Every finding on record at Dixon Rehab & HCC

Based on interview and record review the facility failed to identify an area of pressure before becoming a stage 3, failed to have a wound evaluated by a wound care professional and failed to assess and document an area of skin breakdown. This applies to one of three residents (R1) reviewed for pressure in the sample of three. This failure resulted in R1 sustaining a stage 3 pressure ulcer with 90% slough and necrotic tissue to her sacrum. The findings include: The facility face sheet for R1 shows she was admitted to the facility on [DATE] with diagnoses to include spinal stenosis, Type 2 Diabetes Mellitus, abnormalities of gait and mobility and urge incontinence. The facility assessment dated [DATE] shows R1 to have severe cognitive impairment and requires maximal assistance with her activities of daily living. The same assessment shows R1 was admitted to the facility with a risk of developing a pressure injury but did not currently have any. The facility's electronic health record census tabs shows R1 was discharged to another facility on 12/3/24. On 1/15/25 at 11:00 AM, V4, R1's Power of Attorney (POA) said her mother was at the facility for rehab after back surgery and then she was to be transferred to another facility for long term care. V4 said she was told by the facility staff that R1 had a stage 2 pressure injury to her sacrum. V4 said she was aware of the pressure injury and had asked for R1 to be seen by a wound care professional, but that had never happened. V4 said when R1 arrived at the new facility, that facility's wound care provider happened to be in the building, and saw R1 that day. V4 said the provider said there was no way the pressure injury was a stage 2 due to all the slough (devitalized tissue) that was present. V4 said the provider debrided the wound and it was determined to be a stage 4 pressure injury with a small amount of bone being visualized. On 1/15/25 at 9:45 AM, V1 Administrator and V2 Director of Nursing said V2 was in charge of wound care when R1 was a resident in the facility. V2 said when a resident gets a new wound it is assessed by her and a treatment is ordered for the care. A wound care professional is contracted by the facility to see all wounds, but the day R1's wound was discovered, she was also diagnosed with COVID-19 and was placed on isolation. V2 said the wound care professional would not see her while she was on isolation for COVID-19. V2 then said that after R1 was off of isolation, it was the Thanksgiving holiday and the wound care professional was not working. V2 said she continued with treatment of the wound and did not feel the wound was getting worse and was improving. V2 said the wound was a stage 3 pressure injury when it was found. The wound was filled with slough. V2 said she tried to get R1 seen by the local wound care clinic but no appointments were available. V1 and V2 said R1's Physician was aware of the wound and had signed orders for the care of the wound. On 1/15/25 at 10:09 AM, V3 Registered Nurse said R1 was being treated for a wound to her sacrum with daily dressing changes. V3 said R1 had some sort of wound to her sacrum area before but she could not recall what the issue was. V3 said when R1 was transferred to another facility the wound care orders were sent with her. V3 said R1 was not seen by the wound care professionals at the facility due to her having been diagnosed with COVID-19 and was on isolation for 10 days. V3 said the wound to the sacrum of R1 had a lot of slough present with a black center found. V3 said you could not see the bottom of the wound. V3 said at one point the daughter asked that her mother be placed back on a medication to help with overactive bladder due to large amounts of incontinence and her mothers bottom was getting very red and sore. V3 said she reached out to the Physician and an order was obtained for the medication. V3 said that was on 11/6/24 that she reached out to the Physician telling him R1 was having large amounts of urine incontinence and her sacrum was having breakdown. On 1/15/25 at 12:25 PM, V5 Nurse Practitioner (NP) said she saw R1 one time while she was at the facility and she was not aware R1 had a pressure injury to her sacrum. On 1/15/25 at 2:20 PM, V6 Medical Doctor (MD) said he does not recall R1 having a pressure injury to her sacrum and does not recall giving any orders for it. V6 said when he is notified of a new pressure injury he usually goes with the nurse to look at the wound. V6 said he does not have any notes showing he did this with R1. V6 said he expects the staff to assess the skin frequently and report to him any skin issues. V6 said debridement of the wound would help with allowing healthy tissue to grow and will prevent infections and other complications. V6 said he was not surprised R1 developed a pressure injury due to her age, recent back surgery, immobility, incontinence and having uncontrolled diabetes. On 1/15/25 at 2:45 PM, V2 said she was not aware R1 had orders for wound care between 9/27/24 and 10/20/24 and feels it must have been for preventative measures for R1. V2 said she expects an area of pressure to be identified prior to it becoming a stage 3. The facility pressure ulcer weekly wound evaluation form dated 11/11/24 shows R1 had a stage 2 facility acquired pressure ulcer to her sacrum with slough present and a moderate amount of drainage. The skin around the wound was labeled as macerated (skin softens and breaks down due to moisture). The date acquired was shown as 11/11/24. No measurements are recorded on this document. The weekly pressure ulcer report dated 11/11/24 shows R1 had a stage 3 pressure ulcer first identified that day and measured 3.0 by 2.5 centimeters with an unknown depth to her sacrum. The wound was 90% slough filled. The note shows to refer to wound care professional once off isolation. The weekly pressure ulcer report dated 11/18/24 shows the wound was measured at 2.9 by 2.5 centimeters and an unknown depth with 90% slough present. The report dated 11/25/24 shows R1's wound was measured at 2.9 by 2.5 centimeters with a depth of 0.2 centimeters with slough still at 90%. The report dated 12/2/24 the day before R1's discharge, shows the wound still had 90% slough and measured 2.8 by 2.0 centimeters. The Physician Order Sheet (POS) shows an order dated 9/26/24 to cleanse the open area to sacral area with wound care cleanser, pat dry, apply medi honey to wound bed, cover with bordered foam dressing daily and as needed. The order shows it was entered by V2 DON. The weekly pressure ulcer report dated 9/3024 does not show any open areas for R1. The facility electronic health record for R1 does not show any evidence of an open area to R1's sacrum being measured or monitored from 9/27/24 to 10/20/24. The facility Treatment Administration Record (TAR) dated 9/2024 and 10/2024 shows a dressing change was completed on R1 between 9/27/24 to 10/19/24. The TAR dated November 2024 shows R1 was on droplet precautions from 11/11/24 to 11/22/24 for a COVID-19 infection. A Physician communication form dated 11/6/24 shows R1 was having large amounts of urine incontinence and had breakdown to her sacral area. The office clinic notes dated 11/29/24 signed by V5 NP does not show any wounds for R1. The progress note dated 11/27/24 signed by V6 MD does not show any skin issues for R1. The facility policy with a revision date of 3/2021 for wound assessment shows it is the policy of the facility to assess each wound at the time the wound is identified. Each would will be assessed weekly thereafter or with any significant change in the wound. The wound policy also shows if the wound base is obscured by slough it is classified as an unstageable wound and the once the slough is removed a stage 3 or 4 ulcer will be revealed.

Based on observation, interview, and record review the facility failed to prevent pressure injuries for residents at risk for pressure, failed to initiate treatment orders when pressure injury was found, failed to monitor a pressure injury for signs and symptoms of infection for 2 of 4 residents (R1, R3) for pressure in the sample of 4. This failure resulted in R1 developing a Stage 3 pressure injury to her right heel that became infected and R3 developing two Stage 2 pressure injuries to his sacrum. The findings include: 1. R1's Nursing Admission data collection dated 10/3/24 shows R1 was admitted on [DATE] due to hysterectomy with bladder sling, no impaired skin integrity, abdominal area has 3 small incision sites. On 11/23/24 at 8:47 AM, R1 was sitting up in a wheelchair at the dining room table eating breakfast. R1 had heel protective boots on both feet and a mechanical lift sling underneath her. R1 said she was doing ok and had the boots on because her foot hurt her. On 11/23/24 at 9:20 AM, V3 Registered Nurse was in R1's room, just finishing wrapping R1's heel with a gauze dressing. V3 said R1 has an unstageable pressure wound to her right heel. V3 said the wound started off as a deep tissue injury and then the area turned black and fell off. V3 said it got infected and R1 was put on antibiotics. V3 said now it is a large area on her heel with white and yellow slough and R1 is seeing the wound doctor now. V3 said when R1 was admitted she was able to stand and pivot and now R1 is transferred with a mechanical lift because she is unable to bear weight on the right foot. V3 said R1 is alert and oriented to self, place, but has some developmental delays so it takes a little bit for her to make her needs known. On 11/23/24 at 10:06 AM, V2 Director of Nursing said she is the acting wound nurse right now. V2 said R1 was sent to see a wound doctor at the local hospital when her wound started getting worse and was looking visibly bigger. V2 said not all residents with pressure injuries see the wound doctor only those whose wounds that the medical doctor think needs more care. V2 could not recall if R1's wound became infected. On 11/23/24 at 11:30 AM, R1 was in bed with heel boots in place. R1 said her foot hurt a little right now, but not like it did at first. R1 said she doesn't like to have a sore foot. On 11/23/24 at 12:34 PM, V2 said a Certified Nursing Assistant mentioned to her that R1 had something on her heel and the nurse on duty did a change in condition report (SBAR). V2 said when she first assessed R1's wound on 10/19/24 (during the weekly pressure ulcer assessments), it was a dark brown/purple area to the right heel and was not open at the time. V2 said she notified the doctor and got orders for treatment. V2 said she was not aware of any changes to R3's wound until 11/11/24. V2 said when she assessed R1's wound on 11/11/24 she noticed the wound was worse, and had opened up at one end with yellow slough and clear yellow drainage. V2 said she did not notice an odor. V2 said she saw R1's wound before V6 Nurse Practitioner (NP) saw R1 on 11/11/24. V2 said V6 saw R1 and ordered antibiotics for the wound and to see the wound doctor. V2 said R1 was seen by the wound doctor at the local hospital on 11/18/24. On 11/23/24 at 1:40 PM, this surveyor with V2 observed R1's wound. R1 had a large irregular open wound with depth. R1's wound was almost R1's entire heal approximately 2 x 4 centimeter and had depth. R1's wound contained yellow slough and this surveyor could smell a foul odor through a surgical mask. V2 completed wound care and applied the treatment to R1's wound. R1 said several times that her foot hurts a little bit. R1's SBAR dated 10/19/24 at 2:35 PM shows open area to right outer aspect of heel. This form does not contain measurements or a description of the wound. The facility's Weekly Pressure Ulcer Report for R1 dated 10/21/24 shows first observation, facility acquired stage 1, right heel, 1.5 x 1.5 x 0.0 centimeters, with treatment orders betadine and foam dressing daily 10/22/23. This document does not contain a description of the wound. R1's Physician Orders shows treatment orders for R1's right inner heel were ordered on 10/22/24 (3 days after wound was found). The facility's Weekly Pressure Ulcer Report for R1 dated 10/28/24 and 11/4/24 shows no change in status, with no description of wound. R1's Skin Check Weekly report dated 10/17/24 shows no new changes this week. with no description of the wound. R1's Physician Communication Form dated 11/10/24 shows Nurse to Provider Communication: Please look at right heel- it is getting worse, foul odor, moderate amount of drainage; and NP/Doctor Response/Orders/Follow Up: 11/11/24- Get R1 into hospital wound care please (re :heel wound-right), Bactrim Ds twice daily for 7 days (heel wound), until seen by wound doctor , cleanse right heel wound with wound cleanser-gently scrub to remove drainage-apply an antibiotic/collagen product and cover with foam dressing. Change dressing every 3 days or if dressing comes off. Foam dressing needs to be securely taped around wound, Keep bilateral heels off bed or any pressure. The facility's Weekly Pressure Ulcer Report for R1 dated 11/11/24 shows Status-Worsened, right heel unstageable, 1.8 x 4.2 x 0.2 centimeters, moderate exudate, no odor. The facility's Weekly Pressure Ulcer Report for R1 dated 11/18/24 shows Status-Worsened, right heel unstageable, 2.0 x 4.0 x 0.3 centimeters, moderate exudate, mild odor. R1's NP Progress Note dated 11/11/24 shows right heel pressure ulcer with foul odor and moderate amount of drainage. Will get her into local Hospital Wound Care as she does need debridement. She does have bilateral heel pads on however she still needs these heels offloaded. Discussed plan of care with nursing staff, they verbalized understanding. R1's Hospital Wound Care Visit Report dated 11/18/24 shows new patient presents to the clinic today after developing a pressure wound after having surgery and being in a nursing care facility. Patient is currently at local nursing care facility, developed a wound a little over a week ago on the posterior aspect of the right heel. Right heel wound is a chronic stage 3 pressure injury. Initial wound encounter measurements are 3.19 x 3.76 x 0.1 cm depth. Necrotic adipose tissue is exposed. There is a large amount of serosanguineous drainage noted which has a mild odor. The patient reports a pain level of 5/10. The wound margin in irregular, wound bed has no-granulation, yes-slough. Advised patient to off-load foot ulcer. Expected duration of skilled wound care therapy 1-3 months. On 11/23/24 at 1:00 PM, V6 NP was called and a message left. There was no return call. 2. On 11/23/24 at 9:35 AM, V4 Certified Nursing Assistant had just finished providing incontinence care for R3. V4 said R3 has a pressure injury on his left hip and a patch on his shoulder but she didn't think he had any other wounds. V4 said R3's bottom was red but there was no open areas that she had seen during care. V4 rolled R3 to his side, and lowered his brief. R3's sacral area was visibly red and there were two small openings on his sacrum area. V4 said R3 should be turned and repositioned every 2 hours and she had not reported R3's redness to his bottom or applied any cream. V4 said she was not sure how long R3's bottom had been red. V5 LPN came into the room and assisted to hold R3. V3 LPN came in and assessed and measured the openings. V4 said both wounds are Stage 2 pressure injuries since the wounds are open. V4 said the lower opening on R3's sacrum measured 1 x 0.4 cm and the upper wound measured 0.5 x 0.2 cm. V4 cleaned both wounds and applied a dressing. V5 said she would notify the doctor and get treatment orders. On 11/23/24 at 12:34 PM, V2 said R3 openings on his sacrum are new, he had nothing there previously. V2 said R3 is at risk for pressure and has pressure reducing interventions of low air loss mattress and wheelchair cushion, float heels, and turn and reposition every 2 hours to reduce pressure. V2 said if R3 had redness to his bottom, cream should be applied. V2 said she was aware that R3 had been having some loose stools which could cause breakdown. V2 said the doctor was notified of R3's wounds and treatment orders were obtained. R3's Progress Note dated 11/23/24 at 10:10 AM, shows resident was noted to have open areas to sacrum. MD notified of new areas. R3's Care Plan shows R3 has actual skin impairment to skin integrity related to decreased mobility, incontinence/moisture, friction and shearing, nutrition and disease process. R3 was admitted with wound to left hip. Interventions: apply moisture barrier with each incontinence episode, and resident needs assistance to turn/reposition frequently and as required. R3's Wound Physician Visit Summary Report dated 11/20/24 shows R3 has a stage 3 full thickness pressure injury to left lateral thigh. Discussed importance of offloading, pressure relief and frequent turning and repositioning changes. Staff present for all education and verbalized understanding. The facility's Pressure Ulcer/Pressure Injury Prevention Policy dated 3/2022 shows An individual plan of prevention will be developed to meet the needs of the resident. It will include the consideration of mechanical support surfaces, nutrition, hydration, positioning, mobility, continence, skin condition, and overall clinical condition of the resident as well as the risk factors as they apply to each individual. The goal is for the resident to be free of preventable pressure ulcer/pressure injury.

Based on interview and record review the facility failed to ensure a resident (R1) was free from physical abuse of (R2) for two of three residents (R1, R2) reviewed for abuse in the sample of 7. The findings include: The State Report dated 10/27/24 for R1 showed, V1 (Administrator) was notified that R1 stated R2 smacked him. Investigation initiated. Staff attempting to assist in this situation and R2 kicked and struck the CNA (Certified Nursing Assistant). Residents separated from one another. R2 refused to let staff near him. R2 being sen out for further evaluation. Family of both residents notified. Provider notified. Police notified. Investigation completed. V9 (Laundry Aide) stated, when I was returning from break, R2 was at the door asking me for help to open the door so he can get out of his room, his roommate hit him. V5 stated that R2 has had a change in condition; the resident is currently experiencing altered mental status and aggressive behavior. He recently moved to the current room. This nurse was notified that the resident and his roommate were in the room together and there were words said to each other. Screaming was heard by CNA staff and when CNA staff entered the residents' room the roommate (R1) said he was slapped across the face. The residents were immediately separated. When CNA staff attempted to intervene, R2 began kicking and swinging his fists at CNA making contact several times before the CNA was able to get out of the room. V1 and V2 (DON/Director of Nursing) met with R2's daughter who insisted that this is not normal behavior for her father and she was extremely upset the day this happened. Upon completion of this investigation it has been determined that there is no visual proof that R1 was slapped across the face, no witness to this encounter and considering R2's altered mental status and change in condition, it is determined that this was the result of the newly diagnosed infection and an isolated incident. On 11/6/24 at 10:16 AM, V4 (R1's daughter/POA - power of attorney) stated the facility moved a new man into her fathers room and introduced him (R2) to R1. V4 stated R1 told her he was talking to R2 and R2 grabbed his hat. The man (R2) said it was his hat and said R1's coat was his too. The man (R2) pushed R1 and R2's hand went to R1's face. R1 was startled; he told the people there. On 11/6/24 at 11:07 AM, V2 (DON) stated she was notified of an altercation; R2 struck R1. The CNAs separated them and the nurse was down there as well. R2 was hitting the CNAs, that is what one CNA reported. V2 stated R2 did not have any behaviors before this that she was aware of. V2 stated both residents have some dementia/cognitive impairment. V2 stated R2 never resolved his pneumonia and had a urinary tract infection when this occurred. On 11/6/24 at 11:39 AM, V6 (RN/Registered Nurse) stated R1 and R2 were both in wheelchairs facing the door and R1 said R2 slapped him. V6 stated she moved R2 over to his side of the room. R2 did not believe it was his room or that R1 was his roommate. V6 stated she questioned R1 and he never said he was hit. The right side of R1's face was red; he said it didn't hurt. On 11/6/24 at 11:59 AM, V5 (LPN/Licensed Practical Nurse) stated she was coming up the hall and she heard a commotion. R1 was screaming; he speaks loud because of his hearing. V5 stated she heard R1 say, He (R2) slapped me. He (R2) slapped me across the face. V5 stated R1 was not in his room by the time she got up the hall. V5 stated R1 said, He slapped me V5; he slapped me in my face. V5 stated she met V7 (CNA) in the hall and V7 told her R1 was saying R2 slapped him and then R2 attacked her. V5 stated she has never see R1 or R2 have any behaviors. On 11/6/24 at 12:40 PM, R1 was asked if he remembered what happened and he stated, He slapped me. He said my leather coat was his and it wasn't. R1 stated it hurt when it happened but he was fine now. The facility's Abuse, Prevention and Prohibition Policy (1/2024) showed, This facility prohibits mistreatment, neglect, or abuse of residents. The residents must not be subjected to abuse by anyone. Resident to resident abuse includes the term willful. The word wilful means that the individual's action was deliberate (not inadvertent or accidental), regardless of whether the individual intended to inflict injury or harm. An example of a deliberate (willful) action would be a cognitively impaired resident who strikes out at a resident within his/her reach, as opposed to a resident with a neurological disease who has involuntary movements (e.g., muscle spasms, twitching, jerking, writhing movements) and his/her body movements impact a resident who is nearby. Physical abuse includes, but is not limited to, hitting, slapping, punching, biting, and kicking. The Face Sheet dated 11/6/24 for R1 showed diagnoses including dysphagia, muscle weakness, type 2 diabetes mellitus, hyperlipidemia, hypertension, congestive heart failure, peripheral vascular disease, emphysema, myocardial infarction, dementia, hemigplegia, and hemiparesis. The MDS Minimum Data Sheet dated 10/23/24 for R1 showed no mood or behavior disturbances. The Care Plan dated 9/12/24 showed, R1 enjoys being social and visiting others. He is hard of hearing and staff must speak loudly for him to understand. He enjoys watching TV in his room and listening to all genres of music. He looks forward to joining others in the dining room for meals. R1's care plan did not show any behaviors. The Face Sheet dated 11/6/24 for R2 showed diagnoses including pneumonia, anemia, dysphagia, cognitive communication deficit, unsteadiness on feet, hypertension, myocardial infarction, left ventricular failure, dyspnea, major depressive disorder, insomnia, and muscle weakness. The MDS dated [DATE] for R2 showed moderate cognitive impairment; no mood or behavior disturbances. The Care Plan dated 10/23/24 for R2 showed, R2 has impaired cognitive function/dementia or impaired thought processes related to his diagnosis of cognitive communication deficit. Provide the resident with necessary cues. Stop and return if agitated. R2's care plan did not show any behaviors.

Based on observation, interview and record review the facility failed to ensure pressure ulcers were assessed, prescribed treatment orders were transcribed and provided, and treatment dressings were in place for residents with pressure ulcers. These failures apply to 4 of 5 (R179, R6, R66, R55) residents reviewed for pressure ulcers in the sample of 18. The findings include: 1. R179's face sheet shows she is a [AGE] year old female admitted to the facility on [DATE], from another facility. Her diagnoses include COPD, unspecified dementia without behavioral disturbance, type 2 diabetes, multiple sclerosis, gastrostomy status, unspecified cerebral infarction. On 10/21/24 at 9:24 AM, V7 (Licensed Practical Nurse/LPN) provided wound care to R179. V7 removed the soiled dressing from her coccyx. A round open area to her coccyx was observed. V7 cleansed the wound, applied calcium alginate and foam dressing but did not apply the medicated cream to the wound bed. V7 said R179's treatment order was santyl and calcium alginate. R179's Wound Assessment form dated 10/2/24 documents a stage 3 coccyx pressure ulcer measuring 3.8 cm (centimeters) x 5.8 cm x 0.9 cm. R179's Treatment Medication Administration Record shows orders to cleanse the wound with normal saline, to irrigate and scrub the wound bed, the apply collagenase santyl, nickel thick (2 millimeters) topically to entire wound bed, edge to edge. Apply calcium alginate to wound bed, cover with foam dressing. R179's Nursing Admission/Readmission Data Collection report dated 10/9/24 documents an open area to her coccyx but it does not include measurements of the wound. R179's EHR (electronic health record) does not show an assessment of R179's wound after 10/9/24. On 10/22/24 at 1:17 PM, V2 (Director of Nursing/DON) said she is the DON and the wound nurse. She has been doing both positions since November 2023. Wounds should be assessed on admission and weekly. The physician prescribes the wound treatment and staff should follow the treatments orders. 2. R6's face sheet shows he is a [AGE] year old male with diagnoses including dysphagia, CHF, atrial fibrillation, acquired absence right leg below knee amputee, type 2 diabetes, depression, and adult t-cell lymphoma/leukemia in remission. On 10/21/24 at 10:38 AM, R6 was lying in his bed. He said he has a wound on his bottom with no dressing on. On 10/21/24 at 1:58 PM, V6 (Registered Nurse/RN) and V8 (CNA-Certified Nursing Assistant) entered R6's room to provide wound care. V7 rolled R6 on his side, there was no treatment dressing to his open wound on his right buttock. Bloody drainage was noted on the incontinent pad. At 2:08 PM, V6 said she was not sure why R6 did not have dressing on, she thinks because R6 had a bed bath earlier but was not sure. On 10/22/24 at 1:17 PM, V2 (DON) said R6 has a stage 2 on his buttock, he should have a treatment dressing in place. R6's Minimum Data Set assessment dated [DATE] shows he has stage 2 pressure ulcer. R6's Wound Progress note dated 10/9/24 documents his right buttock wound measuring 6.8 cm x 0.2 cm x 5 cm with treatment orders including to cleanse wound with hydrochlorous, apply calcium alginate to wound bed and apply foam dressing daily. 3. R66's face sheet shows he is a [AGE] year old male with diagnoses including muscle wasting, encounter for orthopedic aftercare following surgical amputation, acquired absence of left leg below the knee, type 2 diabetes, peripheral vascular disease, and non-pressure chronic leg ulcer of right lower extremity. On 10/21/24 at 1:45 PM, V6 (RN) said R66 was admitted with a pressure wound to his sacrum and left below knee amputation. R66 was lying in bed. To his right lower extremity, an ace wrap was in place and left below knee amputee. V8 (CNA) assisted him on side. Two foam dressings were in place to the right and left sacrum. V6 removed the old dressing, cleansed the wound and applied medi-honey, calcium alginate and foam dressing. On 10/21/24 at 2:08 PM, V6(RN) said the floor nurses do the treatment orders on wounds, but she was not sure who is measuring wounds and wounds should be measured weekly. R66's Wound Weekly Report dated 9/5/24 documents left sacrum wound measuring 4.5 cm x 6.0 cm and right sacrum measuring 2.0 cm x 3.5 cm. R66's Pressure Ulcer Weekly Wound Evaluation report dated 10/14/24 documents stage 2 sacrum pressure measuring 2.3 cm x 1.7 cm x 0.1 cm signed by V2 (DON) on 10/22/24. The same report does not include the two open areas to his sacrum. R66's EHR does not show documentation of the sacral wounds after 9/5/24 to 10/22/24 approximately six weeks. On 10/22/24 at 1:17 PM, V2 (DON) said she has been the wound nurse and DON since November of last year. Wounds should be assessed weekly to ensure wounds are not getting worse. She got behind on things and did not measure R66's wound until today. 4. On 10/21/24 at 10:01 AM, R55 was observed sitting in her wheelchair, she said she has wound on her bottom with a dressing in place. R55's Physician Wound Assessment report dated 10/9/24 documents a stage 3 sacrum pressure ulcer measuring 4.5 cm x 3 cm x 0.2 cm. Treatment orders include cleanse wound with hypochlorous acid, apply skin prep to wound, apply calcium alginate to wound bed, and cover with bordered foam daily. R55's Treatment Administration Record (T.A.R.) shows orders to cleanse sacral wound with wound cleanser, apply medihoney, calcium alginate and bordered gauze daily and as needed. The T.A.R did not show orders were changed until 10/22/24 (13 days later) with orders to cleanse wound with hypochlorous acid, apply skin prep to wound and apply calcium alginate to wound bed, cover with bordered foam daily. On 10/22/24 at 1:17 PM, V2 (DON) said the wound physician comes weekly, she receives the wound report that day or the day after, and she changes the orders if needed. She confirmed R55's treatment orders were not changed until today and she was not receiving the prescribed treatment. The facility's Pressure/Wound List provided on 10/22/24 does not include R179, R6, R66 and R55's pressure ulcers. The facility's Pressure Ulcer/Pressure Injury Prevention Policy dated 2022 states, A facility must identify whether the resident is at risk for developing or has a pressure ulcer upon admission and thereafter, evaluate resident specific risk factors and changes to the resident condition that may impact the development and;/or healing of pressure ulcer, implement, monitor and modify interventions .provide treatment .

Based on observation, interview and record review the facility failed to ensure effective fall interventions were in place for resident's safety who is a high risk for falls and has a history of falls. This failure resulted in R45 falling out of bed and sustaining a left hip fracture needing surgical repair for 1 of 18 residents (R45) reviewed for safety in the sample of 18. The findings include: R45's Physician Order Sheet show R45 is [AGE] year old with diagnoses of vascular dementia, hypertension, weakness and left hip fracture R45's facility assessment dated [DATE] show R45 is severely cognitively impaired (BIMS of 1) R45's fall risk assessment dated [DATE] show R45 as a high risk for falls. On 10/21/24 at 9AM, R45 was in bed moaning I am sore. V19 (Registered Nurse) was with R45 at this time and said R45 has a hip fracture due to fall. On 10/21/24 at PM, V20 (R45's daughter) said she was very disappointed at the facility. My mom has had four (4) falls. All of these falls were her trying to go to the bathroom. Staff knew this is what she does so they needed to check on her often to see if she needed to use the bathroom. Staff should have made a schedule for her to go to the bathroom before she even tries to get up on her own. She (R45) had injuries due to these falls. She (R45) had large cut in her forehead when she fell late last year. She fell face forward while in the bathroom. This latest fall, last week, had resulted in her breaking her hip and had to have surgery to fix her broken hip. Again she was trying to go to the bathroom. V20 said [R45] has dementia and reminders for her not to get up by herself does not work, she won't remember that. R45 is weak and unsteady, she needs her device (walker) and a staff to bring her to the bathroom. Review of R45's fall incident reports show: 11/7/2023-(fall with injury) R45 self transferred from her bed into the bathroom .she lost her balance falling forward striking her head on the floor. Laceration to forehead, nose and right hand . Careplan documents intervention as follows: Do not leave resident in bathroom unattended. 1/31/24-resident audibly moaning, and door was shut . at 23:15 resident was on the floor in her bathroom .resident was sitting on the floor in front of her toilet, with her legs stretched out in front of her . Careplan documents intervention as follows: Call don't fall sign. Make sure R45's call light is within reach and encourage to use it for assistance as needed. (R45 has dementia) 9/8/24-This writer was notified by 200 hall nurse resident was in bathroom floor lying on her stomach with her head near the doorframe . Careplan documents intervention as follows: Encourage leaving bedroom door open for increased visualization and safety. R45's latest fall dated 10/16/24 (fall with injury) timed at 5:35 AM Residents roommate came out of the nurses station to say resident had fallen in her room. Resident was lying at the foot of the bed on her left side .complained of left hip pain .resident sent to ER. Hospital records dated 10/16/24 show, Fall at (nursing home), patient was getting to go to the bathroom when she fell and landed on her left side. Radiology report dated 10/16/24 show acute comminuted left intertrochanteric fracture. 10/17/24 [R45] had surgery for the left hip fracture. On 10/23/24 at 9 AM V1 (Administrator) and V2 (DON) said they completed R45's investigation and concluded that R45 was attempting to go to the bathroom again and not waiting for assistance. A Facility Reported incident sent to the state agency with date of incident 10/16/24 shows, Resident noted by roommate attempting to self-ambulate from bed. Roommate states she told resident to wait for help and use call light, resident continued to attempt self-transfer and subsequently fell . Resident noted to have her one slipper on and one off. Resident did not use her assistive device. Roommate notified nurse of fall. Injury: Closed intertrochanteric fracture of left hip. . Resident readmitted to facility (10/19/24) s/p surgical hip pinning for closed intertrochanteric fracture of left hip and new diagnosis of UTI. R45 is alert and oriented x 1. Upon investigation of fall, it was determined that resident did not use her call light or wait for assistance despite reminders to do. On 10/22/24 at 2:24 PM, V21 (CNA) said she was R45's CNA on 10/16/24. R45 gets up to go to the bathroom and does not wait for assistance even when told repeatedly. R45 was toileted at 3:30 AM. V21 said at 5AM, she started to get up other residents. At around 5:30 AM, she heard R45 fell trying to get up unassisted. V21 said R45 might be trying to go to the bathroom at that time, that's also 2 hours after she was toileted earlier. V21 said R45 has dementia and forgets reminders. On 10/22/24 at 12:45 PM, V22 (LPN) said she was R45's nurse on 10/16/24. She last saw R45 around midnight and R45 was asleep. At around 5:30 AM, R18 (roommate) came to the nurses station and said R45 fell . R45 was at the foot of her bed lying in her left side. R45 got up from her bed unassisted. R45 was sent to the hospital due to left leg pain. She was found to have left hip fracture. V22 said R45 has been reminded to ask for assistance. V22 confirmed R45 has dementia and reminders for her to wait for staff do not work. R18 (R45's roommate) alert and oriented said she heard a loud sound. She saw R45 on the floor at the foot of R45's bed saying help me! R18 said she put her call light on and waited, then went to the desk and said. Please help she's on the floor! Two of them (staff) came and lifted her to bed then she left to go to the hospital. This surveyor clarified with V1 (Administrator) and V2 (DON) R45's fall interventions and their effectiveness. V2 confirmed that all of R45's four falls involved R45 trying to go to the bathroom unassisted. R45 has dementia (BIMS of 1). V2 (DON) said more frequent checks and toileting schedule would have been more appropriate interventions for R45 to prevent these falls. V1 (Administrator) said they recognized that residents interventions in the careplan were not specifics and resident centered. V1 said they have a started working with their Nurse Consultant regarding this matter. The facility's Fall Policy dated 9/17/19 shows, The purpose of the fall management program is to develop, implement, monitor and evaluate an interdisciplinary team fall prevention approach and manage strategies and intervention that foster residents independence and quality of life.

Based on observation, interview and record review the facility failed to accurately assess a residents weight loss and ensure nutritional interventions were implemented for a resident with significant weight loss. This failure resulted in R66's significant weight loss. This applies to 1 of 5 residents (R66) reviewed for weight loss in the sample of 18. The findings include: R66's face sheet shows he is a [AGE] year old male admitted to the facility on [DATE] with diagnoses including muscle wasting, encounter for orthopedic aftercare following surgical amputation, acquired absence of left leg below the knee, type 2 diabetes, peripheral vascular disease, and a non-pressure chronic leg ulcer of right lower extremity. R66's weight report provided on 10/22/24 documents: 8/27/24- 208.8 lb (pounds) 9/24/24- 184 lb 10/8/24- 186 lb 10/17/24- 182.2 lb R66's electronic health medical record documents Regular Diet, Regular Texture, Regular liquid Consistancy. Needs double portions of meat, eggs and milk at each meal for wound healing, start date: 8/26/24. R66's Dietary Note dated 10/10/24 documents he triggered significant weight loss of 6% in one month and 11% weight loss since admission. R66 had a left below knee prior to admission, was admitted with a cast to leg per DON (Director of Nursing). Currently has a stage II pressure ulcer to sacrum per DON. Diet regular, double meats, eggs and milk all meals .weight loss may be partially related to cast removal . will advise to increase liquid protein to 30 ml (milliliters) twice a day and continue to monitor weight. R66's weight report shows he lost 4 additional pounds since 10/10/24. On 10/21/24 at 12:02 PM, R66 was in his room eating in bed, using his right hand to feed himself. On 10/22/24 at 8:55 AM, R66 was in his room lying in bed. He said he noticed he has been losing weight but not sure why. An elastic bandage was wrapped to his right leg and left leg below knee amputee. He said he never had a cast on his leg and he has not been seen by V24 (Dietitian) recently. On 10/23/24 at 9:47 PM, V24 said nutrition assessments are done on admission, quarterly and if a resident triggers for weight loss. She monitors the weight report, if a resident triggers for weight loss the resident should be re-assessed with interventions implemented. She is at the facility twice a week but it could take up to two weeks or longer before she assesses the resident. R66 triggered for significant weight loss last month, he had double proteins in place and she recommended increasing his liquid protein from daily to twice a day. She said she did not physically see him, she was told he had a cast on his leg and contributed part of his weight loss to that. She said she sends the recommendations to V2 DON. R66's EHR (electronic health record) does not show documentation of a cast to his leg. R66's Physician Order Sheets dated October 2024 shows orders for liquid protein daily (not twice a day). The facility's Nutrition (Impaired)/Unplanned Weight Loss Policy states, The threshold for significant unplanned and undesired weight loss will be based on the following criteria: a. 1 month -5% weight loss is significant, greater than 5% is severe .the staff and physician will identify pertinent interventions based on identified causes and overall resident condition, prognosis and treatment wishes .the staff will implement appropriate general or cause-specific interventions, as indicated .

Based on observation, interview and record review the facility failed to ensure residents pain was managed after undergoing hip surgery. This failure resulted in R45 experiencing severe pain to 1 of 18 residents (R45) reviewed for pain management in the sample of 18. The findings include: R45 has diagnoses that include fractured left hip undergoing hip surgery, dementia, hypertension and weakness. R45 was readmitted to the facility on [DATE] after undergoing surgical repair to her left hip fracture caused by a fall. On 10/21/24 at 9AM, R45 was in bed moaning I am sore. V19 (Registered Nurse/RN) was with R45 at this time and said R45 has a hip fracture due to fall. On 10/21/24 at 12 PM, R45's room was closed but can hear audible moaning. This surveyor entered R45's room. R45 was in the bathroom sitting in the toilet seat. V18 (Certified Nursing Assistant) was with R45. R45 was crying in pain. It's sore!, it is so painful! I can't take this please, I can't, please help me, it hurt's so bad. V18 asked this surveyor to get the nurse. When V19 (RN) was in the room, she asked R45 what's wrong? R45 responded, this is so painful! pointing to her left hip. It is so sore, please help. V19 told R45 you had hip fracture! of course it will hurt!, do you want to go back to the hospital ? R45 answered I don't think that was necessary but my hip hurts so bad, I just want to go lay down!. V17 and V18 (both CNAs) tried to lift R45 up using using a gait belt to her wheelchair. R45 cannot bear weight and cried out I cannot move!, no please! this is sore touching her left hip again it is so painful! A walker was then placed in front of R45. R45 was directed to use the walker to get up. R45 said she cannot move, her legs hurts. V3 (Assistant Director of Nursing) came in the room. R45 said she cannot take the pain in her hip any longer. V3 informed R45 she understood R45 was experiencing severe pain and will try to put R45 to bed. V3 (ADON) was able to transfer R45 via sit to stand and R45 was placed in bed. R45 continued to moan. V19 (RN) then gave a pill to R45 and left the room. At 12:30 PM, This surveyor asked V19 (RN) what did she give R45. V19 said she gave R45 her pain medication. V19 said R45 has an old order of pain meds even before having surgery given four times a day 8AM, 12PM, 4PM, 8PM. Date of order 5/1/24. V19 said R45's pain is increased at this time due to hip surgery. R45's pain level was 6 (severe pain) At 2PM V3 ADON said R45 was definitely experiencing severe pain after this hip surgery At 2:48 PM, V18 (CNA) said R45 does this whimpering sound but earlier when R45 was toileted she had this excruciating pain in her hip that she cannot even move. R45's pain had definitely increased. R45's hospital discharge orders dated 10/19/24 after having hip surgery show a new pain med order of Norco 5/325 (Narcotic pain medication) 1 tab every four hours (approximately 3 days ago). Review of R45's Physician Order sheet dated 10/24 and R45's medication administration sheet (MAR) still has R45's old order (5/1/24) of Norco 1 tab four times a day. The new order of R45's Norco (every 4 hours) was not carried out. On 10/22/24 at 1:10 PM, V2 (DON) said when residents were readmitted , medications were reviewed to ensure all the ordered medications were carried out. R45's careplan with a revision date of 10/21/24 show R45 has pain whimpering .further risk for pain related to recent fall with left hip fracture. R45 does complain of pain during transfers. With intervention that include, monitor residents complaint of pain. Notify physician if intervention are unsuccessful or if current complaint is a significant change from residents past experience. On 10/23/24 at 9AM, V2 (DON) confirmed to this surveyor that R45's pain med from the hospital discharge orders had been corrected to reflect the correct order for R45's pain medications order last 10/19/24. (Norco 5/325 1 tab every 4 hours.)

Based on observation, interview and record review the facility to ensure dishes were handled in a sanitary manner to prevent cross contamination. This failure has the potential to affect all 89 residents in the facility. The findings include: The facility's Long-Term Care Facility Application for Medicare and Medicaid form dated 10/21/24 showed the facility's resident census as 89 residents. On 10/22/24 at 9:32 AM, R15 Dietary Aide placed dirty dishes and cups onto a dishwasher rack and pushed the rack into the dishwasher to be cleaned. Without washing her hands, R15 then walked over to a tray of dry, clean dishes and began placing those dishes onto a storage rack. R15 repeated the same process again, of loading dirty dishes into the dishwasher and immediately touching clean dishes without washing her hands. On 10/22/4 at 11:44 AM, V16 Dietary Manager stated, if one staff member is operating the facility's dishwasher, the staff member is to wash their hands after touching dirty dishes and before touching clean dishes. V16 stated, If they don't wash their hands in between, I would be worried about cross-contamination. The facility's Dish Machine Operation policy (undated) showed, The Dining Services staff shall maintain the operation of the dishwashing machine according to established procedure and manufacturer guidelines posted or contained in this guideline to ensure effective cleaning and sanitizing of all tableware and equipment used in the preparation and service of food . Use clean, washed hands to pull out clean racks, and allow to air dry .

Based on interview and record review that facility failed to ensure a resident with a diagnosis of congestive heart failure had daily weights performed as ordered for 1 of 18 residents (R15) reviewed for quality of care in the sample of 18. The findings include: R15's Face Sheet shows that she has diagnoses of acute on chronic combined systolic (congestive) and diastolic (congestive) heart failure (CHF), myocardial infarction, atrial fibrillation, chronic kidney disease, shortness of breath, hypertension, chronic obstructive pulmonary disease and atherosclerotic heart disease. R15's Physician's Order Sheet shows an order dated 2/28/24 for daily weights for a diagnosis of CHF. R15's Weights and Vitals summary printed on 10/22/24 shows that between 7/13/24 and 10/22/24, R15 did not receive a weight on 7/13, 7/14, 7/15, 7/18, 8/7, 8/15, 8/16, 8/24, 8/29, 9/6, 9/14, 9/16, 9/26, 9/27, 9/28, 9/29, 10/2, 10/6, 10/8, 10/9, 10/13, 10/14, 10/16, 10/17, 10/19 and 10/21/24. On 10/22/24 at 12:58 PM, V2 (Director of Nursing) said that if weights are ordered daily for a resident, they should be done daily and recorded in the electronic medical record. V2 said that it is important to get ordered weights for CHF residents to assess for weight gain or fluid overload due to their heart failure. The facility's Weight Assessment and Interventions Policy dated 1/2017 shows, Weights will be recorded in the individual's medical record.

Based on observation, interview and record review the facility failed to ensure a resident received Passive Range of Motion (PROM) to her left upper and lower extremity and failed to ensure a splint was applied for 1 of 4 residents (R27) reviewed for range of motion in the sample of 18. The findings include: R27's Minimum Data Set assessment dated [DATE] shows that her cognition is intact, she has an impairment of one side of her upper and lower extremity and has no rejections of care. On 10/21/24 at 9:00 AM, R27 had a contracted left hand. There was no splint in place on R27's left hand. R27 said that she is unable to move her left arm or left leg due to a stroke. On 10/22/24 at 8:45 AM, R27 was laying in bed. R27 did not have a splint on her left hand. On 10/23/24 at 8:40 AM, R27 said that they do not do exercises (ROM) on her left arm or left leg. R27 said that she did have a brace for her left hand in the past but they have not put it on her recently. R27 said that she would love exercises done to her left arm and left leg because she can not yet move them herself. On 10/22/24 at 1:40 PM, V10 (Restorative Aide) said that R27 is not on his assignment for ROM. V10 said that R27 likes to do it herself. V10 said that R27 used to have a splint but she didn't like it so he never put it on her. V10 said that if R27 wants ROM, he will do it but he didn't think that she wanted it. On 10/23/24 at 8:45 AM, V9 (Physical Therapy Assistant) said that R27 can not move her left arm and left leg on her own due to them being flaccid. V9 said that they have tried a splint on R27's left hand in the past but she did not like it. R27's Care Plan printed on 10/22/24 shows, Resting hand splint when in bed. If resident complaints of pain, may remove .Active Range of Motion .Cue [R27] to perform AROM exercises to right arm and right leg, 3 sets of 10 repetitions .Passive Range of Motion .Assist [R27] with PROM exercises to left arm and left leg, 3 sets of 10 repetitions. The facility's Restorative Nursing Policy and Procedure revised on 7/1/24 shows, It is the policy of this facility to provide restorative nursing which promotes the resident's ability to adapt and adjust to living as independently and safely as possible. Restorative nursing focuses on achieving and/or maintaining optimal physical, mental, and psychological function of the resident.

Based on observation, interview and record review the facility failed to ensure a resident who was experiencing increased depression received psychiatric services timely as prescribed. This applies to 1 of 18 residents (R29) reviewed for behavioral services in the sample of 18. The findings include: R29's face sheet shows he is a [AGE] year old male with diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, major depressive disorder, restlessness and agitation, calculus of kidney, unspecified psychosis, insomnia, hypertension and anxiety. On 10/21/24 at 10:25 AM, R29 was observed sitting in his wheelchair outside of his room with his call light on. He said he needed to use the bathroom. V7 and V18 (Both Certified Nursing Assistant's) assisted R29 to the bathroom using the mechanical stand lift. R29 did not express any concerns or behaviors. On 10/22/24 at 3:00 PM, R29 was observed in his room lying in bed. He said has made self-harm threats in the past, but says he was joking and is seen by psych. On 10/22/24 at 11:49 AM, V6 (RN-Registered Nurse) said R29 has been pleasant towards me, but has had behaviors in the past of making self-harm statements, hitting himself, and staff found him with a garbage bag over his head at one time. He has a history of kidney stones and several months ago he decided he was not going to follow up with the urologist, he was complaining of pain and making statements of self-harm. He was sent out to the local hospital, physician was notified, and recommended he follow up with the urologist and psych. He did have a kidney stone that was removed sometime in October 2024. He has a history of not getting along with his roommates and is on his third roommate. On 10/22/24 at 1:17 PM, V2 (DON) said R29 is being seen by psych services, he had increased behaviors due to pain and has followed with urology. On 10/23/24 at 8:39 AM, V5 (SSD-Social Service Director) said R29 has behaviors of getting angry, has had suicidal thoughts, and history of not getting along with his roommates. When he does not get his way or is having pain he makes statements of self-harm. He has told me he does not mean what he says it's just he's having pain. She talks to R29 weekly and does not think he is at risk for self-harm R29's Nurse Practitioner (NP) progress note dated 9/9/24 documents, R1 seen today for nursing concerns of increased depression/concern for self harm. He complains of bilateral low back pain that started a couple of days ago. R1 states, it is kidney stone pain.Nursing reports that two nights ago a staff person walked into his room and he had a garbage over his head and stated he wanted to die at that time. During my visit with him today he denies self harm however states he did that with the garbage bag because he was in pain .will address pain and have psych see him today .he does follow up with urology tomorrow. R29's Physician Orders dated 9/9/24 documents please have psych see today for increased depression. R29's Psych Progress note dated 9/16/24 (7 days later) documents chief complaint: depression, anxiety and insomnia staff reports of wanting to give up this is related to patient reported kidney pain .he reported not wanting to live due to pain and expressed no plans for self-harm. On 10/23/24 at 11:10 AM, V2 (DON) said on 9/9/24 there was an order for him to be seen by psych. We sent the referral, she did not know the order was for him to be seen that day. He would have been sent to the ER to be seen by psych because they do not come out on emergent cases. Psych usually comes to the facility on Mondays and the provider was on vacation that week. She did not call R29's NP to inform her psych was not available. R29's careplan initiated on 3/14/22 documents he has a history of suicidal ideation's with a known plan with interventions including try to reason with him, remove any threatening or potentially harmful objects and notify nurse, MD, NP and POA, monitor behavior, and intervene as necessary. His careplan also shows he has depression related to loss of independence with interventions offer him mental health services, including individual counseling, arrange for psych consult and follow up as indicated. The facility's Behavioral Assessment, Intervention and Monitoring Policy states, The staff will identify, document and inform the medical practitioner about specific details regarding changes in an individuals mental status, behavior, and cognitive .interventions will be individualized to provide the highest level of well being .

Based on observation, interview and record review the facility failed to ensure a resident's medications were administered according to standards of practice for 1 of 18 residents (R15) reviewed for storage of medications in the sample of 18. The findings include: On 10/21/24 at 9:03 AM, R15 was sitting in a chair in her room eating breakfast. R15 had 8 pills in a medication cup on her bedside table. R15 stated, Those are my morning pills. There was no nurse present in the room. On 10/21/24 at 9:13 AM, V6 (Registered Nurse) said that she administered R15's morning medications already so she does not know what medications would have been on R15's bedside table. V6 said that medications should never be left in a resident's room and the nurse should always ensure that the resident takes the medications before leaving the resident. On 10/21/24 at 9:15 AM, V6 entered R15's room. The pills that were on R15's bedside table were gone. R15 stated, I just took my morning pills that you left, you know that I don't take them until after I am done with breakfast. On 10/22/24 at 12:58 PM, V2 (Director of Nursing) said that the nurse should make sure that the resident takes their medications before they leave the room . V2 said that it is not a practice of the facility to just leave them in the room. V2 said that if they are left, the nurse can not ensure that the medication was taken. R15's Nursing Notes dated 10/21/24 shows, This nurse administered resident AM medications. At approximately 0905 it was reported to this nurse that resident had a cup with medication at her bedside. When this nurse entered resident's room there was no cup with medications present. Resident stated to this nurse that she had just taken this cup of medications, but this nurse had observed resident take AM medications with nurse present. No such cup of medication was at bedside after administration of medications. MD (Physician) updated on probable ingestion of additional unknown medications of unknown quantity. The facility's Administration of Medications Policy revised on 4/21 shows, The nurse's station shall have necessary items and equipment available for proper administration of medications, and current standards of practice should be followed.

Based on interview and record review the facility failed to ensure an as needed antipsychotic was limited to 14 days and failed to ensure an as needed antianxiety medication had a stop date for 1 of 5 residents (R69) reviewed for psychotropic medications in the sample of 18. The findings include: R69's Physician's Order Sheet (POS) shows an order dated 8/30/24 for: Haloperidol Lactate (antipsychotic)-Give 0.25 ml (milliliters) by mouth every two hours as needed for agitation. There is no end date documented on the POS. R69's POS shows an order dated 8/30/24 for: Lorazepam (antianxiety) 0.5 mg (milligrams)-Give one tablet by mouth every two hours as needed for shortness of breath, air hunger or anxiety. There is no end date documented on the POS. R69's POS shows an order dated 10/8/24 for: Lorazepam 2 mg/ml-Give 0.5 mg by mouth every two hours as needed for restlessness or anxiety. There is no end date documented on the POS. On 10/22/24 at 1:35 PM, V2 (Director of Nursing) said that all psychotropic medications are ordered for only 14 days. V2 said that if after the 14 days, the physician feels that the resident needs the medication for longer, they can extend the duration. V2 said that the orders should always have a stop date entered that should be either 14 days or what the physician wants but it has to have an end date entered in the order. V2 said that the facility does not use as needed antipsychotics. R69's 9/9/24 Pharmacy Medication Regimen Review shows, Resident has the following PRN (as needed) antipsychotic without a stop date. Haloperidol as needed for agitation .CMS instituted a 14 day limit on PRN antipsychotic orders. If the medication is necessary beyond 14 days, the the prescriber must directly (in person) evaluate the patient, document the specific diagnosed condition and indication, and write justification for writing a new order Resident started on Lorazepam PRN .CMS instituted a 14 day limit on new PRN psychotropic orders. If the order is to extend beyond 14 days, the prescriber must directly or indirectly evaluate the patient, then document the specific diagnosed condition and indication as well as a specific duration that the medication will continue. The facility's Psychotropic Medication Use Policy dated 9/2022 shows, The timeframe for PRN psychotropic medications, which are not antipsychotic medications, will be limited to 14 days unless a longer timeframe is deemed appropriate by the attending physician or the prescribing practitioner. The timeframe for PRN psychotropic medications which are antipsychotic medications will be limited to 14 days. A new order will not be entered without the physician or prescriber first evaluating the resident.

Based on observation, interview, and record review the facility failed to ensure the safety of a resident while ambulating in the shower room. This applies to one of three residents (R1) in the sample of three reviewed for safety and supervision. This failure resulted in R1 falling and sustaining a fractured right humerus, a fractured nose and a right frontal lobe brain hemorrhage. The findings include: The facility face sheet for R1 shows she has diagnoses to include congestive heart failure, hypertension, chronic kidney disease and has a history of falls. The facility assessment dated [DATE] for R1 shows her to be cognitively intact and uses a walker for ambulation. The same assessment shows R1 requires moderate assistance with showering. The fall risk assessment dated [DATE] shows R1 to be at a high risk for falls. The facility state report dated 2/6/24 shows R1 was walking into the shower room for her shower when she fell and obtained fractures to her right arm, a laceration to her right side of her forehead and a skin tear to her right arm. The report shows R1 was transferred to the local emergency room . On 2/20/24 at 10:00 AM, R1 was observed in her wheel chair with her right arm in a cast, a large scabbed area to her right fore head and bruising to her face. R1 said she was walking with her walker into the shower room for her shower with V5 CNA (Certified Nursing Assistant) walking behind her. R1 said she was not wearing a gait belt as one was not offered to her. R1 said there was a blanket on the ground where she was supposed to walk. R1 said she did not know why there was a blanket on the ground where she was walking. R1 said the blanket was wrinkled up and she must have tripped over it. R1 said if she had been wearing a gait belt, V5 would have had something to grab to try and keep her from falling so hard on the floor of the shower room. R1 asked, Why would they have a blanket on the floor? R1 said she had to be transferred to the hospital and now she needs help with things she used to be able to do for herself. R1 said the injuries have caused her a lot of pain. On 2/20/24 at 10:15 AM, V5 said she had prepared the shower room for R1's shower by turning on the water to warm up, locked the wheels of the shower chair and placed a blanket down on the floor to absorb the water collecting on the floor. She then went and got R1 and was walking with R1 into the shower room to give her a shower. V5 said R1 was walking to the shower chair and she had asked R1 to stop so she could get next to R1, but R1 did not stop and kept walking towards the shower. V5 said R1 fell to the ground. V5 said it happened very quickly and she attempted to grab R1's waist to stop the fall but was not able to. V5 said if R1 had been wearing a gait belt she would have had something to grab her with and maybe she wouldn't have fallen so hard. V5 said R1 always refuses to use the gait belt. On 2/20/24 at 11:20 AM, V4 RN (Registered Nurse) said she responded to the shower room after R1 fell . V4 said R1 was lying on her right side and blood was seen on her head. V4 said a blanket was observed on the floor of the shower room near R1's walker. V4 said R1 was not wearing a gait belt. V4 said when 911 arrived at the facility a skin tear to her right arm was observed as well as her right wrist looked mishaped. V4 said R1 was confused after the fall for about 5 minutes, but then became more aware of what was going on. On 2/20/24 at 12:08 PM, V6 CNA said she has just left the shower room when R1 and V5 walked in. V6 said she was in the hall and heard V5 ask R1 to stop and then she heard R1 fall. V6 said she ran into the shower room to help, and she saw R1 lying on the floor on her right side. V6 said she saw a blanket on the floor near where R1 had fallen and R1 was not wearing a gait belt. On 2/20/24 at 12:25 PM, V3 Medical Director said he was not present when R1 fell and can only say what he was told. V3 said he was told R1 refused the gait belt, but this could have helped prevent the fall or lessened the severity of the fall. V3 said he was told R1 was given instructions about a wet towel on the floor and R1 was not responding to the instructions. V3 believes R1 was experiencing an altered mental status around the time of the fall. R1's labs at the hospital showed evidence of it but no further testing was done at the hospital. On 2/20/24 at 12:45 PM, V2 Director of Nursing said a gait belt should be used, but R1 refuses to wear a gait belt. V2 said she expects the staff to clean up the shower rooms before use. Remove excess linen and make sure the floor is free of clutter and water. On 2/20/24 at 12:50PM, V1 Administrator said it is not a safe practice to have a blanket on the floor of the shower room. At 1:55 PM, V1 said after the fall, the facility re-enacted the incident and discovered the shower was leaking out onto the floor, and that is why a towel was being used on the floor. A nursing narrative note from the hospital R1 was first sent to on 2/5/24 shows a phone call was placed to the facility regarding the fall. The note shows the facility RN, V4 telling the hospital nurse that R1 was walking into the bathroom and there was a bath blanket on the floor. The notes goes on to show the hospital discovered R1 had a nasal fracture, a brain hemorrhage and a fracture to her right elbow. The emergency department note dated 2/5/24 for R1 shows the facility was called regarding the fall and were told R1 walking in the bathroom with a walker and her walker got caught and she tripped and fell forward on her face, hitting her head and face against the floor. The note goes on to show R1 was transferred to another facility for a higher level of care. The x-ray report dated 2/5/24 for R1 shows a fracture to the distal humerus. The CAT scan dated 2/5/24 shows a nasal fracture and a suspected hemorrhage to the right frontal lobe of the brain. The neurosurgery notes from the second hospital R1 was transferred to dated 2/6/24 shows R1 was receiving assistance with a shower and had walked over a crumpled up towel with her walker and she fell on to the floor. The notes also show R1 had a right frontal hemorrhage. The facility care plan dated 11/15/2019 for R1 shows R1 requires one staff participation with transfers with walker. R1 prefers to not have a gait belt during ambulation and transfers. The intervention was updated after the fall on 2/5/24 to show education to resident on safety and importance of gait belt use. The same care plan also shows an intervention that R1 requires a safe environment with even floors free from spills and or clutter . The nursing progress note dated 2/5/24 shows R1 fell in the shower room. R1 was observed on the floor lying on her right side. R1's right arm was pinned under her body, and a small pool of red blood near her head. 911 was called and when the paramedics arrived and moved R1, a skin tear was observed to her right arm that was bleeding, bruising to her right hand and purple bruising to her right temple and right cheek. R1 was transferred to the hospital. The facility fall policy with a revision date of 9/17/2019 shows the facility shall ensure that a fall management program will be maintained to reduce the incidence of falls and risk of injury to the resident and promote independence and safety.

Based on observation, interview, and record review the facility failed to ensure a resident with dysphagia and nectar thickened liquids was provided supervision when drinking liquids in her room for 1 of 1 residents (R13) reviewed for safety and supervision in the sample of 19. The findings include: On 12/19/23 at 9:43 AM, R13 was sitting in a wheelchair in her room watching television. R13 had a pink liquid in a clear cup in her room sitting next to her on a stand. The pink liquid did not appear to be a nectar thick consistency. R13 was able to pick up the cup and bring it to her lips independently. R13 had a non productive cough present that sounded wet with rhonchi present and was audible without a stethoscope. On 12/19/23 at 12:21 PM, V3 CNA (Certified Nursing Assistant) stated R13 is her grandmother. V3 stated R13 is on a pureed diet and thickened liquids because she has swallowing problems. R13 failed her swallow evaluation recently; they said the swallow evaluation did not go to well and they are supposed to be having a meeting about it. V3 was feeding R13 and stated R13 is able to pick up her drinks on her own. On 12/19/23 at 12:31 PM, V4 CNA stated R13 is on a pureed diet and thickened liquids. R13 has problems swallowing and coughs a lot. It is like her food gets lodged. R13 went for a swallow evaluation not too long ago. We leave fluids at bedside for R13 and make sure its thickened up. On 12/19/23 at 12:35 PM, V6 RN (Registered Nurse) stated R13 just had a swallow evaluation done, she did not do well and we are waiting on the family for a course of treatment. I don't know if they wanted a feeding tube or palliative care. R13 is on nectar thick liquid and pureed food. R13 has been on a pureed diet and thickened liquids since at least before August 2023. R13 needs supervision for eating and drinking due to the risk of aspiration. Some signs of aspiration would be a wet cough and after awhile it could lead to a pneumonia. The the person could get a fever and become ill. V6 stated she gave R13 a strawberry supplement in a cup that morning and stated it was like strawberry milk. On 12/21/23 10:45 AM, V1 (Administrator) stated the facility doesn't have a policy for safety and supervision; they follow current standards of practice. On 12/21/23 at 10:50 AM, V8 (Assistant Dietary Manager) went to the refrigerator in the kitchen and showed 3 boxes of vanilla shakes in individual cartons. The label on the side of the carton showed they were nectar consistency. V8 stated the shakes they had last week were strawberry and were nectar consistency. V8 stated they have vanilla shakes this week. V8 stated the thickener is in the bottom of the carton. V8 stated to activate the thickener the carton has to be shaken really well and then the liquid inside will be a nectar thick consistency. V8 opened a supplement carton without shaking it and poured it into a cup and it appeared thin. V8 showed the bottom of the carton and stated, if you look at the bottom of the carton that is where the thickener is; that is why it needs to be shaken real well. The Face Sheet dated 12/19/23 for R13 showed medical diagnoses including cerebral infarction, dysphagia, facial weakness, vascular dementia, cognitive communication deficit, and weakness. The Physician's Orders dated 12/20/23 for R13 showed on 11/28/23 a swallow evaluation was to be completed for possible advancement/upgrade of diet; 7/18/23 - Regular diet, pureed texture, nectar thick fluids consistency. Resident prefers straws or sippy cup for all drinks for diet; and 6/30/23 - health shake three times per day. The Nurse Practitioner Notes dated 12/18/23 - addendum: Discussed with daughter/POA (power of attorney) options of non-oral nutrition versus continuing a pureed diet. At this time POA would like to continue feeding R13 the pureed diet; we discussed the risks versus benefit with this choice including risk of pneumonia or death. She verbalized understanding. The Nurse Practitioner note dated 12/15/23 showed, Chief Complaint - patient seen today after reviewing swallow study results. Assessment/Plan - aspiration of food. Swallow study done to assess whether we could advance R13's diet. R13 has severe dysphagia with silent aspiration of thick liquids during the swallow study with significantly increased risk of aspiration after the swallow with all remaining consistencies due to deep penetration without clearance with liquids and significant residue in the pharynx with all trialed consistencies. Given the patient's limited awareness also increases patient's risk of aspiration of residue after the swallow increased material in the trachea after some trials and suspicious of further aspiration. The Care Plan dated 9/6/23 for R13 showed, R13 is on a general diet with puree texture and nectar thick liquids. R13 is to have a house shake TID (three times per day) for malnutrition. R13 has a swallowing problem related to coughing or choking during meals or swallowing medication. R13 failed the swallow study. Date Initiated: 12/19/2023; Revision on: 12/19/2023. The resident will have clear Lungs, no signs and symptoms of aspiration through the next review date. The resident will have no choking episodes when eating through the review date. All staff to be informed of resident;s special dietary and safety needs. Diet to be followed as prescribed. Instruct resident to eat in an upright position, to eat slowly, and to chew each bite thoroughly. Monitor for shortness of breath, choking, labored respirations, lung congestion. Monitor/document/report to nurse/dietitian and medical doctor PRN (as needed) for difficulty swallowing, holding food in mouth, prolonged swallowing time, repeated swallows per bite, coughing, throat clearing, drooling, pocketing food in mouth. Keep head of bed elevated 45 degrees during meal and thirty minutes afterwards. The facility's Diet and Nutrition Care Manual (2021) showed, caregivers and staff should follow guidelines for safe feeding for individuals with dysphagia as follows: Assuring foods and fluids are of the appropriate texture/consistency Liquids for dysphagia - thickened liquids move more slowly through the mouth and esophagus and allow better control of the swallow than thin liquids. Each individual with dysphagia should receive the least restrictive fluid order possible and the appropriate thickness of liquid. Fluid intake and hydration status should be monitored and evaluated, with changes in the plan of care as needed. On 12/21/23 V1 (Administrator) presented a document from R13's physician that was dated 12/20/23 with an order stating supervision was not needed when drinking because R13 was going to aspirate with/without supervision. The facility consulted the physician after the concern was brought forward on 12/19/23 that R13 was on thickened liquids, with a drink in her room that was not the right consistency and she had no supervision provided.

Based on observation, interview, and record review the facility failed to ensure an indwelling catheter bag and tubing were changed as ordered and failed to ensure a catheter drainage bag was kept below the level of the bladder for 2 of 2 residents (R280 & R62) reviewed for catheters in the sample of 19. The findings include: 1. R280's computerized face sheet printed 12/20/23 showed an admitted [DATE] and diagnoses including but not limited to traumatic subarachnoid hemorrhage, aphasia (difficulty speaking), neurogenic bladder, and dysphagia (difficulty swallowing). R280's facility assessment dated [DATE] showed no severe cognitive impairment and staff assistance required for eating, hygiene, and dressing. R280's December 2023 physician order sheet showed an order to change the catheter drainage bag at the night shift every Sunday dated 12/8/23. On 12/19/23 at 9:43 AM, R280 was seated in a wheelchair in her room with a catheter drainage bag hooked underneath and inside a dignity bag. The catheter tubing was visible and had a cloudy, white dried substance inside of it. On 12/20/23 at 11:44 AM, R280 was in her wheelchair in her room and the catheter tubing still showed the dried white substance. The urine in the tubing was visible and had a thick, clumpy sediment in it. On 12/20/23 at 12:28 PM, V10 (Licensed Practical Nurse) inspected R280's catheter tubing and took the drainage bag out of the dignity cover. V10 said the tubing needs to be changed because of the sediment. V10 noted the date on the drainage bag was 11/21 (30 days ago and prior to admission). V10 said bag is well overdue too and the 11/21 represents the last time the bag was changed. V10 said catheter tubing and bags need to be changed as ordered. There is the potential for urinary tract infections, blockage, and odors to develop if it is not done. On 12/21/23 at 10:05 AM, V2 (Director of Nurses) stated catheter bags and tubing need to be changed as ordered to prevent infections and any potential systemic kidney issues. Nurses should always be following physician orders correctly. Residents are at risk for a decline in health and not getting the full effect of prevention. It is a normal standard of care. R280's Treatment Administration Record (TAR) was reviewed and showed staff were documenting the catheter bag changes being done each Sunday on the evening shift. The facility was unable to provide an explanation of the discrepancy between the catheter bag last changed date of 11/21 and the documentation on the TAR. The facility's Catheter Care, Urinary policy review dated 1/2017 states under the changing catheter section: Catheters will be changed per medical practitioner order. 20042 2. On 12/20/23 at 9:39 AM, V12 CNA (Certified Nursing Assistant) and V4 CNA went into R62's room with the mechanical lift device. R62 was sitting in a reclining padded wheelchair with a catheter drainage bag in a dignity bag under his chair. V4 grabbed the drainage bag and placed it in R62's lap and stood back to control the lift device. V12 picked up the drainage bag from R62's lap and attached it to the mechanical lift sling and V4 started to lift R62 from the chair, V12 grabbed the drainage bag to hold onto it during the rest of the transfer as he guided the sling and they transferred R62 to the bed. V12 CNA stated catheter drainage bag should not go on the residents lap for infection control reasons. V12 and V4 did not state the drainage bag should be kept below the level of the resident's bladder. On 12/20/23 at 9:58 AM, V2 DON (Director of Nursing) stated the catheter drainage bag should be below the level of the bladder or opening for a resident with a suprapubic catheter to prevent backflow of urine and an infection. The catheter drainage bag should not be on the resident's lap for the same reason and infection control. The Face Sheet dated 12/20/23 for R62 showed medical diagnoses including schizophrenia, multiple sclerosis, muscle weakness, urinary tract infection, depression, oropharyngeal dysphagia, cognitive communication deficit, and neuromuscular dysfunction of the bladder. The Care Plan printed on 12/20/23 for R62 with a revision date of 7/22/22 showed, R62 has a catheter related to neuromuscular dysfunction of the bladder. Position catheter bag and tubing below the level of the bladder and away from entrance room door or covered with a dignity bag. The facility's Catheter Care, Urinary policy (1/2017) showed, the urinary drainage bag must be held or positioned lower than the bladder at all times to prevent the urine tubing and drainage bag from flowing back into the urinary bladder. Use standard precautions when handling or manipulating the drainage system.

Based on observation, interview, and record review the facility failed to ensure PPE (personal protective equipment) was worn in a manner to prevent cross contamination for 1 of 1 resident (R280) reviewed for infection control in the sample of 19. The findings include: On 12/19/23 and 12/20/23, R280 had a PPE bin outside her door. There was a large sign on the wall by the door that said, STOP Enhanced Barrier Precautions. The signage had illustrations to show gloves and gowns must be worn when inside the room. The sign clearly stated gowns to be worn when high-contact resident care activities were performed. The care activities included but were not limited to: urinary catheters and feeding tubes. On 12/20/23 at 12:28 PM, V10 (Licensed Practical Nurse-LPN) entered the room and flushed R280's feeding tube. V10 changed R280's catheter drainage bag and tubing. V10 donned and doffed gloves appropriately throughout the cares but did not wear a gown at any time. On 12/20/23 at 1:11 PM. V11 (Infection Control Preventionist) stated R280 is on enhanced barrier precautions. It is a type of isolation for residents with devices like feeding tubes, catheters, wounds, and such. It is to prevent the spread of infections. It is a preventative based isolation. Gowns and gloves are to be worn for anyone providing care. Contamination can spread if the proper PPE is not worn. V10 (LPN) was present during the interview and stated she should have had a gown on during the feeding tube and catheter procedures. The facility's undated Infection Prevention and Control Manual-Enhanced Barrier Precautions policy states: Enhanced Barrier Precautions are an infection control intervention designed to reduce transmission of multidrug-resistant organism (MDROs) in nursing homes. High-contact resident care activities where a gown and gloves should be used include: Caring for or using an indwelling medical device.

Based on observation, interview, and record review the facility failed to stop attempts of inserting a urinary drainage tube after the resident refused it's insertion. The facility also failed to document the attempts of inserting the urinary drainage tube. This applies to one of three residents (R1) reviewed for resident rights in the sample of 8. The findings include: The facility face sheet for R1 shows diagnoses to include abscess of buttock, type 2 diabetes, obesity, depression and anxiety. The facility assessment dated [DATE] shows R1 to be cognitively intact and required assistance of one staff for activities of daily living. On 10/18/23 at 4:45 PM, R1 said she was a resident in the facility for wound care. R1 said her wound was not healing and the staff were having a hard time keeping the dressing attached to her, so a urinary drainage tube was ordered on 10/4/23. R1 said she agreed to the tube but after 3 attempts to insert were not successful, she asked the staff to stop and they did not, they kept trying. On 10/19/23 at 9:34 AM, V6 LPN (Licensed Practical Nurse) said she was the nurse who first attempted to insert a urinary drainage tube into R1. V6 said she had 3 CNA's (Certified Nursing Assistants) in the room with R1 to help hold her legs open and to hold up R1's abdominal folds. V6 said R1 was tense about the procedure but agreed to it. V6 said she was having trouble getting the drainage tube inserted and had given it 3 attempts when R1 asked her to stop trying. V6 said she sent one of the CNA's to go get another nurse to attempt inserting the drainage tube. On 10/19/23 at 9:45 AM, V7 RN (Registered Nurse) said she was asked by a CNA to come help insert a urinary drainage tube into R1. V7 said she grabbed some supplies and went to R1's room. V7 said R1 was agreeable to me trying to put in the drainage tube, but after my second attempt she yelled for me to stop. V7 said she was not aware R1 had asked V6 to stop trying to insert the drainage tube. On 10/19/23 at 9:51 AM, V12 CNA said she was helping to hold R1's legs so a urinary drainage tube could be inserted. V12 said after V6 tried 3 times, R1 yelled for her to stop. V12 said V6 told another staff to go get V7 to help. V12 said V7 came into the room and attempted twice to insert the drainage tube and then R1 yelled stop. On 10/19/23 at 10:04 AM, V11 CNA said she was helping to hold R1's legs while the nurses were trying to insert a urinary drainage tube. V11 said V6 attempted 3 times to insert the tube and then V11 heard R1 tell her to stop. V11 said a second nurse (V7) then came to help and attempted two more times to try and insert the tube after R1 had asked V6 to stop. On 10/19/23 at 12:20 PM, V1 Administrator said the residents have a right to refuse a procedure and the staff are expected to honor a residents request to stop a procedure. V1 said she expects to staff to notify the medical provider of any refusals of treatment and to document in the residents medical record. The Physician orders for R1 dated 10/4/23 shows an order to insert a urinary drainage tube. The nursing progress notes for R1 dated 10/1/23 to 10/13/23 do not show any documentation of the staff attempting to insert a urinary drainage tube, R1's refusal of the having the tube inserted or notifying the provider of the residents refusal of the drainage tube. An undated facility teaching tool provided to the surveyor entitled Your rights and protections as a nursing home resident shows a resident has the right to participate in the decisions that affects your care.

Based on observation, interview, and record review the facility failed to complete daily weights, failed to notify the physician of weight changes, and failed to monitor intake and output for residents with congestive heart failure for 1 of 1 residents (R5) in the sample of 18 and 1 resident (R65) outside of the sample. The findings include: 1. R65's face sheet showed she was admitted to the facility on [DATE] with diagnoses to include acute and chronic respiratory failure with hypoxia, interstitial pulmonary disease, dyspnea, heart failure, and hypertension. R65's facility assessment dated [DATE]. R65's facility assessment dated [DATE] showed R65 requires extensive assist of two staff members for most activities of daily living. R65's October 2022 physician order sheet showed an order started 4/15/22, Daily Weights: Notify NP (Nurse Practitioner) of 3# gain in 24 hours OR 5# gain in 1 week; please view under wt/vitals tab - NURSE - ENSURE THESE ARE COMPLETED AND YOU HAVE COMPARED RECENT WEIGHTS FOR PROPER NOTIFICATION AND MED ADMINISTRATION. R65's weights and vitals record for October 2022 showed no daily weight was obtained for R65 for 12 of the 30 days in October 2022. R65's weights showed on 10/16/22 she weighed 187.4 lbs and on 10/17/22 she weighed 195.4 lbs (an 8 lb weight gain in 24 hours), she weighed 10/21/22. R65's medical record showed no evidence of physician notification of R65's weight change on 10/17/22. R65's nurse practitioner visit note dated 10/28/22 showed, Chief Complaint: Acute visit: increase weight, swelling, CHF (Congestive Heart Failure) . Staff reports that patient has had a 16 lb weight gain within the last week. She has increase swelling and some shortness of breath . Extremities: . Increased edema to BLE (bilateral lower extremities), pitting . R65's care plan initiated on 4/15/22 showed, [R65] has altered cardiovascular status r/t atrial fibrillation, congestive heart failure, atrial flutter, and hypertension . DAILY WEIGHTS: notify NP of 3 lb gain in 24 hours OR 5 # in 1 week; please view under weight/vitals tab. NURSE :: ENSURE THESE ARE COMPLETED AND YOU HAVE COMPARED RECENT WEIGHTS FOR PROPER NOTIFICATION AND MED[ICATION] ADMINISTRATION . On 1/19/23 at 10:00 AM, V6 CNA (Certified Nursing Assistant) said she does daily weights. V6 said she writes the weight on a piece of paper and gives it to the nurse. V6 said the nurse looks at it and if there is a 3 lb difference they have them reweigh the resident. On 1/19/23 at 10:03 AM, V8 RN (Registered Nurse) said, All CHF (congestive heart failure) patients are weighed daily, the weights are usually done by the CNAs. The CNAs report the weight to the nurse and we put them into the resident's record. We look at the previous weights documented and monitor the weights to make sure they are not changing, usually everyone on daily weights has standing orders to call the physician or NP, update them, and see if they have any new orders. When we notify the NP we make a progress note that shows we notified them and if there were any changes made. The reason for the daily weights is to monitor the resident's CHF. On 1/19/23 at 10:21 AM, V2 DON (Director of Nursing) said CHF patients are to be weighed daily by either the CNA or nurse. V2 said there would be an order in the resident's record for daily weights. Weights are done to see how much fluid the resident is retaining. At 11:13 AM, V2 said R65's nursing notes should show documentation about notifying the NP for the weight changes. V2 said the facility had seen that there are some issues with the weights. V2 said she would expect the NP or physician to be notified of changes of 3 lbs in a day or 5 lbs in a week. 01/19/23 11:10 AM V9 (Nurse Practitioner) said, The reason for a resident to be on daily weights is to monitor their fluid status with the CHF. The standard order is to contact us if resident has gained 3 lbs in a day or 5 lbs in a week. If we are notified of a weight gain we would evaluate the patient and see if they have any symptoms, such as shortness of breath or peripheral edema. It is important for us to be notified because the weight change is our first clue that the patient is starting to have a problem. The facility's policy with revision date of 01/2017 showed, Weight Assessment and Intervention . 2. Weights will be recorded in the individuals medical record . 39537 2. On 1/19/23 at 9:15 AM, R5 was lying in bed with the head of the bed at 30 degrees. R5 had a stainless steel cup of ice water sitting on her bedside table. V6 (CNA) was preparing the resident for catheter care. R5 stated, Don't lay me flat. It's too hard for me to breathe and I panic. I was in the hospital over Christmas for heart failure and that was scary. I really couldn't breathe. They (facility staff) were keeping track of my fluids, but I don't think they are doing that anymore. I'm supposed to be a daily weight because of my heart problems. R5's Face sheet dated 1/19/23 showed diagnoses to include, but not limited to: congestive heart failure (CHF), periprosthetic fracture around internal prosthetic knee, generalized muscle weakness, dysphagia, depression, anxiety, chronic obstructive respiratory disease (COPD), diabetes, and atrial fibrillation. R5's facility assessment dated [DATE] showed she was cognitively intact; required extensive assistance for bed mobility, toilet use, and personal hygiene; was totally dependent on staff for transfers; and had an indwelling catheter. R5's Physician Order Sheet dated 1/19/23 showed, .1200 ml fluid restriction. 6-2 Nursing, 180 ml. 2-10 Nursing, 180 ml. 10-6 Nursing, 120 ml. Total by Nursing 480 ml. Total given by dietary: 720 ml . Daily weight. Notify MD/NP of weight gain of > 3 pounds in a day or > 5 pounds in a week . R5's Weights and Vitals Summary dated 1/19/23 showed R5 did not have daily weights completed on 12/31/22, 1/7/23, 1/13/23, or 1/17/23. R5's progress notes were reviewed for the dates of missed daily weights and did not show R5 refused to be weighed. R5's Dietician assessment dated [DATE] showed, R5 was on a 1200 ml fluid restriction related abnormal electrolyte lab results and was readmitted to the facility following hospitalization related to a CHF exacerbation and fluid overload. The plan was to continue to monitor weights, medications, labs, skin integrity, and intakes. R5's January 2023 Medication Administration Record (MAR) showed there was no documentation of the amount of fluids provided, for R5's fluid restriction, on the evening shift of 1/4, 1/8, 1/13, 1/15, 1/16 and 1/17/23. There was no documentation for R5's Strict I&O order: on the evening shift of 1/8 or 1/17/23. R5's Monitor - Output History showed that R5 only had 1 entry on 1/18/23. There were no other output measurements for R5, in the previous 14 days. (R5 should have had a minimum of daily outputs entered from 1/5/23 - 1/18/23). R5's Progress Note dated 12/24/22 at 9:32 PM, showed, complaining of SOB (shortness of breath). O2 placed. Felt worse over time. BP 156/67, 73, 23, and 97.6. Unable to get pulse ox despite warming hands and trying multiple locations and different machines. Resident requested to be sent to ED (emergency department). Nail beds dusky and face pale and flushed . At 10:08 PM sent to ER. R5's progress noted dated 12/26/22 at 1:36 AM, showed, admitted to [local hospital] for CHF exacerbation and fluid/electrolyte overload. In ICU (Intensive Care Unit). On 1/19/23 at 10 AM, V6 (CNA) said the CNAs usually pass waters to the residents. We keep track of intakes and outputs (I&O's) if there is an order to do so. We would chart in the electronic medical record. They don't allow us to document on any paper. If a resident has an order for Strict I & O, then we should be doing it. I don't think we are tracking R5's I&O. The daily weights are done by the CNAs. We document them on a paper and give it to the nurse. The nurse reviews the weights. If there is a weight change of 3 or more pounds, then the nurse will ask us to re-weigh the resident. On 1/19/23 at 10:21 AM, V2 (DON) said orders are entered for daily weights. The daily weights should be completed as ordered. If the resident refuses to be weighed, then there will be a note in the progress notes. Daily weights are completed for residents with CHF to see how much fluid they are retaining. The weights are used to determine the appropriate interventions for residents and/or diuretic use. R5 has had multiple CHF exacerbations. The I & O's should be documented in the EMR by the CNAs. The facility doesn't do I & O for all residents, only those that have an order. I don't think we are doing I & O's for R5. The nurses also document on the MAR. The nurses and CNAs should be following all the doctor's orders. The facility's Intake & Output Policy (reviewed 1/17) showed, 1. Recording of intake and output should only be done if there is an order from the medical practitioner. 2. Staff responsible for recording fluid intake and output will be notified by the nurse receiving the order . 5. Intake and output will be recorded every shift in the medical record. 6. The evening shift nurse is responsible to document the 24 hour total intake and 24 hour total output, as ordered, in the MAR.

Based on observation, interview, and record review the facility failed to ensure catheter care was provided in a manner to prevent cross-contamination for 1 of 4 residents (R56) reviewed for catheters in the sample of 18. The findings include: On 1/19/23 at 9:08 AM, V7 (Certified Nursing Assistant - CNA) performed catheter care on R56. V2 (Director or Nursing - DON) stated, I'll stay and observe the care and get an audit out of the way. R56 was lying flat in bed. V7 cleansed around R56's groin with no concerns. V7 obtained a clean washcloth to clean R56's penis and catheter tubing. V7 used the washcloth to cleanse R56's penis from the shaft toward the meatus. Then V7 cleansed R56's catheter tubing toward the meatus. The urine in R56's catheter bag was cloudy yellow with milky sediment noted. R56's Face sheet dated 1/19/23 showed diagnoses to include, but not limited to: schizophrenia, multiple sclerosis, dysphagia, cognitive communication deficit, generalized muscle weakness, seizures, and neurodysfunction of the bladder. R56's facility assessment dated [DATE] showed R56 had severe cognitive impairment; required extensive assistance from staff with bed mobility, transfers, toilet use, and personal hygiene; and had an indwelling catheter. R56's Progress Notes dated 1/16/23 at 4:54 AM, showed, This nurse spoke with a RN at the local hospital. Resident being discharged with a diagnosis of UTI (urinary tract infection) ., esophagitis, and constipation. Resident was given 1 gram of Rocephin (antibiotic) and 1 liter of NS (normal saline). Catheter was changed . R56's Catheter Care Plan revised 6/2/22 showed, R56 has a catheter related to neuromuscular dysfunction of the bladder . On 1/19/23 at 10:13 AM, V2 (DON) said when cleaning the penis, the CNA should wipe from the meatus down the shaft of the penis. The catheter tubing should be cleaned from the meatus down the tubing. I don't know why she (V7) didn't do that during the catheter care, she did it correctly when we practiced. The risk for developing a UTI increases when catheter care isn't performed properly. Catheter Care, Urinary Policy (reviewed 1/17) showed, The purpose of this procedure is to prevent catheter-associated urinary tract infections . Steps in the Procedure: . 11. For a male resident: Use a washcloth with warm water and soap to cleanse around the meatus. Cleanse the glans using circular strokes from the meatus outward. Change the position of the washcloth with each cleansing stroke. With a clean washcloth, rinse with warm water using the above technique . 12. Use a clean washcloth with warm water and soap to cleanse and rinse the catheter from insertion site outward .

Based on interview and record review the facility failed to supervise a male resident with known sexual aggression to prevent resident from having access to female residents on the dementia unit. This failure resulted in R2 and R3 experiencing nonconsensual sexual contact by R1. The Immediate Jeopardy began on (MONTH) 27, (YEAR). On (MONTH) 6, (YEAR) at 8:22 AM, the Administrator was informed of the Immediate Jeopardy relating to R1's lack of supervision and nonconsensual sexual contact of 2 female residents. The immediacy was removed on (MONTH) 6, (YEAR). The facility remains out of compliance at a severity level two. Additional time is needed to monitor and evaluate the effectiveness of the revised policies and procedures to ensure their implementation. This failure applies to 3 of 3 residents (R1, R2. R3) reviewed for supervision in the sample of 6. The findings include: R1's face sheet dated (MONTH) 29, (YEAR) showed R1 was admitted to the facility on (MONTH) 6, (YEAR) with a most recent readmitted (MONTH) 12, (YEAR). R1's [DIAGNOSES REDACTED]. R1's MDS-Minimum Data Set, dated dated dated (MONTH) 25, (YEAR) shows a BIMs-Brief Interview for Mental Status of 14 (cognitively intact). This MDS shows, R1 has other behavioral symptoms not directed towards others on a daily basis and requires supervision and assist of one person for ambulation. R1's Care Plan dated (MONTH) 18, (YEAR) showed R1 had a behavior problem and can become verbally agitated and aggressive towards others; sexually inappropriate comments/gestures directed towards others; pacing the halls; makes repetitive statements/questions; has had episodes of physical behavioral symptoms directed towards other residents putting him at risk of abuse related to a [DIAGNOSES REDACTED].R1's behavior interventions dated (MONTH) 18, (YEAR) include; monitor and record targeted behaviors of pacing, wandering, disrobing, inappropriate verbal communication, violence/aggression towards others. R1 is to be redirected with an activity when displaying behaviors. R1 is to be supervised when he is restless and pacing the halls for entrance into other resident rooms. R1's location is to be monitored every 15 minutes. There are no behavior interventions listed for the (MONTH) 27, (YEAR) incident between R1 and R3. There are no documented interventions from (MONTH) 18, (YEAR) until the care plan was cancelled on (MONTH) 23, (YEAR), after R1's discharge from the facility. On (MONTH) 29, (YEAR) at 10:38 AM, V4 (CNA-Certifed Nursing Assistant) said R1 mainly stayed in his room. He was on 15 minute checks for close monitoring when he would pace the hallways. R1 would wander into other resident rooms. On (MONTH) 22, (YEAR) he was on 15 minute checks. V4 said she and V3 were moving a resident chair from their room to the family room. R1 was pacing up and down the hall. V3 and V4 put the chair in the family room out of the sight of R1. R1 was by his room when we went into the family room. V3 went to get a pad for the chair from the linen cart. V3 said she saw R1 in R2's room. R1 was covering up R2. V3 said she asked R1 what he was doing. R1 was taken to his room. V4 was asked to do 1:1 with R1 in his room. On (MONTH) 29, (YEAR) at 9:44 AM, V3 (CNA) stated R1 was on 15 minute checks, to keep an eye on him. We needed to make sure where he was. He would wander in and out of resident rooms. V3 stated on (MONTH) 22, (YEAR) around 2:00 PM, R1 was unsupervised and was in R2's room. R1 was standing over the bed. As she walked into the room V3 saw R1 place the cover over R2. V3 heard R2 say, That hurts. V3 took R1 out of the room and asked him what he was doing. R1 stated he was, Finger f**king her. On (MONTH) 29, (YEAR) at 2:14 PM, V9 (Licensed Practical Nurse) stated R1 preferred to be in room and he would come out for meals. He was independent with his ADLs-Activities of Daily Living. He would have spontaneous laughter which was inappropriate at times. He had repetitive behaviors and would become impatient. He would continually ask until he got what he wanted. He would fixate on things like his chocolate milk. He was easily re directed. He had a hospitalization at a psychiatric hospital after an incident with a male resident. R1 started having increased behaviors and would say inappropriate things to staff like, you're a fox, nice butt. Approximately three weeks ago he told a visitor she had a nice bottom. He had an incident with R3 in which he was inappropriate. R3 reported R1 poked her and touched her on her right side and right hip and rubbed his hand down her side. We did 15 minute checks. The day of the incident (November 22, (YEAR)) he was having a good day. He was waiting for his wife to bring him dinner. V9 said she was in the nurse's station charting. It was around 2:00 PM. V9 heard the CNA say what are you doing. When V9 got to the end of the hall, she said to R1 what are you doing. R1's said finger f**king and was smelling his fingers. V9 immediately took R1 to his room and assigned V4 (CNA) to do 1:1's. On (MONTH) 29, (YEAR) at 12:03 PM, V8 (Social Services Director) stated R1 was admitted to the secure unit due to a history of elopement. R1 had repetitive behaviors that had changed over his stay. R1 was re directed and able to understand. V8 was asked if R1 had any hospitalization s since his admission. V8 reported R1 was hospitalized twice at a psychiatric hospital following a resident to resident altercation. V8 stated there was an incident when R1 inappropriately touched R3. The facility put 15 minute checks into place and R1 was to sit next to other men in the dining room. V8 stated R1's fixations were becoming more intense and sexual. V8 stated she and the administrator spoke with R1's wife a few days before the incident, about R1 continuing to have sexual behaviors and the facility staff were concerned. We suggested a facility that housed male and female residents separately would be more appropriate for R1. The staff were to make sure R1 was not interacting with female residents by increasing supervision of R1. R1 was on 15 minute checks. She was aware of R1 escalating sexual fixation. R1 should never have been in R2's room. V8 was asked if R1 was being supervised. V8 said obviously not if he got into R2's room. On (MONTH) 29, (YEAR) at 3:11 PM, V2 (Director of Nursing) stated R1 started to exhibit sexual behaviors about a month ago. He started with making inappropriate comments to staff, referring to their bottoms. R1 was transferred out that afternoon following the incident of (MONTH) 22, (YEAR). R1 was sent out because of his risk to the other residents. V2 said R1 was involved in another incident with a female resident (R3) on (MONTH) 27, (YEAR). He inappropriately touched her across her chest and down her leg. We separated them and he was put on 15 minute checks. On (MONTH) 18, (YEAR), R1 made an inappropriate comment about a resident. The resident did not hear. The comment was reported to the nurse. R1 said, I want her, can I have her. R1 was re-directed and his 15 minute checks were continued. V2 stated R1 was ambulatory and had a history of [REDACTED]. V2 said we should have had him on 1:1 supervision. V2 was asked about the incident when R1 was asking female residents to kiss him. V2 stated he (R1) was to sit next to male residents in the dining room so he couldn't kiss female residents at the table. He was continued on 15 minute checks. V2 stated R1 had become more sexually heightened. I didn't think he would act on his impulses. When I was told of what happened, I was physically sick. On (MONTH) 29, (YEAR) at 10:17 AM V1 (Administrator) stated R1's dementia changed over time. When he first arrived he had repetitive behaviors. He had a physical altercation with another resident. He was blocking the resident from leaving the room and wanted the other resident to say hi. He kept repeating hi over and over. The other resident hit him with his walker. He had an unwitnessed episode with a female resident (R3) on the couch. The staff went to get him to the table near meal time. When they got him up, R3 said she didn't know who that man was but her husband would get upset. She said his hand was up towards her hip. R1 was on 1:1 and 15 minute checks depending on how he was doing. When he was in his room he was on 15 minute checks. He would pace the hallways and we kept a close eye on him. If he was acting suspicious he was on 1:1's. Otherwise he was on 15 minute checks. He was easily re- directed. The day of the incident (November 22, (YEAR)) the two CNAs were moving a chair from the end of the hall to the dining room. R1 was visualized in the hallway near the dining room. The girls put the chair in the dining room. V3 (CNA) went to get a pad off the linen cart for the chair. When she got to the linen cart which was outside of R2's room she saw R1 in the room over R2. She asked R1 what he was doing and he made the vulgar comment. The nurse overheard the comment and asked R1 what he said. R1 repeated the vulgar comment. On (MONTH) 30, (YEAR) at 10:20 AM, V7 (R1's Family Member) stated R1 had been at the facility since (MONTH) (YEAR). She could no longer care for him at home. He required 24 hour supervision and couldn't be left alone anymore. R1 has temporal frontal dementia and has repetitive behaviors. V7 stated her husband was not supervised. When she would come to visit, she would go into his room and close the door. Hours would go by before anyone would knock on the door. They would say, Oh, didn't know you were here. V7 stated her husband would walk up and down the hall and look out the end door and check and see if her car was there. V7 stated the nurse practitioner told her due to her husband's disease process, there could be an increase in sexual urges. If R1 started to display increased sexual urges, they could start him on hormonal therapy to help decrease the urges. V7 stated R1 had two hospitalization s one in (MONTH) and one in (MONTH) at a psychiatric hospital. R1 had a physical altercation with a male resident. The facility agreed to take him back after they increased his medications. About a month after the second hospitalization , R1 had a rapid decline. He was making a lot of sexual comments to the staff. One incident the facility told me about was he was trying to grab a female resident's waist. R1 told the aides they had nice a**es and he was becoming more sexual. On (MONTH) 20th, V7 received a phone call from the facility. They suggested he move to another facility because he was making more sexual comments. They said he needed to leave for the safety of everyone. V7 called the nurse practitioner and she suggested a smaller unit so there was less stimulation. V5 (Psychiatric Nurse Practitioner) also suggested hormonal therapy for R1. V7 agreed to the hormonal therapy. They gave him the injection the morning of Thanksgiving. Later the same day, V7 went to the facility. The administrator told her, about 30 minutes prior to her arrival, R1 went into another resident's room and placed his hand between her legs. They shipped him out an hour and a half later. On (MONTH) 30, (YEAR) at 11:46 AM, V5 (Psychiatric Nurse Practitioner) stated she was seeing R1 for his behaviors. He had two hospitalization s at a psychiatric hospital. One in (MONTH) and one in September. R1 was sent out for increasing behaviors after having physical altercations with a resident. During the (MONTH) hospitalization his [MEDICATION NAME] was increased to help with re- direction and repetitive behaviors. In September, R1 was diagnosed with [REDACTED]. The staff reported he was more easily redirected after the start of the Nudexta and increase in medications. R1 started first having inappropriate sexual behaviors in October. The staff reported he tried to kiss a resident. V5 stated she increased his [MEDICATION NAME] to decrease his sexual urges. A short time later she received a fax from the facility requesting to try hormonal therapy for increasing sexual desire. V5 asked the staff to clarify why they wanted hormonal therapy, they reported he tried to kiss a resident. V5 increased his [MEDICATION NAME] and did not feel hormonal therapy was appropriate at the time. In early November, V5 saw R1 and reviewed the nurses notes and asked staff how he was doing, they vocalized R1 wanted to have sex with another resident. V5 was told by facility staff R1 was easily redirected. V5 stated the last time she saw R1 was on (MONTH) 20th, V5 reviewed the nurse's notes and saw he made a comment to a visitor about having a nice a**. On (MONTH) 20th, V5 added hormonal monthly injections to decrease sexual urges. V5 stated she was not sure how long it would take for the injections to be therapeutic and R1 was to be supervised. V5 was asked if she was aware of the incident between R1 and the female resident on the couch and his inappropriately touching her chest and sliding his hand down her side on (MONTH) 27, (YEAR). V5 stated she was not aware of the incident. Had she known R1 would have been sent out to the psychiatric hospital for a psychiatric evaluation, just like he had been twice before for the physical to physical altercation. R1 should have been on 1:1's until he was sent out. The facility's Final Incident Report dated (MONTH) 1, (YEAR), showed on (MONTH) 27, (YEAR) at approximately 4:45 PM, R1 was sitting closely next to R3 on the couch. A Licensed Practical Nurse attempted to try to redirect R1 to another location and he was not listening to her direction. The living room aide, V4 (CNA-Certified Nursing Assistant) then went over and was able to redirect R1 to another spot in the living room. As R1 was walking away, V4 observed R3 making a motion in the air with her hand as if pretending to smack someone. V4 went over to R3 and asked her if she was okay, and R3 stated, I don't know who that guy was but he kept touching me (while motioning with her hand rubbing down her arm and across her chest) and poking me (while motioning towards her hips.) R1 was placed on increased behavioral monitoring at the time. The facility's Final Incident Report dated (MONTH) 27, (YEAR), showed on (MONTH) 22, (YEAR) at approximately 2:08 PM, R1 was observed standing in R2's room. V3 (CNA- Certified Nursing Assistant) immediately intervened and asked R1 what he was doing. R2 was observed by V3 as being covered by her bed sheet and in no distress. He (R1) walked out of the room and he made a sexual comment to V3 regarding R2. He (R1) was immediately placed on 1:1 observation per the nurse on duty (V9- LPN-Licensed Practical Nurse) until he was transferred out of the facility. The facility's Behavioral Assessment, Interventions and Monitoring policy dated (MONTH) (YEAR), shows the interdisciplinary team (IDT) will evaluate behavioral symptoms in residents to determine the degree of severity, distress and potential safety risk to the resident and develop a plan of care accordingly. Safety strategies will be implemented immediately to protect the resident and others from harm. The IDT will monitor the progress of individuals with impaired cognition and behaviors. Any resident with behaviors that has been identified that would present a potential danger to either himself or other residents will be place on at least 15 minute checks, unless immediate interventions are needed. On (MONTH) 30, (YEAR) at 1:04 PM V6 (R1's Physician/Medical Director) stated he was R1's physician. V6 stated R1 was having psychotic escalation. R1 should have been on 1:1 supervision follow the first incident. V6 stated maybe he should have ordered the 1:1 supervision. V6 stated due to R1's frontal temporal dementia he would have social and behavioral issues. V6 was asked about the letter he wrote dated (MONTH) 28, (YEAR) and which female resident he was referring to. V6 stated he was referring to R2. V6's letter dated (MONTH) 28, (YEAR), showed R1 was a resident on the dementia unit at the facility. He has a [DIAGNOSES REDACTED]. There has been a number of minor resident to resident incidents over the past several weeks. There has also been inappropriate sexually explicit comments made to female facility staff. Importantly there has been a recent escalation of sexual 1.comments and actions directed toward female residents on the dementia unit. Most recently an event occurred of molestation of a female resident. The resident was followed by V6 and psychiatric care consulting service. V6 states in the letter, R1's persistent and refractory behavioral issues pose a distinct and ongoing threat to the other residents on the unit. On (MONTH) 6, (YEAR), the surveyor confirmed through observation, interview and record review the facility took the following actions to remove the immediacy. 1. R1 was discharged from the facility on (MONTH) 22, (YEAR). 2. On (MONTH) 30, (YEAR), the Director of Nursing initiated training with all nursing staff on the following: The facility's behavior policy, including any residents that have behaviors are being tracked and reported to nurse managers. The abuse policy and types of abuse including sexual behaviors, and to call the abuse coordinator if abuse is suspected. Fifteen minute checks are to be performed and charted accurately. The inservicing was completed on (MONTH) 4, (YEAR). 3. An audit of all residents having behaviors including those with sexual behaviors, was completed to ensure accuracy of the plan of care. 4. The administrator notified the medical director on (MONTH) 22, (YEAR) and on (MONTH) 6, (YEAR) of the plan. 5. Nursing staff will be educated at the time of hire on the above information as part of the orientation process, including the behavior policy and abuse policy. Staff will be educated upon hire about the behavior policy, including sexual behaviors and abuse policy, which covers the types of abuse. 6. The facility nurse management team will question staff on appropriate action if resident experiencing behaviors, including sexual behaviors, and appropriate interventions 5 times a week on various shifts. 7. The facility administrator will randomly question at least 5 staff members a week on the appropriate action if resident is found to be exhibiting behaviors, including sexual behaviors and proper interventions. 8. The facility administrator will randomly review residents with new behaviors daily to ensure policy is being followed. 9. The facility will continue to utilize the behavior policy for residents with behaviors to ensure staff appropriately use interventions in place. 10. A Quality Assurance (QA) plan of action was created to ensure staff are aware of the behavior policy and safety of other residents. 11. Corrective action will be taken immediately if concern is identified and revision to the plan made when needed. The plan will be reviewed weekly in the Compliance QA meeting.

Based on interview and record review, the facility failed to safety transfer a resident using a mechanical lift. This failure resulted in a resident falling to the floor and sustaining a laceration requiring three staples. This applies to 1 of 3 residents (R1) reviewed for mechanical lift transfers in the sample of 3. The findings include: R1's Electronic Medical Record shows R1 was admitted to the facility on (MONTH) 18, 2007 with [DIAGNOSES REDACTED]. R1's Minimum Data Set (MDS) dated (MONTH) 4, (YEAR), shows R1 has total dependence on two staff members for transferring. R1's Care Plan dated (MONTH) 3, (YEAR), shows R1 requires a mechanical lift with two assistants for transfers. The facility's Incident Report dated (MONTH) 29, (YEAR), shows Today during a (mechanical lift) transfer with two staff members present, (R1) slid out of (R1's) (mechanical lift sling). Staff attempted to intervene, but were unsuccessful in doing so in which the resident landed on the floor on (R1's) left side .a laceration was noted to the back of (R1's) head .resident was transferred to the emergency room where (R1) is being evaluated for further injury .immediate education is being provided to all staff on (mechanical lift) transfers. Received a notification from the emergency room that (R1) had received treatment with three staples to the laceration of the 'upper occipital lobe'. On (MONTH) 5, (YEAR) at 8:50 AM, V1 Administrator stated V7 CNA (Certified Nursing Assistant) and V8 RN (Registered Nurse) were transferring (R1) from (R1's) bed to the chair. While over the bed V7 and V8 visually checked the (mechanical lift sling) straps, but did not physically check. We would expect them to physically check the straps. V7 pulled the machine from the bed and pushed it forward. (V7) felt a tug and the top left hook became detached and (R1) fell and landed on (R1's) left side. (R1) had a laceration to (R1's) head and was sent to the hospital. (R1) received three staples. The staff was reeducated on mechanical lift transfers and physically checking the straps. V7 and V8 were terminated for not following facility policy. At 9:32 AM, V2 DON (Director of Nursing) stated V2 came in to the facility to do an investigation. V2 stated V7 and V8 reenacted what happened. They said they visually observed the hooks but unfortunately did not physically check them. The left top loop came off and (R1) fell on the ground. Both staff were terminated for not following policy that resulted in a resident injury. R1's Progress Note dated (MONTH) 29, (YEAR), shows, (R1) was treated with three staples to the laceration to the upper occipital lobe. The facility's Safe Lifting and Movement of Residents policy reviewed (MONTH) (YEAR), shows, Staff shall perform routine checks and maintenance of equipment used for lifting to ensure that it remains in good working order. The facility's undated Total Dependent Lift Competency check list shows, To demonstrate knowledge and ability to safely transfer a resident from different surfaces using a total dependent lift .using remote control, lift resident and apply pressure to the tilting frame to maintain an upright position .position resident over chair or bed in upright position. Lower resident with remote while maintaining pressure to tilting frame to maintain upright position. The manufacturer instructions on the mechanical lift revised (MONTH) 16, 2013, shows, Lift the resident above the bed by using the hand control while watching and reassuring them.

Based on interview and record review the facility failed to ensure R1 was transferred in a safe manner using a mechanical lift. This failure resulted in R1 sustaining a left [MEDICAL CONDITION]. This applies to 1 of 3 residents (R1) reviewed for safe transfers in the sample of 6. The findings include: R1's electronic face sheet showed R1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R1 was readmitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. R1's Minimum Data Set, dated dated dated [DATE], showed R1 was totally dependent on staff for transfers. R1's fall care plan dated [DATE] showed R1 required a mechanical lift with the assistance of two persons for transfers and to ensure this was the method used (This intervention was dated [DATE]). On [DATE] there was a new intervention recorded to educate CNAs (Certified Nursing Assistant) on proper placement of mechanical lift sling. The facility's initial report to Illinois Department of Public Health dated [DATE], showed,Today during a mechanical lift transfer with two CNAs present, R1 slid out of her mechanical lift sling. Staff attempted to intervene and lower her to the floor, but were unsuccessful in doing so in which R1 landed on the floor on her buttock. A skin assessment was performed immediately and range of motion was noted to be within normal limits. R1 did complain of pain to her left hip, physician was notified and orders were given to send R1 to the hospital for x-rays. The hospital called to notify the facility that R1 has an acute comminuted intertronchanter [MEDICAL CONDITION] hip . The facility's final report to Illinois Department of Public Health dated [DATE], showed the facility determined through interview and investigation the right bottom loop on the mechanical lift sling was not secured and detached from the mechanical lift which resulted in the resident (R1) sliding out of the sling. The staff were unsuccessful in their attempt to intervene and the resident landed on her buttock/left hip. The director of nursing inspected the sling and found the sling in good working condition. The maintenance director inspected the mechanical lifts and found no deficiency. R1's family chose not to have a surgical intervention for R1's fracture from this occurrence. R1 will return to the facility on [DATE]. On [DATE] at 8:20 AM, V2 (Director of Nursing) stated on [DATE], V3 and V4 (CNAs) were transferring R1 from her bed to her wheelchair using a mechanical lift. R1 slid out of the sling onto the floor. R1 sustained a broken hip and passed away on Friday ([DATE]). R1's family choose not to have R1's [MEDICAL CONDITION] surgically repaired. V2 was asked how R1 slid from the mechanical lift sling. V2 stated V3 did not secure the loop on the mechanical lift sling and the loops came loose and R1 slid out. V2 stated V3 should have ensured all four loops were secured for a safe transfer. On [DATE] at 8:30 AM, V1(Administrator) stated the incident on [DATE] occurred when the loop (on the sling) came undone (from the mechanical lift). It was not equipment error it was human error. The sling and mechanical lift were checked and there were no issues. It was human error. On [DATE] at 9:05 AM, V5(CNA) stated she was working [DATE] on R1's hall. Around lunch time she entered R1's room to help with the transfer and saw R1 on the floor. V3 and V4 said R1 slipped out of the sling. V5 went to get R1's nurse. When V5 came back to the room, R1 had a pillow under her head and a blanket on. R1 was moaning. V5 stated the mechanical lift sling was attached by three of the four loops. One of the leg loops was not attached. V5 stated R1 was sent out to the hospital and was admitted with a [MEDICAL CONDITION]. V5 stated R1 returned to the facility a few days later. R1 was not the same person, she had declined. R1 was moaning when she usually would yell out. R1 was not eating or drinking. V5 stated prior to the fall R1 ate in the dining room and would converse with the staff. R1 was not a big eater but with encouragement the staff could get her to eat and drink. After R1 returned from the hospital she was bed ridden with orders not to transfer and reposition her from her back to her right side. R1 was not eating or drinking. R1 passed a few days later. It was the worst thing I have ever seen. On [DATE] at 9:20 AM, V6 (CNA) stated prior to R1's fall she was alert but had some memory issues. R1 was a mechanical lift and was total care. R1 was a sweetheart and had an infectious smile. She had her days but for the most part she was happy. She was able to converse using short sentences. R1 could be combative with cares but never had an issue with being transferred with the mechanical lift. V6 stated R1 was not the same when she returned from the hospital from the fall. R1 was no longer speaking with her, she would randomly scream out. She would look at you, but she would look through you. She would not eat or drink. Before she loved her fruit and vegetables and cranberry juice. After the fall I couldn't get her to eat them or drink the juice. She had a blank stare and before she talked a lot. V6 stated she was surprised to hear that R1 had fallen out of the sling. if the loops are secured they don't fall off. On [DATE] at 11:05 AM, R5 stated she was R1's roommate for the past six months. R5 was not in the room when the incident occurred on [DATE]. R5 stated R1 was different when she came back from the hospital. She was in bad shape. She stayed in bed all the time. She was moaning and yelling out. The girls couldn't get her to eat. A few days later there was a commotion in my room, they told me to go to the activity room. I knew she died . She is in a better place now. On [DATE] at 1:40 PM, V3 stated she was working the first and second shift on [DATE]. V3 was assigned the 200 hall. She finished getting her residents up for lunch and went over to the 100 hall to help them get residents up for lunch. V5 asked her to help transfer R1 into her chair. They walked down towards R1's room. A bathroom call light went off and V5 went to answer the light. V3 proceeded to R1's room. V3 stated she placed the sling and hooked R1 up to the lift. V3 stated she tugged on the sling and thought the loops were secure. V3 went to the door to get V5. V4 was in the hall and said she would help with the transfer. V3 stated she worked the lift and V3 was by R1's wheelchair. V3 maneuvered the lift toward the wheel chair when the strap by R1's right leg came loose and R1 fell . R1 landed on her buttock and left hip. At that time V5 entered the room, V3 asked V5 to get the nurse. V7(Registered Nurse) entered the room and did an assessment and then left to get V2. V7 and V2 looked R1 over. Then we put the sling under her and lifted her up into bed. V3 was asked how she thought R1 fell from the sling. V3 stated she must not have put the loop on all the way and with the weight of R1 the loop slid off and R1 fell . V3 stated there was no fraying or malfunction of the sling. On [DATE] at 2:00 PM, V4 stated she was working R1's hall on [DATE]. She had transferred R1 earlier in the shift with the mechanical lift with no problems. V4 said around 11 :30 AM, she went to help V3 transfer R1 from the bed to her wheelchair. when V4 entered the room R1 was already hooked up to the lift. V4 went behind R1's wheelchair to guide her and V3 operated the lift. One corner of the sling slid off the lift and R1 fell to the ground and landed on her back and buttock. R1 said it hurt and Ouch. V4 put a pillow under her head and a blanket on R1 because R1 said it was cold. V2 and V7 came into the room and checked R1 out. We took the sling off the lift and rolled R1 onto the sling and then we (V2, V3, V4, V5 and V7) lifted R1 unto her bed. V4 stated the next time she saw R1 was a week later. R1 was not her normal self. R1 was bedridden, on oxygen which was new for R1. On [DATE] at 11:30 AM, V7 stated on [DATE], V5 came to the nurses station and reported that the CNAs needed her in R1's room immediately. R1 was on the floor. V5 entered R1's room and saw R1 on the floor, the mechanical lift was in the middle of the room and the sling was hanging on the lift by 3 loops and one loop was not attached to the sling. V7 went over to R1 and asked her how she was doing. R1 said she was cold and had no other complaints. V7 stated she assessed R1 and found no injuries. V7 stepped into the hall and asked V2 to come down to R1's room. V2 and V7 assessed R1, did range of motion and neuro check. R1 had a skin tear to her left elbow. V2 left to get the wound nurse. We (V2, V3, V4, V5 and V7) log rolled R1 unto the sling and manually lifted her unto her bed. V2 stayed with R1 while V7 went to call R1's physician. We called R1's daughter and told her we were sending R1 out to the emergency room . We called the paramedics and they transported her to the emergency room . V7 said she asked R1 if she knew what happened. R1 saidI don't know. I just fell . V7 stated prior to the incident R1 was alert and oriented to person and place. She was total care. R1 was able to talk in short sentences. After the incident, R1 was alert. R1 was left in bed due to pain control issues and a [MEDICAL CONDITION] that was not surgically repaired. R1 was admitted to hospice when she returned from the hospital. R1 was not eating or drinkingmuch when she returned. R1's oral medications were discontinued because she was having difficulty swallowing when she returned. V7 was asked how she thought R1 fell . V7 stated there was no malfunction of the sling nor lift. One of the loops on the sling came off the loop because it wasn't all the way on. The loop should not come off if it is put on properly. R1's hospital history and physical dated [DATE], showed R1 was admitted to the hospital with [REDACTED]. R1 slid out of a mechanical lift and landed on her left hip. R1 was complaining of left ankle pain at the time and was sent to the emergency room and was found to have a left femoral neck fracture. R1 was seen by the emergency room physician, who after a prolonged discussion with R1's Power of Attorney, has advised against surgery. At this time R1's POA is present and we have discussed conservative management including a referral to hospice care. R1 has no pain at present but does have severe pain with movement. R1 has severe [MEDICAL CONDITION] and had low oxygen saturations of 88 percent during the night. R1 is on oxygen at 2 liters per minute via nasal cannula. Assessment and plan include R1 has a left [MEDICAL CONDITION]. R1 is not a surgical candidate, and the recommendation is for hospice referral to which the POA is going to discuss with her siblings. R1 is not able to take much opiods secondary to her [MEDICAL CONDITION]. At the present time the patients pain seems to be controlled. In the recent past when R1 was restricted to her room, she got severely depressed and stopped eating secondary to the [MEDICAL CONDITION]. R1 may experience pain that is not fully controlled especially when moved. The POA will discuss this also with the family. The history and physical was electronically signed by V8 (R1's personal physician). R1's CT scan (Computed Tomography scan) of pelvis without contrast dated [DATE], showed acute comminuted intertrochanteric [MEDICAL CONDITION] hip.

Based on interview and record review the facility failed to provide nursing services by not initiating cardiopulmonary resuscitation (CPR) on [DATE], for a resident who chose to be a full code. The facility failed to know the code status of 6 other residents in the facility. These failures resulted in an Immediate Jeopardy when staff failed to initiate CPR on [DATE] for R2 who wanted to receive full cardiopulmonary resuscitation. R2 expired on [DATE]. On [DATE] at 1:45 PM, an immediate jeopardy was identified. The immediacy began on [DATE]. On [DATE] at 2:30 PM, E2 (Director of Nursing) was informed of the Immediate Jeopardy related to the failure of facility staff to perform CPR to R2 on [DATE]; and the failure to have accurate resuscitation orders for 6 residents (R7 & R8 and R,[DATE]) currently residing in the facility. While the immediate jeopardy was removed on [DATE] at 7:00 PM, the facility remains out of compliance at a severity level 2 due to the need to monitor and evaluate the effectiveness of the revised policies and procedures and education of staff when finding someone unresponsive. This applies to 7 of 82 residents (R2 and R7 & 8, and R,[DATE]) reviewed for Advanced Directives. The findings include: R2 's Physician Transfer order sheet shows R2 was admitted to the facility on [DATE]. The transfer orders document R2 ' s resuscitation status as a full code. The facility ' s computerized POS (Physician order [REDACTED]. The hard chart does not contain the state approved Uniform Advanced Directive form giving physician orders [REDACTED]. Nursing Notes (written by E4) of [DATE] documents at 8:30 PM, E2 ' s respirations were 40 (breaths per minute) and labored, his temperature was 100.6. The notes show Z1 (Nurse Practitioner) and Z2 were notified of R2 ' s change in condition. The notes document at 9:20 PM the resident ' s temperature was 99.2. The next entry in the nurse ' s notes was at 10:00 PM. The notes state, " C.N.A. reported mucous at sides of mouth checked at this time expired also assessed by another nurse. (Z1) family notified and coroner called. " On [DATE] at 3:30 PM, E6 (Social Services) said she did the admission paperwork for R2 at 6:30 PM on [DATE]. E6 said she asked Z2 (spouse) what R2 's code status was. Z2 said R2 had no Advanced Directives. E6 stated, " ...wife stated he was going to be a full code ...Paperwork was done and passed on to the nurses. They were given a ' heads up ' that he was coming and he was a full code. " On [DATE] at 2:30 PM, E4 (Licensed Practical Nurse) said when she came on her shift, on [DATE], she was told R2 's condition had deteriorated. E4 said she did not know R2 ' s code status. She said she could not find R2 ' s code status. E4 said CPR was not initiated when R2 was found pulseless. E4 said, " If no DNR (Do not resuscitate) on chart, CPR should have been started. " E4 said she didn ' t find R2 's Full Code status until preparing paperwork for the coroner. On [DATE] at 3:00 PM, E9 (LPN) stated in interview that E4 asked her to come to R2 ' s room and verify R2 had expired. E9 said, " We always have 2 nurses verify a death. I assumed she checked (R2 's) code status. If the code status is not known, CPR should be initiated. The resident ' s code status should be in the front of the hard chart. " E9 said R2 did not have any vital signs, and she concurred with E4 that R2 had expired. E9 said, " She (E4) did not ask for assistance so I resumed my duties. " On [DATE] at 10:45 AM, Z1 (nurse practitioner) said during interview that she had received a call from the day shift nurse on [DATE] with a condition update. At that time the nurse informed Z1 that R2 was a full code. On [DATE] from 4:15 PM through 4:30 PM, E10 - E13 (CNAs) and E3 (Assistant Director of Nursing) and E5 (LPN) all said if a resident is found not breathing/pulseless the front of the hard chart should be immediately checked to determine the resident ' s code status. E5 said if the chart doesn ' t have a signed DNR, the resident is a full code. On [DATE] the code status was reviewed for all 81 residents (according to the Facility Data Sheet of [DATE]) currently residing in the facility. Of the 81 residents, 6 of the residents (R7, 8, 10, 11, 12, &13) had conflicting orders where the state Physician orders [REDACTED]. On [DATE] at 2:30 PM, E2 (Director of Nursing) was informed of the Immediate Jeopardy related to the failure of facility staff to perform CPR to R2 on [DATE]. On [DATE] at 7:00 PM, the surveyor confirmed the facility took the following actions to remove the immediacy of the situation: 1) On [DATE] the Director of Nursing initiated training with all nursing staff on the following: a. Any time a resident has a significant change in condition the nurse is responsible to check te code status of the resident. b. If the resident has no declared Advanced Directive the resident is considered a FULL CODE. c. Nurse cannot pronounce death or end a code. CPR must be initiated on all full code residents or residents with no declared status. 2) As of [DATE], all but 3 nurses and CNAs have been re-educated on the above information. All nursing staff will be re-educated prior to returning to duty by the Director of Nursing or a nurse manager. 3) The Director of Nursing notified the Medical Director on [DATE] of the Immediate Jeopardy and the facility ' s plan of removal. 4) Nursing staff will be educated at the time of hire on the above information as part of the orientation process, including location of information on Advanced Directives. 5) Five times a week, the facility nurse management team will question staff on appropriate action if a resident is found unresponsive and/or has no pulse or blood pressure 6) The facility administrator will randomly question at least three staff members a week on the appropriate action if a resident is found unresponsive and has no pulse or blood pressure 7) The facility will continue to utilize the current system in place, for identification of code status by the staff retrieving the chart for the nurse in the event of an arrest. As a backup, the facility will also print a current list of all resident ' s code status, at midnight, and place the list in the 24 hour wing report book. 8) Night nurses will be educated on how to obtain the code status report. Printed instructions will also be kept on the 24 hours report. 9) The Social Service Designee will be responsible for maintaining updates to Advanced Directives and ensuring copies are placed in the hard chart. 10) Nurses will be educated to notify the nurse manage on call of a new admission on weekends and after hours. The nurse manager will verify the code status with the nurse of the resident at the time of admission. The nurse will communicate the code status on the 24 hour report. 11) A Quality Assurance (QA) plan of action will be created to ensure Advance Directives are reflecting resident ' s current wishes. The resident ' s Advanced Directives will be audited monthly to ensure the directive accurately reflects a resident ' s current wishes. 12) Hard charts will remain available and paper will be used as the back-up when the electronic charting system is down. 13) Corrective action will be taken immediately if a concern is identified and when revision to the plan is needed. The QA plan will be reviewed weekly in the Compliance QA meeting.

Based on interview and record review the facility neglected to follow its Advanced Directives Policy and Procedure by not performing Cardiopulmonary Resuscitation (CPR) for a resident who was a full code. The facility also neglected to know the end of life preferences for 6 residents (R7 & R8, and R,[DATE]). This failure contributed to the death of R2. This applies to 7 of 82 residents (R2, R7 & R8, and R,[DATE]) reviewed for Advanced Directives. The findings include: 1.R2 ' s Physician Transfer order sheet shows R2 was admitted to the facility on [DATE]. The transfer orders document R2 ' s resuscitation status as a full code. The facility ' s computerized POS (Physician order [REDACTED]. The hard chart does not contain the state approved Uniform Advanced Directive form giving physician orders [REDACTED]. Nursing Notes (written by E4) of [DATE] documents at 8:30 PM, E2 ' s respirations were 40 (breaths per minute) and labored, his temperature was 100.6. The notes show Z1 (Nurse Practitioner) and Z2 were notified of R2 ' s change in condition. The notes document at 9:20 PM the resident ' s temperature was 99.2. The next entry in the nurse ' s notes was at 10:00 PM. The notes state, " C.N.A. reported mucous at sides of mouth checked at this time expired also assessed by another nurse. (Z1) family notified and coroner called. " On [DATE] at 3:30 PM, E6 (Social Services) said she did the admission paperwork for R2 at 6:30 PM on [DATE]. E6 said she asked Z2 (spouse) what R2 ' s code status was. Z2 said R2 had no Advanced Directives. E6 stated, " ...wife stated he was going to be a full code ...Paperwork was done and passed on to the nurses. They were given a ' heads up ' that he was coming and he was a full code. " On [DATE] at 2:30 PM, E4 (Licensed Practical Nurse) said when she came on her shift, on [DATE], she was told R2 ' s condition had deteriorated. E4 said she did not know R2 ' s code status. She said she could not find R2 ' s code status. E4 said CPR was not initiated when R2 was found pulseless. E4 said, " If no DNR (Do not resuscitate) on chart, CPR should have been started. " On [DATE] at 3:00 PM, E9 (LPN) said E4 asked her to come to R2 ' s room and verify R2 had expired. E9 said, " We always have 2 nurses verify a death. I assumed she checked (R2 ' s) code status. If the code status is not known, CPR should be initiated. The resident ' s code status should be in the front of the hard chart. " E9 said R2 did not have any vital signs, and she concurred with E4 that R2 had expired. E9 said, " She (E4) did not ask for assistance so I resumed my duties. " 2. On [DATE] the code status was reviewed for all 81 residents (according to the Facility Data Sheet of [DATE]) currently residing in the facility. Of the 81 residents, 6 of the residents (R7, 8, 10, 11, 12, &13) had conflicting orders where the State Physician orders [REDACTED]. The facility ' s Advance Directives for Residents policy and procedure ([DATE]) states, " 1. Prior to, or upon admission, the Social Service designee or Admission Coordinator will ask the resident, and/or family members about the existence of any advanced directives. This will be followed by Social Services. 2. Should the resident indicate that he/she has issued advanced directives about his/her care and treatment, the facility will require that copies of such directives be included in the medical record ... " The facility ' s Abuse, Prevention and Prohibition of (,[DATE]) states, " This facility prohibits mistreatment, neglect or abuse of residents. This also includes the deprivation by an individual including a caretaker, of good or services that are necessary to attain or maintain physical, mental and psychosocial being, necessary to avoid physical harm, mental anguish, or mental illness.being ... " Neglect is defined in the policy as the failure to provide goods and services.

Based on interview and record review the facility failed to give [MEDICATION NAME] as ordered for a resident with Diabetes. This failure contributed to a resident ' s hyperglycemic state between [DATE] [DATE]. This applies to 1 of 3 residents (R2) reviewed for medications, in the sample of 13. The finding includes: R2 was admitted to the facility on [DATE], according to the hospital transfer form. His [DATE] Medication Review Report shows R2 ' s [DIAGNOSES REDACTED]. On [DATE] at 10:45 AM, Z1 (Nurse Practitioner ) said R2 was admitted to the facility on Friday night ([DATE]). Z1 said, " I began getting phone calls on him regarding elevated blood sugars. As I see it, (R2) was a sick man. He was discharged from the hospital too early. His blood sugars were all over the board. We couldn ' t get his blood sugars back under control. " Z1 said his blood sugars were running anywhere from 342 to 586. Z1 said she gave an order to a nurse (uncertain who) to administer 20 units [MEDICATION NAME] subcutaneously for [MEDICAL CONDITION]. Z1 said the resident did not receive the insulin on [DATE]. Z1 said the nurse told her they did not have [MEDICATION NAME] for R2 and cannot borrow from another resident. Z1 said they just kept chasing R2 ' s blood sugars, after missing his dose on [DATE]. We never did get them under control. A [DATE] nurses notes, written by E4 (Licensed Practical Nurse) at 10:00 PM states Insulin [MEDICATION NAME] 100u/ml ([MEDICATION NAME]), inject 20 units subcutaneously at bedtime for [MEDICATION NAME]. Waiting on supply. The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Nursing Notes (written by E4) of [DATE] documents at 8:30 PM, E2 ' s respirations were 40 (breaths per minute) and labored, his temperature was 100.6. The notes show Z1 (Nurse Practitioner) and Z2 were notified of R2 ' s change in condition. The notes document at 9:20 PM the resident ' s temperature was 99.2. The next entry in the nurse ' s notes was at 10:00 PM. The notes state, " C.N.A. reported mucous at sides of mouth checked at this time expired also assessed by another nurse. (Z1) family notified and coroner called. " On [DATE] at 3:00 PM, E2 (Director of Nursing) said the pharmacy told her medication can be gotten 24 hours a day. They said there is also a local pharmacy available to receive emergency medication. E2 was asked if [MEDICATION NAME] is kept in the pharmacy emergency box (e-box). E2 presented a copy of the label of the e-box showing the facility did have 1 vial of [MEDICATION NAME] available for resident use. The facility ' s Medication Shortages/Unavailable Medication ([DATE]) states, " Upon discovery that facility has an inadequate supply of medication to administer, facility staff should immediately initiate action to obtain medication from the pharmacy ...If the next available delivery causes delay or a missed dose in the resident ' s medication schedule, facility nurse should obtain the medication from the Emergency Medication Supply ... "