Every finding on record at Country Club Retirement CTR IV

Based on review of medical records, review of hospital and pharmacy records, and interviews with resident and staff, the facility failed to provide timely medical intervention when a resident experienced an acute change in condition. This affected one resident (#6) of two residents reviewed for hospitalization. In addition, the facility failed to provide treatment to a resident's skin tear. This affected one resident (#53) of four residents reviewed for skin conditions. The facility census was 45.Actual harm occurred on 10/02/25 when Resident #6, with a known history of gastric reflux with esophagitis, two recent emergency room visits for duodenitis and gastritis, and was taking routine ibuprofen (non-steroidal anti- inflammatory medication) and a routine Plavix (anti-platelet medication), experienced continued stomach pain with vomiting a reddish-brown liquid. The facility failed to notify the medical provider of the change in condition on 10/02/25 to provide medical treatment thereby delaying necessary care and treatment. On 10/10/25 Resident #6 continued to have abdominal pain with symptoms of anemia (low blood count) and required a four-day hospitalization for treatment including a blood transfusion of a bleeding stomach ulcer. Findings include: 1. Review of the medical records for Resident #6 revealed admission to the facility on [DATE] with diagnoses including chronic lung disease, heart disease, psychosis, history of stroke with left side paralysis, acid reflux with esophagitis (inflammation of the esophagus increasing risk of ulceration), heart failure, depression, diabetes with neuropathy (decreased sensation of nerve endings in hands and feet), multiple sclerosis (progressive muscle condition leading to hardening of muscle to prevent use), dementia (forgetfulness and confusion). Further review of the medical record for Resident #6 revealed admission to hospice services within the facility on 09/07/25 for the primary diagnosis of multiple sclerosis. Review of the medication profile for Resident #6 revealed the resident was prescribed Plavix (an anti-platelet medication prescribed to prevent further strokes)75 mg on 12/01/23 and Ibuprofen (an anti-inflammatory medication prescribed for pain) 800 milligrams (mg) three times a day on 09/30/24. Review of the resident's care plans revealed no evidence on 12/01/23 or 09/30/24 of a care plan for increased bleeding risk or to monitor for signs and symptoms of bleeding. Review of the order dated 09/30/24 for the Ibuprofen revealed a black box warning (the federal food and drug administration (FDA) most serious safety alert indicating life threatening risk) listed beside the medication on the medication order screen in the electronic medical record (EMR). The black box icon remained beside the Ibuprofen order while it remained as an active order in the EMR. Review of the FDA black box warning for Ibuprofen found in the EMR when hovering over the black box warning icon revealed the following: NSAIDs such as ibuprofen may cause ulcers, bleeding, or holes in the esophagus (tube between the mouth and stomach), stomach, or intestine. These problems may develop at any time during treatment, may happen without warning symptoms, and may cause death. The risk may be higher for people who take NSAIDs for a long time, are older in age, have poor health, smoke, or drink large amounts of alcohol while taking ibuprofen. Also tell your doctor if you have or have ever had ulcers, bleeding in your stomach or intestines, or other bleeding disorders. If you experience any of the following symptoms, stop taking ibuprofen and call your doctor: stomach pain, heartburn, vomit that is bloody or looks like coffee grounds, blood in the stool, or black and tarry stools. Review of the facility care plan from July 2025 to October 2025 for Resident #6 revealed no evidence of Resident #6 having a care plan to increase monitoring of gastro-intestinal (GI) status and no evidence of a care plan for Resident #6 to be monitored for signs and symptoms of bleeding. Review of the medical record revealed on 7/31/25 Resident #6 reported severe abdominal pain and was evaluated in the emergency room. Resident #6 was diagnosed with a urinary tract infection and duodenitis (inflammation of the upper small bowel, near the stomach). Resident #6 returned to the facility the same day with a new prescription for Carafate (anti-ulcer medication) 1 gram (gm) every 6 hours for 7 days and a referral was made for a gastroenterologist. There was no evidence of ibuprofen being prescribed and no order to continue the ibuprofen on the after-visit summary (AVS) dated 07/31/25 from the emergency room. There was no ibuprofen listed on the AVS. Review of the annual minimum data set (MDS) 3.0 comprehensive assessment completed on 08/20/25 for Resident #6 revealed a brief interview for mental status (BIMS) score of 12/15; indicating moderate cognitive impairment. Further review of the MDS revealed Resident #6 was prescribed a high-risk drug classification medication, an anti-platelet medication. Review of the medication administration record (MAR) for August of 2025 revealed Resident #6 continued on all the medications she had been receiving at the facility (including the ibuprofen 800 mg three times a day and Plavix 75 mg a day) and the new prescription for Carafate 1 gm every 6 hours for seven days was added. Continued review of the medical record revealed on 08/25/25 Resident #6 began having severe abdominal pain and was again evaluated in the emergency room. Resident #6 was diagnosed with gastritis (inflammation of the stomach) and prescribed Carafate 1 gm every 6 hours for 7 days again and an additional Protonix to 40 mg twice a day for 14 days (in addition to the current Protonix 20 mg daily). Resident #6 returned to the facility the same day. There was no ibuprofen prescribed and no order to continue the ibuprofen on the AVS dated 08/25/25 from the emergency room. There was no ibuprofen listed on the AVS. Review of the MAR from 8/24/25 to 8/31/25 and the MAR for the month of September 2025 revealed Resident #6 continued all medications that she had been receiving at the facility including the ibuprofen 800 mg three times a day, Plavix 75 mg a day, Protonix 20 mg a day and the new prescriptions for Carafate 1 gm every 6 hours and increased Protonix 40 mg twice a day for 14 days were added. Review of the monthly pharmacy medication reviews dated 08/29/25 and 09/29/25 during the period of time in which Resident #6 was seen in the emergency room and new medications were prescribed revealed no recommendations from the pharmacist to the physician or to the director of nursing regarding Resident #6 having increased risk of bleeding or increased risk for the development of a stomach ulcer related to the Ibuprofen and Plavix being taking concurrently. Review of the nursing progress notes dated 10/01/25 revealed the hospice nurse made a visit to see Resident #6. Resident #6 had complained of continued abdominal pain and nausea, and new orders were received. Review of the facility hospice communication note dated 10/01/25 revealed that Resident #6 had nausea and abdominal pain and the medical provider from hospice was notified and a new order to restart Carafate1 gm four times a day was given. Review of the MAR from 10/01/25 to 10/10/25 revealed Resident #6 continued to receive the prescribed Protonix, Ibuprofen, and Plavix. Review of a nursing progress note dated 10/02/25 revealed that Resident #6 had a reddish-brown emesis (vomit) with nausea that subsided after the episode of emesis. There was no evidence in the progress note that the resident's medical provider was notified of the resident's nausea and vomiting at this time. Review of the hospice RN supervision note dated 10/06/25 revealed Resident #6 had reported 10/10 pain abdomen the past 48 hours affecting sleep and appetite and was exacerbated by movement. Further review of the note revealed Resident #6 was pale with poor turgor and had only consumed 25% of meals. The hospice notes also revealed that communication of Resident #6 status was communicated to unspecified facility staff. There was no evidence that this information was communicated to the resident's medical provider. Continued review of the nursing progress notes revealed on 10/10/25 the hospice nurse practitioner (NP) made a visit and noted Resident #6 had a beefy tongue and pale skin (signs of anemia/low blood count) and the hospice NP ordered laboratory tests including complete blood count (CBC) and comprehensive metabolic profile (CMP) to be completed on 10/13/25. Further review of the nursing progress notes revealed on 10/10/25 at 8:00 P.M. Resident #6 demanded to go to the emergency room for severe 8/10 upper right sided abdominal pain. Resident #6 went to the emergency room and was admitted to the hospital on [DATE] for a bleeding stomach ulcer. Review of the hospital history and physical completed by the hospitalist on 10/11/25 revealed that Resident #6 had nausea and vomiting and abdominal pain x 1 month and had been seen in the emergency room for similar on 08/25/25. Further review revealed Resident #6 reported that she could not hold down food except broth or hot chocolate. Resident #6 further reported to the hospitalist that the last time she vomited she was told she had blood in it. The hospitalist did make a notation that Resident #6 was taking Ibuprofen 800 mg three times a day as well as being on Plavix daily. Further review of the hospital records revealed a discharge summary authored by the hospitalist that revealed the Plavix was put on hold while in the hospital and to resume the Plavix 75 mg daily on discharge back to facility. There were specific orders that Resident #6 was to stop all ibuprofen and increase Protonix to 40 mg twice a day for 90 days. Review of the medical record for Resident #6 revealed a quarterly minimum data set (MDS) version 3.0 assessment completed on 05/23/26. The MDS assessment revealed that Resident #6 had impairments on both left arm and lower leg and required substantial to maximum assistance for bathing and dressing. Resident #6 was able to utilize a wheelchair to navigate self in room and other small areas. A brief interview for mental status (BIMS) was conducted and revealed a score of 15/15 indicating Resident #6 was cognitively intact. Interview on 06/01/26 at 12:37 P.M. with Resident #6 revealed she had a hospitalization related to her stomach ulcer and bleeding and since then has been trying to eat milder foods and often buys herself additional soups instead of what is provided with meals to make sure she does not irritate her ulcer and get the stomach pain again that she had. Interview on 06/07/26 at 12:17 P.M. with the consulting pharmacist (PH) #209 from the facility's contracting pharmacy revealed a resident could be at increased risk for gastrointestinal bleeding and ulceration if taking Ibuprofen and Plavix concurrently. PH #209 also revealed that she saw orders for residents taking an as needed dose of Ibuprofen for short durations with Plavix, however if it was routinely scheduled dose of Ibuprofen then she would consult the prescriber for discussion and guidance due to increased risk of bleeding. Further interview with PH #209 revealed she did not see any pharmacy recommendations for Resident #6 on the pharmacy end related to the Plavix and Ibuprofen during the time frame of July 2025 to October 2025 and that the monthly medication reviews are contracted with a third-party pharmacy company. Interview on 06/07/26 at 12:30 P.M. with the Director of Nursing (DON) and Registered Nurse (RN) #205 revealed confirmation that the medical provider was not notified on 10/02/25 of Resident #6's change in condition with vomiting up reddish-brown liquid and continued abdominal pain. The DON further verified that the AVS from the emergency room visit on 07/31/25 and 08/24/25 did not have Ibuprofen listed as being prescribed or continued. RN #205 revealed verification that Resident #6 continued scheduled Ibuprofen and Plavix from 7/31/25 to 10/10/25 on the MAR. Both the DON and RN #205 agreed that the combination of the medication Plavix and Ibuprofen did increase the resident's risk of bleeding and development of gastric ulcers. The DON verified there was no updated care plan related to the emergency room visits for increased GI monitoring and there was no care plan related to Resident #6 being on an anti-platelet medication and monitoring of signs and symptoms of bleeding. Interview on 06/09/26 at 11:46 A.M. with the Nurse Practitioner (NP) #210 revealed she was not notified of the resident having a reddish-brown emesis prior to her hospitalization on 10/11/25. However, NP #210 reported that the staff had been good about reporting her stomach issues because two times she had to override hospice and direct the staff to send her to the emergency room last summer. NP #210 reported that in her opinion Ibuprofen should not be given routinely with other blood thinning medications due to risk of increased bleeding. NP #210 verified that ibuprofen can be used with other blood thinning medication in an as needed capacity and infrequently. Continued interview with NP #210 revealed that she thought that Resident #6 was seen twice in the emergency room for her stomach issues, and the hospital had not found anything wrong. NP#210 admitted she prescribed Resident #6 to continue the facility medications after each emergency room visit and did not realize that the Ibuprofen was continued as a scheduled dose and thought it was an as needed medication prescribed by hospice for pain management. NP #210 further revealed that when hospice is involved in the care of a resident she is often left out of the loop unless the facility calls her to address something hospice will not. Interview on 06/09/26 at 11:55 A.M. with the Director of Nursing and the Regional Nurse (RN) #202 revealed that when orders are entered into the EMR and a black box warning appears it is the nurse's responsibility to notify the provider of the warning and obtain further orders. If the provider wants the medication continued despite the black box warning the warning box will stay on the order screen as long as the resident was prescribed to remind the nursing staff and medical providers of the medication risk. Review of the facility policy titled, Resident Condition Changes revised 04/01/23 revealed, The nurse will contact the resident's physician immediately when any resident has a perceived change in condition. An assessment will be made by the nurse prior to the phone call so that nurse is prepared to discuss condition change. Nurse will have resident's chart as well as all other pertinent documentation i.e., lab results and diagnostic testing. A change in condition includes but is not limited to: change in physical or mental status, refusal of medications or treatment, a need to alter treatment, an accident, need to transfer or discharge, development of wounds or other new conditions, inability to provide an ordered medication or treatment, lab or radiology results. 2. Review of the medical record revealed Resident #53 was admitted to the facility on [DATE] with diagnoses including atrial fibrillation, weakness, acute kidney failure, chronic obstructive pulmonary disease, and anxiety. Review of a clinical admission nursing progress note dated 05/27/26 at 8:14 P.M. revealed Resident #52 had an abrasion to her left arm due to a fall at the hospital prior to admission to the facility.Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #53 had intact cognition. There were no behaviors or rejection of care identified on the assessment. The resident required physical assistance from staff with activities of daily living. Review of the physician order dated 05/30/26 revealed the order to clean the left, forearm skin tear with wound cleanser, apply Xeroform, abdominal pad (ABD), and wrap three times per week and as needed until healed. Review of the Care Plan, initiated on 06/01/26, revealed the resident had a skin tear on the left forearm with interventions including applying treatment as ordered and to monitor the area for signs/symptoms of infection. Interview on 06/01/26 at 10:45 A.M. with Resident #53 revealed she had asked the nurse twice on 05/31/26 to have the dressing located on her left forearm changed because it was bleeding. She stated the nurse told her she would be back to change her dressing but never returned to do so. The resident stated she couldn't wait any longer and placed a napkin over the wound and used her own tape, which she had in her purse. Observation on 06/01/26 at 10:46 A.M. revealed Resident #53's left forearm was wrapped with a white, paper dinner-type napkin and secured loosely with tape. Interview on 06/01/26 at 10:55 A.M. with Licensed Practical Nurse (LPN) #114 confirmed Resident #53's left forearm skin tear was covered with a napkin, and the dressing was not applied as ordered by the physician. LPN #114 stated the resident should not have tape on her skin as it was fragile, and she would immediately apply a new dressing. LPN #114 further stated she had not yet completed the resident's dressing change today. Review of the facility's policy titled Clean Dressing Change Policy, dated 04/16/26, revealed it is the policy of this facility to provide wound care in a manner to decrease potential for infection and/or cross-contamination. Physician's orders will specify type of dressing and frequency of changes.

Based on observation, interview, and record review, the facility failed to have an adequately equipped call system which relayed the call directly to a staff member or centralized staff work area from each resident's bedside or toilet and bathing facility. During a call system outage, there was a delay providing hand bells and a monitoring system to monitor resident needs. There also was not a way for residents to call for assistance from a toilet or bathing area. This affected all 45 residents residing in the facility. The facility census was 45.Findings include: On 06/02/26 at 8:20 A.M., during a facility tour, observation revealed there was no functioning electronic call light system in the facility. On 06/02/26 at 9:15 A.M., an interview with Resident # 23 revealed she sat in urine from 6:30 A.M. until 8:00 A.M. on the day of the interview. She reported her call light was not working and they gave me this bell this morning, but I had to wait for them to come in at 8:00 A.M. because apparently, they didn't know I had put my call light on and I didn't have the bell yet.On 06/02/26 at 9:40 A.M., an interview with the Administrator revealed he was unsure of the time the system went down, but he had been notified early that morning, so he believed that was when it went down. Residents were using hand bells to call for assistance. He indicated it had been early in the morning when the bells were delivered to residents. Maintenance was called in to see if they could fix it, however the part would not be available until 06/03/26.On 06/02/26 at 9:45 A.M., an interview with the Director of Nursing (DON) revealed the call system had gone down in the middle of the night. She indicated the Housekeeping Director (HD) was in charge of the call systems and had been at the facility when she arrived on 06/02/26 at 2:30 A.M. She was not certain how long before her arrival the system had been down. She and the certified nurse aides who were working the night shift began passing out hand bells to residents at around 3:30 A.M. There were not enough bells for all of the residents and they had to wait until morning to go to [named business] to get more. The facility had begun to do rounding at approximately 6:00 A.M. on 06/02/26. The staff had not educated the resident on the hand bells in the middle of the night, but she believed the residents now knew how to use them.On 06/02/26 at 10:05 A.M., an interview with the Corporate Maintenance Director revealed he was notified the system went down at 3:40 A.M., which was when the HD notified him. The HD came into the facility and tried to reboot the system, but it would not reboot. Contacted the system administrators called [named company]. They remotely looked at the system and determined there was a bad network connector. This part could not be ordered until 06/02/26 at 9:00 A.M. On 06/02/26 at 10:11 A.M., an interview with Certified Nurse Aide (CNA) #170 revealed he was not certain what a resident would do if they were in the bathroom and needed a call light when the system was not functioning. He reported the resident would usually just press the button in there. He reported if he were assisting a resident to the restroom with the system down, he would stay nearby and check on them, but if a resident was independent and needed assistance in an emergency, he did not know how staff would recognize this with the call light system down.On 06/02/26 at 10:20 A.M., an interview with the Corporate Maintenance Director confirmed there was no available call system, or back up system, in place at the time of the interview which would be able to notify staff if a resident would fall in the restroom or be in the restroom without a hand bell, which was being used at the time. He indicated the bells were just given to residents for bedside use.On 06/02/26 at 10:47 A.M., an interview with Resident #3 revealed she did not know what to do with the bells and did not think there was any way staff would hear them. She did not have to use the system because she had not needed incontinence care but was not confident the system would work if she needed it.On 06/03/26 at 2:40 P.M., an interview with the Housekeeping Director reported the system had gone down on 06/02/26 at 1:30 A.M. He had received the new part at 1:46 P.M. on 06/03/26, however it had not worked to correct the issue. At 2:38 P.M. on 06/03/26, he had discovered the issue and been able to reset the system and get it functioning. Confirmed the call light system had been down from approximately 1:30 A.M. on 06/02/26 to 2:38 P.M. on 06/03/26.Review of facility policy titled Call lights, updated 12/01/25 revealed call lights were signaling devices which allowed residents to request assistance. A warning there was a call light out would indicate the call light system was non-functional or not visible/audible to staff. Per the policy, staff would strive to answer call lights and meet resident needs as promptly as possible. The call lights would only be silenced after the resident's needs were met. Staff would contact the Maintenance Supervisor immediately regarding any problems with the call light system. The maintenance supervisor would monitor for correct system functioning, and contact technician for repair if indicated. If maintenance supervisor was unable to resolve the issue promptly, the call light system company would be notified. All residents would be provided with a portable bell or whistles to alert staff of needs. A designated staff member would do door checks on all residents every 15 minutes.

Based on medical record review and interview, the facility failed to ensure the comprehensive care plan was reviewed and revised by an interdisciplinary team. This affected four residents (#11, #41, #32 and #46) residents reviewed for care plans. The facility census was 45.1.Review of the medical record for Resident #11 revealed an admission date of 07/27/24. Diagnoses included hypothyroidism, chronic obstructive pulmonary disease, chronic combined systolic and diastolic heart failure, adult failure to thrive, chest pain, and dementia. Review of the care plan for Resident #11 revealed a focus of care for assistance from staff to meet activities of daily living (ADL) needs due to acute kidney failure, weakness, adult failure to thrive, dementia, and depression, initiated on 07/30/24. Interventions included supervision for transfers and ambulation with four wheeled walker (FWW), with the resident to walk to dining room with the FWW two to three times daily, four to six days per week. Review of the care plan for Resident #11 revealed a focus of care for renal failure, initiated on 12/23/24. The staff was to report decreased urine output less than 400 milliliters in 24 hours or greater than 500 milliliters in 24 hours if in the diuretic phase, initiated 12/23/24. The staff was to monitor, document, and report to the physician as needed any weight gain of more than two pounds per day, difficulty breathing, neck vein distention, elevated blood pressure, skin temperature, peripheral pulses and monitor breath sounds for crackles. Review of a quarterly Minimum Data Set (MDS) version 3.0, dated 04/04/26, for Resident #11 revealed a Brief Interview of Mental Status (BIMS) score of 12 on a 0-15 scale. A score of 12 would indicate moderate problems with thinking and memory. The MDS revealed the resident could self-propel in a wheelchair both 50 and 150 feet and required partial to moderate assistance with upper body dressing and personal hygiene and substantial to maximum assistance with all other activities of daily living. An interview on 06/03/26 at 3:50 P.M. with MDS revealed the care plan for Resident #11 had not been updated to reflect his current needs. He was incontinent, and his output was no longer able to be measured, and since he had been admitted to hospice he was no longer weighed daily. Further, he was no longer able to use a FWW to ambulate to the dining room with or without assistance. 2. Review of the medical record for Resident #41 revealed an admission date of 10/17/24. Diagnoses included chronic combined systolic and diastolic congestive heart failure; anxiety disorder; chronic obstructive pulmonary disease; hyperlipidemia; hypothyroidism, presence of a cardiac pacemaker, dependence on supplemental oxygen, hypertension, and the need for assistance with personal care. Review of a care plan for Resident #41 included an intervention for active infection: UTI (urinary tract infection). The intervention was initiated on 07/01/25. Review of a quarterly Minimum Data Set (MDS) version 3.0 for Resident #41, dated 02/20/26, revealed a Brief Interview for Mental Status (BIMS) score of 99. This score indicated the resident was unable to complete the questions on the test. The MDS further revealed the resident required set up assistance for meals, substantial/maximal assistance for upper body dressing and personal hygiene and was dependent for all other activities of daily living (ADLS). An interview with MDS nurse on 06/03/26 at 4:23 P.M. confirmed Resident #41 did not have an active urinary tract infection and her care plan had not been updated. 3. Review of the medical record revealed Resident #32 was admitted to the facility on [DATE] with diagnoses including diabetes mellitus, rhabdomyolysis, dementia, anxiety disorder, and schizophrenia. Review of the Minimum Data Set (MDS) assessment, dated 04/13/26, revealed Resident #32 had intact cognition, required staff assistance with activities of daily living, and had a diagnosis of dementia. Review of Resident #32's care plan did not reflect a dementia diagnosis nor indicate interventions for dementia care and treatment. Interview on 06/03/26 at 3:46 P.M. with Licensed Practical Nurse/MDS Nurse #154 confirmed Resident #32's care plan did not reflect a dementia diagnosis or interventions for care and treatment. Interview on 06/03/26 at 3:58 P.M. with the Director of Nursing (DON) confirmed Resident #32's care plan was not comprehensive and did not include interventions related to dementia care and treatment. 4. Review of the medical record revealed Resident #46 was admitted to the facility on [DATE] with diagnoses including osteomyelitis of vertebra, Clostridium difficile (C. diff) infection, wedge compression fracture of fourth lumbar vertebra, anemia, and atrial fibrillation. The resident was discharged on 03/22/26. Review of the Minimum Data Set (MDS) 3.0 assessment, dated 03/13/26, revealed the resident had intact cognition and required physical staff assistance with activities of daily living. Review of physician orders dated 03/20/26 revealed the order to monitor dressing to drain located on the right, lower back every shift and the order to empty accordion drain and record output. Review of the Care Plan, dated 03/20/26, revealed it was not comprehensive and did not include the intervention for monitoring an abscess drainage device and recording output; and monitoring the dressing to the right lower back every shift. Interview on 06/03/26 at 3:44 P.M. with Licensed Practical Nurse/MDS Nurse #154 confirmed Resident #46's care plan did not include the interventions of monitoring an abscess drainage device and recording output; and monitoring the dressing to the right lower back every shift. Interview on 06/03/26 at 3:57 P.M. with the Director of Nursing (DON) confirmed Resident #46's care plan was not comprehensive and did not include the interventions of monitoring an abscess drainage device and recording output; and monitoring the dressing to the right lower back every shift.

Based on record review, policy review, and staff interview, the facility failed to ensure timely responses from medical providers to pharmacy recommendations. This affected eight (#12, #14, #15, #25, #27, #41, #58, and #59) of 48 residents who had recommendations made during the facility monthly medication review for December 2025. The facility census was 45. Findings include:1.Review of the monthly medication review binder revealed a listing completed on 12/31/25 (review dates between 12/01/25 and 12/31/25) by the consulting pharmacist that identified 48 residents were reviewed for actual or potential medication problems. Further review of the monthly medication binder revealed of the 48 residents reviewed, eight had notes made by the pharmacist to the medical provider notifying of potential or actual medication concerns. The following pharmacist recommendations were made on 12/31/25 and acknowledged and signed by the director of nursing (DON) on 02/03/26, approximately 5 weeks later. a. Recommendation for Resident #25, Resident is receiving routine oral sodium bicarbonate supplementation and iron supplementation that are being administered at the same time. Since sodium bicarb can inhibit iron absorption, can we please separate administration of the two products by as much time as possible? Response of agree with signature of a telephone order obtained by the DON. b. Recommendation for Resident #27, Resident is receiving tamsulosin (Flomax) in the morning. Since this medication is better given at HS (bedtime) to reduce risk of adverse effects including orthostasis, can we please change the administration time to QHS (every bedtime)? Response of agree with signature of a telephone order obtained by the DON. c. Recommendations for Resident #41, Resident has an order for the inhaled corticosteroid Budesonide. Can we please add rinse mouth and spit after use, to the order to remind nursing to rinse residents' mouth to avoid formation of thrush (yeast overgrowth in the mouth)? Response of agree with signature of a telephone order obtained by the DON. d. Recommendations for Resident #12, Resident has an order for the inhaled corticosteroid Trelogy. Can we please add rinse mouth and spit after use, to the order to remind nursing to rinse residents' mouth to avoid formation of thrush. Response of agree with signature of a telephone order obtained by the DON. e. Recommendation for Resident #14, This resident is receiving the bisphosphonate alendronate. In order to follow the manufacturers' specifications, please amend the order to include the following: Administer in the morning at least 30 min prior to food or other medications. Patient should take with 6-8 oz of water and remain upright for at least 30 minutes after administering. Response of agree with signature of a telephone order obtained by the DON. 2. The following pharmacist recommendations were made on 12/31/25 and acknowledged and signed by the director of nursing (DON) with no date noted. a. Recommendation for Resident #59, Resident has an order for a cephalosporin and has a noted allergy to penicillin. Since there is the potential for a cross-sensitivity reaction that can occur between the two beta lactam antibiotics, can we please be sure the cross allergy has been addressed and noted and that nursing is observing resident for signs and symptoms of an allergic reaction during this course of treatment? Response of agree with a note indicating MD aware and no adverse reaction noted. Signed by a nurse with no MD name listed and no date listed. 3. The following pharmacist recommendations were made on 12/31/25 and acknowledged and signed by the director of nursing (DON) on 02/05/26, approximately 5 weeks later. a. Recommendations for Resident #58, Resident has been receiving anxiolytic therapy with LORAZEPAM 05. Every day for some time now without a gradual dosage reduction. In order to achieve the minimal effective dose can we please consider a dose reduction? If reduction is not warranted at this time, can we please add documentation to the medical record indicating why, in this resident, a reduction would be detrimental to their mental or physical health? Response other, patient is under hospice care and requires current medication for increased anxiety signed and date by provider and director of nursing on 02/05/26. b. Recommendation for Resident #15, This hospice resident is receiving high dose (10,000 units every day) vitamin D and has been for some time. In order to mitigate risk can we please reduce dose to normal supplemental dose of 1,000 units daily? Response agree and signed by both provider and director of nursing on 02/05/26. c. Recommendations for Resident #27, Resident has orders for both twice a day Advair inhaler and twice a day budesonide aerosol for COPD (chronic lung disease) representing a duplication of inhaled corticosteroid therapy. Can we please verify whether both orders are needed or in order to avoid duplication of therapy can we please consider discontinuing one? Response agree with comment to discontinue budesonide signed by the provider and DON and dated 02/05/26. Interview on 06/04/26 at 4:19 P.M. with registered nurse (RN) #205 revealed that the facility expectation would be that the monthly pharmacy recommendations would be reviewed weekly and no later than two weeks for non-urgent issues. RN #205 also revealed that urgent medication issues would be called immediately to the provider by the director of nursing who oversees the monthly medication reviews and ensures physician notification. Further interview with RN #205 revealed that the pharmacy recommendations dated for December review on 12/31/25 for Residents #12, #15, #25, #27, #41, #58, and #59 were not addressed timely and were not signed off until 02/03/36 and 02/05/26 almost 5 weeks later by the DON and provider. RN #205 verified that the recommendations for Resident #14 did not have a date of when the provider or nurse addressed the recommendations. Interview on 06/04/26 at 4:44 P.M. with RN #205 revealed there was no other evidence in the medical records of the above recommendations being addressed earlier than 02/03/26 and 02/05/26 for the affected residents. Review of the facility policy titled, Medication Monitoring and Management, revealed, The resident's medication regimen is evaluated when one or more of the following occur. When there is a significant negative change from baseline (designated with an asterisk*), medications should be ruled out as a cause in accordance with the policy on adverse consequence detection and prevention. The policy further indicated resident changes to include some of the following : admission or re-admission, a clinically significant change in condition/status, a new, persistent, or recurrent clinically significant symptom or problem, an unexplained decline in function or cognition, a worsening of an existing problem or condition, a new or worsening psychiatric manifestation or distressed behavior, a new medication order or renewal of orders, and significant changes in diet that may affect medication absorption.

Based on observation, interview and policy review, the facility failed to safely store medications in a locked storage area. This had the potential to affect all resident who were independently mobile in the facility. The facility identified 20 residents (Residents #9, 4, 13, 5, 20, 22, 24, 3, 31, 32, 53, 34, 14, 7, 33, 36, 6, 2, 40, and 49) who were independently mobile, seven of which were identified as being confused (Residents #6, 40, 49, 4, 20, 22, and 32). The facility census was 45. Findings include:On 06/04/26 at 2:02 P.M., observation of a medication cart in front of the back nurse's station revealed the medication cart was unlocked. All drawers on the cart except for the controlled substance drawer could be opened. There was no staff in the area. On 06/04/26 at 2:12 P.M., an interview with licensed practical nurse (LPN) #112 confirmed she had walked away from the medication cart and not locked it. She locked it at the time of the interview.On 06/04/26 at 4:40 P.M., an interview with the Director of Nursing confirmed it was her expectation all medication carts were locked at all times.The facility identified 20 residents (#9, #4, #13, #5, #20, #22, #24, #3, #31, #32, #53, #34, #14, #7, #33, #36, #6, #2, #40, and #49) who were independently mobile, seven of which were identified as being confused (#6, #40, #49, #4, #20, #22, and #32).Review of a facility policy titled Administration Procedures for All Medications, dated 07/21/21, revealed the purpose was to administer medications in a safe and effective manner. All medication storage areas, which included carts, medication rooms, and central supply were to be locked at all times unless in use and under the direct observation of the medication nurse/aide.

Based on record review, observation and interview, the facility failed to provide oxygen therapy according to physician order, which included the correct respiratory equipment used, care of equipment, the frequency, and the correct prescribed flow rates of the oxygen. This affected four residents (#11, #41, #15, and #35) of four residents reviewed for oxygen use. The facility census was 45. Findings include:1.Review of the medical record for Resident #11 revealed an admission date of 07/27/24. Diagnoses included hypothyroidism, chronic obstructive pulmonary disease, chronic combined systolic and diastolic heart failure, adult failure to thrive, chest pain, and dementia. Review of a quarterly Minimum Data Set (MDS) version 3.0, dated 04/04/26, for Resident #11 revealed a Brief Interview of Mental Status (BIMS) score of 12 on a 0-15 scale. A score of 12 would indicate moderate problems with thinking and memory. The MDS failed to reveal the resident required oxygen therapy. Review of the care plan for Resident #11 revealed a focus of care for potential alteration in respiratory function related to shortness of breath. Interventions established that date included the administration of oxygen as ordered. Review of the orders for Resident #11 failed to reveal any oxygen orders. On 06/01/26 at 10:56 A.M., an observation of Resident #11 revealed he was on continuous oxygen via nasal cannula. The oxygen concentrator was set to a flow rate of 4 Liters. There was no humidifier on the concentrator and the tubing of the nasal cannula was not dated. This was confirmed by Registered Nurse (RN) #138 during an interview of 06/01/26 at 11:08 A.M. On 06/01/26 at 11:08 A.M., RN #138 confirmed Resident #11 was on oxygen via nasal cannula with a flow rate of 4 Liters. She further confirmed the resident did not have any orders on his medical record for oxygen, and that the oxygen was not humidified nor the tubing dated. 2. Review of the medical record for Resident #41 revealed an admission date of 10/17/24. Diagnoses included chronic combined systolic and diastolic congestive heart failure; anxiety disorder; chronic obstructive pulmonary disease; hyperlipidemia; hypothyroidism, presence of a cardiac pacemaker, dependence on supplemental oxygen, hypertension, and the need for assistance with personal care. Review of a care plan for Resident #41 revealed a focus of care for cardiac impairment, initiated 10/24/24. Interventions included administering oxygen as ordered. There was a focus of care for alteration in respiratory function, initiated 10/24/24. Interventions included administering oxygen as ordered. Review of a quarterly Minimum Data Set (MDS) version 3.0 for Resident #41, dated 02/20/26, revealed a Brief Interview for Mental Status (BIMS) score of 99. This score indicated the resident was unable to complete the questions on the test. The MDS further revealed the resident was on oxygen and received hospice services. Review of physician orders for Resident #41 revealed an order written 04/07/25 for oxygen (O2). The order was continuous oxygen at 3 Liters (L) via nasal cannula, monitor pulse ox (oxygen level using a pulse oximeter) twice daily. There was no order to change her oxygen tubing or humidification bottle. On 06/01/26 at 10:25 A.M., an observation of Resident #41 revealed she was on oxygen via nasal cannula. The flow rate of oxygen on the oxygen concentrator was set at 4.5 L. The oxygen tubing was dated 05/13/26, and the humidifier bottle was dated 05/21/26. On 06/01/26 at 11:12 A.M., an interview with RN #138 confirmed Resident #41's oxygen flow rate order was for 3L continuous; however, her flow rate was set on 4.5 L. She further confirmed the oxygen tubing, and humidifier had not been changed weekly and there was no existing order for them to be changed. 3.Review of the medical record for Resident #15 revealed an admission date of 10/17/25. Diagnoses included chronic obstructive pulmonary disease; acute and chronic respiratory failure with hypercapnia; atherosclerotic heart disease of native coronary artery without angina pectoris; essential primary hypertension; type two diabetes without complications, depression; hyperlipidemia; morbid obesity and metabolic encephalopathy. Review of a quarterly Minimum Data Set (MDS) version 3.0, dated 04/28/26 for Resident #15, revealed a Brief Interview of Mental Status (BIMS) score of 14 on a 0-15 scale. A score of 14 would indicate the resident was cognitively intact. The MDS indicated the resident did not receive oxygen therapy. On 06/01/26 at 10:40 A.M., an observation of Resident #15 revealed she was on oxygen via nasal cannula. The oxygen concentrator was set at a flow rate of 4.5 Liters (L). The humidifier bottle was disconnected from the system, and dated 05/21/26. The oxygen tubing was not dated. On 06/01/26 at 11:01 A.M., an interview with RN #138 confirmed the oxygen order for Resident #15 was oxygen 3L via nasal cannula continuous and further confirmed the resident's flow rate was set at 4.5L via nasal cannula continuous and the humidifier was disconnected and dated for 05/21/26. The oxygen tubing was not dated. She confirmed there was no order for humidification, but she thought everyone had their oxygen humidified for comfort. An interview with the MDS nurse on 06/03/26 at 4:11 P.M., confirmed Resident #15 had been receiving oxygen therapy and it had been included in the care plan since 10/20/25. The MDS indicated the resident did not have oxygen therapy. 4. Review of the medical record revealed Resident #35 was admitted to the facility on [DATE] with diagnoses including syncope and collapse, chronic congestive heart failure, acute respiratory failure with hypoxia, and hypertension. Review of the annual Minimum Data Set (MDS) assessment, dated 04/02/26, revealed Resident #35 had intact cognition, required physical assistance from staff with activities of daily living, and received oxygen therapy. Review of Resident #35's physician order, dated 05/25/26, revealed the order for oxygen to be administered continuously at two liters per minute via nasal cannula. Observation on 06/01/26 at 10:40 A.M. revealed Resident #35's oxygen was infusing at three liters via nasal cannula. Interview on 06/01/26 at 10:50 A.M., Licensed Practical Nurse (LPN) #114 confirmed Resident #35's oxygen was infusing incorrectly at three liters per nasal cannula and per the physician order, the oxygen should be infused at two liters per minute. Review of the facility policy titled, Oxygen Therapy, dated 04/01/26, revealed oxygen will be administered, in accordance to orders given by the attending physician or prior to physician notification in incidence of acute status changes, to those residents in which adequate tissue perfusion is lacking.

Based on medical record review, observation of medication administration, and interview with staff, the facility failed to ensure routine medication was available for all residents. This affected one resident (#36) of four residents observed receiving medication during the medication administration pass. The facility census was 45. Findings include:Review of the medical record for Resident #36 revealed admission to facility on 10/24/24 with diagnoses including chronic lung disease, history of stroke with right side paralysis, depression, anxiety, low back pain, high blood pressure, repeated falls, dementia (forgetfulness and confusion), and neuropathy (loss of sensation in nerve endings). Further review of the medical record revealed Resident #36 had a quarterly minimum data set (MDS) version 3.0 assessment completed on 04/26/26 that indicated a brief interview for mental status score of 15/15 meaning Resident #36 was cognitively intact. Further review of the MDS 3.0 assessment revealed Resident #36 required the use of a wheelchair for mobility and partial to moderate assistance with bathing and dressing and transferring. Review of Resident #36's physician orders revealed an order prescribed by the primary care physician and dated 04/12/26 for methocarbamol (a muscle relaxer) oral tablet 500 milligrams (mg), give one tablet by mouth two times a day for pain and swelling and give one tablet by mouth as needed for pain and swelling not to be given within 6 hours of routine AM (morning) or HS (bedtime) dose. Observation on 06/03/26 at 7:55 A.M. revealed licensed practical nurse (LPN) #128 administered methocarbamol 500 mg to Resident #36. Further observation of the medication administration revealed LPN #128 reviewed the medication card containing the methocarbamol 500 mg tablets and removed one tablet to administer to Resident #36. Review of the medication card itself revealed the following medication information; a large label on the upper left corner indicating the medication was a PRN (as needed), the pharmacy label on the top right corner read methocarbamol 500 mg give one tablet by mouth as needed for pain and swelling NOT to be given within 6 hours of routine AM or HS dose. Review of Resident #36's medication administration record revealed LPN #128 had signed off that she had administered the routine AM dose of methocarbamol and not the PRN dose. Interview on 06/03/26 at 2:48 P.M. with LPN #128 revealed she did administer the methocarbamol dose from the PRN medication card. Further interview with LPN #128 revealed that there was no card in the medication cart for the routine dose and it appeared that the routine dose ran out on 05/28/26 and had not been reordered by the nurse or refilled by the pharmacy. LPN #128 reported she should have reviewed the label more closely. LPN #128 proceeded to send a communication note to the pharmacy to have the routine dose medication sent to the facility later in the day. Review of the facility policy titled Medication Administration dated 07/01/2021 revealed prior to administering medication check the label on the medication against the order on the medication administration record.

Based on record review, observation, interview and review of facility policy, the facility failed to maintain the respect and dignity of a resident. This affected one resident (#44) of one resident reviewed for dignity. The facility census was 45.Findings include: Review of the medical record for Resident #44 revealed an admission date of 05/11/26. Diagnoses included type two diabetes mellitus without complications; chronic kidney disease, stage three B; pure hypercholesterolemia; benign prostatic hyperplasia without lower urinary tract symptoms; gastroesophageal reflux disease; post-traumatic stress disorder; edema; essential hypertension; lymphedema; acute on chronic diastolic congestive heart failure; anemia; presence of cardiac pacemaker and unspecified atrial fibrillation.Review of the care plan for Resident #44 revealed a focus of care for a deep tissue injury on his left heel and coccyx/sacral bilateral buttocks, initiated 05/11/26. Interventions included providing treatment to the wounds as needed, which was initiated on 05/13/26. Review of the care plan further revealed the resident required assistance from staff to meet ADL (activities of daily living needs), initiated 05/27/26. Interventions included assisting the resident with ambulation, incontinent care, oral care, toileting, transfers, bed mobility clothing choices and dressing, providing verbal cues as needed, and assisting with bathing.Review of the admission Minimum Data Set (MDS) version 3.0 for Resident #44, dated 05/13/26, revealed a Brief Interview of Mental Status (BIMS) score of 15 on a 0-15 scale. A score of 15 would indicate the resident was cognitively intact.Review of orders for Resident #44 revealed an order dated 05/13/26 for skin interventions. The order was for pressure redistribution mattress, barrier cream topically to buttocks. Provide routine ski care, encourage to offload heels, encourage bilateral heel boots. Encourage pillow between BLE (bilateral lower extremities).On 06/01/26 at 10:34 A.M., an observation of Resident #44 revealed he could be visualized from the hallway. He was clothed in only an incontinence brief. From the doorway, it could be observed there was a wound on his left heel with a piece of gauze falling off of it. On closer observation, he had dried blood on his right shin, there was nothing covering the resident from view from the hallway. There was no curtain which could be pulled to provide the resident privacy from the door. On 06/01/26 at 10:43 A.M., an interview with Registered Nurse (RN) #138 confirmed Resident #44 was unclothed, his dressing was coming off and there was blood on his leg. She confirmed the resident was too exposed to the public and this was not good for the resident to be unclothed and visible from the hallway in public view.Review of a facility policy titled Dignity and Respect last reviewed on 04/01/26, revealed the facility would treat all residents in full recognition of their right to dignity and respect. The facility would treat all residents with kindness, dignity and respect in recognition the facility provided a homelike environment. Residents would be treated in a manner which maintained the privacy of their body. A closed door or drawn curtain would shield the resident from passerby. The privacy of a resident's body should be maintained during toileting, bathing, and other activities of personal hygiene, except as needed for the resident's safety or assistance.

Based on record review, staff interview, and policy review, the facility failed to ensure residents receiving psychotropic medications were educated on the risks/ benefits associated with the use of psychotropic medications and failed to obtain informed consent from the resident and/or their representative prior to use. This affected three residents (#32, #42, and #4) of five residents reviewed for unnecessary medications. The facility census was 45. Findings include: 1. Review of the medical record revealed Resident #32 was admitted to the facility on [DATE] with diagnoses including diabetes mellitus, rhabdomyolysis, dementia, anxiety disorder, and schizophrenia. Review of the admission Minimum Data Set (MDS) assessment, dated 04/13/26, revealed Resident #32 had intact cognition, required staff assistance with activities of daily living, and received an anxiety, antidepressant, and antipsychotic medication. Review of Resident #32's physician order, dated 04/07/26, revealed the order for alprazolam oral tablet 0.5 milligrams (mg), one tablet by mouth four times per day for anxiety; lurasidone HCL oral tablet 120 mg, one tablet by mouth once daily for schizophrenia; and the physician order, dated 04/08/26, revealed the order for sertraline oral tablet 5 mg, one tablet by mouth once daily for depression. Review of Resident #32's medication administration record (MAR) dated June 2026 revealed the resident received alprazolam oral tablet 0.5 mg, one tablet by mouth four times per day for anxiety; sertraline oral tablet 5 mg, one tablet by mouth once daily for depression; and lurasidone HCL oral tablet 120 mg, one tablet by mouth once daily for schizophrenia. Review of Resident #32's consent form titled, Psychoactive Medication Authorization dated 10/21/25, revealed the consent form did not include or indicate the psychoactive medication or related diagnoses. Interview on 06/04/26 at 3:52 P.M. with the Director of Nursing (DON) confirmed Resident #32's consent form for the use of psychotropic medications failed to indicate the psychotropic medication being administered and the diagnoses for use. 2. Review of the medical record revealed Resident #42 was admitted to the facility on [DATE] with diagnoses including anxiety disorder, malignant neoplasm of left breast, depression, dementia, and bipolar II disorder. Review of the quarterly Minimum Data Set (MDS) assessment, dated 05/04/26, revealed Resident #42 had intact cognition, required staff assistance with activities of daily living, and received an antipsychotic medication. Review of Resident #42's physician orders, dated 04/21/26, revealed the order for lorazepam oral tablet 0.5 milligrams (mg), one tablet by mouth once daily for anxiety; risperidone oral tablet 0.5 mg, one tablet by mouth twice daily for bipolar disorder; and risperidone oral tablet 1 mg, one tablet by mouth twice daily for bipolar disorder. Review of Resident #42's medication administration record (MAR) dated June 2026 revealed the resident received lorazepam oral tablet 0.5 mg, one tablet by mouth once daily for anxiety; risperidone oral tablet 0.5 mg, one tablet by mouth twice daily for bipolar disorder; and risperidone oral tablet 1 mg, one tablet by mouth twice daily for bipolar disorder. Review of Resident #42's consent form titled, Psychoactive Medication Authorization dated 08/26/25, revealed the consent form did not indicate the psychoactive medication or related diagnosis. Interview on 06/04/26 at 3:55 P.M. with the Director of Nursing (DON) confirmed Resident #42's consent forms for the use of psychotropic medications failed to indicate the psychotropic medication being administered and the diagnosis for use. Review of the facility's policy titled, 'Psychotropic Medications, dated 05/07/26, revealed it is the policy of the facility that psychoactive medications be given only in accordance with all regulations. The facility will not use medications as restraints. Before administration of psychotropic medications, the negative outcomes of this therapy will be fully explained to the resident and/or their family, power of attorney, or legal representative. A consent form will be completed for each resident who takes psychotropic medications; this will be signed after medication diagnosis, reason for use, and behaviors have been discussed with the responsible party. Potential side effects and adverse reactions will be reviewed. 3. Review of the medical record for Resident #4 revealed an admission date of 10/16/25. Diagnoses included non-ST elevation myocardial infarction, displaced intertrochanteric fracture of unspecified femur, chest pain, atherosclerotic heart disease, hyperlipidemia, hypertension, cerebrovascular disease, and paranoid schizophrenia. Review of a quarterly Minimal Data Set (MDS) version 3.0, submitted 05/18/26, revealed a Brief Interview of Mental Status (BIMS) score of 12 on a 0-15 scale. A score of 12 would indicate moderate problems with thinking and memory. The MDS review revealed the resident had verbal behavioral symptoms directed towards others, such as threatening others, screaming at others, and cursing at others, which did not occur daily. She had behaviors such as hitting or scratching herself, pacing, rummaging, etc., which did not occur daily. She would reject care such as bloodwork, medications, and activities of daily living assistance daily. The MDS indicated the resident took antipsychotic medications on a daily basis. Review of the medical record for Resident #4 revealed an order for a psychoactive medication. The order was for fluphenazine decanoate (an antipsychotic medication given monthly for schizophrenia) 2.5 milligrams per milliliter to be given intramuscularly one time per month. Review Resident #4's medical record revealed a facility form titled Psychoactive Medication Authorization for Resident #11. The form was dated 10/24/25. The form did not indicate the medication for which the consent was being obtained. The side effects of any one medication were not listed, and the signature line for the resident/responsible party read verbal, with no specific person with whom the facility spoke. This was confirmed by the Director of Nursing (DON) on 06/04/26 at 4:44 P.M. An interview with the Director of Nursing (DON) on 06/04/26 at 4:44 P.M. confirmed the psychoactive medication authorization was not complete. She confirmed it did not specify the ordered medication or side effects, and did not have a signature noting who gave verbal consent for the medication.

Based on review of the medical record and staff interviews, the facility failed to provide necessary medical information to the receiving facility when residents were transferred to the hospital for emergent medical care. This affected two residents (#6 and #46) of two residents reviewed for hospitalization. The facility census was 45. Findings include: 1. Review of the medical record for Resident #6 revealed admission to the facility on [DATE] with diagnoses including chronic lung disease, heart disease, psychosis, history of stroke with left side paralysis, reflux, heart failure, depression, diabetes with neuropathy (decreased sensation of nerve endings in hands and feet), multiple sclerosis (progressive muscle condition leading to hardening of muscle to prevent use), and dementia (forgetfulness and confusion). Further review of the medical record for Resident #6 revealed a quarterly minimum data set (MDS) version 3.0 assessment completed on 05/23/26. The MDS assessment revealed that Resident #6 had impairments on both left arm and lower leg and required substantial to maximum assistance for bathing and dressing. Resident #6 was able to utilize a wheelchair to navigate self in room and other small areas. A brief interview for mental status (BIMS) was conducted and revealed a score of 15/15 indicating Resident #6 was cognitively intact. Review of the medical records revealed Resident #6 was sent to the hospital emergency room three separate times from 07/30/25 to 10/10/25. On 07/31/25 Resident #6 was sent to hospital for severe abdominal pain and was evaluated in the emergency room and diagnosed with duodenitis and returned to the facility on the same day with new medications prescribed. On 08/24/25 Resident #6 was sent to the hospital for severe abdominal pain and was evaluated in the emergency room and diagnosed with gastritis and returned to the facility on the same day with new medications prescribed. On 10/10/25 Resident #6 was sent to hospital again for severe abdominal pain and admitted to the hospital for gastrointestinal bleeding from a stomach ulcer. Review of the facility progress notes for Resident #6 revealed no evidence of a transfer form including Resident #6's current medications being completed and sent to the hospital on [DATE]. Further review revealed no evidence of a transfer form including a list of Resident #6's current medications being completed and sent to the hospital on [DATE]. Interview on 06/04/26 at 12:06 P.M. with the Director of Nursing (DON) revealed that since she took over the DON position in March of 2026, she had been working with staff on utilizing a new transfer form found in the electronic medical record to be completed and sent to the hospital when a resident was transferred. The DON verified that prior to the form being used it was up to the nurse on duty to compile any necessary information and send it to the hospital but did not have any evidence of this she could produce and would review the medical records for Resident #6 to determine if a transfer information was sent to the hospital with each of her transfers. Interview on 06/04/26 at 3:42 P.M. with the DON revealed verification that there was no evidence of transfer forms including a copy of the current medication sent to the hospital for Resident #6 on 07/31/25, 08/24/25, and 10/10/25. 2. Review of the closed medical record revealed Resident #46 was admitted to the facility on [DATE] with diagnoses including osteomyelitis of vertebra, Clostridium difficile (C. diff) infection, wedge compression fracture of fourth lumbar vertebra, anemia, and atrial fibrillation. The resident was discharged on 03/22/26. Review of the Minimum Data Set (MDS) 3.0 assessment, dated 03/13/26, revealed the resident had intact cognition and required physical assistance from staff with activities of daily living. Further review of the medical record revealed Resident #46 was transferred to the emergency department on 03/22/26 due to altered mental status. Review of the Hospital Transfer Form dated 03/22/26 revealed the diagnoses section of the form blank and did not include any diagnoses. Interview on 06/03/26 at 3:39 P.M. with the Director of Nursing (DON) confirmed Resident #46's Hospital Transfer Form did not reflect Resident #46's altered mental status and did not contain pertinent diagnoses. The DON stated the transfer form is sent to the hospital with the resident and should reflect as much information as possible.

Based on record review and interview, the facility failed to assure that each resident received an accurate assessment, reflective of the resident's status at the time of the assessment. This affected three residents (#11, #15, and #41) of four residents reviewed for accuracy of assessments. The facility census was 45. Findings include:1.Review of the medical record for Resident #11 revealed an admission date of 07/27/24. Diagnoses included hypothyroidism, chronic obstructive pulmonary disease, chronic combined systolic and diastolic heart failure, adult failure to thrive, chest pain, and dementia.Review of the care plan for Resident #11 revealed a focus of care for bowel incontinence, initiated 07/30/24. Interventions established that date included applying barrier cream after incontinence care.Review of the care plan for Resident #11 revealed a focus of care for potential alteration in respiratory function related to shortness of breath, initiated 05/20/25. Interventions established that date included the administration of oxygen as ordered.Review of orders for Resident #11 revealed a medication order for Depakote, an anticonvulsant medication. The order was for Depakote Delayed Release tablets 500 milligrams one tablet by mouth three times daily. The order was written 10/10/25. Review of a quarterly Minimum Data Set (MDS) version 3.0, dated 04/04/26, for Resident #11 revealed a Brief Interview of Mental Status (BIMS) score of 12 on a 0-15 scale. A score of 12 would indicate moderate problems with thinking and memory. The MDS revealed the resident could self-propel in a wheelchair both 50 and 150 feet and required partial to moderate assistance with upper body dressing and personal hygiene and substantial to maximum assistance with all other activities of daily living. The MDS further revealed the resident was at risk for developing pressure ulcers. It indicated the resident did not have a pressure reducing device for his chair or his bed and did not require the application of ointments/medications other than to his feet. It indicated he did not take any anticonvulsant medications. Review of the orders for Resident #11 failed to reveal any oxygen orders. Review of the orders, care plan and Minimum Data Set (MDS) for Resident #11 all failed to reveal the resident used a Hoyer/mechanical lift for transfers. On 06/01/26 at 10:56 A.M., an observation of Resident #11 revealed he was on continuous oxygen via nasal cannula. The oxygen concentrator was set to a flow rate of 4 Liters. There was no humidifier on the concentrator and the tubing of the nasal cannula was not dated. He had a pressure reduction cushion in his wheelchair and a pressure reducing mattress on his bed. On 06/02/26 at 11:00 AM, an observation of Resident #11 revealed she was up in his wheelchair in the dining room for lunch. There were a Hoyer pad and pressure relieving pad in his wheelchair. His spouse reported he could not walk but occasionally would try and would fall. She was not certain when the facility started using the Hoyer lift.On 06/03/26 at 3:41 P.M., an interview with the Director of Nursing (DON) revealed Resident #11 should have orders to be transferred using a Hoyer lift. She confirmed there were no orders or other documentation noted on the resident record which reflected Hoyer use.On 06/03/26 at 3:48 P.M., an interview with the MDS nurse confirmed there were errors on Resident #11's most recent quarterly MDS dated [DATE]. She confirmed the resident had a pressure reducing cushion for his wheelchair and a pressure reducing mattress on his bed, although the MDS was answered no to both. She confirmed the resident took Depakote, an anticonvulsant, though the answer on the MDS for anticonvulsant use was no. She also confirmed Resident #11 was on oxygen, however the MDS indicated no for oxygen use. She reported since there were no orders in the chart for the oxygen she would not have known to update it. She further confirmed there was no documentation noted in the resident orders, care plan or MDS which indicated the resident was to be transferred using a Hoyer lift with the assist of two. She reported she was responsible for updating care plans and MDS, however if a nurse obtained a new order, it should be the responsibility of that nurse to update her of the changes. If no one told her things had changed, she had no way to know to update the records.2. Review of the medical record for Resident #15 revealed an admission date of 10/17/25. Diagnoses included chronic obstructive pulmonary disease; acute and chronic respiratory failure with hypercapnia; atherosclerotic heart disease of native coronary artery without angina pectoris; essential primary hypertension; type two diabetes without complications, depression; hyperlipidemia; morbid obesity and metabolic encephalopathy.Review of a quarterly Minimum Data Set (MDS) version 3.0, dated 04/28/26 for Resident #15, revealed a Brief Interview of Mental Status (BIMS) score of 14 on a 0-15 scale. A score of 14 would indicate the resident was cognitively intact. The MDS indicated the resident did not receive oxygen therapy. An interview with the MDS nurse on 06/03/26 at 4:11 P.M. confirmed Resident #15 had errors on her most recent quarterly MDS, dated [DATE]. The resident had been receiving oxygen therapy and it had been included in the care plan since 10/20/25. The MDS indicated the resident did not have oxygen therapy. 3. Review of the medical record for Resident #41 revealed an admission date of 10/17/24. Diagnoses included chronic combined systolic and diastolic congestive heart failure; anxiety disorder; chronic obstructive pulmonary disease; hyperlipidemia; hypothyroidism, presence of a cardiac pacemaker, dependence on supplemental oxygen, hypertension, and the need for assistance with personal care.Review of a quarterly Minimum Data Set (MDS) version 3.0 for Resident #41, dated 02/20/26, revealed a Brief Interview for Mental Status (BIMS) score of 99. This score indicated the resident was unable to complete the questions on the test. The MDS further revealed the resident was on oxygen and received hospice services. The MDS failed to indicate the resident required a pressure-relieving mattress and wheelchair cushion for pressure relief. Review of a care plan for Resident #41, initiated 10/24/24 and revised 12/30/24, revealed a focus of care for risk of skin breakdown. Interventions included pressure redistribution cushion to wheelchair, initiated 10/24/24, and low air-loss mattress to bed, initiated 10/24/24 and revised on 04/08/26.On 06/03/26 at 4:20 P.M., an interview with the MDS nurse confirmed the most recent quarterly MDS dated [DATE] for Resident #41 contained errors. The resident had both a pressure relieving cushion in her wheelchair and a pressure relieving mattress on her bed, however the MDS indicated no to the resident having these.

Based on record review and interview, the facility failed to ensure a comprehensive baseline care plan to indicate interventions for a Clostridium difficile (C. diff) infection and failed to obtain the signature of the resident and/or resident representative. This affected one resident (#46) of five newly admitted residents reviewed for baseline care plans. The facility census was 45. Findings include:Review of the closed medical record revealed Resident #46 was admitted to the facility on [DATE] with diagnoses including osteomyelitis of vertebra, Clostridium difficile (C. diff) infection, wedge compression fracture of fourth lumbar vertebra, anemia, and atrial fibrillation. The resident was discharged on 03/22/26. Review of the Baseline Care Plan-V3, dated 03/10/26, revealed the care plan did not include interventions for a C. diff infection including contact isolation precautions and did not indicate the signature of the resident and/or resident representative. Review of the Minimum Data Set (MDS) 3.0 assessment, dated 03/13/26, revealed the resident had intact cognition and required physical staff assistance with activities of daily living. Interview on 06/03/26 at 3:45 P.M. with Licensed Practical Nurse/MDS Nurse #154 confirmed Resident #46's baseline care plan did not reflect the resident's signature nor interventions for the C. diff infection. Interview on 06/03/26 at 3:57 P.M. with the Director of Nursing (DON) confirmed Resident #46's baseline care plan failed to include interventions for the C. diff infection nor the resident's signature.

Based on closed medical record review, review of hospice notes, review of photos, review of pharmacy records, policy review, and interviews, the facility failed to ensure Resident #40 received adequate and necessary care and services for end-of-life care. This affected one resident (#40) of three residents reviewed for quality care and services.Actual harm was identified on 11/26/25 involving Resident #40, who was admitted to the facility for end of life care and hospice services. The facility failed to ensure the resident received comprehensive assessments and adequate monitoring of his condition, including evaluation and management of ongoing pain and anxiety associated with his terminal illnesses. The facility did not implement or administer the ordered treatments and medications necessary to promote comfort and symptom relief. As a result, the resident experienced continued anxiety and unrelieved pain, necessitating transfer to an inpatient hospice facility on 11/27/25. The resident expired on 11/28/25.Findings include:Closed medical record review revealed Resident #40 was admitted to the facility from an inpatient hospice facility on 11/26/25 at 10:21 A.M. with diagnoses including pancreatic cancer, secondary malignant neoplasm of liver and intrahepatic bile duct, history of skin cancer, hypertension, diabetes, depression, and urinary tract infection. The resident was receiving hospice services at the time of admission. The resident was discharged from the facility on 11/27/25 at 2:15 P.M. back to the inpatient hospice facility.Review of Resident #40's hospice packet (location prior to his admission to the long-term care facility) revealed a code status form dated 10/29/25 that identified the resident's code status was Do Not Resuscitate (DNR) Comfort Care.Review of Resident #40's hospice transfer information dated 11/21/25 (prior to the resident's admission to the long-term care facility on 11/26/25) revealed the resident's primary diagnosis was malignant neoplasm of pancreas and he was not a candidate for chemotherapy due to worsening liver function. The resident was hopeful for treatment and was noted to be tearful, felt depressed, and was losing the desire to live due to his prognosis, pain, and symptoms. He had grimacing and stated the pain was seven (7) out of ten (10) in his abdomen. The pain was severely impacting his daily life by his inability to perform activities of daily living. He was struggling with insomnia due to the pain. He had developed a Stage II pressure ulcer to his coccyx. The resident was hoping for his pain to be a zero (0). The resident was totally bed bound, unable to do any activity, and required total care. The resident's level of consciousness was full or drowsy sometimes confused. The (resident's) wife's biggest concern was the resident being comfortable. The resident's active medications included (but were not limited to): acetaminophen 650 mg every twelve hours for pain, aspirin 81 (nonsteroidal anti-inflammatory) milligrams (mg) daily, mirtazapine (depression) 15 mg at bedtime, oxycodone (narcotic pain medication) 5 mg every six hours as needed for pain , morphine 15 mg 0.5 tablet by mouth sublingual every four hours as needed for pain or shortness of breath, and senna 8.6 mg 1-2 tabs daily as needed for constipation. The resident had urinary foley catheter that may be irrigated with normal saline as needed and changed every thirty days and as needed.Review of hospice attending physician form dated 11/25/25 revealed the patient representative changed attending physician from the facility's hospice provider to the facility's long-term care facility's provider. Review of hospice facility assessment dated [DATE] (the day prior to the resident's admission to the long-term care facility) revealed the resident had facial grimacing, rapid respirations, thrashing, labored breathing, hyperventilation, fists clenched, rigid, knees pulled up, pulling or pushing away, and striking. He was alert, agitated, restless, confused, and disoriented. His urine had a strong smell and a foley catheter was inserted with 550 milliliters (ml) return, he required aspiration precautions and had wounds. He was totally dependent on staff and was a fall risk. Review of hospice facility medication administration records dated 11/25/25 and 11/26/25 revealed on 11/25/25 the resident received Ativan and Morphine four times and one dose of MS Contin for pain, anxiety, and restlessness. On 11/26/25 (prior to admission to the long-term care facility) the resident received a dose of Roxanol (highly concentrated morphine sulfate oral solution used to treat moderate-to-severe chronic or acute pain, particularly in hospice settings) at 1:53 A.M., Ativan and Morphine at 4:47 A.M., and Roxanol and Ativan at 9:08 A.M. The resident was ordered Roxanol 20 mg every eight hours, Ativan 0.5 mg every four hours as needed, Morphine 10 mg every two hours as needed, and MS Contin 15 mg twice daily.Review of the hospice facility progress note dated 11/26/25 at 9:00 A.M., revealed the resident was unable to respond to questions. The foley catheter was patent. The resident was medicated with scheduled Roxanol 20 mg and Ativan 0.5 mg related to restlessness, facial grimacing and moaning out. The assessment indicated the resident did not have three days or less life expectancy. Report was called to the skilled facility and spoke to Licensed Practical Nurse (LPN) #200. Faxed all paperwork to number given. The resident left the hospice facility at 9:30 A.M. Spoke to LPN #200 and updated her that the Roxanol script was signed by the doctor and should be available from the facility's pharmacy. The Ativan script was electronic (e)-scribed. The resident's diet was nothing by mouth and he had no intake the last two days. Review of Resident #40's census report revealed the resident was admitted to the long-term care facility on 11/26/25 at 10:21 A.M. Review of Resident #40's nursing admission checklist dated 11/26/25 revealed the code status was blank, the consents were blank, orders were put in and verified by physician were blank, the diet was blank, nursing assessments were open but not completed, and progress note was placed in the computer. The form was not signed by the nurse. Review of Resident #40's plan of care revealed no evidence an acute plan of care was initiated for the resident. Review of Resident #40's assessment dated [DATE] revealed the following assessments were not completed (blank): admission, bowel and bladder, Braden (pressure ulcer), fall, oral, tuberculosis assessment, vitals and pain evaluation, and abnormal involuntary movement scale (AIMS), and elopement. The only comprehensive assessment completed was the functional assessment (admission and discharge) and pressure ulcer assessment dated [DATE] (the day after admission).Review of Resident #40's progress notes revealed there was a drafted note dated 11/26/25 at 1:38 P.M., authored by LPN #200 revealed the resident arrived via gurney accompanied by two staff and slid to bed. Wife arrived shortly after. Consents were signed, history obtained, and medication reviewed with the physician. No medications were ordered at this time. Morphine and Ativan for comfort. (Please note this is a contradictory statement identifying that no medications were ordered and then saying Morphine and Ativan for comfort) 14 French foley with 10 milliliter (ml) balloon patent draining dark yellow urine at this time. Hospice reported 72 hours of no intake with 200 ml urine output in the last 24 hours.Review of Resident #40's facility admission orders dated 11/26/25 revealed no evidence of medication orders (please note medications had been ordered on the hospice transfer sheet), no diet orders, or urinary catheter orders. The resident was ordered hospice services; Morphine 20 mg three times a day (6:00 A.M., 2;00 P.M., and 10:00 P.M.) for pain and shortness of breath. There was no evidence of an Ativan order per the drafted progress note on 11/26/25 at 1:38 P.M.Review of Resident #40's diet order and communication form dated 11/26/25 revealed the resident was on a pureed texture diet with pleasure foods as tolerated. The diet order (regular, no added salt, controlled carbohydrates, full liquids, clear liquids, or nothing by mouth) was blank. The communication form was signed by the previous Director of Nursing, (DON) #100.Review of Resident #40s' psychoactive medication authorization form dated 11/26/25 revealed Resident #40's wife and a facility representative had signed the section that psychoactive medications were recommended by the physician and had been discussed with her, and she agreed to the use of the psychoactive medication as described to her and she understood the diagnosis and reasons for use of this/these medications.Review of Resident #40's Morphine control sheet dated November 2025 revealed the Morphine 20 mg was signed out at 7:30 P.M. on 11/26/25, 6:00 A.M., on 11/27/25, and 1:50 P.M. on 11/27/25. However, the 1:50 P.M. dose on 11/27/25 was not signed off/documented on the medication administration record as having been administered.Review of Resident #40's medication and treatment administration record dated November 2025 revealed the resident received two doses of Morphine 20 mg (one at bedtime on 11/26/25 and A.M. dose on 11/27/25). The two doses were signed off by a medication technician (MT) #706 and rated the resident's pain as zero. There was no evidence of a comprehensive assessment of the resident prior to the medication administration.There was one other progress note (a warning that populated over on the progress note when there is a warning, no author identified for this warning) dated 11/26/25 that the Morphine order was outside the recommended dose or frequency and the medical director for hospice gave orders to continue as ordered. There was no evidence of any other progress notes noted for 11/26/25.Review of Resident #40's progress notes dated 11/27/25 revealed at 5:55 A.M., Morphine 20 mg was administered. At 2:10 P.M., report given to emergency transport, the resident was transferred to the cot with maximum assistance of three. Report called to hospice facility. Wife at beside. At 4:46 P.M., late note entered that the wound Nurse Practitioner (NP) saw the resident and new orders were received. Resident and family aware. There was no other documentation for 11/27/25.Review of the visiting hospice note authored by Hospice Registered Nurse (RN) #1001 dated 11/27/25 revealed per the wife she wanted the resident to go back to the hospice facility for pain control. The resident had hypoactive bowel sounds and had not taken senna (laxative) due to no (oral) intakes. Will let the skilled nursing staff know. The facility staff (LPN #208) walked in, and the resident's legs were hanging off the bed and wife was at the bedside. The hospice nurse spoke to LPN #208 regarding when his medication was due and the wife's concerns. When the hospice nurse asked how the resident was doing, LPN #208 responded, He was fine until his wife got here. LPN #208 stated the wife was unrealistic to the resident's decline. The resident's pain level was assessed as nine out of ten (1-10 scale). LPN #208 reported she had given the resident an as needed Ativan (benzodiazepine used for the treatment of anxiety) (however, there was no order, control sheet, or record that Ativan was administered) at 10:00 A.M., and he was due for his scheduled Morphine at 2:00 P.M. The wife was very upset during the visit and didn't want the resident at the facility any longer. Review of Resident #40's discharge Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was admitted on [DATE] from a hospice institutional facility and discharged on 11/27/25 back to a hospice institutional facility. The resident had severe cognition impairment. There was no response to the mood, and he had no behaviors noted. The functional status was marked dependent on staff for all activities of daily living. He had an indwelling urinary catheter and was always continent of bowels. The resident was receiving scheduled pain medication regimen, and the pain assessment interview was blank. The resident had a life expectancy of less than six months. He weighed 165 pounds and was 65 inches tall. The resident was not receiving any tube feeding, no mechanically altered diet, or no therapeutic diet. The resident was admitted with one unstageable ulcer and two deep tissue injuries. The resident received opioids and no anti-anxiety medications. Resident #40 received hospice care.Review of Resident #40's census report dated 11/27/25 revealed the resident was discharged on 11/27/25 at 2:15 P.M.Review of Resident #40's hospice facility notes revealed on 11/27/25 (after discharge from the long-term care facility) the resident received Ativan 0.5 mg and Roxanol (morphine) 20 mg upon admission at 3:00 P.M. for pain and anxiety. At 6:00 P.M., he received Morphine for pain. At 10:20 P.M, he received Ativan and Morphine for pain and restlessness. On 11/28/25 at 12:50 A.M., he received Roxanol 20mg for pain. At 2:20 A.M., he received Haldol for restlessness, Ativan for restlessness, and Morphine 10 mg for pain. At 3:10 A.M., he received Ativan for restlessness, 4:30 A.M. and 6:30 A.M., Morphine for pain. At 8:45 A.M., he received Ativan and Roxanol for anxiety and pain. Interview on 03/10/26 at 1:22 P.M. and 2:32 P.M., with Corporate Clinical Director (CCD) #102 confirmed there was no evidence Resident #40 had medication orders except for the Morphine. CCD #102 confirmed the admission assessment along with vitals and pain evaluation were all blank. CCD #102 confirmed no orders were signed off on the medication and treatment records except for two doses of Morphine; however, the control sheet indicated three doses were administered. Interview on 03/10/25 at 2:15 P.M. with Hospice Representative (HR) #104 confirmed Resident #40 was a resident of their 12 bed in-facility hospice unit. The resident was discharged to a skilled (long-term care facility) per the wife's request on 11/26/25; however, she requested the resident to return to the inpatient hospice facility on 11/27/25 after some concerns with staffing at the skilled facility. HR #104 reported upon discharge from the inpatient hospice facility to the long-term care facility on 11/26/25 the resident had the following medications ordered for pain: Oxycodone 5 mg as needed, Morphine 0.5 mg every four hours as needed, MS Contin 15 mg at bedtime, and Tylenol 650 mg as needed. Review of Resident #40's closed medical record revealed no evidence the resident had received these medications while at the long-term care facility.Interview on 03/11/26 at 10:21 P.M., with CCD #102 revealed she had reached out to LPN #200, who no longer worked for the facility, and she could not recall any information regarding Resident #40's admission and why she didn't complete the resident assessment or orders. CCD #102 revealed the morphine order was sent to the pharmacy on 11/26/25 at 11:44 A.M., the medication was pulled from the emergency medication box at 4:29 P.M., however the Morphine was not administered at 2:00 P.M. or 6:00 P.M. per the orders. CCD #102 confirmed the first dose of Morphine was not administered until 11/26/25 at 7:30 P.M., per the control sheet. CCD #102 confirmed the nurse never wrote the Ativan order nor was the medication administered. Interview on 03/11/26 at 1:24 P.M, with LPN #208 confirmed she was the nurse assigned to Resident #40 on 11/27/25. The LPN revealed the resident's wife had voiced concerns about not having enough supervision and fall interventions and requested the resident to be transferred back to the hospice facility. LPN #208 stated she had administered morphine to the resident due to the resident having facial grimacing and yelling out. She couldn't remember if she administered Ativan or not. LPN #208 reported she trained the medication technicians, and they could document pain levels if the resident verbalized pain rating; however, non-verbal or cognitively impaired residents would have to be assessed by the nurse. LPN #208 reported Resident #40 could not verbalize pain rating and would have been assessed by a nurse. LPN #208 reported she doesn't know why LPN #200 did not follow up on the Ativan order and stated Ativan was available in the emergency box and there should not have been a delay in administration with the Morphine or the Ativan. LPN #208 stated she had administered the 1:50 P.M. dose of Morphine on 11/27/25, however she did not sign off the Morphine on the administration record. Interview on 03/11/26 at 6:08 P.M. with Resident #40's wife revealed on 11/26/25 when she arrived at the facility at 3:00 P.M. staff were trying to force feed her husband. The resident had not eaten for two days. She stated the staff stopped feeding him immediately after she entered. She stated she had rung the call light for pain medication, but no one responded. Before she left two aides were picking up food trays and they helped reposition Resident #40 to make him more comfortable, but no one came to give him pain medication. (Per the administration record (MAR) the Morphine was not administered until 7:30 P.M on 11/26/25). On 11/27/25 she stated she could see he was in a lot of pain, so she asked for liquid morphine for pain, and staff refused. The resident had been receiving Morphine and Ativan at the hospice facility. She stated she had asked the facility about the Ativan, and it was one excuse after another why they didn't have his Ativan. The resident was yelling out in pain, restless, and trying to get out of bed. Staff reported it wasn't time for his pain medication. At this point she stated she called the hospice nurse and she came to the facility and could see he was in a lot of pain and not being properly cared for so she called the hospice facility and had him transferred back that evening. The resident's wife voiced concerns the facility refused to give him pain medication when he was actively dying. She had told two nurses about his pain and they did nothing. The wife reported she only moved her husband to the facility because it was only ten minutes from her house and she didn't like to drive far in the winter weather. The wife provided photo evidence of the resident on 11/27/25 (prior to being transferred back to the hospice facility) that confirmed he was restless (trying to get up) and had facial grimacing. Interview on 03/12/26 at 8:35 A.M., with CCD #102 confirmed she had reached out to hospice to verify the resident admission orders on 11/26/25 and it was the same paperwork that was sent on 11/21/25. CCD #102 reported there were several medications on the admission orders from hospice; however, the drafted note from LPN #200 indicated no medication ordered except Morphine and Ativan for comfort. CCD #102 confirmed the Ativan order was never entered into the electronic medical record or administered. CCD #102 reported hospice did not provide updated orders when the resident was admitted on [DATE] and all the facility had was the referral orders from 11/21/26 even though the hospice notes indicated records were faxed to the facility's number on 11/26/25. On 03/12/26 at 8:35 A.M. review of photos of Resident #40 (provided to the surveyor by the resident's wife) and shared with CCD #102 confirmed the photos were taken at the facility. CCD #102 confirmed the photos of Resident #40 which showed in one photo evidence the resident was at the edge of the bed, a second photo which reflected the resident was in pain as evidenced by the resident's facial expression, and a third photo of the pressure area on the resident's buttocks as evidenced by the staff initials on the dressing was one of the facility's employees.Interview on 03/12/26 at 2:14 P.M., with Pharmacy Technician #900 confirmed the facility's pharmacy had received a script on 11/26/25 for Morphine and two additional scripts on 11/28/25 for Morphine and Ativan; however, the scripts on 11/28/25 were not sent to the facility because the resident had already been discharged . Interview on 03/16/26 at 4:00 P.M., with Hospice Representative (HR) #104 confirmed the hospice nurse had submitted orders for Morphine and Ativan prior to the resident's arrival to the nursing home facility on 11/26/25.Interview on 03/16/26 at 4:05 P.M., with Director of Nursing (DON) #103 confirmed the photos provided by Resident #40's wife to the surveyor were taken in the facility. The DON confirmed the photo reflected the resident was in pain as evidenced by the resident's facial expression in the photos. Review of the facility's policy and procedure titled, Pain Management Program, last revised 03/19/25 revealed that based on a resident's comprehensive assessment, the facility would provide treatment and care in accordance with professional standards of practice, the comprehensive care plan, and the resident's choices related to pain management.This deficiency represents non-compliance investigated under Master Complaint Number 2789590 and Complaint Number 2785293.

Based on closed medical record review, review of hospital records, policy review and interview, the facility failed to implement a comprehensive, individualized and effective pain management program for Resident #41, who had a diagnosis of migraines. Actual harm occurred on 11/29/25 (three days after admission) when Resident #41, who was diagnosed with severe intractable migraines prior to admission to the facility, did not receive ordered anti-migraine medication resulting in the resident's transfer to the hospital for intractable headaches with vomiting and hypertension. The resident was hospitalized from [DATE] until 12/06/25 for management of intractable migraines. Findings Include: Closed medical record review revealed Resident #41 was admitted to the facility on [DATE] with diagnoses including migraine without aura, intractable, with status migrainosus (a severe debilitating migraine attack lasting longer than 72 hours that does not respond to standard treatment and is considered a neurological emergency), anxiety, depression, cerebrovascular disease, fibromyalgia, and hypertension.Review of Resident #41's admission medication orders revealed the resident was ordered Aspirin 81 milligrams (mg) daily for pain, Gabapentin (a prescription anticonvulsant used to treat partial seizures and nerve pain. It works by calming overactive nerves), 300 mg daily for pain until 11/29/25, then every two days starting on 11/30/25, Losartan (a medication used to treat high blood pressure) 100 mg daily for blood pressure, Metoprolol (a medication used to treat high blood pressure) 50 mg twice a day, and Acetaminophen 325 mg two tablets every four hours as needed for pain. Review of Resident #41's vital signs and pain evaluation dated 11/26/25 revealed the vital and pain assessments were not completed (blank).Review of Resident #41's admission assessment dated [DATE] revealed on 11/27/25 the resident had rated her pain level four out of 10 (1-10 scale) with verbal complaints of pain. The pain location was posterior neck, was described as aching and occurred daily. The resident was assessed to be alert and oriented times three (to person, place and time). Review of Resident #41's care plan titled potential for alteration in comfort related to fibromyalgia dated 11/28/25 and revised on 12/05/25 revealed to administer medication as ordered and per resident's preference/request, encourage resident to report pain early prior to becoming severe, and observe for any signs and symptoms of pain. Review of Resident #41's five-day Minimum Data Set (MDS) assessment dated [DATE] revealed the resident's cognition was intact. The resident received scheduled and as needed pain medication. The resident had pain in the last five days rated 10 out of 10. The pain was frequent, occasionally affected her sleep and frequently affected her day-to-day activities.Review of Resident #41's vital signs revealed the resident's blood pressure was taken on 11/27/25 at 3:32 A.M. in the left arm sitting and the results were 157/82 mm/Hg (normal blood pressure is considered 120/80 mm/Hg) and on 11/28/25 at 6:06 P.M., in the left arm sitting and the results were 154/78 mm/Hg. There was no documented evidence that the resident's blood pressure was obtained on 11/29/25.Review of Resident #41's progress notes authored by Licensed Practical Nurse (LPN) #208 revealed on 11/27/25 at 2:30 P.M. the resident was administered Acetaminophen 325 milligrams (mg) two tablets by mouth for a headache that was unrelieved by low lighting and quiet environment. The medication was documented as being effective.Review of Resident #41's progress note authored by LPN #608 dated 11/28/25 at 3:16 A.M., revealed the resident was in her room vomiting and complaints of headaches which were causing her to vomit per resident statement. Tylenol 325 mg two tablets were administered by mouth, and the medication was documented as being effective.Review of Resident #41's progress note authored by LPN #208 dated 11/28/25 at 5:15 P.M., revealed the nurse, resident, and resident's daughter had spoken to the Nurse Practitioner #1002. New orders were received for Topamax (a prescription anticonvulsant medication used to treat certain types of seizures (epilepsy), prevent migraine headaches), Imitrex (a prescription medication used to treat, not prevent, acute migraine or cluster headaches in adults), Magnesium (nutrient for preventing and reducing the frequency and intensity of migraines), Perphenazine (antipsychotic) and to consult the consulting psychiatrist. Review of Resident #41's orders dated 11/28/25 revealed new orders for Magnesium 400 mg daily for supplement, Perphenazine 4 mg tablet daily for obsessive compulsive disorder (OCD), Topamax 100 mg daily for migraines until 12/06/25 then decrease to 50 mg daily on 12/07/25, and Imitrex 50 mg every two hours as needed for migraine maximum dose of two every 24 hours.Review of Resident #41's medication administration record (MAR) and treatment administration record (TAR) dated November 2025 revealed the resident's pain level on 11/27/25 was zero and on 11/28/25 and 11/29/25 the pain level was marked not applicable (NA); however, the resident had received Acetaminophen 325 mg two tablets on 11/27/25 for a pain of eight and 11/28/25 for a pain of 10. Further review revealed no evidence the resident had received Topamax or the Imitrex per the orders dated 11/28/25.Review of Resident #41's progress note authored by LPN #200 dated 11/29/25 at 12:17 P.M., revealed the resident's daughter was in the facility at this time requesting that the nurse send her mother to the emergency room for complaints of headache and nausea. The daughter stated, My mother is vomiting all over herself and she was not getting any better here. The Nurse Practitioner was notified and new orders received to send to emergency room for evaluation and treatment. Spoke to daughter earlier regarding concerns of the resident not getting medication. At that time daughter phoned, and the nurse was preparing to give the resident her medication.Review of Resident #41's progress note dated 11/29/25 at 12:23 P.M., revealed the squad was in the facility to transport the resident to the hospital. Review of Resident #41's late entry Nurse Practitioner #1002 Discharge summary dated [DATE] revealed the resident was a [AGE] year-old female who was in no acute distress; staff advised that the resident was complaining of headache, she was given Topamax (Please note-there was no documented evidence the Topamax was given) for her headache. The daughter came in to see her mother and came out and reported her mother was now vomiting and she wanted her mother to be sent to the emergency room. The resident was admitted to the hospital with vomiting and headache.Further review of Resident #41's medical record revealed no evidence of a transfer notice to the hospital. Review of Resident #41's hospital notes dated 11/29/25 revealed the resident was admitted for intractable headaches with vomiting and hypertension. The residents' blood pressure was 200/100 mm/Hg in the emergency room. The resident reported she wasn't feeling well today with a severe headache and vomiting. The resident was given a dose of Dilaudid (opioid medication) in the emergency room for headache and developed severe bradycardia in the 30's (pulse). The resident's pulse did come up spontaneously to the 50's and 60's. The resident reported that she had a severe headache rating the pain nine out of 10 with severe vomiting. The resident's blood pressure was still elevated despite the intravenous hydralazine (vasodilator) which was a contributing factor to the resident's history of migraines. Neurology and cardiology were consulted. Thorazine (a medication that can be used in the treatment of severe nausea) 12.5 mg every eight hours intramuscular ordered, vital signs every four hours and magnetic resonance imaging (MRI) of the brain was ordered. The resident was admitted to the hospital for intractable headaches. Review of Resident #41's hospital Discharge summary dated [DATE] revealed the resident's primary admission diagnoses were intractable headaches/migraines and hypertensive emergency. The MRI showed no acute findings on 11/29/25. The resident's condition improved during her stay, and she was stable to be discharged . The resident was discharged home with a home health referral. Interview on 03/11/26 at 2:00 P.M., with LPN #200 confirmed she was the nurse who was assigned to Resident #41 on 11/29/25. The LPN revealed on this date she was responsible to provide nursing care for residents in the Assisted Living and the skilled unit on the Skilled Nursing Home side. On 11/29/25, Resident #41's daughter had called stating her mom hadn't received her medications yet. The LPN could not recall the time she had received the call from the resident's daughter. LPN #200 reported she told the resident's daughter that she was outside her room and was getting ready to pull her mom's medications to administer. The resident had complained of a headache; however, LPN #200 never administered the Topamax because the medication was scheduled to be administered in the afternoon and in addition, she was not aware the resident had a new order received the day prior for Imitrex. Later, the resident's daughter arrived and asked why her mom was still here after she had requested her to be sent to the emergency room. LPN #200 reported she explained to the daughter that she had asked the resident, and the resident wanted to wait to see if the medication (gabapentin) was effective. The daughter requested the resident be sent to the hospital and LPN #200 spoke to the resident, and the resident agreed she wanted to go to the hospital, so LPN #200 called the provider and received new orders to send the resident to the emergency room. LPN #200 confirmed if she had known the resident had an order for Imitrex she would have administered it for the resident's headache. LPN #200 confirmed the resident was ordered Topamax and Imitrex on 11/28/25 and those medications had not been administered. LPN #200 confirmed she did not administer the as needed Tylenol for the residents' headache/migraine and had just administered her scheduled gabapentin. LPN #200 confirmed she did not complete the transfer form to send to the hospital as well.Interview on 03/12/26 at 10:26 A.M., with Resident #41's daughter (#302) confirmed she was Resident #41's daughter and was the family member who had called and came to the facility on [DATE] as stated in the nursing progress note. The daughter reported the resident and family had a bad experience with the facility. The daughter voiced concerns Resident #41 had to be re-hospitalized three days after her admission due to the facility's neglect to administer medication and monitor her mother's blood pressure adequately. Daughter #302 reported she visited the facility every day her mother was there and had concerns regarding her mother's care; however, the Director of Nursing (DON) never returned her call to discuss. Daughter #302 voiced concerns that when she was visiting she could never find staff and when she called the facility no one would answer the phone. Daughter #302 revealed on 11/29/25 her mom called her crying because she had a migraine and had vomited and was nauseated. The daughter stated the facility had every excuse why she hadn't received her medication yet. The daughter reported she tried calling the facility and tried continuously on her way to the facility to follow up on her mom's condition; however, no one answered the phone. When she arrived Resident #41 was covered in vomit and there was vomit on the floor and she had to clean the resident up. The daughter reported that her mom didn't receive her migraine medications as ordered and had to be transferred to the emergency room. When they arrived at the hospital her mom's blood pressure was critically high and she was admitted for seven days before she was stable to be discharged . Her mom refused to return to the facility and said she would rather die. The daughter reported the experience left her mom terrified to go to any nursing facility and it has caused a burden on the family and her mother to be at home. Interview on 03/12/26 at 10:40 A.M., with Resident #41 revealed she was hospitalized (on 11/29/25), which had prolonged her recovery a month due to the facility lack of administering medication as ordered. The resident reported she had a horrible migraine, and she didn't receive her medication as ordered, which resulted in her blood pressure going up. The resident reported she begged her family and the hospital not to send her back to the facility. The resident reported there wasn't adequate staffing to assist her needs and administer medication as ordered. During an interview, the resident reported prior to her hospitalization and nursing home admission she took Hydralazine 25 mg by mouth for her migraines. At the hospital they were administering the hydralazine by injection, and she stated she believed she was supposed to receive the medication again orally when she got to the facility (beginning 11/26/25). However, she did not think she was getting all her medication correctly at the facility. During an interview on 03/16/26 at 8:53 A.M. with the DON, concerns with Resident #41 not being administered ordered medications to treat and alleviate pain associated with the resident's migraine headaches and nausea and vomiting was shared. The DON confirmed Resident #41 did not receive her medications and staff failed to monitor her blood pressure. Review of the facility's Pain Management policy and procedure dated 04/29/99 and revised 03/19/25 revealed purpose of the policy was to recognize when the resident was experiencing pain and identify circumstances when pain can be anticipated. Evaluate existing pain and identify the cause and manage or prevent pain, consistent with comprehensive assessment and plan of care, current professional standards of practice and the resident's goals and preferences. Resident's pain level would be monitored daily, and prior to administering as needed pain medication and after administration to assess effectiveness. This deficiency represents non-compliance investigated under Complaint Number 2785293.

Based on review of infection control log, interview, and policy review the facility failed to ensure the facility had a comprehensive infection control program that including tracking and monitoring for infection trends. This had the potential to affect all 37 residents residing in the facility.Findings Include: Review of the infection control trending of infections dated 10/2025 to 03/2026 revealed no evidence the facility was trending for infections. The facility was utilizing a map for trending. In the corner of the map was the key that indicated respiratory was blue, gastrointestinal was green, urinary tract infections (UTI) were yellow, wounds were pink and others were purple. There was no evidence of the type of infections to ensure there was not a pattern. Further review of the infection log dated 12/2025 to 03/2026 revealed the facility started utilizing a new log. In December 2025 the facility had four UTI's that didn't indicate the organism, in January 2026 three UTI's that didn't include organisms, February 2026 seven UTI's that didn't include organisms and two infections that didn't include the site of infection or organism, and March 2026 one UTI that didn't include the organism. Interview on 03/16/26 at 9:15 A.M., with Infection Preventionist (IP)/Licensed Practical Nurse (LPN) confirmed the infections were not monitoring for trends to indicate the type of infections to ensure there was not a pattern and most of the UTI's she did not have a culture to identify if there was a trend with organisms. The IP reported she had voiced concerns with the previous director of nursing (DON) #100 was told not to contact the providers and to administer antibiotics as ordered. Review of the infection control policy dated 10/19/29 revealed the purpose of the policy was to establish a process that investigates, monitors, identifies, controls, and surveys infections. When a resident was admitted to the facility with an infection or when a resident acquires an infection, an infection report will be completed by the infection preventionist (IP). Antibiotic orders will be obtained from the physician and implemented upon proper microorganism identification, if necessary. When a resident acquired an infection, the IP will update the surveillance map by reviewing the location the residents, type and location of infections. If there is a pattern, this will be discussed in the weekly QA program meeting. This deficiency represents an incidental finding of non-compliance investigated under Complaint Number 2789590.

Based on interview, record review, review of infection-Antibiotic (ATB) Surveillance logs and facility policy, the facility failed to have a qualified designated infection preventionist (IP) who effectively monitored and implemented the facility's Antibiotic Stewardship Program. This had the potential to affect all 39 residents residing in the facility. The facility census was 39.Findings include: Upon entrance to the facility on [DATE], the facility identified Licensed Practical Nurse (LPN) #97 as the Infection Preventionist (IP).Review of the facility infection control log for March 2026 revealed the facility did not meet the requirements for antibiotic stewardship. Review of the antibiotic stewardship documentation provided by the facility demonstrated a lack of understanding of the importance of receiving hospital documentation to support the need for antibiotics upon return to the facility. In addition, review revealed the timing and accuracy of completing McGeer's evaluations that led to errors in the decision making process as to whether a resident met criteria for antibiotic use affecting the effectiveness of the facility's antibiotic stewardship program.Interview on 03/31/26 at 5:47 P.M. with LPN #97 related to the accuracy of the antibiotic stewardship program revealed she had not performed the infection control (IP) role since 2019. The surveyor requested the Infection Preventionist certification of training and testing.Interview on 04/01/26 at 5:23 P.M. with LPN #97 revealed she was hired 10/16/25 as the Minimum Data Set (MDS) Assessment nurse. She took over infection control in December of 2025 when former Director of Nursing (DON #110) asked her to be the Infection Preventionist. Prior to that, the Former DON #110 was in charge of infection control since her hire in August 2025. LPN #97 revealed she provided Former DON #110 her Infection Preventionist Certificate but it was not in her personnel file. LPN #97 provided a form stating she completed the Infection Preventionist course on 02/12/21. LPN #97 stated that would be the same date she would have successfully passed the examination and received the Infection Preventionist certificate. However, LPN #97 was unable to provide a certificate. LPN #97 indicated she called her former employer who was unable to provide her her certificates and continuing education. LPN #97 stated they could send the information 04/02/26. She indicated the only other infection control classes she had taken since completing the Infection Preventionist Course was standard infection control bloodborne pathogen education provided through Relias, this was with her former employer. LPN #97 verified she did not renew her training every two years to reflect the updated guidelines and stay current with updated training. During the course of the survey (03/31/26-04/03/26) the facility did not provide an Infection Preventionist Certificate for LPN #97. The facility provided an Infection Preventionist Certificate of Training dated 08/29/25 for LPN #58. The Administrator and DON indicated LPN #58 worked part time on midnight shift, when she was going to school to be a registered nurse. The Administrator and DON said LPN #58 was returning full time as of 04/01/26 and the plan was LPN #58 would become the Infection Preventionist at some point.Review of the facility Infection Preventionist policy (last reviewed 11/30/23) did not include the requirement for a certificate of completion of an infection preventionist program professional and continuing education to maintain competency in updates. It also did not specifically address antibiotic stewardship in the nursing home setting.

Based on review of concerns forms, review of email communication, interviews, observation, and policy review the facility failed to ensure a functioning call light system that was not able to be turned off until the call light was responded to by staff. This had the potential to affect all 37 residents residing in the facility.Findings Include: Review of an email dated 02/20/26 to the previous Director of Nursing (DON) #100 from Resident #28's daughter revealed Resident #28's daughters' friend was visiting her mother and had called her because the visitor had asked someone walking down the hall to check Resident #28 after waiting a long time for someone to come. That person checked her mom and said she was dry. The friend knew that Resident #28 was not dry because she could smell the urine. Two other people and the physical therapist came in and took Resident #28 to the bathroom. The physical therapist said that since Resident #28 was not bearing any weight on her legs, they would not be able to continue to get her into the bathroom. The daughter was also concerned her mom would be incontinent of urine and stool and she would have to lay in it for hours before getting changed. Even with calling out for help, it takes an extended amount of time for assistance to come if they come at all. The Certified Nursing Assistant (CNA's) were supposed to check on residents every two hours, but they do not. Resident #28's daughter reported she had witnessed this every time she had been in the facility. The DON's response was that the nurses are aware to make sure Resident #28 was checked on often and assisted as needed. Review of a concern form, which was not on the concern form log, dated 02/16/26 revealed Resident #28's daughter had concerns that incontinence care was not performed timely and pressure ulcer was not identified by staff. The corrective action didn't address the daughter's concerns regarding incontinence care not performed timely. Interview on 03/12/26 at 10:59 A.M., with Resident #28's daughter revealed there had been concerns recently while a friend was visiting her mom on 02/20/26 and she had to wait an extended amount of time for someone to respond to the call light.Observation on 03/12/26 at 2:22 P.M., of Resident #15's call light revealed the state surveyor activated the resident's call light. At 2:33 P.M., the surveyor activated the call light again even though it was red (indicating it was alarming). At 2:38 P.M., the surveyor activated the light again due to the red light having disappeared. At 2:40 P.M., Certified Nurse Aide (CNA) #405 answered the call light and confirmed the walkie talkie alerted her to the room but she could not tell the surveyor the time it was activated, however the computer should be able to give the exact times. Resident #15 revealed he was not sure if his call light was working properly or if staff were just not answering it timely. Interview on 03/12/26 at 3:04 P.M., with Maintenance Director (MD) and Maintenance Director Assistant (MDA) confirmed Resident #15's call light was activated on 03/12/26 at 2:22 P.M. for 16 minutes and 15 seconds and then activated again at 2:38 P.M. The MD and MDA reported the call light resets after 16 minutes and 15 seconds, which would require the resident to re-activate the call light again. The MDA showed the surveyor on the computer the activation date and times and how long the call light was on but unable to print results due to when they tried to print it would crash the computer. The Administrator arrived during interview and reported the company was in the process of buying a new computer and was aware of the issue. Interview with anonymous Staff Member #500 during the survey confirmed currently call lights were not answered timely, and residents have voiced concerns to her as well. Interview on 03/16/26 at 7:43 A.M., with Corporate Clinical Director (CCD) #102 confirmed the concern form was not on the concern log, and she had found it in the Director of Nursing's office. Review of the facility's policy titled Call Lights dated 03/12/16 revealed staff will strive to answer call lights and meet residents' needs as promptly as possible. Call lights will be silent only after the residents' needs are met. This deficiency represents non-compliance investigated under Complaint Number 2789590 and 2785293.

Based on medical record review, review of concern forms, review of meal ticket, observation, and interview the facility failed to ensure a resident received fluids per order. This affected one resident (#28) of three residents reviewed for hydration.Findings Include: Medical record review revealed Resident #28 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses including urinary tract infections, hypotension, gastric reflux, protein-calorie malnutrition, and dysphagia. Review of Resident #28's dietary note dated 07/17/25 revealed the fluid intake recommendation was 1950 milliliters (ml). Review of a concern form dated 02/12/26 revealed Resident #28's daughter had concerns after her mother fractured left femur, she would be less mobile and had concerns with urinary tract infections and hydration. The resolution included therapy to evaluate, dietary would offer extra fluids as tolerated, would obtain order for UTI stat, (supplement) from physician, and have dietician evaluate resident. The daughter was fully satisfied with recommendations on 02/13/26 and signed off on the concern form. Review of Resident #28's dietary note dated 02/12/26 revealed the resident was re-admitted on [DATE] after fracturing her left hip; 240 milliliters (ml) extra fluids with lunch and dinner. No edema was noted. The resident meets criteria for malnutrition related to decreased energy intake and muscle wasting. Recommend magic cup daily at lunch. Review of Resident #28's order dated 02/11/26 revealed 240 ml fluids extra with lunch and dinner. Review of Resident #28's diet order and communication form dated 02/12/26 revealed extra 240 ml at lunch and supper. Review of Resident #28's supper meal ticket dated 03/11/26 revealed no evidence of extra 240 ml of fluids. Review of Resident #28's fluid intakes dated 02/11/26 to 03/12/26 revealed the residents' intakes varied from 60-240 ml for each meal. There were two days (02/18/26 and 02/23/26) there were only intakes recorded for two meals and four meals recorded the resident refused fluids. The resident average intake was 760 ml daily. Review of Resident #28's orders revealed no evidence the resident was receiving a diuretic medication. Review of Resident #28's potential for decreased fluid volume due to diuretic medication use care plan dated 03/02/18 and revised 03/04/20 revealed record intakes and outputs as ordered or nursing judgement. There was no evidence of extra 240 ml of fluids at lunch and dinner. Review of Resident #28's risk for altered nutrition plan of care dated 10/15/18 and revised 02/18/26 revealed to encourage intakes. There was no evidence of extra 240 ml of fluids at lunch and dinner. Observation on 03/11/26 at 4:20 P.M., of Resident #28 revealed the resident had one 240 ml cup of pink drink with ice and 120 ml cup of light orange colored drink. Interview on 03/11/26 at 4:38 P.M. with Dietary Manger (DM) #205 revealed she was unaware the resident was to receive an extra 240 ml with lunch and dinner. DM #205 confirmed if there were special dietary instructions it would be documented on the meal ticket and she had also had a sheet hung in the kitchenette to remind staff. DM #205 showed the surveyor the list from the kitchenette, and the order for extra fluids for lunch and dinner was not listed on the list in the kitchenette. Licensed Practical Nurse (LPN) #208 was near the kitchenette and reviewed Resident #28's orders with the surveyor and DM and confirmed Resident #28 was to receive an extra 240 ml of fluids with lunch and dinner. LPN #208 wrote a new dietary communication form and gave it the DM to add to the resident meal ticket. The DM confirmed the resident only had one 240 ml cup of fluids and the 120 ml cup was the UTI stat (supplement) the nurse gave her during medication administration. It was not the extra 240 ml of fluids because she was unaware of the order. Interview on 03/12/26 at 10:59 A.M., with Resident #28's daughter revealed she was concerned her mother was not provided adequate hydration due to decreased urination, dark urine, and urinary tract infections. She had spoken to the facility regarding her concerns regarding her mother's hydration needs but didn't feel they were addressed. This deficiency represents non-compliance investigated under Complaint Number 2789590.

Based on medical record review, observation, interviews, and policy review the facility failed to ensure fall interventions were in-place per the resident's plan of care. This affected one resident (#28) of three residents reviewed for accident/hazards. Findings Include: Medical record review revealed Resident #28 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses including displaced intertrochanteric fracture of left femur, hypotension, urinary incontinence, dizziness, difficulty walking, and muscle weakness. Review of Resident #28's risk for falls/injury related to dizziness, impaired gait, muscle weakness, and use of psychoactive medication plan of care dated 03/02/18 and revised 10/21/25 revealed on 10/21/25 bright color paper used for visual aide to ask for help and use the call light system was added to the interventions. Additional intervention included bright colored tape applied to brake handles as visual reminders, and dycem to seat of wheelchair. Observation on 03/12/26 at 8:15 A.M., with Registered Nurse (RN) #204 of Resident #28 revealed there was no evidence the bright color paper used for visual aide to ask for help and use the call light system per the plan of care. In addition there was no evidence of bright colored tape on brake handles on the wheelchair or dycem to seat of wheelchair. The RN reported Resident #28 had a fall with fracture last month and had received new wheelchair and staff did not apply the bright colored tape or dycem to the new wheelchair. The RN also confirmed the signs in the resident's room were not bright colored per the fall plan of care. Interview on 03/12/26 at 10:59 A.M., with Resident #28's daughter revealed she felt the facility failed to implement preventive measure to prevent her mother's fall which resulted in a fracture. She had requested information regarding the fall and care plan, however the information had not been provided to her at this time. Review of the facility's policy titled Fall Policy and Procedures dated 07/04/05 and revised on 01/27/20 revealed based upon the assessment, the interdisciplinary team will develop interventions based upon the resident risk factors and individual needs and implement a fall plan of care in point click care. The fall care plan would be reviewed at least quarterly and as needed by the team and updated in point click care. This deficiency represents non-compliance investigated under Complaint Number 2789590.

Based on medical record review, review of concerns form, observation, interview, and policy review the facility failed to implement appropriate pressure relieving interventions timely to prevent pressure ulcers and failed to identify and treat pressure ulcer. This affected one resident (#28) of three residents reviewed for pressure ulcers.Findings Include:Medical record review revealed Resident #28 was admitted to the facility on [DATE] and re-admitted on [DATE] after sustaining a fall with left femur fracture. Review of Resident #28's risk for skin breakdown related to peripheral vascular disease and incontinence plan of care dated 03/02/18 and revised on 11/29/22 revealed weekly skin assessments, pressure redistribution mattress to bed, consult with wound nurse practitioner as needed, and tubi- grips to both legs on in the morning and off at bedtime. Review of Resident #28's re-admission skin assessment dated [DATE] revealed the resident had no skin issues except left hip surgical incision. There was no additional skin assessment completed until 02/16/26 when Resident #28's daughter had identified a skin alteration on the resident's coccyx. Review of Resident #28's Braden assessment (tool used for predicting pressure ulcer risk) dated 02/11/26 revealed the resident was at moderate risk for pressure ulcers. There was no evidence that new interventions were implemented to prevent pressure ulcers.Review of Resident #28's five-day minimum data set (MDS) dated [DATE] revealed the resident had cognition impairment. The residents had one to three days of rejection of care. The resident needs some help with self-care. The resident was dependent on staff for rolling left and right, sitting to lying, lying to sitting on side of bed, sit to stand, chair/bed-to-chair transfer, and toilet transfer. The resident was frequently incontinent of urine and always incontinent of bowel. The resident had fracture related to a fall in the last six months that required a repair of the fracture. Resident #28 was at risk for developing a pressure ulcer/injury. The resident did not have a pressure-reducing device for chair or bed, not on a turning/repositioning program, no nutritional or hydration interventions to manage skin problems, or pressure ulcer/injury care. The resident was receiving opioid and antiplatelet medications. Review of a concern form dated 02/16/26 and completed by Resident #28's daughter revealed on 02/08/26 her mother fractured her hip and had surgery on 02/09/26 and returned to the facility on [DATE] at 5:00 P.M. Her mother was not properly checked back into the facility by the registered nurse (RN). A decubitus (pressure) ulcer was noticed by the resident's daughter today. The staff were totally unaware. There was a great risk for infection due to the decubitus ulcer is on the coccyx and was approximately three inches wide by two inches long. This would be considered a facility acquired bedsore. The daughter had spoken with the previous director of nursing (DON) #100 on 02/16/26 at 11:20 A.M., and RN #204. RN #204 placed a protective dressing on the decubitus ulcer in the daughter's presence today 02/16/26. Staff was not able to take a photograph of the ulcer. DON #100's immediate plan of action was to have the wound nurse see the resident, air mattress, weekly skin assessment, and new treatment orders to open area on coccyx. DON #100 updated Resident #28's daughter. Review of Resident #28's skin assessment completed by the consulting wound nurse practitioner dated 02/16/26 revealed the resident was [AGE] years old and was re-admitted for a left hip fracture with open reduction and internal fixation. The resident had a new in-house acquired wound on the pelvis/sacrococcygeal area that was staged as partial thickness (Stage II) that measured 7.5 centimeters (cm) by 6.5 cm by 0.1cm with moderate serosanguineous drainage. The wound bed was 80 percent epithelial; however, there was no documentation what the other 20% of the wound bed appeared to be. Interventions included barrier cream per facility's protocol (already implemented twice a shift since 06/02/23), float heels, low air loss mattress (was not implemented until 03/05/26), and turn and reposition per facility policy. Review of the facility wound assessment dated [DATE] revealed Resident #28 had unstageable pressure ulcer (full thickness tissue loss) on the coccyx/sacral area that measured 7.5 cm by 6.5 cm and unable to determine depth due eschar covered 80% of the wound bed and the other 20% was granulation. The wound was draining moderate serosanguinous drainage. Review of Resident #28's unstageable on coccyx/sacral bilateral buttocks and hembullas on bilateral heels plan of care initiated on 02/16/26 and revised on 03/09/26 revealed only one intervention to apply treatment to areas as ordered. Review of the facility wound notes revealed no evidence of skin alteration to the heels on 03/08/26.Review of consulting wound nurse practitioner note dated 03/09/26 revealed the pelvis/sacrococcygeal wound was now unstageable measuring 3.0 cm by 5cm by 0.1 cm and was being treated with Cipro for an infection with proteus and pseudomonas. The pelvis area was still unstageable and measured 3.0 cm by 5.0 cm by 0.1 cm. The nurse reported the resident had new wounds on the heels onset 03/08/26. The left heel measured 4.5 cm by 7.3 cm x 0.1 cm and was a suspected deep tissue injury. There were no measurements of the right heel until an amendment note was added on 03/13/26 that indicated the right heel measured 4 cm by 7 cm and depth was undetermined. Treatment plan indicated mesalt (debriding agent) daily to pelvis and A&D twice daily and as needed to heel. Further review revealed wound notes dated 03/09/26 that revealed the resident had suspected deep tissue injuries to the right and left heels. The resident's right heel measured 0.4 cm by 7.5 cm and the left heel measured 4.5 cm by 7.3 cm. Review of Resident #28's medication administration record dated 03/2026 revealed the resident received Cipro 500 milligrams (mg) twice a day for positive wound culture from 03/07/26 to 03/16/26. Review of Resident #28's treatment administration record dated March 2026 revealed on 02/24/26 the resident was ordered to cleanse coccyx/sacral bilateral buttocks with normal saline or wound cleanser and apply mesalt (debriding agent) and dry dressing daily.There was no documented evidence that the treatment was administered on 03/03/26 or 03/11/26. On 03/05/26 an air mattress was added to the treatment administration record (TAR) (which was part of the plan of correction to the concern form completed by Resident #28's daughter on 02/16/26), on 03/08/26 heel boots as tolerated was added for prevention, since 02/17/26 staff were to encourage resident to offload (not specified what to offload) twice daily as prevention, and the resident had been receiving barrier cream to coccyx/buttocks twice daily and as needed for preventions since 06/02/23. On 03/10/26 there was an order added to cleanse bilateral heels with mild soap and water and apply A&D twice daily. There was no documented evidence that the treatment was administered on 03/11/26 for day shift. Further review of the TAR revealed no evidence the resident refused heel boots. Observation on 03/12/26 at 8:12 A.M., of Resident #28 revealed the resident was in bed and the heel boots were not in-place. Registered Nurse (RN) #204 confirmed findings and indicated the heel boots were tolerated, and she would have to check the TAR. Interview on 03/16/26 at 2:13 P.M. with the Director of Nursing (DON) #103 confirmed the resident had a Stage II pressure ulcer on the coccyx area that was not initially identified by the staff, however, was identified by a family member. The DON confirmed upon the resident's readmission that the resident's Braden scale was re-assessed, and it was determined the resident went from low risk to moderate risk for skin breakdown and the staff didn't implement any new intervention until the resident had acquired a pressure ulcer. The DON reported her expectation would have been to review previous interventions and implement new interventions such as pressure relieving devices. The DON reported originally the wound nurse had assessed the wound as unstageable, however the same day the facility contracted wound nurse practitioner had visited and staged the coccyx wound as a Stage II. The DON confirmed there was documented evidence that the resident had received treatments to the coccyx on 03/03/26 or 03/11/26 or the heels on 03/11/26. The DON confirmed she had reached out to the nurses that worked on dayshift and nightshift and both confirmed they did not administer the treatment. The DON confirmed there was no documented evidence on the TAR that resident had refused heel boots. The DON reported turning and positioning was part of all resident's daily care. The DON confirmed the only intervention on the plan of care for the pressure ulcers was to provide treatments as ordered. Review of the facility wound policy titled Wound and Skin Care Program dated 12/20/24 revealed the resident would be assessed for the risk of skin breakdown and appropriate interventions would be initiated. The resident would have a full skin assessment conducted by the admitting nurse and will have appropriate resident specific interventions and treatments initiated. A second skin assessment would be completed in 24-72 hours to verify existing skin alterations. Be reviewed by the Interdisciplinary team (IDT) to identify resident specific interventions to promote skin integrity (i.e. off-loading of heel post hip fracture repair). Once identified interventions to promote skin integrity will be communicated to licensed nurses and nursing assistants through physician orders, care planning, and point of care. Any newly identified skin impairments would be reported to the nurse for assessment. Assessment findings would then be reported to the physician for treatment guidance and evaluation of further interventions. Newly identified skin impairments will be documented under risk management and in point click care. Wound treatment/dressing will be supported by the physician order. This deficiency represents non-compliance investigated under Complaint Number 2789590.

Based on record review, facility policy review, and interview, the facility failed to ensure dietary recommendations were timely implemented and the physician was updated timely on a resident's severe weight loss. Actual harm occurred to Resident #1 when nutrition recommendations were not implemented, and the physician was not updated resulting in the resident sustaining an avoidable 16.6% severe weight loss in one month. This affected one (Resident #1) of three residents reviewed for nutrition.Findings include:Review of the medical record for Resident #1 revealed an admission date of 05/02/25 with diagnoses including atherosclerotic heart disease, dementia, ventricular tachycardia, chronic kidney disease, congestive heart failure (CHF), and depression. Review of the quarterly Minimum Data Set (MDS) assessment, dated 07/30/25, revealed Resident #1 had moderately impaired cognition. Resident #1 required staff assistance with eating and had a weight loss of five percent (%) or greater within last month.Review of the physician order dated 06/10/25 revealed an order for oral med pass (high calorie nutritional supplement) 120 milliliters (ml) two times per day (BID). The order was discontinued on 07/17/25.Review of the dietary progress note dated 06/18/25 at 1:32 P.M. revealed current weight was 200.8 pounds (lbs). The resident's weight monitored daily for congestive heart failure management; history of edema; diuretic treatment with Torsemide 10 milligrams (mg) every day. Regular diet with no added salt. Meal intakes are between 76-100% acceptance. Weight loss related to history of edema and fluid changes. Current diet and supplements were meeting estimated needs. No new recommendations.The nursing progress note dated 07/15/25 at 8:31 A.M. revealed Resident #1 returned from the hospital with a new order for Keflex (antibiotic) 500 milligrams(mg) by mouth four times per day for 10 days prophylactically due to increased white blood cell count and left ventricular assist device (LVAD).Review of Resident #1's weight log revealed on 07/14/25, weight was 197.5 lbs. and weight on 07/16/25 was 183.8 lbs.; this was a 13.7 lb. severe weight loss. There was no evidence of physician notification.The dietary progress note dated 07/18/25 at 1:41 P.M. revealed Resident #1's current weight was 183.8 lbs. which indicated an 11.8% severe weight loss compared to weight of 208.3 lbs. on 06/16/25. Accuracy of weight was questioned due to weight being down 13.7 lbs. in two days. Meal intakes 51-100%. No noted chewing or swallowing impairment. Med Pass was discontinued on 07/17/25 following Resident #1 being sent to the emergency department (ED) on 07/15/25 related to shortness of breath and altered mental status. The resident returned with an antibiotic order. Recommendation for a re-weight and to restart oral med pass four ounces (120 ml) BID. This nutrition recommendation was not initiated until 12 days later 07/30/25.Resident #1's weight log revealed on 07/27/25, weight was 182.0 lbs. and weight on 07/28/25 was 173.2 lbs.; this was an 8.8 lb. loss. in two days and 10.6 lbs. weight loss in two weeks, a 6.1% severe weight loss. There was no evidence of physician notification.Review of the physician order dated 07/30/25 revealed the order for four ounces of oral med pass BID for supplement.Review of the July 2025 Medication Administration Record (MAR) revealed Resident #1 did not receive oral med pass four ounces BID from 07/18/25 through 07/29/25. On 07/30/25, Resident #1 began receiving four ounces of med pass BID for supplementation.The dietary progress noted dated 08/06/25 at 4:12 P.M. revealed current weight was 166.2 lbs. and was a 16.6% severe weight change since 07/05/25. Weight was down an additional 4.4 lbs. since 07/30/25. Meal intakes vary. Remeron started on 08/05/25 and Torsemide discontinued. Resident #1 more lethargic with labs ordered. Four ounce med pass daily started on 07/30/25 with good acceptance. Recommendation to increase med pass four ounces to three times per day. The nursing progress noted dated 08/07/25 revealed Resident #1 was taken to emergency room (ER) due to lethargy, refusing to eat, drink, or take medications. Physician notified and order given to transfer to ER. Family notified.Interview on 08/26/25 at 3:26 P.M. with Registered Dietician (RD) #320 revealed she had noted Resident #1's med pass had been discontinued on 07/17/25 following a return from the ER and not restarted until 07/30/25. RD #320 stated she didn't know why the med pass had been discontinued but this was during the time of the transition of the previous Director of Nursing (DON) and current DON and she did notify nursing of the discrepancy. Resident #1 stated the resident's weight loss was initially attributed to fluctuations due to CHF and diuretic therapy, but the last couple of weeks the resident stated he didn't feel like eating and an appetite stimulant (Remeron) was added, and the med pass was increased to three times daily.Interview on 08/26/25 at 3:48 P.M. with the DON revealed Resident #1's med pass was discontinued on 07/17/25 and she isn't sure why. The DON confirmed the med pass should not have been discontinued and verified it was re-started on 07/30/25.Interview on 08/27/25 at 8:21 A.M. with the DON confirmed there was no documentation which indicated the physician was notified of the weight loss on 07/16/25 or 07/28/25.Review of the facility policy titled Resident Condition Changes dated 04/01/23 revealed the nurse will contact the resident's physician immediately when any resident has a perceived change in condition. A change in condition includes but is not limited to, a change in physical or mental status, refusal of medications or treatment, a need to alter treatment, an accident, need to transfer or discharge, development of wounds or other new condition, inability to provide an ordered medication or treatment, lab or radiology results. The nurse will notify the resident's responsible party of condition change.This deficiency represents non-compliance investigated under Master Complaint Number 2600641 and Complaint Number 2595112.

Based on review of a closed medical record, hospital records, death certificate, facility investigation and staff interview the facility failed to develop and implement comprehensive and individualized fall/safety interventions and provide adequate supervision for one resident (Resident #46), who was assessed as cognitively impaired, at risk for falls and required extensive staff assistance for transfers and ambulation. Resident #46 sustained 18 falls while residing in the facility between [DATE] and [DATE]. This resulted in Actual Harm that was Immediate Jeopardy on [DATE] when Resident #46 sustained an unwitnessed fall in his room sustaining an intracranial bleed, multiple facial fractures, lacerations to his right forehead/scalp which required six sutures to control vascular bleeding, two cervical spine fractures and a right frontal skull fracture with a scalp hematoma. Resident #46 expired (in the hospital) on [DATE] as a result of the injuries sustained during the fall. The cause of death on the death certificate indicated [MEDICATION NAME] force injury due to a fall. This affected one resident (#46) of five residents reviewed for falls. The facility census was 51. On [DATE] at 2:59 P.M. the Administrator (LNHA) and Corporate Registered Nurse (RN) #94 were notified Immediate Jeopardy began on [DATE] when Resident #46, who was at high risk for falls, cognitively impaired and required extensive assistance from staff for transfers and ambulation sustained an unwitnessed fall in his room which resulted in multiple serious injuries including a skull fracture and cervical spine fractures. The resident was subsequently transported to the emergency room and admitted to the hospital where he later expired as a result of complications from the fall. The death certificate, dated [DATE] revealed Resident #46's cause of death was from [MEDICATION NAME] force injury due to the fall. The Immediate Jeopardy was removed on [DATE] when the facility implemented the following corrective action: · On [DATE] at 7:22 P.M., Resident #46 was sent to the hospital and subsequently expired. · On [DATE] the facility initiated an investigation regarding Resident #46's injuries/fall on [DATE]. · On [DATE] the DON/designee completed fall risk assessments for all 52 residents residing in the facility as of [DATE]. Ten residents (Resident #9, #12, #18, #19, #21, #28, #37, #42, #43, and #297) were identified to be at risk for falls. On [DATE] at 10:30 P.M. RN #19, RN #94, RN #23, RN #96, Social Service Director (SSD) #6, Licensed Practical Nurse (LPN) # 38 and Physical Therapy Assistant (PTA) #95 observed fall risk safety interventions in place as planned for the ten current residents identified to be at risk for falls. A plan for the DON/designee to audit fall safety interventions being in place three times per week for an indefinite period of time was implemented. · On [DATE] at 6:30 P.M. nine residents (#9, #12, #19, #21, #28, #37, #42, #43, #297) identified by the facility to have experienced falls from [DATE] through [DATE] were reviewed by the DON/designee to ensure a thorough investigation was completed to determine the root cause of the fall and to determine if interventions were implemented appropriately. The plan of care for all each resident was reviewed and revised on [DATE] by Corporate RN #94. · Beginning on [DATE] a plan for all residents to have a fall risk assessment completed on admission, quarterly, and as needed by the DON/ designee to ensure interventions were implemented that would decrease the number of falls and the risk for injury. The DON would ensure care plans were revised based on the risk assessment. In addition, a plan for a fall risk re-assessment to be completed after each fall was implemented. · On [DATE] a new fall intervention listing sheet for each resident was initiated by Corporate RN #94. The list is to be reviewed at the nurses' station by nursing staff during shift changes. The purpose of this fall intervention listing was to provide easily accessible, visual information to the direct care staff. A plan was implemented for the Assistant Director of Nursing (ADON) to review the listing three times per week. · Beginning [DATE] fall investigations were to be initiated immediately, at the time of a fall, by the licensed nurse on duty. A new fall investigation form was developed to be utilized to include what was the location of the resident prior to the fall, where was the resident last seen and by whom, what was the resident doing when last seen, does the resident wear glasses and if so, were the glasses on at the time of the fall, were all previous interventions in place and if so, what were those interventions, was the call light within reach, was the call light on at the time of the fall and was it working. · Beginning on [DATE] a plan for the interdisciplinary (IDT) team consisting of Corporate RN #94, the DON, ADON, Programs Nurse, Therapy Director, and the SSD to review all fall investigations to ensure a thorough investigation and a root cause analysis was done in order to ensure individualized interventions and revision/review of fall care plans. · On [DATE] Corporate RN #94 provided education to all nurse managers which included the DON, ADON, MDS Nurse and Programs Nurse on the fall program, thorough investigation with root cause analysis and individualized interventions for residents at risk for falls or with actual falls. · On [DATE] beginning at 3:56 P.M. the DON/designee provided education to 27 STNAs either in person or via telephone related to fall interventions and the fall intervention listing sheet. As of [DATE] the facility identified only one STNA who had not received the education. A plan for this employee to receive the training prior to the next scheduled work shift was implemented. · On [DATE] the DON/designee provided education to 17 licensed nurses either in person or via telephone related to the all program, implementation of immediate interventions, fall intervention listing sheet and the investigation of falls. As of [DATE] the facility identified three licensed nurses who could not be reached and implemented a plan to ensure all three received the education prior to their next scheduled work shift. · On [DATE], audits were started by the DON/designee, to be conducted for four weeks, then monthly for two months, and then ongoing by the DON/designee to ensure falls have thorough investigations, individualized interventions based on the root cause analysis. · On [DATE], a Quality Assurance and Performance Improvement (QAPI) review included discussion of Resident #46's fall and the lack of a thorough fall investigation, lack of root cause analysis, and if fall/safety interventions were appropriate. A plan to review fall investigations to ensure they include a thorough investigation and a root cause analysis to implement interventions that are individualized was developed. · Observation on [DATE] between 1:45 P.M. and 4:25 P.M. revealed fall risk interventions were in place for Resident #21, #28, #42 and #43. No concerns were identified. · Interviews on [DATE] between 1:55 P.M. and 4:22 P.M. with RN #15, LPN #88 and State tested Nursing Assistants STNAs) #11, #60, and #73 revealed the staff interviewed were knowledgeable of the facility fall policy, fall expectations and the fall intervention listing binder. Although the Immediate Jeopardy was removed on [DATE], the deficiency remains at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was in the process of implementing their corrective action including all staff education, audits and interdisciplinary team follow up. Findings Include: Review of Resident #46's closed medical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was admitted to the facility from an acute care hospital with a history of falls and inability to ambulate with recommendations for occupational therapy (OT) due to functional mobility, dressing and transfer decline. The resident was also noted to have deficits in strength, balance and coordination affecting his functional mobility and transfer ability requiring physical therapy (PT) at the time of admission. Record review revealed the resident was cognitively impaired. Review of the admission physician's orders [REDACTED]. Review of the STNA task documentation revealed on [DATE] the resident was to use a wheeled walker with two staff and a gait belt during ambulation. This directive remained in place for the duration of the resident's stay at the facility. Review of the admission fall risk assessment, dated [DATE] revealed Resident #46 had a history of [REDACTED]. The assessment revealed the resident was at moderate risk for falls. Review of an immediate plan of care, dated [DATE] revealed Resident #46 required assistance from one staff person for toileting, ambulation and transfers. The resident used both a walker and a wheelchair for mobility. The care plan indicated Resident #46 was at risk for falls with interventions that included reduce clutter, provide proper lighting and ensure the call light was within place. Resident #46 wore glasses. The immediate plan of care did not address the resident's cognition or ability to use the call light. Review of the initial OT evaluation, dated [DATE] revealed Resident #46 had a decline affecting his functional transfers requiring OT intervention. The resident was noted to have a decline in functional mobility, dressing and transfers due to physical, cognitive and/or psychosocial skills which resulted in activity limitations and/or participation restrictions. Minimal to moderate modifications of tasks, including modified visual cues, were needed to enable the resident to complete the evaluation. There were concerns related to engaging in daily life activities including balance and communication. Functional cognition revealed the resident needed some help from another person to complete activities. Transfers from chair and/or bed to chair, and sit to stand tasks needed contact guard assist due to unsteadiness. The resident needed cuing and/or redirection for safety on two occasions during the evaluation and the resident needed minimal assistance of one person for dressing. Review of the PT evaluation, dated [DATE] revealed Resident #46 had limitations and participation restrictions with strength, balance and coordination affecting functional mobility, transfer ability and endurance. The resident had performance deficits in functional mobility, dressing and toilet transfers related to physical, cognitive or psychosocial skills including being a fall risk. Resident #46 required partial assistance of another person with ten percent visual cueing for safety for ambulation using a four wheeled walker which enabled him to ambulate 90 feet. Resident #46 also had a wheelchair for mobility. The resident needed minimal assistance of one person for toilet transfers and needed minimal to moderate assistance of one person for picking up objects. Resident #46's safety orientation was to person and place only. The therapy evaluation revealed Resident #46's safety was impaired by functional limitations as evidenced by need for assist with transfers, gait and bed mobility. Static standing balance was fair and he was able to maintain balance with occasional hand held support. The resident was at moderate fall risk (,[DATE]%) due to balance issues and having kyphosis (forward rounding of the back). The resident had minimal impairment (up to 25%) for coordination of the right and left extremities. Review of the admission Minimum Data Set (MDS) 3.0, dated [DATE] revealed a Brief Interview for Mental Status (BIMS) was not completed due to the resident not being understood. The MDS assessment indicated Resident #46 required extensive assistance from one person for bed mobility, transfers and toileting, was not steady when ambulating and had impairment on one side of the lower extremities. The resident was mobile with both a walker and a wheelchair. Review of the speech therapy initial evaluation, dated [DATE] for communication revealed the resident was having extreme difficulty communicating and following directions. The resident was confused, had profound impairment (with less than 10 percent comprehension) in auditory comprehension when answering yes/no questions. The resident had severe impairment requiring extensive cueing for following one step commands. Upon discharge from speech therapy ([DATE]) the staff were educated on compensatory communication strategies including use of a notebook, picture sheets, eye contact, limiting choices and repetition. Review of the signed (MONTH) 2019 monthly physician orders [REDACTED]. Further review of the treatment administration record (TAR) and the STNA tasks (each resident had their individual needs on tasks in the computer the STNAs were to sign as the task was completed) revealed there were no fall interventions documented as being completed for the resident. Record review revealed the resident sustained [REDACTED]. Review of the nurse's note, dated [DATE] revealed the STNA reported an area of discoloration to the resident ' s tailbone. Further review of the note revealed the resident informed the nurse he had a prior fall but was not able to give any details. The nurse observed bruising to the resident's tail bone, left hip, right shoulder blade and right lateral thigh. A raised toilet seat was initiated after the fall. Review of the nurse's note, dated [DATE] revealed the STNA found the resident sitting on the floor with two skin tears to the left hand and two to the left knee. Review of the fall investigation revealed the resident fell at 4:40 P.M. when getting up from the dining room table. The investigation was contradictory, one statement indicated the resident fell when he did not lock the wheels of the wheelchair and another statement indicated the resident did not lock the wheels of the walker. Record review revealed the resident's plan of care was updated on [DATE] for staff to anticipate the resident ' s needs, apply non-skid gripper socks when shoes were off and have therapy evaluate (which was already being done). The care plan interventions from the immediate care plan indicated the room be clutter free and provide adequate lighting as interventions. There were no interventions to ensure the wheels were locked of either the walker or the wheelchair. Review of the nurse's note, dated [DATE] revealed Resident #46 was guarded with his right lower quadrant and showed staff a bruise to his right lower quadrant. The resident pointed to the foot board of the bed and indicated he fell into it. Further review of the fall investigation revealed on [DATE] at 11:45 [NAME]M., the resident fell into the foot board and sustained bruising (there was no further description of the bruising). The resident indicated he was walking in the room but was not able to say why or what he was trying to do. The intervention was a noodle covering the foot board to pad and protect from further harm. The care plan was updated [DATE] to reflect the use of the covering. Review of the nurse's note, dated [DATE] revealed Resident #46 had skin tears to the left lower hand, to the left upper hand/forearm, to the left upper knee and to the lower knee all with drainage needing treatments related to a fall. There was no additional information available related to these injuries and no investigation was completed. Review of the nurse's note, dated [DATE] at 10:44 P.M., revealed the STNA called the nurse to Resident #46 ' s room. The nurse observed the resident laying on his right side on the floor beside his bed and above his head was a trash can. The STNA stated she witnessed the resident fall and the resident did hit his head on the trash can. The nurse asked the resident if he had any injuries and he pointed to his right hip. The resident was observed with a large bruise on the front of his groin and his hip. The resident was sent to the hospital for evaluation. Review of the hospital x-ray dated [DATE] revealed the resident sustained [REDACTED]. The resident returned to the facility on [DATE]. Record review revealed no new fall or safety interventions were put in place and no investigation of the fall was completed. Review of the nurse's note, dated [DATE] at 5:47 P.M., revealed the STNA called the nurse to the room. The note revealed Resident #46 attempted to take himself to the restroom and fell to his knees, caught himself with the grab bar and lowered himself to his knees. Further review of the fall investigation indicated the fall occurred at 5:00 P.M. but did not include evidence the facility attempted to determine the root cause or if any prior interventions were in place at the time of the fall. No new interventions were implemented following the incident. Review of the [DATE] nurse's note revealed the resident was observed on his hands and knees in front of his recliner chair. The recliner chair was in the highest position and the resident had a skin tear to the left elbow. Further review of the fall investigation revealed the fall occurred at 1:15 P.M. and the resident was not able to provide any information related to the fall. There was no evidence any prior fall interventions were in place at the time of the fall. Following the incident, a Dycem (non-skid mat) was to placed to the seat of the recliner chair. Review of the nurse's note, dated [DATE] revealed the resident was found lying on the floor on his left side with no visible injuries. Further review of the fall investigation revealed the fall occurred at 5:30 [NAME]M. Resident #46 was not able to provide any information related to the fall due to his confusion. An intervention for the resident's bed to be in the lowest position was added to the care plan on [DATE]. Review of the nurse's note, dated [DATE] reveled the nurse was called to the room by the STNA who reported the resident was on the floor. Resident #46 was observed to be in the doorway of the room on his knees with his arms resting on the wheelchair seat. The STNA reported he had been in his recliner the last time he was seen (by staff). The resident did have a skin tear to his right lateral knee requiring treatment. Further review of the fall investigation revealed the fall occurred at 7:45 P.M. There was no evidence the Dycem was in place as planned at the time of the fall. The investigation revealed a sign was placed in the room reminding the resident not to get up by himself despite his confusion. However, this was not added to the care plan until [DATE]. Review of the signed (MONTH) 2019 monthly physician's orders [REDACTED]. Further review of the TAR and the STNA tasks revealed none of the care planned fall interventions were documented as being in place or monitored. Review of the nurse's note, dated [DATE] at 4:00 [NAME]M. revealed the nurse was called to the room by the STNA who reported the resident had a skin tear to his right elbow and there was blood on the wheelchair. The resident was not able to say what happened or how he obtained the skin tear. The STNA stated the last time she observed the resident he was in bed. There was no investigation of the injuries completed in an attempt to determine the root cause and no interventions were put into place for what appeared to have been a fall for the resident. Review of the nurse's note dated [DATE] at 1:33 P.M., revealed the nurse was called to Resident #46's room by an STN[NAME] The resident was observed sleeping on the floor next to the bed with a pillow and blanket with his eyes closed. Further review of a fall investigation revealed at 7:45 [NAME]M. the resident was found sleeping on the floor. The resident was alert and oriented times two. Following the incident, a new intervention was initiated to keep the resident in high traffic areas. A defined perimeter mattress (DPM) was implemented. However, the use of the DPM was not noted on the care plan until [DATE]. Review of the physician's progress note, dated [DATE] revealed the resident had a history of [REDACTED]. There was no other information related to the resident's falls and/or safety needs or fall risk interventions. Review of the nurse's note, dated [DATE] revealed a note see the fall assessment. However, there was no fall assessment completed on this date. There was no further nurse's note in the medical record related to a fall occurring on this date. However, review of a fall investigation revealed on [DATE] at 10:39 [NAME]M., Resident #46 sustained a fall when attempting to transfer himself to the recliner from the wheelchair. The initial intervention was to remind the resident to use the call light (which had been implemented on admission on the immediate care plan). Staff also placed bright tape to the foot rest of the recliner on [DATE]. Review of a fall investigation revealed Resident #46 sustained a fall on [DATE] at 9:00 P.M. The nurse entered the resident's room with his medications and the resident was sitting in his wheelchair with skin tears and blood running down both legs. The resident also had skin tears to the right upper back. The resident was not able to answer any questions. The resident was reminded to use his call light when needing help and this message was written on the resident's dry erase board. The investigation also revealed to keep the resident in high traffic areas. Review of the nurse's note, dated [DATE] at 5:01 [NAME]M., revealed Resident #46 tipped his wheelchair over backwards in the hallway and struck the back of his head on the wall and wooden banister. There was a large abrasion noted to the back of his head and the resident complained of head and neck pain and wanted to be sent to the hospital for evaluation. The resident returned to the facility with no new orders. Anti-tippers to the rear of the wheelchair were added after the fall. The use of the anti-tippers were not added to the resident ' s plan of care until [DATE]. Review of the nurse's note, dated [DATE] at 1:10 P.M., revealed the nurse was called to Resident #46's room and upon arrival, the resident was sitting on the floor. The STNA witnessed the resident backing out of his room quickly into the hallway while in his wheelchair, running into another resident. This resulted in Resident #46's wheelchair flipping and the resident falling out of the wheelchair. Further review of the investigation revealed the resident ' s wheelchair flipped backwards. There was no evidence the rear anti-tippers were in place at the time of the fall. The investigation did not attempt to determine why the resident was in his wheelchair alone in his room and not in high traffic areas or how the resident got into his wheelchair. The investigation did not specify if previous planned interventions were in place prior to the fall. Following the incident, the resident was educated to wheel frontwards while in the wheelchair. Review of a PT discharge summary, dated [DATE] revealed therapy goals were not met. Resident #46 continued to need assistance from one person for transfers and ambulation. The summary revealed the goals were not met due to the resident's limited cognition and [MEDICAL CONDITION]. The resident was referred to a restorative nursing program. Review of the signed (MONTH) 2019 monthly physician's orders [REDACTED]. Further review of the TAR and the STNA task documentation revealed no evidence the care planned fall interventions were being monitored to ensure they were in place. The resident's OT services were extended for neuromuscular re-education and gait training. Review of a therapy referral for restorative services, dated [DATE] revealed recommendations for restorative services for transfers on and off the toilet, in and out of bed and in and out of the chair with one person assistance. Review of the STNA task documentation revealed no evidence the restorative nursing program was implemented for the resident. Record review revealed on [DATE] a change in physician services occurred due to family request. Review of the signed clinical nurse practitioner progress note, for the new physician, dated [DATE] revealed the resident was up in the wheelchair, was alert and oriented times two with slurred speech from a prior stroke. The plan was to monitor the resident for neurological deficits. There was no mention of the resident having any falls including the fall with a fracture or safety needs. Review of a nurse's note, dated [DATE] revealed the STNA called the nurse to Resident #46's room. The resident was observed face down on the floor with his head and body under the bed and his body positioned at an angle. The resident was not able to respond to any questions due to [MEDICAL CONDITION]. There were two raised areas noted to the mid spine area and both were surrounded by purplish blue bruising. The resident also had bruising to the left rib areas, a skin tear to the top of the left outer knee, abrasion to the top of left great toe and a skin tear to the left elbow with active bleeding. The resident was groaning. Emergency Medical Services (EMS) was called and the resident was sent to the emergency department of the local hospital. The resident returned to the facility with a [DIAGNOSES REDACTED]. Further review of the fall investigation revealed the resident fell at 10:30 [NAME]M. At the time of the fall he was barefoot and was not wearing his glasses. There was no additional information documented regarding the fall including a root cause analysis. Following the fall, staff were to complete a side rail assessment, an initial bowel and bladder tracker and provide aromatherapy at night. Review of the OT discharge summary, dated [DATE] revealed the resident needed one person assistance with transfers to and from the wheelchair and recliner. The summary revealed Resident #46 did not meet his transfer goal of being independent due to balance and lack of safety awareness concerns. Staff were educated on balance precautions. The resident was occasionally able to respond to needs and occasionally able to follow direction and/or respond appropriately through gestures. The summary revealed OT discussed with staff the need for supervision during transfers. Record review revealed on [DATE] an order was obtained for a wanderguard (an alert bracelet that alarms if a person tries to leave an area unsupervised) due to the resident's impaired cognition. Review of the nurse's note, dated [DATE] revealed the nurse was called to Resident #46's room by the housekeeper. The resident was observed on his knees on the floor. The housekeeper revealed the resident was trying to transfer himself to the chair and did not make it. Review of the fall investigation revealed the fall occurred at 10:00 [NAME]M. There was no evidence any fall safety interventions were in place at the time of the fall. The investigation did not contain a root cause analysis and did not address why the resident was not in a high traffic area as previously planned. No new fall interventions were implemented following this fall. Review of the [DATE] physician progress notes [REDACTED]. Review of the nurse's note, dated [DATE] at 6:45 P.M. and authored by RN #16 revealed the nurse was called to Resident #46's room. The note indicated upon arrival to the room, the resident was observed standing naked, walking away from the doorway with copious amounts of blood noted to the floor surrounding the resident. The resident had facial injuries with excessive amounts of blood on his head, face and chest. Pressure was applied to a large laceration above the resident's right eye and the resident was assisted to a seated position on his bed. The nurse was not able to assess the resident's facial wounds because of the need to keep continuous pressure to control active bleeding from his laceration and his nose. EMS was called and the resident was transported to the hospital. The resident left the facility at 7:15 P.M. and did not return. Review of a fall investigation, dated [DATE] revealed Resident #46 was found standing in his doorway holding onto his wheelchair bloody from head to toe at 6:45 P.M. when an STNA was walking down the hall assisting another resident. The STNA paged the nurse to the resident's room. Upon entering the resident's room, the nurse observed large puddles of blood on the carpet on the right side of bed (the side closest to the window). Blood spats were found throughout the entire traffic areas of the carpet. Blood was found on the toilet and the sink and blood spots were observed throughout the bathroom floor. The investigation revealed it appeared Resident #46 either fell head first when getting out of bed or fell head first on the right side of the bed while ambulating, then got himself up and ambulated to the bathroom and then towards the doorway. (The investigation did not fully determine how the resident fell as the fall was unwitnessed). The water was running in the bathroom sink but there was no water on the floor. The investigation revealed the resident had last been seen at the nurse's station at 6:30 P.M. when the nurse changed the resident's dressing. The nurse then walked by the resident as he propelled himself back to his room and was seen messing with items on his bed. The resident was not kept in a high traffic area and there was no evidence of any other fall/safety interventions being in place at the time of the fall. The resident was in his bare feet. Review of the EMS run sheet, dated [DATE] at 7:06 P.M., revealed when EMS personnel arrived to the facility, they found Resident #46 sitting on the bed surrounded by staff. Two staff members were holding pressure to the resident's face. There was a substantial amount of blood found on the floor, bed and in the bathroom. The resident had a one inch laceration above the right eye with a large goose egg and an abrasion on the top of his head. The resident was bleeding from both nostrils with blood clots, he was bleeding from the lip and mouth and had abrasions on the left shoulder and both knees. The bleeding from all locations was uncontrolled. The resident's right eye was purple and swollen shut. The resident's airway needed suctioned on the way to the hospital because of blood in his mouth and pressure was applied to the resident's wounds for the duration of the transport to the hospital. Review of the hospital emergency department note, dated [DATE] revealed Resident #46 had an unwitnessed fall and was found face first on the ground. The resident's right eye above the eyebrow/forehead had a deep skin tear with some lateral bleeding showing tremendous swelling around the orbit. Abrasions were observed to both knees, the left thumb had a skin tear, and the left shoulder had an abrasion and hematoma. The resident required six sutures to the right forehead/scalp laceration to control the bleeding. The resident was assessed to have multiple complex facial fractures, a right frontal skull fracture with scalp hematoma, multiple neck fractures and intracranial bleeding. (TRUNCATED)

Based on observation, medical record review, review of incidents and fall investigations, policy review and interview, the facility failed to ensure the environment was free of accident hazards, falls were thoroughly investigated and interventions were implemented to prevent falls. This affected three (Resident #51, #69 and #77) of five residents reviewed for accidents. Harm resulted to Resident #51 when fall interventions were not implemented resulting in multiple falls between October 2016 and July 2017 with injuries including abrasions, lacerations and a fractured patella (kneecap). The resident was at high risk for a fall, and the room was to be free of clutter. Staff positioned a bedside commode (BSC) next to the resident's bed. On 07/10/17, the resident fell trying to transfer herself to the BSC resulting in a laceration of the forehead requiring nine sutures, and a non-displaced fracture of the left patella. Findings include: 1. Resident #51 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the care plan for Activities of Daily Living (ADL) needs dated 02/17/16 revealed the resident's cognition was impaired and they required assistance for completion of all ADL. Interventions included to reduce clutter in the room. Review of the facility policy and procedure for Falls revised 07/20/16 revealed residents with falls or potential for falls were to be monitored and assessed. Based on the fall assessment, the interdisciplinary team was to develop interventions based upon the resident risk factors, individual needs and implement a fall risk care plan. Residents with one or more documented falls will be assessed and applicable interventions were to be implemented in accordance with the assessment. Appropriate interventions were to be documented on the plan of care. When a fall occurred an incident report was to be completed, the root cause of the fall was to be determined, immediate fall interventions implemented, the incident documented in the medical record, and the fall nurse was to communicate fall interventions to the staff and revise the plan of care. Review of Resident #51's Fall Risk assessment dated [DATE] revealed the resident was a high fall risk. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident was cognitively intact for daily decision-making, required limited assistance of one staff with transfers and toilet use, and was not steady completing surface-to-surface transfers without staff assistance. Review of Resident #51's Nurse Progress Notes and Fall Investigations revealed on 10/30/16, Resident #51 was found lying on the floor next to her bed after getting up to use the bathroom. The fall intervention was to encourage the use of her call light. The fall investigation did not include environmental factors or information regarding an abrasion of the left knee measuring 6.0 centimeters (cm) by 0.5 cm. On 12/17/16, Resident #51 was found on the floor after she slid off the bed. She stated she was getting up to go to the bathroom. The fall investigation did not include environmental factors or if the resident was wearing any footwear. The fall intervention was to remind the resident to call for assistance. On 03/18/17, Resident #51 had two falls. At 12:00 A.M., the resident was found lying on her back on the floor beside her bed with no socks or footwear. The resident stated she tried to get up and slid off her bed. Licensed Practical Nurse (LPN) #15 assisted her back to bed without taking the resident to the bathroom. The fall intervention included to increase the resident's awareness to use the call light, wear non-skid footwear and frequently toilet the resident. At 12:15 P.M., the resident was found laying on the floor with a laceration above her eyebrow. Interventions included to encourage the importance of call light use and a bladder program to toilet before meals, at bedtime and upon rising. There was no evidence the program was implemented. On 03/19/17 at 1:30 A.M., Resident #51 slid out of bed onto the floor. The resident was wearing non-skid socks, had a urinary tract infection and had been toileted 15 minutes prior to the fall. The fall interventions included education on call light use, a wide mattress with bolsters to the bed and the bladder program was changed to toilet in advance of need. There was no evidence the program was implemented. Review of the quarterly MDS assessment dated [DATE] revealed the resident was moderately impaired for daily decision-making and required extensive assist of two for transfers and toilet use. Review of the care plan: Risk for Falls/Injury related to impaired bed mobility and history of falls revised 04/10/17 revealed interventions including taking the resident to the bathroom before each meal and maintain room pathways free of clutter with adequate lighting. Fall investigation dated 07/10/17 at 10:30 P.M. revealed Resident #51 was observed trying to stand, fell on her right side and was bleeding from her forehead. The resident complained of a headache and bilateral knee pain. The resident stated she got out of bed to use the bathroom, indicating the bedside commode (BSC), fell down on her knees and hit her head. The fall intervention implemented was to remove the bedside commode from the room. The investigation was not thorough and did not indicate the resident required emergency treatment, did not indicate why there was a BSC in the resident's room, what interventions were in place at the time of the fall or what caused the laceration. Review of the Nurse Notes dated 07/10/17 revealed the resident's son called and told the facility the resident had a broken knee cap and a laceration to the left side of her forehead with eight to nine sutures. Review of the hospital History and Physical dated 07/10/17 revealed Resident #51 presented to the emergency room with a head injury requiring sutures and a non-displaced patellar fracture secondary to repeated mechanical falls. The resident had fallen after ambulating from the BSC, fell to her knees then fell forward striking her head. The resident had a history of [REDACTED]. Review of the monthly Physician Orders dated July 2017 revealed no fall interventions including a BSC were ordered for Resident #51. Review of the record revealed no evidence therapy had assessed the resident for the use of a BSC related to safety and maintaining an uncluttered environment. There was no evidence of a nursing assessment that the resident was safe to use a BSC. Review of the Bladder Program documentation dated March 2017 through August 2017 revealed Resident #51 was to be assisted with toileting after meals and at bedtime. The bladder program was documented as being completed on 03/18/17 at 6:59 A.M., and on 07/10/17 at 1:06 A.M. and 11:59 P.M Review of the record revealed no other evidence the bladder program was implemented to prevent falls. Review of the State tested Nurse Aide (STNA) Bedside Kardex report dated 08/17/17 revealed interventions including maintain pathways and room free of clutter and adequate lighting, call light within reach, remove BSC, two staff assist with transfers, and complete bladder program after meals and at bedtime. On 08/17/17 at 1:53 P.M., interview with STNA #68 revealed Resident #51 required a sit-to-stand lift with two staff for transfers and all fall interventions would be indicated on the electronic STNA Kardex. On 08/17/17 at 1:55 P.M., observation revealed Resident #51 was lying in bed and the bed was in a high position approximately waist high. STNA #68 verified the resident was at risk for falls, the bed was in high position and the bed should be in the lowest position when the resident was in the bed. Review of the Physician Orders dated July and August 2017 revealed no fall interventions were ordered. On 08/17/17 between 2:09 P.M. and 2:52 P.M., interview with LPN #43 verified Resident#51's fall investigations were not thorough or accurate and a bladder program was developed in December 2016 to prevent falls. LPN #43 verified there was no evidence the bladder program was implemented except for three to four times between December 2016 and August 2017 and the resident had four additional falls trying to go to the bathroom. LPN #43 stated it was unknown when and by whom the BSC was put in the resident's room because it was not recommended by therapy. On 08/1717 at 3:44 P.M. interview with LPN #43 revealed routine fall interventions were not always documented on the treatment administration record but would be documented on the STNA Kardex. LPN #43 verified there was no evidence the bladder program was completed or evaluated to be effective. LPN #43 stated it was probably put in the room because staff was having trouble getting her to the bathroom. However, having the BSC at the bedside consequently contributed to the fall causing a laceration and fractured patella. On 08/17/17 at 4:29 P.M. and 4:36 P.M., LPN #43 verified fall investigations were not thorough, new interventions including bladder programs were not implemented as written, interventions such as non-skid socks had been discontinued and it was unknown what interventions were in place at the time of the falls because they were not recorded on the investigations. Resident #51 should not have had a BSC in her room on related to her cognition and previous attempts to get out of bed to go the bathroom. 2. Review of Resident #69's medical record revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. A quarterly fall risk assessment dated [DATE] indicated Resident #69 was at moderate risk for falls. Care planned interventions included keeping the beside table within reach when in bed, non-skid strips on the floor next to the bed; not to leave Resident #69 unattended in the dining room, keeping the call light in the resident's reach, maintaining his room and pathways free of clutter and provide adequate lighting. Review of Resident #69's falls revealed the following concerns: a. A nursing progress note dated 07/26/16 at 8:26 P.M. revealed Resident #69 was propelling himself into the building when he slid out of the wheelchair. No injuries were sustained. A nursing progress note dated 07/27/16 at 1:42 P.M. revealed the interdisciplinary team (IDT) reviewed the fall. While Resident #69 was attempting to wheel himself through the front entrance, his wheel stuck on the door, his cushion slid forward and he was observed sitting on the ground. The IDT implemented an intervention to place dycem (a non-slip pad) on his wheelchair seat and Resident #69 was encouraged to call for assistance when exiting and entering the building. A nursing progress note dated 08/25/16 at 1:00 P.M. indicated Resident #69 fell in the assisted living hallway attempting to transfer and landed on his buttocks. No injury was sustained. A nursing progress note dated 02/18/17 at 3:53 P.M. indicated Resident #69 was self-propelling on the unit and went outside of the assisted living door to sit outside. Resident #69 slid out of his wheelchair. The note indicated Resident #69 was educated on maintaining safety when outside, to check for obstacles and uneven pavement. A nursing note dated 05/08/17 at 7:00 A.M. indicated Resident #69 was observed sitting on his buttocks on the floor in front of his wheelchair. Resident #69 stated he scooted too close to the edge of the chair and slid off. On 08/16/17 at 9:01 A.M., LPN #43 was interviewed and stated Resident #69 used to transfer from his wheelchair to the couch in the assisted living. LPN #43 revealed the fall investigation for the fall on 07/26/16 did not indicate if the dycem was in place. On 08/16/17 at 9:13 A.M., LPN #43 verified the fall investigation did not reveal if the dycem or other fall interventions were being implemented at the time of the fall which occurred on 02/18/17. On 08/16/17 at 9:25 A.M., LPN #43 verified Resident #69 continued to have an intervention for dycem to his wheelchair at the time of the fall on 05/08/17 but the fall investigation did not specify if the non-skid material was in place. b. A quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #69 had moderate cognitive impairment and required supervision with transfers and toilet use. Resident #69's balance was assessed as unsteady with staff assistance needed to stabilize moving from a seated to standing position, moving on and off the toilet, and during surface to surface transfers. A nursing note dated 10/17/16 at 7:26 P.M. indicated Resident #69 was observed on his knees facing his wheelchair in the bathroom doorway of his room. One side of the wheelchair was locked. The other side of the wheelchair was not locked. Resident #69 stated he was trying to sit in his wheelchair and fell . A new intervention was added to the care plan 10/17/16 to encourage Resident #69 to make sure both wheels on the wheelchair were locked before transfers. A nursing note dated 11/22/16 at 7:10 P.M. revealed a nursing assistant observed Resident #69 on the floor. Resident #69 reported he was transferring from the wheelchair to the bed and forgot to lock the brakes and the chair rolled. An annual MDS dated [DATE] indicated Resident #69 had moderate cognitive impairment, required limited assistance with toilet use, and required transfer help with bathing. A nursing progress note dated 02/18/17 at 3:53 P.M. indicated Resident #69 was self-propelling on the unit and went outside of the assisted living door to sit outside. Resident #69 slid out of his wheelchair. The note indicated Resident #69 was educated on maintaining safety when outside, to check for obstacles and uneven pavement. A nursing note dated 02/28/17 at 9:30 A.M. revealed Resident #69 was trying to use the restroom and slipped, having to lower himself to the floor. Review of a fall investigation dated 02/28/17 indicated the immediate approach to ensure Resident #69's safety was to re-educate him on the importance of locking the wheelchair and using grab bars. On 03/01/17, an intervention was added for non-skid strips to the floor in front of the toilet (later discontinued 06/20/17). On 08/16/17 at 9:07 A.M., LPN #43 agreed residents with moderate cognitive impairment were less likely to retain information when education was used as a fall intervention. On 08/16/17 at 9:13 A.M., LPN #43 verified although Resident #69 was moderately cognitively impaired, the only intervention implemented after the fall on 02/18/17 was educating him. c. A nursing progress note dated 10/29/16 at 6:21 A.M. indicated Resident #69's wife reported Resident #69 slid off his bed onto the floor. Resident #69 reported he missed the chair. On 10/31/16, an intervention was added to the care plan to apply non-skid/gripper socks when Resident #69's shoes were off. A nursing note dated 06/07/17 at 2:30 A.M. indicated Resident #69 was observed sitting on his buttocks on the floor in the doorway of his bathroom. Resident #69 was wearing regular socks. During observations of Resident #69 on 08/16/17 at 7:50 A.M., LPN #43 verified Resident #69's feet were bare and his interventions for non-skid footwear were not implemented. On 08/16/17 at 9:30 A.M., LPN #43 verified Resident #69 was not wearing non-skid socks during the fall on 06/07/17. On 08/16/17 at 10:42 P.M., Resident #69 was observed lying in bed with his eyes closed. Resident #69's feet were uncovered and he was not wearing non-skid socks. On 08/16/17 at 11:04 P.M., STNA #56 was interviewed and was unaware of Resident #69's fall prevention interventions, including the use of gripper socks. d. A nursing note dated 03/16/17 at 9:55 A.M. revealed Resident #69 was observed sitting on the floor. Resident #69 reported his bed moved when he was trying to get up for breakfast. No injuries were noted. The note indicated new wheels for the bed were being obtained. On 08/16/17 at 9:16 A.M., LPN #43 and the Director of Nursing (DON) reported their investigation showed the locking mechanisms on the bed did not function properly and were replaced the same day. e. A late entry nursing note dated 06/09/17 at 1:26 P.M. indicated Resident #69 was observed sitting on his buttocks between his bed and wheelchair. Resident #69 stated he was attempting to get into his wheelchair when it rolled. Resident #69 stated he had locked the wheelchair but it moved. The brakes were in the locked position. A nursing note dated 06/09/17 at 9:40 A.M. indicated IDT reviewed the fall from 06/09/17 and the wheelchair brakes did not function properly. f. A nursing progress note dated 06/14/17 at 3:45 P.M. indicated Resident #69 did not call for assistance when transferring off the commode and was observed laying on the floor. Resident #69 sustained a 7.5 centimeters (cm) x 2.5 cm abrasion on the right side of his back. On 08/16/17 at 9:40 A.M., LPN #43 stated after the fall on 06/14/17 a new intervention was implemented to increase staff assistance with toileting. LPN #43 verified fall investigations did not indicate if previous fall interventions were in place. When asked what was meant by increased staff assistance with toileting, the DON (who was present during review of the falls) stated staff were to be more observant of Resident #69 but verified the intervention was vague and not measurable or clear. g. A nursing note dated 07/27/17 at 9:30 P.M. indicated Resident #69 was observed on the floor with his head resting on the bottom frame of the over bed table. Resident #69 sustained a 1 cm x 1 cm laceration to his right ear. On 08/16/17 at 9:53 A.M., LPN #43 verified fall investigations did not indicate if Resident #69's care plan interventions were being implemented at the time his falls occurred. LPN #43 stated prior to the fall on 07/27/17 Resident #69 was in his bed and he fell trying to go to the bathroom. LPN #43 verified the investigation was incomplete as she was unable to identify if Resident #69's wheelchair was near the bed or if he was attempting to walk into the bathroom. LPN #43 verified the more thorough an investigation, the more likely it was to implement appropriate interventions. h. Review of the facility's Falls Policy and Procedures , revised 07/20/16, revealed when a fall occurred, the licensed nurse would assess the resident's condition, determine the root cause of the fall, complete an incident report, complete the falls investigation including witness statements, implement immediate fall interventions until the falls committee could meet and review interventions for appropriateness, refer the resident to the therapy department for screening, document incidents in the medical record, notify the physician and responsible party, and notify the falls committee. The falls committee was to review for appropriate interventions. The falls nurse was required to communicate falls interventions to staff and revise the plan of care as indicated. The resident was to be added to the active falls program. The falls nurse was responsible for the system of fall prevention and tracking. Falls were required to be reviewed weekly in programs meeting. Residents with one or more documented falls would be on the Active Falls Program and a progress note made weekly and as needed by the restorative nurse/designee in the resident's file located in Point Click Care. If the resident was free from falls for three months, the resident would move to the Falls Maintenance Program where the resident would be monitored an additional three months. A monthly falls note would be recorded in the resident's file located in point click care. If a resident had been free from falls during the three months in the falls maintenance program, then the resident would be discontinued from the falls program with the current interventions. The resident would then be reviewed on a quarterly basis and as needed based upon the plan of care schedule. On 08/16/17 at 5:45 P.M., LPN #43 verified weekly and monthly notes were not documented in accordance with the facility's policy. 3. Review of Resident #77's medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the physician orders included a PVC low bed, a floor mat next to the left side of the bed, and front anti-tippers to the wheel chair. Review of the MDS 3.0 dated 06/07/17 revealed the resident had severe cognitive impairment and required extensive assistance of two staff members with bed mobility, transfers, walking in her room and corridor and toilet use. The resident required extensive assistance of one staff member with dressing, eating and personal hygiene. Resident #77 was always incontinent of bowel and bladder. Review of the fall risk assessment dated [DATE] revealed the resident was at high risk for falls. Review of the falls care plan, initiated on 10/19/16 and revised 01/30/17, revealed he was at risk for falls/injury related to impaired mobility, muscle weakness, history of CVA with [DIAGNOSES REDACTED] and a history of falls. Interventions included encourage to lay down after the evening meal, front anti-tippers to the wheel chair, mat next to left side of bed, offer to lay down after breakfast if appears sleepy, PVC low bed, restorative to ambulate if appears restless after breakfast, call light within resident's reach. Review of the Treatment Administration Records (TARS) for June and July 2017 revealed no evidence fall interventions were in place. Review of fall investigations dated 10/21/16, 10/22/16 (two falls) 01/03/17, 01/06/17, 01/11/17, 01/13/17, 03/18/17, 03/28/17, 04/05/17, 04/26/17 and 07//19/17 revealed lack of thorough investigation related to whether previous fall interventions were in place at the time of the fall, if environmental risks were a factor or what the resident was doing when last seen by the staff. Review of the fall investigation dated 01/06/17 at 6:30 A.M. revealed the resident slid out of her bed to the floor. The resident's bed alarm was re-adjusted but the investigation did not reflect why the alarm was re-adjusted or if the alarm sounded. No new intervention was implemented. Review of the fall investigation dated 08/06/17 at 6:15 A.M. revealed the resident was found lying on her back in her room after a fall from her bed. All fall interventions were in place however, no new fall intervention was implemented. Review of the falls policy and procedure dated 07/05 and revised 07/20/16 revealed when a fall occurs an immediate intervention will be implemented until the falls committee can meet and review the interventions for appropriateness. On 08/17/17 at 9:25 A.M. LPN #43 verified the falls were not thoroughly investigated to determine all causative factors and new interventions were not implemented after falls on 01/06/17 and 08/06/17. LPN #43 also verified there was no evidence fall interventions were being implemented per the TAR. This deficiency is an example of continued noncompliance from the complaint survey completed 08/07/17.

Based on medical record review, call light response log review, policy review, and interview, the facility failed to manage and timely medicate a resident for pain. This affected one (Resident #50) of three residents reviewed for pain. Harm resulted when Resident #50 activated her call light at 4:13 P.M., staff did not respond until 4:45 P.M. and the resident rated a pain level of eight out of 10. The facility census was 49. Findings include: Closed medical record review revealed Resident #50 was admitted on [DATE] with [DIAGNOSES REDACTED]. The resident was discharged on [DATE] to another facility. Review of the admission Nursing assessment dated [DATE] revealed Resident #50 was receiving hospice care and experienced frequent, moderate pain. Review of the Call Light Response log for Resident #50's room dated 07/12/17 revealed the resident alarmed the call light pendant at 4:13 P.M. and staff did not respond to the call light until 4:45 P.M Review of the Individual Resident's Controlled Substance Record (Controlled Substance Record) dated 07/12/17 at 4:45 P.M. revealed the resident was administered [MEDICATION NAME] for pain. Review of the late entry Nurses Progress Note dated 07/12/17 at 4:58 P.M. revealed the resident's family called the Director of Nursing (DON) to the resident's room and stated the resident was in pain and needed pain medication. The resident was resting quietly in bed, no grimacing or non-verbal signs of pain. The DON re-positioned the resident in bed and asked her to rate her pain on a scale zero to 10. The daughter interrupted and stated the resident did not understand what a pain scale was. The resident then replied with a pain rated an 8. The DON administered [MEDICATION NAME] (narcotic pain medication) 20 milligrams as ordered. Review of the hospice Progress Note dated 07/12/17 revealed family stated the resident will not ask for pain medication. The facility nurse was asked to bring the resident pain mediation and 45 minutes later they were asked again. The resident rated her pain an 8 of 10 on a pain scale. On 08/06/17 at 4:57 P.M., interview with the Director of Nursing (DON) verified the resident's call light was not answered for over 30 minutes, the resident did not have any visible signs of pain but rated her pain an eight of 10, and the resident was administered [MEDICATION NAME] 20 mg as ordered. On 08/07/17 at 3:40 P.M., interview with the DON and Registered Nurse (RN) #5 stated there was no call light response policy; however, the facility standard was to answer call lights within 10 to 15 minutes. An emergency light was to be answered immediately. On 08/07/17 at 5:13 P.M., interview with RN #5 stated it was an expectation that pain was assessed both verbally and non-verbally and treated in a timely manner. RN #5 and the DON verified thirty minutes was not an acceptable timeframe for pain management. Review of the policy: Pain Management Program revised 06/12/17 revealed the goal was to identify, assess, manage and treat residents' pain. Each resident was to assessed every shift for pain and record pain level in the medical record. This deficiency substantiates Complaint Number OH 546.

Based on observation, medical record review, policy review and interview, the facility failed to ensure fall interventions were implemented. This affected one (Resident #18) of three residents sampled for hospice. The facility census was 49. Findings include: Medical record review revealed Resident #18 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the care plan: Fall Risk related to confusion revised 11/28/16 revealed the resident was to be wearing well-fitting footwear with non-slip soles and was not to be left unattended in the dining room. Review of the quarterly Minimum Data Set assessment dated [DATE] revealed the resident was severely impaired for daily decision-making. Review of the post Fall Risk assessment dated [DATE] revealed Resident #18 was at high risk for falls. On 08/06/17, observations revealed the following: At 8:00 A.M., Resident #18 was sitting in wheelchair against the wall outside the main dining room. The resident's red gripper socks were observed to be too large and falling off the resident's left foot. At 8:30 A.M., Resident #18's left gripper sock had slipped off exposing the back of her foot. The surveyor informed State tested Nurse Aide (STNA) #7 and the resident's gripper sock was repositioned. At 9:06 A.M., STNA #8 wheeled the resident into the dining room after taking her to the bathroom. STNA #8 placed the resident in front of the television and then left the dining room. There was no staff observed in the dining room. At 1:59 P.M., Resident #18's red gripper socks were loosely hanging on her feet with approximately three inches of the sock extending past her toes. On 08/06/17 at 2:15 P.M., interview with Licensed Practical Nurse #11 verified Resident #18 was at risk for falls and the gripper socks were loose and too large. On 08/06/17 at 4:32 P.M., interview with the Director of Nursing verified the resident was not to be left unattended in the dining room according to the resident's fall care plan. Review of the Falls policy and procedure revised 09/12/14 revealed interventions were based upon the assessment, risk factors, and individual needs, and a fall care plan was to be implemented. Applicable interventions were to be implemented according to the assessment. This deficiency is an incidental finding during Complaint Number OH 546.

Based on observation, medical record review, policy review, physician, medical director, resident and staff interviews, the facility failed to assess, monitor and implement ordered treatments for one of two residents reviewed for vascular ulcers resulting in actual harm as osteo[DIAGNOSES REDACTED] (bone infection) and [MEDICAL CONDITION]. This resulted in Immediate Jeopardy for one resident (Resident #7) of two residents with peripheral vascular ulcers. The facility census was 55. On 05/26/16 at 5:25 P.M., the Licensed Nursing Home Administrator, Director of Nursing (DON), Director of Operations, and Corporate Director of Nursing (CDON) #151 were notified Immediate Jeopardy began on 03/09/16 at 2:45 P.M. when Resident #7 was evaluated by Physician #100 for the treatment of [REDACTED]. On 04/20/16, Resident #7 returned to Physician #100's office for a follow-up appointment and the resident's right heel had necrotic (dead) tissue with a strong odor, obvious infection and gangrene (a bacterial infection that produces gas within tissues). Resident #7 was sent to the hospital and diagnosed with [REDACTED]. The Immediate Jeopardy was removed on 06/01/16 at 11:40 A.M. when the facility implemented the following corrective actions: · On 05/26/16, CDON #151 revised the facility's Wound and Skin Care policy to include weekly skin grids to be completed for all wounds regardless of care provided by other practitioners until the wounds were resolved. All residents were to have weekly skin assessments completed by the charge nurse. State tested nurse aides (STNAs) were to document skin areas on shower sheets and report all skin issues to the charge nurse who would follow the wound policy for assessment, notification and treatment. · On 05/26/16, CDON #151 educated Licensed Practical Nurse (LPN) #24 regarding the Skin and Wound Care policy revisions with additional focus on the requirement that weekly skin grids were to be completed for all wounds regardless of care provided by other practitioners until the wounds were resolved. LPN #24 was also educated on wound assessment practice, signs and symptoms of gangrene, wound monitoring and treatment. · On 05/26/16, CDON #151 educated two LPNs, two Registered Nurses (RN), and one STNA; LPN #67 educated two RNs, five LPNs and 10 STNAs on the Wound and Skin Care policy and gangrene. · On 05/26/16, a Shower Audit Tool, Treatment Audit Tool, Weekly Skin Grid Completion Audit and Weekly Skin Assessment Audit tool were developed. The facility initiated a quality assurance process with ongoing monitoring daily for two weeks, weekly for two weeks, monthly for three months and quarterly thereafter. · On 05/26/16, the DON, RN #13 and RN #74 began completing skin audits on all residents. In addition, audits of treatment orders, physician/responsible party notification, treatment initiation and implementation of care planned interventions was completed. · On 05/27/16, the DON educated two RNs and one LPN; and LPN #67 educated four LPNs and 11 STNAs on the Wound and Skin Care policy and gangrene. STNA #5, STNA #23, STNA #28, STNA #46, STNA #47 and LPN #38 received education by the DON via the phone on the Wound and Skin Care policy and gangrene. · On 05/29/16 between 6:55 A.M. and 8:54 A.M., interviews with STNA #5, STNA #23, STNA #33, STNA #71, STNA #39, LPN #38, LPN #40, LPN #65 and RN #20 verified they had received education from the DON or LPN #67 between 05/26/16 and 05/27/16 on wound assessments, implementing physician orders, gangrene and notification of changes. · On 05/30/16 between 12:45 P.M. and 1:07 P.M., interviews with STNA #15, STNA #18, STNA #37, STNA #54, STNA #60 and LPN #30 verified they had been in-serviced on wound assessments, shower sheet documentation, skin sheet documentation, implementing physician orders, gangrene and notification of changes. · On 05/30/16, the DON, RN #13 and RN #74 had completed accurate skin audits on Residents #7, #11, #14, #18 #23, #36, #42, #43, #44, #51, #52, #55, #59, #74, #75 and #99. · On 05/31/16, the DON responsibilities were revised to include weekly measurements for all wounds, ensuring new orders were implemented and subsequent appointments scheduled, reviewing phone/verbal orders for implementation and notification, ensuring shower and skin audits were completed and new areas addressed, ensuring treatments completed as ordered, completing random skin audits and providing nursing staff ongoing education regarding skin and wound care. · On 05/31/16 at 3:00 P.M., the DON was provided education regarding accuracy of skin assessments and vascular ulcers by Wound Certified Nurse Practitioner (CNP) #153. CNP #153 was to follow facility wounds weekly and as needed with the DON until wound care certification was obtained in July, 2016. · On 05/31/16 at 7:14 A.M., interview with STNA #27 verified she had been in-serviced on shower sheet documentation, gangrene and notification of changes. · On 06/01/16 at 11:36 A.M., the DON and LPN #24 were re-educated by CDON #151 regarding inspection of every area of skin from head to bottom of feet and physician notification of new skin areas due to skin impairments not identified on original skin audits. Although the Immediate Jeopardy was removed on 06/01/16 the facility remained out of compliance at Severity Level 2 (no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy) as all staff had not been in-serviced on skin and wound management, and the facility was in the process of implementing weekly audits to monitor for on-going compliance. The facility also failed to monitor Resident #29's vascular ulcer, identify or treat Resident #42's skin impairment and ensure a urinary catheter was inserted correctly for Resident #71. This affected three additional residents of 18 residents reviewed, Residents #29, #42 and #71. Findings include: 1. Medical record review revealed Resident #7 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the nursing progress notes dated 09/09/15 revealed the resident's right heel was mushy and slightly reddened. Review of the admission 5-day Minimum Data Set 3.0 (MDS) assessment dated [DATE] revealed Resident #7 was cognitively intact for daily decision-making and had no vascular ulcers. Review of the At risk for Skin Breakdown related to incontinence, history of skin breakdown and diabetes care plan initiated 01/19/16 revealed interventions included to complete treatments as ordered. Review of the care plans revealed there was no vascular care plan prior to 01/19/16. Review of the Wound Evaluation Flow Sheet dated 09/25/15 through 03/08/16 revealed weekly monitoring of Resident #7's right heel wound. On 03/08/16, Resident #7's right heel was documented as unstageable (wound bed not visible due to covering of dead or nonviable tissue) measuring 3.2 centimeters (cm) in length (l) by 1.4 cm in width (w) by 0.1 cm in depth (d) with 75-100% hard eschar (thick, leathery, devitalized tissue). Review of the Wound Evaluation Flow Sheets and Progress Notes dated 03/08/16 through 04/20/16 revealed no further assessment of the resident's right heel. Review of Physician #100's podiatry progress notes dated 03/09/16 revealed the resident was assessed to have a non-healing, posterior right heel vascular wound approximately 3.0 cm in diameter which was dry, dark and ischemic (restricted in blood supply); a distal-medial right hallux vascular wound with no measurements documented; and a right, lateral heel vascular wound measuring 1.5 cm in diameter. Physician #100 ordered to apply [MEDICATION NAME] spray (topical aerosol which stimulates the vascular bed of chronic wounds to help promote healing) to the right heel and hallux wounds daily and return for a follow-up appointment in three weeks. Review of the Treatment Administration Record (TAR) dated March 2016 revealed Resident #7's [MEDICATION NAME] treatment was circled as not completed. There was no documentation in the record as to why it was not completed between 03/10/16 and 03/16/16. Review of physician orders [REDACTED].#7's attending physician (Physician #101) ordered to irrigate the resident's right heel wound with sterile saline, pat dry, use [MEDICATION NAME] powder (topical nutrients that form a protective coating, and maintains a moist environment while controlling odor and drainage) and cover with a dressing daily. Review of the progress notes and TAR dated March 2016 revealed this treatment was not completed on 03/19/16, 03/20/16, 03/21/16, 03/22/16, 03/24/16, 03/28/16, 03/29/16 and 03/30/16. Review of Physician #100's progress note dated 03/30/16 revealed Physician #100 was not notified until the resident arrived at the appointment on 03/30/16 that [MEDICATION NAME] spray was not available to be used as ordered to treat Resident #7's heel and hallux wounds. The right hallux measured 1.5 cm diameter and the posterior right heel and lateral heel measurements remained unchanged. The distal right hallux wound and the posterior right heel wound both appeared gangrenous (a type of necrosis caused by a critically insufficient blood supply. This potentially life-threatening condition may occur after an injury or infection or in people suffering from any chronic health problem affecting blood circulation). Physician #100 made no changes in treatment and the resident was to follow-up in three weeks. Review of the TAR dated April 2016 revealed Resident #7's treatment to the posterior right heel was not completed on 04/06/16 or 04/18/16. The right hallux treatment ordered on [DATE] which included applying [MEDICATION NAME] daily was not completed on 03/06/16, 03/07/16 and 03/08/16. On 03/09/16, Physician #100 discontinued the treatment to apply [MEDICATION NAME] to the right hallux; however, the treatment was not discontinued and the treatment was completed without a physician order [REDACTED]. Review of the quarterly MDS assessment dated [DATE] revealed Resident #7 remained cognitively intact for daily decision-making and had no vascular ulcers. Review of Physician #100's progress note dated 04/20/16 revealed the resident's posterior right heel had a very strong odor emanating from the necrotic ulcer that measured 5.0 to 6.0 cm (w) by 8.0 cm (l) by 0.7 cm in (d). The base of the ulceration was completely necrotic, stringy and avascular appearing. The distal-medial first and second toes of the right foot were black. [DIAGNOSES REDACTED]. The progress note indicated the need for intravenous antibiotics and further treatment including debridement of the heel in the operating room. The distal right hallux wound and the posterior right heel wounds both appeared gangrenous. Physician #100 ordered the resident to be sent to the emergency room . Review of the Hospital Admission History and Physical dated 04/20/16 revealed the right heel was noted to be necrotic with a strong odor, obvious infection and gangrenous changes. The patient reported pain in the area and there was swelling to the right foot. The ulcer was infected with necrosis of the bone and osteo[DIAGNOSES REDACTED] of right foot. The right heel was open with black areas and white discoloration. A faint pedal pulse was obtained with Doppler (a device that uses reflected sound waves to evaluate blood as it flows through a blood vessel). Review of the Right Joint Lower Extremity Magnetic Resonance Imaging (nuclear magnetic resonance imaging used in radiology to image the anatomy and the physiological processes of the body in both health and disease) with-and-without contrast dated 04/20/16 revealed large soft tissue ulcer with loss of soft tissue, osteo[DIAGNOSES REDACTED] and severe, high-grade almost complete tear of the Achilles tendon. Review of the hospital Progress Notes dated 04/22/16 revealed no change in Resident #7's infected necrotic right heel ulcer with gangrene and osteo[DIAGNOSES REDACTED]. Patient and family agreed to below knee amputation but other options were discussed. On 05/25/16 at 8:58 A.M., observation revealed Resident #7 was lying in bed with a right [MEDICAL CONDITION] wrapped with an ace wrap. The resident had a wheelchair next to the bed. On 05/26/16 at 2:10 P.M. and 2:30 P.M., interviews with Licensed Practical Nurse (LPN) #24 verified the following. The facility stopped monitoring Resident #7's right lower extremity wounds after 03/08/16. [MEDICATION NAME] spray was not available to complete the treatment ordered on [DATE] and the treatment was not completed. Staff did not notify Physician #100 the [MEDICATION NAME] spray was not available and the treatment was not completed. Staff did not complete Physician #101's order to irrigate the right heel wound, use [MEDICATION NAME] powder and cover with a dressing daily as ordered. Staff did not document wound changes, did not notify the physician of the deterioration of Resident #7's right heel and hallux wounds and Resident #7 developed osteo[DIAGNOSES REDACTED] and gangrene requiring amputation of the right lower leg. On 05/26/16 at 5:00 P.M., interview with Resident #7 revealed he developed a sore on his right foot, it rotted and he had to have his leg amputated. The resident was observed sitting up in a wheelchair and the resident stated he did not have a prosthetic leg. On 05/27/16 between 9:56 A.M. and 10:11 A.M., phone interview with Physician #100 verified Resident #7 was referred to him for a non-healing chronic vascular wound, the resident was seen approximately every three weeks, he was unaware treatments were not being implemented as ordered, and the facility had not notified him of any changes; otherwise, it would be documented in his electronic system. Physician #100 stated it was his expectation for physician orders [REDACTED]. On 05/27/16 at 10:45 A.M., interview with Physician #101 revealed it was his expectation that physician orders [REDACTED]. It was also his expectation that the facility should monitor any wound regardless if the resident was being seen by the podiatrist or wound specialist service. Review of the Wound and Skin Care policy revised 08/25/15 included if an ulcer was present, the resident was to be measured and tracked weekly, treatments were to be initiated as ordered and the physician notified of any signs of infection. Review of the Notification of Condition Changes policy revised 11/09/15 revealed the nurse was to assess the resident for a change in condition, notify the physician immediately and implement all new physician orders [REDACTED]. 2. Review of Resident #71's closed medical record revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Resident #71's admission assessment revealed the use of an indwelling catheter. Resident #71 was able to respond to painful stimuli. On 12/21/15, an order was received to discontinue the urinary catheter. On 12/23/15, an order was received to insert an urinary catheter. A nursing note by Licensed Practical Nurse (LPN) #38 dated 12/23/15 at 10:44 P.M. indicated Resident #71 had a Foley (urinary) catheter inserted on day shift. As of 8:00 P.M., Resident #71 had no urine output in the catheter tubing or drainage bag. Resident #71's abdomen was distended and firm to the touch. The note indicated a LPN notified Resident #71's family who requested Resident #71 be sent to the hospital. At 4:50 A.M., the hospital staff notified the LPN Resident #71 was admitted for observation with leukocytosis (elevated white blood count), [MEDICAL CONDITION], and urethral injury. Review of a hospital history and physical (H&P) dated 12/24/15 indicated H&P information was obtained through Resident #71's granddaughter, review of his medical history, and information provided by the nursing facility. Resident #71 was sent to the emergency department after an unsuccessful attempt to replace a Foley catheter. The resident had not been eating or drinking well for a couple days. When it was noted he was not eating or drinking well, it was felt he was retaining urine so the facility attempted to place a Foley catheter. They were unable to get it all the way inserted but inflated the balloon anyway and traumatized his urethra. The report indicated at the time the facility inserted the catheter and inflated to balloon, hematuria was noted. When the emergency room staff inserted a new catheter, two liters of dark urine was drained. Resident #71 received [MEDICATION NAME] and [MEDICATION NAME] (antibiotics) in the emergency room . The physician documented the [MEDICATION NAME] would be continued due to urethral injury and potential for secondary infection. Resident #71 returned to the facility 12/25/15. On 05/26/16 at 6:25 A.M., LPN #38 was interviewed regarding Resident #71's catheterization on 12/23/15. LPN #38 stated the urinary catheter had been inserted on dayshift. LPN #38 stated he sent Resident #71 to the hospital due to no urinary output. On 05/26/16 at 10:43 A.M., Registered Nurse (RN) #20 was interviewed as she was Resident #71's assigned nurse on day shift on 12/23/15. RN #20 stated she recalled receiving the order to insert the catheter. However, due to inexperience with inserting a urinary catheter in a male, she requested assistance from LPN #44. RN #20 stated LPN #44 was unable to insert the urinary catheter while she was in the room. On 05/26/16 at 10:45 A.M., LPN #44 stated he could not recall Resident #71 and was unable to provide additional information. On 05/26/16 at 10:55 A.M., a request was made of LPN #24 for any information she had regarding the attempted catheterization of Resident #71 on 12/23/15. At 11:12 A.M., LPN #24 stated she was unable to find documentation. LPN #24 stated the nurse who inserted catheter no longer worked at the facility. Review of the facility's policy, Catheter Insertion - Female and Male Straight Catheter, revised 08/08/14, revealed when inserting a catheter, the catheter should be inserted until urine return was noted. Insert the catheter another centimeter, attach the syringe and fill the balloon. After detaching the syringe, gently pull on the catheter until resistance was felt. 3. A review of Resident #29's medical record revealed the resident was admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. A review of Resident #29's admission history and physical dated 12/18/15 revealed his chief complaint was a fall with [MEDICAL CONDITION] with a large intracranial bleed. His past medical history also included [MEDICAL CONDITION] (a bacterial skin infection). There was no indication of the resident having any vascular ulcers at the time of his admission. A review of Resident #29's wound evaluation flow sheet revealed he was admitted with pressure ulcers to the right and left buttocks that resolved on 01/11/16. There was no evidence of any additional skin issues including any vascular ulcers of the right foot being present at the time of his admission. A review of a dietary progress note dated 03/28/16 revealed the dietician was notified by the nurse on the unit that Resident #29 had a kind of a scab, not open on his toe. A review of the nurses' progress notes revealed there was no documentation by a nurse of a scabbed area being noted on Resident #29's toe. The only progress note that mentioned the scabbed area on the toe was from the dietician who indicated it was reported to her by a nurse. There was no documented evidence of the physician being notified of Resident #29 having a scabbed area to see if he wanted any treatments ordered. The next note entered in the progress notes was a note dated 04/10/16 when Resident #29 was sent to the emergency room to have his right great toe evaluated as requested by the family. The resident was admitted to the hospital with [REDACTED]. He remained hospitalized between 04/10/16 and 04/16/16 and returned to the facility on [DATE]. A review of Resident #29's readmission orders [REDACTED]. There was treatment ordered for the right great toe upon his return. Resident #29 was scheduled for an amputation of the right great toe on 04/25/16. His surgery dates had been canceled and rescheduled several times for various reasons including being too anticoagulated (delayed clotting time of blood from receiving anticoagulant medication) from the use of [MEDICATION NAME] despite orders being given to hold the medication several days pre-op. His latest scheduled date for surgery was 06/03/16. While in the facility and awaiting surgery he had been out of the facility several times for appointments with the podiatrist. He had also been seen by a vascular surgeon on 05/04/16. A visit note with the vascular surgeon dated 05/04/16 revealed a treatment had been ordered to apply [MEDICATION NAME] to Resident #29's right great toe daily. A visit note with the podiatrist dated 05/09/16 revealed it was the first time he had seen Resident #29 in his office. He was seen upon referral from the vascular surgeon. A dry sterile dressing was ordered to be applied twice daily. A review of Resident #29's medical record revealed there was no documented evidence of any ongoing weekly monitoring being completed of the right great toe as a wound evaluation flow sheet had not been completed. There was no documentation in the nurses' progress notes that showed evidence of any ongoing monitoring of the right great toe by the facility staff outside of what was being done by the podiatrist during the office visits. A wound evaluation flow sheet was not initiated until 05/26/16 for the area on the resident's right great toe after it was brought to the facility staff's attention that weekly monitoring was not being completed. Findings were verified by Licensed Practical Nurse (LPN) #24. On 05/27/16 at 3:45 P.M., an interview with LPN #24, who was the facility's wound nurse, revealed she was responsible for assessing wounds weekly. She denied that she had been assessing Resident #29's right great toe since he had returned on 04/17/16. She stated she did not feel she needed to monitor the right great toe as the resident was being followed by a podiatrist and the resident was scheduled to have surgery to have the toe removed. She indicated she did not initiate a wound evaluation flow sheet until 05/26/16. She stated she had not been made aware of Resident #29 having a scabbed area on his right great toe until he returned from the hospital on 04//17/16. She stated it was then that she realized the extent of the issue the resident was having with his right great toe. She reported the nurses on the floor provided the treatments to the area as ordered. She did not know she needed to evaluate the wound weekly to see how it was responding to the treatment ordered. On 05/31/16 at 10:48 A.M., an observation of Resident #29's right great toe revealed he had a large necrotic area that measured 4.6 centimeters (cm) x 7 cm. The depth of the wound could not be determined due to the area being necrotic and covered with eschar. The wound margin was defined and the peri-wound area was pink. The resident denied having any pain when the toe was handled. A review of the facility's notification of condition changes policy revised 11/9/15 revealed the nurse would contact the physician immediately when a resident had a perceived change in condition. An assessment would be made by the nurse prior to the phone call so the nurse was prepared to discuss the condition change. The nurse would also notify the resident's responsible party of a condition change. The nurse would then document the condition change and the physician contact information in the electronic medical record. On 05/31/16 at 11:15 A.M., an interview with Physician #101, who was Resident #29's attending physician, revealed he was not able to recall whether or not he was notified when the resident was noted to have a scabbed area on the right great toe around 03/28/16. He stated that was too long ago for him to recall. He stated if he had been notified it would have been documented in the nurses' progress notes. He stated if he had been informed about a scabbed area on the resident's toe he would not have given any treatment orders other than to monitor the area. On 05/31/16 at 1:35 P.M., an interview with the Director of Nursing (DON) confirmed there was no documented evidence of the physician being notified of the scabbed area on the resident's right great toe. She stated, since the nurse did not document it in the progress notes when the scabbed area was first identified, she was not sure if it originated on 03/28/16 as first mentioned in the dietary note or before that. She also confirmed there was no further documentation of an assessment of the right great toe being completed between 03/28/16 and 04/10/16 prior to the resident being transferred to the emergency room for an evaluation of the right great toe. She also denied there was documented evidence of the facility staff doing ongoing weekly monitoring of the right great toe between 04/17/16 and 05/26/16 which was after his return from hospital and when the weekly wound evaluation flow sheet was initiated. 4. On 05/25/16 at 7:00 A.M., Resident #42 was observed lying on her bed. Resident #42 stated her buttocks hurt. Review of Resident #42's medical record revealed [DIAGNOSES REDACTED]. A plan of care dated 02/26/16 indicated Resident #42 was at risk for impaired skin related to incontinence and assistance was needed with toileting and mobility. On 05/25/16 at 2:00 P.M., observations of Resident #42's buttocks with State tested Nursing Assistant (STNA) #60 revealed red discoloration midway down both buttocks. There was no evidence of a treatment. On 05/25/16 at 2:16 P.M., LPN #44 stated he was unaware of any skin breakdown on Resident #42. LPN #44 was informed of Resident #42's complaints of sore buttocks when sitting in her wheelchair and of the discoloration on her buttocks observed with STNA #60. On 05/25/16 at 2:43 P.M., LPN #44 stated he checked Resident #42's buttocks and did not identify any skin impairment Observations of Resident #42's buttocks were made with LPN #44 and STNA #23 and both acknowledged Resident #42 had impaired skin observed on both buttocks after the exact area was brought to their attention.

Based on observation, medical record review, policy review and interview, the facility failed to ensure pressure ulcers were comprehensively assessed (Resident #71), interventions were implemented and treatments were completed as ordered (Residents #7 and #93) resulting in the development of avoidable pressure ulcers. Harm resulted to Resident #93 when the resident's right heel unstageable pressure ulcer (wound bed not visible due to covering of dead or nonviable tissue) increased in size and the resident developed two avoidable facility acquired Stage II pressure ulcers (Partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed without slough). This affected three of four residents reviewed for pressure ulcers. Findings include: 1. Medical record review revealed Resident #93 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the admission Nursing Assessments dated 03/31/16 and 04/15/16 revealed the resident was at risk for pressure ulcer development. Review of the physician order [REDACTED]. Review of Resident #93's Wound Management Progress Note dated 04/18/16 revealed positioning and pressure reduction interventions included the resident was to be up for meals only and positioned side-to-side every two hours. Review of the 5-day Minimum Data Set 3.0 (MDS) assessment dated [DATE] revealed the resident was cognitively intact for daily decision-making, required extensive assist with bed mobility, was at risk for pressure ulcer development, and was admitted with three Stage II and three unstageable pressure ulcers. Review of the Wound Evaluation Flow Sheet revealed the following measurements regarding Resident #93's unstageable right heel pressure ulcer. 04/18/16 - 2.8 centimeters (cm) in length (l) by 2.2 cm in width (w). 05/02/16 - 2.8 cm in (l) by 2.4 cm in (w). 05/09/16 - 4.5 cm in (l) by 3.0 cm in (w). 05/16/16 - 5.0 cm in (l) by 5.0 cm in (w). 05/23/16 - 5.6 cm in (l) by 6.0 cm in (w). Review of the Wound Management Progress Notes dated 05/09/16, 05/16/16, and 05/24/16 revealed wound Certified Nurse Practitioner (CNP) #153 ordered Santyl (enzymatic [MEDICATION NAME] ointment that breaks down dead skin), Hydrogel (highly absorptive and maintains the wound in a moist state to promote healing) and a foam dressing daily for Resident #93's right heel pressure ulcer. Pressure relieving interventions included the resident was to be up for meals only, heels were to be floated or off-loaded with a pillow, and positioned side-to-side every two hours. Review of the Treatment Administration Record dated May 2016 revealed [MEDICATION NAME] was applied daily to the right heel and left open to air between 05/01/16 and 05/27/16. There was no evidence the order to treat with Santyl, Hydrogel and a foam dressing was completed daily as ordered until 05/29/16. Review of the Open Area on Bilateral Ischial Areas, Sacrum and Right Heel related to incontinence and decreased mobility care plan revised on 05/17/16 revealed treatments were to be completed as ordered, elevate heels in bed, encourage the resident to turn and reposition, and provide a low air loss mattress. There was no evidence the care plan was revised to reflect being up for meals only, position side-to-side every two hours and heels to be floated or off-loaded with pillow. Observation of Resident #93 on 05/25/16 at 12:20 P.M., revealed he was in a reclined geri-chair (specialized wheelchair) in the hallway. The resident was moved to the hallway after eating lunch. At 2:49 P.M., Resident #93 was lying in bed on his back with an air mattress set to firm. On 05/25/16 at 3:10 P.M., interview with LPN #24 verified the resident's air mattress should not be set at firm unless care was being provided. Observation of Resident #93 on 05/26/16 at 9:03 A.M., revealed the resident was lying in bed on his back with his feet elevated off the air mattress. At 9:05 A.M., Resident #93's geri-chair was observed in the room with a pressure relief cushion. The cushion was sunken in the middle with the bottom of the cushion extended out to the sides of the chair. Observation of Resident #93's pressure ulcer treatments on 05/26/16 between 9:13 A.M. and 9:30 A.M., revealed Licensed Practical Nurse (LPN) #40 applied [MEDICATION NAME] to the resident's right heel and left it open to air. LPN #40 verified the resident's right heel measured 7.5 cm in (l) by 6.3 cm in (w) and was black, necrotic (dead) from the posterior heel extending up and above the back of the ankle. LPN #40 verified the resident had an unstageable pressure ulcer to the dorsal right foot measuring 3.0 cm in (l) by 0.5 cm in (w) covered with brown eschar (thick, leathery dead devitalized tissue). LPN #40 stated the dorsal right foot pressure ulcer was due to pressure from a boot strap that had since been discontinued. LPN #40 rolled the resident towards the wall and removed a thin, Duoderm ([MEDICATION NAME]) dressing from the resident's coccyx. There was no Calcium alginate observed on the wound when the dressing was removed and LPN #40 verified the removed dressing was not the ordered treatment for [REDACTED].#40 measured the newly identified pressure ulcers including the upper coccyx measuring 0.9 cm in (l) by 0.5 cm in (w), the lower coccyx pressure ulcer measured 0.4 cm in (l) by 0.4 cm in (w) and the right lower buttock measured 0.5 cm in (l) by 0.25 cm in (w) by <0.1 cm in depth (d). Observation of Resident #93 on 05/26/16 at 2:20 P.M., revealed he was lying in bed on his back. Observation of Resident #93 on 05/27/16 between 8:20 A.M. and 8:41 A.M., revealed he was sitting in a geri-chair with no chair cushion. The resident attempted twice to reposition himself and was unable. At 8:35 A.M., the resident's right foot was bare and pressed against the floor with brown food debris scattered around his foot on the floor. The resident was wearing a sock to the left foot which was pressed against the metal stand of the table with no pressure relief. At 8:41 A.M., State tested Nurse Aide (STNA) #18 approached the resident in the dining room, moved the geri-chair away from the table and asked the resident to lift up his feet. The resident's bare right foot from the posterior right heel extending above the ankle was black and necrotic. STNA #18 verified the geri-chair did not have a pressure relief cushion, his right foot was bare and pressed against the floor with food debris. STNA #18 stated the resident's feet were to be elevated and covered. On 05/27/16 at 9:13 A.M., interview with LPN #40 verified the pressure relief cushion in the resident's geri-chair did not provide adequate pressure relief and she would notify therapy. On 5/28/16 at 8:42 A.M., Resident #93 was observed sitting in a reclined geri chair in front of a television. Resident #93 was fidgeting and occasionally drawing lower extremities up and rubbing his feet against the geri-chair. The cushion under the resident appeared to be sagging in the center. At 8:55 A.M., the surveyor brought to the attention of LPN #24 (the facility wound nurse and assistant director of nursing) that Resident #93 was rubbing his heels against the geri-chair. LPN #24 stated staff could put pillows under his feet but she was going to get staff to lay him down. On 5/29/16 at 9:20 A.M., Resident #93 was observed lying in bed with his heels resting against the mattress. A pillow was observed lying to the left side of his feet. On 05/30/16 at 9:50 A.M., Resident #93 was observed lying in bed on his back with heels against the mattress. At 11:05 A.M. and 11:16 A.M., the resident was in the dining room seated in wheelchair with both heels against the floor with no pressure relief. At 12:41 P.M., the resident was observed lying in bed on his back with both feet elevated on pillows. On 06/01/16 at 9:10 A.M., interview with LPN #24 verified Resident #93's care plan was not revised to reflect current positioning and pressure reduction interventions; LPN #24 was unaware of the new pressure ulcers identified on 05/27/16; LPN #24 confirmed pressure relief interventions were not implemented as ordered resulting in the development of two new pressure ulcers, and treatments were not completed as ordered resulting in the deterioration of the unstageable pressure ulcer. On 06/01/16 at 12:30 P.M., interview with LPN #40 verified she had identified new pressure ulcers when she completed the resident's treatments on 05/27/16, did not notify the family or physician, and did not notify therapy of the resident's cushion not providing adequate pressure relief. On 06/02/16 at 9:43 A.M., interview with LPN #24 verified Resident #93's right heel pressure ulcer treatment for [REDACTED]. On 06/02/16 at 11:43 A.M., interview with wound Certified Nurse Practitioner (CNP) #153 verified she was not notified of changes or declines in Resident #93's right heel pressure ulcer until she assessed the area weekly. CNP #153 stated she was unaware the right heel treatment and interventions were not being implemented as ordered and the area had deteriorated; however, the resident's advanced age and [DIAGNOSES REDACTED]. CNP #153 also stated the air mattress was to be placed at a setting that allowed the resident to sink 1/2 to 1 inch into the mattress and was only to be set at firm setting when care was being provided. 2. Medical record review revealed Resident #7 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the admission 5-day MDS assessment dated [DATE] revealed Resident #7 was cognitively intact and required extensive assist with transfers and locomotion. Review of the At Risk for Skin Breakdown related to a history of skin breakdown care plan revised 01/28/16 revealed interventions including heel boots, encourage the resident to turn and reposition, and elevate heels in bed. Review of the Braden Scale assessment dated [DATE] revealed Resident #7 was at low risk for pressure ulcer development. Review of the readmission Nursing assessment dated [DATE] revealed the resident had a Stage II pressure ulcer to the right and left buttock measuring 3.0 cm in (l) by 2.0 cm in (w). No depth was documented. Review of the monthly physician orders [REDACTED]. Observations of Resident #7 on 05/25/16 at 8:58 A.M., revealed the resident lying in bed on his back on an air mattress. At 9:59 A.M., the resident was lying in bed on his back with his left heel pressed against the air mattress. A heel lift boot was observed on the chair. At 10:05 A.M., the resident was incontinent of bowel with no dressing to the Stage II left and right buttock pressure ulcers (Partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed without slough). At 2:40 P.M. the resident was sitting in a wheelchair in his room with his left foot against the floor. On 05/26/16 between 7:30 A.M. and 8:38 A.M., Resident #7 was observed sitting in a wheelchair. At 4:13 P.M., the resident's heel lift boot was observed lying on the resident's bed and the resident was sitting in a wheelchair in the dining room with his left foot raised on foot pedals with no padding. At 5:00 P.M. Resident #7 was sitting in a wheelchair with his left foot pressed against the foot pedal. Review of the record revealed no weekly monitoring or comprehensive assessment of Resident #7's right and left buttock pressure ulcers. Review of the Wound and Skin Care policy revised 08/25/15 revealed documentation on the skin grid was to include measurements, description of the site, and the stage of the pressure ulcer. Ulcers were to be assessed weekly, and progress of healing was to be reported to the physician as needed at least every two to four weeks. On 05/25/16 at 9:59 A.M., interview with LPN #44 verified the resident was not turned side-to-side and his heel boot was not on. On 05/25/16 at 5:00 P.M., interview with LPN #24 verified there was no monitoring or comprehensive assessment of Resident #7's right and left buttock pressure ulcers; LPN #24 was unaware the resident had pressure ulcers, and the resident was not put back to bed after meals or turned side-to-side. On 05/26/16 at 5:00 P.M., interview with Resident #7 revealed staff only put the boot on him when he was in bed, and staff did not lay him down after meals. On 05/26/16 at 5:10 P.M., interview with STNA #14 revealed Resident #7 did not have any interventions for his foot, did not need to be laid down between meals, the resident remained in the wheelchair until bedtime around 8:00 P.M., and STNA #14 was unaware of any pressure ulcers. On 05/27/16 at 10:45 A.M., interview with Physician #101 revealed it was his expectation the facility should monitor any wound. 3. Review of Resident #71's closed medical record revealed [DIAGNOSES REDACTED]. Resident #71 was originally admitted to the facility on [DATE]. admission orders [REDACTED]. Review of the admission nursing assessment dated [DATE] indicated Resident #71 was semi-comatose and only responded to painful stimuli. Resident #71 was assessed as needing two assists with bed mobility, transfers, dressing, toileting, personal hygiene, and bathing. Resident #71 was assessed as immobile and restricted to the chair. Resident #71 was assessed as being dependent on staff for positioning/repositioning. Resident #71's skin was intact. Under the section of the assessment for skin care protocol, the nurse placed check marks for turning/repositioning program, moisturize skin, incontinence care, wound care per order/changes to treatment as needed, consult with wound nurse practitioner, consult primary care physician for lab testing as needed, notify and document that responsible party was updated on all changing orders. Resident #71 was assessed at high risk for development of pressure ulcers. Review of a care plan dated 12/21/15 indicated Resident #71 had an open area related to decreased mobility. Interventions included applying treatment to the area as ordered and encouraging Resident #71 to turn and reposition. There was no evidence of a treatment order on 12/21/15. On 12/22/15, a daily skilled nurses note timed 11:37 A.M. indicated Resident #71 had an area of friction on the lower coccyx. The nursing note indicated [MEDICATION NAME] was placed on the site as ordered. On 12/23/15, an order was written to turn Resident #71 every two hours from side to side while in bed. On 12/23/15, an order was also written for Duoderm (dressing that allows wounds to heal in a moist environment that is sealed to prevent bacteria and other infecting agents from getting in the wound) to an open area on the coccyx every three days and as necessary until healed. There was no comprehensive assessment in the medical record to further describe the wound on the coccyx. A nurse's progress note dated 12/23/15 at 5:37 P.M. revealed a notation to float heels off the bed. An order to float the heels off the bed was written. Review of a five day MDS assessment dated [DATE] indicated Resident #71 was totally dependent on staff for bed mobility with two assists. The MDS assessment revealed Resident #71 was at risk for the development of pressure ulcers and there was no pressure reducing device to the bed or chair and no pressure ulcer care. Skin and ulcer treatments indicated as being implemented on the MDS assessment included a repositioning program and application of ointments to somewhere other than the feet. Resident #71 was hospitalized from [DATE] after 8:00 P.M. until 12/25/16. On 12/25/16, an admission nursing assessment revealed no pressure ulcers. A nursing progress note dated 12/27/15 at 6:41 P.M. indicated Resident #71 had a fluid filled blister on his right heel. The note indicated keeping bilateral feet elevated off of mattress. A 12/28/15 daily skilled nurses notes at 1:52 P.M. indicated Resident #71 had an area of friction on the lower coccyx. [MEDICATION NAME] was placed on the site as ordered. A 12/29/15 daily skilled nurse note timed 5:25 P.M. indicated [MEDICATION NAME] was placed on an area of friction on Resident #71's lower coccyx. A daily skilled nurses note dated 01/01/16 did not indicate any skin impairment. Review of a wound evaluation flow sheet dated 01/04/16, indicated Resident #71 had a facility acquired pressure ulcer, described as a fluid filled blister. The blister measured 2.4 centimeters (cm) x 4.6 cm and date of discovery was listed as 01/04/16. Preventative interventions listed were a chair cushion, a pressure redistribution mattress, and floating heels. Review of a nutritional risk assessment dated [DATE] indicated nutritional risk factors included Stage II (shallow or blister) pressure ulcer, non-healing skin tears, stasis ulcer, an open area on the coccyx, blister to the heel, and red groin/buttocks. The dietitian recommended a nutritional supplement of Resource 2.0, 60 milliliters twice a day. Review of an individual nutrition recommendations/response form dated 01/05/16 indicated the recommendation for the Resource supplement was responded to by the physician with an agreement for the recommendation. The date by the physician signature appeared to read 01/12/16. A nursing note dated 01/08/16 at 6:30 P.M. revealed Resident #71 was sent to the hospital for unsafe feeding. During an interview on 05/25/16 at 11:16 A.M., Licensed Practical Nurse (LPN) #24 stated the interventions listed on the 12/19/16 assessment were not treatments/interventions that were in place at the time of the assessment but were interventions that may be implemented later. LPN #24 stated Resident #71 had no pressure ulcers when he was admitted [DATE] so the interventions checked for providing treatments according to orders and consulting the wound nurse were not interventions that would have been implemented at the time of admission. LPN #24 indicated it was unclear if any of the interventions checked were initiated at the time of the assessment. LPN #24, who was responsible for monitoring wounds, stated she was unable to recall Resident #71 having an open area on 12/21/15 when the care plan was initiated. LPN #24 stated she only had a wound evaluation flow sheet for the heel dated 01/04/16. LPN #24 verified there was no comprehensive assessment of the open area on Resident #71's coccyx. LPN #24 verified there was no indication Resident #71 was using a pressure reduction device in the chair prior to the documentation of the open area. LPN #24 stated she was never notified of an open area on Resident #24's coccyx and was not notified of the blister on the right heel when nurses first observed the blister. LPN #24 stated she did not become aware of the blister until she completed the wound evaluation flow sheet on 01/04/16. LPN #24 verified she was unable to locate any documentation on the treatment administration records to reflect the use of the [MEDICATION NAME] on a routine basis, the order/application of the Duoderm when ordered, the implementation of the recommended supplement (was unable to read date of the physician's response on the nutrition recommendation form), or the implementation of ordered interventions such as elevating the heels and repositioning Resident #71 from side to side when in bed. Review of the facility's Pressure Ulcer Policy, revised 08/25/15, indicated a skin care assessment would be completed on admission, quarterly and as necessary. After initial skin evaluation, the skin care protocol would be activated according to residents' needs. All new admissions and readmissions were to be placed on skin program for four weeks. For new admissions that did not have a pressure area/ulcer, the resident was still to be placed in P.U.M.P. (pressure ulcer management program) for at least four weeks. If no areas developed, the resident would be discharged from P.U.M.P. with current interventions. The resident would be reassessed quarterly and as necessary. If pressure areas/ulcers were present, residents would be placed on P.U.M.P. and the area would be measured/tracked weekly and as necessary. Treatment was to be initiated as ordered by the physician. The physician was to be contacted as indicated for changes in treatment orders and notified of any signs of infection. Documentation of pressure areas/ulcers was to include measurement of the area in centimeters, width, length, depth, wound margins, undermining, and clock hands for tunneling. Describe the site. Treatment orders were to be implemented by the charge nurse. Pressure ulcers were to be assessed weekly. Ineffectiveness of treatment or progress of healing was to be reported to the physician as needed with changes/adjustments recommended by the physician. All information was to be tracked on the skin grids. During an interview of LPN #24 on 05/25/16 at 12:02 P.M., she stated residents newly admitted to the facility had their skin condition reviewed weekly by the interdisciplinary (IDT) team. LPN #24 stated she was responsible for informing the team of any skin impairment the residents had. Only those identified with skin impairment were discussed. LPN #24 stated because she was unaware of Resident #71's skin impairment, his skin issues were not discussed by the IDT team. On 05/25/16 at 12:23 P.M., LPN #24 verified there was no evidence of physician notification when the facility identified the blister to Resident #71's heel on 12/27/15.

Based on observation, staff interview, medical record review, review of Self-Reported Incidents (SRIs), and review of the policy and procedure for Abuse, the facility failed to ensure residents were free from verbal abuse. This affected one of four sampled residents reviewed for abuse (Resident #75). The facility census was 51. Findings include: On 10/11/11 at 5:15 P.M., observation revealed Resident #75 was seated in a wheelchair in the facility with her son seated on a bench visiting. The resident's son was overheard yelling "Shut Up! Shut Up!" in a loud angry tone of voice. After the son had yelled, Resident #75 was observed hanging her head down in a dejected manner almost touching the lap buddy that was extended over the arms of the wheelchair. On 10/11/11 at 5:16 P.M., interview with State-tested Nurses Aide (STNA) #3 revealed she had overheard the son yelling in a loud angry tone for Resident #75 to "shut up" several times in the past. STNA #3 also reported she had overheard the son yelling "you have a diaper on use it" upon Resident #75 shouting that she needed to go to the restroom. STNA #3 related she had reported the son speaking in a mean tone to Resident #75 in the past to the facility nurses. On 10/11/11 at 5:19 P.M., interview with the Director of Nursing (DON) revealed the son had been overheard in the past talking to Resident #75 in a loud angry tone and the facility had met with the son and discussed this was not appropriate. On 10/11/11 at 5:30 P.M., review of the SRIs revealed the facility had not completed or reported any incidents regarding Resident #75 being yelled at by her son. On 10/12/11 at 4:40 P.M., review of the medical record revealed Resident #75 was admitted to the facility on [DATE] with medical [DIAGNOSES REDACTED]. Review of the minimum data set (MDS) assessment dated [DATE] revealed Resident #75 was severely cognitively impaired. Review of the plan of care dated 08/12/11 revealed Resident #75 had behavior problems of being socially inappropriate daily that were not easily altered. An intervention was identified as the staff was to observe interaction between the son and Resident #75 and report any harsh words or harsh interactions to the DON. Review of a progress note dated 10/11/11 revealed documentation that Resident #75 was out in the hallway with her son and the son screamed "shut up" to Resident #75. Resident #75 was talking loud and was upset and the son continued to yell "shut up." The DON approached the son and instructed the son that he should not speak to Resident #75 in that tone or manner. The DON further documented that Resident #75 became more upset when the son spoke to her in that manner. On 10/12/11 at 9:30 A.M., review of the policy and procedure for Abuse (dated 09/07/11) revealed the facility would prevent occurrences of abuse, identify possible abuse situations, investigate abuse, protect the residents, report abuse, and give a response to the potential abuse. On 10/11/11 at 6:10 P.M., interview with the DON verified she had overheard Resident #75's son yell "shut up" in a loud, angry tone of voice. The DON verified one staff had disclosed they had heard the son speak to Resident #75 in a loud harsh manner several times in the past, had reported this to the facility nurses, and there had not been an investigation conducted by the facility. The DON further verified the facility had failed to prevent Resident #75's son from speaking to her in a loud and angry manner.

Based on medical record review and staff interview, the facility failed to ensure that a resident who displayed mental and psychosocial adjustment difficulties received the appropriate treatment and services to correct the problem in the area of newly onset behaviors. This affected one of 22 sampled residents reviewed for psychosocial needs (Resident #84). The facility identified 11 residents with behavioral symptoms and only one resident received a behavior management program. Harm occurred to Resident #84 when she received two antipsychotic medications for the attempt to control behavior without a behavior management program. Findings include: Resident #84's medical record review revealed the admission Minimum Data Set (MDS) assessment dated [DATE] revealed this resident had no behaviors, no hallucinations, no [MEDICAL CONDITION], and was not receiving any antipsychotic medications. On 07/22/11, the facility obtained an order for [REDACTED]. Review of the [MEDICAL CONDITION] drug use care area assessment dated [DATE], revealed Resident #84 experienced agitation and acted out with staff especially in the evening. On 08/25/11, Resident #84 was placed on a routine dose of [MEDICATION NAME] 1 milligram (mg) twice a day and 2 mg as needed. On 09/23/11, this resident was started on a second antipsychotic medication ([MEDICATION NAME]). This resident had a [DIAGNOSES REDACTED]. Review of the nurses' notes revealed on 07/30/11 at 1:45 A.M., the resident was standing in her bathroom with only a bra on asking for and then refusing help. The resident threw her walker at the State-tested nurse aide (STNA). The note stated the nurse was unable to calm or redirect the resident and the nurse informed the resident she was getting a little shot. The resident turned to swing at the nurse and the resident lost her balance and stumbled between the toilet and the sink. The resident received skin tears to her right and left elbow. On 08/10/11, this resident was yelling at the nurse to get out of her room and told the nurses they were stupid. On 08/18/11, this resident was hitting staff and walking toward the front door. On 08/23/11, this resident was aggressive and combative and tried to leave her room with no clothes on. On 08/24/11, this resident was throwing feces at the staff and the resident was verbally abusive to staff. On 08/26/11, the resident was yelling and throwing feces at staff. On 08/27/11, the resident was yelling and it was documented redirection and counseling were ineffective. This resident received the [MEDICATION NAME] on 08/11/11 and 08/13/11 with no reason for administering this medication. Resident #84 received the as needed [MEDICATION NAME] on 08/11/11, 08/13/11, 08/24/11, 08/25/11, 09/05/11, 09/10/11, 09/12/11, 09/15/11, and 09/28/11. There was no evidence of what non pharmacological interventions were attempted prior to the administration of this medication. On 08/25/11, this resident was started on 1 mg of [MEDICATION NAME] twice a day and on 09/23/11, this resident was placed on a second antipsychotic medication ([MEDICATION NAME]) 25 milligrams twice a day due to agitation and increased behavior. Review of Resident #84's social service notes dated 07/26/11 revealed this resident was alert and oriented with periods of confusion at times short term. The resident was independent for daily decision making. The note stated the resident was pleasant and cooperative and socialized well and got along well with others. The next social service note dated 09/14/11 stated Resident #84 had explosive behaviors, she was verbally and physically abusive, hitting and scratching staff to throwing meals. She would walk out into the hall pushing her over bed table with her attends (adult incontinence product) falling down. She would smart off stating she was not treated like a human being. She had thrown BM and pee on her floor. Resident #84 had an appointment with a psychiatrist but refused treatment. Review of Resident #84's plan of care for Inappropriate Behavior dated 09/04/11 called for staff to allow resident privacy, anticipate needs to decrease frustrations and explain all procedures. Approach in a calm slow manner; assess and observe the environment/situation for possible cause of behavior; counsel for inappropriate behavior; document all behaviors and interventions; keep physician aware of resident's status; listen to resident and meet requests when possible; provide verbal support as needed daily; remove source of agitation; remove to a quiet environment with close supervision as needed for disruptive behaviors; and use plastic utensils and Styrofoam dinnerware at all meals. On 10/14/11 at 8:50 A.M., interview with the Director of Nursing (DON) confirmed no behavioral interventions were used except for redirection with this resident. On 10/14/11 at 9:44 A.M., interview with Licensed Social Worker (LSW) #46 revealed she talked to Resident #84 when the resident was having a behavior. If Resident #84 refused care, LSW #46 tried to talk to her to see what might be bothering her. LSW #46 stated the resident did not have behaviors at the assisted living she came from. There was no indication the resident had behaviors prior to admission here. Resident #84 was considered for Assisted Living Waiver here and she completed her own application for Medicaid. Resident #84 was scheduled an appointment with the psychiatrist as it was a drastic sudden change and LSW #46 thought there might be a medical reason for the change. LSW #46 verified Resident #84 did not want to come out of her room for meals or activities and did not turn on the TV.