (MDS, an assessment protocol) was an admission assessment with an Assessment Reference Date (ARD) of 11-26-18. The document was not completed until 12-1-18. Resident #210 was coded on this document (after her discharge) with a Brief Interview of Mental Status (BIMS) score, of unable to complete, with severe cognitive impairment. Resident #210 was coded as requiring extensive to total assistance of one to two staff members for all activities of daily living at the end of her stay in the facility. The Resident was coded as having no pain during this stay, and, as having had 2 falls during this stay. Resident #210 was coded as now incontinent of bowel and bladder. The Resident was on a Regular, with thin liquids, diet. The Resident's weight records were reviewed from the hospital and facility, and revealed an unexpected and undesired significant weight loss. Those weights follow below. Hospital discharge on 11-19-18 (173.63 pounds) Facility admission on 11-19-18 (172.4 pounds) Discharge from facility on 11-26-18 (151.6 pounds) indicating a loss of 20 pounds in 1 week. Meal consumption records were reviewed and indicated that the Resident consumed the following; Breakfast - 50-75% every day including 11-26-18. Lunch - 50-75% 11-20-18 through 11-23-18, 25-50% on 11-24-18, nothing on 11-25-18, and 50-75% on 11-26-18. Dinner - 50-75% 11-20-18 through 11-23-18, nothing 11-24-18 through 11-26-18. Progress notes indicated that the Resident was unresponsive on 11-26-18 from 10:00 a.m., until discharge at 2:00 p.m., and could not have consumed any meals that day. The bedtime snack record also indicated no consumption for 11-21-18, 11-24-18, and 11-25-18. The Bladder and Bowel continence records indicated that the Resident became completely incontinent of bowel and bladder on 11-24-18. The record goes on to show that the Resident did not have any urine production on 11-24-18, and 11-25-18 on the 3p.m.-11p.m. shift, and on 11-25-18 on the 11p.m.-7a.m. shift. The bowel record documented that the Resident had a medium bowel movement every day shift from 1:00 p.m. to 3:00 p.m. with the exception of 11-23-18 when there was no bowel movement. No other shifts record any other bowel movements occurring at any other time or day the descriptions were exactly identical, and documented by the same individual every day during this stay. Further review of the nursing and physician progress notes [REDACTED]. 11-19-18 - Admission - 3:30 p.m., Resident was oriented to person, place, and time. Her respiratory status was without difficulty and 98% oxygen perfusion on room air. The Resident was continent of bowel and bladder, with normal bowel sounds in all 4 quadrants. The Resident required only 1 staff assistance with activities of daily living such as ambulation (walking), bed mobility, bathing, dressing, eating, toileting, and transfers. 11-20-18 - Resident continues to adjust well, no discomfort or distress noted, per nursing. 11-20-18 - The nurse practitioner was in to see the Resident that day and documented left flank and abdominal pain with movement or palpation, but improving, urinary tract infection resolving, alert and oriented to person and place, follows commands speaks little English, is Spanish speaking, and granddaughter (daughter) translates, no respiratory problems, no weight loss, and is tolerating diet without any issues. 11-20-18 - the social worker was in to see the Resident and documented that the granddaughter posted her phone number in the room so staff could call her as needed and use her as a translator. 11-21-18 - The doctor was in to see the Resident, and documented the Resident had no acute findings and would receive physical therapy for ambulation and stair climbing. 11-21-18 - Nursing notes document ambulating with assistance from staff and continent of bowel and bladder, and a new order was received to decrease pain medication from 1-2 tablets of 50 milligram [MEDICATION NAME] every 6 hours as needed for pain, to one tablet 4 times per day on a routine schedule. 11-22-18 - Nursing notes indicate a change in condition due to 2 falls, occurring at approximately 4:00 a.m., and at 6:50 a.m. Resident with no new injuries noted, able to make her needs known, eating meals with no assistance needed. A left hip x-ray with KUB (kidneys/ureters/bladder) view was ordered and obtained. The result was normal with no problems. 11-23-18 - the nurse practitioner was in to see the Resident who has a cough and is producing mucus, and has indigestion. The nurse practitioner documented [MEDICATION NAME] for indigestion, and speech following. No speech therapy orders were ever received, and no speech therapy notes existed in the clinical record according to examination of the clinical record by surveyors, and a statement by the medical records staff member, there are none. 11-24-18 - The Resident has a productive cough/congestion, thick phlegm, wheezing, shortness of breath, abnormal lung sounds, and oxygen saturation perfusion is at 87% (dangerously low), oxygen is ordered via nasal cannula at 2 liters per minute for shortness of breath, [MEDICATION NAME] inhaled medicine via nebulizer is ordered to open airways, [MEDICATION NAME] is ordered to relieve mucus and a chest x-ray is ordered to be performed STAT (immediately) at 1:00 p.m. The chest x-ray was completed and results obtained at 4:00 p.m. that day, which showed mild [MEDICAL CONDITION]. The physician ordered [MEDICATION NAME] 40 milligrams every day, on that day, however, the Resident did not receive it until the following day. The [MEDICATION NAME] was in the building in the emergency box, and available to be given, when it was ordered. At 10:45 p.m. the doctor documented general weakness ongoing, and resident was worse. 11-25-18 - Change in condition, Resident eating less than 50% of meal in 24 hours, no [DIAGNOSES REDACTED]. Mighty shake supplements were started, to be given with each meal, three times per day. The narcotic pain medication [MEDICATION NAME] was changed back again to one 50 milligram tablet every 6 hours as needed, from the 4 times per day routinely which was started on 11-21-18. 11-26-18 - The diet order was changed from regular to no added salt. No dietician evaluation was completed for this Resident until 11-26-18, at 1:14 p.m., just before discharge. The dietician note states not able to ascertain weight status because of refusals/omissions. However, the Resident had a weight obtained that morning at 6:47 a.m., and revealed weight loss. The note goes on to say average meal intake 50-75%. Meal consumption records indicated that the Resident consumed that at breakfast, however, at lunch the Resident consumed 25-50% on 11-24-18, and nothing on 11-25-18, and 11-26-18. At dinner nothing 11-24-18 through 11-26-18. 11-26-18 - The Social worker wrote at 10:35 a.m., that the Resident was non-responsive to questioning, and her eyes were closed. At 2:10 p.m., - nursing documented [DIAGNOSES REDACTED]. 11-26-18 - The doctor wrote at 2:52 p.m., that the Responsible party was at bedside, poor appetite - ongoing, altered mental status, non-verbal, no command following, deficits noted, diminished lung sounds, send to ER (emergency room ) for evaluation, on [MEDICATION NAME] x 3 days, however, she had only taken the 40 milligrams of [MEDICATION NAME] 2 days. The nursing home transfer form indicated the Resident was sent to the hospital at 3:00 p.m., on 11-26-18. Hospital records were reviewed for the admission on 11-26-18. The records revealed (The Resident) was a week ago walking and talking and now is bedridden and not talking/eating. Spanish speaking only, brought in due to unresponsiveness. Last meal Saturday (11-24-18) in the morning very small amount. admitted with [MEDICAL CONDITION] (high blood potassium) of 7, (normal is 3.5-5.0, a reading of 7 is considered severe [MEDICAL CONDITION]). Creatinine sodium and chloride were also high, and a [MEDICATION NAME] enema was administered to bring the numbers down, twice, but with poor results as the Resident was so constipated. The Resident had an abdominal x-ray on admission which shows generalized impaction. After D50 ([MEDICATION NAME] intravenous infusion) and insulin, (the Resident was not diabetic this was to decrease the high minerals in her blood) the Resident improved. The Resident was started on fluid resuscitation for dehydration from not consuming fluids, and began to have a good urinary output. Her abdomen was described as soft, tender, and distended, a frontal radiograph of her abdomen was obtained and stated No bowel obstruction (such [MEDICAL CONDITION] etc), Large quantity of fecal material mainly in the ascending, [MEDICATION NAME], and descending colon. The Resident's care plan was reviewed and revealed no dietary care plan until 11-27-18, after the Resident was discharged on [DATE], and no bowel care plan at all. There was an incontinence care plan which stated assist as needed with incontinence. The Resident was not incontinent on admission. The facility policy for Bowel disorders was reviewed and revealed That the staff and physician will identify risk factors related to bowel dysfunction such as recent antibiotic use, (diuretics, antidepressants) medications that may cause dysmotility (movement, narcotics), symptoms such as abdominal pain, presence of cramps or bloating, localized tenderness. The nurse shall assess/document/report signs of dehydration (such as) altered levels of consciousness, lethargy, dizziness, recent change in mental status, dry mucus membranes, decreased urine output. (failing to eat or drink). In summary, the Resident was administered opioid, diuretic, cardiac, [MEDICATION NAME], and antibiotic medications on a routine basis. The Resident had become immobile, and stopped eating and drinking, and no dietary or bowel management programs had been instituted for this Resident. The Resident stopped eating and drinking on 11-24-18, lost significant weight, weakening the Resident, she became bowel impacted, and dehydrated causing the need for re-hospitalization , and treatment. On 2-25-19 the Administrator and the Director of Nursing were informed of the findings. No additional information was submitted.

Based on observation, staff interview, facility documentation review, and clinical record review the facility staff failed to assess and implement interventions to prevent an unstageable pressure wound resulting in harm for Resident #5. This is a past non-compliance citation (PNC). The facility staff failed to monitor and assess Resident #5 resulting in the development of an unstageable pressure wound on her sacrum. Findings included: Resident #5, a [AGE] year-old female, was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Resident #5's most recent MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 9/8/2017 was coded as a quarterly assessment. Resident #5 was coded as having severely impaired cognition by staff assessment. She was also coded as being totally dependent on 1-2 persons for her ADL's (activities of daily living) and as being always incontinent of bowel and bladder. A review of Resident #5's clinical record was conducted on 11/7/2017 at 2:00 PM. MDS records showed that Resident #5 had no wounds on admission to the facility. Braden scale is a clinical tool for predicting pressure wound risk. It consists of 6 categories-sensory, moisture, activity, mobility, nutrition, and friction/shear. Total scores can range from 6-23, with lower scores indicating a higher risk. Resident #5's Braden scale score on 6/7/2017 was 16/23, indicating a mild risk for pressure wound development. Progress notes revealed a note dated 6/7/2017 stating Change in condition noted related to resident noted with open areas to left buttock and sacrum. This change in condition started on 6/7/2017. A Pressure Injury Record described this new wound as originating on 6/7/2017 and being a facility acquired wound to the sacrum. This record described the wound as unstageable 3.5 cm (centimeters) x 1.8 cm x 0.1 cm containing 100% yellow necrosis. Wound Care Specialist Initial Evaluation, a report by a contracted wound care physician, dated 6/14/2017 stated that the wound was caused by pressure and described it as unstageable necrosis 3.2 cm x 1.5 cm x 0.1 cm. The physician surgically debrided the wound and prescribed Dakins moistened gauze with dry protective dressing daily. The physician followed up with Resident #5 every 7-10 days. An additional progress note dated 6/14/2017 stated Sacral wound noted at unstageable with 100% necrotic tissue in the wound bed. A review of Resident #5's Care Plan revealed interventions dated 11/14/2016 related to skin integrity as follows: Barrier crème to perianal area/buttocks as needed' Encourage and assist to reposition Observe skin condition with ADL (activities of daily living) care daily; report abnormalities Pressure redistributing device for bed/chair Provide preventative skincare routinely and PRN (as needed) Suspend/float heels as able On 11/8/2017 at 10:10 AM an interview was conducted with RN (Registered Nurse) C, wound care nurse. She verified that the wound on Resident #5's sacrum was initially found at an unstageable wound. Resident #5 was seen in her room on 11/8/2017 at 10:00 AM with RN C to examine the wound. The wound was seen at the bottom of the sacrum within the gluteal folds. The measurements were 1.4 cm x 1.5 cm x 0.5 cm. Muscle below the subcutaneous tissue was visible. It was a Stage 3 at this point. At the end of day meeting on 11/8/2017 at 4:00 PM Administration A, Administrator; Administration B, Director of Nursing; Administration C, Corporate RN Consultant; and Administration D, Corporate RN Consultant were informed of the possibility of a harm level citation for Resident #5's wound. On 11/9/2017 at 9:00 AM Administration B, Director of Nursing and Administration C, Corporate RN Consultant stated that the facility had identified problems identifying and preventing pressure wounds as a result of a mock survey performed in July 2017. Resident #5 was included in the mock survey. A plan of correction was developed based on these findings with an A(NAME) (Allegation of Compliance) date of 8/3/2017. Resident #5's wound was found on 6/7/2017, prior to the A(NAME) date. The Plan of Correction is as follows: 1. Residents with potential for wounds-Review new admissions Bradens x 4 weeks. Utilize calendar sheets to help track dates due for Bradens. Care plan updates need to be verified at change of skin condition. Foley catheter care plans need to include the size of the catheter and balloon. Update all as needed. 2. Like residents-all residents are potential like residents. 3. Education to staff on completing Bradens, fall interventions, and skin/Foley/fall care plans. 4. Audits-all new admissions for Braden scheduling, skin/catheter/fall care plans records. Three times per week. 5. A(NAME) date 8/3/2017 A total of 7 Residents with pressure wounds was included in the survey. Resident #5 had the only wound subject to a deficiency. Administration was informed of findings on 11/9/2017 at 11:00 AM.

Based on observation, staff interview, Resident interview, facility documentation review, and clinical record review, the facility staff failed for 2 residents (Resident #19, and #12), to identify and treat pressure ulcers, resulting in harm for both residents, in a survey sample of 25 residents. 1. For Resident #19, the facility staff failed to identify a pressure ulcer until found at 100% escharon the right heel. 2. For Resident #12, the facility staff failed to identify a pressure ulcer until found at 100% eschar on the left heel, and failed to treat a pressure ulcer, specifically, did not apply protective boots during survey observations. The findings included; 1. Resident #19, was originally admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Resident #19's most recent MDS (minimum data set) with an ARD (assessment reference date) of 10-19-16 was coded as a quarterly assessment. Resident #19 was coded as being at risk for pressure ulcers, as having memory deficits, and having severe cognitive impairment. The Resident was also coded as needing extensive assistance of one staff member to perform activities of daily living. On the previous assessment with an ARD of 7-27-16, the Resident was also coded as At risk for pressure ulcers. Review of Resident #19's clinical record nursing progress notes revealed that on 8-1-16, the Resident was noted to have a 2 cm (centimeter) by 2 cm Eschar pressure ulcer on the right lateral heel. The Resident had no other wounds, and this was the first identification of this facility acquired pressure ulcer. Definitions of pressure ulcers provided by NPUAP (National Pressure Ulcer Advisory Panel): The goal for revising the definition of unstageable ulcers was to reduce the tendency to classify an ulcer with any necrotic tissue as unstageable, when the depth of the ulcer can be seen. The new definition is Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Note the phrase the base of the ulcer is used to denote the inability to determine the depth. If necrotic tissue is present, for example, on the edge of the ulcer, but the base is bone, the ulcer should be staged as a Stage IV. Further description of Stage IV ulcers include these phrases: Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore stage, cannot be determined. Stable (dry, adherent, intact without [DIAGNOSES REDACTED] or fluctuance) eschar on the heels serves as ' the body's natural (biological) cover' and should not be removed. Review of the facility Pressure Ulcer Record sheets for 8-1-16, 8-9-16, 8-18-16, and 8-30-16 revealed that the pressure ulcer on Resident #19's right lateral heel was first identified at Thick, hard, black, leathery, necrotic, tissue, 100% eschar , unable to stage. The documents state the family and doctor were notified. On 8-1-16. The doctor issued an order for [REDACTED]. The Weekly skin assessment sheets for 8-1-16, 8-8-16, 8-15-16, 8-22-16, and 8-29-16 revealed that the pressure ulcer on Resident #19's right lateral heel was first identified on 8-1-16 at Eschar. On 9-2-16 nursing progress notes indicated the wound was healed. On 9-3-16 the treatment order was discontinued. Review of the bath records for July and August 2016 regarding skin condition, all documented no skin issues, even the day of and the day following the discovery of the heel wounds. The bath and grooming areas of the facility ADL (activities of daily living) Flow Sheet indicated the Resident received care daily, and three times daily on most days, which included nail care to hands and feet. Review of the care plan dated 4-1-15 revealed the following: At risk for alteration in skin integrity. The goal was to Skin will remain free of breakdown within limits of disease process. The following interventions were in place: Medications and treatments as ordered, diets and supplements per doctors order, encourage adequate fluid and food intake, keep clean and dry, encourage and assist to reposition frequently every shift. Check for incontinence, Observe skin with ADL care daily and report abnormalities, obtain labs, Pressure redistributing device on bed and chair, provide preventive skin care routinely and as needed, float heels as tolerated (bunny boots) as tolerated. On 11-10-16 at 10:00 a.m., and again at 11:00 a.m., Resident #19 was observed sitting at her bedside in a wheel chair with her feet in a dependant position, resting flat on the floor. No foot rests were attached to the wheel chair. She was wearing socks, and no bunny boots, or shoes. On 11-10-16 at 11:10 a.m. an interview was conducted with the LPN (E), who tracks the facility's wounds. When asked about Resident #19, LPN (E) stated, The area to her heel was blackened. It was eschar when it was found. She went on to say that the Resident will prop her feet up on her bed while she sits in her wheel chair, and that the back of the heels were pushed down. She also stated, That is likely what caused the wound. On 11-10-16 at approximately 11:15 a.m., the DON (director of nursing) stated that wounds are not usually found at eschar. The Administrator and DON were notified of this harm level deficiency. On 11-14-16 at 9:35 a.m. a skin assessment was completed for Resident #19. The unit manager was present. Resident #19 had no wounds, the heels were intact and were dry and flaky. On 11-14-16 at 1:00 p.m., the Wound specialist doctor was interviewed about wounds. He stated, Wounds can be found at all stages of development, and pressure wounds with eschar can come from a traumatic event causing the wound. Tissue dies, causing eschar, pressure causes slow death of a tissue, and you don't see full effect of tissue death for some time. Review of the facility policy and procedure for the prevention and treatment of [REDACTED]. If any skin concerns are noted, they are to be reported immediately to the designated nurse. On 11-10-16, and 11-14-16, at the end of day debriefs, the DON and Administrator were notified of above findings at harm level. No further information was presented by the facility during survey. 2. For Resident #12, the facility staff failed to identify and treat a pressure ulcer, prior to it becoming 100% eschar and did not apply protective boots during survey. Resident #12, was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Resident #12's most recent MDS (minimum data set) with an ARD (assessment reference date) of 10-22-16 was coded as an admit assessment. Resident #12 was coded as being at risk for pressure ulcers, and having no cognitive impairment. The Resident was also coded as needing extensive assistance of one staff member to perform activities of daily living. Observation of Resident #12 on 11-8-16 at 1:00 p.m., during initial tour of the facility revealed the Resident laying in bed fully dressed with socks on and heels laying directly on the bed, putting pressure on his heels, with no protective boots on. On 11-10-16 at approximately 11:15 a.m., the DON (director of nursing) stated that wounds are not usually found at eschar. Review of Resident #12's clinical record physician progress notes [REDACTED]. The note described the Resident as noted to have a discoloration to left medial heel area DTI (deep tissue injury). Float heels, skin prep every day, frequent positioning. Another Late entry note was documented for 11-7-16, and did not include the date or time the entry was actually placed in the record. That note describes DTI left heel stable, continue care. Review of Resident #12's clinical record Nursing progress notes revealed that the first documentation by nursing of the pressure wound was completed on 11-7-16 by the wound nurse, denoting DTI. Review of the facility Pressure Ulcer Record provided to surveyors on 11-14-16 at 4:35 p.m. by the Administrator and Director of Nursing (DON) revealed that on 11-2-16 the RN (Registered Nurse) wound nurse (C) described the wound as 1.8 cm (centimeter) by 1.5 cm DTI, 100% Eschar pressure ulcer on the left heel. The Resident had no other wounds, and this was the first identification of this facility acquired pressure ulcer. Definitions of pressure ulcers provided by NPUAP (National Pressure Ulcer Advisory Panel): The goal for revising the definition of unstageable ulcers was to reduce the tendency to classify an ulcer with any necrotic tissue as unstageable, when the depth of the ulcer can be seen. The new definition is Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Note the phrase the base of the ulcer is used to denote the inability to determine the depth. If necrotic tissue is present, for example, on the edge of the ulcer, but the base is bone, the ulcer should be staged as a Stage IV. Further description of Stage IV ulcers include these phrases: Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore stage, cannot be determined. Stable (dry, adherent, intact without [DIAGNOSES REDACTED] or fluctuance) eschar on the heels serves as 'the body's natural (biological) cover' and should not be removed. Review of the facility Pressure Ulcer Record sheet for 11-2-16, 11-7-16, and 11-9-16 during survey revealed that the pressure ulcer on Resident #12's left heel was first identified 11-2-16 at Thick, hard, black, leathery, necrotic, tissue, 100% eschar. The document states the family and doctor were notified, and the Resident was experiencing pain at the wound site. On 11-2-16 the doctor issued an order for [REDACTED]. The Weekly skin assessment sheets for October and November 2016 were reviewed from admit. Those sheets were dated; 10-17-16, 10-24-16, 10-31-16, and the last one was completed on 11-7-16. The sheets revealed no documentation of a pressure wound ever found. Review of the bath records for October and November 2016 regarding skin condition, all documented no skin issues, even the day of and the day following the discovery of the heel wounds. The bath and grooming areas of the facility ADL (activities of daily living) Flow Sheet indicated the Resident received care daily, and two times daily on most days, which included nail care to hands and feet. Review of the skin care plan dated 11-2-16 revealed the following: Actual skin breakdown related to (deep tissue injury left heel) revised 11-8-16. The goal was to Will show continued signs of healing. Interventions were; Administer treatment per physician's orders, suspend float heels as able, provide preventative skin care routinely and as needed, use pillows/positioning devices as needed. Target date 1-10-17. The focus mentions that the Resident refuses to wear heel protective boots. There is no documentation in the clinical record stating that the Resident ever refused to wear the heel protective boots. During the observation of Resident #12 on 11-14-16 at 1:15 p.m., the Resident was found laying in bed, fully clothed, wearing socks on his feet which were laying directly on the mattress, putting pressure on his heels, with no protective boots on. The Resident was interviewed, and asked why he did not like to wear his protective boots. The Resident responded that he did like the boots, that they kept his feet warm, and if his feet got cold they would ache. He continued to say that the nurses don't always put them on, and that he could not reach them in the top of his closet to put them on himself. Observation of Resident #12 continued on 11-14-16 at 2:15 p.m., and finally at 3:15 p.m. revealed the Resident laying in bed fully clothed wearing socks on his feet which were laying directly on the mattress, putting pressure on his heels, with no protective boots on. At 3:15 p.m. LPN (Licensed Practical Nurse) (J) was called into the room to show the surveyor the Resident's heels. LPN (J) removed the Resident's socks, and showed the surveyor the heels. The pressure wound now was documented as measuring 3.2 cm by 4.5 cm , DTI, 100% eschar, on 11-9-16 according to the pressure ulcer records. After the observation was complete, LPN (J) was asked why the Resident was not wearing protective boots on his feet, and she did not answer, but rather went to the Resident's closet, and retrieved the boots from the top of the closet and applied them to the Resident's feet, and exited the room. Review of the facility Report of Incident/Accident provided to surveyors on 11-14-16 at 4:35 p.m. by the Administrator and Director of Nursing (DON) revealed that on 11-2-16 the RN (Registered Nurse) wound nurse (C) described the wound as 1.8 cm (centimeter) by 1.5 cm DTI, 100% Eschar pressure ulcer on the left heel. The Resident had no other wounds, and the Resident had complained of the heel hurting him and feeling like It was on fire. this was the first identification of this facility acquired pressure ulcer. Review of the Wound Care Specialist Initial Evaluation dated 11-9-16, and during survey, the doctor described the wound as greater than 1 day old, Unstageable DTI, 3.2 cm long by 4.5 cm wide by an unmeasurable depth. Plan was to continue skin prep every shift, and Follow up in 7 days. On 11-14-16 at 1:00 p.m., the Wound specialist doctor was interviewed about wounds. He stated, Wounds can be found at all stages of development, and pressure wounds with eschar can come from a traumatic event causing the wound. Tissue dies, causing eschar, pressure causes slow death of a tissue, and you don't see full effect of tissue death for some time. Review of the facility policy and procedure for the prevention and treatment of [REDACTED]. If any skin concerns are noted, they are to be reported immediately to the designated nurse. On 11-14-16, at the end of day debriefs, the DON and Administrator were notified of above findings at harm level. No further information was presented by the facility during survey.

Based on staff interview, facility documentation review, clinical record review, and in the course of a complaint investigation, the facility staff failed to administer medication without significant medication errors for 1 of 4 residents, Resident #1. The facility staff failed to clarify an insulin order. For Resident #1, the facility staff administered 100 units of insulin instead of 50 units as prescribed. The resident ' s blood glucose level dropped to 41 mg/dL (milligrams per Deciliter) (normal range 70-105 mg/dL). The resident was sent to the emergency room with a blood sugar level of 33. The resident was treated for [REDACTED]. The findings included: Resident #1 was admitted to the facility on [DATE] and discharged on [DATE]. [DIAGNOSES REDACTED]. Resident #1's Admission Evaluation dated 01/23/2015 documented, "Cognition: Alert, Disoriented to: Time, Mental function varies. Eating & Nutrition: Set up assist only." Hospital Record (Current Discharge Medication List) for Resident #1 date 01/22/2015 documented, "insulin Concentrated regular 500 unit/mL (milliter) Soln (solution). Commonly known as: U-500 Concentrated. Dose: 50 Units 0.1 mL by Subcutaneous route before breakfast, lunch, and dinner. Patient draws up to the 20 unit mark on a U-100 syringe four times daily." Hospital Record (Discharge Instructions) for Resident #1 dated 01/22/2015 documented, "He was titrated appropriately up to U-500 dose of (0.1 mL which is 50 units, 3 times per day before meals)." Hospital Record (Current Discharge Medication List) for Resident #1 dated 01/23/2015 documented, "insulin Concentrated regular 500 unit/mL Soln. Dose: 50 Units 0.1 mL by Subcutaneous route before breakfast, lunch, and dinner. Draw up to 10 unit mark on the U-100 syringe. That will equal 50 units." Hospital Record (Discharge Instructions) for Resident #1 dated 01/23/2015 documented, "...With improved PO (by mouth) intake and his infection, he was switched back to U-500, titrated appropriately to U-500 dose of (0.1 mL which is 50 units, 3 times per day before meals)." physician's orders [REDACTED].(okay) and renewed (Physician's Name)." physician's orders [REDACTED]." Medication Record for Resident #1 dated 01/23/2015 documented, "Insulin concentrated regular 500 units/ml soln 50 units/0.1 ml sub Q before breakfast lunch and dinner and at bedtime draw up to 20 unit mark on a U-100 syringe." Medication Record for Resident #1 dated 01/24/2015 indicated Resident #1 received insulin at 11:30 a.m. Medication Record for Resident #1 dated 01/24/2015 indicated Resident #1 received insulin at 11:30 a.m. (20 units on the U-100 syringe which equals 100 units of the concerntrated regular insulin). Nursing Progress Notes for Resident #1 dated 01/25/2015 (charting for 01/24/2015 event)documented, "...as residents BS (blood sugar) was 41 @ (at) 1715 (5:15 p.m.). Orange juice and apple juice was provided, BS 43 @ 1730 (5:30 p.m.). Third cup with 3 packs sugar added provided BS rechecked @ 1745 (5:45 p.m.) = 91. Wife out in hall stated "you are taking too long you need to get a move on right now." Resident left facility via (Facility) EMS (emergency medical services) @ 1805 (6:05 p.m.) without incident. (Physician) aware." Emergency Patient Record for Resident #1 dated 01/24/2015 documented, "Fingerstick Blood Sugar (Mg/Dl) (milligrams per Deciliter) 33 (normal range 70-105 mg/dL)" Emergency Patient Record for Resident #1 dated 01/24/2015 documented, "Primary Impression: [DIAGNOSES REDACTED]" Hospital Record (Laboratory Tests) for Resident #1 dated 01/24/2015 documented, "Glucose 33 * L (low)." Hospital Record (History of Present Illness) for Resident #1 dated 01/24/2015 documented, "Today afternoon when son went to visit him, he was found on the floor. His blood sugar was 40 at that time, but he was alert, awake, and he was talking at that time. Upon asking the patient, he is very confused and disoriented....Patient was given juice and was given something to eat, but he again had drop in blood sugar to 33 and because of recurrent [DIAGNOSES REDACTED], patient was advised to be admitted and observe blood sugar more closely." Nursing Progress Notes for Resident #1 dated 01/25/2015 documented, "Called (Hospital) at approximately 0350 (3:50 a.m.). Resident was admitted with [DIAGNOSES REDACTED]. Hospital Record (Consultation Report) for Resident #1 dated 01/25/2015 documented, "He was discharged to rehab 2 days ago and came in yesterday afternoon after he was found on the floor with a blood sugar of 40." On 02/24/2015 at 1:39 p.m., an interview was conducted with Licensed Practical Nurse-A (LPN-A) via phone. Administrator and Director of Nursing (DON) also present during this phone interview. LPN-A stated she administered 20 units (using the U-100 syringe) of the concentrated regular 500 unit/mL insulin to Resident #1 on 01/24/2015. On 02/24/2015 at 1:55 p.m., an interview was conducted with LPN-B. LPN-B stated the above insulin order was "very confusing". According to LPN-B, she would clarify the order with physician before administering. On 02/24/2015 at 1:58 p.m., an interview was conducted with LPN-C. LPN-C stated the above insulin order was "very confusing". According to LPN-C, she would clarify the order with physician before administering. On 02/24/2015 at 2:05 p.m., an interview was conducted with Registered Nurse-B (RN-B), Unit Manager. RN-B stated she would clarify the above insulin order with physician before administering. RN-B also stated she would make sure the order was transcribed correctly before administering. On 02/24/2015 at 2:10 p.m., an interview was conducted with LPN-D. LPN-D stated she would not administer the above insulin order; she would clarify with physician first. On 02/24/2015 at 4:15 p.m., an interview was conducted with DON. DON stated 20 units on the U-100 syringe equals 100 units of the concentrated regular 500 unit/mL insulin. DON also stated that if an order was unclear, staff should clarify with physician. On 02/24/2015 at 4:35 p.m., an interview was conducted with Medical Director. Medical Director stated 20 units on the U-100 syringe equals 100 units of the concentrated regular 500 unit/mL insulin. Medical Director stated the insulin order should be clarify before administering. On 02/25/2015 at 11:00 a.m., an interview was conducted with Resident #1's physician. Resident #1's physician stated 10 units on the U-100 syringe equals 50 units of the concentrated regular 500 unit/mL insulin. If nurse administered 20 units (using the U-100 syringe) of the concentrated regular 500 unit/mL insulin, that's 100 units. Resident #1's physician stated the insulin order should be clarify before administering. Facility Policy/Procedure titled "Insulin Administration" stated, "The type of insulin, dosage requirements, strength, and method of administration must be verified before administration, to assure that it corresponds with the order on the medication sheet and the physician's orders [REDACTED]. Syringes-insulin syringes must match the unit dose (e.g., (for example) 100 unit/ml insulin must be administered in a 100 unit/ml insulin syringe.) Facility Policy/Procedure titled "General Guidelines For The Administration Of Medications" stated, "The nurse observes the five rights in administering each medication: (a) The right resident (b) The right time (c) The right medication (d) The right dose (e) The right method of administration." "Dosing Formulas U-100 insulin syringe: Divide prescribed dose (actual units of [MEDICATION NAME] R U-500) by 5 = unit markings in a U-100 insulin syringe" (Reference: www.[MEDICATION NAME].com) "Warnings-[MEDICATION NAME] R U-500 contains 500 units of insulin in each milliliter (5 times more concentrated than [MEDICATION NAME] R U-100). For [MEDICATION NAME] R U-500, extreme caution must be observed in the measurement of dosage because inadvertent overdose may result in serious adverse reaction or life-threatening [DIAGNOSES REDACTED]." (Reference: www.[MEDICATION NAME].com) "Precautions-Dosing Confusion/Dosing Errors: Medication errors associated with [MEDICATION NAME] R U-500 have occurred and resulted in [MEDICAL CONDITION], [DIAGNOSES REDACTED], or death. The majority of errors occurred due to errors in dispensing, prescribing, or administration." (Reference: www.[MEDICATION NAME].com) "[DIAGNOSES REDACTED]-[DIAGNOSES REDACTED] is the most common adverse reaction of all insulin therapies, including [MEDICATION NAME] R U-500. [DIAGNOSES REDACTED] may occur suddenly. Severe [DIAGNOSES REDACTED] may lead to unconsciousness, convulsions, temporary or permanent impairment of brain function, or death." (Reference: www.[MEDICATION NAME].com) The Administrator and Director of Nursing were made aware of these findings on 02/27/2015 at 2:50 p.m., no further information provided. Complaint Deficiency

Based on staff interview, facility documentation review, clinical record review, and in the course of a complaint investigation, the facility staff failed to follow/clarify physician order and provide care that meet professional standards for 2 of 4 residents, Resident #1 and #2. (1) For Resident #1, the facility staff failed to clarify an insulin order. For Resident #1, the facility staff administered 100 units of insulin instead of 50 units as prescribed. The resident ' s blood glucose level dropped to 41 mg/dL (milligrams per Deciliter) (normal range 70-105 mg/dL). The resident was sent to the emergency room with a blood sugar level of 33. The resident was treated for [REDACTED]. (2) For Resident #2, the facility staff failed to obtain an oxygen order before administering. The findings included: (1) Resident #1 was admitted to the facility on [DATE] and discharged on [DATE]. [DIAGNOSES REDACTED]. Resident #1's Admission Evaluation dated 01/23/2015 documented, "Cognition: Alert, Disoriented to: Time, Mental function varies. Eating & Nutrition: Set up assist only." Hospital Record (Current Discharge Medication List) for Resident #1 date 01/22/2015 documented, "insulin Concentrated regular 500 unit/mL (milliters) Soln (solution). Commonly known as: U-500 Concentrated. Dose: 50 Units 0.1 mL by Subcutaneous route before breakfast, lunch, and dinner. Patient draws up to the 20 unit mark on a U-100 syringe four times daily." The Resident #1's physician approved the "Current Discharge Medication List", dated 1/22/15. Hospital Record (Discharge Instructions) for Resident #1 dated 01/22/2015 documented, "He was titrated appropriately up to U-500 dose of (0.1 mL which is 50 units, 3 times per day before meals)." Hospital Record (Current Discharge Medication List) for Resident #1 dated 01/23/2015 documented, "insulin Concentrated regular 500 unit/mL Soln. Dose: 50 Units 0.1 mL by Subcutaneous route before breakfast, lunch, and dinner. Draw up to 10 unit mark on the U-100 syringe. That will equal 50 units." Hospital Record (Discharge Instructions) for Resident #1 dated 01/23/2015 documented, "...With improved PO (by mouth) intake and his infection, he was switched back to U-500, titrated appropriately to U-500 dose of (0.1 mL which is 50 units, 3 times per day before meals)." Physician's Orders for Resident #1 dated 01/23/2015 documented, "Hosp (hospital) D'C (discharge) orders ok'd (okay) and renewed (Physician's Name)." Physician's Orders for Resident #1 dated 01/23/2015 documented, "Insulin concentrated regular 500 units/ml soln 50 units/0.1 ml sub Q (subcutaneous) before breakfast lunch and dinner and at bedtime draw up to 20 unit mark on a U-100 syringe." Medication Record for Resident #1 dated 01/23/2015 documented, "Insulin concentrated regular 500 units/ml soln 50 units/0.1 ml sub Q before breakfast lunch and dinner and at bedtime draw up to 20 unit mark on a U-100 syringe." Medication Record for Resident #1 dated 01/24/2015 indicated Resident #1 received insulin at 11:30 a.m. (20 units on the U-100 syringe which equals 100 units of the concerntrated regular insulin). Nursing Progress Notes for Resident #1 dated 01/25/2015 (charting for 01/24/2015 event)documented, "...as residents BS (blood sugar) was 41 @ (at) 1715 (5:15 p.m.). Orange juice and apple juice was provided, BS 43 @ 1730 (5:30 p.m.). Third cup with 3 packs sugar added provided BS rechecked @ 1745 (5:45 p.m.) = 91 . Wife out in hall stated "you are taking too long you need to get a move on right now." Resident left facility via (Facility) EMS (emergency medical services) @ 1805 (6:05 p.m.) without incident. (Physician) aware." Emergency Patient Record for Resident #1 dated 01/24/2015 documented, "Fingerstick Blood Sugar (Mg/Dl) (milligrams per Deciliter) 33 (normal range 70-105 mg/dL)" Emergency Patient Record for Resident #1 dated 01/24/2015 documented, "Primary Impression: [DIAGNOSES REDACTED]" Hospital Record (Laboratory Tests) for Resident #1 dated 01/24/2015 documented, "Glucose 33 * L (low)." Hospital Record (History of Present Illness) for Resident #1 dated 01/24/2015 documented, "Today afternoon when son went to visit him, he was found on the floor. His blood sugar was 40 at that time, but he was alert, awake, and he was talking at that time. Upon asking the patient, he is very confused and disoriented....Patient was given juice and was given something to eat, but he again had drop in blood sugar to 33 and because of recurrent [DIAGNOSES REDACTED], patient was advised to be admitted and observe blood sugar more closely." Nursing Progress Notes for Resident #1 dated 01/25/2015 documented, "Called (Hospital) at approximately 0350 (3:50 a.m.). Resident was admitted with [DIAGNOSES REDACTED]. Hospital Record (Consultation Report) for Resident #1 dated 01/25/2015 documented, "He was discharged to rehab (rehabilitation, nursing home facility) 2 days ago and came in yesterday afternoon after he was found on the floor with a blood sugar of 40." On 02/24/2015 at 1:39 p.m., an interview was conducted with Licensed Practical Nurse-A (LPN-A) via phone. Administrator and Director of Nursing (DON) also present during this phone interview. LPN-A stated she administered 20 units (using the U-100 syringe) of the concentrated regular 500 unit/mL insulin to Resident #1 on 01/24/2015. On 02/24/2015 at 1:55 p.m., an interview was conducted with LPN-B. LPN-B stated the above insulin order was "very confusing". According to LPN-B, she would clarify the order with physician before administering. On 02/24/2015 at 1:58 p.m., an interview was conducted with LPN-C. LPN-C stated the above insulin order was "very confusing". According to LPN-C, she would clarify the order with physician before administering. On 02/24/2015 at 2:05 p.m., an interview was conducted with Registered Nurse-B (RN-B), Unit Manager. RN-B stated she would clarify the above insulin order with physician before administering. RN-B also stated she would make sure the order was transcribed correctly before administering. On 02/24/2015 at 2:10 p.m., an interview was conducted with LPN-D. LPN-D stated she would not administer the above insulin order; she would clarify with physician first. On 02/24/2015 at 4:15 p.m., an interview was conducted with DON. DON stated 20 units on the U-100 syringe equals 100 units of the concentrated regular 500 unit/mL insulin. DON also stated that if an order was unclear, staff should clarify with physician. On 02/24/2015 at 4:35 p.m., an interview was conducted with Medical Director. Medical Director stated 20 units on the U-100 syringe equals 100 units of the concentrated regular 500 unit/mL insulin. Medical Director stated the insulin order should be clarify before administering. On 02/25/2015 at 11:00 a.m., an interview was conducted with Resident #1's physician. Resident #1's physician stated 10 units on the U-100 syringe equals 50 units of the concentrated regular 500 unit/mL insulin. If nurse administered 20 units (using the U-100 syringe) of the concentrated regular 500 unit/mL insulin, that's 100 units. Resident #1's physician stated the insulin order should be clarify before administering. Facility Policy/Procedure titled "Insulin Administration" stated, "The type of insulin, dosage requirements, strength, and method of administration must be verified before administration, to assure that it corresponds with the order on the medication sheet and the physician's order. The nurse shall notify the Director of Nursing Services and Attending Physician of any discrepancies, before giving the insulin. Syringes-insulin syringes must match the unit dose (e.g., (for example) 100 unit/ml insulin must be administered in a 100 unit/ml insulin syringe.) Facility Policy/Procedure titled "General Guidelines For The Administration Of Medications" stated, "The nurse observes the five rights in administering each medication: (a) The right resident (b) The right time (c) The right medication (d) The right dose (e) The right method of administration." "Dosing Formulas U-100 insulin syringe: Divide prescribed dose (actual units of [MEDICATION NAME] R U-500) by 5 = unit markings in a U-100 insulin syringe" (Reference: www.[MEDICATION NAME].com) "Warnings-[MEDICATION NAME] R U-500 contains 500 units of insulin in each milliliter (5 times more concentrated than [MEDICATION NAME] R U-100). For [MEDICATION NAME] R U-500, extreme caution must be observed in the measurement of dosage because inadvertent overdose may result in serious adverse reaction or life-threatening [DIAGNOSES REDACTED]." (Reference: www.[MEDICATION NAME].com) "Precautions-Dosing Confusion/Dosing Errors: Medication errors associated with [MEDICATION NAME] R U-500 have occurred and resulted in [MEDICAL CONDITION], [DIAGNOSES REDACTED], or death. The majority of errors occurred due to errors in dispensing, prescribing, or administration." (Reference: www.[MEDICATION NAME].com) "[DIAGNOSES REDACTED]-[DIAGNOSES REDACTED] is the most common adverse reaction of all insulin therapies, including [MEDICATION NAME] R U-500. [DIAGNOSES REDACTED] may occur suddenly. Severe [DIAGNOSES REDACTED] may lead to unconsciousness, convulsions, temporary or permanent impairment of brain function, or death." (Reference: www.[MEDICATION NAME].com) (2) Resident #2 was admitted to the facility on [DATE] and discharged on [DATE]. [DIAGNOSES REDACTED]. Resident #2's Minimum Data Set (MDS-an assessment protocol) with an Assessment Reference Date of 01/27/2015 coded Resident #2 with the ability to understand others and makes self understood. In addition, the MDS coded Resident #2 with a BIMS (Brief Interview for Mental Status) score of 6. The MDS also coded Resident #2 as independent with setup help only in terms of eating. Resident #2 was coded with no signs/symptoms of possible swallowing disorder. Physician Telephone Orders for Resident #2 dated 01/23/2015 documented, "Nicotine [MEDICATION NAME] (apply) 21 mg/day q (every) 24 hrs (hours)." Physician Telephone Orders for Resident #2 dated 01/26/2015 documented, "[MEDICATION NAME] 14 mg qd (everyday)." Medication Record for Resident #2 dated 01/22/2015 through 01/31/2015 indicated Resident #2 did not receive Nicotine patch on 01/23/2015, 01/24/2015, 01/25/2015, 01/26/2015 and 01/27/2015. Medication Record for Resident #2 dated 01/25/2015 documented, "Nicotine patches not here." Medication Record for Resident #2 dated 01/27/2015 documented, "Nicotine patch not placed, unavailable from pharm (pharmacy)." On 02/27/2015 at 2:05 p.m., an interview was conducted with DON. DON stated staff should notify physician when medications not given/not available. According to DON, staff did not notify physician. Facility Policy/Procedure titled "Stat Orders" stated, "Nurse will check the facility's Emergency Kit list, Back Up Medication list and Stock list to determine if the medication needed is available. If the medication is not available within the facility, the nurse will fax a copy of the order to the pharmacy. Nurse will follow faxing of order with a phone call to the pharmacy. Nurse will speak with a pharmacist and alert pharmacist that a "STAT" order is needed and has been faxed. Pharmacist will ensure that order has been received and that the order is processed and delivered as quickly as possible." (2) Nursing Progress Notes for Resident #2 dated 01/22/2015 documented, "...on 3 liters oxygen via NC (nasal cannula), O2 Sats (oxygen saturation) at 96%..." Nursing Progress Notes for Resident #2 dated 01/23/2015 documented, "...O2 (oxygen) via n/c (nasal cannula) present..." Nursing Progress Notes for Resident #2 dated 01/24/2015 documented, "O2 @ (at) 2 L (2 liters) via NS...." Nursing Progress Notes for Resident #2 dated 01/26/2015 documented, "Oxygen via n/c." On 02/25/2015 at 1:02 p.m., an interview was conducted with Administrator. Administrator stated Resident #2 did not have a physician order for [REDACTED]. On 02/25/2015 at 4:45 p.m., an interview was conducted with DON. DON stated Resident #2 did not have a physician order for [REDACTED]. Facility Policy/Procedure titled "Oxygen Administration" stated, "Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration." The Administrator and Director of Nursing were made aware of these findings on 02/27/2015 at 2:50 p.m., no further information provided. Complaint Deficiency

Based on staff interview, facility documentation review, clinical record review, and in the course of a complaint investigation, the facility staff failed to ensure Resident #1 was free from an unnecessary drug for 1 of 4 residents, Resident #1. For Resident #1, the facility staff administered 100 units of insulin instead of 50 units as prescribed. The resident ' s blood glucose level dropped to 41 mg/dL (milligrams per Deciliter) (normal range 70-105 mg/dL). The resident was sent to the emergency room with a blood sugar level of 33. The resident was treated for [REDACTED]. The findings included: Resident #1 was admitted to the facility on [DATE] and discharged on [DATE]. [DIAGNOSES REDACTED]. Resident #1's Admission Evaluation dated 01/23/2015 documented, "Cognition: Alert, Disoriented to: Time, Mental function varies. Eating & Nutrition: Set up assist only." Hospital Record (Current Discharge Medication List) for Resident #1 date 01/22/2015 documented, "insulin Concentrated regular 500 unit/mL (milliter) Soln (solution). Commonly known as: U-500 Concentrated. Dose: 50 Units 0.1 mL by Subcutaneous route before breakfast, lunch, and dinner. Patient draws up to the 20 unit mark on a U-100 syringe four times daily." Hospital Record (Discharge Instructions) for Resident #1 dated 01/22/2015 documented, "He was titrated appropriately up to U-500 dose of (0.1 mL which is 50 units, 3 times per day before meals)." Hospital Record (Current Discharge Medication List) for Resident #1 dated 01/23/2015 documented, "insulin Concentrated regular 500 unit/mL Soln. Dose: 50 Units 0.1 mL by Subcutaneous route before breakfast, lunch, and dinner. Draw up to 10 unit mark on the U-100 syringe. That will equal 50 units." Hospital Record (Discharge Instructions) for Resident #1 dated 01/23/2015 documented, "...With improved PO (by mouth) intake and his infection, he was switched back to U-500, titrated appropriately to U-500 dose of (0.1 mL which is 50 units, 3 times per day before meals)." physician's orders [REDACTED].(okay) and renewed (Physician's Name)." physician's orders [REDACTED]." Medication Record for Resident #1 dated 01/23/2015 documented, "Insulin concentrated regular 500 units/ml soln 50 units/0.1 ml sub Q before breakfast lunch and dinner and at bedtime draw up to 20 unit mark on a U-100 syringe." Medication Record for Resident #1 dated 01/24/2015 indicated Resident #1 received insulin at 11:30 a.m. (20 units on the U-100 syringe which equals 100 units of the concerntrated regular insulin). Nursing Progress Notes for Resident #1 dated 01/25/2015 (charting for 01/24/2015 event)documented, "...as residents BS (blood sugar) was 41 @ (at) 1715 (5:15 p.m.). Orange juice and apple juice was provided, BS 43 @ 1730 (5:30 p.m.). Third cup with 3 packs sugar added provided BS rechecked @ 1745 (5:45 p.m.) = 91. Wife out in hall stated "you are taking too long you need to get a move on right now." Resident left facility via (Facility) EMS (emergency medical services) @ 1805 (6:05 p.m.) without incident. (Physician) aware." Emergency Patient Record for Resident #1 dated 01/24/2015 documented, "Fingerstick Blood Sugar (Mg/Dl) (milligrams per Deciliter) 33 (normal range 70-105 mg/dL)" Emergency Patient Record for Resident #1 dated 01/24/2015 documented, "Primary Impression: [DIAGNOSES REDACTED]" Hospital Record (Laboratory Tests) for Resident #1 dated 01/24/2015 documented, "Glucose 33 * L (low)." Hospital Record (History of Present Illness) for Resident #1 dated 01/24/2015 documented, "Today afternoon when son went to visit him, he was found on the floor. His blood sugar was 40 at that time, but he was alert, awake, and he was talking at that time. Upon asking the patient, he is very confused and disoriented....Patient was given juice and was given something to eat, but he again had drop in blood sugar to 33 and because of recurrent [DIAGNOSES REDACTED], patient was advised to be admitted and observe blood sugar more closely." Nursing Progress Notes for Resident #1 dated 01/25/2015 documented, "Called (Hospital) at approximately 0350 (3:50 a.m.). Resident was admitted with [DIAGNOSES REDACTED]. Hospital Record (Consultation Report) for Resident #1 dated 01/25/2015 documented, "He was discharged to rehab 2 days ago and came in yesterday afternoon after he was found on the floor with a blood sugar of 40." On 02/24/2015 at 1:39 p.m., an interview was conducted with Licensed Practical Nurse-A (LPN-A) via phone. Administrator and Director of Nursing (DON) also present during this phone interview. LPN-A stated she administered 20 units (using the U-100 syringe) of the concentrated regular 500 unit/mL insulin to Resident #1 on 01/24/2015. On 02/24/2015 at 1:55 p.m., an interview was conducted with LPN-B. LPN-B stated the above insulin order was "very confusing". According to LPN-B, she would clarify the order with physician before administering. On 02/24/2015 at 1:58 p.m., an interview was conducted with LPN-C. LPN-C stated the above insulin order was "very confusing". According to LPN-C, she would clarify the order with physician before administering. On 02/24/2015 at 2:05 p.m., an interview was conducted with Registered Nurse-B (RN-B), Unit Manager. RN-B stated she would clarify the above insulin order with physician before administering. RN-B also stated she would make sure the order was transcribed correctly before administering. On 02/24/2015 at 2:10 p.m., an interview was conducted with LPN-D. LPN-D stated she would not administer the above insulin order; she would clarify with physician first. On 02/24/2015 at 4:15 p.m., an interview was conducted with DON. DON stated 20 units on the U-100 syringe equals 100 units of the concentrated regular 500 unit/mL insulin. DON also stated that if an order was unclear, staff should clarify with physician. On 02/24/2015 at 4:35 p.m., an interview was conducted with Medical Director. Medical Director stated 20 units on the U-100 syringe equals 100 units of the concentrated regular 500 unit/mL insulin. Medical Director stated the insulin order should be clarify before administering. On 02/25/2015 at 11:00 a.m., an interview was conducted with Resident #1's physician. Resident #1's physician stated 10 units on the U-100 syringe equals 50 units of the concentrated regular 500 unit/mL insulin. If nurse administered 20 units (using the U-100 syringe) of the concentrated regular 500 unit/mL insulin, that's 100 units. Resident #1's physician stated the insulin order should be clarify before administering. Facility Policy/Procedure titled "Insulin Administration" stated, "The type of insulin, dosage requirements, strength, and method of administration must be verified before administration, to assure that it corresponds with the order on the medication sheet and the physician's orders [REDACTED]. Syringes-insulin syringes must match the unit dose (e.g., (for example) 100 unit/ml insulin must be administered in a 100 unit/ml insulin syringe.) Facility Policy/Procedure titled "General Guidelines For The Administration Of Medications" stated, "The nurse observes the five rights in administering each medication: (a) The right resident (b) The right time (c) The right medication (d) The right dose (e) The right method of administration." "Dosing Formulas U-100 insulin syringe: Divide prescribed dose (actual units of [MEDICATION NAME] R U-500) by 5 = unit markings in a U-100 insulin syringe" (Reference: www.[MEDICATION NAME].com <http://www.[MEDICATION NAME].com>) "Warnings-[MEDICATION NAME] R U-500 contains 500 units of insulin in each milliliter (5 times more concentrated than [MEDICATION NAME] R U-100). For [MEDICATION NAME] R U-500, extreme caution must be observed in the measurement of dosage because inadvertent overdose may result in serious adverse reaction or life-threatening [DIAGNOSES REDACTED]." (Reference: www.[MEDICATION NAME].com <http://www.[MEDICATION NAME].com>) "Precautions-Dosing Confusion/Dosing Errors: Medication errors associated with [MEDICATION NAME] R U-500 have occurred and resulted in [MEDICAL CONDITION], [DIAGNOSES REDACTED], or death. The majority of errors occurred due to errors in dispensing, prescribing, or administration." (Reference: www.[MEDICATION NAME].com <http://www.[MEDICATION NAME].com>) "[DIAGNOSES REDACTED]-[DIAGNOSES REDACTED] is the most common adverse reaction of all insulin therapies, including [MEDICATION NAME] R U-500. [DIAGNOSES REDACTED] may occur suddenly. Severe [DIAGNOSES REDACTED] may lead to unconsciousness, convulsions, temporary or permanent impairment of brain function, or death." (Reference: www.[MEDICATION NAME].com <http://www.[MEDICATION NAME].com>) The Administrator and Director of Nursing were made aware of these findings on 02/27/2015 at 2:50 p.m., no further information provided. Complaint Deficiency

Based on observation, resident interview, staff interview, facility documentation review and clinical record review, the facility staff failed to identify a pressure ulcer, prior to it being discovered as an unstageable ulcer, resulting in harm. For Resident #1, the facility staff failed to accurately identify in a timely manner a left heel pressure ulcer before it reached an unable to stage pressure ulcer identifed on 6/19/14. The findings included: Resident #1 was admitted to the facility on [DATE] and readmitted following hospitalization due to a left [MEDICAL CONDITION] on 6/2/14. Resident #1's [DIAGNOSES REDACTED]. MDS info: The MDS prior to the heel wound formation on 6/19/14 was a 14 day PPS assessment with an Assessment Reference Date (ARD) of 6/16/14. The MDS coded Resident #1 with no cognitive impairment; required extensive assistance with bed mobility, locomotion on the unit, dressing, eating and personal hygiene; was dependent on staff for transfers, toilet use and bathing; had impaired range of motion of both lower extremities; and was frequently incontinent of bowel and bladder. Section M, Skin Conditions listed Resident #1 was at risk of developing pressure ulcers and had one or more unhealed pressure ulcers at Stage 1 or higher. Section M0300, Current Number of Unhealed Pressure Ulcers at Each Stage coded one Stage 3 pressure ulcer that was present upon admission/entry or reentry which measured 1.5 cm (centimeters) in length and 0.4 cm in width. Section M1200, Skin and Ulcer Treatments included: Pressure reducing device for chair, pressure reducing device for bed, nutrition or hydration interventions to manage skin problems, pressure ulcer care, surgical wound care, application of nonsurgical dressings, and applications of ointments/medications other than to feet. Section O, Special Treatments, Procedures and Programs coded 140 minutes of Occupational Therapy and 313 minutes of Physical Therapy in the last 7 days. The MDS completed after the development of the heel pressure ulcer was a 30 day PPS assessment with an ARD of 6/30/14. The MDS coded Resident #1 with no cognitive impairment; required extensive assistance from staff for bed mobility, locomotion on unit, dressing, eating and personal hygiene; was dependent on staff for transfers, toilet use and bathing; had impaired range of motion of one side of upper extremity and both lower extremities; and was frequently incontinent of bowel and bladder. Section M, Skin Conditions listed Resident #1 was at risk of developing pressure ulcers and had one or more unhealed pressure ulcers at Stage 1 or higher. Section M0300, Current Number of Unhealed Pressure Ulcers at Each Stage coded one Stage 3 pressure ulcer that was present upon admission/entry or reentry and one Unstageable-Deep tissue: Suspected deep tissue injury in evolution. Dimensions were 5.2 cm in length and 9.1 cm in width. Section O, Special Treatments, Procedures and Programs coded 275 minutes of Occupational Therapy and 321 minutes of Physical Therapy in the last 7 days. The most recent Minimum Data Set (MDS) was a quarterly assessment with an Assessment Reference Date (ARD) of 10/21/14. The MDS coded Resident #1 with no cognitive impairment; required extensive assistance from staff for dressing and hygiene; was dependent on staff for bed mobility, transfers, toileting and bathing; always incontinent of bowel and bladder; and ambulation did not occur. Pressure Ulcer record and skin Assesment: A "Pressure Ulcer Record" dated 6/19/14 and written by Wound Nurse Registered Nurse-D (RN-D) read: "Date of origin: 6/19/14, Site Location: (L) heel, facility acquired Stage: Unstageable, Exudate: None, Wound Bed: Eschar-thick, hard, leathery, black necrotic tissue, Surrounding skin: Normal for skin..... Specialty Interventions: Mattress, type: LAL (low air loss), W/C/Chair cushion, Prevalon Boots, Nutritional Interventions: Supplements, Progress Notes: Resident noted to have dark soft eschar to (L) heel. Recent mult (multiple) appts out of facility [MEDICAL TREATMENT], all on stretcher with no heel floatation when out of bldg (building). Skin prep/prevalon boots applied. Orders to wear boots to all appt (appointments)." Review of the readmission skin assessment form dated 6/2/14 revealed Resident #1 did not have any skin conditions of the left foot or heel. The Braden scale, a tool to help assess the risk of developing a pressure ulcer, was scored as a 16 which equals a mild risk of developing a pressure ulcer. Admission physician orders [REDACTED]." A Braden Scale dated 6/10/14 was scored as a 14 which equals a moderate risk. Review of the Medication Administration Record [REDACTED]. Prevalon boots at all times as tolerated and skin prep to left heel were initiated on the treatment record on 6/19/14, which was the date of discovery of the unstageable pressure ulcer. A "Weekly Skin Assessment" form dated 6/16/14 did not contain any skin issues on the heels. Certified Nursing Assistant charting on the "ADL (activities of daily living) Flow Sheet" revealed a bed bath was given on 6/17/14 on the night and day shift and a partial bath was given on the evening shift. On 6/18/14 a bed bath on the night shift and partial baths were given on the day and evening shifts. A bed bath was also documented on the night shift of 6/19/14. Care Plan: The " Master Care Plan for Resident " dated 6/12/14 had the admitted as 6/2/14 READMIT. The section " SKIN INTEGRITY " had the following problems/strength listed: Potential for skin breakdown due to weakness r/t (related to) recent hospitalization for fall with LT (left) hip fx (fracture), decreased mobility, frequent incontinence of bladder/bowel and dx (diagnosis) of diabetes. He has amputations of toes on RT (right) foot. He requires extensive to total assistance with bed mobility (assist of two at times). He has SDTI (suspected deep tissue injury) to LT inner buttocks and incision site to LT hip healing nicely (32 staples intact). L (left) flank/lower (symbol) axillary healed. Interventions/Approaches included: Turn and position frequently q shift (every shift) assist as needed (assist of two at times), report any dry, weeping or non intact skin or bruising, report any complaints of itching and monitor for rash, avoid pressure areas, apply medicated treatments if ordered, wash and dry body creases daily as needed, float heels as tolerated-Prevalon boots on at all times (hand written in without a date), keep clean and dry, tx (treatment) as ordered (hand written in without a date), notify if no improvement in LT/RT buttocks, notify MD if any s/sx (signs/symptoms) of infection noted to LT hip incision area, LAL (low air loss) mattress to bed (check functioning qs-every shift), send w/c (wheelchair) cushion with resident to [MEDICAL TREATMENT], added 6/12-Nephro supplement as ordered to facilitate wt (weight) gain and wound healing. Care Plan dated 8/7/14 included the above measures with the addition of: [MEDICAL TREATMENT] center educated on use of boots while at their facility, Prevalon boots worn when out to [MEDICAL TREATMENT], LT inner buttocks healed 8/4/14 and Protein supplement as ordered 10/7/14 Observations: On 10/22/14 at 8:55 a.m. Resident #1, a Caucasian male, was observed sleeping on his back on an air mattress. An interview was conducted with the Unit Manager, Registered Nurse-A (RN-A) at 9:15 a.m. When asked if Resident #1 had any wounds, RN-A stated he had a "necrotic" area on his heel. RN-A proceeded to explain that he "Was pretty sick for a while and had [MEDICAL TREATMENT] a few days in a row." Resident #1's weight was discussed. RN-A stated Resident #1 "Did have a weight loss over a 6 month period, that he was a picky eater, family is helping by bringing in food and that he gets Nepro (a supplement drink) during the day." RN-A stated he "Has had a weight gain the past month." On 10/22/14 at 9:25 a.m. Resident #1 was observed lying in bed with the head of bed up approximately 90 degrees with his breakfast tray in front of him. All but the scrambled eggs were eaten. An air mattress was in use, call bell within reach and bilateral protective boots were observed to be on. Resident #1 was alert, oriented and willing to have a conversation. Resident #1 stated he goes out of the building to [MEDICAL TREATMENT] on Tuesdays, Thursdays and Saturdays and usually feels tired and nauseous afterwards; he proceeded to reveal his left arm [MEDICAL TREATMENT] shunt. Resident #1 was unable to lift his left arm but able to rotate his shoulder stating "That's my bad arm." He was unable to lift his left leg. Resident #1's clinical record was reviewed on 10/22/14 at approximately 9:30 a.m. The current signed physician's orders [REDACTED]. "Treatments-Skin prep apply topically to (L)-left heel every shift. Activities-sponge bath only Non treatment sheet-Float heels as tolerated on pillows, hoyer lift for transfers, prevalon boots at all times as tolerated, APM (alternating pressure mattress) and skin observation every week on Monday 7-3 (7 a.m.-3 p.m. shift) and Nepro 5 cans p.o. (by mouth) q day (every day)." On 10/22/14 at 4:00 p.m., the Administrator, Director of Nursing and Corporate staff were informed of the wound not being found until it was an unstageable pressure ulcer. When asked how skin is assessed, the Administrator (Admin-A) stated that "Licensed nurses do weekly skin assessments and skin is looked at with care and bathing." Admin-A stated "CNA's (certified nursing assistants) would report any skin changes to the nurse." On 10/23/14 at 8:30 a.m. an interview was conducted with Licensed Practical Nurse-D (LPN-D). LPN-D stated she was the day shift nurse at the time of the pressure ulcer discovery. LPN-D stated "He had increased anxiety after he came back from the hospital for fear of falling" LPN-D stated "He didn't always allow us to reposition him or give him a full bath." When asked about preventative measures, LPN-D stated "He would remove the pillows under his heels with his good arm." When asked if she knew why it wasn't discovered earlier, LPN-D stated "I really don't know, he was in and out to appointments that week, maybe the CNA's didn't notice." When asked how the nurses do weekly skin assessments, LPN-D stated they "Look head to toe at all areas." On 10/23/14 at 8:50 a.m. an interview was conducted with Wound Nurse RN-D. RN-D presented documentation that Resident #1 [MEDICAL CONDITION] of his legs and stated "[MEDICAL CONDITION] further compromises resting pressure and tissue tolerance." RN-D presented lab results showing the resident was anemic and a timeline prior to the discovery of the pressure ulcer. The resident was shown to have been out of the building for [MEDICAL TREATMENT] and doctor appointments on 6/4, 6/5, 6/7, 6/10, 6/12, 6/13, 6/14, 6/16, 6/17 and 6/18/14. RN-D stated the area on Resident #1's heel was found as a deep tissue injury on 6/19/14 at 6 a.m. by the CNA and reported to the night supervisor. Discussed with RN-D that the initial findings were not documented as a deep tissue injury but as a black necrotic area. A "Skin and Body Alert Form" (a form used by staff to communicate any new skin areas) was presented dated 6/16/14 and written by a certified nursing assistant listed "Bed Bath" and "OK." LPN-D signed the form and under "Initial Interventions Initiated" "None required; continue prevention intervention and close observation." On 10/23/14 at 10:00 a.m. an interview was conducted with Certified Nursing Assistant-B (CNA-B). When asked what things do you look for when working with a resident? CNA-B stated "Look for changes in the skin, appearance, wounds and bruising." When asked if she would describe the different types of baths, CNA-B explained a "full bed bath" was washing head to toe and applying lotion to the skin and a "partial bed bath" was washing of the face, underarms and private areas. CNA-B stated "If I see a change in condition I would notify the nurse." On 10/23/14 at 1:00 p.m., Resident #1 was observed lying in bed with head of bed up almost 90 degrees. Bilateral prevalon protective boots were in place. Observation of Resident #1's left heel was conducted with the nursing staff. An approximately 4.7 by 6.8 centimeter black necrotic area was observed on the left heel. The necrotic area was stable with no surrounding redness. The right heel was intact with no redness observed. At 1:10 p.m. an interview was conducted with Resident #1. When asked if he had any pain in his heel he stated "Never had pain in the heel and one day the nurses put boots on me and said I had a wound." Resident #1 proceeded to state that he was transferred to [MEDICAL TREATMENT] on a stretcher and then transferred to a [MEDICAL TREATMENT] chair and because his legs are long his feet usually hang over the edge of the leg rest. Guidance regarding presentation and early identification of a pressure ulcer was provided at: "International NPUAP-EPUAP Pressure Ulcer Definition (National Pressure Ulcer Advisory Panel)A pressure ulcer is localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear. A number of contributing or confounding factors are also associated with pressure ulcers; the significance of these factors is yet to be elucidated Unstageable/Unclassified: Full thickness skin or tissue loss - depth unknownFull thickness tissue loss in which actual depth of the ulcer is completely obscured by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Until enough slough and/or eschar are removed to expose the base of the wound, the true depth cannot be determined; but it will be either a Category/Stage III or IV. Stable (dry, adherent, intact without [DIAGNOSES REDACTED] or fluctuance) eschar on the heels serves as "the body's natural (biological) cover " and should not be removed." www.npuap.org. "Skin, the largest organ in the body, constitutes 15% of the total adult body weight (Wysocki, 2012). It is a protective barrier....Injury to the skin poses risks to safety and triggers a complex healing response. A nurse's most important responsibilities include assessing and monitoring skin integrity; identifying problems; and planning, implementing, and evaluating interventions to maintain skin integrity." Fundamentals of Nursing, Eighth Edition, Potter-Perry, page 1176. On 10/23/14 at approximately 2:45 p.m., the Administrator, Director of Nursing and Corporate staff were informed of the failure to identify a pressure ulcer prior to it becoming an unable to stage ulcer, resulting in harm for Resident #1.

Based on observations, resident interviews, staff interviews, facility document reviews, clinical record reviews and in the course of a complaint investigation, the facility staff failed to provide supervision and assistive devices to prevent falls for two residents (Resident #3 and #1) in the survey sample of three residents who were at risk for falls and had a previous fall. 1. For Resident #3, the facility staff failed to review/revise the care plan and to assess the resident for continued risk for falls and failed to prevent falls on 11/27/11 and 04/02/2012. Resident #3 sustained multiple lacerations resulting from the fall on 04/02/2012, which required 6 sutures. 2. For Resident #1, the facility staff failed to review/revise the care plan and assess the resident for continued risk for falls and failed to prevent falls on 04/03/2012, 04/13/2012, and 04/22/2012. The findings included: According to facility's Falls Policy and Procedure (effective date: January 2009), the center will provide each resident with: * Appropriate assessment at the time of admission, readmission, change of condition, and quarterly to assess the resident's risk for falls; *Appropriate interventions to reduce the risk to the resident from falling; *Appropriate assessment, investigation, and interventions should a fall occur; and *A continual process of Performance Review to analyze, trend, review, and/or revise processes to provide a safe environment to each resident/patient. 1. Resident #3 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Resident #3's Minimum Data Set (an assessment protocol) with an Assessment Reference Date of 03/23/2012 coded Resident #3 as requiring extensive assistance with 2 or more people physical assist for transfer, requiring extensive assistance with 1 person physical assist for toilet use. Resident #3 was coded as requiring one person physical assist for bathing. In addition, the MDS coded Resident #3 as being not steady when moving from seated to standing position, not steady when moving on and off toilet, and not steady during surface-to-surface transfer (transfer between bed and chair or wheelchair). Wheelchair was checked as Resident #3's mobility devices. The MDS also coded Resident #3 as frequently incontinent for both urine and bowel. Fall Risk assessment dated [DATE] (Admission Assessment) documented Resident #3 had a score of 10. Fall Risk assessment dated [DATE] documented Resident #3 had a score of 13. Fall Risk Assessment Policy & Procedure (effective date: January 2009) documented "Score of 10 or above represents a high risk for falls and will require the implementation of a Care Plan. Reviewed of physician's orders [REDACTED]." Nurses Notes, dated 11/27/2011, documented "At 9:55 a.m. (Resident #3) was in bathroom getting a bath. Certified Nurse Aid (CNA) walked out of bathroom into (Resident #3's) room to get a wash cloth and heard a noise. Resident was found on floor beside wheelchair. When writer asked resident if she hit her head, she stated Yes. Skin tear noted on left arm by elbow, a red mark on left thigh, and a bruise on top of her head. Neuro checks started, every 15 minutes x 4, then every shift x 72 hours. Range of Motion within normal limit, neuro check within normal limit. Resident #3 denied any pain. Vital signs: 97.6-73-24-102/55. Will continue to monitor." No Fall Risk Assessment noted for this fall or revision of care plan. Monthly Nursing Summary under Functional Status dated 03/2012 documented Resident #3 was totally dependent in terms of bathing. The staff performs the total activity. Resident #3 required one person physical assist during baths. According to Care Plan dated 10/13/2011, 01/05/2012 and 03/29/2012, staff will provide extensive assistance when bathing Resident #3. Also, the Care Plan for Resident #3 was reviewed. Under the heading "Problem" the care plan read, "On 11/27/2011 (Resident #3) fall in bathroom stated hit head, skin tear left arm, red mark left thigh, bruise on top of head, neuro checks started." Under the heading "Goal" it documented "All area from fall will heal over the next 14 days 12/12/11." Under the heading "Interventions" it documented the following interventions: -"Neuro checks as ordered, -Apply treatment to skin tear left arm for 7 days." Interventions for Resident #3 included the same interventions and were dated on 10/13/2011, 01/05/2012, and 03/29/2012's, which included: -Assist resident out of bed daily as tolerated (encourage resident not to attempt to get up without assistance). -Blood pressure checks as indicated. -Keep personal items within reach. -Keep room and halls free from clutter, spills, equipment, etc. -Place call bell within reach at all times. -Lab results as ordered. Report abnormal findings to MD (doctor). -If head injury occurs, neurochecks as ordered. -Report side effects of psychotropic medication such as: dizziness, drowsiness, headache, lethargy, increased agitation, etc. -Attempt trial reduction of psychotropic medication unless contraindicated -Bed in low position and locked position. -1/2 siderail up x 2 to assist with turning and positioning due to generalized weakness R/T (related to) CHF (congestive heart failure). -Pressure alarm at all times. Under the heading "Problem" read, "On 04/02/2012 (Resident #3) found lying on floor in front of her wheelchair. 2 gashes to forehead. ROM WNL (range of motion within normal limit). Ice pack & pressure dsg (dressing) applied. Alert & verbal-neuro checks done. Sent out to ER (emergency room ) admitted ." Reviewed of Resident #3's care plan for falls failed to reveal any evidence that new assessments/interventions were added to the care plan to prevent falls following the fall documented on 11/27/2011 and 04/02/2012. Progress Note dated 04/02/2012 documented "7:50 p.m. Resident #3 found lying on floor in front of her wheelchair. Two gashes to forehead. Range of Motion within normal limit. Ice pack and pressure dressing applied. Resident alert and verbal. Responsible party and doctor notified. Nurse and Certified Nurse Aid assisted resident back into wheelchair." Progress Note dated 04/02/2012 documented "8:15 p.m.-8:30 p.m. Physician ordered to send to ER (emergency room ). Transport here to pick up (Resident #3), transported to hospital." emergency room Report, dated 04/02/2012, read, "(Resident #3) injury occurred nursing home. Patient sustained multiple lacerations. Symptoms located in the forehead. Wound #1 length of laceration=4 centimeters (cm). Number sutures used: 4. Wound #2 length of laceration=1 cm. Number sutures used:2." On 05/11/2012 at 3:30 p.m., an interview was conducted with Certified Nurse Aid-A (CNA-A). CNA-A stated she was not assigned to care for Resident #3. CNA-A heard an alarm went off around 7 or 7:30 p.m. on 04/02/2012. CNA-A went into Resident #3's room and found resident lying on the floor. CNA-A stated Resident #3 had slipped out of the wheelchair. There was blood on the floor and Resident #3's forehead was bleeding. CNA-A called for help, a nurse came in and assisted CNA-A with Resident #3. They put Resident #3 back into the wheelchair, and called the supervisor. On 05/11/2012 at 3:55 p.m., a phone interview was conducted with CNA-B. CNA-B stated she was the primary CNA for Resident #3 on 04/02/2012. CNA-B stated she was training a new CNA on 04/02/2012. CNA-B stated " Maybe around 6:00 p.m., (Resident #3) finished her dinner and was brought back to her room. At 6:15 p.m., we went back to the floor, because we still have to pass trays to other residents. At around 7:10 p.m.., the doctor was on the wing, I had to get a blood pressure cuff for the doctor. Then me and the other CNA) went to dinner ourselves at around 7:35 p.m.. (Resident #3) was found on the floor around 7:30-8:00 p.m.. I was going to put her to bed after my dinner break." On 05/11/2012 at 4:10 p.m., an interview was conducted with Director of Nursing (DON). The Care Plan dated, 10/13/2011, 01/05/2012 and 03/29/2012 for Resident #3 was provided to surveyor. Surveyor asked to see Resident #3's Fall Risk Assessment for January through December 2011, and February through April 2012. DON stated these assessments were not available. No Fall Risk Assessment for the Year of 2011 for Resident #3. Surveyor asked if facility had revised the care plan for Resident #3 after the falls on 11/27/2011 and 04/02/2012, DON stated "We would have care planned her when she returns, but she never did." Complaint Deficiency 2. Resident #1 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Resident #1's Minimum Data Set (an assessment protocol) with an Assessment Reference Date of 03/16/2012 coded Resident #1 as being independent for transfer and toilet use. In addition, the MDS coded Resident #1 as being steady when moving from seated to standing position, walking, turning around, moving on and off toilet, and surface-to-surface transfer (transfer between bed and chair or wheelchair). On 05/09/2012 at 11:45 a.m. Resident #1 was sleeping, all 4 bed side rails were down. On 05/09/2012 at 12:40 p.m. Resident #1 was walking with a walker by herself from bed to the sink, no staff present at this time. On 05/09/2012 at 1:09 p.m. Resident #1 was sleeping, all 4 bed side rails were down. On 05/09/2012 at 2:50 p.m. Resident #1 was in bed, all 4 bed side rails were down. Resident #1 was on the Fall List (3 or more falls in 3 months), which was given to surveyor on 05/11/2012. C.A.R.E Notes dated 10/26/2011 documented "Resident #1 discussed at CARE meeting. Resident #1 observed on floor next to bed on 10/22/2011 with no apparent injury. Resident #1 denies hitting her head. Resident toilets herself and ambulates independently in room & hall. Resident is not a candidate for floor mats because of her ambulatory with walker. Resident stated that she must have rolled off of bed. Bed continue to be in lowest position when in bed." No Care Plan noted for this fall. Care Plan dated 12/29/2011 and 03/22/2012 documented "On 04/03/2012 Resident #1 lost her balance and fell . No injury noted." No Fall Risk Assessment noted for this fall. Nurses Notes dated 04/13/2012 documented "Called to room by CNA due to Resident #1 being on floor. Resident was lying on her back, her walker was in front of the sink, it appeared she fell straight back, resident denies hitting her head and denies any new pain as she has chronic joint pain, no bruising or skin tears noted at this point. Two team members were required to assist resident up." No Fall Risk Assessment noted for this fall. No revisions to Care Plan noted for this fall. Nurses Notes dated 04/22/2012 documented "97.9, 74, 18, 153/80 at 4:30 p.m. Resident #1 had pulled her emergency cord in the bathroom. Both doors were locked to her bathroom. After using a wrench to get the door open, Resident #1 was observed sitting on the floor by the toilet. Assessed for injury, none apparent." No Fall Risk Assessment noted for this fall or revisions to care plan. The Care Plan for Resident #1 was reviewed. Under the heading "Problem" documented "04/03/2012 Resident lost her balance & fell . No injury noted. 04/22/2012 Observed on floor in bathroom. No apparent injury." Under the heading "Goal" documented "Resident will have no falls or injury related to falls over next 90 days. Goal date: 03/22/2012, 06/14/2012." Under the heading "Interventions" documented "Encourage resident to open blinds & utilize light in room." Interventions for Resident #1 dated 12/29/2011 and 03/22/2012's care plan included: -Assist resident out of bed daily as tolerated. -Blood pressure checks as indicated. -Fall assessment upon admission, quarterly and PRN (as needed). -Keep personal items within reach. -Keep room and halls free from clutter, spills, equipment, etc. -Place call bell within reach at all times. -Report an unsteady gait, ataxia, etc. -Lab results as ordered. Report abnormal findings to MD (doctor). -If head injury occurs, neurochecks as ordered. -Report side effects of psychotropic medication such as dizziness, drowsiness, headache, lethargy, increased agitation, etc. -Attempt trial reduction of psychotropic medication unless contraindicated. Further review of Resident #1's care plan for falls failed to reveal any evidence that new assessments/interventions were added to the care plan to prevent fall following the incidents documented on 10/22/2011, 04/03/2012, 04/13/2012, and 04/22/2012. On 05/09/2012 at 2:50 p.m., an interview was conducted with Registered Nurse-B (RN-B, Unit Manager). Surveyor asked to see Resident #1's Fall Risk Assessment. RN-B stated "I don't see one in here." On 05/09/2012 at 3:00 p.m., an interview was conducted with DON. Surveyor asked to see Resident #1's Fall Risk Assessment. "Will get it for you." On 05/09/2012 at 3:10 p.m., an interview was conducted with DON. She stated "We are looking at the purged record right now." On 05/09/2012 at 3:20 p.m., Fall Risk Assessment for Resident #1 dated 12/18/2011 was given to surveyor. Fall Risk Assessment for Resident #1 was 10 (High Risk). When surveyor asked DON for a more recent Fall Risk Assessment for Resident #1, DON stated "I am going to be honest with you. RN-B did not do it. She is doing it right now as we speak." According to Fundamentals of Nursing Lippincott Williams and Wilkins 2007 pages 65-77 documented, "A written care plan serves as a communication tool among health care team members that helps ensure continuity of care...The nursing care plan is a vital source of information about the patient's problems, needs, and goals. It contains detailed instructions for achieving the goals established for the patient and is used to direct care...expected to review, revise, and update the care plan regularly, when there are changes in condition, treatments, and with new orders..."

Based on observation, staff interview, clinical record review, and facility documentation review, the facility staff failed to ensure one of 27 Residents in the survey sample (Resident #2) did not develop an avoidable pressure ulcer. For Resident #2, the facility staff failed to prevent the development of a pressure ulcer and failed to assess after the development of a pressure ulcer resulting in debridement and a Stage III pressure sore. The findings included: Resident #2, a [AGE] year old female, was admitted to the facility 3/26/11. Her [DIAGNOSES REDACTED]. Resident #2's most recent MDS (minimum data set) with an ARD (assessment reference date) of 5/21/11 was coded as a 60 day Medicare PPS assessment. Resident #2 was coded as having short and long term memory deficits and required minimal assistance in making daily life decisions. She was also coded as requiring assistance with all of her activities of daily living. Her weight was documented as being 162 pounds and she was 64 inches in height. Resident #2 was observed and interviewed 7/20/11 at 8:20 a.m. She was in bed, with a specialty mattress in place. Resident #2 was alert, oriented to place and person, and verbally responsive. Resident #2 was interviewed 7/20/11 at 10:50 a.m. She was alert, oriented and verbally responsive. Resident #2 was also observed 7/21/11 at 2:35 p.m. when an observation of her wounds occurred. The area on her sacrum appeared to be a healing stage III with a vascular base and yellow film overlay. Two smaller abraded areas were noted bilaterally on the buttocks adjacent to the actual sacral pressure ulcer. No odor or swelling was noted at any of the wounds. Review of Resident #2's clinical record revealed Resident #2 had fallen at home and fractured her left leg. An ORIF (open reduction and internal fixation) was performed and Resident #2 was admitted to the facility for skilled nursing and rehab. Prior to her fall, Resident #2 had lived independently at home. The admitting nursing assessment, conducted on the day of admission 3/26/11, by an RN, revealed 11 different areas of "SKIN CONDITIONS." Area #6 on the body picture of the nursing assessment was noted to be at the sacrum. The description entered included, "Approx (approximately) 1" long, narrow strip coccyx crease lt (light) pink." The assessing nurse had written "open" and subsequently crossed that entry out with her initials adjacent to the crossed out entry. Review of all the other areas revealed no open areas. Resident #2 was noted to have a surgical incision with staples on her left upper leg. Review of the actual admitting nursing note completed 3/26/11 at 12:55 p.m., indicated no open areas on Resident #2's sacrum. The admitting nurse completed a "Braden Scale" at the time of admission. The scale determined Resident #2 to be at moderate risk of developing pressure ulcers due to a score of "14." The "Braden Scale" is a system of "Predicting Pressure Sore Risk." On 3/28/11 the treatment nurse, LPN #25, wrote a note regarding Resident #2. The note included, "Buttocks old dry abrasions to (L) buttocks. Resident also have white scar to center of upper buttocks open 3 x 3.4 cm (centimeters). Resident stated it was not hurting as I touched area-Resident stated it was old scar from a fall when she was a child years ago. noted unstageable...Heels floated off pillows. Resident on pressure reducing mattress." No description of the "open" wound was evident for the wound base, depth, drainage, etc. The rest of the page was "Xed" off with an entry written over the X of "Treatment order obtained for sacral wound" with LPN #25's signature. Upon initially reviewing the note in Resident #2's record no entry was observed regarding obtaining an order for [REDACTED]. When asked how the two skin assessments could have been so different in two days, LPN #25 stated, "I wasn't in the room when the admitting nurse did her assessment." Review of Resident #2's admitting orders revealed orders were obtained for medications and treatment to the surgical wound on 3/26/11. An entry was noted on the orders dated 3/26/11 that included "cleanse sacral area (c line over-with) NS (normal saline) apply Santyl oint cover (c line over-with) gauze & [MEDICATION NAME] Q (every) Mon Wed Fri." While Resident #2 was not evaluated by LPN #25 until 3/28/11, the entry was in LPN #25's hand writing and entered on orders obtained by the nurses on 3/26/11. According to the manufacturer's website, www.santyl.com, Santyl is "a sterile enzymatic [MEDICATION NAME] ointment" used to chemically debride a wound with necrotic tissue. Necrotic tissue is tissue that is devitalized (dead). NPUAP (National Pressure Ulcer Advisory Panel) defines necrotic tissue as "4 - Necrotic Tissue (Eschar):black, brown, or tan tissue that adheres firmly to the wound bed or ulcer edges and may be either firmer or softer than surrounding skin." [MEDICATION NAME] is a dressing that covers the wound with an occlusive covering. When interviewed 7/21/11 at 2:35 p.m., LPN #25 stated she was able to write the order for the treatment on the 3/26/11 orders (even though she did not assess Resident #2 until 3/28/11), "because the doctor had not signed the orders yet." Review of the March MAR/TAR (medication/treatment administration record) revealed no treatment was begun for Resident #2's sacral wound until 4/1/11 when the wound treatment of [REDACTED]. LPN # 25 further stated the treatment had not been put on the March MAR/TAR. When the April MAR/TAR was reviewed, the order was entered and treatment was begun on the sacral wound. LPN #31, a nurse on the unit, stated 7/21/11 at 11:42 a.m., that if an area had been noted upon admission, the admitting nurse would have gotten some type of treatment for [REDACTED]. Review of the discharge information from the hospital revealed no notation of any open area on Resident #2's body with the exception of the surgical incision. Review of the admitting history and physical completed at the facility by Resident #2's physician, 3/31/11, revealed no documentation of any open areas on Resident #2's body except for a description of the area around her surgical wound. Weekly nursing skin assessments, conducted by the floor nurses, revealed no entry for the sacral wound until 4/26/11. Review of all the skilled nursing notes from the day of admission revealed no documentation of any sacral wound. The admission MDS assessment with an ARD of 4/1/11 revealed no areas, with the exception of the surgical incision, was coded. Resident #2 was coded as being at risk for the development of pressure ulcers on the assessment. A thorough review of Resident #2's "Care Plan Report" revealed no care plan had been developed for the prevention or treatment of [REDACTED].#2. An entry under the "Problem" of falls was entered on the Care Plan Report, "5/11/11 D/C (discontinue) santyl oint (ointment) to sacral wound stage 3 (c line over-with) daily drsg (dressing). N.O. cleanse sacral wound stage 3 cover (c line over-with) Santyl 1:1 [MEDICATION NAME] cover (c line over-with) drsg daily & prn (as needed)." Adm 7, stated 7/21/11 at 10:45 a.m., "We reviewed the care plan and there was not a care plan for pressure ulcer prevention and skin care." Review of LPN #25's wound tracking revealed no entry was made on the tracking system regarding a wound on Resident #2's sacrum until 5/3/11. While Resident #2 was entered on the tracking system, the only entry was for her surgical wound. The surgical wound was considered healed on 4/13/11. LPN #25 stated, 7/21/11 at 12 noon, "She fell through the cracks until 4/13/11" for wound care tracking. Resident #2 was assessed by the wound care specialist (WCS) on 4/13/11 and by the time the area was assessed by her, the area required surgical debridement of the wound. The keflex was ordered 4/28/11 and was in response to the wound on the lower leg. There were no measurements as the wound on the sacrum was not on any tracking or skin sheet until _______ (Name of Doctor) saw it on 4/13/11. After [MEDICATION NAME] it measured 2.2x2x0.1 cm. Surgical debridement is a procedure using a scalpel with the area of necrotic (dead) tissue surgically cut from the wound. After the debridement, WCS staged the wound as a stage III pressure ulcer. The wound care of cleaning with normal saline, apply Santyl ointment and cover with a dry dressing was continued three days a week. NPUAP defines Stage III pressure ulcers, "Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling." Further Description: "The depth of a stage III pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and stage III ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep stage III pressure ulcers. Bone/tendon is not visible or directly palpable." The mattress that had been on Resident #2's bed was a pressure reducing mattress, the same mattress all of the Residents utilized in the facility. Documentation revealed on 4/17/11 an order was obtained for an air mattress and the mattress was put on Resident #2's bed. When interviewed, Adm 7, the director of operations, stated 7/21/11 10:15 a.m., that an air mattress would not be used at the facility until a Resident had developed two Stage IIs pressure ulcers or a Stage III pressure ulcer or greater. Treatment, including bed rest from 5/21 until 6/15/11, continued on the sacral wound and on 6/20/11 the area was healed. Documentation revealed the sacral wound reopened and on 7/7/11 treatment began again. As of the end of the survey, Resident #2 was still receiving treatment to her sacral wound. While documentation revealed, at times, Resident #2 did not want to turn and reposition, when interviewed, LPN #25 stated that preventatively Resident #2 was on a pressure reducing mattress until 4/13/11 and was turned and positioned every two hours. LPN #25 also stated a pillow was used to Resident #2's back when repositioned. MVI (multivitamin), Vitamin C, Zinc, Vitamin A, [MEDICATION NAME] (a protein supplement) were not ordered for administration to Resident #2 until 6/13/11 . Blood work to assess Resident #2's protein stores for healing was ordered in July, 2011. Documentation revealed the blood work and supplements were ordered in response to the non-healing of wounds on Resident #2's right leg, not in response to concern over healing of the sacral wound. Review of the facility's policy, "Skin Integrity Program: Evaluation and Documentation of Wounds" revealed: "Upon admission of a resident with a wound, or upon discovery of a new wound on an existing resident in the center the following observations should be made and documented: 1.1 Type and/or nature of the wound:... 1.2 Location... 1.3 Measurements... 1.4 The stage (if caused by pressure) or dept of tissue involvement (partial thickness or full thickness) for non pressure wounds. 1.5. General appearance of the wound... Following initial observations, wounds should be observed on a daily basis as follows: 3.1 Evaluate the wound/ulcer if no dressing is present... 3.2 Evaluate the status of the dressing if a dressing is present and not due to be changed.... Weekly wound tracking is an ongoing system of monitoring wound progress and the incidence and prevalence of various types of wounds in the facility. 4.5 Once the weekly wound evaluations are complete, the current information will be entered onto the unit specific tracking form. Separate tracking forms are used for pressure ulcers and non pressure ulcers. 4.5.2 Information gathered should be used to assist in the evaluation of quality of care..." Also, "Skin Integrity Program: Wound Care Treatment" 1. A comprehensive evaluation of the resident's clinical condition, risk factors for pressure ulcer development, the current status of healing, and all characteristics of existing wounds will be made by a qualified individual. 2. The nurse will communicate with the physician or designated provider to obtain treatment orders that reflect the wound characteristics, overall treatment goals, and any other pertinent considerations (i.e. location of the wounds, infection, mobility, etc.) 3. The nurse will document the treatment orders as required. 4. The treatment will be administered as ordered and documented..." The DON stated that no other information was available for the prevention of pressure ulcers for Resident #2, 7/21/11 at 11:17 a.m. At 12:30 P.M., the administrator, assistant administrator, DON and Adm 7 were advised of the harm deficiency because of the development of a stage III pressure ulcer for Resident #2.