Every finding on record at Creswell Post Acute

Based on observation, interviews, and record review, it was determined the facility failed to provide adequate respiratory care and services for 2 of 2 sampled residents (#s 3 and 4) reviewed for respiratory services. The facility failed to obtain and follow physician orders for tracheostomy care in a timely and consistent manner, which resulted in multiple hospitalizations This placed residents at risk for respiratory complications. Findings include:The 8/1/24 Tracheostomy Care Policy and Procedure Revealed staff were to verify physician orders and identify the resident. The 2025 facility assessment revealed: staff training/competencies and skill sets are required. Clients are reviewed prior to admission to determine if additional training is needed and is provided. 1. Resident 3 admitted to the facility on [DATE] with diagnoses including dysphonia (difficulty speaking), dysphagia (difficulty swallowing) and Barrett's esophagus without dysplasia (lining of the food pipe has changed due to acid reflux). The 12/5/25 Hospital Discharge Orders indicated tracheostomy care as directed. No additional tracheostomy specific care instructions were included in the discharge documentation. The 12/5/25 Nursing Admission/readmission Evaluation Assessment revealed Resident 3 required tracheostomy care (small opening in the neck that helps a person breathe). The resident's daughter provided all tracheostomy supplies. The resident had difficulty communicating verbally but was to notify staff when care was needed. A 12/8/25 at 11:45 AM, Nurse's Note revealed Resident 3 did not have tracheostomy care orders in place. The resident's tracheotomy appeared to be dislodged (the hole in their neck used for breathing come out completely), and the resident was sent to the hospital for evaluation and placement of the tracheostomy tube. The resident requested transfer to the hospital and returned at 10:30 PM. A 12/9/25 Physician Order directed staff to clean around the tracheostomy site with normal saline and apply gauze around the insertion site every evening shift. A 12/18/25 Physician Order directed staff to suction Resident 3's trach at 120 mm using a suction catheter kit with normal saline for a maximum of 15 seconds in a circular motion every four hours for trach care. A 12/19/25 at 11:54 PM, Nurse's Note revealed during suctioning, thick secretions were noted, and the inner cannula was found to be completely occluded (blocked or closed off). The resident requested to be sent to the hospital for further evaluation. A 12/20/25 at 2:34 PM, Nurse's Note revealed staff were unable to replace Resident 3's tracheostomy inner cannula and provide suctioning. During the attempt, the nurse noted the resident's tracheostomy had become displaced. The nurse attempted to reposition the tracheostomy; however, placement could not be successfully re-established. The resident reported extreme discomfort. Due to concerns with the resident's breathing, the resident was transferred to the hospital for replacement of the tracheostomy cannula. A 12/20/25 at 6:00 PM, Nurse's Note revealed Resident 3 returned from hospital and was sent with three additional inner cannulas from the emergency department. The 12/20/25 Emergency Department Encounter revealed Resident 3 was admitted for tracheostomy obstruction. Resident 3 reported a nurse from the care facility inserted the wrong tracheostomy tube size two weeks ago and she/he had increasing pain since. The resident stated she/he had her/his tracheostomy cannula for the past two weeks and reported increased secretions form her/his tracheostomy and tonight, it was all plugged up, prompting her/him to present to the emergency department. The 12/20/25 through 12/21/25 Emergency Department Encounter revealed Resident 3 admitted with tracheostomy concerns. Hospital staff had difficulty replacing the tracheostomy tube because of swelling. After consulting with the specialist, a smaller tube was used, and the airway was gradually widened to allow placement. The resident was then discharged back to the facility. At discharge, the resident's tracheostomy supplies were different brands than those available at the facility. Resident 3 was noted to have heavy secretions, requiring regular inner cannula replacement. A 12/21/25 Physician Order directed staff to change Resident 3's tracheostomy tube to size 5.5 and tracheostomy ties daily as needed for obstruction on every day shift for tracheostomy care. The 12/30/25 Emergency Department Encounter revealed Resident 3 was admitted to the hospital due to shortness of breath and reported difficulty getting enough air through the tracheostomy. Resident 3 stated this occurred multiple times. The resident's tracheostomy was found to be plugged. A 12/31/25 at 12:48 AM, Nurse's Note revealed Resident 3 had difficulty breathing at the beginning of the shift. The nurse attempted suctioning and replacement of the inner cannula. The resident continued to have difficulty breathing and requested transfer to the hospital and was sent for evaluation. A 1/3/26 at 11:00 PM, Nurse's Note revealed the resident's humidifier machine was continuously cycling between high and low settings with no visible mist output into the resident's tracheostomy. A 1/3/26 at 11:35 PM, Nurse's Note revealed Resident 3 frequently called throughout the shift requesting assistance with suctioning and stated she/he did not believe the humidifier was functioning. A 1/10/26 at 5:13 PM, Nurse's Note revealed Resident 3's cannula was nearly completely blocked and could not be cleared. The resident showed minimal response, and no additional secretions were able to be suctioned at that time. A 1/10/26 at 5:18 PM, Nurse's Note revealed Resident 3 stated that it felt like her/his tracheostomy tube was not in the correct position. The nurse assessed the site and noted the cannula had been displaced. The resident requested transfer to the hospital for evaluation. A 1/18/26 Physician Order directed staff to administer seven percent sodium chloride inhalation motion via nebulizer every six hours as needed for thick secretions, and three ml every six hours for secretions for two days. Review of Resident 3's clinical record revealed staff did not obtain orders for tracheostomy care after admission. During this period, Resident 3 experienced multiple episodes of respiratory distress that resulted in hospitalizations. Multiple attempts were made to contact the nursing staff who authorized the Nursing Notes; however, these attempts were unsuccessful, and staff were not available to provide additional clarification. On 1/26/26 at 2:43 PM, Resident 3 reported she/he requested assistance for tracheostomy suctioning multiple times and stated she/he experience extended wait times before care was provided. On 1/29/26 at 12:38 PM, Staff 26 (Agency LPN) stated not all nurses were trained to provide tracheostomy care. Staff 26 stated she had to provide instructions to some nurses regarding tracheostomy care. Staff 26 stated the facility did not always have the correct tracheostomy supplies readily available. Staff 26 reported on one occasion; the facility did not have the correct tracheostomy tube size on hand and obtained a replacement tube the following day. Staff 26 stated Resident 3 was dependent on staff for tracheostomy care needs and experienced anxiety related to difficulty breathing. Staff 26 stated she overheard an agency nurse state in the presence of the resident, that she did not know how to provide tracheostomy care. Staff 26 further stated the resident's facial expression appeared concerned at the time of the statement. On 1/29/26 at 2:14 PM, Staff 27 (Admission/Marketing/LPN) reviewed Resident 3's Hospital Discharge Orders and confirmed the tracheostomy orders were unclear and lacked detailed instructions. Staff 27 stated nursing staff were expected to follow up in a timely manner. On 1/29/26 at 7:13 PM, Witness 1 stated she provided tracheostomy care for Resident 3 prior to the resident's admission to the facility and reported the resident had not experienced the frequency of tracheostomy related complications observed after admission to the facility. Witness 1 stated shortly after Resident 3's admission the resident began experiencing breathing difficulties. Witness 1 stated during visits to the facility, she observed delays in staff responding to Resident 3's request for tracheotomy suctioning. She reported this on multiple occasions; she performed suctioning herself due to the delay. Witness 1 stated Resident 3 removed her/his inner cannula on occasion because of anxiety and fear of not being able to breathe. Witness 1 expressed concerns to nursing staff stating she was worried nursing staff were not knowledgeable or competent in providing tracheostomy care and suctioning. On 1/30/26 at 1:07 PM, Staff 6 (LPN) stated Resident 3 requested replacement of her/his inner cannula. Staff 6 stated he was unfamiliar with the procedure and requested assistance. After removal of the tracheostomy tube, staff were unable to locate the correct size replacement and did not know where the resident's tracheostomy supplies were kept. The resident was then transferred to the hospital. On 1/30/26 at 3:43 PM, Staff 2 (DNS) stated the facility expected nursing staff to be competent prior to providing tracheostomy care and to follow up on resident orders in a timely manner. Staff 2 stated Resident 3's tracheostomy tube and supplies were expected to be available as needed. Staff 2 further stated if staff had appropriate tracheostomy supplies and training, some of the resident's hospitalizations could have potentially been avoided. 2. Resident 4 was admitted to the facility in 10/2025 with diagnoses including chronic obstructive pulmonary disease (a progressive, long-term lung disease that makes it hard to breathe by damaging the airways and air sacs). A review of orders revealed an 8/15/25 physician order for oxygen as needed. On 1/27/26 at 8:47 AM, Resident 4 was observed with oxygen on, the concentrator filter was observed to be dirty. On 1/29/26 at 11:15 AM, Staff 12 (Regional Nurse) observed the oxygen concentrator filter and acknowledged the filter was dirty and needed cleaning. Staff 12 stated staff were expected to clean the concentrator filters regularly.

Based on observation and interview it was determined the facility failed to ensure an ice machine had the required air gap for 1 of 2 facility ice machines reviewed for kitchen sanitation. This placed residents at risk for cross contamination and foodborne illness. Findings include: On 1/28/26 at 10:04 AM, Staff 8 (Maintenance Director) was observed cleaning the ice machine in the janitor closet on the North Hall. Staff 8 stated he did not know what an airgap was or if the ice machine had an airgap (space between a water pipe sink or drain that prevents dirty water from flowing back into the clean water supply). Staff 8 confirmed the drainpipe was located below the sink basin and stated he did not believe this presented a problem in the event of the sink backflow. On 1/28/26 at 11:54 AM Staff 1 (Administrator) reviewed the ice machine and drain and stated it would be repaired. On 1/28/26 at 10:34 AM the ice machine in the janitor closet on the North Hall was observed. The ice machine drained into a sink on the floor with the top of the sink extending above the bottom of the drain, resulting in no air gap between the drain and the sink. The sink on the floor had trash in it, appeared dirty, and had reddish discoloration where the ice machine dripped into the sink. Staff 8 (Maintenance Director) confirmed the ice machine drain placement but did not feel it was an issue. On 1/28/26 at 11:54 AM Staff 1 (Administrator) reviewed the ice machine and drain and stated it would be repaired.

Based on observation and interview it was determined the facility failed to properly sanitize and store resident care equipment for 1 of 3 halls reviewed for infection control. This placed residents at risk for exposure to blood borne pathogens and cross contamination. Findings include:1. On 1/28/26 at 11:19 AM Staff 6 (LPN) was on the central hall checking CBGs (blood sugar measurement) and moved to the south hall. Staff 6 had one glucometer on top of the medication cart with no cleaning supplies in sight. Staff 6 stated he cleaned the glucometer with an alcohol pad and opened the drawer and pointed to small alcohol prep pads. At this time another staff provided Staff 6 with the purple top Super Sani-Cloth Wipes. On 1/28/26 at 11:43 AM Staff 6 stated prior to moving to the south hall he checked one CBG with the glucometer and cleaned it with an alcohol prep pad. On 1/28/26 at 12:46 PM Staff 2 (DNS) stated the staff were to use the purple top wipes, Super Sani-Cloth Wipes, when cleaning the glucometer and the alcohol prep pads were not an appropriate cleaning product. 2. On 1/27/26 at 3:00 PM a gray plastic bedpan was observed lying on the floor, beneath the sink of the restroom shared between Rooms 15-16. The bedpan was sitting directly on the floor and was uncovered. This restroom was shared by two rooms with total capacity of four residents. On 1/28/26 at 9:19 AM a gray plastic bedpan was observed lying on the floor beneath the sink, uncovered and lying partially on top of a clear plastic bag. Part of the bedpan directly touched the floor of the restroom shared between Rooms 15-16. Staff 23 (CNA) indicated on 1/28/26 at 10:07 AM bedpans were labeled with resident names and stored in plastic bags in the restroom when not being used. Staff 2 (DNS) stated on 1/28/26 at 10:45 AM the expectation for bedpans was for them to be labeled by staff, cleaned after use, and stored in a closed plastic bag in the restroom when not in use. On 1/30/26 at 10:35 AM two gray bedpans were observed lying stacked one atop the other in the shared restroom between Rooms 15-16. The bottom bedpan was partially within a clear plastic bag but not enclosed. The top bedpan had no bag around it. Staff 2 observed the bedpans in the shared restroom between Rooms 15-16 at 10:36 AM and confirmed this was not the proper process for storage of bedpans when they were not in use.

Based on interview and record review it was determined the facility failed to provide a COVID-19 vaccine for 1 of 5 sampled residents (#13) reviewed for immunizations. This placed residents at risk for COVID-19. Findings include: Resident 13 admitted to the facility in 2018 with a diagnosis of respiratory failure.A 11/6/25 Informed Consent revealed Resident 13 consented to receive a COVID-19 vaccine.A review of Resident 13's immunization record revealed she/he did not receive a COVID-19 vaccine.On 1/30/26 at 1:59 PM Staff 2 (DNS) confirmed Resident 13 did not receive the COVID-19 vaccine during the facility's 11/2025 COVID-19 clinic.

Based on observation, interview and record review it was determined the facility failed to ensure residents who wished to self-administer medications were assessed for 1 of 2 sampled resident (#21) reviewed for ADLs. This placed residents at risk for unsafe self-administration of medications. Findings include: Resident 21 admitted to the facility in 1/2026 with a diagnosis of diabetes. On 1/26/26 at 11:04 AM Resident 21 was observed to have a box of Senokot (a laxative) on her/his overbed table, no staff were in the room, and Resident 21 stated she/he was told by a medical provider to take Senokot (a laxative) a couple times a day. A review of Resident 21's medical record revealed no order for self-administration of Senokot and no assessment for self-administration of Senokot. On 1/29/26 at 11:15 AM Staff 5 (LPN) reviewed Resident 21's medical record and stated there was no approval for her/him to keep medication at the bedside. Staff 5 went to Resident 21's room and confirmed there was Senokot on the overbed table and removed it from the room. Resident 21 told Staff 5 she/he had taken some of the Senokot during her/his stay in the facility. On 1/30/26 at 10:15 Staff 2 (DNS) stated residents who wished to have medication at bedside were to have an assessment completed, a physician order for self-administration, have a care plan in place, and the medication was to be stored in a lock box in the resident room.

Based on interview and record review it was determined the facility failed to comprehensively complete a baseline care plan within 48 hours of a resident's admission for 3 of 3 sampled residents (#s 76 and 78) reviewed for care plans. This placed residents at risk for unmet needs. Findings include:1. Resident 76 was admitted to the facility on [DATE] with diagnoses including diabetes and subarachnoid hemorrhage (bleeding in the brain). A 1/27/26 record review revealed no evidence of a baseline care plan. On 1/27/26 at 1:18 PM, Staff 25 (CNA) stated resident care needs are in the care plan and Staff 25 stated Resident 76 did not have a care plan. On 1/27/26 at 1:21 PM, Staff 3 (LPN Resident Care Manager) stated Resident 76 admitted on [DATE] and acknowledged Resident 76 did not have a care plan. On 1/27/26 at 2:19 PM, Staff 2 (DNS) started it was the expectation for staff to formulate a baseline care plan for new residents at admission. 2. Resident 77 was admitted to the facility on [DATE] with diagnoses including Stage 4 pressure ulcer on the sacral region (full-thickness skin and tissue loss on the lower back), and osteomyelitis (bone infection). On 1/27/26 at 12:59 PM, Staff 10 (CNA) was asked how she learned residents' care needs. Staff 10 stated she read the resident's Kardex. Staff 10 was asked to review the Kardex and confirmed no Kardex existed. Staff 10 further stated oh she/he did not have one because she/he was a new resident. On 1/27/26 at 1:07 PM, Staff 11 (Agency CNA) stated sometimes residents did not have a Kardex and staff would have to ask the charge nurse about the resident's care needs. Staff 11 was asked to review Resident 77's Kardex and confirmed it only contained information related to catheter care. The 1/26/26 Baseline Care Plan Person-Centered Care Plan revealed Resident 77 had a Stage 4 pressure ulcer on her/his sacral region, required wound vac treatment (medical device that applies negative pressure to a wound bed), antibiotics, and had a lot of pain. Resident 77 was dependent on staff. No documentation was found in the clinical record to indicate Resident 77 had a baseline care plan addressing the Stage 4 pressure ulcer, including treatment, pain management, intravenous (IV) antibiotics, or any other identified needs. On 1/27/26 2:27 PM, Staff 12 (Regional Nurse) confirmed Resident 77's baseline care plan was not completed timely.

Based on interview and record review it was determined the facility failed to implement comprehensive care plans for 3 of 7 sampled residents (#'s 3, 9 and 32) reviewed for unnecessary medications, diarrhea, and hospice. This placed residents at increased risk for unmet needs. Findings include: 1. Resident 3 admitted to the facility in 12/2025 with diagnoses including dysphonia (difficulty speaking) and depression. The 12/5/25 Hospital Discharge Summary revealed Resident 3 had a PHQ-9 (patient health Questionnaire) score of 21 which indicated severe depression. The 12/8/25 admission MDS indicated Resident 3 was cogitatively intact, had no mood disorders, and she/he received scheduled antidepressant and antipsychotic medications. The 12/8/25 Psychosocial Well-Being CAA indicated Resident 3 had little interest and/or pleasure in doing things. Resident 3 reported over the last year she/he had significant health issues and was currently needing a trach to support breathing. Resident 3 was at risk for psychosocial issues secondary to a lack of interest in participating in favorite activities. No additional documentation was provided. A 12/9/25 at 5:10 PM Physician Note revealed Resident 3 reported feeling emotional but did not want to make any psychotropic changes. The 12/9/25 Interdisciplinary Conference Note revealed Resident 3 felt uncomfortable around others. Staff were to encourage activity participation. Residents 3's Care Plan did not include resident-centered interventions related to depression, anxietyor mood. On 1/30/26 at 11:28 AM, Staff 4 (LPN/Resident Care Manager) confirmed Resident 3's care plan was not comprehensive. On 1/30/26 at 12:35 PM, Staff 13 (Social Service Director) stated she was not aware Resident 3 was taking antipsychotic mediations and confirmed the resident's care plan was not comprehensive. 2. Resident 9 was admitted to the facility in 6/2025 with diagnoses including hypertension (high blood pressure) and chronic obstructive pulmonary disease (a progressive, long-term lung disease that makes it hard to breathe by damaging the airways and air sacs). A review of Resident 9's medical record revealed she/he was admitted to hospice in 6/2025. A review of Resident 9's 6/27/25 care plan revealed no evidence of a hospice care plan. On 1/29/26 at 3:19 PM, Staff 3 (LPN Resident Care Manager) stated Resident 9 had been on hospice since 6/2025. Staff 3 acknowledged Resident 9 did not have a hospice care plan and stated it was expected for residents to have hospice included in their comprehensive care plans. 3. Resident 32 was admitted to the facility in 8/2023 with diagnoses including retention of urine (inability to completely empty the bladder) and protein malnutrition. The 7/12/24 Care Plan indicated Resident 32 was at risk for bowel incontinence related to reduced mobility. The 10/11/25 Care Plan indicated Resident 32 was at risk for skin impairment related to mixed incontinence and occasional diarrhea. The 11/11/25 Quarterly MDS revealed Resident 32 had moderate cognitive impairment and was always continent of bowel. The Physician Follow up notes from 12/4/25, 12/11/25, 12/18/25, 1/1/26, and 1/6/26 indicated Resident 32 had a history of chronic diarrhea. The Bowel Task from 12/29/25 through 1/27/26 indicated Resident 32 had 19 episodes of loose diarrhea. On 1/26/26 at 1:01 PM, Resident 32 reported experiencing frequent diarrhea for the past the year. Resident 32 stated she/he was taking medications for this condition, which provided some relief. Resident 32 stated a couple months ago she/he asked to see a gastroenterologist to help better understand the underlying cause of her/his chronic diarrhea. On 1/28/26 at 9:36 AM, Staff 15 (CMA) stated Resident 32 experienced both diarrhea and constipation for at least the past six months. Staff 15 stated recent adjustments to her/his bowel medications appeared to be more effective for the past few months. On 1/28/26 at 9:46 AM, Staff 16 (CNA) stated resident 32 was prone to diarrhea and may have multiple episodes in a day, sometimes up to four. Staff reported resident 32 consistently notified them of bowel issues and requested anti-diarrheal medication as needed. On 1/28/2026 10:15 AM Resident 32 was observed lying in bed, wearing a shirt and gray brief, in the fetal position. The brief contained a stool stain approximately 3 inches long and .5 inches wide, appearing to be diarrhea. The resident's wheelchair was covered with disposable chucks. During observation, resident 32 did not respond to verbal stimuli. On 1/28/26 at 10:16 AM, Resident 32's roommate stated over the past six months Resident 32 frequently complained about her/his diarrhea, and she/he spent a significant amount of time in the bathroom because she/he had frequent diarrhea, sometimes up to five times per day. On 1/28/26 at 10:19 AM, Staff 14 (CNA) stated last night, he found Resident 32 sleeping on the toilet where she/he had been for approximately 30 to 45 minutes. Staff 14 reported Resident 32 had experienced multiple episodes of diarrhea. Staff 14 further stated over the past four to five weeks Resident 32 had regular episodes of diarrhea. On 1/30/26 at 11:40 AM, Staff 4 (LPN/RCM) stated she was aware Resident 32 had chronic diarrhea and her/his care plan was not comprehensive. On 1/30/26 at 2:51 PM, Staff 2 (DNS) confirmed Resident 32 had a history of diarrhea and expected her/his care plan to be comprehensive.

Based on observation, interview, and record review it was determined the facility failed to provide bathing for 2 of 2 sampled residents (#s 20 and 21) reviewed for ADLs. This placed residents at risk for unmet care needs. Findings include: 1. Resident 20 was admitted to the facility on 1/2025 with diagnoses including chronic pain syndrome. The 1/29/25 admission MDS revealed Resident 20 had a BIMS score of 9 indicating moderate cognitive impairment and was dependent for bathing. On 1/26/26 at 1:21 PM Resident 20 stated feeling she/he did not get as clean as she/he would like due to staff rushing through showers and not cleaning her/his genitals thoroughly. The resident stated she/he needed help bathing due to pain. The 1/2026 shower schedule specified Resident 20's bathing days were Sundays and Wednesdays. Saturdays were the make-up bathing day for any residents who missed a scheduled shower during the week. The bathing task was reviewed for 12/31/25 through 1/28/26. Resident 20 declined bathing Wednesday 1/7/26 and 1/21/26 with no documented follow up attempts. There was no documented bathing on Sunday 1/4/26 or Sunday 1/11/26. No make-up bathing was documented for any Saturday during 1/2026. Resident 20's 1/2026 progress notes revealed no documented attempts at make-up bathing on Saturdays, or a reason bathing was not completed 1/4/26 and 1/11/26. On 1/28/26 at 9:35 AM Resident 20 was observed in bed with greasy hair. The resident was unable to recall her/his bathing schedule. On 1/28/26 at 1:36 PM Staff 24 (CNA) said the bathing schedule was inconsistent due to agency staff in the building, showers did not always get done or rescheduled. Staff 24 said when a resident refused their scheduled bathing time, the expectation was to try again at another time or have a different staff offer. On 1/29/26 at 9:50 AM Staff 22 (CNA) reported residents had two scheduled days per week for bathing. If a resident declined a shower on their scheduled day, the expectation was for staff to offer a make-up shower on Saturdays. On 1/29/26 at 11:17 AM Staff 4 (LPN Resident Care Manager) reported facility staff were available at any time to provide bathing services. She said there was no formal process for adding a resident to the Saturday make-up schedule, but the expectation was for staff to follow through on re-scheduling missed showers. 2. Resident 21 was admitted to the facility on [DATE] with a diagnosis of diabetes. A 1/26/26 admission MDS revealed Resident 21 had a BIMS of 13, which indicated she/he was cognitively intact, and required assistance with bathing. A comprehensive care plan revised 1/19/26 revealed Resident 21 required extensive assistance with bathing. A 1/21/26 facility shower schedule revealed Resident 21 was to be bathed during the day on Mondays and Thursdays. A review of Resident 21's Bathing Tasks revealed she/he was bathed on 1/22/26. The scheduled shower days of 1/19/26 and 1/26/26 were documented as no (not scheduled for this shift) and no additional showers were documented as completed. On 1/26/26 at 11:03 AM Resident 21 was observed in bed in a hospital gown and her/his hair appeared unwashed and uncombed. Resident 21 stated she/he was bathed only one time since admission on [DATE]. Resident 21 stated she/he asked about being bathed, but the staff did not do it. On 1/26/26 at 9:20 AM Resident 21 was observed in a hospital gown and her/his hair appeared unwashed. Resident 21 stated she/he was not yet bathed that week. On 1/28/26 at 2:40 PM Staff 9 (CNA) stated on days when the designated shower aid was moved to CNA she would focus on basic care and may miss completing bathing for the residents. On 1/29/26 at 9:50 AM Staff 7 (CNA) stated on days when there was less staff, she would not always assist residents with bathing. On 1/29/26 at 2:25 PM Staff 3 (LPN Resident Care Manager) stated staff were expected to offer bathing as scheduled and if missed during the week, bathing was to be offered on Saturdays.

Based on observations, interviews, and record review it was determined the facility failed to ensure staff completed competencies prior to caring for a resident with a tracheostomy for 1 of 1 sampled resident (#3) reviewed for respiratory care. This placed residents at risk for respiratory complications. Findings include: The 2025 Facility Assessment identified the Competencies and skills required for staff. The facility implemented an orientation program for new hires that included completion of a competency checklist. Staff competencies are evaluated annually, continuously monitored, and supplemented with additional training as necessary. Resident 3 admitted to the facility on [DATE] with diagnoses including dysphonia (difficulty speaking), dysphagia (difficulty swallowing) and Barrett's esophagus without dysplasia (lining of the food pipe has changed due to acid reflux). The 12/5/25 Hospital Discharge Orders revealed tracheostomy care as directed. No additional tracheostomy specific care instructions were included in the discharge documentation.The 12/5/25 Nursing Admission/readmission Evaluation Assessment revealed Resident 3 required tracheostomy care (surgical opening created in the trachea (windpipe) through the neck to provide an airway and/or allow removal of secretions from the lungs. On 1/26/26 at 2:43 PM, Resident 3 reported she/he requested assistance for tracheostomy suctioning multiple times and experienced extended wait times before care was provided.On 1/29/26 at 12:38 PM, Staff 26 (Agency LPN) stated not all nurses were trained to provide tracheostomy care. Staff 26 stated she provided instructions to some nurses regarding tracheostomy care. Staff 26 stated Resident 3 was dependent on staff tracheostomy care needs and experienced anxiety related to difficulty breathing. Staff 26 stated she overheard an agency nurse state in the presence of the resident, that she did not know how to provide tracheostomy care. On 1/29/26 at 7:13 PM, Witness 1 reported overhearing a nurse tell another nurse that she did not know how to provide tracheostomy care for Resident 3. Witness 1 also stated she had to provide suctioning on multiple occasions due to delays in staff response, and she believed staff were not competent to provide tracheostomy care.On 1/30/26 at 1:07 PM, Staff 6 (LPN) stated Resident 3 was admitted to the facility with tracheostomy care needs and reported he did not know how to provide tracheostomy care and had not received prior training from the facility. Staff 6 stated he requested assistance from another nurse during an attempt to change the resident's tracheostomy tube, Staff 6 reported the incorrect tube size was used, and the tracheostomy tube was inadvertently removed. Staff 6 further stated staff were unsure where the resident's tracheostomy supplies were located and the resident was sent to the hospital.On 1/30/26 at 3:43 PM, Staff 2 (DNS) stated the facility expected nursing staff to be competent prior to providing tracheostomy care. Staff 2 further stated if staff had appropriate tracheostomy supplies and training, some of the resident's hospitalizations could have potentially been avoided.

Based on interview and record review it was determined the facility failed to acquire medications resulting in missed doses for 1 of 1 sampled resident (#56) reviewed for pharmacy services. This placed residents at risk for missed medications. Resident 56 was admitted to the facility 1/2026 with diagnoses including a skin infection and wounds.On 1/26/26 at 10:40 AM Resident 56 reported missed medication doses due to the facility not ordering medications before they ran out.On 1/6/26 Resident 56 was prescribed oral antibiotic Rifaximin 550 mg tablets with one tablet given two times a day.The 1/2026 Medication Administration Record revealed missed doses of Rifaximin on 1/8/26, 1/9/26, 1/15/26, 1/16/26, and 1/25/26. Progress notes indicated the Rifaximin was on order 1/8/26, 1/9/26, 1/15/26, 1/16/26, and 1/25/26. There was no documentation indicating follow up with the pharmacy to check the medication's order status.On 1/29/26 at 10:40 AM Staff 21 (CMA) stated it was the responsibility of staff administering medications to put in an order prior to medications running out. On 1/29/26 at 11:38 AM Staff 2 (DNS) reported Rifaximin was not a medication kept on hand in the facility and required ordering. Staff 2 said the expectation was for staff to follow up with the pharmacy to see if a medication on hand in the facility was an acceptable substitute or if the pharmacy could satellite the medication to the facility, which typically had a four-hour turnaround time. She said communication with the pharmacy should have been documented.

Based on interview and record review it was determined the facility failed to provide influenza and pneumococcal vaccines for 1 of 5 sampled residents (#6) reviewed for immunizations. This placed residents at risk for influenza and pneumonia. Findings include: Resident 6 admitted to the facility in 9/2022 with a diagnosis of diabetes. An 8/19/25 Informed Consent revealed Resident 6 consented to receive a pneumonia vaccine.A review of Resident 6's medical record revealed no indication she/he was offered a current influenza vaccine. A review of Resident 6's immunization record revealed no evidence Resident 6 received a pneumonia vaccine or an influenza vaccine. On 1/30/26 at 1:59 PM Staff 2 (DNS) stated the facility offered influenza vaccines in 9/2025 and 10/2025 and it should have been offered to Resident 6. Staff 2 stated the pneumonia vaccine should have been administered to Resident 6 at the same time as the influenza vaccine, and she/he did not receive the vaccines.

Based on interview and record review, it was determined the facility failed to complete timely MDS assessments for 2 of 7 sampled residents (#s 27 and 34) who were reviewed for catheter use and staffing. This placed residents at risk for unassessed needs. Findings include:1. Resident 27 was admitted to the facility in 11/2025 with diagnoses including fractured femur and osteoarthritis. On 12/8/25 a review of Resident 27's clinical record revealed the admission MDS assessment was marked in progress and overdue by 15 days. On 12/8/25 at 12:06 PM, Staff 11 (MDS Coordinator) confirmed she was behind on 11/2025's MDS reports. On 12/11/25 at 11:54 AM Staff 2 (DNS) confirmed MDS assessments should be completed timely. 2. Resident 34 was admitted to the facility in 11/2024 with diagnoses including pressure ulcer and chronic kidney disease. On 12/9/25 a review of Resident 34's clinical record revealed her/his annual MDS assessment was in progress and overdue by 15 days. On 12/11/25 at 11:54 AM Staff 2 (DNS) confirmed MDS assessments should be completed timely.

Based on interview and record review, it was determined the facility failed to report timely to the State Survey Agency an allegation of injury of unknown source for 1 of 3 sampled residents (#18) reviewed for abuse. This placed residents at risk for abuse. Findings include:Resident 18 was admitted to the facility in 6/2022 with diagnoses including behavioral disturbance and dementia. A facility incident report dated 1/15/25 indicated Resident 18 was found on 1/15/25 with a bruise to the left eye. Staff did not know how the injury occurred and the resident was unable to explain what happened. An Incident Investigation dated 1/15/25 indicated on 1/10/25, Staff 24 (CNA) observed a bruise to Resident 18's eye and reported the bruise to Staff 10 (LPN). On 12/11/25 at 9:45 AM, Staff 2 (DNS) confirmed the incident was not reported to the State Agency in a timely manner. The incident met the criteria for non-compliance as follows:1. The incident indicated non-compliance for F609 2. There was sufficient evidence the facility corrected the non-compliance and was in substantial compliance with F609 as evidenced by:-No deficient practice was found at F609 with additional sampled residents.-The facility identified the deficient practice and provided in-service training to nursing staff on reporting injuries of unknown origin.-Weekly audits were implemented for four weeks, followed by monthly audits for three months.

Based on interview and record review it was determined the facility failed to provide a discharge plan for 1 of 3 residents (# 21) reviewed for discharged planning. This place residents at risk for not having a discharge plan. Findings include:A review of the resident 21's clinical record revealed no evidence of a discharge plan in the resident file. A notification on the Evaluations tab of the clinical record indicated the discharge plan was 16 days overdue. The resident's Care Plan dated 11/26/25 revealed the resident's discharge preferences were not addressed in the Care Plan. Care Conference Notes dated 12/3/25 revealed no documentation of the resident's discharge plan.On 12/11/25 at 1:58 PM, Staff 36 (Social Services Coordinator) stated she should have had the resident's discharge plan completed. On 12/11/25 at 2:00 PM, Staff 2 (DNS) stated she was not familiar with the discharge planning procedure, but it was the responsibility of Social Services to complete a discharge plan.

Based on interview and record review the facility failed to update the resident's care plan for 1 of 2 residents (#20) reviewed for abuse. This placed residents at risk for a lack of planned interventions. Findings include:Resident 20 was admitted to the facility 5/1/25 with diagnoses including dementia. A Facility Reported Incident (FRI) dated 5/22/25 revealed Resident 20's care plan was revised to keep the resident further than an arm's length away from other residents when she/he appeared agitated. A FRI dated 6/5/25 revealed Resident 20 was involved in physical aggression towards another resident. Resident 20's Care Plan revealed the intervention to keep the resident away from other residents when she/he appeared agitated was added to the Care Plan on 6/5/25. On 12/11/25 at 12:35 PM, Staff 2 (DNS) stated the resident's care plan should have been updated within five days of the 5/22/25 FRI and she had failed to update the resident's care plan timely.

Based on observation, interview, and record review, it was determined the facility failed to provide sufficient staffing to meet the needs of 2 of 4 residents (#17 and 33) during random observations. This placed residents at risk for unmet needs. Findings include:1. Resident 17 was admitted to the facility in 9/2025 with diagnoses including chronic kidney disease and epilepsy. An 8/20/25 admission MDS indicated Resident 17 had a BIMS score of 14 (cognitively intact). On 12/9/25 at 9:23 AM, the call light monitor was observed and revealed Resident 17's call light was activated at 8:47 AM and completed at 9:34 AM, a total wait time of 47 minutes. On 12/9/25 at 9:53 AM, Resident 17 stated call light wait times were sometimes long. On 12/9/25 at 1:12 PM, Staff 29 (CNA) stated during Resident 17's call light wait time, he was assisting another resident with incontinent care. Staff 29 stated the facility used to have devices to communicate with other staff, but they were no longer available. On 12/11/25 at 11:55 AM, Staff 2 (DNS) stated she expected resident's needs to be met and confirmed Resident 17's call light wait time was too long. 2. Resident 33 was admitted to the facility in 9/2025 with diagnoses including anxiety and chronic pain. A 9/29/25 admission MDS indicated Resident 33 had a BIMS score of 15 (cognitively intact). On 12/9/25 at 9:23 AM, an observation of the call light monitor revealed Resident 33's call light was activated at 8:53 AM and completed at 9:33 AM, a total wait time of 40 minutes. On 12/10/25 at 10:14 AM, Staff 34 (CNA) stated during Resident 33's call light time, she was assigned to work in the dining room. On 12/11/25 at 11:55 AM, Staff 2 (DNS) stated she expected resident's needs to be met and confirmed Resident 33's call light wait time was too long.

Based on interview and record review it was determined the facility failed to complete a discharge summary which included a final summary of the resident's status for 3 of 4 sampled residents (#s 2, 4, and 5) reviewed for discharge. This placed residents at risk for an unsafe discharge. Findings include: 1. Resident 2 was admitted to the facility in July 2024, with diagnoses including diabetes. Review of a Discharge Summary/Plan of Care form dated 8/28/24, revealed the final summary of the resident's status did not include all items consistent with the resident's most recent comprehensive assessment which included but not limited to functional abilities, urinary incontinence, psychosocial well-being, nutritional status, dental care, pressure ulcer and pain. 2. Resident 4 was admitted to the facility in July 2024, with diagnoses including heart failure. Review of a Discharge Summary/Plan of Care form dated 9/4/24, revealed the final summary of the resident's status did not include all items from the resident's most recent comprehensive assessment which included but not limited to functional abilities, urinary incontinence, psychosocial well-being, nutritional status, dental care, pressure ulcer and pain. 3. Resident 5 was admitted to the facility in June 2018, with diagnoses including dementia. Review of a Discharge Summary/Plan of Care form dated 8/26/24, revealed the final summary of the resident's status did not include all items from the resident's most recent comprehensive assessment which included but not limited to functional abilities, urinary incontinence, psychosocial well-being, nutritional status, dental care, pressure ulcer and pain. In an interview on 10/9/24 at 2:01 PM, Staff 1 (DNS) acknowledged Resident 2, 4 and 5's discharge summaries did not include a complete summary of the resident's final status on discharge.

Based on observation, interview, and record review it was determined the facility failed to follow physician orders, provide bowel care, and administer medications timely for 9 of 12 sampled residents (#s 2, 4, 8, 13, 14, 41, 43, 47, 203) reviewed for change of condition, restraints, pain, bowel care, and medication pass. This placed residents at risk for ineffective interventions. Findings include: 1. Resident 2 admitted to the facility in 3/2010 with a diagnosis of cancer. A care plan initiated in 2020 revealed Resident 2's bed had bed rails to improve bed mobility. On 8/26/24 at 2:47 PM Witness 1 (Family Member) stated Resident 2 used mobility bars to assist with bed mobility, the facility removed the bars, and she was not informed the reason the mobility bars were removed. On 8/27/24 at 1:59 PM Resident 2 was observed in bed. The bed did not have bed rails. On 8/27/24 at 2:46 PM Staff 3 (RNCM) stated Resident 2's original bed was replaced with a new bed and the rails were not transferred to the new bed. 2. Resident 47 admitted to the facility in 7/2024 with a diagnosis of paralysis after spinal surgery. a. A care plan initiated on 7/25/24 revealed Resident 47 was at risk for constipation. Interventions included: -Staff were to monitor Resident 47 for constipation. Symptoms to monitor included nausea, vomiting, and abdominal distention. -Provide non-pharmacological interventions. -Provide medications to relieve constipation. Resident 47's 7/2024 and 8/2024 Documentation Survey Report revealed: -7/27/24 day shift Resident 47 had a bowel movement. -7/28/24 no bowel movement. -7/29/24 no bowel movement. -7/30/24 no bowel movement. -7/31/24 no bowel movement. -8/1/24 day shift Resident 47 had a small bowel movement. A 7/2024 MAR revealed on 7/30/24 Resident 47 received Milk of Magnesia (laxative) which was documented as effectiveness unknown. No additional laxatives were administered. An 8/2024 MAR revealed on 8/1/24 Resident 47 was administered Milk of Magnesia and sennoside (laxative) and the medication was effective. 7/2024 Progress Notes revealed no assessments of the resident's bowel status or abdomen. On 8/28/24 at 9:56 AM Staff 5(CMA) stated every morning she looked at the bowel report. If a resident did not have a bowel movement in two days, on the third day bowel care was provided. If a resident refused a medication the nurse was notified. On 8/28/24 at 10:11 AM Staff 2 (DNS) stated if a resident was constipated and a medication was not effective, additional interventions should be provided and documented in the progress notes. Staff 2 acknowledged there were no assessments in the progress notes and staff did not provide additional interventions prior to 8/1/24. b. Resident 47's 7/2024 and 8/2024 MARs revealed she/he was to be administered hydromorphone (narcotic pain medication) every four hours at 1200 AM, 4:00 AM, 8:00 AM, 12:00 PM, 4:00 PM and 8:00 PM. Medications were administered one hour or later on the following dates and times: -7/25/24 12:00 dose -7/27/24 8:00 AM dose -8/3/24 4:00 PM dose -8/4/24 4:00 PM dose -8/8/24 12:00 AM dose -8/9/24 8:00 PM dose -8/13/24 4:00 AM dose -8/15/24 8:00 PM dose -8/17/24 12:00 AM dose -8/20/24 12:00 MA dose -8/25/24 4:00 PM dose On 8/27/24 at 1:25 PM Staff 5 (CMA) stated it was difficult to pass the medications, especially in the morning, to 50 residents. Staff 5 also stated at times it was hard to administer Resident 47 her/his medications at the scheduled times and Resident 47 did not like to wait for her/his medications. On 8/28/24 at 10:25 AM Staff 2 (DNS) acknowledged there were multiple days when Resident 47's medications were administered more than one hour after the scheduled time. 47001 3. Resident 43 admitted to the facility in 2/2024 with diagnoses including alcohol use. A 6/1/24 Quarterly MDS indicated Resident 43 had moderate cognitive impairment. A review of a 7/30/24 progress note written at 2:26 PM revealed Resident 43 returned from an outing fatigued with a decreased level of responsiveness, was diaphoretic, had abnormal vitals signs and EMTs were called. A review of a 7/30/24 progress note written at 2:43 PM revealed Resident 43 returned to baseline after the EMTs arrived to the facility and refused to go to the hospital. Resident 43 reported he consumed four beers while out of the facility on an outing. An 8/2/24 public complaint alleged the facility failed to ensure resident safety regarding alcohol consumption during an outing and the facility failed to notify the resident representative in a timely manner regarding the resident's change of condition. An 8/7/24 public complaint alleged the facility failed to ensure the resident's safety during a community outing. An 8/14/24 public compliant alleged the facility failed to ensure a safe environment for the resident while on an outing with staff. An investigation dated 8/16/24 revealed two staff members, Staff 26 (Staffing Coordinator) and Staff 25 (HR), took Resident 43 to the river to go rock hunting. Orders were received for Resident 43 to have 12 ounces of beer while on the outing. Upon arrival to the river, Staff 26 gave one 12-ounce can of beer that she/he spilled; Resident 43 drank half to three quarters of this beer before it was spilled. Staff 26 gave another 12-ounce beer to Resident 43. Staff 26 and Staff 25 were in the river rock hunting, and Resident 43 was on the riverbank with Staff 25's son. Staff 25's son obtained the rest of the beers from the vehicle per Resident 43's request. Staff 26 and Staff 25 stated they were unaware Resident 43 drank more beers than beers Staff 26 gave to her/him. Resident 43 stated he drank three and a half 12-ounce beers in total. Upon return to the facility Staff 26 and Staff 25 stated Resident 43's nurse was not notified of her/his consumption of more than the 12-ounces of beer allowed by the physician order. Resident 43 went back to her/his room, staff noticed her/his change of condition and called EMTs. Resident 43 was back to baseline when the EMTs arrived and she/he declined to go to the hospital. On 8/29/24 at 11:53 AM Staff 25 stated Resident 43 asked her a week before they went to the river to go rock hunting she/he wanted a beer. Orders for the beer were obtained by Staff 2 (DNS). Staff 25 stated when they arrived at the river Resident 43 was given a beer which spilled and Staff 26 gave her/him another one. Staff 25 stated she and Staff 26 went into the river to rock hunt and Resident 43 stayed on the riverbank. Staff 25 stated she and Staff 26 were supervising Resident 43, but she was unaware Resident 43 drank more than the beer Staff 26 gave her/him and she was unaware of her son getting the rest of the beers and bringing them down to the river. Staff 25 stated her son was unaware of how many beers Resident 43 could drink. Staff 25 stated they became aware how many beers were consumed when they were cleaning up and heading back to the facility. Staff 25 stated Resident 43 drank 2 to 3 beers but she was unsure. Staff 25 stated Staff 26 brought Resident 43 into the facility. Staff 25 stated she did not inform anyone how many beers Resident 43 drank. On 8/28/24 at 12:07 PM Staff 26 stated she verified the order with Resident 43's provider prior to the outing at the river. Staff 26 stated the provider stated she gave orders for Resident 43 to have 12 ounces of beer. Staff 26 stated she and Staff 25 were supervising Resident 43 but she was unaware Resident 43 consumed more beers than what she provided to her/him. Staff 26 stated she was unaware how many beers Resident 43 consumed but thought she/he had two 12-ounce beers and maybe a sip of another can. Staff 26 stated she brought Resident 43 back into the facility after the outing and informed the nurse Resident 43 needed a change of clothes, a shower and a nap. Staff 26 stated she did not inform the nurse how many beers Resident 43 consumed. On 8/29/24 at 12:16 PM Staff 2 stated she received orders for Resident 43 to consume 12 ounces of beer on the outing to the river, and both Staff 26 and Staff 25 were aware of the order. Staff 2 stated Staff 25's son gave Resident 43 more beers and Resident 43 consumed three and a half 12-ounce cans of beer. Staff 2 stated Staff 26 and Staff 25 did not inform anyone how many beers Resident 43 consumed upon return to the facility. Staff 2 confirmed Resident 43's physician orders were not followed. Resident 43 should have had no more than one 12-ounce can of beer and Staff 26 and Staff 25 should have informed Resident 43's nurse how many beers Resident 43 consumed so the nurse could inform the provider. 50897 4. Resident 14 admitted to the facility 2/2022 with diagnoses including chronic obstructive pulmonary disease. A review of a nursing Progress Note dated 4/11/24 at 7:56 PM revealed Staff 10 (LPN) noted a discrepancy in the Medication Administration Record and the Narcotics Log and said she believed the resident was given oxycodone instead of methadone for pain that morning. A review of the Medication Error report completed by Staff 10 on 4/11/24 revealed Staff 12 administered oxycodone to Resident 14 during the morning medication pass instead of methadone. Staff 12 correctly completed the Narcotics Log for oxycodone but entered methadone in the Medication Administration Report. On 8/29/24 at 1:04 PM Staff 11 (CMA) stated she noted the discrepancy in the Narcotics Log while administering methadone to Resident 14 during her afternoon medication pass on 4/11/24, and reported the discrepancy to Staff 10. On 8/29/24 at 1:17 PM Staff 12 (CMA) stated she did not recall administering the wrong medication to Resident 14 on 4/11/24. On 8/29/24 at 3:47 PM Staff 10 stated Staff 11 alerted her of the discrepancy in the Medication Administration Record the afternoon of 4/11/24, and informed her Resident 14 was likely administered oxycodone instead of methadone during morning medication pass. Staff 10 stated Resident 14 had no adverse side effects from receiving oxycodone. On 8/29/24 at 3:53 PM Staff 2 (DNS) stated she was aware of the medication error on 4/11/24 regarding Resident 14. Staff 2 stated she expected staff to ensure they followed physician orders and verify residents received the correct medications. 50930 5. Resident 4 admitted to the facility in 5/2023 with diagnoses including a brain tumor and epilepsy (a seizure disorder). A review of Resident 4's 8/28/24 Medication Admin Audit Report revealed the following: -Staff were to administer levothyroxine sodium (endocrine medication) at 7:00 AM, but the levothyroxine was not administered until 8:45 AM (one hour and 45 minutes late). -Staff were to administer apixaban (blood thinner) at 10:00 AM, but the apixaban was not administered until 11:42 AM (one hour 42 minutes late). -Staff were to administer lacosamide (anti-seizure medication) at 10:00 AM, but the lacosamide was not administered until 11:41 AM (one hour and 41 minutes late). -Staff were to administer baclofen (muscle spasm medication) at 10:00 AM, but the baclofen was not administered until 11:42 AM (one hour and 42 minutes late). -Staff were to administer levetiracetam (anti-seizure medication) at 10:00 AM, but the levetiracetam was not administered until 11:42 AM (one hour and 42 minutes late). -Staff were to administer pregabalin (nerve pain medication) at 10:00 AM, but the pregabalin was not administered until 11:41 AM (one hour and 41 minutes late). On 8/28/24 at 12:53 PM Staff 5 (CMA/CNA) verified there were multiple late medications for the 8/28/24 AM medication administration. She stated she was the only person responsible for passing all the resident medications and she struggled to administer medications on time due to high resident acuity. On 8/28/24 at 12:28 PM Staff 2 (DNS) stated the facility had flex and scheduled medication administration times and the expectation was all medications were administered at those times. On 8/28/24 at 3:05 PM Staff 8 (RN) stated multiple residents complained regarding late medications on day shift. 6. Resident 8 admitted to the facility in 7/2024 with diagnoses including stroke and chronic obstructive pulmonary disease. A review of Resident 8's 8/28/24 Medication Admin Audit Report revealed the following: -Staff were to administer acetaminophen (pain medication) at 8:00 AM, but the acetaminophen was not administered until 11:17 AM (three hours and 17 minutes late). On 8/28/24 at 12:53 PM Staff 5 (CMA/CNA) verified there were multiple late medications for the 8/28/24 AM medication administration. She stated she was the only person responsible for passing all the resident medications and she struggled to administer medications on time due to high resident acuity. On 8/28/24 at 12:28 PM Staff 2 (DNS) stated the facility had flex and scheduled medication administration times and the expectation was all medications were administered at those times. On 8/28/24 at 3:05 PM Staff 8 (RN) stated multiple residents complained regarding late medications on day shift. 7. Resident 13 admitted to the facility in 6/2024 with diagnoses including chronic obstructive pulmonary disease and arthritis. A review of Resident 13's 8/28/24 Medication Admin Audit Report revealed the following: -Staff were to administer metoprolol tartrate (blood pressure medication) at 8:00 AM, but the metoprolol tartrate was not administered until 11:19 AM (3 hours and 19 minutes late). -Staff were to administer Oxycodone HCL (opioid pain medication) at 8:00 AM, but the Oxycodone HCL was not administered. This medication was scheduled every four hours and the last dose was administered at 4:00 AM on 8/28/24. -Staff were to administer gabapentin (nerve pain medication) at 8:00 AM, but the gabapentin was not administered. This medication was scheduled for every eight hours. On 8/28/24 at 12:53 PM Staff 5 (CMA/CNA) verified there were two medications not given (Oxycodone and gabapentin), and multiple late medications for the 8/28/24 AM medication administration. She stated she was the only person responsible for passing all the resident medications and she struggled to administer medications on time due to high resident acuity. On 8/28/24 at 12:28 PM Staff 2 (DNS) stated the facility had flex and scheduled medication administration times and the expectation was all medications were administered at those times. On 8/28/24 at 3:05 PM Staff 8 (RN) stated multiple residents complained regarding late medications on day shift. 8. Resident 41 admitted to the facility in 2/2024 with diagnoses including diabetes and chronic kidney disease. An 8/28/24 Medication Admin Audit Report of Resident 41's AM medication administration revealed the following: -Staff were to administer metformin HCL (diabetic medication) at 8:00 AM, but the metformin HCL was not administered until 11:35 AM (three hours and 35 minutes late). On 8/28/24 at 12:53 PM Staff 5 (CMA/CNA) verified there were multiple late medications for the 8/28/24 AM medication administration. She stated she was the only person responsible for passing all the resident medications and she struggled to administer medications on time due to high resident acuity. On 8/28/24 at 12:28 PM Staff 2 (DNS) stated the facility had flex and scheduled medication administration times and the expectation was all medications were administered at those times. On 8/28/24 at 3:05 PM Staff 8 (RN) stated multiple residents complained regarding late medications on day shift. 9. Resident 203 admitted to the facility in 5/2024 with diagnoses including sepsis (severe infection) and chronic pain syndrome. An 8/28/24 Medication Admin Audit Report of Resident 203's AM medication administration revealed the following: -Staff were to administer gabapentin (nerve pain medication) at 8:00 AM, but the gabapentin was not administered until 9:38 AM (one hour and 38 minutes late). -Staff were to administer apixaban (blood thinner) at 8:00 AM, but the apixaban was not administered until 9:37 AM (one hour and 37 minutes late). -Staff were to administer acetaminophen (pain medication) at 8:00 AM, but the acetaminophen was not administered until 9:37 AM (one hour and 37 minutes late). -Staff were to administer Oxycontin (opioid pain medication) at 8:00 AM, but the Oxycontin was not administered until 9:38 AM (one hour and 38 minutes late). This medication was scheduled for every 8 hours. On 8/28/24 at 12:53 PM Staff 5 (CMA/CNA) verified there were multiple late medications for the 8/28/24 AM medication administration. She stated she was the only person responsible for passing all the resident medications and she struggled to administer medications on time due to high resident acuity. On 8/28/24 at 12:28 PM Staff 2 (DNS) stated the facility had flex and scheduled medication administration times and the expectation was all medications were administered at those times. On 8/28/24 at 3:05 PM Staff 8 (RN) stated multiple residents complained regarding late medications on day shift.

Based on observation, interview and record review it was determined the facility failed to ensure proper storage and labeling of medication and biologicals for 1 of 2 treatment carts and 1 of 1 medication and biologicals refrigerator reviewed for biologicals and medication storage. This placed residents at risk for reduced efficacy of medication, inaccurate tuberculosis testing, and decreased vaccine efficacy. Findings include: During an audit of the South Hall treatment cart with Staff 8 (RN) on [DATE] at 3:50 PM, an open vial of Insulin Glargine dated [DATE] was observed in the cart. Staff 8 examined the vial and confirmed the date on the vial was over 28 days and it should have been discarded. While conducting an audit of the medication and biologicals refrigerator on [DATE] at 11:14 AM with Staff 9 (LPN) an open and undated multi-dose vial of tuberculin solution (a solution used in testing for Tuberculosis), and multiple closed vials of Spikevax (COVID - 19 vaccine) with an expiration date of [DATE] were found in a basket on a shelf. Staff 9 verified there was no open date on the tuberculin and placed it in the sharps container (plastic container designed to safely hold needles and other sharps). Staff 9 verified the vials of Spikevax were expired and stated the facility was waiting for the pharmacy to exchange them for viable vaccines. The tuberculin manufacturer package insert, revised ,d+[DATE], indicated the tuberculin vial was to be discarded 30 days after opening. On [DATE] at 2:11 PM Staff 3 (RNCM) stated the expectation was for all medications to have an open date, the insulin and tuberculin to be put in the sharps container when expired, and for the Spikevax vaccines to be labeled as do not use and returned to the pharmacy.

Based on interview and record review it was determined a resident was not spoken to in a dignified manner for 1 of 3 sampled residents (#47) reviewed for dignity. This placed residents at risk for lack of self-worth. Findings include: Resident 47 admitted to the facility in 7/2024 with a diagnosis of post-surgical procedure paraplegia. On 8/14/24 Witness 9 (Anonymous) reported to the State agency Staff 7 (CNA) would not change Resident 47's sheets and it caused Resident 47 to feel afraid and Resident 47 felt she/he had to argue to receive care. A 7/31/24 admission MDS revealed Resident 47 was cognitively intact. On 8/26/24 at 3:30 PM Resident 47 stated her/his sheets were wet from sweat and requested Staff 7 (CNA) to change the sheets. Staff 7 insisted the sheets were not wet. Resident 47 stated it was frustrating to have to always argue with staff to have care provided. Eventually the sheets were changed. On 8/28/24 at 10:31 AM Staff 2 (DNS) stated if a resident requested her/his sheets to be changed, staff should honor the request. Staff 2 stated Resident 47 reported she/he requested her/his sheets to be changed, staff left, and Resident 47 felt it took too long for staff to return. On 8/29/24 at 10:26 AM Staff 7 (CNA) stated on one occasion Resident 47 stated her/his sheets were wet from sweat and wanted the sheets changed. Staff 7 stated she checked the sheets and told resident the sheets were not wet and did not need to be changed. However, she left the room, found another CNA, returned to the resident's room, and they changed her/his sheets.

Based on interview and record review it was determined the facility failed to ensure staff followed the care plan related to fall safety for 1 of 3 sampled residents (# 1) reviewed for accidents. Resident 1 fell and sustained a right [CONDITION(S)]. Findings include: A public complaint was received on 7/13/20 that alleged the facility failed to provide appropriate care and services related to resident's fall. Resident 1 admitted to the facility in 2018 with diagnoses including stroke, abnormal gait and lack of coordination. A comprehensive care plan dated 1/17/20 indicated Resident 1 was a high fall risk and to keep call light in reach, floor free of clutter and Resident 1 was to wear non-skid socks with ambulation. Resident 1 was a one-person extensive assist for toileting and required the use of a gait belt when transferring and using her/his FWW (front wheeled walker). An incident report initiated on 7/12/2020 revealed the following: -Staff 14 (CNA) assisted Resident 1 to the bathroom using her/his FWW and as Resident 1 made her/his way to the bathroom Staff 14 followed behind her/him. Resident 1's FWW got caught on her/his roommates walker and caused Resident 1 to lose her/his balance and fall to the ground landing on her/his right hip. Staff 14 was unable to get from behind her/him and catch her/him in time. Resident 1 did not have a gait belt on during the time of the transfer. -Staff 14 alerted Staff 22 (RN) who entered the room and Resident 1 was on the ground, complaining of right hip pain. Staff 22 assessed the resident and directed staff to transfer her/him to bed by use of a mechanical lift. -Staff 22 notified the on-call physician and an in-house x-ray was completed and results showed a fracture to the right hip that appeared to be subacute to chronic in nature. -On 7/13/20 Resident 1 had increased pain in the morning and was sent to the hospital for evaluation. It was confirmed Resident 1 did fracture her/his right hip and was admitted for possible surgery. -Staff 14 indicated she got report from her fell ow CNAs that Resident 1 took herself/himself to the bathroom with the use of an FWW. Staff 14 stated she approached Resident 1 and asked the resident if she/he had been using a gait belt during ambulation and she/he stated she/he did not need a gait belt and did fine without one. Staff 14 stated based on what Resident 1 said she did not utilize a gait belt. -It was determined Staff 14 failed to utilize a gait belt during Resident 1's ambulation and the policy stated all residents had gait belts used with transfers/ambulation unless it was medically contraindicated. A 7/12/20 Plan of Correction revealed the following: -An incident report for the right [CONDITION(S)] was completed, MD and family were notified. The resident was sent to the hospital for possible surgical interventions. Education was completed with Staff 14 regarding the use of gait belts with all transfers and ambulation unless medically contraindicated and were specified on resident's care plan. -All residents that required assistance with transfers/ambulation were at risk for the deficient practice. Nurse management identified other residents that required assistance with transfers and ensured care plans were accurate -Nursing staff was re-educated on the use of gait belts with all residents that required assistance with transfers and ambulation. -Licensed nurses were educated regarding reviewing care plan and standards of care after each incident in which resident falls during ambulation, or transfers with staff present, to ensure a gait belt was used. -To ensure ongoing compliance Staff 2 DNS or designee will complete audits weekly times four weeks, then monthly times two months to validate that transfers and ambulation were being conducted with the use of a gait belt. -The results of the audits completed were brought to Quality Assurance and Performance Improvement and further audits would be completed as directed by the committee. A 7/16/20 Hospital Discharge Summary indicated Resident 1 had a ground level fall at her/his nursing facility resulting in a right [CONDITION(S)] that required right hip surgery with no intraoperative complications. Resident 1 was discharged back to her/his nursing facility. Attempts were made to reach Witness 5 (Complainant) but were unsuccessful. On 12/21/21 at 12:50 PM Staff 18 (CNA) stated she was not present on 7/12/20 when Resident 1 broke her/his hip but stated she/he was a fall risk. Staff 18 stated Resident 1 used a FWW and required a one-person extensive assist with transfers and ambulation and required a gait belt for safety. Attempts were made to reach Staff 22 but were unsuccessful. On 12/22/21 at 12:55 PM Staff 14 stated she recalled the incident on 7/12/20 when Resident 1 fell . Staff 14 stated Resident 1 was a one-person extensive assist with the use a gait belt. Staff 14 stated Resident 1 needed assistance to the bathroom and she did not place a gait belt on Resident 1. When the resident ambulated with her/his FWW she/he fell which resulted in a fractured hip. Staff 14 stated Resident 1 was complaining of pain to her/his hip. Staff 14 stated she called for backup, a nurse entered the room and assessed Resident 1 and they placed her/him back into bed. Staff 14 stated she thought Resident 1 was not sent out to the hospital until the following day. Staff 14 further stated she should have reviewed the care plan. On 12/23/21 at 10:28 AM Resident 1 stated she/he recalled the fall on 7/12/20. Resident 1 stated a CNA helped her/him while using her/his FWW. Resident 1 stated the FWW got caught up on something and caused her/him to fall to the ground and she/he broke her/his right hip. Resident 1 stated she/he could not recall if a gait belt was used but stated the break was painful. Resident 1 stated she/he thought she/he was sent out later that evening to the hospital but could not recall. On 12/22/21 at 4:00 PM and 12/29/21 at 10:37 AM Staff 2 (DNS) acknowledged the 7/12/20 fall incident which resulted in Resident 1 sustaining a right [CONDITION(S)]. Staff 2 stated she expected Staff 14 (CNA) to review the care plan and utilize the gait belt when transferring Resident 1.

Based on interview and record review it was determined the facility failed to obtain physician orders for skin monitoring and care of a soft cast splint for 1 of 3 sampled residents (#3) reviewed for pressure ulcers. Resident 3 developed two stage 3 pressure ulcers which required additional treatment. Findings include: Resident 3 was admitted to the facility in 2019 with [DIAGNOSES REDACTED]. Review of hospital transfer orders dated 5/3/19 revealed the resident was non weight bearing on the right ankle due to an ankle fracture and the resident was to follow up with orthopedics in two weeks. The orders indicated the resident had a soft cast splint on the right leg and the resident had no pressure ulcers. Review of a baseline care plan dated 5/3/19 revealed no documentation the resident was care planned for care and monitoring of the resident's right leg soft cast splint. Review of nursing notes from 5/6/19 through 5/14/19 revealed no documentation the facility received physician orders for skin care and monitoring of the resident right lower leg under the soft cast. Review of a facility incident report dated 5/15/19 revealed Resident 3 had a soft cast to the right lower leg due to a leg fracture. The report indicated the resident went to a follow up appointment with orthopedics and when the soft cast was removed two pressure ulcers were found. The wounds were on the resident's right heel and top of the resident's right foot which were caused by rubbing or pressure from the soft cast. The resident had a [DIAGNOSES REDACTED]. The report indicated the resident returned to the facility with wound care orders and a would care referral. The report also indicated the wounds were avoidable and facility staff did not obtain physician orders for removal of the soft cast and monitoring of the resident's skin on the right lower leg. Review of a wound nurse practitioner note dated 5/15/19 revealed the resident had a right heel and foot deep tissue injury with persistent non-blanchable deep red, maroon or purple discoloration. The note indicated debridement would be medically necessary due to significant necrotic tissue. The resident was no longer in a soft cast and wore a walking boot. Review of a wound nurse practitioner note dated 5/22/19 revealed Resident 3 was seen for follow up to a facility acquired right heel and foot pressure ulcer. The note indicated the resident's wounds were debrided and contained eschar (dry, black, hard necrotic tissue) and slough (dead tissue, usually cream or yellow in color). The wounds were considered to be unstageable pressure injuries obscured full thickness skin and tissue loss. Review of a wound nurse practitioner note dated 6/5/19 revealed the resident's wounds were debrided and showed improvement. The right heel wound had 51-75% slough and the right foot wound had 76-100% slough. In an interview on 6/24/19 at 9:40 AM Staff 3 (LPN) said Resident 3 was admitted to the facility with a soft cast splint to the right leg. Staff 3 said she did not remove the resident's splint on admission to check the resident's skin and did not contact the resident's physician to obtain orders for skin monitoring and care of the soft cast splint. In an interview on 7/8/19 at 8:13 AM Staff 1 (DNS) acknowledged the facility failed to obtain physician orders regarding skin care and monitoring of the resident's soft cast splint which contributed to the resident developing two stage 3 pressure ulcers. The facility updated the resident's care plan on 5/15/19 which identified the resident had a walking boot on the right leg and was at risk for developing a pressure ulcer. Interventions included following physician orders for wound care and monitoring the resident's skin and the resident's wounds would be assessed once a week. The facility identified on 5/15/19 other residents who may be affected by the deficient practice and ensured the residents had physician orders in place for skin monitoring. The facility provided staff training on the use of external appliances such as splints and soft casts on 5/20/19. The facility DNS conducted weekly audits to ensure documentation was completed on resident skin integrity while an appliance was used. Results of the audits would be reported to QAPI for further recommendations.

Based on interview and record review it was determined the facility failed to follow the care plan regarding transfers for 1 of 6 sampled residents (#1) reviewed for accidents. Resident 1 was hit in the head by a Hoyer lift and had a laceration which required treatment at a local hospital. Findings include: Resident 1 was admitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. Review of an in-room care plan dated 9/4/18 revealed the resident required the use of a Hoyer lift and the assistance of two staff for transfers. Review of a nurse's note dated 9/27/18 at 1:54 PM revealed the charge nurse was called to the resident's room by a CNA. The note indicated the resident was lying on the resident's bed on top of Hoyer sling and there was blood on the bed, the resident's head and upper arm. The Hoyer lift was on the ground next to the resident's bed. The note indicated the resident had a laceration on the head, direct pressure was applied to wound and the resident was sent to a local hospital for evaluation. Review of a hospital note dated 9/27/18 revealed the resident was diagnosed with [REDACTED]. The note indicated the resident was hit in the head by a Hoyer lift during a transfer. Review of a Nursing Facility Self-Report form dated 9/28/18 revealed on 9/27/18 Staff 4 (CNA) transferred Resident 1 from a wheelchair to bed using a Hoyer lift. Staff 4 repositioned the resident over the resident's bed and the Hoyer lift tipped over on to the ground. The lift hit the resident in the head, caused a laceration and the resident was sent to a local hospital for treatment. Review of a facility incident investigation dated 9/28/18 revealed on 9/27/18 Resident 1 was transferred from a wheelchair to bed with the use of a Hoyer lift. The investigation indicated Staff 4 transferred the resident without additional assistance from staff per the resident's care plan. The Hoyer lift hit the resident in the head and caused a laceration which required an emergency room visit and four staples to close the wound. The investigation concluded the cause of the accident was due to Staff 4 not following the resident's care plan regarding transfers. In an interview on 11/15/18 at 8:15 AM Resident 1, who was alert and oriented, said on 9/27/18 she/he was being transferred from a wheelchair to bed when the Hoyer lift tipped over and the cross bar hit her/him on the head. Resident 1 said the Hoyer was operated by one CNA (Staff 4). Resident 1 said she/he had a laceration on the head and was sent to a local hospital for treatment. In an interview on 11/15/18 at 9:28 AM Staff 5 (LPN) said on 9/27/18 Staff 4 transferred Resident 1 via a Hoyer without the assistance of another staff person. Staff 5 said the resident had a [MEDICAL CONDITION] and was sent to a local hospital for treatment. In an interview on 11/29/18 at 9:31 AM Staff 6 (LPN) said on 9/27/18 Staff 4 came to her and reported the resident had an injury and needed to be assessed. Staff 6 said Staff 4 attempted to transfer the resident to bed by herself using a Hoyer lift, the Hoyer tipped over and the resident was hit in the head which caused a laceration. Staff 6 said the resident was assessed and sent to a local hospital for treatment. Staff 6 said the incident was caused by Staff 4 attempting to transfer the resident to bed alone without additional staff assistance.

Based on multiple immediate jeopardy situations and the number of citations including care and services, lab services, comprehensive assessments, treatments and services to prevent pressure ulcers, diabetic management, delay in treatment for [REDACTED]. This resulted in multiple occurrences of immediate jeopardy and substandard quality of care. Findings include: 1. Resident 92 experienced a delay in treatment of [REDACTED]. Refer to F-684 2. Resident 143 experienced a delay in treatment for [REDACTED]. Refer to F-684 and F-692 3. Resident 29 was not properly assessed for pain and experienced severe pain and hospitalization . Refer to F-697 4. Resident 92 had a delay in treatment for [REDACTED]. Refer to F-760 5. The facility failed to ensure Resident 153 received timely laboratory services as ordered. This caused Resident 153 to have a worsening of her/his infection creating a limited range of motion to the resident's infected area. Resident's 153, 27, 30 and 92 were provided antibiotic medication without the required laboratory testing to determine appropriate dosing placing them at immediate risk for serious harm related to worsening infections and severe adverse medication side effects. Refer to F-770 and F-757

Based on interview and record review it was determined the facility's quality assessment and assurance committee (QAA) failed to systematically identify and correct deficiencies in the areas of care and services, lab services, comprehensive assessments, treatments and services to prevent pressure ulcers, accidents, medications, significant medication errors, and nursing services. This resulted in multiple occurrences of immediate jeopardy and substandard quality of care. Findings include: 1. The facility failed to thoroughly investigate 5 out of 7 resident's incident reports reviewed for falls. 2. The facility failed to complete comprehensive admission assessments for 8 of 17 sampled residents. 3. The facility failed to implement, follow and maintain care plans for 11 of 22 sampled residents. 4. The facility failed to revise care plans for 7 out of 12 residents reviewed. 5. The facility failed to ensure discharge planning for 2 of 2 residents reviewed. 6. The facility failed to provide care and services to maintain good grooming and hygiene for 6 out of 6 residents reviewed. 7. The facility failed to provide timely care and services for 15 out of 15 residents. 8. The facility failed to provide ordered treatments in a timely manner for pressure ulcers for 2 of 3 residents reviewed for pressure ulcers. 9. The facility failed to keep the resident environment free of hazards for 1 of 1 sampled resident. 10. The facility failed to provide timely treatment for [REDACTED]. 11. The facility failed to ensure there was sufficient staff for 3 of 3 halls. 12. The facility failed to ensure staff had the competencies and skills to provide care to the residents. 13. The facility failed to comprehensively assess and provide appropriate care and services for residents with dementia for 2 of 2 residents. 14. The facility failed to follow up on pharmacy recommendations for 3 of 5 residents. 15. The facility failed to consistently monitor side effects for 8 of 14 residents which resulted in an immediate jeopardy situation. 16. The facility failed to ensure residents were free from significant medication errors for 3 of 5 residents which resulted in an immediate jeopardy situation. 17. The facility failed to ensure timely lab services for 4 of 5 residents which resulted in immediate jeopardy situation. 18. The facility failed to discontinue use of an antibiotic for 1 of 5 residents. On 1/30/18 at 2:34 PM Staff 1 (Administrator) stated he was new to the facility and there was a plan to conduct a mock survey to identify areas of concern. Refer to F607, F636, F656, F657, F660, F677, F684, F686, F689, F692, F725, F726, F744, F756, F757, F760, F770, and F881

Based on interview and record review it was determined the facility failed to ensure timely laboratory services were provided as ordered for 4 of 5 sampled residents (#s 27, 30, 92 and 153) reviewed for intravenous (injection into a vein) [MEDICATION NAME] (antibiotic used to treat acute infections). Resident's 153, 27, 30 and 92 were provided antibiotic medication without the required laboratory testing to determine appropriate dosing placing them at immediate risk for serious harm related to worsening infections and severe adverse medication side effects. Findings include: On 1/12/18 at 6:47 PM Staff 1 (Administrator) and Staff 37 (Regional Director of Operations) were informed of the failure of current measures used by the facility to ensure labratory testing was completed as ordered which constituted a situation of immediate jeopardy to health and welfare for residents. Surveyors requested a plan of correction to immediately protect the residents from harm be developed and implemented. On 1/12/18 at 9:51 PM a final immediate plan of correction was accepted from the facility, and at 11:04 PM the plan was verified as implemented removing the immediate risk to resident health and welfare. The immediate plan of correction included: - The facility verified to follow pharmacy recommendations for obtaining [MEDICATION NAME] (antibiotic) troughs (lab tests to determine the amount of [MEDICATION NAME] in the blood) with the contracted facility medical director. - The facility inserviced licensed nurses on obtaining appropriate orders for [MEDICATION NAME] to include trough orders per pharmacy recommendations. - A staff training roster was created to ensure training of staff currently working and staff scheduled on subsequent shifts. - Agency nursing staff were added to the staff training roster as they were scheduled in order to ensure they received training prior to working. - Training was provided by the DNS, nurse consultant or trained designee. - The DNS or a trained designee would, using a monitoring tool, monitor daily for any new orders for [MEDICATION NAME] or any intravenous (injected into the vein) medication which required labs to assure orders were written appropriately and to follow pharmacy recommendations. - DNS was responsible to ensure compliance. When [MEDICATION NAME] is used in the treatment of [REDACTED]. This allows for adjustments to the prescribed dosage by the physician or pharmacist. If [MEDICATION NAME] concentration in the blood is below therapeutic levels, the result is an ineffective treatment of [REDACTED]. If the concentration is above therapeutic levels it can result in [MEDICATION NAME] toxicity which can lead to serious consequences including acute renal (kidney) failure. 1. Resident 153 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 153's Discharge Orders dated 10/15/17 revealed the following: - [MEDICATION NAME] (antibiotic) inject into the vein every 24 hours for 31 days. - Weekly [MEDICATION NAME] troughs (lab test to determine the amount of [MEDICATION NAME] in the blood) with the first trough to be completed on 10/17/17. - Weekly labs including Complete Blood Count (CBC) with differential, Comprehensive Metabolic Panel (CMP), Erythrocyte Sedamentation Rate (ESR), and C-Reactive Protein (CRP) (labs to test the resident general health status) with the first labs to be completed on 10/17/17. A review of Resident 153's medical record revealed no evidence a [MEDICATION NAME] trough, CBC with differential, CMP, ESR or CRP labs were completed on 10/17/17. laboratory results dated [DATE] revealed the resident's first [MEDICATION NAME] trough, CBC with differential, CMP, ESR or CRP labs were not completed until 10/23/17. Review of Resident 153's medical record revealed no further lab testing aside from [MEDICATION NAME] trough labs was completed and the resident's [MEDICATION NAME] therapy ended on 11/1/17. On 1/31/18 at 7:02 AM Staff 2 (DNS) confirmed Resident 153 did not have her/his first [MEDICATION NAME] trough completed until 10/23/17. 2. Resident 27 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 27's hospital Discharge Orders dated 12/19/17 revealed the following: - [MEDICATION NAME] 500 mg injection into vein daily for 28 days. - Pharmacy to follow, order follow up levels per protocol and make any needed [MEDICATION NAME] dosing adjustments. Lab results from 12/29/17 showed a [MEDICATION NAME] trough (lab test to test the level of [MEDICATION NAME] in the blood) was completed on 12/29/17. Resident 27's medical record revealed no evidence any [MEDICATION NAME] troughs were completed before 12/29/17. A pharmacy communication sheet dated 1/3/18 instructed staff to complete a [MEDICATION NAME] trough on 1/7/18 prior to the resident's 10:30 PM dose of [MEDICATION NAME]. Review of the medical record revealed no evidence a [MEDICATION NAME] trough was completed on 1/7/18 as ordered. A lab report showed the resident had a [MEDICATION NAME] trough completed on 1/8/18. On 1/12/17 at 1:53 PM Staff 35 (IV Pharmacist) stated the standard of practice when the pharmacy was managing [MEDICATION NAME] was for the first [MEDICATION NAME] trough to be completed before the fourth dose of [MEDICATION NAME] was administered and to complete troughs two times a week until the resident was stable on the [MEDICATION NAME] dose. On 1/30/18 at 5:06 PM Staff 2 (DNS) confirmed the resident's first [MEDICATION NAME] trough was not completed until ten days after the residents admission and the resident had a [MEDICATION NAME] trough that was ordered to be completed on 1/7/18 but was not completed until 1/8/18. 3. Resident 30 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 30's Discharge Orders dated 11/22/17 revealed the following: - [MEDICATION NAME] (antibiotic) inject into the vein daily at noon - Weekly [MEDICATION NAME] troughs (test to indicate the level of [MEDICATION NAME] in the blood) - Pharmacy to manage the resident's [MEDICATION NAME] dosing Pharmacy communication notes dated 11/23/17 through 11/25/17 revealed the pharmacy was managing and dosing the resident's [MEDICATION NAME] as ordered. A Progress Note dated 12/1/17 indicated Resident 30 was sent to the emergency room related to increased confusion. A discharge order report dated 12/5/17 revealed the resident was discharged from the hospital on [DATE] with continued orders for [MEDICATION NAME] injections daily at noon. No orders were present regarding who managed the [MEDICATION NAME] dosing. A Progress Note dated 12/5/17 indicated the resident readmitted to the facility. A pharmacy communication dated 12/11/17 indicated the resident's current [MEDICATION NAME] trough level was unknown and instructed staff to complete a [MEDICATION NAME] trough on 12/12/17. Resident 30's medical record revealed no evidence the resident had a [MEDICATION NAME] trough completed from readmission on 12/5/17 through 12/11/17 and the pharmacy increased the resident's [MEDICATION NAME] dosage based on the results of the 12/12/17 [MEDICATION NAME] trough. On 1/12/17 at 1:53 PM Staff 35 (IV Pharmacist) stated the standard of practice when the pharmacy was managing [MEDICATION NAME] was for the first [MEDICATION NAME] trough to be completed before the fourth dose of [MEDICATION NAME] was administered and to complete troughs two times a week until the resident was stable on the [MEDICATION NAME] dose. On 1/30/18 at 5:13 PM Staff 2 (DNS) confirmed no [MEDICATION NAME] troughs were completed for the resident from 12/5/17 through 12/11/17. 4. Resident 92 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 92's admission orders [REDACTED]. A pharmacy communication report dated 9/2/17 revealed an order for [REDACTED]. A lab report dated 9/4/17 revealed a [MEDICATION NAME] trough was completed on 9/4/17 and the result was 23.4. According to the report the therapeutic range for the medication was between 15 and 20. A pharmacy communication report dated 9/5/17 revealed an order for [REDACTED]. A lab report dated 9/7/17 revealed a [MEDICATION NAME] trough was completed on 9/7/17 (one day after the trough was ordered to be completed) and the result was 17.52. A pharmacy communication report dated 9/7/17 revealed an order for [REDACTED]. A lab report dated 9/14/17 revealed a [MEDICATION NAME] trough was completed on 9/13/17 (one day after the trough was ordered to be completed) and the result was 13 (below the therapeutic range). A pharmacy communication report dated 9/14/17 revealed an order for [REDACTED]. A lab report dated 9/16/17 revealed a [MEDICATION NAME] trough was completed on 9/16/17 (one day after the trough was ordered to be completed) and the result was 17. A pharmacy communication report dated 9/16/17 revealed an order for [REDACTED]. Resident 92's medical record revealed no evidence [MEDICATION NAME] troughs were completed on 9/5/17, 9/6/17, 9/12/17, 9/13/17 and 9/15/17 as ordered by the pharmacy. No labs or pharmacy recommendations were located in the resident's medical record for the period of 9/19/17 through 9/26/17. On 1/30/18 at 2:49 PM Staff 24 (RCM-traveling) confirmed the resident's [MEDICATION NAME] troughs were late and not completed as ordered. On 1/31/17 at 10:35 AM Staff 11 (Director of Operations, Pharmacy) confirmed a [MEDICATION NAME] trough was not completed on 9/19/17 until 11:03 PM and no changes to the [MEDICATION NAME] dose were indicated. The next trough was ordered for 9/25/17 and was not completed until 9/26/17.

Based on interview and record review it was determined the facility failed to provide appropriate monitoring and dosing of medications for 8 of 14 sampled residents (#s 1, 4, 15, 20, 27, 30, 92 and 153) reviewed for medications, pressure ulcers, hospitalization and behavior. Resident 153 received a sub thereuputic dose of antibiotics used to treat an acute infection resulting in a worsening in her/his infection and a partial imobilization to her/his infected area. Residents 27, 30 and 92 experienced delayed treatment for [REDACTED]. Findings include: On 1/12/18 at 6:47 PM Staff 1 (Administrator) and Staff 37 (Regional Director of Operations) were informed of the failure of current measures used by the facility to ensure appropriate monitoring and dosing of medications which constituted a situation of immediate jeopardy to health and welfare for residents. Surveyors requested a plan of correction to immediately protect the residents from harm be developed and implemented. On 1/12/18 at 9:51 PM a final immediate plan of correction was accepted from the facility, and at 11:04 PM the plan was verified as implemented removing the immediate risk to resident health and welfare. The immediate plan of correction included: - The facility verified to follow pharmacy recommendations for obtaining [MEDICATION NAME] (antibiotic) troughs (lab tests to determine the amount of [MEDICATION NAME] in the blood) with the contracted facility medical director. - The facility inserviced licensed nurses on obtaining appropriate orders for [MEDICATION NAME] to include trough orders per pharmacy recommendations. - A staff training roster was created to ensure training of staff currently working and staff scheduled on subsequent shifts. - Agency nursing staff were added to the staff training roster as they were scheduled in order to ensure they received training prior to working. - Training was provided by the DNS, nurse consultant or trained designee. - The DNS or a trained designee would, using a monitoring tool, monitor daily for any new orders for [MEDICATION NAME] or any intravenous (injected into the vein) medication which required labs to assure orders were written appropriately and to follow pharmacy recommendations. - DNS was responsible to ensure compliance. When [MEDICATION NAME] is used in the treatment of [REDACTED]. This allows for adjustments to the prescribed dosage by the physician or pharmacist. If [MEDICATION NAME] concentration in the blood is below therapeutic levels, the result is an ineffective treatment of [REDACTED]. If the concentration is above therapeutic levels it can result in [MEDICATION NAME] toxicity which can lead to serious consequences including acute renal (kidney) failure. 1. Resident 153 admitted to the facility on [DATE] with diagnosed including: [DIAGNOSES REDACTED]. Resident 153's Discharge Orders dated 10/15/17 revealed the following: - [MEDICATION NAME] 1,000 mg inject 1500 mg into the vein every 24 hours for 31 days. - Weekly [MEDICATION NAME] troughs with the first trough to be completed on 10/17/17. - Instructions to fax all requested lab results upon receipt to Oregon Health & Science University (OHSU) Adult Outpatient [MEDICATION NAME] Antimicrobial Therapy (OPAT) clinic. - Antibiotic treatment to continue through 11/15/17. - Do not hold the [MEDICATION NAME] therapy unless the trough results were above 20. A review of Resident 153's medical record revealed no evidence a [MEDICATION NAME] trough was completed on 10/17/17. A Physician Telephone Order dated 10/20/17 revealed the resident's primary care physician asked the facility if the pharmacy was managing the resident's [MEDICATION NAME]. A faxed communication from the pharmacy to the facility dated 10/20/17 revealed a note from a pharmacist stating according to the pharmacy records the OHSU Adult OPAT clinic was monitoring and adjusting Resident 153's [MEDICATION NAME] therapy. laboratory results dated [DATE] revealed a [MEDICATION NAME] trough lab was completed on 10/23/17 and the [MEDICATION NAME] level was eight. According to the report the thereuputic range for this medication was between 15 and 20. A faxed communication from the resident's primary care physician dated 10/23/17 revealed the facility had faxed the results of the 10/23/17 [MEDICATION NAME] trough to the resident's primary care physician and the physician responded asking if the pharmacy had adjusted the resident's [MEDICATION NAME] dose. A faxed communication dated 10/26/17 revealed the facility faxed the resident's primary care physician stating the resident's [MEDICATION NAME] trough was drawn on 10/24/17 and her/his [MEDICATION NAME] was being held until further instructions were received. The physician responded back stating the pharmacy was to manage the resident's [MEDICATION NAME] therapy and the goal trough was between 15 and 20. A pharmacy communication form dated 10/27/17 revealed a request from the pharmacy for resident information regarding the resident's [MEDICATION NAME] and a request for the physician to authorize the pharmacy dosing and monitoring the [MEDICATION NAME]. The resident's primary care physician responded back on 10/27/17 with authorization. A pharmacy communication form dated 10/27/17 revealed the pharmacy ordered a change in the [MEDICATION NAME] dosing. The form listed the antibiotic stop date as 11/15/17. A pharmacy communication sheet dated 10/30/17 stated the resident's [MEDICATION NAME] trough was nine as of 10/30/17 and directed the next [MEDICATION NAME] trough be completed on 11/1/17. A pharmacy communication sheet dated 11/1/17 stated the resident's [MEDICATION NAME] trough was 11 as of 11/1/17. The pharmacy directed staff to change the [MEDICATION NAME] dosing, to complete the next [MEDICATION NAME] trough on 11/5/17 and to discontinue the antibiotic on 11/15/17. No further pharmacy communications regarding the resident's [MEDICATION NAME] trough were located in the resident's medical record. Resident 153's Medication Administration History Report dated 10/15/17 through 11/14/17 revealed the following: - The resident was administered [MEDICATION NAME] at a dosage of 1500 mg every 24 hrs from 10/15/17 through 10/27/17. The medication was not administered on 10/23/17. There was no change in dosage following the resident's low trough on 10/23/17. - The resident was administered [MEDICATION NAME] at a dosage of 1,000 mg every 12 hrs from 10/28/17 through 11/1/17. No signed physician's order was located in the resident's medical record for the discontinuation of [MEDICATION NAME] therapy on 11/1/17. An emergency room encounter dated 11/5/17 stated the resident admitted to the emergency room for a displaced PICC line (intervenous access site). The report stated the hospital staff called the facility and the facility reported the resident had concluded [MEDICATION NAME] treatment on 11/1/17 so the resident's PICC line was not reinserted. Resident 153's medical record revealed no evidence the facility attempted to contact OHSU Adult OPAT regarding the resident's [MEDICATION NAME] or to contact the resident's primary care physician regarding the pharmacy's response to the 10/10/17 fax stating OHSU Adult OPAT was to be managing the resident's [MEDICATION NAME] therapy. There was no evidence the pharmacy was re-contacted between 10/20/17 and 10/27/17 regarding the primary care physician's additional requests for the pharmacy to manage the resident's [MEDICATION NAME] dosing. On 1/9/17 at 6:07 PM Witness 12 (Physician) stated the resident's [MEDICATION NAME] was to be dosed according to [MEDICATION NAME] levels and lab work. She stated when she saw the resident six days after admission she wrote an order asking if the pharmacy was managing the [MEDICATION NAME] and assumed the facility had followed up on the order. A week later a [MEDICATION NAME] trough was drawn and the level was low. The trough was faxed to Witness 12. A nurse held the medication even though the trough was low. Witness 12 stated she contacted the pharmacy and the pharmacy responded the order for the pharmacy to dose was never received. The pharmacy was under the impression someone else was managing the [MEDICATION NAME]. Witness 12 stated the resident went to the emergency room and her/his PICC line was not replaced and her/his [MEDICATION NAME] was stopped on 11/5/17. Witness 12 was under the impression the [MEDICATION NAME] was to continue until 11/15/17. Witness 12 stated the continued low trough results indicating a less then therapeutic dose of [MEDICATION NAME] with no dosage adjustments and the discontinuation of the [MEDICATION NAME] before it was ordered to end caused Resident 153 to have a worsening in her/his infection creating a partial imobilization to her/his infected area. On 1/25/18 at 5:36 PM Staff 22 (RN) stated she did not remember if she had checked the orders for Resident 153 when she/he admitted . She stated normally if labs were ordered a lab slip would be filled out upon admission. She stated generally she would call the pharmacy for instructions when labs came back. Staff 22 also stated she had been instructed by some individuals to hold the [MEDICATION NAME] when the troughs were low or high and other individuals to go ahead and administer the medication. She was unsure which was correct. She stated she did not recall specifically receiving an order to discontinue the resident's [MEDICATION NAME]. On 1/31/18 at 7:02 AM Staff 2 (DNS) confirmed Resident 153 did not have her/his first [MEDICATION NAME] trough completed until 10/23/17 and her/his [MEDICATION NAME] was not adjusted based on her/his low trough until 10/28/17. On 1/31/18 at 10:04 AM Staff 23 (Regional Nurse Consultant) confirmed there was no signed physician's order located for the discontinuation of the resident's [MEDICATION NAME] on 11/1/17. On 1/31/17 at 10:35 AM from Staff 11 (Director of Operations Pharmacy) stated on 10/19/17 the pharmacy received a fax from the facility questioning if the pharmacy was monitoring the resident's [MEDICATION NAME] and the pharmacist communicated to the facility OHSU Adult OPAT was ordered to monitor the [MEDICATION NAME]. Staff 11 further stated on 10/27/17 the pharmacy received a communication the resident's primary care physician was going to be monitoring the resident's [MEDICATION NAME] and she wanted the pharmacy to manage the medication. The pharmacy started monitoring the medication on 10/27/17. 2. Resident 27 admitted to the facility in 12/2017 with diagnosed including: [DIAGNOSES REDACTED]. Resident 27's Discharge Orders dated 12/19/17 revealed the following: - [MEDICATION NAME] inject into vein daily for 28 days. - The pharmacy was to manage labs and [MEDICATION NAME] dosing adjustments. A pharmacy communication sheet dated 12/19/17 asked the facility to fill out information on the resident's [MEDICATION NAME] and to obtain authorization from the physician for the pharmacy to manage the resident's [MEDICATION NAME] if appropriate. The form was not completed by the facility. Lab results from 12/29/17 showed a [MEDICATION NAME] trough (lab test to measure the level of [MEDICATION NAME] in the blood) was completed on 12/29/17 and the result was 16. Resident 27's medical record revealed no evidence any [MEDICATION NAME] troughs were completed before 12/29/17 and no evidence the facility communicated with the pharmacy until 12/29/17. A pharmacy communication sheet dated 1/3/18 instructed staff to complete a [MEDICATION NAME] trough on 1/7/18 prior to the resident's 10:30 PM dose. Review of the medical record revealed no evidence a [MEDICATION NAME] trough was completed on 1/7/18 as ordered. A lab report showed the resident had a [MEDICATION NAME] trough completed on 1/8/18. On 1/12/18 at 2:42 PM Staff 34 (Agency LPN) stated he was not aware of any instance where the pharmacy would ever manage a resident's medications and was not aware of the pharmacy and the facility procedures regarding the pharmacy management of [MEDICATION NAME]. He stated he did not remember going over Resident 27's orders or contacting the pharmacy upon the resident's admission. On 1/12/17 at 1:53 PM Staff 35 (IV Pharmacist) stated when residents admit to the facility with orders for intravenous antibiotics the pharmacy would send an intake form and it was the facilities responsibility to fill the form out and obtain a physician's signature. Staff 35 stated the standard of practice when the pharmacy was managing [MEDICATION NAME] was for the first [MEDICATION NAME] trough to be completed before the fourth dose of [MEDICATION NAME] was administered and to complete troughs two times a week until the resident was stable on the [MEDICATION NAME] dose. On 1/30/18 at 5:06 PM Staff 2 (DNS) confirmed the resident's first [MEDICATION NAME] trough was not completed until ten days after the resident's admission and the resident had a [MEDICATION NAME] trough ordered to be completed on 1/7/18 which was not completed until 1/8/18. On 1/31/17 at 10:35 AM from Staff 11 (Director of Operations, Pharmacy) stated the pharmacy attempted to contact the facility for completion of the paperwork needed to authorize the pharmacy to manage the resident's [MEDICATION NAME] during 12/2017 on 12/19, 12/20, 12/24 and 12/27. Staff 11 stated on 12/28/17 the pharmacy was contacted and it was reported the pharmacy was responsible for the dosing of the [MEDICATION NAME] and no [MEDICATION NAME] troughs had been completed. 3. Resident 30 admitted to the facility on [DATE] with diagnosed including: [DIAGNOSES REDACTED]. Resident 30's hospital Discharge Orders dated 11/22/17 revealed the following: - [MEDICATION NAME] (antibiotic) Inject into the vein daily at noon - Weekly lab testing including a [MEDICATION NAME] trough (test to indicate the level of [MEDICATION NAME] in the blood) - an order for [REDACTED]. Pharmacy communication notes dated 11/23/17 through 11/25/17 revealed the pharmacy was managing and dosing the resident's [MEDICATION NAME] as ordered. A Progress Note dated 12/1/17 indicated Resident 30 was sent to the emergency room related to increased confusion. A Discharge Order Report dated 12/5/17 revealed the resident was discharged from the hospital on [DATE] with continued orders for daily [MEDICATION NAME] injections at noon. No physician's order was found directing who managed the [MEDICATION NAME] dosing. A Progress Note dated 12/5/17 indicated the resident readmitted to the facility. A pharmacy communication dated 12/11/17 indicated the resident's current [MEDICATION NAME] trough level was unknown and instructed staff to complete a [MEDICATION NAME] trough on 12/12/17. Resident 30's medical record revealed no evidence the resident had a [MEDICATION NAME] trough completed from readmission on 12/5/17 through 12/12/17 and the pharmacy increased the resident's [MEDICATION NAME] dosage based on the results of the 12/12/17 [MEDICATION NAME] trough. Resident 30's 12/2017 MAR indicated [REDACTED]. No [MEDICATION NAME] troughs were completed until 12/12/17 and the medication dosing was not verified to ensure appropriate dosing was provided to Resident 30. On 1/12/17 at 1:53 PM Staff 35 (IV Pharmacist) stated when residents admit to the facility with orders for intravenous antibiotics the pharmacy would send an intake form and it was the facility's responsibility to fill the form out and obtain a physician's signature. Staff 35 stated the standard of practice when the pharmacy was managing [MEDICATION NAME] was for the first [MEDICATION NAME] trough to be completed before the fourth dose of vanco was administered and to complete troughs two times a week until the resident was stable on the [MEDICATION NAME] dose. Staff 35 stated the [MEDICATION NAME] dosing was adjusted by the pharmacy based on a resident's [MEDICATION NAME] trough results. On 1/12/18 at 3:12 PM Staff 36 (Agency LPN) she did not have much knowledge regarding [MEDICATION NAME] troughs. She stated she would contact the resident's primary care physician regarding any labs. She stated she was not aware of the pharmacy ever managing a resident's [MEDICATION NAME] and had not been provided any training on [MEDICATION NAME] troughs. She stated she could not remember the details of Resident 30's 12/5/17 readmission from the hospital and if she had contacted the pharmacy. On 1/30/18 at 5:13 PM Staff 2 (DNS) confirmed no [MEDICATION NAME] troughs were completed for Resident 30 from 12/5/17 through 12/11/17. On 1/31/18 at 10:35 AM Staff 11 (Director of Operations Pharmacy) revealed the pharmacy faxed the facility on 12/6/17 to verify who was monitoring the [MEDICATION NAME] and obtain authorization to monitor if appropriate. The facility did not respond until 12/11/17. 4. Resident 92 was admitted to the facility in 8/2017 with diagnosed including: [DIAGNOSES REDACTED]. Resident 92's admission orders [REDACTED]. A pharmacy communication report dated 9/2/17 revealed an order for [REDACTED]. A lab report dated 9/4/17 revealed a [MEDICATION NAME] trough was completed on 9/4/17 and the result was 23.4 (According to the report the therapeutic range for this medication was between 15 and 20). Resident 92's medical record revealed no evidence a [MEDICATION NAME] trough was completed on 9/5/17 as ordered by the pharmacy. A pharmacy communication report dated 9/5/17 revealed an order for [REDACTED]. A lab report dated 9/7/17 revealed a [MEDICATION NAME] trough was completed on 9/7/17 (one day after the trough was ordered to be completed) and the result was 17.52. A pharmacy communication report dated 9/7/17 revealed an order for [REDACTED]. A lab report dated 9/14/17 revealed a [MEDICATION NAME] trough was completed on 9/13/17 (one day after the trough was ordered to be completed) and the result was 13 (below the therapeutic range). A pharmacy communication report dated 9/14/17 revealed an order for [REDACTED]. A lab report dated 9/16/17 revealed a [MEDICATION NAME] trough was completed on 9/16/17 (one day after the trough was ordered to be completed) and the result was 17. A pharmacy communication report dated 9/16/17 revealed an order for [REDACTED]. No labs or pharmacy recommendations were located in the resident's medical record for the period of 9/19/17 through 9/26/17. On 1/30/18 at 2:49 PM Staff 24 (RCM-traveling) confirmed the resident's [MEDICATION NAME] troughs were late and not completed as ordered. An email communication on 1/31/17 at 10:35 AM from Staff 11 (Director of Operations, Pharmacy) revealed a [MEDICATION NAME] trough was not completed on 9/19/17 until 11:03 PM and no changes in dosing were made. The next trough was ordered for 9/25/17 and was not completed until 9/26/17. 5. Resident 20 was admitted to the facility in 12/2017 with diagnosed including: [DIAGNOSES REDACTED]. A Physician's Order Report for 12/2017 indicated Resident 20 had an order for [REDACTED]. A review of Resident 20's electronic health record revealed no [DIAGNOSES REDACTED]. On 1/26/18 at 12:40 PM Staff 11 (Pharmacy Regional Director) acknowledged there was no [DIAGNOSES REDACTED]. 6. Resident 4 was admitted to the facility in 2/2013 with diagnosed including: [DIAGNOSES REDACTED]. a. Signed physician orders dated 1/3/18 with a start date of 3/28/16 instructed staff to administer [MEDICATION NAME] (treat heartburn) 30 minutes before meals. No documentation was located in the resident's medical record for indications for use for Resident 4's [MEDICATION NAME]. On 1/23/18 at 3:17 PM Staff 3 (Regional Nurse Consultant) confirmed there were no indications for use for Resident 4's [MEDICATION NAME]. b. Signed physician orders dated 1/3/18 with a start date of 2/20/17 instructed staff to administer Eliquis (anticoagulant) two times a day. No documentation was located in the residents medical records Resident 4 was being monitored for bruising or bleeding while on an anticoagulant or indications for the use of the anticoagulant. On 1/23/18 at 3:17 PM Staff 3 (Regional Nurse Consultant) confirmed there was no monitoring or indications for use in place for Resident 4 for her/his anticoagulant. 7. Resident 15 was admitted to the facility in 11/2017 with diagnosed including: [DIAGNOSES REDACTED]. a. Signed physician orders dated 1/4/18 instructed staff to administer Eliquis twice a day (anticoagulant) with a start date of 11/17/17. The 1/2018 MAR indicated [REDACTED]. No documentation could be located in the resident's medical record indicating Resident 15 was monitored for taking an anticoagulant. On 1/29/18 at 12:52 PM Staff 2 (DNS) and Staff 3 (Regional Nurse Consultant) confirmed Resident 15 was taking an anticoagulant and no monitoring for side effects was in place. b. Signed physician orders dated 1/4/18 instructed staff to administer [MEDICATION NAME] (diuretic) with a start date of 11/17/17. The 1/2018 MAR indicated [REDACTED] No documentation could be located in the resident's medical record indicating Resident 15 was receiving monitoring for taking an diuretic. On 1/29/18 at 12:52 PM Staff 2 (DNS) and Staff 3 (Regional Nurse Consultant) confirmed Resident 15 was taking a diuretic and no monitoring of side effects was in place. 8. Resident 1 was admitted to the facility in 10/2012 with diagnosed including: [DIAGNOSES REDACTED]. Physician orders signed 1/3/18 instructed staff to administer Xarelto (anticoagulant) once a day. a. The MAR indicated [REDACTED]. b. The comprehensive care plan edited date of 10/11/17 instructed staff to observe for signs of active bleeding, and other side effects for anticoagulant therapy. No documentation was located in the resident's medical record indicating Resident 1 was monitored for side effects for an anticoagulant. On 1/25/18 at 1:08 PM Staff 2 (DNS) and Staff 3 (Regional Nurse Consultant) confirmed there were no indications for use or monitoring for an anticoagulant medication.

Based on observation, interview and record review it was determined the facility failed to follow physician's orders and provide care to maintain the highest practicable level of well being for 14 of 15 sampled residents (#s 1, 4, 6, 15, 17, 20, 29, 30, 39, 40, 92,143,147 and 153) reviewed for medications, hospice and accidents. As a result of this deficient practice Resident 92 experienced a delay in treatment of [REDACTED]. Resident 143 experienced a delay in treatment for [REDACTED]. An immediate jeopardy situation was called. Findings include: On 1/26/18 at 3:22 PM Staff 1 (Administrator), Staff 2 (DNS), Staff 3 (Regional Nurse Consultant), Staff 23 (Regional Nurse Consultant), and Staff 37 (Regional Director of Operations) were informed of the failure of current measures used by the facility to ensure physician's orders were followed which constituted a situation of immediate jeopardy to health and welfare for residents. Surveyors requested a plan of correction to immediately protect the residents from harm be developed and implemented. On 1/26/18 at 9:33 PM a final immediate plan of correction was accepted from the facility, and at 10:05 PM the plan was verified as implemented removing the immediate risk to residents health and welfare. The immediate plan of correction included: -All residents admitted in the last 30 days from 1/26/18 were reviewed to verify physician orders were followed. -Managing acute changes of condition (MACC) process to audit all new admissions until 2/26/18, followed by two residents per week for eight weeks. -Other residents which could be effected were identified and reviewed. -Training was completed on 1/26/18 for floor nurses which included medication administration, and processing new orders. Training for staff working after 1/26/18 was completed each shift for any untrained staff, and the training was documented and kept by the DNS. -To ensure physicians orders were followed after 1/26/18, and were accurately transcribed into the MAR, TAR, and diabetic administration record, new orders were reviewed using the MACC process and was reviewed by a trained designee on the weekend until compliance was achieved. -The DNS was responsible for assuring compliance. -All findings were brought to quality assurance and performance improvement for analysis. 1. Resident 92 was admitted to the facility in 8/2017 with [DIAGNOSES REDACTED]. a. A Progress Note dated 8/26/17 stated the resident arrived at the facility at 2:30 PM on 8/26/17. Resident 92's hospital Discharge Summary Report dated 8/26/17 revealed Resident 92 was ordered medications including: -Insulin [MEDICATION NAME] (insulin) to be administered per sliding scale instructions. Instructions stated to call the physician if CBG reading (test to see the amount of glucose present in a person's blood) was at or over 300. -[MEDICATION NAME] HCL (diabetic medication) take orally two times per day with meals. -[MEDICATION NAME] HCL Injection (intravenous antibiotic medication) intravenously every 8 hours. -[MEDICATION NAME] Sodium injection (intravenous antibiotic medication) take intravenous (IV) piggyback every 24 hours, 100 ml per hour for 6 hours. -[MEDICATION NAME] APAP (narcotic pain medication with [MEDICATION NAME]) -take one tab orally every four hours as needed for pain. Resident 92's 8/2017 MAR, DAR (Diabetic Administration Record) and TAR revealed Resident 92 was not administered the first dose of the following medications until 8/27/17 at the following times: -[MEDICATION NAME] insulin, 5:00 PM. -[MEDICATION NAME], 5:00 PM. -[MEDICATION NAME], 6:00 pm. -[MEDICATION NAME], 2:50 pm. On 8/27/17 Resident 92's CBG reading was 317 at 5:00 PM and 314 at 8:00 PM (Per the American Diabetic Association normal blood glucose parameters for a person with diabetes range from 80-130). A facility Incident Investigation dated 8/27/17 through 8/29/17 revealed Resident 92's medication and treatment was not transcribed on the MAR, DAR and TAR upon admission to the facility. The resident missed three doses of [MEDICATION NAME], one dose of [MEDICATION NAME] sodium, CBGs, sliding scale insulin and all other ordered medications. The report further stated the resident she/he asked for pain medication and only received Tylenol even though she/he had an order for [REDACTED]. Lack of appropriate treatment of [REDACTED]. On 1/30/18 at 2:25 PM Staff 24 (RCM-traveling) confirmed Resident 92 missed receiving her/his medications upon admission. b. Resident 92's Nursing Home Care Transfer form dated 8/26/17 revealed an order to test the resident's CBGs (test to determine the amount of glucose present in a person's blood) four times daily before meals and at bedtime and to report any CBG readings under 70 and over 300 to the resident's physician. Resident 92's 8/2017 DAR (Diabetic Administration Record) revealed on 8/27/17 Resident 92's CBG reading was 317 at 5:00 pm and 314 at 8:00 pm. On 1/30/18 at 10:11 AM Staff 22 (RN) stated she did not remember if she had notified the physician regarding the resident's high CBGs on 8/27/17. She stated she would have charted in the resident's record if she notified the physician. Resident 92's medical record contained no evidence the physician was notified of the resident's high CBG readings. 2. Resident 143 was admitted to the facility in 1/12/18 at 12:41 PM with [DIAGNOSES REDACTED]. Resident 143's Care Transfer Form dated 1/11/18 revealed an order for [REDACTED]. Resident 143's SNF Patient Admit to Service Orders dated 1/12/18 revealed an order to record fluid intake including clysis (subcutaneous fluid administration) and oral intake. A review of Resident 143's 1/2018 TAR revealed the following: -A treatment with a start date of 1/15/18 (three days after the resident's admitted ) for the administration of Clysis subcutaneous normal saline at 50 ml per hour times two liters for the first two hours and increased up to 75 ml if tolerated. -A treatment with a start date of 1/18/18 (six days after the resident's admitted ) for the monitoring of oral and clysis fluid intake. On 1/23/18 at 11:18 AM Staff 9 (Medical Records) stated she usually transcribed resident admission orders [REDACTED]. She stated the charge nurse was to check the orders however this did not always occur. She further stated Resident 143 had orders which were faxed prior to her/his admission which included the order for dehydration treatment. When Resident 143 arrived she/he had additional orders and the original orders were never transcribed into the electronic health record. Staff 9 stated she missed transcribing the monitoring of fluid intake and a nurse did not check the resident's orders upon admission. Untreated dehydration can result in serious harm including [MEDICAL CONDITION], hypovolemic shock (life threatening condition which causes a drop of blood pressure and oxygen in the body), coma and death. On 1/29/18 at 2:20 PM Witness 10 (Physician) stated she found the clysis treatment was not administered on admission as ordered and she notified the facility. She stated the resident had to have a second clysis treatment while at the facility and stated she would have prescribed the second treatment a day or two sooner if the resident had received the first treatment as ordered. Witness 10 stated there was definite potential for negative outcomes regarding the delay in the administration of the clysis treatment. 3. Resident 29 was admitted to the facility in 12/14/17 with [DIAGNOSES REDACTED]. Resident 29's Discharge Orders dated 12/14/17 revealed an order for [REDACTED]. Resident 29's 12/2017 and 1/2018 MARs and TARs revealed the resident was administered [MEDICATION NAME] medication 12/15/17 through 1/24/18 (a period greater than five weeks). On 1/24/18 at 1:02 PM Staff 3 (Regional Nurse Consultant) verified no order could be located regarding the use of [MEDICATION NAME] past the original order for a five week course of treatment. 4. Resident 17 was admitted to the facility on hospice care in 8/2017 with [DIAGNOSES REDACTED]. A physician order dated 12/27/17 revealed an order for [REDACTED]. A review of the 12/2017 and 1/2018 MARs revealed the first dose of [MEDICATION NAME] medication was not administered until 1/4/18. On 1/19/18 at 4:07 PM Witness 9 (hospice nurse) stated the resident was ordered [MEDICATION NAME] as Resident 17 refused narcotic pain medication and [MEDICATION NAME] was being used as an alternative pain management therapy. She further stated there was a delay from the time the hospice physician ordered the [MEDICATION NAME] to the time the resident received the [MEDICATION NAME]. On 1/30/18 at 5:44 PM Staff 2 (DNS) confirmed an order for [REDACTED]. On 1/31/18 at 8:24 AM Staff 11 (Director of Operations-Pharmacy) stated the pharmacy received the order for [MEDICATION NAME] on 12/27/17 and the medication was delivered to the facility on [DATE] at 1:00 AM. 5. Resident 153 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Prior to admission the resident underwent [REDACTED]. Resident 153's discharge orders dated 10/15/17 revealed an order for [REDACTED]. Resident 153's 10/2017 TAR revealed a treatment for [REDACTED]. The first documented administration of this treatment was not until 10/22/17 (seven days after the resident's admission to the facility). On 1/9/17 at 6:07 PM Witness 12 (Physician) stated she saw Resident 153 six days after her/his admission and the resident had not received any dressing changes to her/his knee wound. On 1/31/18 at 7:18 AM Staff 23 (Regional Nurse Consultant) confirmed wound care was ordered for Resident 153 on 10/15/17 and not administered until 10/22/17. 6. Resident 30 was admitted to the facility in 11/2017 with [DIAGNOSES REDACTED]. A Discharge Orders Report dated 11/22/17 revealed Resident 30 had an order for [REDACTED]. A physician's order dated 11/24/17 revealed Resident 30 had a change in her/his [MEDICATION NAME] order three times per day scheduled for five days and then three times per day as needed after the five days. Resident 30's 11/2017 MAR revealed the resident received [MEDICATION NAME] scheduled three times per day from 11/25/17 through 11/29/17. Resident 30's 11/2017 PRN MAR revealed Resident 30 received a dose of PRN [MEDICATION NAME] on 11/26/17 even though the order had been changed to scheduled during the time period of 11/25/17 through 11/29/17. On 1/31/18 at 6:43 PM Staff 2 (DNS) acknowledged the resident recieved a PRN dose of Flexiril on 11/26/17 in error as the resident's physician orders were not followed. 7. Resident 147 was admitted to the facility in 1/2018 with [DIAGNOSES REDACTED]. a. Physician orders dated 1/3/18 directed staff to administer Humalog (insulin) before meals. The 1/2018 TAR revealed Humalog was scheduled for 11:00 AM on 1/5/18 and staff administered the medication at 12:07 PM. b. The physician orders dated 1/3/18 directed staff to administer [MEDICATION NAME] (insulin) before meals. The 1/2018 TAR revealed [MEDICATION NAME] was scheduled for 11:00 AM on 1/5/18 and staff administered the medication at 12:07 PM. c. The physician orders dated 1/3/18 directed staff to notify the physician if Resident 147's blood sugar was below 149. The 1/2018 TAR revealed Resident 147's blood sugar was 122 on 1/3/18 at 5:00 PM and 122 at 9:00 PM. No documentation was located in the medical record to indicated the physician was notified. On 1/23/18 at 1:35 PM Staff 2 (DNS) and Staff 3 (Regional Nurse Consultant) confirmed the late administrations of insulin and the failure to notify the physician for blood sugar levels outside of parameters as ordered by the physician. 8. Resident 4 was admitted to the facility in 2/2013 with [DIAGNOSES REDACTED]. a. Signed physician orders dated 1/3/18 instructed staff to apply compression stockings in the morning and remove the stockings in the evening. Review of 1/2018 TAR revealed Resident 4's compression stockings were applied in the mornings but not removed in the evenings on the following days: -1/2/18 through 1/7/18 -1/9/18 -1/11/18 through 1/17/18 -1/19/18 through 1/20/18 b. Signed physician orders dated 1/3/18 instructed staff to administer [MEDICATION NAME] (to treat heartburn) orally two times a day 30 minutes before meals. Review of the 1/2018 TAR revealed Resident 4's [MEDICATION NAME] was administered late eight times from 1/1/18 through 1/20/18. On 1/23/18 at 3:17 PM Staff 3 (Regional Nurse Consultant) confirmed physician orders were not being followed for Resident 4's compression stockings and administration of [MEDICATION NAME]. 9. Resident 15 was admitted to the facility in 11/2017 with [DIAGNOSES REDACTED]. a. Signed physician orders dated 1/4/18 instructed staff to administer [MEDICATION NAME] (insulin) sliding scale before meals. Review of the 1/2018 DAR (diabetic administration record) revealed Resident 15 received [MEDICATION NAME] late two times from 1/5/18 through 1/16/18. On 1/29/18 at 12:52 PM Staff 2 (DNS) and Staff 3 (Regional Nurse Consultant) confirmed Resident 15 received her/his insulin late and physician orders were not followed. b. Signed physician orders dated 1/4/18 instructed staff to administer [MEDICATION NAME] (pain medication) three times a day in the morning 6:00-11:00 AM, mid-day 11:00 AM-1:00 PM, and in the evening 7:00-9:00 PM. Review of the 1/2018 MAR revealed Resident 15 received [MEDICATION NAME] late on the following days: -1/9/18 administered at 10:30 PM for evening dose. -1/13/18 administered at 1:38 PM for morning dose. On 1/29/18 at 12:52 PM Staff 2 (DNS) and Staff 3 (Regional Nurse Consultant) confirmed Resident 15 received her/his pain medication late and physician orders were not followed. c. Signed physician orders dated 1/4/18 instructed staff to apply compression stockings in the morning and to remove in the evening. On 1/17/18 at 9:48 AM Resident 15 stated she/he turns on the call light but staff do not come to apply the compression stockings. Resident 15 stated her/his compression stockings were not on. On 1/22/18 at 1:05 PM Resident 15 was observed in bed with her/his pajamas on. Resident 15 stated she/he did not have the compression stockings as she/he was waiting for a shower before having them applied. She/he reported the staff did not apply her/his compression stockings on 1/20/18 or 1/21/18. Review of the TAR dated 1/2018 directed staff to apply compression stockings in the morning and remove in the evening. The TAR revealed Resident 15 did not have compression stockings applied 11 times from 1/1/18 through 1/25/18. On 1/29/18 at 12:52 PM Staff 2 (DNS) and Staff 3 (Regional Nurse Consultant) confirmed physician orders were not being followed regarding Resident 15's compression stockings. 10. Resident 40 was admitted to the facility in 9/2017 with [DIAGNOSES REDACTED]. a. The admission orders [REDACTED]. Current physician orders signed 10/20/17 revealed the following: - To administer [MEDICATION NAME] sliding scale at bedtime and if blood sugar was less than 200 to call the physician, start date 9/16/17. - To administer [MEDICATION NAME] (insulin) at bedtime and notify physician if blood sugar was below 70 or above 500, start date 9/19/17. The 9/2017 and 10/2017 Diabetic Administration Records revealed Resident 40's blood sugar was outside of parameters on the following days. -9/17/17 CBG was 96 -9/19/17 CBG was 84 -9/20/17 CBG was 74 -9/21/17 CBG was 52 in the morning and 94 in the evening -9/21/17 CBG was 54 -9/24/17 CBG was 182 -9/25/17 CBG was 153 -9/27/17 CBG was 158 -9/29/17 CBG was 185 -10/1/17 CBG was 165 -10/2/17 CBG was 150 -10/3/17 CBG was 135 -10/6/17 CBG was 130 -10/7/17 CBG was 140 -10/8/17 CBG was 139 -10/9/17 CBG was 125 -10/12/17 CBG was 164 No documentation was located in medical record to indicate the physician was notified on any of the above dates. On 1/29/18 at 2:30 PM Staff 2 (DNS) and Staff 3 (Regional Nurse Consultant) confirmed the physician was not notified for blood sugars outside of the physician ordered parameters. b. The Admission MDS dated [DATE] revealed Resident 40 had an infection of the foot. The 9/2017 and 10/2017 TARs revealed to apply [MEDICATION NAME] (non-adhering wound dressing) to the right foot and shin once a day and to secure with gauze. On 9/25/17 and 9/26/17 Resident 40's right foot did not receive treatment. Physician orders signed 10/20/17 revealed to apply [MEDICATION NAME] to the right foot and shin once a day with a start date of 9/23/17. On 1/29/18 at 2:30 PM Staff 2 (DNS) and Staff 3 (Regional Nurse Consultant) confirmed physician orders were not followed for treatment of [REDACTED]. c. Physician orders signed 10/20/17 revealed to administer [MEDICATION NAME] Diskus (to help with breathing) one puff twice a day with a start date of 9/23/17. The 9/2017 and 10/2017 MARs revealed the following regarding [MEDICATION NAME] Diskus: - 9/24/17 [MEDICATION NAME] Diskus was unavailable and was not administered. - 9/25/17 [MEDICATION NAME] Diskus was not available and was not administered in the evening. - 9/26/17 [MEDICATION NAME] Diskus was not available and was not administered in the evening. On 1/29/18 at 2:30 PM Staff 2 (DNS) and Staff 3 (Regional Nurse Consultant) confirmed physician orders were not followed for administration of [MEDICATION NAME] Diskus. 11. Resident 6 was admitted to the facility in 11/2014 with [DIAGNOSES REDACTED]. Physician orders signed 12/6/17 revealed to check CBGs (test to determine the amount of glucose present in a person's blood) before meals and at bedtime and to notify the physician if CBGs were below 80 or above 400 with a start date of 7/6/17. The 11/2017 Diabetic Administration Record (DAR) revealed CBGs were outside of parameters on the following dates and the physician was not notified: - 11/1/17 CBG was 425 in the morning, 403 in the afternoon and 428 in the evening. - 11/4/17 CBG was 422 - 11/7/17 CBG was 415 - 11/8/17 CBG was 440 early morning and 401 late morning. The 12/2017 DAR revealed CBGs were outside of parameters on the following dates and the physician was not notified: - 12/1/17 CBG was 402 - 12/2/17 CBG was 593 - 12/4/17 CBG was 401 in the afternoon and 468 in the evening. - 12/7/17 CBG was 518 - 12/9/17 CBG was 404 On 1/29/18 at 1:50 PM Staff 2 (DNS) and Staff 3 (Regional Nurse Consultant) confirmed the physician orders were not followed for contacting the physician for CBGs being outside of parameters. 12. Resident 1 was admitted to the facility in 10/2012 with [DIAGNOSES REDACTED]. a. Physician orders signed 1/3/18 instructed staff to administer [MEDICATION NAME] (pain medication) two times a day between 6:00-8:00 AM and between 2:00-4:00 PM . The 1/2018 MAR revealed Resident 1 received [MEDICATION NAME] on 1/2/18 at 9:43 AM, 1/9/18 at 8:23 PM, 1/13/18 at 10:24 AM and 1/14/18 at 9:24 AM. b. Physician orders signed 1/3/18 instructed staff to administer [MEDICATION NAME] oxalate (antidepressant) once a day in the evening and to notify the physician if the resident refused the medication. The MAR dated 1/2018 revealed Resident 1 refused [MEDICATION NAME] oxalate on 1/7/18, 1/16/18, 1/19/18 and 1/23/18. No documentation was located indicating the physician was notified of the refusals. c. Physician orders signed 1/3/18 instructed staff to apply a protective boot to the right lower extremity as tolerated all day every day and may remove for bathing and skin care with a start date of 5/2/16. On 1/24/18 at 12:06 PM Resident 1 was in the hall by the nurses' station. No boot was observed on the resident's right lower extremity. On 1/25/18 at 1:08 PM Staff 2 (DNS) and Staff 3 (Regional Nurse Consultant) confirmed Resident 1 received [MEDICATION NAME] over an hour late four times and the physician was not notified of the refusals of [MEDICATION NAME] oxalate. Staff 2 stated the physician order for [REDACTED]. 13. Resident 39 was admitted to the facility in 12/2017 with [DIAGNOSES REDACTED]. A Physician Order Report dated 1/2018 indicated an order for [REDACTED]. Instructions for the medication stated to [MEDICATION NAME] as prescribed. Resident 39's MARs for 12/2017 and 1/2018 included instructions [MEDICATION NAME] to be taken with meals at 8:00 AM, 12:00 PM and 5:00 PM. Resident 39's 12/2017 MAR indicated six times when the medication was administered one to two hours late on 12/19, 12/20 (two times), 12/26, 12/29 and 12/30. Resident 39's 1/2018 MAR indicated five times when the medication was administered one to two hours late on 1/2, 1/5, 1/6, and 1/15 (two times). On 1/23/18 at 4:16 PM Staff 2 (DNS) acknowledged the [MEDICATION NAME] not given with meals as ordered. 14. Resident 20 was admitted to the facility in 12/2017 with [DIAGNOSES REDACTED]. The Hospital Discharge Orders Report dated 12/3/17 contained an order for [REDACTED]. The 12/2017 MAR indicated no order for [MEDICATION NAME] and no documentation the resident received it during 12/2017. On 1/29/18 at 10:46 AM Staff 9 (Medical Records) stated she transcribed the medication orders onto the MAR for Resident 20 who was a new admit and the medication [MEDICATION NAME] was not entered. After she finished transcribing the orders they went to a nurse who reviewed the transcription. The nurse missed the medication. The orders should have gone through the quality assurance process the next day for a third review, but the transcription error was missed a second time. On 1/30/18 at 10:18 AM Staff 9 stated the pharmacist received a copy of the Hospital Discharge Orders before the orders were transcribed onto the MAR. The [MEDICATION NAME] transcription error was missed by the pharmacist. On 1/29/18 at 12:02 PM Staff 11 (Pharmacy Regional Director) addressed the missed medication. Staff 11 wrote This medication order was missed during new admission processing. We did not enter the order into our system or send it. I also do not see any additional communication from the facility requesting it.

Based on interview and record review it was determined the facility failed to ensure residents were free from significant medication errors for 3 of 5 sampled residents (#s 17, 29 and 92) reviewed for medication administration. Resident 92 experienced a delay in treatment of [REDACTED]. Findings include: On 1/26/18 at 3:22 PM Staff 1 (Administrator), Staff 2 (DNS), Staff 3 (Regional Nurse Consultant), Staff 23 (Regional Nurse Consultant), and Staff 37 (Regional Director of Operations) were informed of the failure of current measures used by the facility to ensure medications were administered as ordered which constituted a situation of immediate jeopardy to health and welfare for residents. Surveyors requested a plan of correction to immediately protect the residents from harm be developed and implemented. On 1/26/18 at 9:33 PM a final immediate plan of correction was accepted from the facility, and at 10:05 PM the plan was verified as implemented removing the immediate risk to resident health and welfare. The immediate plan of correction included: - All residents admitted during the 30 days prior to 1/26/18 were reviewed to verify physician orders [REDACTED]. - A Managing Acute Changes of Condition (MACC) process was identified to audit all new admissions until 2/26/18, followed by two residents audited per week for eight weeks. - Other at risk residents were identified and reviewed. - Training was completed on 1/26/18 for floor nurses which included medication administration and processing new orders. Training for staff working after 1/26/18 was completed each shift for any untrained staff; the training was documented and maintained by the DNS. - To ensure physicians orders are followed and accurately transcribed into the MAR, TAR, and diabetic administration record after 1/26/18, new orders were reviewed using the MACC process and additionally reviewed by a trained designee. - DNS responsible for assuring compliance. - All findings presented to quality assurance and performance improvement for analysis. 1. Resident 92 was admitted to the facility in 8/2017 with [DIAGNOSES REDACTED]. A Progress Note dated 8/26/17 stated the resident arrived at the facility at 2:30 PM on 8/26/17. Resident 92's hospital Discharge Summary Report dated 8/26/17 revealed Resident 92 was ordered medications including: - Insulin [MEDICATION NAME] (diabetic medication) to be administered per sliding scale instructions. Instructions stated to call the physician if CBG reading (test to see the amount of glucose present in a person's blood) was at or over 300. - [MEDICATION NAME] HCL (diabetic medication) orally two times per day with meals. - [MEDICATION NAME] HCL Injection (intravenous antibiotic medication) intravenously (IV) every 8 hours. - [MEDICATION NAME] Sodium injection (intravenous antibiotic medication) IV piggyback every 24 hours. - [MEDICATION NAME] APAP (narcotic pain medication) every four hours as needed for pain. Resident 92's August 2017 MAR, Diabetic Adminisration Record (DAR) and TAR revealed the following: - Resident 92 was not administered her/his first dose of [MEDICATION NAME]until 8/27/17 at 5:00 PM. - Resident 92 was not administered her/his first dose of [MEDICATION NAME] until 8/27/17 at 5:00 PM. - Resident 92 was not administered her/his first dose of [MEDICATION NAME] until 8/27/17 at 6:00 PM. - Resident 92 was not administered her/his first dose of [MEDICATION NAME] until 8/27/17 at 2:50 PM. - On 8/27/17 Resident 92's CBG reading was 317 at 5:00 PM and 314 at 8:00 PM (Per the American Diabetic Association normal blood glucose parameters for a person with diabetes range from 80-130). A facility Incident Investigation dated 8/27/17 through 8/29/17 revealed Resident 92 missed three doses of [MEDICATION NAME], one dose of [MEDICATION NAME] sodium, all other ordered medications, CBGs and sliding scale insulin. Lack of appropriate treatment of [REDACTED]. On 1/30/18 at 2:25 PM Staff 24 (RCM-traveling) confirmed Resident 92 missed receiving her/his medications upon admission. 2. Resident 29 was admitted to the facility in 12/2017 with [DIAGNOSES REDACTED]. Resident 29's Discharge Orders dated 12/14/17 revealed an order for [REDACTED]. Progress notes from 12/15/17 revealed Resident 29 admitted to the facility on [DATE]. Resident 29's 12/2017 MAR and TAR revealed the resident was administered [MEDICATION NAME] medication 12/15/17 through 12/31/17. Resident 29's 1/2018 MAR revealed the resident was administered [MEDICATION NAME] medication 1/1/18 through 1/24/18 (longer than the 5 weeks the medication was ordered for). Continued use of antibiotic therapy passed the physician ordered stop date can lead to antibiotic resistance and ineffective treatment of [REDACTED]. On 1/24/18 at 1:02 PM Staff 3 (Regional Nurse Consultant) verified no order could be located regarding the use of [MEDICATION NAME] past the original order for a five week course of treatment. See F881 3. Resident 17 was admitted to the facility on hospice care in 8/2017 with [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. A review of the 12/2017 and 1/2018 MARs revealed the first dose of [MEDICATION NAME] medication was not administered until 1/4/18. On 1/19/18 at 4:07 PM Witness 9 (hospice nurse) stated the resident was ordered [MEDICATION NAME] as Resident 17 refused narcotic pain medication and [MEDICATION NAME] was being used as an alternative pain management therapy. She further stated there was a delay from the time the hospice physician ordered the [MEDICATION NAME] to the time the resident received the [MEDICATION NAME]. On 1/30/18 at 5:44 PM Staff 2 (DNS) confirmed an order for [REDACTED].

Based on observation, interview and record review the facility failed to provide timely treatment for [REDACTED].#s 38 and 143) reviewed for hydration and nutrition. Resident 143 experienced a delay in dehydration treatment which placed the resident at immediate risk for serious harm related to dehydration complications. Findings include: On 1/26/18 at 3:22 PM Staff 1 (Administrator), Staff 2 (DNS), Staff 3 (Regional Nurse Consultant), Staff 23 (Regional Nurse Consultant), and Staff 37 (Regional Director of Operations) were informed of the failure of current measures used by the facility to ensure physician's orders [REDACTED]. Surveyors requested a plan of correction to immediately protect the residents from harm be developed and implemented. On 1/26/18 at 9:33 PM a final immediate plan of correction was received from the facility, and at 10:05 PM the plan was verified as implemented removing the immediate risk to resident healtha nd welfare. The facility's immediate plan of correction included: - All residents admitted during the 30 days prior to 1/26/18 were reviewed to verify physician orders [REDACTED]. - A Managing Acute Changes of Condition (MACC) process was identified to audit all new admissions until 2/26/18, followed by two residents audited per week for eight weeks. - Other at risk residents were identified and reviewed. - Training was completed on 1/26/18 for floor nurses which included medication administration and processing new orders. Training for staff working after 1/26/18 was completed each shift for any untrained staff; the training was documented and maintained by the DNS. - To ensure physicians orders are followed and accurately transcribed into the MAR, TAR, and diabetic administration record after 1/26/18, new orders were reviewed using the MACC process and additionally reviewed by a trained designee. - DNS responsible for assuring compliance. 1. Resident 143 was admitted to the facility on [DATE] at 12:41 PM with [DIAGNOSES REDACTED]. Resident 143's Baseline Careplan dated 1/12/18 did not contain information regarding the resident's admitting [DIAGNOSES REDACTED]. Resident 143's Care Transfer Form dated 1/11/18 revealed an order for [REDACTED]. Resident 143's SNF Patient Admit to Service Orders dated 1/12/18 revealed an order to record fluid intake including clysis (subcutanious administration) and oral intake. A review of Resident 143's 1/2018 TAR revealed the following: - A treatment with a start date of 1/15/18 (three days after the resident's admitted ) for the administration of clysis subcutaneous normal saline at 50 ml per hour times two liters for the first two hours and increase up to 75 ml if tolerated. - A treatment with a start date of 1/18/18 (six days after the resident's admitted ) for the monitoring of oral and clysis fluid intake. Review of the Resident 143's medical record revealed no evidence the resident's clysis fluid intake and the oral fluid intake between meals was monitored from 1/12/18 through 1/17/18. On 1/23/18 at 9:49 AM Staff 5 (LPN) stated Resident 143's fluid intake was not monitored upon admission to the facility. On 1/23/18 at 11:18 AM Staff 9 (Medical Records) confirmed there was a three day delay in Resident 143's clysis treatment and a six day delay in the monitoring of fluid intake for Resident 143. Untreated dehydration can result in serious harm including [MEDICAL CONDITION], hypovolemic shock (life threatening condition which causes a drop of blood pressure and oxygen in the body), coma and death. On 1/29/18 at 2:20 PM Witness 10 (Physician) stated she found the clysis treatment had not been administered on admission as ordered and she notified the facility. She stated the resident had to have a second clysis treatment while at the facility and stated she would have prescribed the second treatment a day or two sooner if the resident received the first treatment as ordered. Witness 10 stated there was definite potential for negative outcomes regarding the delay in the administration of the clysis treatment. 2. Resident 38 was admitted to the facility in 3/2015 with [DIAGNOSES REDACTED]. Resident 38's care plan dated 7/14/15 instructed staff to keep the physician and the significant other and/or designated family member(s) informed of any weight loss, weigh the resident routinely and report any weight concerns to the physician. A review of Resident 38's electronic health record indicated the following: - Weight 7/17/17 137 lbs. - Weight 1/16/18 122 lbs. There was a 10.95 percent weight loss in a 6 month period which was considered a significant weight loss. A review of the Nutrition Progress Notes for Resident 38 included the following: - On 11/22/17 at 1:18 PM the resident was at the facility for weight loss and seemed to be doing well with meals recently, the resident might not be consistent with her/his eating habits. If she/he was fed (assisted with meals) the resident tended to consume more food therefore resident will be given a liquid nutritional supplement three times a day. - On 11/22/17 at 1:30 PM the resident had no significant weight changes in last six months and would be discharged from Nutrition at Risk (NAR) monitoring. - A Registered Dietician's Progress Note dated 11/22/17 at 2:25 PM stated the resident's current weight was 121.5 lbs. (a 13% weight loss in six months). - A NAR Progress Note dated 12/06/17 at 10:20 AM stated as of 12/6/17 resident's weight was 123.5. A month prior on 11/4/17 the weight was 122 lbs. Three months prior the weight was 135 lbs. (a 9.63 percent weight loss in three months, which is a significant weight loss). Resident 38 was observed during meals on 1/19/18, 1/22/18, and 1/23/18 and the resident consumed more food when staff were sitting nearby and cueing her/him. On 1/24/18 at 9:53 AM and 10:30 AM Staff 12 (Registered Dietician) indicated he did not identify a weight loss for Resident 38, and the facility had put the resident back on NAR as of 1/17/18 due to weight loss. On 1/31/18 at 10:53 AM Staff 2 (DNS) re-weighed Resident 38. The resident's weight was 119 lbs, a 13.14 percent weight loss and was considered a significant weight loss. On 1/31/18 at 10:06 AM Staff 2 acknowledged there was a problem with how the facility was monitoring weights and the staff were not following up on the weight variances.

Based on interview and record review the facility failed to accurately assess underlying causes of pain, develop person centered plans and provide pain medications as ordered for 2 of 2 sampled residents (#s 29 and 140) reviewed for pain management. Resident 29 experienced severe pain and hospitalization . Findings include: 1. Resident 29 was admitted to the facility in 12/2017 with [DIAGNOSES REDACTED]. Resident 29's Admission MDS dated [DATE] revealed a pain assessment was not completed. Resident 29's comprehensive care plan last revised 1/10/18 revealed no care planned problem, approaches or interventions related to pain management. Resident 29's In Room Care Plan created 12/19/17 and last revised 1/17/18 stated to notify charge nurse if the patient experienced pain. No other information related to pain management techniques was present on the care plan. Discharge Orders dated 12/14/17 revealed an order for [REDACTED].>A physician order [REDACTED]. A review of Progress Notes from 12/14/17 through 12/24/17 revealed the resident verbalized pain to staff on 12/14, 12/15, 12/18, 12/20, 12/22, 12/23 and 12/24. A review of Resident 29's 12/2017 PRN MAR indicated [REDACTED] - Resident 29 was administered PRN [MEDICATION NAME]-[MEDICATION NAME] multiple times daily from 12/15/17 through 12/20/17 (the medication was discontinued on 12/20/17) and the medication effectiveness varied from effective to not effective. - Resident 29 was administered PRN Tylenol on 12/17, 12/18, 12/22, 12/13, 12/24 and 12/27/18 and the medication effectiveness varied from effective to not effective. A review of Resident 29's 12/2017 MAR indicated [REDACTED] - An entry for [MEDICATION NAME]-[MEDICATION NAME] scheduled every four hours starting on 12/20/17. The MAR indicated [REDACTED]. The notes stated a valid prescription was needed from the physician and the drug item was unavailable. - Eight late administrations of scheduled [MEDICATION NAME]-[MEDICATION NAME] between 12/20/17 and 12/31/17. The medical record contained no evidence the Resident's physician was notified regarding the resident's pain from 12/14/17 through 12/20/17. Review of Progress Notes dated 12/22/17 through 12/24/17 revealed the facility attempted to contact the resident's physician to request a valid prescription for the scheduled [MEDICATION NAME]-[MEDICATION NAME]. A progress note dated 12/24/17 revealed Resident 29 was transported to the hospital. She/he was complaining of uncontrolled pain at a level of 10 out of 10. A Physicians Progress Note dated 1/4/18 revealed Resident 29 ran out of her/his pain medications for a total of three days and was sent to the emergency department. The note further stated the nursing staff alerted the physician and the physician faxed the prescription to the wrong pharmacy. A review of Resident 29's 1/2018 MAR indicated [REDACTED]. On 1/17/18 at 11:43 AM Resident 29 reported she/he went to the hospital on [DATE] because she/he ran out of pain medications and the facility was unable to contact her/his physician. Resident 29 stated she experienced excruciating pain before being transferred to the hospital. On 1/19/18 at 9:52 AM Staff 33 (Agency/RN) stated resident medications are often passed late. On 1/19/18 at 3:34 PM Staff 22 (RN) stated medications are administered late every evening. On 1/23/18 at 9:49 AM Staff 5 (LPN) stated she was not always able to pass out her medications on time. On 1/24/18 at 10:38 AM Resident 29 reported her pain medications were not always administered on time and the facility had not discussed the use of any non-pharmacological interventions to manage pain with her/him. On 1/29/18 at 9:08 AM Staff 13 (SSD) stated Resident 29's pain was discussed in her/his 72-hour care conference. Resident 29 expressed she/he was unable to fully participate in physical therapy due to pain. On 1/29/18 at 2:12 PM Staff 5 (LPN) stated Resident 29 had complained of pain since admission and before the resident's order was changed from a PRN to scheduled narcotic pain medication the resident had outward signs of pain including grimacing and moaning with movement. The resident stayed in bed much of the time and when she/he did get up to use the walker she/he would be hunched over the walker as she/he was not able to fully stand up straight. Staff stated the only time Resident 29 complained of pain now was if staff administered her/his pain medication on the later side of the administration window. On 1/30/18 at 3:00 PM Staff 2 (DNS) acknowledged the resident was not comprehensively assessed for pain during her/his stay at the facility and the resident missed dosages of her/his pain medications due to not having a valid prescription. Staff 2 stated staff were supposed to notify the DNS to if they were having difficulty receiving medications so she could assist in a resolution. 2. Resident 140 was readmitted to the facility in 1/2018 with [DIAGNOSES REDACTED]. The resident also reported a history of knee injuries with resulting chronic pain. physician's orders [REDACTED]. [MEDICATION NAME] PRN (an antianxiety medication) was added on 1/12/18. A 1/11/18 Pain Assessment Update identified pain was managed moderately in the previous five days and the resident reported low back pain due to a fall at home. [MEDICATION NAME] was used as needed for pain. Continued treatment, monitoring and documentation was planned. The assessment did not identify other contributing factors to the resident's pain or the resident's goals for her/his pain management. From 1/11/18 through 1/24/18, progress notes identified eight times the resident reported both pain and anxiety. A 1/12/18 physician's progress note identified a [DIAGNOSES REDACTED]. On 1/18/18, the resident reported to staff she/he had caught her hand in the door as it was closing. No bruising was noted at that time but continued monitoring was planned. There was no further evaluation of the resident's pain related to her/his injury found in the medical record. According to the resident's MAR from 1/12/18 through 1/24/18, the PRN [MEDICATION NAME] and PRN [MEDICATION NAME] were given at the same time six times. The PRN [MEDICATION NAME] was usually taken two times a day (which was the maximum dose) and the PRN [MEDICATION NAME] was taken three times a day (which was the maximum dose) on 6 of 13 days reviewed. There was no evidence in the medical record the resident's continuous use of PRN pain and antianxiety medication use was evaluated in relation to her/his [DIAGNOSES REDACTED]. The care plan for pain was not initiated until 1/22/18 and only focused on therapy for strength training and use of mobility devices. No symptoms of her/his pain, the relationship to related [DIAGNOSES REDACTED]. Observation of the resident on 1/16/18 at 5:11 PM revealed scabs on her lower arms and on 1/23/18 at 11:33 AM, left hand swelling and redness. The resident reported an awareness of her/his injuries and stated she/he had closed a door on the hand recently and tended to be accident prone. When asked about her/his level of pain Resident 140 reported sometimes the pain was too much and the [MEDICATION NAME] did not always adequately cover the pain symptoms. The resident described underlying pain which was dull and constant with moments of sharp, burning and stabbing pain. The symptoms made her/him feel grumpy and tired. Resident 140 was uncertain if the pain and anxiety were related but voiced a desire to take the Klonopin, [MEDICATION NAME] and [MEDICATION NAME] together at times. On 1/23/18 at 1:04 PM Staff 5 (LPN) stated the resident generally reported knee and hand pain. The resident's anxiety often lead her/him to shake which was felt to cause or increase the pain. Resident 140's alcohol withdrawal was a causal factor as well. Staff 5 was unaware of non-pharmalogical approaches which were effective in decreasing the resident's pain, but stated the resident was self-directing with her/his care. On 1/23/18 at 4:02 PM Staff 27 (Agency LN) stated the resident expressed pain verbally by talking quickly and voicing pain, but could also become tearful. Anxiety and pain could look alike but if the resident was experiencing anxiety, sitting down and talking with her/him would calm the resident and redirection could then occur. On 1/25/18 at 11:28 AM Staff 24 (RNCM-traveling) and Staff 29 (RNCM) stated upon admission, the resident's pain was assessed and medications were verified. If the pain was not controlled, the physician would be faxed with a request for re-evaluation. After admission, pain management would be reviewed on a quarterly basis unless there was a sudden change in the level of pain. According to Staff 29, the resident reported pain mainly in her/his knees and used a wheelchair to be mobile. The potential interrelation of anxiety, pain and history of alcohol withdrawal, and the impact of the new hand injury was discussed with Staff 24 and 29 with no further assessment of the resident located.

Based on observation, interview and record review it was determined the facility failed to provide the necessary care and services to prevent the development of an avoidable pressure ulcer, implement treatment or monitor healing of a pressure ulcer for 1 of 2 sampled residents (#10) reviewed for pressure ulcers. Resident 10 developed a Stage 3 pressure ulcer that worsened. Findings include: Resident 10 was admitted to the facility in 2013 with [DIAGNOSES REDACTED]. The resident's current care plan revealed approaches to keep skin clean, minimize exposure to moisture, keep linens clean, dry and wrinkle free and use a cushion for pressure reduction when in chair. The 11/6/16 Quarterly MDS identified Resident 10 was at risk for pressure ulcers and indicated no unhealed pressure ulcers were present at the time of the assessment. A 1/5/17 progress note indicated Resident 10 was observed during a shower to have a small 1 cm x 1 cm area on her/his inner left buttock. Witness 1 (Former LPN) assessed the area as covered with slough (dead tissue), pink to surrounding skin with no swelling or drainage and blanchable (loses redness when pressed). Witness 1 documented barrier cream was applied for protection and she notified the resident's family and physician. On 1/9/17 the MACC Book (alert charting documentation) revealed an entry dated 1/5/17 which noted: wound to left inner buttocks, resolve without further complication and treat pain prior to dressing changes. The 1/2017 MAR indicated [REDACTED]. There was no documentation of wound care on the MAR from 1/5/17 through 1/12/17. On 1/13/17 at 3:37 pm a progress note by Staff 8 (LPN) revealed the wound on Resident 10's left buttock continued to be open, pink, sore and will continue to monitor. According to a fax to the physician on 1/13/17 Staff 2 (DNS) indicated Resident 10's open left sacral area had worsened to a Stage III area with visible slough and mild drainage with a tinge of blood. Staff 2 documented the area was mildly uncomfortable to the resident and she requested wound treatment orders and an air mattress for the resident's bed. The physician responded to the fax on 1/13/17 (eight days after the wound was identified) with an approval for the air mattress and orders to clean the wound daily with normal saline or wound cleanser, calcium alginate (absorbent fiber dressing) into wound bed and cover with [MEDICATION NAME] (gel) dressing with adhesive border and to change every three days and PRN. Skin Grid documentation for Resident 10's left buttock wound was initiated on 1/13/17 by Staff 7 (RNCM) and indicated the wound was identified on 1/5/17. The Skin Grid revealed the probable cause of the wound was pressure, assessed as Stage 3 and measured 2.1 cm long by 2.2 cm wide and 0.1 cm in depth. A progress note on 1/13/17 at 5:06 pm revealed Staff 7 (RNCM) documented Resident 10's open area to the left sacral area has now become a stage 3 and wound care was provided according to physician's orders [REDACTED]. In an interview on 02/21/17 at 1:57 pm Staff 7 stated Resident 10's wound was a facility acquired Stage 3 on the left buttocks and was now almost a Stage 1. Staff 7 further stated the resident had been through a decline, was less mobile and staff weren't turning the resident. On 2/23/17 at 11:07 am Resident 10 was observed lying in bed on her/his right side. The bed had an air pressure mattress and the wheelchair was fitted with a pressure relieving cushion. The resident stated she/he was aware of the wound, staff changed the dressing that morning and she/he was not having discomfort. Staff 13 (CNA) stated the resident was a one person assist with transfer and was able to move and participate with transfers. On 2/24/17 at 1:47 pm the RN surveyor and Staff 7 (RNCM) observed while Staff 6 (LPN) provided treatment to Resident 10's left buttock wound. The wound was clean with no visible drainage and current measurements were 1.6 cm long by 1.0 cm wide. During interviews on 2/27/17 from 12:32 pm through 2:16 pm Staff 7 and Staff 4 (RNCM) acknowledged there was no follow-up documentation regarding Resident 10's left buttocks wound after the physician was notified on 1/5/17. Staff 7 stated he was unable to locate documentation of treatments or monitoring from 1/6/17 through 1/12/17. On 2/27/17 at 2:26 pm Staff 2 (DNS) acknowledged Resident 10's wound was discovered on 1/5/17 and there was no further documentation until 1/13/17. Staff 2 stated she asked the RNCM to follow up because Witness 1 was not great about wounds and not good about describing wounds. Staff 2 indicated neither she nor the RNCM followed up and the resident's wound worsened. At 12:25 pm on 2/28/17 Staff 7 indicated barrier cream was applied to the resident's left buttocks wound by Witness 1 when she identified it on 1/5/17. Staff 7 confirmed there was not an order for [REDACTED].

Based on interview and record review it was determined the facility failed to ensure medications prescribed to one resident was not administered to another resident for 1 of 17 sampled residents (#1) reviewed for medication administration. Resident 1 was incorrectly administered a significant amount of opioid narcotic pain medication and required hospitalization to reverse the affects of the pain medication. Findings include: Resident 1 was admitted to the facility in 2015 with [DIAGNOSES REDACTED]. Resident 1's 7/1/15 through 7/31/15 Physician order [REDACTED]. The resident's 7/22/15 at 2:32 pm note indicated Resident 1 received medications scheduled for another resident. The resident was administered 40 mg of [MEDICATION NAME] (opioid narcotic used to treat pain), 60 mg of [MEDICATION NAME](strong long acting opioid narcotic pain medication) and 120 mg of [MEDICATION NAME] Immediate Release (opioid narcotic pain medication). The resident's physician was notified and the resident was ordered to be sent to the emergency room for evaluation. Resident 1 was noted to be alert and oriented per the resident's baseline but was very sleepy. The resident was transported from the facility at 8:45 am. Resident 1's 7/22/15 Incident Investigation included a written statement from Staff 1 (LPN). The statement indicated Staff 1 was at the medication cart outside of Resident 1 and Resident 2's room. Resident 2 came to Staff 1 and requested her/his medication. The investigation indicated Resident 2's medications included 40 mg of [MEDICATION NAME], 60 mg of [MEDICATION NAME] 120 mg of [MEDICATION NAME] Immediate Release. Resident 2 left the area and indicated she/he would return to take the medications. Staff 1's written statement indicated she placed Resident 2's medications in a drawer of the medication cart. After Resident 2 left the area, Resident 1 was assisted out of her/his room. Staff 1 administered Resident 2's medications to Resident 1. The report indicated Resident 2 returned to the medication cart. Staff 1 gave Resident 2 the medications that were previously prepared and placed in the medication cart. Resident 2 informed Staff 1 the medications in the medication cup did not look familiar to the resident. At that time, Staff 1 realized Resident 1 was administered Resident 2's medications. The report indicated Resident 1's physician was notified and the resident was sent to the hospital for evaluation. On 10/2/15 at 10:45 am Staff 1 (LPN) stated she was assigned to pass medications on the day of 7/22/15. Staff 1 stated she was familiar with Resident 1 and Resident 2. She indicated the day the incident occurred she did not feel rushed. Staff 1 indicated she did not know how she accidentally gave Resident 2's medications to Resident 1. Staff 1 indicated as soon as Resident 2 reported the medications she placed in a medication cup for Resident 2 were not familiar to her/him, she immediately knew Resident 1 received Resident 2's pain medications. Resident 2 did not take Resident 1's medications. Staff 1 indicated the facility immediately called the resident's physician and family and the resident was transported to the hospital for evaluation and treatment. The resident's 7/27/15 hospital Discharge Summary included the resident was admitted to the hospital on [DATE] with [DIAGNOSES REDACTED]. The resident was initially lethargic and snoring. The resident was administered a [MEDICATION NAME] drip (medication to reverse opioid medication administered through a vein). The summary indicated the resident improved during the hospitalization . The resident did not have evidence of new neurological deterioration.

Based on interview and record review it was determined the facility failed to follow the care plan and provide two person assistance for bed mobility for 1 of 4 sampled residents (#1) reviewed for falls. The resident fell out of bed which resulted in a right knee fracture and prolonged increased pain. Findings include: Resident 1 was admitted to the facility in 2012 with [DIAGNOSES REDACTED]. Review of a Fall CAA dated 9/8/13 revealed the resident was at risk for falls due to a history of a stroke and right sided [DIAGNOSES REDACTED]. The assessment indicated the resident needed extensive assistance with transfers. Review of an In-Room Care Plan dated 12/15/13 revealed the resident needed two person assistance for bed mobility Review of a nurse's note dated 1/1/14 at 10:03 pm revealed a CNA had reported the resident had rolled out of bed to the floor while the resident's bed linens were changed. The note indicated the resident was sitting on the floor next to the bed and reported right knee pain. The resident was alert and oriented and able to respond to questions. The resident was assisted back to bed, monitored and the resident's physician was notified. Review of a fall investigation for 1/1/14 revealed the resident was assisted and repositioned onto the resident's right side, the resident was unable to maintain the position and fell out of bed while the resident's linens were changed. The investigation determined the CNA who assisted the resident had not received help from a 2nd CNA as instructed on the care plan. Review of a nurse's note dated 1/2/14 at 4:45 pm revealed the resident complained of right knee pain and received pain medication. The note indicated the resident's right knee had a dark purple bruise to the area and a request for an x-ray was sent to the resident's physician. Review of a nurse's note dated 1/2/14 at 11:40 pm revealed the resident complained of "a considerable amount of pain" due to the recent fall. The note indicated the resident was calling out at the slightest touch of the right leg and pain medication was administered. Review of a two view x-ray dated 1/2/14 revealed no fracture of the right knee. Review of a nurse's note dated 1/3/14 at 10:53 pm revealed the resident complained of knee pain and received pain medication. Review of a nurse's note dated 1/17/14 at 3:00 am revealed the resident was medicated for knee pain and spasms. Review of a nurse's note dated 1/24/14 revealed physician orders [REDACTED]. Review of an three view x-ray dated 1/24/14 revealed a non-displaced fracture of the right knee with a small degree of callus formation. The December 2013 MAR revealed the resident received 55 doses of narcotic medication for pain. The January 2014 MAR revealed the resident received 74 doses of narcotic medication for pain. Review of the resident's record on 3/21/14 revealed no other injuries, accidents or incidents were reported by staff or the resident from 1/1/14 through 1/24/14 to account for the need of increased pain medication. In an interview on 3/20/14 at 11:52 am Staff 5 (RNCM) indicated she completed the incident investigation for the resident's fall on 1/1/14. Staff 5 concluded Staff 6 (CNA) attempted to roll the resident to the right side of the bed without assistance from another staff member and the resident fell to the floor. Staff 5 said the resident complained of pain and had bruising to the right knee. Staff 5 said the first x-ray did not show any fracture but the second x-ray showed a fracture of the right knee due to the fall. Staff 5 said the resident was able to use a sit-to-stand device for transfers but staff now used a Hoyer lift. Staff 5 acknowledged Staff 6 did not follow the care plan which resulted in the resident's fall. In an interview on 3/21/14 at 8:45 am Staff 6 indicated she rolled the resident to the right side of the bed in order to change the resident's linens. Staff 6 said she was at the end of the bed when the resident rolled off the bed to the floor. Staff 6 said she notified the charge nurse who assessed the resident and the resident complained of right knee pain. Staff 6 said she was the only staff person in the room assisting the resident when the resident fell . In an interview on 3/21/14 at 9:00 am Staff 4 (RNCM) said if the care plan indicated a resident needed two person assistance for bed mobility this would include repositioning a resident to one side in bed. In an interview on 3/21/14 at 9:30 am Staff 3 (CNA) said the resident needed two person assistance for bed mobility and would not change the resident's linens by herself. In an interview on 3/21/14 at 1:04 pm Resident 1 indicated Staff 6 had assisted her/him onto her/his right side on the right side of the bed in order to change the bed linens. The resident indicated Staff 6 was standing at the left side of the bed when she/he fell to the floor. The resident said Staff 6 was the only CNA in the room at the time. The resident indicated the right knee was painful and received pain medication to decrease the pain. The resident also indicated two CNAs usually assisted with bed mobility. In an interview on 1/1/14 at 2:30 pm Staff 7 (Administrator) acknowledged the resident's care plan was not followed by Staff 6 and the facility had conducted a complete investigation of the fall. Staff 7 indicated the resident's right knee fracture was caused by the resident's fall on 1/1/14 and not any other incident.

Based on observation, interview and record review it was determined that the facility failed to provide a care plan that reflected the current status for 1 of 3 sampled residents (# 94) with pressure ulcers. Findings include: Resident 94 was admitted to the facility on [DATE] following surgical repair of a fractured left femur neck and with [DIAGNOSES REDACTED]. The 2/3/11 admission comprehensive assessment identified the resident was at risk for skin breakdown. A weekly RNCM narrative note dated 2/23/11 indicated that on 2/16/11 the resident had developed a "rub spot" on his "left buttocks gluteal fold from brief." On 3/1/11 the wound had progressed to unstageable with 90% slough covering the wound base. The in-room care plan was updated on 3/1/11 and included the use of an air mattress for pressure reduction. The care plan had directions to the staff that included: prop feet/ankles up to prevent contractures, use boot to left foot to protect scaly skin and use non-skid foot wear. The chart care plan was updated 3/1/11 and identified a "wound to the resident's left gluteal fold." There was no indication that the resident had an unstageable pressure ulcer with yellow slough. On 3/23/11 at 7:30 am Resident 94 was observed in a wheelchair sitting in the dining room. There was a thin gel pad in his wheelchair seat. There was an alternating air mattress on the resident's bed that had the pump set so that only one indicator light was illuminated. There was a sign posted over the resident's bed with swallowing precautions. On 3/23/11 at 9:05 am Staff 16 and Staff 17 (CNAs) were observed to transfer the resident from his wheelchair to bed using a mechanical lift. The resident was wearing a plastic brace on his left foot. The gel pad wheelchair seat cushion was noted to be hard to the touch when the resident was removed from the wheelchair. At 9:15 am Staff 16 was questioned about the bed pump setting and she stated that it was usually set "very soft" due to his condition. The resident's care plan was reviewed on 3/23/11. There were no directions to staff regarding the resident's swallowing precautions, the correct placement of the left foot splint/brace, care of the resident's skin under the left foot splint/brace, use of a wheelchair seat cushion, or the correct air mattress pump setting. On 3/24/11 at 5:10 am the air mattress bed pump was observed to be set with two lights illuminated. At 5:30 am the resident was observed wearing a brace to his left foot. The brace was positioned incorrectly with the plastic form not under the resident's foot. The resident's heels/ankles were not propped. Staff 2 (RNCM) stated that the brace was removed when the resident was showered and when lotion was applied. Staff 14 (CNA) was unsure of the type of lotion to use on the resident's left foot and was verbally directed by Staff 2 to use [MEDICATION NAME]. Staff 14 stated during interview at 5:40 am that she was the routine night shift care giver for Resident 94. At 5:45 am Staff 2 was observed to place a 4-inch thick Keen cushion in the resident's wheelchair. On 3/24/11 at 6:30 am Staff 2 stated that the air mattress pump should be adjusted so that between 2 to 4 lights were illuminated. She stated that she did not put the bed pump setting on the care plan so that CNAs would not adjust the bed. She was unaware that the pump had been set with only one light showing and that the thinner wheelchair pad had been used on 3/23/11. She verified that the size of the wheelchair pad was not care planned and that it should be a 4 inch gel pad. Refer to F 314 regarding pressure ulcer development.

Based on observation, interview and record review it was determined that the facility failed to prevent development of a pressure ulcer for 1 of 3 sampled residents (# 94) with pressure ulcers. Resident 94 developed an unstageable eschar covered pressure ulcer. Findings include: Resident 94 was admitted on [DATE] following surgical repair of a fractured left femur neck with [DIAGNOSES REDACTED]. A Braden Scale for predicting pressure sore risk was completed on 1/24/11 and the resident was identified to be at moderate risk. The facility's RD (Registered Dietician) evaluated the resident on 1/28/11. The evaluation identified a 1/25/11 weight of 165 lbs. The resident was noted to have good skin turgor and a moist mouth. The resident was on a general/regular diet and his nutritional needs were identified as: 1700-1800 kcal/day, 57-67g protein/day, 1800-1900 ml fluid/day. The RD recommended calcium with vitamin D for bone support and multivitamin for general nutrition support. A physician order [REDACTED]. The resident's admission MDS dated [DATE] indicated that pressure ulcers were triggered for comprehensive assessment. The Care Area Assessment for pressure ulcers identified that the resident was at risk for skin breakdown due to immobility and Alzheimer's dementia. The resident had been admitted with a pink area on his coccyx that had resolved. A wound care evaluation completed by Staff 2 (RNCM) on 2/23/11 indicated that the resident had a small open area from a skin tear from a brief that was 1.8 cm x 0.7 cm in size with small scattered purple spots. A weekly narrative note dated 2/23/11 was provided by Staff 2. It indicated that on 2/16/11 the resident had developed a "rub spot" on his "left buttocks gluteal fold from brief." On 3/1/11 the wound had progressed to unstageable with 90% slough covering. An air mattress and RD evaluation were requested. The in-room care plan was updated on 3/1/11 and included the use of an air mattress for pressure reduction. The care plan had directions to the staff that included: total assistance needed for transfers, incontinent care, and grooming/hygiene, and extensive assistance for eating. Staff were also directed to avoid lying the resident on his left side and he was to be out of bed only for meals to avoid pressure to the left gluteal fold. The staff were to prop his feet/ankles up to prevent contractures and to apply a protective boot to his left foot. The chart care plan was updated 3/1/11 and identified a "wound to the resident's left gluteal fold." The care plan included treatment to the wound, RD assessment as needed, monitor skin and encourage fluids. On 3/3/11 the RD documented a wound note that indicated the resident had a left buttock crease wound that was initially a brief related blister but was "now worse." On 3/3/11 the nutritional interventions included: general/pureed diet with large portions, Nutritionally Enhanced Meals, nectar thick fluids, and that the resident was tracked by the facility's nutrition at risk committee. The RD requested that the resident receive multivitamins and 100% juice for all meals. No further recommendations or evaluation of the resident's nutritional needs for wound healing were provided. A weekly skin audit dated 3/8/11 indicated that the unstageable wound size was 4.1 cm x 3.8 cm. The amount of slough covering the wound bed had increased to 95%. The 3/15/11 weekly skin audit indicated that the wound was still unstageable, was 4.1 cm x 3.6 cm in size, and had 90% of the wound bed covered with slough. The weekly narrative note indicated that there were also suspected deep tissue injury areas. A physician order [REDACTED]. The results were received on 3/18/11 and revealed low levels of [MEDICATION NAME] 2.7 (norm 3.5 - 5.0), total protein 5.6 (norm 6.2 - 8.4), and pre-[MEDICATION NAME] 13.5 (norm 20.0 - 40.0). All three levels reflected protein deficiencies. The weekly narrative note dated 3/22/11 indicated that the surrounding tissue had deep tissue injury and that the wound continued to be unstageable. The weekly audit revealed a decrease in the size of the wound bed but the amount of slough covering the wound bed was still described as 90%. On 3/23/11 at 7:30 am the resident was observed in a wheelchair with a thin gel pad seat cushion. There was an air mattress on the resident's bed with one light illuminated on the mattress pump. At 9:00 am the resident was transferred from the wheelchair to the bed. The gel pad in his wheelchair was approximately 1 inch thick and was hard to the touch. At 9:05 am Staff 16 (CNA) verified that the pump was set at its lowest setting with one light illuminated and that it was usually set "very soft" due to his condition. At 12:40 pm the resident was in the wheelchair in the dining room. The thin gel pad was observed in the seat of the wheelchair. On 3/24 at 5:10 am Staff 2 (RNCM), Staff 15 (LPN) and Staff 14 (CNA) were observed to enter the resident's room. The resident's air mattress pump was observed to have two lights illuminated. A thin, hard wheelchair pad was in the seat of the resident's wheelchair. The resident was uncovered and the boot on his left foot was observed to be positioned incorrectly. His feet/ankles were not propped as per the care plan. Staff 2 was observed by a Registered Nurse surveyor as she performed the wound treatment for [REDACTED]. She described the surrounding issue as less purple than it had been and soft, not hard or mushy, to touch. She also stated that there was a ridge at the upper lateral edge of the wound. The wound was observed to be covered in dark eschar and was unstageable. At 5:45 am Staff 2 placed a 4 inch thick gel pad in the resident's wheelchair. She verified that the thin pad in the chair was not the correct pressure relieving pad. Staff 2 stated that she adjusted the bed air mattress pump to show between 2 and 4 lights illuminated and that she did not put the bed setting on the care plan so that CNAs wouldn't adjust the bed. She also verified that the size of the wheelchair pad was not care planned. During an interview with Staff 2 at 6:30 am she was informed of the inaccurate bed setting and wheelchair pad observations from 3/23/11. The 3/3/11 RD note and the current care plan were reviewed. Staff 2 verified the lack of specific individualized care plan directions/interventions, use of the incorrect bed setting and wheelchair gel pad for pressure relief and the delay in RD evaluation of wound healing needs with protein deficiencies early in the progression of the wound. Staff 2 verified that the facility failed to provide appropriate interventions to promote healing of an eschar covered unstageable pressure ulcer.